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Reproductive Health Block > General Gynaecology > Flashcards

General Gynaecology Flashcards

1
Q

What is the vulva?

A

Visible external female genitalia.

Borders:

  • Anterior - mons pubis
  • Posterior - anus
  • Laterally - genitocrural folds
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2
Q

What is the perineum?

A

Area between the urethral meatus and the anus, including the overlying skin and the underlying muscle.

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3
Q

What are the 2 layers of the pelvic floor?

A

Superficial perineal compartment

Pelvic diaphragm

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4
Q

What 2 muscles make up the pelvic diaphragm?

A

Levator ani and coccygeus muscles.

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5
Q

What is puberty?

A

Transition between childhood and sexual maturity

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6
Q

What is menarche?

A

Onset on menstruation that typically occurs between ages 8 and 16 (average age = 12)

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7
Q

What is menopause?

A

Cessation of menses, usually occuring around age 50

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8
Q

If a woman beyond the age of 55 continues to bleed, what should we do?

A

Investigate to rule out malignancy

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9
Q

What are the phases of the menstrual cycle?

A
  1. The menstrual phase = day1- end of bleeding (usually day 4/5)
  2. The proliferative phase = end of menstruation - ovulation (day 13/14)
  3. The luteal/secretory phase = ovulation - day 28
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10
Q

Which cells in the oocyte do LH and FSH stimulate respectivey?

A

LH -> thecal cells

FSH -> granulosa cells

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11
Q

What happens to the oocyte during the menstrual cycle?

A

It matures in the follicle from day 1 untilthe LH surge, when ovulation occurs roughly 24-36 hours later. The oocyte will go on for implantation, and the follicle will turn into the corpus luteum.

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12
Q

What is the corpus luteum?

A

Endocrine organ formed by the follicle after ovulation. It produces progesterone.

It degenerates if there is no implantation.

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13
Q

What are the common presentation in gynae?

A 
Abnormal vaginal bleeding
Abdominal pain
Pelvic pain
Vaginal discharge
Vulval lesions
Dyspareunia
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14
Q

How might vaginal bleeding be abnormal?

A 
May be prolonged or heavy bleeding at regular or irregular intervals
Inter-menstrual bleeding
Short intervals between menses
Long interval between menses
Post-menopausal bleeding
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15
Q

What reproductive tract diseases could cause abnormal vaginal bleeding?

A
  • Pregnancy related conditions such as ectopics, miscarriage, implantation bleeding.
  • Uterine lesions
  • Cervical lesions
  • Iatrogenic - IUD, steroid use/HRT, OCP at start of use, POP, or some herbal medications.
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16
Q

What systemic disorders can cause abnormal vaginal bleeding?

A
  • Bleeding and clotting disorders e.g. von Willebrand disease, prothrombin deficiency
  • Hypothyroidism
  • Cirrhosis
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17
Q

What endocrine disorders can cause abnormal vaginal bleeding?

A
  • Anovulatory dysfunctional uterine bleeding

- Ovulatory DUB

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18
Q

When assessing a pt with abnormal vaginal bleeding, what is the most important to factor to consider?

A

Age!

If reproductive age, ruling out something pregnancy-related should be the first step!

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19
Q

Where is the most common site for ectopic pregnancy to occur?

A

The ampulla of the fallopian tube

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20
Q

How many ectopic pregnancies are tubal?

A

97%

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21
Q

What is the main clinical indication for starting HRT?

A

Vasomotor symptoms

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22
Q

What kind of HRT should women with a uterus be given, and why?

A

Combined oestrogen and progesterone.

Progesterone reduces risk of endometrial cancer, which is a risk of unopposed oestrogen.

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23
Q

What causes the vasomotor symptoms associated with menopause?

A

Decreasing oestrogen levels in the perimenopausal period.

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24
Q

What are the 2 types of amenorrhoea?

A

Primary (failure to start menses by age 16) and secondary (cessation of regular established menstruation)

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25
Q

What are some of the main causes of secondary amenorrhoea?

A
  • Hypothalamic amenorrhoea
  • PCOS
  • Hyperprolactinaemia
  • Premature ovarian failure
  • Thyrotxicosis and hypothyroidism
  • Sheehan’s syndrome
  • Asherman’s syndrome
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26
Q

What are some of the main causes of primary amenorrhoea?

A

Turner’s syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of genital tract

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27
Q

A 26 year old woman presents with cessation of periods. Her last period was 8 months ago. She is not on any contraception, and is not pregnant.

How should we investigate?

A

Urinary/serum bHCG just in case she is preggo
Gonadotrophins - if low -> hypothalamic, if high -> ovarian.
Prolactin
Anrogens -> raised in PCOS
Oestradiol
TFTs

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28
Q

What is PID?

A

Infection and inflammation of the female pelvic organs, usually secondary to an ascending infection from the endocervix.

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29
Q

What is the most common cause of PID?

A

Chlamydia trachomatis

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30
Q

A 26 years old woman presents with lower abdominal pain and a fever.
What other features would lead you to suspect PID?

A 
Deep dyspareunia
Dysuria/menstrual irregularities
Hx of STI
Vaginal/cervical discharge
Cervical excitation
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31
Q

How should suspected PID be investigated?

A

Screen for Chlamydia and Gonorrohoea

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32
Q

How should PID be managed?

A

With a low threshold for treatment.

IM ceftriaxone stat + oral doxycline + oral metronidazole BD for 14 days

OR

Oral ofloxacin + oral metronidazole BD for 14 days

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33
Q

What are the potential complications of PID?

A

Infertility - up to 10-20% after a single episode.
Chronic pelvic pain
Ectopic pregnancy

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34
Q

What is post-menopausal bleeding, and why is it a concern?

A

PV bleeding occuring after 12 months or amenorrhoea in a woman where menopause can be expected.

Although the cause is often benign, malignancy must be excluded!

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35
Q

How common is post-menopausal bleeding?

A

Very, makes up 5% of all gnae outpatients appointments.

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36
Q

What is the most common malignancy we want to rule out as a cause of post-menopausal bleeding?

A

Endometrial cancer

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37
Q

A woman presents with post-menopausal bleeding. What do you need to find out from the history to assess her risk for endometrial cancer?

A 
General oestogen exposure:
-Unopposed oestrogen-only HRT
-Tamoxifen use
-Low parity/infertility
-Early menarche/late menopause
-Increasing age
-PCOS
-Obesity
HTN
Hereditary non-polyposis colorectal cancer
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38
Q

What causes are the of post-menopausal bleeding? Which is the most common?

A
  • Vaginal atrophy (most common)
  • HRT
  • Endometrial hyperplasia
  • Endometrial/cervical/ovarian/vaginal/vulval cancer
  • Endometrial/cervical polyps
  • Trauma
  • Bleeding disorder
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39
Q

How should post-menopausal bleeding be managed?

A

Treat it as cancer until proven otherwise i.e. 2ww to gynae appointment with imaging and biopsy.

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40
Q

What is a good first line investigation for a woman with PMB? Why is this good?

A

Transvaginal ultrasound.

Endometrial thickness can be assessed. As it is thinner in post-menopausal women, if it is thickened on TVUS, there is a higher likelihood of pathology and therefore further investigation.

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41
Q

What is the cut-off endometrial thickness on TVUS for further investigation?

A

5mm

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42
Q

How can a definitive diagnosis be made for PMB?

A

Endometrial biopsy sent for histology.

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43
Q

What happens at a gynae one-stop clinic?

A

All the consultations, imaging, and biopsies are done:

  • TVUS
  • Consultation with doctor
  • External examination
  • Hysteroscopy and biopsy
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44
Q

What cautions do we need to keep in mind when seeing a woman with PMB?

A
  • They may not be able to tell urinary or PR bleeding from vaginal
  • Having atrophic vaginitis is almost a diagnosis of exclusion - must rule out all other pathology as it may co-exist.
  • Pts on HRT still need investiagting for PMB
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45
Q

How do women on tamoxifen differ to other women when it comes to PMB?

A

Tamoxifen causes changes to the endometrium so TVUS is less reliable and harder to interpret. They should have TVUS as well as hysteroscopy and biopsy as standard.

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46
Q

What is intermenstrual bleeding?

A

PV bleeding other than post-coital at any time during the menstrual cycle other than during normal menstruation. It is a SYMPTOM.

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47
Q

What is post-coital bleeding?

A

Non-menstrual bleeding that occurs immediately after sexual intercourse. It is a SYMPTOM.

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48
Q

What is breakthrough bleeding?

A

Irregular bleeding associated with hormonal contraception. It is a SYMPTOM.

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49
Q

How common is post-coital bleeding?

A

1-9% of menstruating women experience it.

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50
Q

Why do intermenstrual and post-coital bleeding cause so much anxiety?

A

They can be symptoms of gynaecological cancer.

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51
Q

What are the potential causes of post-coital bleeding?

A
  • Infection
  • Polyps
  • Cervical/vaginal cancer
  • Trauma/sexual abuse
  • Vaginal atrophic changes
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52
Q

What are the potential causes of intermenstrual bleeding?

A
  • Pregnancy-related
  • Physiological (around ovulation/pre-menopause)
  • Vaginal factors (adenosis/vaginitis/tumour)
  • Cervical factors (infection/cancer/polyps/ectropion)
  • Uterine factors (fibroids/polyps/cancer/adenomyosis/endometritis)
  • Oestrogen-secreting ovarian tumours
  • OTC/herbal remedies taken with hormonal contraception
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53
Q

How can we distinguish between the causes of post-coital and intermenstrual bleeding?

A

By taking a careful history:

  • menstrual
  • Obstetric
  • gynae
  • sexual
  • medical
  • drugs inc. OTC/herbal remedies
  • Systemic symptoms (thinking about cancer)
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54
Q

What are Bartholin’s glands?

A

A pair of glands the size of a pea situated at 4 and 8 o’clock on the inferior aspect of the opening of the vagina.

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55
Q

What do Bartholin’s gland’s do?

A

Secrete moisture onto the vestibular surface of the vagina.

56
Q

How does a Bartholin’s cyst occur?

A

Blockage of ostium of duct from Bartholin’s gland. The cyst may become infected.

57
Q

Are Bartholin’s cysts usually unilateral or bilateral?

A

Unilateral

58
Q

How common are Bartholin’s cysts?

A

About 3% of womenare affected, usually around childbearing age.

59
Q

What are the risk factors associated with Bartholin’s cysts?

A
  • Nulliparity or low parity

- Risk of infection increases with risk of STIs.

60
Q

How does a Bartholin’s cyst present?

A

Labial oedema followed by painful swelling.

May be pain on walking, sitting, or superficial dyspareunia.

Small cysts may be found incidentally.

61
Q

How does a Bartholin’s abscess present?

A

Like a cyst, but the painful swelling is worse and onset is more acute

62
Q

What findings might there be O/E of a Bartholin’s cyst?

A
  • Wide-legged gait
  • Unilateral labial mass which is soft, fluctuant, and non-tender
  • Fever/pelvic lymphadenopathy if infected
63
Q

What findings might there be O/E of a Bartholin’s abscess?

A
  • Wide-legged gait
  • Unilateral labial mass which is tense and hard with surrounding erythema.
  • Fever/pelvic lymphadenopathy if infected
64
Q

Wehn should a pt with a Bartholin’s cyst have a biopsy?

A

If they are over 40 to rule out carcinoma.

65
Q

How should a Bartholin’s cyst be investigated?

A

Swab for infective organisms.

Biopsy if pt over 40 to rule out malignancy.

66
Q

A pt presents with a unilateral labial swelling. What are you differentials?

A
  • Bartholin’s cyst/abscess
  • Sebaceous cyst
  • Carcinoma of the vulva
  • Lipomata
  • STI
  • Folliculitis
67
Q

When is conservative management recommended for Bartholin’s cyst?

A

If the cyst is small and not causing any problems e.g. no infection, little/no pain.

68
Q

Is incision of a Bartholin’s cyst routine?

A

Not for a little one - recurrence is common.

69
Q

How is a Bartholin’s abscess managed?

A

Incision and drainage may be required.
Warm baths may encourage spontaneous rupture.
Abx for infection.

70
Q

What technique is used as definitive management of Bartholin’s cysts?

A

Marsupialisation

71
Q

What is the prognosis associated with Bartholin’s cysts?

A

About 1/3 have recurrence, highest with incision and drainage, lower with marsupialisation.

72
Q

What structures in the vulva can have problems?

A

Skin
Mucous membranes
Glands

73
Q

How common is vulval pruritus?

A

Very, especially in postmenopausal women.

74
Q

What might cause vulval pruritis?

A 
Infection
Dermatological conditions
Hormonal deficiency
Systemic diseases
Malignant/pre-malignant change
75
Q

What other symptoms might a woman have alongside vulval pruritus?

A
  • Pain/discomfort
  • Irritation
  • Dyspareunia
  • Discharge
  • Dysuria/other urinary symptoms
  • Symptoms in sexual partner
  • Skin problems e.g. psoriasis
76
Q

What infections would cause vulval pruritus?

A
  • Candidiasis
  • Varicella
  • Genital herpes
  • Genital warts
  • Shingles
  • Infestations
77
Q

How does vulval candidiasis present?

A

Pruritus with white curdy discharge and vulvitis. Red rash also present.

78
Q

How should vulval candidiasis be managed?

A

Topical antifungals usually adequate.

79
Q

When would you expect a varicella vulval infection?

A

In girls with chickenpox - they can sometimes get vesicles around the vulva.

80
Q

How should varicella vulval infection be managed?

A

Treat the symptoms - tepid baths, soothing lotions, and topical aneasthetic if pain significant.

81
Q

How do genital herpes on the vulva present?

A

Painful, fluid-filled vesicles around genital area.

82
Q

What needs to be done if vulval pruritus is caused by HSV?

A

Culture virus from the fluid.

Sexual contact notification w/ referral to GUM clinic

83
Q

How should a vulval HSV infection be managed?

A 
-Salt baths
Analgesia
Loose underwear
Antiviral therapy
Abstinence
Contact tracing
84
Q

What dermatological conditions can cause vulval itching?

A
  • Nappy rash (irritant contact dermatitis)
  • Vulval dermatitis
  • Lichen planus
  • Psoriasis
  • Behcet’s syndrome
85
Q

How does nappy rash/irritant contact dermatitis occur around the vulva?

A

Skin exposed to friction and excessive hydration, repeatedly soiled with faeces causing high irritation and skin damage.

86
Q

How should irritant contact dermatitis be managed?

A
  • Frequent changing of nappy/pads
  • Barrier preparation
  • Topical hydrocortisone for up to a week to treat inflammation
87
Q

How does Lichen planus present?

A

Painful erosive vulvitis
May also be oral involvement
Intense erythema, oedema, and superifical ulceration.

88
Q

How does lichen planus affected the vuvla need to be managed?

A

Systemic steroids often required.

89
Q

How does lichen sclerosus present?

A

Usually post-menopausal woman with vulval pruritis, vulvodynia, superficial dyspareunia.
Skin is thin, white, and crinkly.

90
Q

What is cervical ectropion?

A

Columnar epithelium of the endocervix is displayed beyond the os.

91
Q

How does cervical ectropion appear?

A

Red ring around the os

92
Q

Why does cervical ectropion occur?

A

Oestrogen exposure causes enlargement of cervix and the endocervical canal becomes everted.

93
Q

Who is cervical ectropion most commonly seen in?

A

Teenagers
Pregnant women
Women on COCP

94
Q

How does cervical ectropion present?

A

It might not at all.

May have a degree of bleeding ot excessive discharge.

95
Q

Is cervical ectropion normal?

A

Yes, and as long as a smear is normal, no management is needed.

96
Q

What is a fibroid?

A

A common benign monoclinal tumour of uterine myometrium.

97
Q

How do fibroids progress?

A

Slowly over many years.

98
Q

What stimulates a fibroid to grow?

A

Oestrogen and progesterone

99
Q

What can happen to a fibroid when it grows past a certain point?

A

Central areas has reduced blood flow so undergoes benign degenration and subsequent calcification.

100
Q

How are fibroids classified?

A

According to location within uterine wall.

101
Q

Where is the most common place within the uterine wall for a fibroid to be found?

A

Intramurally

102
Q

What symptoms can fibroids cause?

A

Can be asymptomatic
Pelvic pain/pressure
Prolonged/heavy menstrual bleeding
Reproductive dysfunction

103
Q

Do fibroids undergo malignant change?

A

No (well very very very rarely they can, but its very very rare)

104
Q

Which demographic groups are fibroids more common in?

A

African-American women
Obese population
Increased lifetime exposure to oestrogen

105
Q

A 40 year old African-American woman presents with prolonged menorrhagia and pelvic pressure. What is the top differential?

A

Fibroids

106
Q

Why do pregnant women with fibroids experience acute pelvic pain?

A

Fibroid degeneration

107
Q

A woman with subfertility has some fibroids removed. Is this likely to have an effect on her fertility?

A

Yes - submucous fibroids are the ones that affect fertility but removal can restore fertility to that person’s baseline.

108
Q

A 40 year old African-American woman presents with prolonged menorrhagia and pelvic pressure. What would you expect to find on examination?

A
  • Palpable abdominal mass in pelvis
  • Enlarged firm non-tender uterus palpable on bimanual examination
  • Aneamia may be evident
109
Q

A woman is being investigated for fibroids. What tests might she undergo?

A
  • Bloods - anaemia
  • Pregnancy test
  • Pelvic USS/TVUS
  • Hysteroscopy with biopsy
  • MRI if USS unclear or myomectomy considered
110
Q

When should fibroids be treated?

A

If they are symptomatic

111
Q

When is expectant management of fibroids most relevant?

A

Peri-menopause, as post-menopause they are likely to become asymptomatic

112
Q

What pharmacological management is available for symptomatic fibroids?

A
  • Trial of NSAIDs or tranexamic acid
  • Combined oral contraceptive pill
  • IUS (more effective than COCP)
  • GnRH agonists
  • Mifepristone
  • Ulipristal acetate
113
Q

What surgical management is available for symptomatic fibroids?

A
  • Myomectomy
  • Hysteroscopic endometrial ablation
  • Total hysterectomy
  • Uterine artery embolisation
114
Q

Which surgical option is used for patients wth fibroids who want to maintain their reproductive potential?

A

Myomectomy

115
Q

Which surgical option is used for patients wth fibroids who have experienced menorrhagia?

A

Hysteroscopic endometrial ablation

116
Q

What complications can occur secondary to uterine fibroids?

A
  • Iron deficiency anaemia
  • Bladder frequency and/or constipation
  • Torsion of pedunculated fibroid
  • Infertility
  • Recurrent miscarriage
  • Foetal malpresentation
  • Red degeneration in pregnancy
  • PPH
117
Q

What is the prognosis with fibroids?

A

They regress with menopause and symptoms resolve.

118
Q

What is an ovarian cyst?

A

Fluid filled sac within the ovary.

119
Q

Do ovarian cysts need management?

A

Not generally unless causing symptoms. If asymptomatic, followup after 12 weeks by scanning usually shows resolution.

120
Q

How can someone with a ?ovarina cyst/?ovarian cancer be stratified wrt risk of malignancy?

A

Risk of Malinancy Index

121
Q

What kind of ovarian cysts develop with endometriosis?

A

Chocolate cysts

122
Q

Why might an ovarian cyst cause chronic pain?

A

Secondary to pressure on badder or bowel causing irritation

123
Q

Why might an ovarian cyst cause acute pain?

A

Bleeding into the cyst
Rupture of cyst
Ovarian Torsion

124
Q

What is the difference between a simple ovarian cyst and a complex ovarian cyst?

A

Simple cyst contains only fluid.

125
Q

What might a complex ovarian cyst contain?

A
  • Solid material
  • Blood
  • Septations
  • Vascularity
126
Q

What benign functional cysts can occur on the ovaries?

A
  • Follicular cysts

- Corpus luteal cysts

127
Q

What benign pathological cysts can occur on the ovaries?

A
  • Endometrioma
  • Polycystic ovaries
  • Theca lutein cyst
128
Q

How can the diagnosis of a simple ovarian cyst be made?

A

By ultrasound only - if it appears complex or diagnosis uncertain, further Ix should be performed.

129
Q

Why is CA125 pretty useless in women pre-menopause?

A

There are multiple benign triggers for it to be raised as it is raised by anything that irritates the peritoneum.

130
Q

If an unknown type of ovarian cyst is being investigated in a woman under 40, which lood tests should be done to ruel out which type of tumour?

A
  • LDH
  • AFP
  • hCG

Germ cell tumours

131
Q

When should a cystectomy or oophrectomy be considered for ovarian cysts?

A
  • Persistent cysts (do not resolve over multiple menstrual cycles)
  • Cysts over 5cm
132
Q

Why should a cyst over 5cm be considered for removal?

A

High risk of ovarian torsion

133
Q

What is endometriosis?

A

Growth of endometrial tissue in sites other than uterine cavity.

134
Q

What are the common sites for endometriosis to occur?

A
  • Pelvic cavity
  • Uterosacral ligaments
  • Pouch of Douglas
  • Rectosigmoid colon
  • Bladder
  • Distal ureter
135
Q

What is adenomyosis?

A

Complication of endometriosis where endometrial tissue invades myometrium.

136
Q

https://patient.info/doctor/endometriosis-pro

A

yeep

Reproductive Health Block (10 decks)

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