General Gynaecology Flashcards
What is the vulva?
Visible external female genitalia.
Borders:
- Anterior - mons pubis
- Posterior - anus
- Laterally - genitocrural folds
What is the perineum?
Area between the urethral meatus and the anus, including the overlying skin and the underlying muscle.
What are the 2 layers of the pelvic floor?
Superficial perineal compartment
Pelvic diaphragm
What 2 muscles make up the pelvic diaphragm?
Levator ani and coccygeus muscles.
What is puberty?
Transition between childhood and sexual maturity
What is menarche?
Onset on menstruation that typically occurs between ages 8 and 16 (average age = 12)
What is menopause?
Cessation of menses, usually occuring around age 50
If a woman beyond the age of 55 continues to bleed, what should we do?
Investigate to rule out malignancy
What are the phases of the menstrual cycle?
- The menstrual phase = day1- end of bleeding (usually day 4/5)
- The proliferative phase = end of menstruation - ovulation (day 13/14)
- The luteal/secretory phase = ovulation - day 28
Which cells in the oocyte do LH and FSH stimulate respectivey?
LH -> thecal cells
FSH -> granulosa cells
What happens to the oocyte during the menstrual cycle?
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.
What is the corpus luteum?
Endocrine organ formed by the follicle after ovulation. It produces progesterone.
It degenerates if there is no implantation.
What are the common presentation in gynae?
Abnormal vaginal bleeding Abdominal pain Pelvic pain Vaginal discharge Vulval lesions Dyspareunia
How might vaginal bleeding be abnormal?
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
What reproductive tract diseases could cause abnormal vaginal bleeding?
- 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.
What systemic disorders can cause abnormal vaginal bleeding?
- Bleeding and clotting disorders e.g. von Willebrand disease, prothrombin deficiency
- Hypothyroidism
- Cirrhosis
What endocrine disorders can cause abnormal vaginal bleeding?
- Anovulatory dysfunctional uterine bleeding
- Ovulatory DUB
When assessing a pt with abnormal vaginal bleeding, what is the most important to factor to consider?
Age!
If reproductive age, ruling out something pregnancy-related should be the first step!
Where is the most common site for ectopic pregnancy to occur?
The ampulla of the fallopian tube
How many ectopic pregnancies are tubal?
97%
What is the main clinical indication for starting HRT?
Vasomotor symptoms
What kind of HRT should women with a uterus be given, and why?
Combined oestrogen and progesterone.
Progesterone reduces risk of endometrial cancer, which is a risk of unopposed oestrogen.
What causes the vasomotor symptoms associated with menopause?
Decreasing oestrogen levels in the perimenopausal period.
What are the 2 types of amenorrhoea?
Primary (failure to start menses by age 16) and secondary (cessation of regular established menstruation)
What are some of the main causes of secondary amenorrhoea?
- Hypothalamic amenorrhoea
- PCOS
- Hyperprolactinaemia
- Premature ovarian failure
- Thyrotxicosis and hypothyroidism
- Sheehan’s syndrome
- Asherman’s syndrome
What are some of the main causes of primary amenorrhoea?
Turner’s syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of genital tract
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?
Urinary/serum bHCG just in case she is preggo
Gonadotrophins - if low -> hypothalamic, if high -> ovarian.
Prolactin
Anrogens -> raised in PCOS
Oestradiol
TFTs
What is PID?
Infection and inflammation of the female pelvic organs, usually secondary to an ascending infection from the endocervix.
What is the most common cause of PID?
Chlamydia trachomatis
A 26 years old woman presents with lower abdominal pain and a fever.
What other features would lead you to suspect PID?
Deep dyspareunia Dysuria/menstrual irregularities Hx of STI Vaginal/cervical discharge Cervical excitation
How should suspected PID be investigated?
Screen for Chlamydia and Gonorrohoea
How should PID be managed?
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
What are the potential complications of PID?
Infertility - up to 10-20% after a single episode.
Chronic pelvic pain
Ectopic pregnancy
What is post-menopausal bleeding, and why is it a concern?
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!
How common is post-menopausal bleeding?
Very, makes up 5% of all gnae outpatients appointments.
What is the most common malignancy we want to rule out as a cause of post-menopausal bleeding?
Endometrial cancer
A woman presents with post-menopausal bleeding. What do you need to find out from the history to assess her risk for endometrial cancer?
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
What causes are the of post-menopausal bleeding? Which is the most common?
- Vaginal atrophy (most common)
- HRT
- Endometrial hyperplasia
- Endometrial/cervical/ovarian/vaginal/vulval cancer
- Endometrial/cervical polyps
- Trauma
- Bleeding disorder
How should post-menopausal bleeding be managed?
Treat it as cancer until proven otherwise i.e. 2ww to gynae appointment with imaging and biopsy.
What is a good first line investigation for a woman with PMB? Why is this good?
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.
What is the cut-off endometrial thickness on TVUS for further investigation?
5mm
How can a definitive diagnosis be made for PMB?
Endometrial biopsy sent for histology.
What happens at a gynae one-stop clinic?
All the consultations, imaging, and biopsies are done:
- TVUS
- Consultation with doctor
- External examination
- Hysteroscopy and biopsy
What cautions do we need to keep in mind when seeing a woman with PMB?
- 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
How do women on tamoxifen differ to other women when it comes to PMB?
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.
What is intermenstrual bleeding?
PV bleeding other than post-coital at any time during the menstrual cycle other than during normal menstruation. It is a SYMPTOM.
What is post-coital bleeding?
Non-menstrual bleeding that occurs immediately after sexual intercourse. It is a SYMPTOM.
What is breakthrough bleeding?
Irregular bleeding associated with hormonal contraception. It is a SYMPTOM.
How common is post-coital bleeding?
1-9% of menstruating women experience it.
Why do intermenstrual and post-coital bleeding cause so much anxiety?
They can be symptoms of gynaecological cancer.
What are the potential causes of post-coital bleeding?
- Infection
- Polyps
- Cervical/vaginal cancer
- Trauma/sexual abuse
- Vaginal atrophic changes
What are the potential causes of intermenstrual bleeding?
- 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
How can we distinguish between the causes of post-coital and intermenstrual bleeding?
By taking a careful history:
- menstrual
- Obstetric
- gynae
- sexual
- medical
- drugs inc. OTC/herbal remedies
- Systemic symptoms (thinking about cancer)
What are Bartholin’s glands?
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.
What do Bartholin’s gland’s do?
Secrete moisture onto the vestibular surface of the vagina.
How does a Bartholin’s cyst occur?
Blockage of ostium of duct from Bartholin’s gland. The cyst may become infected.
Are Bartholin’s cysts usually unilateral or bilateral?
Unilateral
How common are Bartholin’s cysts?
About 3% of womenare affected, usually around childbearing age.
What are the risk factors associated with Bartholin’s cysts?
- Nulliparity or low parity
- Risk of infection increases with risk of STIs.
How does a Bartholin’s cyst present?
Labial oedema followed by painful swelling.
May be pain on walking, sitting, or superficial dyspareunia.
Small cysts may be found incidentally.
How does a Bartholin’s abscess present?
Like a cyst, but the painful swelling is worse and onset is more acute
What findings might there be O/E of a Bartholin’s cyst?
- Wide-legged gait
- Unilateral labial mass which is soft, fluctuant, and non-tender
- Fever/pelvic lymphadenopathy if infected
What findings might there be O/E of a Bartholin’s abscess?
- Wide-legged gait
- Unilateral labial mass which is tense and hard with surrounding erythema.
- Fever/pelvic lymphadenopathy if infected
Wehn should a pt with a Bartholin’s cyst have a biopsy?
If they are over 40 to rule out carcinoma.
How should a Bartholin’s cyst be investigated?
Swab for infective organisms.
Biopsy if pt over 40 to rule out malignancy.
A pt presents with a unilateral labial swelling. What are you differentials?
- Bartholin’s cyst/abscess
- Sebaceous cyst
- Carcinoma of the vulva
- Lipomata
- STI
- Folliculitis
When is conservative management recommended for Bartholin’s cyst?
If the cyst is small and not causing any problems e.g. no infection, little/no pain.
Is incision of a Bartholin’s cyst routine?
Not for a little one - recurrence is common.
How is a Bartholin’s abscess managed?
Incision and drainage may be required.
Warm baths may encourage spontaneous rupture.
Abx for infection.
What technique is used as definitive management of Bartholin’s cysts?
Marsupialisation
What is the prognosis associated with Bartholin’s cysts?
About 1/3 have recurrence, highest with incision and drainage, lower with marsupialisation.
What structures in the vulva can have problems?
Skin
Mucous membranes
Glands
How common is vulval pruritus?
Very, especially in postmenopausal women.
What might cause vulval pruritis?
Infection Dermatological conditions Hormonal deficiency Systemic diseases Malignant/pre-malignant change
What other symptoms might a woman have alongside vulval pruritus?
- Pain/discomfort
- Irritation
- Dyspareunia
- Discharge
- Dysuria/other urinary symptoms
- Symptoms in sexual partner
- Skin problems e.g. psoriasis
What infections would cause vulval pruritus?
- Candidiasis
- Varicella
- Genital herpes
- Genital warts
- Shingles
- Infestations
How does vulval candidiasis present?
Pruritus with white curdy discharge and vulvitis. Red rash also present.
How should vulval candidiasis be managed?
Topical antifungals usually adequate.
When would you expect a varicella vulval infection?
In girls with chickenpox - they can sometimes get vesicles around the vulva.
How should varicella vulval infection be managed?
Treat the symptoms - tepid baths, soothing lotions, and topical aneasthetic if pain significant.
How do genital herpes on the vulva present?
Painful, fluid-filled vesicles around genital area.
What needs to be done if vulval pruritus is caused by HSV?
Culture virus from the fluid.
Sexual contact notification w/ referral to GUM clinic
How should a vulval HSV infection be managed?
-Salt baths Analgesia Loose underwear Antiviral therapy Abstinence Contact tracing
What dermatological conditions can cause vulval itching?
- Nappy rash (irritant contact dermatitis)
- Vulval dermatitis
- Lichen planus
- Psoriasis
- Behcet’s syndrome
How does nappy rash/irritant contact dermatitis occur around the vulva?
Skin exposed to friction and excessive hydration, repeatedly soiled with faeces causing high irritation and skin damage.
How should irritant contact dermatitis be managed?
- Frequent changing of nappy/pads
- Barrier preparation
- Topical hydrocortisone for up to a week to treat inflammation
How does Lichen planus present?
Painful erosive vulvitis
May also be oral involvement
Intense erythema, oedema, and superifical ulceration.
How does lichen planus affected the vuvla need to be managed?
Systemic steroids often required.
How does lichen sclerosus present?
Usually post-menopausal woman with vulval pruritis, vulvodynia, superficial dyspareunia.
Skin is thin, white, and crinkly.
What is cervical ectropion?
Columnar epithelium of the endocervix is displayed beyond the os.
How does cervical ectropion appear?
Red ring around the os
Why does cervical ectropion occur?
Oestrogen exposure causes enlargement of cervix and the endocervical canal becomes everted.
Who is cervical ectropion most commonly seen in?
Teenagers
Pregnant women
Women on COCP
How does cervical ectropion present?
It might not at all.
May have a degree of bleeding ot excessive discharge.
Is cervical ectropion normal?
Yes, and as long as a smear is normal, no management is needed.
What is a fibroid?
A common benign monoclinal tumour of uterine myometrium.
How do fibroids progress?
Slowly over many years.
What stimulates a fibroid to grow?
Oestrogen and progesterone
What can happen to a fibroid when it grows past a certain point?
Central areas has reduced blood flow so undergoes benign degenration and subsequent calcification.
How are fibroids classified?
According to location within uterine wall.
Where is the most common place within the uterine wall for a fibroid to be found?
Intramurally
What symptoms can fibroids cause?
Can be asymptomatic
Pelvic pain/pressure
Prolonged/heavy menstrual bleeding
Reproductive dysfunction
Do fibroids undergo malignant change?
No (well very very very rarely they can, but its very very rare)
Which demographic groups are fibroids more common in?
African-American women
Obese population
Increased lifetime exposure to oestrogen
A 40 year old African-American woman presents with prolonged menorrhagia and pelvic pressure. What is the top differential?
Fibroids
Why do pregnant women with fibroids experience acute pelvic pain?
Fibroid degeneration
A woman with subfertility has some fibroids removed. Is this likely to have an effect on her fertility?
Yes - submucous fibroids are the ones that affect fertility but removal can restore fertility to that person’s baseline.
A 40 year old African-American woman presents with prolonged menorrhagia and pelvic pressure. What would you expect to find on examination?
- Palpable abdominal mass in pelvis
- Enlarged firm non-tender uterus palpable on bimanual examination
- Aneamia may be evident
A woman is being investigated for fibroids. What tests might she undergo?
- Bloods - anaemia
- Pregnancy test
- Pelvic USS/TVUS
- Hysteroscopy with biopsy
- MRI if USS unclear or myomectomy considered
When should fibroids be treated?
If they are symptomatic
When is expectant management of fibroids most relevant?
Peri-menopause, as post-menopause they are likely to become asymptomatic
What pharmacological management is available for symptomatic fibroids?
- Trial of NSAIDs or tranexamic acid
- Combined oral contraceptive pill
- IUS (more effective than COCP)
- GnRH agonists
- Mifepristone
- Ulipristal acetate
What surgical management is available for symptomatic fibroids?
- Myomectomy
- Hysteroscopic endometrial ablation
- Total hysterectomy
- Uterine artery embolisation
Which surgical option is used for patients wth fibroids who want to maintain their reproductive potential?
Myomectomy
Which surgical option is used for patients wth fibroids who have experienced menorrhagia?
Hysteroscopic endometrial ablation
What complications can occur secondary to uterine fibroids?
- Iron deficiency anaemia
- Bladder frequency and/or constipation
- Torsion of pedunculated fibroid
- Infertility
- Recurrent miscarriage
- Foetal malpresentation
- Red degeneration in pregnancy
- PPH
What is the prognosis with fibroids?
They regress with menopause and symptoms resolve.
What is an ovarian cyst?
Fluid filled sac within the ovary.
Do ovarian cysts need management?
Not generally unless causing symptoms. If asymptomatic, followup after 12 weeks by scanning usually shows resolution.
How can someone with a ?ovarina cyst/?ovarian cancer be stratified wrt risk of malignancy?
Risk of Malinancy Index
What kind of ovarian cysts develop with endometriosis?
Chocolate cysts
Why might an ovarian cyst cause chronic pain?
Secondary to pressure on badder or bowel causing irritation
Why might an ovarian cyst cause acute pain?
Bleeding into the cyst
Rupture of cyst
Ovarian Torsion
What is the difference between a simple ovarian cyst and a complex ovarian cyst?
Simple cyst contains only fluid.
What might a complex ovarian cyst contain?
- Solid material
- Blood
- Septations
- Vascularity
What benign functional cysts can occur on the ovaries?
- Follicular cysts
- Corpus luteal cysts
What benign pathological cysts can occur on the ovaries?
- Endometrioma
- Polycystic ovaries
- Theca lutein cyst
How can the diagnosis of a simple ovarian cyst be made?
By ultrasound only - if it appears complex or diagnosis uncertain, further Ix should be performed.
Why is CA125 pretty useless in women pre-menopause?
There are multiple benign triggers for it to be raised as it is raised by anything that irritates the peritoneum.
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?
- LDH
- AFP
- hCG
Germ cell tumours
When should a cystectomy or oophrectomy be considered for ovarian cysts?
- Persistent cysts (do not resolve over multiple menstrual cycles)
- Cysts over 5cm
Why should a cyst over 5cm be considered for removal?
High risk of ovarian torsion
What is endometriosis?
Growth of endometrial tissue in sites other than uterine cavity.
What are the common sites for endometriosis to occur?
- Pelvic cavity
- Uterosacral ligaments
- Pouch of Douglas
- Rectosigmoid colon
- Bladder
- Distal ureter
What is adenomyosis?
Complication of endometriosis where endometrial tissue invades myometrium.
https://patient.info/doctor/endometriosis-pro
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