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Year 4 - 1. Reproductive Health > Group A - Menstrual Disorders and Gynaecological Cancer > Flashcards

Group A - Menstrual Disorders and Gynaecological Cancer Flashcards

1
Q

Define dysfunctional uterine bleeding (DUB)

A

Heavy menstrual bleeding, with:
- No recognisable pelvic pathology
- No pregnancy
- No bleeding disorders

I.e. it is a diagnosis of exclusion

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2
Q

List some causes of abnormal/heavy menstrual bleeding

A

PALM COEIN

Polyps
Adenomyosis
Leiomyomas (fibroids)
Malignancy

Coagulation disorders
Ovulatory pathology
Endometriosis
Iatrogenic
Not yet classified

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3
Q

Outline the factors that determine whether a woman with HMB is low risk or high risk and what investigations they need based on their risk

A

Low risk:
< 45
No intermenstrual bleeding
No risk factors for endometrial cancer
Investigations: FBC only (anaemia) - then begin treatment for HMB

High risk:
> 45
Intermenstrual bleeding
Risk factors for endometrial cancer
Investigations: FBC (anaemia), ultrasound and hysteroscopy + biopsy
Then begin treatment for HMB

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4
Q

Outline the medical and surgical management of HMB

A

Medical:
- Tranexamic acid (symptomatic)
- Mefenamic acid (symptomatic)
- GnRH analogues or Ulipristal acetate (fibroids)
- Progesterone hormone products, Mirena coil 1st line
- COCP

Surgical:
- Hysteroscopic removal (polyps)
- Myomectomy (fibroids)
Risk of reducing children in future…
- Uterine artery embolisation
- Endometrial ablation
- Hysterectomy

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5
Q

Outline how to manage HMB in the short term / emergency

A
  • Tranexamic acid
  • Norethisterone (progesteron product)
  • GnRH analongues
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6
Q

Outline how tranexamic acid works in HMB

A

Inhibits plasminogen activation
Reduces fibrolysis (encourages clotting)
= Reduces menstrual loss

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7
Q

Outline how mefenamic acid works in HMB

A

NSAID - reduces production of prostaglandins
= Analgesia, anti inflammatory and reduces menstrual loss (although less effectively than tranexamic acid)

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8
Q

List the following cancers in most common to least common
- Endometrial
- Cervical
- Vulval
- Ovarian

A
  1. Endometrial
  2. Ovarian
  3. Cervical
  4. Vulval
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9
Q

For the following cancers, state the peak age of incidence:
- Endometrial
- Ovarian
- Cervical

A

Endometrial: 65-75 (declines after 80)
Ovarian: 70-75 years (mostly between 50-80)
Cervical: bimodal at 30s and 80s

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10
Q

Outline risk factors for endometrial cancer
Also list some protective factors

A

Risk factors:
Anything that causes endometrial hyperplasia!
- Obesity
- BRCA1/2
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- Unopposed oestrogen = PCOS or Tamoxifen
- Poorly controlled diabetes
- Untreated endometrial polyps

Protective factors:
- SMOKING
- Combined HRT
- COCP
- Physical activity

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11
Q

Briefly explain endometrial hyperplasia and its management

A
  • Precancerous condition, involving thickening of endometrium
  • 2 types:
    1. Hyperplasia without atypia
    2. Atypical hyperplasia

Most cases will return to normal over time, however <5% can become endometrial cancer
- Risk factors are similar to those for endometrial cancer

Management:
Depends on type of hyperplasia
1. Hyperplasia without atypia = progesterone (POP or Mirena coil)
2. Atypical hyperplasia = hysterectomy +/- bilateral salpingo oophorectomy

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12
Q

List red flag symptoms for endometrial cancer

A
  • Postmenopausal bleeding
  • Abnormal vaginal discharge

If premenopausal:
- Heavy vaginal bleeding
- Abnormal bleeding e.g. IMB, PCB

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13
Q

Outline the main cell type of endometrial carcinoma

A

80% = adenocarcinoma

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14
Q

Outline referral criteria for post-menopausal bleeding and diagnostic tests indicated

A

Automatic 2 week wait urgent gynae cancer referral for endometrial cancer

  • Transvaginal ultrasound (thickness > 4mm)
  • If >4mm: endometrial (Pipelle) biopsy
  • If high risk/suspicious: hysteroscopy + biopsy
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15
Q

Other than post-menopausal bleeding, suggest other presenting symptoms that prompt a referral for investigation of endometrial cancer in women over 55

A

In women over 55:
- Unexplained vaginal discharge
- Visible haematuria PLUS anaemia / raised platelets / raised glucose

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16
Q

Outline management options for endometrial cancer in terms of surgical and non-surgical options

A

Surgical:
- Total hysterectomy +/- bilateral salpingo oophorectomy

Non-surgical:
- Progestagens e.g. Mirena coil
- Primary radiotherapy

PLUS adjuvant therapies:
- External beam
- Brachytherapy

Depends on stage:
Stage 1 (localised) = total hysterectomy +/- bilateral salpingo oophorectomy with peritoneal wash out
Stage 2 = Radical hysterectomy and lymphadenectomy +/- adjuvant therapy
Stage 3 = Maximal debulking surgery + chemotherapy + radiotherapy
Stage 4 = Maximal debulking surgery / palliative approach

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17
Q

Outline the most common cell line types for ovarian cancer

A

Epithelial:
- Serous
- Mucinoid

Germ cell:
- Teratoma

Stomal / sex cord: rare!

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18
Q

Outline risk factors for ovarian cancer
Also list some protective factors

A

Risk factors:
- Obesity
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- BRCA1/2 or family history
- Unexposed oestrogen = PCOS or Tamoxifen
- Endometriosis

Protective factors:
- COCP
- Pregnancy / breastfeeding
- Oopherectomy (+/- hysterectomy)

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19
Q

Outline some red flag symptoms for a patient with ovarian cancer

A
  • Persistent abdominal bloating
  • Pain or dyspareunia
  • Anorexia
  • Nausea and vomiting
  • Weight loss
  • Vaginal bleeding
  • Increased urinary frequency
  • Bowel changes
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20
Q

Outline some diagnostic tests to consider for suspected ovarian cancer

A

Bloods:
- Ca125 tumour marker
- FBC / U&Es, LFTs (routine bloods)

Imaging:
- Ultrasound
- CT to assess for further disease
- Chest x-ray

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21
Q

Outline the possible management options for ovarian cancer: epithelial and non-epithelial

A

Epithelial:
- Surgery
- Chemotherapy (Platinum and Taxane)

Non-epithelial:
- Chemotherapy only (very chemo-sensitive)

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22
Q

Outline risk factors for cervical cancer
Also list some protective factors

A

Risk factors:
- Non-compliance with cervical screening
- Known diagnosis of CIN (premalignant changes)
- HPV positive
- Related to HPV exposure: early first sexual experience, multiple sexual partners, lack of barrier contraception
- Immunosuppression
- Smoking
- COCP long term

Protective factors:
- HPV vaccine!
- Compliance with cervical screening

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23
Q

Outline briefly how HPV increases the risk of cervical cancer

A
  • HPV produce E6 and E7 proteins
  • These proteins inhibit the tumour suppressor genes in keratinocytes
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24
Q

Briefly explain cervical intraepithelial neoplasia (CIN) and at which area of the cervix CIN occurs

A

CIN is a grading system for level of dysplasia / premalignant changes in the cells of the cervix
- Can be diagnosed during colposcopy
- Level of CIN grade, suggests the level of premalignant changes and the likely of progression to cervical cancer

Area of the cervix:
- Transformation zone

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25
Q

List some red flag symptoms for cervical cancer

A
  • Post-coital bleeding
  • Intermenstrual bleeding
  • Post menopausal bleeding
  • Dyspareunia
  • Blood stained vaginal discharge
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26
Q

Outline the FIGO staging of cervical cancer

A

Stage 1: confined to cervix
Stage 2: beyond cervix, but not on side pelvic wall or lower 1/3 vagina
Stage 3: spreads beyond cervix, on sides of pelvic wall or lower 1/3 vagina
Stage 4: invades adjacent organs

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27
Q

Outline the management for cervical cancer in the following conditions:
- CIN and early stage 1a (very early disease)
- 1b to 2a (localised)
- 2b to 4a (greater spread)

A

CIN and early stage 1a:
- LLETZ procedure
- Cone biopsy

1b to 2a (localised):
- Radical hysterectomy and removal local lymph nodes with chemo and radio

2b to 4a (greater spread):
- Chemotherapy
- Radiotherapy

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28
Q

Outline some complications of surgical management and radiotherapy management of cervical cancer

A

Surgical:
- General e.g. infection, VTE, haemorrhage
- Vesicovaginal fistula
- Bladder dysfunction
- Short vagina

Radiotherapy:
- Vaginal dryness
- Stenosis
- Cystitis
- Proctitis
- Loss of ovarian function

29
Q

Outline the frequency of cervical smears (for the 2 age groups)

A

25-50: every 3 years
50-65: every 5 years

After 65: selected patients only

30
Q

Outline some red flag symptoms for vulval cancer

A
  • Vulval pain / soreness
    persistent vulval itching
  • Lump or thickened, raised patches (red, white or dark)
31
Q

List some risk factors for vulval cancer

A
  • Lichen sclerosus
  • HPV
  • Herpes simplex virus type 2
  • Smoking
  • Immunosuppression
  • Chronic vulvar irritation
32
Q

Briefly outline the following for lichen sclerosus:
- Pathophysiology
- Presentation
- Management

A

Pathophysiology:
- Chronic inflammatory skin disease in the anogenital region in women, possibly autoimmune
- Bimodal: pre-puberty and post-menopausal
- Can be debilitating
- Potential to progress to squamous cell carcinoma (vulval cancer)

Presentation:
- White atrophic patches in anogenital region
- Itching (associated excoriations and pain)
- Fusion of vulval tissue
- Dyspareunia
- Can be asymptomatic

Management:
- Conservative e.g. avoid irritants
- Topical steroids
- Regular follow ups due to risk of squamous cell carcinoma

33
Q

Outline the general management options for vulval cancer

A
  • Wide local excision surgery +/- lymphadenectomy
  • Radiotherapy / chemotherapy
34
Q

2 medications that can stop periods

A
  • Antipsychotics
  • Breast cancer treatment e.g. Tamoxifen

Plus contraceptives!
- Contraceptive pill
- Mirena coil

35
Q

State for what ages breast cancer screening is offered

A

Between 50-70

36
Q

Outline how smears are conducted in terms of HPV testing and cytology

A

Initially tested for presence of HPV

If HPV absent -> no further investigation, return to routine screening

If HPV present -> cytology to look for dyskaryosis
Cytology normal = recall in 12 months
Cytology abnormal = refer for colposcopy

37
Q

Outline the 2 liquids used in cytology to visualise cells and what colours they turn in normal and abnormal cells

A
  1. Acetic acid
    Normal: no change
    Abnormal: white
  2. Iodine
    Normal: brown
    Abnormal: no change / don’t stain
38
Q

Outline 2 future tests for biopsy in suspicious looking cells in colposcopy

A
  1. Punch biopsy
  2. LLETZ (large loop excision of transformation zone)
39
Q

List some complications of a LLETZ procedure

A
  • Risk of infection
  • Cervical stenosis
  • Cervical incompetence (pregnancy)

Can make follow up smears more difficult

40
Q

Outline some potential clinical signs (not symptoms) of cervical cancer

A

On speculum examination:
- Visible irregularity of cervix e.g. ulceration
- Evidence of discharge / bleeding
- Cervical tenderness

If advanced disease:
- Pelvic mass
- PR bleed / PR mass
- Hydronephrosis
- Hepatomegaly

41
Q

Outline some potential clinical signs (not symptoms) of ovarian cancer

A
  • Abdominal distension
  • Abdominal mass (axdendal)

Advanced:
- Pleural effusion
- Ascites

42
Q

Outline some potential clinical signs (not symptoms) of endometrial cancer

A
  • Abdominal distension
  • Abdominal mass (axdendal)
  • Abdominal tenderness
  • Haematuria

Laboratory:
- Anaemia
- Raised platelet count

43
Q

Outline some potential clinical signs (not symptoms) of vulval cancer

A
  • Ulceration +/- discharge
  • Skin changes e.g. thickened skin, colour change (red, white, dark brown)
  • Tenderness on palpation
44
Q

List the 4 types of fibroid

A
  • Intramural (within myometrium)
  • Subserosal (outside layer)
  • Submucosal (internal layer)
  • Pedunculated (on a stalk)
45
Q

List some symptoms and signs of fibroids

A

Symptoms:
- Heavy menstrual bleeding
- Prolonged menstrual bleeding
- Abdominal pain
- Bloating / fullness / reduced appetite
- Urinary or bowel symptoms
- Deep dyspareunia
- Fertility issues

Signs:
- Palpable pelvic mass (abdominal exam)
- Enlarged firm non-tender uterus (bimanual exam)

46
Q

List some investigations for suspected fibroids

A
  • Hysteroscopy initially (if submucosal causing HMB)
  • Pelvic ultrasound if larger
  • MRI scan prior to surgical interventions
47
Q

List some management options for fibroids

A

Conservative:
- Leave if not causing problems
- Symptomatic management with NSAIDs and tranexamic acid

Medical:
- Mirena coil (first line if small)
- COCP / POP
- GnRH analogues may be used short term

Surgical:
- Endometrial ablation
- Resection during hysteroscopy if submucosal
If >3cm
- Uterine artery embolism
- Myomectomy
- Hysterectomy

48
Q

List some complications of fibroids

A
  • Heavy menstrual bleeding and anaemia
  • Infertility / impact on pregnancy
  • Constipation / urinary outflow obstruction
  • Red degeneration / ischaemia / necrosis
  • Torsion of fibroid if pedunculated
  • Malignant change (rare)
49
Q

State the 3 Rotterdam features for diagnosis of PCOS

A

Need 2 of 3 features for a diagnosis of PCOS

  1. Irregular periods (oligoovulation or anovulation)
  2. Hirsutism
  3. Polycystic ovaries on USS (>10cm or >12 cysts)
50
Q

State presenting features of PCOS

A
  • Irregular / absent periods
  • Infertility
  • Hirsutism
  • Acne
  • Obesity
  • Male pattern hair loss
51
Q

State some blood tests and other investigations to do in suspected PCOS (also helps to rule out other conditions)

A

Bloods:
- LH
- FSH
- Testosterone
- Sex hormone binding globulin
- Prolactin
- Thyroid stimulating hormone

Other investigations:
- Pelvic ultrasound which shows ‘string of pearls’ (multiple cysts or large volume cyst)
- OGTT

52
Q

State the findings for the following blood tests in PCOS:
- LH
- LH:FSH ratio
- Testosterone
- Insulin
- Oestrogen

A

LH = raised
LH:FSH ratio = raised
Testosterone = raised
Insulin = raised
Oestrogen = normal / raised

53
Q

List some investigations for suspected endometriosis

A
  • Transvaginal USS = rule out any ovarian masses or chocolate cysts
  • Laparoscopy = gold standard
54
Q

State some presenting symptoms and signs of endometriosis

A

Symptoms:
- Dysmenorrhoea
- Cyclical abdominal / pelvic pain
- Deep dyspareunia
- Infertility
- Cyclical bleeding from other sites e.g. haematuria

Signs:
- Fixed cervix
- Presence of endometrial tissue in vagina
- Tenderness of vagina, cervix and adnexa

55
Q

State some presenting symptoms of endometrial polyps

A
  • Irregular bleeding: PCB, PCB, postmenopausal bleeding
  • Heavy menstrual bleeding
  • Infertility
  • Dull pelvic pain
56
Q

State common causative organisms for pelvic inflammatory disease

A
  • Neisseria gonorrhoeae (more severe)
  • Chlamydia trachomatis
  • Mycoplasma genitalium

Less common:
- Gardnerella vaginalis
- Haemophilus influenzae
- E coli

57
Q

State risk factors for pelvic inflammatory disease

A
  • Previous PID
  • Existing sexually transmitted diseases
  • Intrauterine device

Sexual risk:
- Young age
- Lack of barrier contraception
- Multiple sexual partners

58
Q

State some presenting symptoms and signs of pelvic inflammatory disease

A

Symptoms:
- Lower abdo / pelvic pain
- Abnormal discharge
- Abnormal bleeding (IMB / PCB)
- Dyspareunia
- Fever
- Dysuria

Signs:
- Cervical motion tenderness
- Tenderness on palpation
- Inflamed cervix
- Purulent discharge

59
Q

List some investigations for suspected pelvic inflammatory disease

A
  • Pregnancy test
  • HVS for STI screen
  • Bloods for CRP and WCC
60
Q

Outline management for pelvic inflammatory disease

A

Empirical antibiotic therapy:
- IM Ceftriaxone
- Doxycycline (14 days)
- Metronidazole (14 days)

61
Q

List some complications of pelvic inflammatory disease

A
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Fitz-Hugh-Curtis syndrome
  • Abscess
  • Sepsis
62
Q

State some initial investigations for primary amenorrhoea

A

Normal bloods:
- FBC and ferritin (anaemia)
- U&Es (CKD)
- Thyroid function tests

Reproductive bloods:
- LH and FSH
- Testosterone (PCOS)
- Prolactin (hyperprolactinaemia)

Specific bloods:
- Coeliac disease
- ILGF-1 (growth hormone deficiency)

63
Q

State some initial investigations for secondary amenorrhoea

A
  • Pregnancy test for pregnancy
  • LH and FSH for premature ovarian failure
  • Thyroid function tests
  • Testosterone for PCOS
  • Pelvis ultrasound for PCOS
  • Prolactin for hyperprolactinaemia
64
Q

State some initial investigations for irregular periods

A
  • Pregnancy test for pregnancy
  • LH and FSH for premature ovarian failure
  • Thyroid function tests
  • Testosterone for PCOS
  • Pelvis ultrasound for PCOS
65
Q

State some initial investigations for menorrhagia or dysmenorrhoea

A
  • Speculum examination
  • Bimanual examination
  • STI screen / swabs
  • Pregnancy test for pregnancy
  • Check up to date with cervical screening
  • FBC and ferritin for anaemia
  • LH and FSH for premature ovarian failure
  • Thyroid function tests
  • Testosterone for PCOS
  • Pelvic ultrasound
  • Hysteroscopy
66
Q

State some management options for PCOS

A

Conservative:
- Encourage a healthy lifestyle and optimal weight management (reduce risk of associated T2DM and cardiovascular disease)

Medical:
- Offer COCP
- If acne, offer topical retinoids
- If hirsutism, offer hair removal methods e.g. waxing
-

67
Q

State some management options for endometriosis

A

Diagnostic laparoscopy

Medical:
- Analgesia
- COCP / POP

Surgical:
- Laparoscopic endometrial ablation or excision (can add hormonal treatments)
- Laparoscopic hysterectomy (+/- oophorectomy)

68
Q

State some management options for endometrial polyps

A

Asymptomatic AND low-risk, may manage conservatively with observation

If suspicious:
- Hysteroscopy and biopsy, including removal of polyp
- Consider use of POP/Mirena coil to prevent formation of future polyps

69
Q
A

Year 4 - 1. Reproductive Health (7 decks)

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