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O&G > Gynae 1 > Flashcards

Gynae 1 Flashcards

1
Q

What is adenomyosis?

A

When the endometrium grows into the myometrium

Similar to endometriosis but not the same:

Endometriosis = endometrial cells existing outside of the uterus

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2
Q

What are the S/S of adenomyosis?

A
  • Menorrhagia ± dysmenorrhoea
  • Chronic pelvic pain (more so during menstruation)
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3
Q

When does adenomyosis present?

A

Most women are in their later childbearing years, between 35 and 50

The major symptoms go away after menopause.

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4
Q

What are the investigations for adenomyosis?

A
  • Bimanual: Bulky and sometimes tender ‘boggy’ uterus (enlarged, soft, and tender uterus / more flaccid than expected)
  • USS: Haemorrhage-filled, distended endometrial glands, may show an irregular nodular development (similar to fibroids)
  • MRI pelvis: GOLD STANDARD - thickening of junctional zone exceeding 12 mm
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5
Q

What is the management of adenomyosis?

A

Adenomyosis often goes away after menopause, so treatment might depend on how close you are to that stage of life.

  • 1st line = LNG-IUS ± NSAIDs
  • Hysterectomy is the only definitive treatment

If amenorrhoea induced, ectopic endometrium becomes quiescent

+DUB/fibroids management pathway

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6
Q

What are the causes of primary amenorrhoea?

A
  • Turner’s syndrome
  • Androgen insensitivity (testicular feminisation)
  • Congenital adrenal hyperplasia
  • Congenital malformations of the genital tract
  • Imperforate hymen
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7
Q

What are the causes of secondary amenorrhoea?

A
  • Hypothalamic amenorrhoea (e.g. secondary to stress, excessive exercise, anorexia)
  • Polycystic ovarian syndrome (PCOS)
  • Hyperprolactinaemia
  • Premature ovarian failure
  • Thyrotoxicosis (hypothyroidism)
  • Sheehan’s syndrome
  • Asherman’s syndrome (intrauterine adhesions)
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8
Q

What is an imperforate hymen?

A

A condition in which the hymen covers the entire opening of the vagina, blocking the vaginal opening

  • All other sexual characteristics developed, but has amenorrhoea and cyclical pelvic pain
  • USS will show haematometra (a collection or retention of blood in the uterus)
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9
Q

What are the investigations for amenorrhoea?

A
  • Serum/urine b-HCG (exclude pregnancy)
  • Bloods: FBC, U&Es, TFTs, coeliac screen
  • Gonadotrophins: Low levels indicate hypothalamic cause, raised levels indicate ovarian problem (e.g. POI) or gonadal dysgenesis (e.g. Turner’s syndrome)
  • Prolactin (prolactinoma)
  • Androgens (raised in PCOS)
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10
Q

What is Asherman’s syndrome?

A

Presence of intrauterine adhesions that may partially or completely occlude the uterine cavity.

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11
Q

What is the aetiology of Asherman’s syndrome?

A
  • Damage to endometrium involving the basal layer, owing to factors such as trauma (from instrumentation, surgery, dilatation and curettage) or infection
  • Leads to fibrosis and adhesion formation
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12
Q

What are RFs for Asherman’s syndrome?

A
  • Endometrial resection
  • Excessive curettage (e.g. following miscarriage, termination)
  • Surgery (myomectomy, C-section)
  • Endometriosis
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13
Q

What are the S/S of Asherman’s syndrome?

A
  • Amenorrhoea
  • Cyclical abdominal pain
  • Subfertility
  • Often no external physical signs
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14
Q

What are the investigations for Asherman’s syndrome?

A
  • sHCG
  • Bloods: TFTs, FSH, LH, prolactin, oestradiol - normal
  • Hysterosalpingogram - irregular, scattered contour of contrast within endometrial cavity
  • Pelvis USS
  • Hysteroscopy - gold standard diagnostic
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15
Q

What is the management of Asherman’s syndrome?

A

Hysteroscopic adhesiolysis

Post procedure:

  • Copper IUCD placed in cavity to prevent adhesions forming
  • PO oestrogens (induce endometrial proliferation)
  • Reassess cavity after 2-3 months after treatment
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16
Q

What is atrophic vaginitis?

A

Vaginal irritation caused by thinning of the vaginal epithelium.

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17
Q

What is the aetiology of atrophic vaginitis?

A
  • Caused by a reduction in circulating oestrogen levels
  • Leads to loss of glycogen in epithelial cells and increases vaginal pH
18
Q

What are RFs for atrophic vaginitis?

A
  • Menopause
  • Prolonged lactation
19
Q

What are the S/S of atrophic vaginitis?

A
  • Vaginal irritation
  • Dyspareunia
  • Superficial dysuria
  • Discharge – may be bloody
  • O/E: pale, thin vaginal walls with loss of rugal folds, cracks or fissures
20
Q

What are the investigations for atrophic vaginitis?

A

Clinical diagnosis

  • Swabs may be taken for superimposed infection.
  • Any suspicious lesions warrant exclusion of malignancy.
  • Presentation with bleeding may necessitate investigation as per PMB
21
Q

What is the management of atrophic vaginits?

A
  • Systemic HRT (systemic progesterone + PV oestrogen)
  • Bleeding on intercourse > water-based moisturisers and lubricants
22
Q

What are the complications of atrophic vaginitis?

A
  • Increased incidence of superinfection due to increase vaginal PH
  • Prognosis – substantial relief can be achieved with treatment
23
Q

What are the investigations for a vaginal infection?

A

Always do speculum before bimanual (lubrication in bimanual ruins speculum swabs)

1. pH:

  • Lateral wall of vagina (avoid cervix) > normal pH 3.5-4.5 (due to lactobacilli in vagina)
  • Low pH = candida (or normal)
  • Raised pH = contamination (blood, semen, lubrication), BV, TV

2. Swabs: 1st endocervical; 2nd high vaginal…

Double swabs:

  • Endocervical (or VVS) NAAT swab - gonorrhoea, chlamydia
  • High vaginal charcoal swab - (fungal and bacterial) BV, TV, candida, GBS

Triple swabs:

  • Endocervical NAAT (or VVS) swab - chlamydia/gonorrhoea
  • Endocervical charcoal swab - gonorrhoea
  • High vaginal charcoal swab - fungal and bacterial (BV, TV, candida, GBS)

3. Bloods:

  • HIV, syphilis
24
Q

What are the RFs for BV?

A
  • Smoking
  • Vaginal Douching
  • Bubble Bathing
  • Sexual activity (sexually associated, not sexually transmitted)
  • New sexual partner
  • Other STIs
  • Copper IUD
  • Vaginal pH increase
25
Q

What are protective factors for BV?

A
  • Condoms
  • Circumcised partner
  • COCP
26
Q

What is the pathophysiology of BV?

A
  • Overgrowth of anaerobic bacteria (Gardnerella vaginalis, Prevotella spp., Mycoplasma hominis, Mobiluncus spp.)
  • Loss of lactobacilli > increased pH > increased likelihood of BV
  • Gardnerella commonly found but commensal in 30-40% women
27
Q

What are the investigations for BV?

A

Diagnosis = clinical + microscopy > offensive, fishy-smelling discharge (no soreness or irritation), high pH

  • HVS – microscopy (clue cells– vaginal epithelium cells coated with lots of bacilli)
  • Hay-Ison criteria or Amsel’s criteria
28
Q

What is Amsel’s criteria?

A

3 out of 4 of…

  • Thin, white, homogenous discharge
  • Clue cells on microscopy
  • Vaginal pH >4.5 (only BV and TV)
  • Fishy odour on adding 10% KOH
29
Q

What is Hay-Ison criteria?

A

applied to gram stain

Grade 3 = BV

30
Q

What is the management of BV?

A

Does not need to be treated if asymptomatic

  • 1st line – metronidazole, PO, 400mg BD, 7 days
  • 2nd line – intravaginal clindamycin PV cream, 5g 2%, 7 days
  • Avoid vaginal douching, shower gel, use of shampoo in bath
31
Q

What are the complications of BV?

A
  • Associated with late miscarriage, preterm birth, PROM and postpartum endometritis
  • Increases risk of acquiring and transmitting STI
32
Q

What is TV?

A

Trichomonas vaginalis (Flagellated protozoan)

  • More common in developing countries
  • Sexually transmitted
33
Q

What are the S/S of TV?

A

Asymptomatic in 50%

Symptomatic:

  • Green/yellow “frothy” vaginal discharge
  • Vulval itch or vaginal soreness
  • Offensive odour
  • Lower abdominal pain and dysuria
  • Dyspareunia
  • O/E = strawberry cervix
34
Q

What are the investigations for TV?

A
  • High vaginal swab > direct microscopy (wet mount of vaginal fluid shows flagellated organism in the middle)
  • Endocervical swabs for other STIs
  • pH >4.5
  • Whiff test
  • Culture and gram stain
  • HIV test, NAAT, VDRL
35
Q

What is the management for TV?

A
  • 1st line = Metronidazole, 400mg BD, PO, 7 days
  • 2nd line = Metronidazole, 2g, PO STAT
  • Contact tracing and treatment of partners in last 4 weeks
  • Abstinence for 7 days
  • Follow-up to check resolution of symptoms
36
Q

What are the complications of TV?

A
  • Pregnancy = PTL, LBW, PPROM
  • Enhance HIV/STI transmission
37
Q

What is candidiasis?

A

Causative organism = Candida albicans (90%) or Candida glabrata (5%)

  • Can be spontaneous or secondary to disruption of normal vaginal flora (2nd most common infection after BV)
  • Classification = Oral (local invasion of oral tissue) or Invasive (systemic invasion of sterile sites)
38
Q

What are the RFs for candidiasis?

A
  • Oestrogen exposure (more common in pregnancy, reproductive years)
  • Immunocompromise (HIV)
  • Diabetes (poorly controlled)
  • Recent ABx (i.e. for a UTI)
  • Intercourse
39
Q

What are the S/S of candidiasis?

A

vulva itching, soreness, irritation, ‘cottage-cheese’-type discharge

40
Q

What are the investigations for candidiasis?

A

No investigations usually required

  • pH low/normal (<4.5) > if high, consider BV or TV
  • Diagnostic = HVS – microscopy, culture and gram stain (speckled gram +ve spores, pseudohyphae)
  • Other = MSU (UTIs), HbA1c (diabetes)

N.B. pseudohyphae ONLY in C. albicans

41
Q

What is the management of candidiasis?

A
  • 1st line – fluconazole (150mg, PO, STAT) - repeat after 72hrs if severe
  • 2nd line (if oral contraindicated) – clotrimazole pessary (500mg, PV, STAT) + 1% clotrimazole cream (BD, topical)
  • If pregnant, only use topical treatment

General advice:

  • Avoid tight fitting synthetic clothing
  • Avoid local irritants (perfume)
  • Do not wash female area with soap/shower gels (or wash >1 day)
  • Do not douche
  • Use simple emollients to moisturise

Recurrent:

  • ≥4 proven symptomatic episodes
  • Check adherence, recheck initial diagnosis
  • Tx with induction and maintenance fluconazole
42
Q

What are the complications of candidiasis?

A
  • Hepatotoxicity associated with systemic azole antifungal therapy – monitor LFT
  • Oesophageal candidiasis or disseminated candidiasis in immunocompromised

O&G (17 decks)

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