Gynae 1 Flashcards
What is endometriosis?
Where does it most commonly affect?
What is adenomyosis?
Growth of endometrial tissue outside the uterine cavity. Chronic, oestrogen dependent condition.
Uterosacral ligaments, pouch of Douglas, rectosigmoid colon, bladder, distal ureter.
Adenomyosis is invasion of endometrial tissue into the myometrium
What are the risk factors for endometriosis?
early menarche/late menopause
short menstrual cycles
obstruction to vaginal outflow
family history
what are the clinical features of endometriosis?
chronic cyclical pelvic pain deep dyspareunia subfertility dysuria/urgency/haematuria dyschezia
posterior fornix/adnexal tenderness
palpable nodules/adnexal masses
chocolate cysts on ovaries
bluish haemorrhagic nodules in posterior fornix
what are the investigations for endometriosis?
laparoscopy: gold standard
TVS routine
MRI (pelvis) for deep endometriomas
urinalysis, chlamydia screen, bhCG
what is the management for endometriosis?
suppression of ovarian function (COCP, GnRH agonists, IUS)
surgical: uterine artery embolisation, excision/ablation, hysterectomy
pharmacological: NSAIDs/COCP/danazol/GnRH agonists (goserelin)
to improve fertility: endometrial lesion ablation/IVF
what cancer does endometriosis predispose to?
ovarian cancer
and increased risk of IBS
what is the pathophysiology of PCOS?
increased LH leads to increased androgen production from ovarian thecal cells
androgens»_space;» oestrogens.
due to the persistently high LH levels, there is no LH surge either = no ovulation.
what are the symptoms and signs of PCOS?
oligomenorrhoea (but when periods occur they are extremely heavy), subfertility, acne, hirsutism, alopecia, obesity, sleep apnoea
what is the Rotterdam criteria for PCOS?
'SHOP' String of pearls Hyperandrogenism Oligomenorrhoea Prolactin normal
what are the investigations for PCOS?
total testosterone: normal or raised
sex hormone binding globulin: normal or low
LH: may be elevated
USS
OGTT
prolactin, T4, TSH (to exclude prolactinoma/hypothyroidism)
for women wishing to conceive, what is the management of PCOS?
for women not planning pregnancy, what is the treatment?
what is the general management of PCOS?
1) clomifene citrate, metformin, ovarian drilling
2) COCP/IUS, co-cyprindol, orlistat
3) weight loss, screen for CVD risk factors, annual OGTT
what is the treatment of PCOS induced acne?
benzoyl peroxide
Yasmin/Dianette (increased risk of VTE)
what is the definition of, and causes of postmenopausal bleeding?
what are the investigations?
vaginal bleeding occurring after 12m of amenorrhoea
causes: vaginal atrophy, endometrial cancer (can be caused by tamoxifen), vulval cancer, vaginal cancer, cervical cancer, HRT use
investigations = TVS (5mm cut off), endometrial biopsy, hysteroscopy and biopsy
what are the symptoms of menopause?
what is early menopause?
what is the normal age of menopause?
hot flushes vaginal discomfort/dryness incontinence mood changes sleep disturbance
early: 40-45 years of age
average age = 51 years
what are the CI to HRT?
current/past breast cancer
any oestrogen sensitive cancer
undiagnosed vaginal bleeding
untreated endometrial hyperplasia
what are the indications of HRT?
women <60 at risk of osteoporotic fractures
treatment of menopausal symptoms where the risk:benefit ratio is favourable
women with early menopause (continued until they reach 51)
what are the benefits and risks of HRT?
benefits: decreased osteoporosis risk, decreased CVD risk, increased quality of life, increased mood
risks: PO increases VTE risk, oestrogen only increases endometrial cancer risk
erratic bleeding can be common in first 3-6m after starting
when should women be prescribed sequential combined HRT?
if their last period was LESS THAN 1 year ago and it is indicated
when can women be prescribed continuous combined HRT?
if;
they have received sequential combined HRT >1yr
>1yr since last period
>2yrs since last period if their menopause was premature
what are the side effects of HRT?
erratic bleeding in first 3-6m
oestrogen: breast tenderness, leg cramps, bloating, nausea
progestogen: premenstrual like symptoms
initial follow up after 3m
outline the features, risk factors, investigations and prognosis of vulval cancer?
features: 85% are squamous, labium majorum is the most common site, highest incidence in elderly
risk factors: VIN, lichen sclerosus, HPV, paget’s disease
investigations: biopsy, examination
prognosis: very good
outline the cervical screening programme and how smears are taken
ages 25-64
24-49: smear every 3 years
50-64: smear every 5 years
smears are taken from the transformation zone
if HPV is found (16 and 18), a woman should be sent for colposcopy
outline the interpretation and subsequent management of cervical smear results?
borderline/mild dyskaryosis: original sample tested for HPV. negative= routine recall. positive = colposcopy
moderate dyskaryosis = CIN II. refer for urgent colposcopy.
severe dyskaryosis = CIN III. refer for urgent colposcopy
suspected invasive cancer = refer for urgent colposcopy
inadequate = repeat smear. 3 times? = colposcopy
those who have had CIN or neoplasia and been treated = invited back after 6m for ‘test of cure’
what are the features, risk factors and investigations for cervical cancer?
features: vaginal bleeding, discharge, vaginal discomfort, urinary symptoms
risk factors: heterosexual, many partners, low socio economic class, smoking, HPV 16&18
80% are squamous cell cancers
investigations: chlamydia test, colposcopy, cone biopsy, CT scan, PET scan, pelvic MRI
what are the grades of CIN?
CIN I: confined to lower third of epithelium
CIN II: confined to lower and middle thirds of epithelium
CIN III: affects full thickness of epidermis
