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Gynae Flashcards

1
Q

Polycystic Ovarian Syndrome

definition of anovulation

A

absence of ovulation

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2
Q

Polycystic Ovarian Syndrome

definition of oligoovulation

A

irregular, infrequent ovulation

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3
Q

Polycystic Ovarian Syndrome

definition of ammenorrhoea

A

absence of menstrual periods

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4
Q

Polycystic Ovarian Syndrome

definition of androgens

A

male sex hormones such as testosterone

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5
Q

Polycystic Ovarian Syndrome

definition of hyperandrogenism

A

effects of high levels of androgens

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6
Q

hirsutism

A

the growth of thick dark hair

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7
Q

Polycystic Ovarian Syndrome

definition of insulin resistance

A

lack of response to insulin, resulting in high blood sugar levels

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8
Q

Polycystic Ovarian Syndrome

what criteria is used to make a diagnosis

A

the Rotterdam Criteria

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9
Q

Polycystic Ovarian Syndrome

diagnosis (rotterdam criteria)

A

2/3 of:

  • oligoovulation or anovulation: irregular or absent
  • hyperandrogenism: hirsutism + acne
  • polycystic ovaries on US (or ovarian volume of >10cm3)
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10
Q

Polycystic Ovarian Syndrome

presentation

A
  • Oligomenorrhoea or amenorrhoea
  • Infertility
  • Obesity (in about 70% of patients with PCOS)
  • Hirsutism
  • Acne
  • Hair loss in a male pattern
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11
Q

Polycystic Ovarian Syndrome

other features and complications

A
  • Insulin resistance and diabetes
  • Acanthosis nigricans
  • CVD
  • Hypercholesterolaemia
  • Endometrial hyperplasia and cancer
  • Obstructive sleep apnoea
  • Depression and anxiety
  • Sexual problems
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12
Q

Polycystic Ovarian Syndrome

what is Acanthosis nigricans

A

thickened, rough skin typically found in the axilla and on the elbows

It has a velvety texture

occurs with insulin resistance

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13
Q

Ddx of hirsutism

A
  • medications
  • ovarian or adrenal tumours that secrete androgens
  • cushing’s syndrome
  • congenital adrenal hyperplasia
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14
Q

Polycystic Ovarian Syndrome

why does insulin resistance result in higher levels of androgens

A

When someone is resistant to insulin, their pancreas has to produce more insulin

Insulin promotes the release of androgens from the ovaries and adrenal glands.

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15
Q

Polycystic Ovarian Syndrome

what does sex hormone-binding globulin (SHBG) do

A

binds to androgens and suppresses their function

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16
Q

Polycystic Ovarian Syndrome

what does insulin do to sex hormone-binding globulin (SHBG)

A

suppresses it

which promotes hyperandrogenism

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17
Q

Polycystic Ovarian Syndrome

why is there anovulation and multiple partially developed follicles

A

The high insulin levels contribute to halting the development of the follicles in the ovaries

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18
Q

Polycystic Ovarian Syndrome

what can help reduce insulin resistance

A

diet, exercise and weight

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19
Q

Polycystic Ovarian Syndrome

which blood tests to diagnose PCOS and exclude other pathology

A
  • Testosterone
  • Sex hormone-binding globulin
  • LH
  • FSH
  • Prolactin (may be mildly elevated in PCOS)
  • TSH
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20
Q

Polycystic Ovarian Syndrome

what will hormonal blood tests show

A
      • raised LH
  • raised LH to FSH ratio **
  • raised testosterone
  • raised insulin
  • normal or raised oestrogen levels
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21
Q

Polycystic Ovarian Syndrome

what is the gold standard for visualising the ovaries

A

transvaginal US

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22
Q

Polycystic Ovarian Syndrome

US: what does it mean by string of pearls

A

The follicles may be arranged around the periphery of the ovary

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23
Q

Polycystic Ovarian Syndrome

diagnostic criteria on US

A

either:
- 12 or more developing follicles in one ovary

  • Ovarian volume of more than 10cm3
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24
Q

Polycystic Ovarian Syndrome

what is the screening test of choice for diabetes in pts with PCOS

A

2-hour 75g oral glucose tolerance test (OGTT)

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25
Q

Polycystic Ovarian Syndrome

general mnx to reduce risks associated with obesity, T2DM, hypercholesterolaemia, CVD

A
  • WEIGHT LOSS
  • Low glycaemic index, calorie-controlled diet
  • Exercise
  • Smoking cessation
  • Antihypertensive medications where required
  • Statins where indicated (QRISK >10%)
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26
Q

Polycystic Ovarian Syndrome

what may be used to help weight loss in women with a BMI>30

A

orlistat

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27
Q

Polycystic Ovarian Syndrome

what is orlistat

A

a lipase inhibitor that stops the absorption of fat in the intestines

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28
Q

Polycystic Ovarian Syndrome

why is there a risk of endometrial cancer

A

women have many of the RFs:

  • obesity
  • diabetes
  • insulin resistance
  • amenorrhoea

+ ENDOMETRIAL HYPERPLASIA

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29
Q

Polycystic Ovarian Syndrome

why is there endometrial hyperplasia

A

do not produce sufficient progesterone (infrequent ovulation so corpus luteum doesn’t produce it)

continued oestrogen production

endometrial lining continues to proliferate without regular shedding during menstruation

similar to giving unopposed oestrogen

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30
Q

Polycystic Ovarian Syndrome

inx if >3m between periods or abnormal bleeding

A

pelvic ultrasound to assess the endometrial thickness

Cyclical progestogens should be used to induce a period prior to the ultrasound scan.

If endometrial thickness > 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.

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31
Q

Polycystic Ovarian Syndrome

Options for reducing the risk of endometrial hyperplasia and endometrial cancer

A
  • Mirena coil: continuous endometrial protection
- Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)

COCP

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32
Q

Polycystic Ovarian Syndrome

what is the initial step for improving fertility

A

weight loss

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33
Q

Polycystic Ovarian Syndrome

Infertility: options where weight loss fails

A
  • Clomifene
  • Laparoscopic ovarian drilling
  • IVF
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34
Q

Polycystic Ovarian Syndrome

Infertility: what is ovarian drilling

A

laparoscopic surgery

punctures multiple holes in the ovaries using diathermy or laser therapy

can improve the woman’s hormonal profile and result in regular ovulation and fertility

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35
Q

Polycystic Ovarian Syndrome

mnx of hirsutism

A
  • Co-cyprindiol (Dianette): licenced for hirsutism + acne

- Topical eflornithine

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36
Q

Polycystic Ovarian Syndrome

hisutism: disadvantage of Co-cyprindiol (Dianette)

A

significantly increased risk of VTE

usually stopped after three months of use.

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37
Q

Polycystic Ovarian Syndrome

1st line for acne in PCOS

A

COCP

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38
Q

Asherman’s Syndrome

what is it

A

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.

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39
Q

Asherman’s Syndrome

when does it usually occur after

A

after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth)

after uterine surgery

after several pelvic infection

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40
Q

Asherman’s Syndrome

how does Endometrial curettage (scraping) cause it

A

it can damage the basal layer of the endometrium

heals abnormally, creating adhesions

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41
Q

Asherman’s Syndrome

presentation

A

after recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea (absent periods)

  • Significantly lighter periods
  • Dysmenorrhoea (painful periods)
  • It may also present with infertility.
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42
Q

Asherman’s Syndrome

gold standard inx

A

Hysteroscopy

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43
Q

Asherman’s Syndrome

other inx for diagnosis other than hysteroscopy

A
  • Hysterosalpingography: contrast is injected into the uterus and imaged with xrays
  • Sonohysterography: uterus is filled with fluid and a pelvic ultrasound is performed
  • MRI scan
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44
Q

Asherman’s Syndrome

mnx

A

dissecting the adhesions during hysteroscopy.

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45
Q

Hormone Replacement Therapy

why do women experience sx peri/postmenopausal

A

decline in oestrogen levels

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46
Q

Hormone Replacement Therapy

why does progesterone need to be given in addition to oestrogen to women with a uterus

A

to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.

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47
Q

Hormone Replacement Therapy

choosing the HRT: woman without a uterus

A

oestrogen-only HRT

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48
Q

Hormone Replacement Therapy

choosing the HRT: Women that still have periods

A

cyclical HRT

and regular breakthrough bleeds

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49
Q

Hormone Replacement Therapy

choosing the HRT: Postmenopausal women with a uterus and >1y without periods

A

continuous combined HRT

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50
Q

Non-Hormonal Treatments for Menopausal Symptoms

A
  • lifestyle changes
  • CBT
  • Clonidine
  • SSRIs
  • Venlafaxine (SNRI)
  • Gabapentin
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51
Q

menopausal sx: which sx is clonidine useful in

A

vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT

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52
Q

menopausal sx: how does clonidine act

A

act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain.

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53
Q

menopausal sx: what does clonidine do

A

lowers BP and reduced HR and also an antihypertensive

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54
Q

menopausal sx: common SEs of clonidine

A
  • dry mouth
  • headaches
  • dizziness
  • fatigue
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55
Q

menopausal sx:

what can sudden withdrawal of clonidine result in

A

rapid increases in BP and agitation

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56
Q

alternative remedies intended to manage vasomotor sx such as hot flushes

A
  • Black cohosh
  • Dong quai
  • Red Clover
  • Evening primrose oil
  • Ginseng
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57
Q

what is evening primrose oil linked with

A
  • significant drug interactions
  • clotting disorders
  • seizures
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58
Q

Hormone Replacement Therapy

indications for HRT (4)

A
  • Replacing hormones in premature ovarian insufficiency, even without symptoms
  • Reducing vasomotor symptoms such as hot flushes and night sweats
  • Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
  • Reducing risk of osteoporosis in women under 60 years
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59
Q

Hormone Replacement Therapy

benefits

A
  • Improved vasomotor and other symptoms of menopause
  • Improved QoL
  • Reduced risk of osteoporosis and fractures
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60
Q

Hormone Replacement Therapy

risks (5)

A
  • breast cancer
  • endometrial cancer
  • VTE
  • stroke + coronary artery disease
  • ovarian cancer (minimal)
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61
Q

Hormone Replacement Therapy

benefits of oestrogen-only HRT (only given to women without a uterus)

A
  • lower risk of breast cancer

- no increased risk of coronary artery disease

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62
Q

Hormone Replacement Therapy

way to reduce risk of VTE

A

using patches rather than pills

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63
Q

Hormone Replacement Therapy

CIs to consider in pts wanting to start

A
  • Undiagnosed abnormal bleeding
  • Endometrial hyperplasia or cancer
  • Breast cancer
  • Uncontrolled hypertension
  • VTE
  • Liver disease
  • Active angina or MI
  • Pregnancy
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64
Q

Hormone Replacement Therapy

assessment before initiating HRT

A
  • check no CIs
  • FH: breast/endometrial cancer and VTE
  • BMI + BP
  • cervical + breast screening up to date
  • encourage lifestyle changes
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65
Q

Choosing HRT

Step 1: local or systemic sx

A

local: topical oestrogen cream
systemic: go to step 2

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66
Q

Choosing HRT

Step 2: does woman have uterus

A

no uterus: continuous oestrogen-only HRT

uterus: combined HRT and got to step 3

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67
Q

Choosing HRT

Step 3: Have they had a period in the past 12 months?

A

Yes (perimenopausal): cyclical combined HRT

No (postmenopausal): continuous combined HRT

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68
Q

Hormonal Replacement Therapy

when is the transdermal route (patches or gel) more suitable than tablets

A
  • women with poor control on oral treatment
  • higher risk of VTE
  • CVD and headaches.
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69
Q

Hormonal Replacement Therapy

when is continuous progesterone used

A

when the woman has not had a period in the past:

  • 24 months if under 50 years
  • 12 months if over 50 years
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70
Q

Hormonal Replacement Therapy

whare are the options for delivering progesterone for endometrial protection

A
  • Oral (tablets)
  • Transdermal (patches)
  • Intrauterine system (e.g. Mirena coil)
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71
Q

Types of Progesterone

what are progestogens

A

any chemicals that target and stimulate progesterone receptors

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72
Q

Types of Progesterone

what is progesterone

A

the hormone produced naturally in the body

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73
Q

Types of Progesterone

what is progestins

A

synthetic progestogens

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74
Q

Types of Progesterone

what are the 2 significant progestogen classes used in HRT

A
  • C19 progestogens
  • C21 progestogens

(refers to number of carbon atoms in the molecule)

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75
Q

Types of Progesterone

what are C19 progestogens

A

derived from testosterone: more ‘male’ in their effects

helpful if reduced libido

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76
Q

Types of Progesterone

what are C21 progestogens

A

derived from progesterone, and are more “female” in their effects

helpful if depressed mood or acne

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77
Q

Types of Progesterone

examples of C19 progestogens

A
  • norethisterone
  • levonorgestrel
  • desogestrel
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78
Q

Types of Progesterone

examples of C21 progestogens

A
  • dydrogesterone

- medroxyprogesterone

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79
Q

Hormone Replacement Therapy

why is the Mirena coil the best way of providing progesterone

A

added benefits of contraception and treating heavy menstrual periods

won’t experience progestogenic side effects

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80
Q

Hormone Replacement Therapy

what is Tibolone

A
  • used as a form of continuous combined HRT
  • a synthetic steroid
  • stimulates oestrogen, progesterone and androgen receptors.
  • can be helpful if reduced libido
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81
Q

Hormone Replacement Therapy

when do you follow up after initiating HRT

A

3months

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82
Q

Hormone Replacement Therapy

how long does it take to gain full effects

A

3-6m so it is worth persisting or at least 3m with each regime

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83
Q

Hormone Replacement Therapy

what is an indication for referral to a specialist

A

problematic or irregular bleeding

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84
Q

Hormone Replacement Therapy

when should you stop oestrogen-containing contraceptives or HRT before major surgery

A

4w

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85
Q

Hormone Replacement Therapy

does HRT act as contraception

A

no, use mirena or POP (in addition to HRT)

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86
Q

Hormone Replacement Therapy

oestrogenic SEs

A
  • Nausea + bloating
  • breast swelling
  • breast tenderness
  • headaches
  • leg cramps
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87
Q

Hormone Replacement Therapy

Progestogenic SEs

A
  • Mood swings
  • Bloating
  • Fluid retention
  • Weight gain
  • Acne and greasy skin
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88
Q

Androgen Insensitivity Syndrome

how is it passed on genetically

A

X-linked recessive genetic condition

caused by a mutation in the androgen receptor gene on the X chromosome

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89
Q

Androgen Insensitivity Syndrome

what is it

A

cells are unable to respond to androgen hormones due to a lack of androgen receptors

Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics

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90
Q

Androgen Insensitivity Syndrome

are patients genetically male or female

A

genetically male, with XY sex chromosome

but female phenotype externally.

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91
Q

Androgen Insensitivity Syndrome

why does the uterus, upper vagina, cervix, fallopian tubes and ovaries not develop

A

the testes (in the abdomen or inguinal canal) produce anti-Müllerian hormone

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92
Q

Androgen Insensitivity Syndrome

are patients fertile

A

no

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93
Q

Androgen Insensitivity Syndrome

how would partial androgen insensitivity syndrome present as

A

micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.

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94
Q

Androgen Insensitivity Syndrome

how does it often present in infancy

A

inguinal hernias containing testes

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95
Q

Androgen Insensitivity Syndrome

how does it often present in puberty

A

primary amenorrhoea

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96
Q

Androgen Insensitivity Syndrome

hormone test results:

  • LH
  • FSH
  • testosterone
  • oestrogen
A
  • LH: raised
  • FSH: normal or raised
  • testosterone: normal or raised (for a man)
  • oestrogen: raised (for a man)
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97
Q

Androgen Insensitivity Syndrome

medical and surgical input

A

Bilateral orchidectomy: avoid testicular cancer

oestrogen therapy

vaginal dilators or vaginal surgery: create adequate vaginal length

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98
Q

Androgen Insensitivity Syndrome

general mnx

A
  • raised as female, but this is sensitive and tailored to the individual
  • counselling to promote their psychological, social and sexual wellbeing.
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99
Q

Lichen Sclerosis

what is it

A

a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin.

autoimmune

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100
Q

Lichen Sclerosis

where does it effect women

A

labia, perineum and perianal skin

can affect axilla, thighs

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101
Q

Lichen Sclerosis

dx

A

usually clinically

if in doubt, a vulval biopsy can confirm dx

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102
Q

what does lichen refer to

A

a flat eruption that spreads

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103
Q

what is lichen simplex

A

chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin.

presents with excoriations, plaques, scaling and thickened skin

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104
Q

what is lichen planus

A

an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

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105
Q

woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva.

what is it

A

Lichen Sclerosis

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106
Q

Lichen Sclerosis

sx

A
  • Itching
  • Soreness and pain possibly worse at night
  • Skin tightness
  • superficial dyspareunia
  • Erosions
  • Fissures
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107
Q

Lichen Sclerosis

what is Koebner phenomenon

A

when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus

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108
Q

Lichen Sclerosis

how can it be made worse

A

tight underwear that rubs the skin,

urinary incontinence

scratching.

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109
Q

Lichen Sclerosis

appearance of affected skin

A
  • “Porcelain-white” in colour
  • Shiny
  • Tight
  • Thin
  • Slightly raised
  • There may be papules or plaques
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110
Q

Lichen Sclerosis

how often is it followed up

A

every 3 – 6 months by an experienced gynaecologist or dermatologist.

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111
Q

Lichen Sclerosis

trx

A

Potent topical steroids: clobetasol propionate 0.05% (dermovate)

emollients

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112
Q

Lichen Sclerosis

directions of use of steroids

A
  • initially OD for 4w
  • gradually reduced to alternate days then twice weekly
  • flares: go back to topical steriods daily
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113
Q

Lichen Sclerosis

cancer complication

A

5% risk of developing squamous cell carcinoma of the vulva

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114
Q

Lichen Sclerosis

other complications

A
  • Pain and discomfort
  • Sexual dysfunction
  • Bleeding
  • Narrowing of the vaginal or urethral openings
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115
Q

Endometriosis

what is it

A

ectopic endometrial tissue outside the uterus.

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116
Q

Endometriosis

what are endometrioma

A

A lump of endometrial tissue outside the uterus

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117
Q

Endometriosis

what are chocolate cysts

A

Endometriomas in the ovaries

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118
Q

Endometriosis

aetiology theories

A
  • retrograde menstruation
  • Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus
  • lymphatic spread of endometrial cells
  • metaplasia (from typical cells of that organ into endometrial cells)
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119
Q

Endometriosis

why may there be blood in urine or stools

A

Deposits of endometriosis in the bladder or bowel

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120
Q

Endometriosis

usually presents with cyclical pain, when may it be non-cyclical

A

Localised bleeding and inflammation can lead to adhesions –> chronic, non-cyclical pain

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121
Q

Endometriosis

why may the woman have reduced fertility

A
  • adhesions around the ovaries and fallopian tubes

- Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.

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122
Q

Endometriosis

symptoms

A
  • cyclical abdo/pelvic pain
  • deep dyspareunia
  • dysmenorrhoea
  • infertility
  • cyclical bleeding from other sites (haematuria)
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123
Q

Endometriosis

what may examination reveal

A
  • endometrial tissue visible in the vagina on speculum
  • fixed cervix on bimanual exam
  • tenderness in vagina, cervix and adnexa
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124
Q

Endometriosis

what may pelvic US show

A

may reveal large endometriomas and chocolate cysts

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125
Q

Endometriosis

what is the gold standard inx for diagnosis

A

Laparoscopic surgery: get a biopsy from it

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126
Q

Endometriosis

hormonal mnx options (before establishing a definitive diagnosis with laparoscopy)

A
  • COCP back to back
  • POP
  • Medroxyprogesterone acetate injection (e.g. Depo-Provera)
  • Nexplanon implant
  • Mirena coil
  • GnRH agonists
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127
Q

Endometriosis

surgical mnx

A
  • Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
  • Hysterectomy
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128
Q

Endometriosis

what may improve fertiltiy

A

Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.

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129
Q

Endometriosis

why may cyclical pain be treated with hormonal medication

A

stop ovulation and reduce endometrial thickening

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130
Q

Endometriosis

why may GnRH agonists like goserelin (Zoladex) or leuprorelin (Prostap) help

A

induce a menopause-like state

shut down the ovaries temporarily and can be useful in treating pain

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131
Q

Heavy Menstrual Bleeding

aka

A

menorrhagia

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132
Q

Heavy Menstrual Bleeding

what is classed as excessive blood loss

A

> 80ml

changing pads every 1 – 2 hours

bleeding lasting >7d

passing large clots

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133
Q

Heavy Menstrual Bleeding

what is dysfunctional uterine bleeding

A

no identifiable cause of menorrhagia

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134
Q

Heavy Menstrual Bleeding

causes

A
  • Extremes of reproductive age
  • Fibroids
  • Endometriosis and adenomyosis
  • PID
  • Contraceptives: copper coil
  • Anticoagulants
  • Bleeding disorders (VWd)
  • Endocrine (DM, hypothyroidism)
  • Connective tissue disorders
  • Endometrial hyperplasia or cancer
  • PCOS
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135
Q

Heavy Menstrual Bleeding

initial inx

A
  • speculum and bimanual: fibroids, ascites, cancer

- FBC: anaemia

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136
Q

Heavy Menstrual Bleeding

when should outpatient hysteroscopy be performed

A

if there is:
- suspected submucosal fibroids

  • suspected endometrial pathology, e.g. hyperplasia or cancer
  • persistent intermenstrual bleeding
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137
Q

Heavy Menstrual Bleeding

when should pelvic and TVUS be arranged

A
  • Possible large fibroids (palpable pelvic mass)
  • Possible adenomyosis (associated pelvic pain or tenderness on examination)
  • Examination is difficult to interpret (e.g. obesity)
  • Hysteroscopy is declined
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138
Q

Heavy Menstrual Bleeding

mnx for woman who does not want contraception and there is no pain

A

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)

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139
Q

Heavy Menstrual Bleeding

mnx for woman who does not want contraception and there is pain

A

Mefenamic acid

(NSAID – reduces bleeding and pain)

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140
Q

Heavy Menstrual Bleeding

mnx when contraception is wanted

A
  1. mirena
  2. COCP
  3. cyclical PO progestogens
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141
Q

Heavy Menstrual Bleeding

when to refer to secondary care

A
  • trx unsuccessful
  • severe sx
  • fibroids >3cm
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142
Q

Heavy Menstrual Bleeding

what is the final option when medical mnx has failed

A

endometrial ablation and hysterectomy.

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143
Q

Atrophic Vaginitis

what is it

A

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

aka genitourinary syndrome of menopause

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144
Q

Atrophic Vaginitis

pathophysiology

A

menopause –> decrease in oestroegen –> mucosa becomes thinner, less elastic and more dry

tissue more prone to inflammation

change in vaginal pH and microbial flora can contribute to localised infections

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145
Q

Atrophic Vaginitis

what can a lack of oestrogen cause

A
  • Atrophic Vaginitis
  • pelvic organ prolapse
  • stress incontinence.
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146
Q

Atrophic Vaginitis

presentation

A

in postmenopausal women:

  • itchy
  • dry
  • dyspareunia
  • bleeding due to localised inflammation
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147
Q

postmenopausal women with recurrent UTIs, stress incontinence or pelvic organ prolapse. Which condition?

A

atrophic vaginitis

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148
Q

Atrophic Vaginitis

examination findings

A
  • Pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
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149
Q

Atrophic Vaginitis

mnx

A
  • vaginal lubricants (Sylk, Replens and YES)

- topical oestrogen: cream, pessary, tablet, ring

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150
Q

Atrophic Vaginitis

what are the contraindications to topical oestrogen

A

breast cancer, angina and venous thromboembolism

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151
Q

Fibroids

what are they

A

benign tumours of the smooth muscle of the uterus

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152
Q

Fibroids

aka

A

uterine leiomyomas

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153
Q

Fibroids

which ethnic group is it more common in

A

black women

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154
Q

Fibroids

are they oestrogen sensitive

A

yes, they grow in response to oestrogen

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155
Q

Fibroids

types

A
  • intramural
  • subserosal
  • submucosal
  • pedunculated
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156
Q

Fibroids

what does intramural mean

A

within the myometrium

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157
Q

Fibroids

what does subserosal mean

A

just below the outer layer of the uterus. These fibroids grow outwards and can become very large

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158
Q

Fibroids

what does submucosal mean

A

just below the lining of the uterus (the endometrium).

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159
Q

Fibroids

what does pedunculated mean

A

on a stalk

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160
Q

Fibroids

presentation

A
  • heavy menstrual bleeding
  • prolonged menstruation (>7d)
  • abdo pain, worse during menstruation
  • bloating/feeling dull in abdo
  • urinary/bowel sx
  • deep dyspareunia
  • reduced fertility
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161
Q

Fibroids

what will abdo and bimanual exam reveal

A

a palpable pelvic mass

or enlarged firm non-tender uterus

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162
Q

Fibroids

initial inx for submucosal fibroids presenting with heavy menstrual bleeding

A

hysteroscopy

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163
Q

Fibroids

inx of choice for larger fibroids

A

pelvic US

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164
Q

Fibroids

what inx may be considered before surgery where more info about the fibroid is needed

A

MRI scanning

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165
Q

Fibroids

medical mnx for fibroids <3cm

A

1st line: mirena

  • NSAIDs
  • tranexamic acid
  • COCP
  • cyclical PO progestogens
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166
Q

Fibroids

surgical mnx for fibroids <3cm with heavy menstrual bleeding

A
  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy
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167
Q

Fibroids

medical mnx for fibroids >3cm

A

refer to gynae

  • NSAIDs, tranexamic acid
  • mirena
  • COCP
  • cyclical PO progestogens
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168
Q

Fibroids

surgical mnx for fibroids >3cm

A
  • uterine artery embolisation
  • myomectomy
  • hysterectomy
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169
Q

Fibroids

what may be used to reduce the size before surgery

A

GnRH agonist e.g. goserelin (Zoladex) or leuprorelin (Prostap)

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170
Q

Fibroids

how do GnRH agonists work

A

inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid

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171
Q

Fibroids

what is a myomectomy

A

surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy

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172
Q

Fibroids

complications

A
  • red degeneration
  • torsion
  • leiomyosarcoma (malignant)
  • iron deficiency
  • reduced fertility
  • miscarriages, premature, obstructive delivery
  • constipation
  • urinary outflow obstruction + UTIs
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173
Q

Fibroids

what is red degeneration

A

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply

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174
Q

Fibroids

who is red degeneration more likely to occur in

A

occurs in fibroids >5cm during 2nd and 3rd trimester of pregnancy.

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175
Q

Fibroids

why does red degeneration occur

A

the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic

kinking in the blood vessels as the uterus changes shape and expands during pregnancy

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176
Q

Fibroids

presentation of red degeneration

A
  • severe abdo pain
  • low grade fever
  • tachycardia
  • vomiting
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177
Q

Fibroids

mnx of red degeneration

A

supportive: rest, fluids, analgesia

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178
Q

Primary Amenorrhoea

definition

A

not starting menstruation

  • by 13y + no signs of pubertal development
  • or by 15y + signs of puberty
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179
Q

Primary Amenorrhoea

when does puberty start in girls

A

8-14y

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180
Q

Primary Amenorrhoea

when does puberty start in boys

A

9-15y

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181
Q

Primary Amenorrhoea

progression of puberty in girls

A
  • breast buds
  • then pubic hair
  • then periods
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182
Q

Primary Amenorrhoea

a lack of oestrogen + testosterone can cause delay in puberty. what are the 2 reasons for this

A
  • Hypogonadotropic hypogonadism

- Hypergonadotropic hypogonadism

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183
Q

Primary Amenorrhoea

what is hypogonadotropic hypogonadism

A

deficiency of LH and FSH, leading to deficiency of oestrogen

184
Q

Primary Amenorrhoea

what could hypogonadotropic hypogonadism be due to

A
  • hypopituitarism
  • damage to hypothalamus or pituitary e.g. radiotherapy
  • chronic conditions: CF, IBD
  • excessive exercise or dieting
  • constitutional delay in growth + development
  • endocrine: GH deficiency, hypothyroidism, cushing’s, hyperprolactinaemia
  • Kallman’s syndrome
185
Q

Primary Amenorrhoea

what is hypergonadotropic hypogonadism

A

the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH)

186
Q

Primary Amenorrhoea

causes of hypergonadotropic hypogonadism

A
  • previous damage to gonads (torsion, cancer, mumps)
  • congenital absence ovaries
  • Turner’s syndrome (XO)
187
Q

Primary Amenorrhoea

what is Kallman Syndrome associated with

A

hypogonadotrophic hypogonadism, with failure to start puberty.

reduced or absent sense of smell (anosmia)

188
Q

Primary Amenorrhoea

what is androgen insensitivity syndrome

A

tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop.

It results in a female phenotype, other than the internal pelvic organs.

189
Q

Primary Amenorrhoea

structural pathology which can cause primary amenorrhoea

A
  • Imperforate hymen
  • Transverse vaginal septae
  • Vaginal agenesis
  • Absent uterus
  • Female genital mutilation
190
Q

Primary Amenorrhoea

what is the threshold for initiating inx

A

no evidence of pubertal changes in a girl aged 13

can also be considered when there is some evidence of puberty but no progression after 2y

191
Q

Primary Amenorrhoea

initial inx (assess for underlying medical conditions)

A
  • FBC + ferritin for anaemia
  • U&E for CKD
  • Anti-TTG or anti-EMA antibodies for coeliac
192
Q

Primary Amenorrhoea

what hormonal blood tests would you order

A
  • FSH + LH
  • TFTs
  • insulin-like growth factor I (screening test for GH deficiency)
  • prolactin
  • testosterone
193
Q

Primary Amenorrhoea

what genetic testing would you do

A

microarray test for Turner’s (X0)

194
Q

Primary Amenorrhoea

what imaging would you do

A
  • xray wrist: constitutional delay
  • pelvic US
  • MRI brain
195
Q

Primary Amenorrhoea

mnx

A

treat the underlying cause

196
Q

Primary Amenorrhoea

mnx of hypogonadotrophic hypogonadism such as hypopituitarism or Kallman syndrome

A

pulsatile GnRH can be used to induce ovulation and menstruation.

pregnancy not wanted? COCP

197
Q

Secondary Amenorrhoea

definition

A

no menstruation for >3m after previous regular menstrual periods

198
Q

Secondary Amenorrhoea

when to consider assessment + inx

A

after 3-6m

In women with previously infrequent irregular period: after 6-12m

199
Q

Secondary Amenorrhoea

what is the most common cause

200
Q

Secondary Amenorrhoea

causes

A
  • pregnancy
  • menopause + premature ovarian failure
  • hormonal contraception
  • Hypothalamic or pituitary pathology
  • Ovarian causes: PCOS
  • Uterine pathology: Asherman’s syndrome
  • Thyroid pathology
  • Hyperprolactinaemia
201
Q

Secondary Amenorrhoea

hypothalamus causes

A

hypothalamus reduces the production of GnRH in response to significant stress

  • Excessive exercise (e.g. athletes)
  • Low body weight and eating disorders
  • Chronic disease
  • Psychological stress
202
Q

Secondary Amenorrhoea

pituitary causes

A
  • pituitary tumours: prolactin secreting prolactinoma

- pituitary failure: trauma, radio, surgery, Sheehan

203
Q

Secondary Amenorrhoea

why does hyperprolactinaemia cause amenorrhoea

A

High prolactin levels act on the hypothalamus to prevent the release of GnRH –> no release of LH + FSH

204
Q

Secondary Amenorrhoea

trx of hyperprolactinaemia

A

Dopamine agonists such as bromocriptine or cabergoline

205
Q

Secondary Amenorrhoea

assessment

A
  • hx + examination
  • hormonal blood tests
  • US: PCOS
206
Q

Secondary Amenorrhoea

what hormone tests would you do

A
  • bHCG: pregnancy
  • high FSH: primary ovarian failure
  • high LH: PCOS
  • prolactin then MRI
  • TFTs
  • high testosterone: PCOS, AIS, CAH
207
Q

Secondary Amenorrhoea

why do women with PCOS need a withdrawal bleed every 3-4m

A

to reduce the risk of endometrial hyperplasia and endometrial cancer.

208
Q

Secondary Amenorrhoea

what can be used to stimulate a withdrawal bleed in PCOS

A

Medroxyprogesterone for 14d, or regular use of the COCP

209
Q

Secondary Amenorrhoea

what are pts with amenorrhoea at increased risk of

A

osteoporosis

210
Q

Secondary Amenorrhoea

when to start trx to reduce the risk of osteoporosis

A

when amenorrhoea lasts more than 12 months

211
Q

Secondary Amenorrhoea

what trx is used to reduce the risk of osteoporosis

A
  • ensure adequate vit D and Ca intake

- HRT or COCP

212
Q

Premenstrual Syndrome

what is it

A

the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

213
Q

Premenstrual Syndrome

symptoms are not present when?

A
  • before menarche
  • during pregnancy
  • after menopause
214
Q

Premenstrual Syndrome

cause

A

fluctuation in oestrogen and progesterone hormones during the menstrual cycle

thought to be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA

215
Q

Premenstrual Syndrome

common sx

A 
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment 
Clumsiness
Reduced libido
216
Q

Premenstrual Syndrome

what is progesterone-induced premenstrual disorder

A

sx in response to COCP or cyclical HRT containing progesterone

217
Q

Premenstrual Syndrome

what is the term used for when features are severe and have a significant effect on QoL

A

premenstrual dysphoric disorder

218
Q

Premenstrual Syndrome

diagnosis is made based on what?

A
  • based on a sx diary spanning 2 menstrual cycles
219
Q

Premenstrual Syndrome

definitive dx

A

GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.

220
Q

Premenstrual Syndrome

mnx initiated in primary care

A
  • healthy lifestyle changes
  • COCP
  • SSRIs
  • CBT
221
Q

Premenstrual Syndrome

1st line COCP

A

containing drospirenone e.g. Yasmin

222
Q

Premenstrual Syndrome

what does drospirenone do

A

has some antimineralocortioid effects, similar to spironolactone.

223
Q

Premenstrual Syndrome

what is required for endometrial protection against endometrial hyperplasia when using oestrogen

A

cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.

224
Q

Premenstrual Syndrome

what can be used in severe cases

A

GnRH analogues to induce a menopausal state

225
Q

Premenstrual Syndrome

what should you take with GnRH analogues and why

A

HRT to add back hormones to mitigate osteoporosis SE

226
Q

Premenstrual Syndrome

mnx when all medical mnx has failed

A

Hysterectomy and bilateral oophorectomy + HRT

227
Q

Premenstrual Syndrome

medical mnx for cyclical breast pain

A

Danazole and tamoxifen (initiated by breast specialist)

228
Q

Premenstrual Syndrome

what may be used to treat the physical sx (breast swelling, water retention, bloating)

A

Spironolactone

229
Q

Adenomyosis

what is it

A

endometrial tissue inside the myometrium (muscle layer of the uterus).

230
Q

Adenomyosis

presentation

A
  • dysmenorrhoea (painful)
  • menorrhagia (heavy)
  • dyspareunia (sex)
231
Q

Adenomyosis

examination findings

A

enlarged and tender uterus (softer than a uterus containing fibroids)

232
Q

Adenomyosis

1st line inx

A

TVUS

MRI + transabdo US if not available

233
Q

Adenomyosis

gold standard inx

A

histological examination of the uterus after a hysterectomy (obviously not a suitable way to establish dx)

234
Q

Adenomyosis

mnx when contraception is wanted or acceptable

A

1st line: mirena

2: COCP
3: cyclical PO progestogens

235
Q

Adenomyosis

mnx for when women do not want contraception

A
  • tranexamic acid

- mefenamic acid (when there is associated pain)

236
Q

Adenomyosis

in pregnancy, what is adenomyosis associated with

A
  • infertility
  • miscarriage
  • preterm birth
  • small for gestational age
  • preterm premature rupture of membranes
  • malpresentation
  • c-section
  • postpartum haemorrhage
237
Q

Menopause

what is it

A

a retrospective diagnosis, made after a woman has had no periods for 12 months

menopause is the point at which menstruation stops

238
Q

Menopause

define postmenopause

A

12 months after the final menstrual period onwards

239
Q

Menopause

define perimenopause

A

the time leading up to the last menstrual period, and the 12 months afterwards

240
Q

Menopause

define premature menopause

A

menopause before the age of 40

it is the result of premature ovarian insufficiency

241
Q

Menopause

pathophysiology

A
  • no growth of ovarian follicles
  • reduced oestrogen
  • increased LH + FSH due to -ve feedback
  • failing follicular development
  • anovulation
  • also no oestrogen –> endometrium doesn’t develop –> amenorrhoea
242
Q

Menopause

what causes the perimenopausal sx

A

a lack of oestrogen

243
Q

Menopause

perimenopausal sx

A
  • Hot flushes
  • Emotional lability or low mood
  • Premenstrual syndrome
  • Irregular periods
  • Joint pains
  • Heavier or lighter periods
  • Vaginal dryness and atrophy
  • Reduced libido
244
Q

Menopause

risks due to lack of oestrogen

A
  • CVD + stroke
  • osteoporosis
  • pelvic organ prolapse
  • urinary incontinence
245
Q

Menopause

A diagnosis of perimenopause and menopause can be made in women over __

A

45y with typical sx without performing any inx

246
Q

Menopause

when should you consider an FSH blood test to help w/ dx

A
  • <40y w/ suspected premature menopause

- 40-45y w/ menopausal sx or a change in menstrual cycle

247
Q

Menopause

how long should women use contraception for after their last menstrual period

A
  • 2y if <50y

- 1y if >50y

248
Q

Menopause

good contraceptive options (UKMEC1: no restrictions)

A
  • Barrier methods
  • Mirena or copper coil
  • Progesterone only pill
  • Progesterone implant
  • Progesterone depot injection (<45y)
  • Sterilisation
249
Q

Menopause

key side effects of the progesterone depot injection (e.g. Depo-Provera

A
  • weight gain

- osteoporosis (why it’s unsuitable for >45y)

250
Q

Menopause

contraceptive option (UKMEC 2 after 40y: advantages generally outweigh risk)

A

COCP containing norethisterone or levonorgestrel in women >40y due to lower risk of VTE

251
Q

Menopause

mnx of perimenopausal sx

A
  • none
  • HRT
  • Tibolone
  • Clonidine
  • CBT
  • SSRIs
  • Testosterone
  • Vaginal oestrogen
  • Vaginal moisturisers
252
Q

Menopause

what is tibolone

A

synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)

253
Q

Menopause

what is clonidine

A

agonists of alpha-adrenergic and imidazoline receptors

254
Q

Premature Ovarian Insufficiency

definition

A

menopause before the age of 40

255
Q

Premature Ovarian Insufficiency

what will hormonal analysis show

A
  • raised FSH

- low oestradiol levels

256
Q

Premature Ovarian Insufficiency

cause

A
  • idiopathic (>50%)
  • iatrogenic: chemo, radio, surgery
  • autoimmune: coeliac, T1DM, thyroid
  • genetic: turner’s
  • infection: mumps, TB, CMV
257
Q

Premature Ovarian Insufficiency

presentation

A
  • irregular periods
  • lack of menstrual periods
  • hot flushes, night sweats, vaginal dryness
258
Q

Premature Ovarian Insufficiency

dx

A

<40

+ typical menopausal sx

+ FSH>25 on 2 consecutive samples separated by >4w

259
Q

Premature Ovarian Insufficiency

mnx

A
  • traditional HRT

- COCP

260
Q

Premature Ovarian Insufficiency

does HRT given before 50y increase risk of breast cancer

A

no (as women would ordinarily produce the same hormones at this age)

261
Q

Premature Ovarian Insufficiency

is there an increased risk of VTE with HRT in women <50y?

A

may be increased so this can be reduced by using transdermal methods (patches)

262
Q

Ovarian cysts

presentation

A

often found incidentally on pelvic USS

  • pelvic pain
  • bloating
  • fullness in abdo
  • palpable pelvic mass
263
Q

Ovarian cysts

when may they present with acute pelvic pain

A

if there is ovarian torsion, haemorrhage or rupture of the cyst

264
Q

Ovarian cysts

what are functional cysts

A

related to the fluctuating hormones of the menstrual cycle,

265
Q

Ovarian cysts

name 2 functional cysts

A
  1. follicular cysts

2. corpus luteum cysts

266
Q

Ovarian cysts

what is a follicular cyst

A

the most common

the developing follicle which fails to rupture and release the egg

harmless

267
Q

Ovarian cysts

what are corpus luteum cysts

A

corpus luteum fails to break down and instead fills with fluid

may cause pelvic discomfort, pain or delayed menstruation

often seen in early pregnancy

268
Q

Ovarian cysts

other types (apart from functional)

A
  • serous cystadenoma
  • mucinous cystadenoma
  • endometrioma
  • dermoid cysts/germ cell tumours
  • sex cord-stromal tumours
269
Q

Ovarian cysts

what are serous cystadenomas

A

benign tumours of the epithelial cells

270
Q

Ovarian cysts

what are mucinous cystadenomas

A

benign tumour of the epithelial cells

can become huge, taking up lots of space in the pelvis and abdomen

271
Q

Ovarian cysts

what are endometriomas

A

lumps of endometrial tissue within the ovary, occurring in patients with endometriosis

can cause pain + disrupt ovulation

272
Q

Ovarian cysts

what are dermoid cysts/germ cell tumours

A

benign ovarian tumours

they are teratomas: come from germ cells, may contain skin , teeth, hair + bone

273
Q

Ovarian cysts

what are dermoid cysts/germ cell tumours associated with

A

ovarian torsion

274
Q

Ovarian cysts

what are sex cord-stromal tumours

A

rare benign or malignant tumours

arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)

275
Q

Ovarian cysts

name some types of Sex Cord-Stromal Tumours

A

Sertoli–Leydig cell tumours and granulosa cell tumours

276
Q

Ovarian cysts

features that may suggest malignancy

A
  • Abdominal bloating
  • Reduce appetite
  • Early satiety
  • Weight loss
  • Urinary symptoms
  • Pain
  • Ascites
  • Lymphadenopathy
277
Q

Ovarian cysts

RFs for ovarian malignancy

A
  • Age
  • Postmenopause
  • Increased number of ovulations
  • Obesity
  • HRT
  • Smoking
  • Breastfeeding (protective)
  • Family history and BRCA1 and BRCA2 genes
278
Q

Ovarian cysts

protective factors

A

Factors that will reduce the number of ovulations:

  • later onset of periods
  • early menopause
  • any pregnancies
  • COCP
279
Q

Ovarian cysts

inx for premenopausal women with a simple ovarian cyst < 5cm on US

280
Q

Ovarian cysts

inx for women <40y with a complex ovarian mass

A

tumour markers for possible germ cell tumour:

  • LDH
  • α-FP
  • HCG
281
Q

Ovarian cysts

causes of raised CA125

A
  • epithelial cell ovarian cancer
  • Endometriosis
  • Fibroids
  • Adenomyosis
  • Pelvic infection
  • Liver disease
  • Pregnancy
282
Q

Ovarian cysts

mnx for possible ovarian cancer (complex cysts or raised CA125)

A

2 week referral to gynae oncology specialist

283
Q

Ovarian cysts

mnx for possible dermoid cysts

A

referral to a gynaecologist for further investigation and consideration of surgery

284
Q

Ovarian cysts

mnx of simple ovarian cyst <5cm

A

almost always resolve within three cycles.

do not require a follow-up scan

285
Q

Ovarian cysts

mnx of simple ovarian cyst 5-7cm

A

routine referral to gynaecology

and yearly ultrasound monitoring.

286
Q

Ovarian cysts

mnx of simple ovarian cyst >7cm

A

consider MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound

287
Q

Ovarian cysts

mnx of cysts in postmenopausal women

A

CA125 result and referral to a gynaecologist

288
Q

Ovarian cysts

mnx of cysts in postmenopausal women with a raised CA125

A

two-week wait suspected cancer referral

289
Q

Ovarian cysts

mnx of cysts in postmenopausal women that are <5cm and a normal CA125

A

US every 4-6m

290
Q

Ovarian cysts

surgical mnx

A

laparoscopy: ovarian cystectomy (removal of cyst) with possible oophorectomy

291
Q

Ovarian cysts

complications

A

torsion
haemorrhage
rupture

292
Q

Ovarian cysts

what is the triad of Meig’s Syndrome

A
  1. ovarian fibroma
    2, pleural effusion
  2. ascites
293
Q

Ovarian cysts

what signs on US point towards a benign diagnosis

A
  • uniocular cysts
  • solid components
  • no blood flow
294
Q

Ovarian Torsion

what is it

A

ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).

295
Q

Ovarian Torsion

what is it usually due to

A

an ovarian mass >5cm such as a cyst or tumour

296
Q

Ovarian Torsion

why does it happen with normal ovaries in younger girls before menarche

A

girls have longer infundibulopelvic ligaments that can twist more easily

297
Q

Ovarian Torsion

why is it an emergency

A

Twisting of the adnexa and blood supply to the ovary leads to ischaemia.

If the torsion persists, necrosis will occur, and the function of that ovary will be lost

298
Q

Ovarian Torsion

presentation

A
  • sudden onset severe unilateral pelvic pain
  • N+V

(not always severe and can take a milder, prolonged course)

299
Q

Ovarian Torsion

what may examination show

A
  • localised tenderness

- maybe a palpable mass

300
Q

Ovarian Torsion

initial inx of choice

301
Q

Ovarian Torsion

what may US show

A
  • “whirlpool sign”
  • free fluid in pelvis
  • oedema of the ovary
302
Q

Ovarian Torsion

what may Doppler studies show

A

a lack of blood flow

303
Q

Ovarian Torsion

inx for definitive diagnosis

A

laparoscopic surgery

304
Q

Ovarian Torsion

mnx

A

emergency

laparoscopic surgery to either:

  • detorsion
  • oopherectomy
305
Q

Ovarian Torsion

complications if not treated

A
  • loss of function in that ovary (other ovary can usually compensate)
  • if other ovary loses function too –> infertility, menopause
  • infection –> abscess –> sepsis
  • rupture –> peritonitis –> adhesions
306
Q

Cervical Ectropion

aka

A

cervical ectopy or cervical erosion

307
Q

Cervical Ectropion

pathophysiology

A

columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix)

308
Q

Cervical Ectropion

why is postcoital bleeding a presentation

A

the endocervix (columnar epithelial cells) are more fragile and prone to trauma

309
Q

Cervical Ectropion

who is it more common in and why

A

associated w/ higher oestrogen levels:

  • younger women
  • COCP
  • pregnancy
310
Q

Cervical Ectropion

what is the transformation zone

A

the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).

311
Q

Cervical Ectropion

presentation

A
  • postcoital bleeding
  • dyspareunia
  • increased vaginal discharge
  • vaginal bleeding
312
Q

Cervical Ectropion

on examination

A

transformation zone: well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the endocervix.

313
Q

Cervical Ectropion

are they associated with cervical cancer

314
Q

Cervical Ectropion

mnx if asymptomatic

A

none: will typically resolve as the patient gets older, stops the pill or is no longer pregnant.

315
Q

Cervical Ectropion

is having a cervical ectropion a contraindication to the COCP

316
Q

Cervical Ectropion

mnx if there is problematic bleeding

A
  • cauterisation of the ectropion using silver nitrate

- or cold coagulation during colposcopy

317
Q

Nabothian Cysts

what are they

A

fluid-filled cysts often seen on the surface of the cervix

318
Q

Nabothian Cysts

aka

A

nabothian follicles or mucinous retention cysts

319
Q

Nabothian Cysts

are they related to cervical cancer

320
Q

Nabothian Cysts

pathophysiology

A

The columnar epithelium of the endocervix (the canal) produces cervical mucus.

When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst.

321
Q

Nabothian Cysts

when can it form

A
  • after childbirth
  • minor trauma to cervix
  • cervicitis secondary to infection
322
Q

Nabothian Cysts

sx

A
  • asymptomatic

- feeling of fullness in pelvis if very large

323
Q

Nabothian Cysts

on examination

A

speculum:

  • smooth rounded bumps on cervix, usually near to os
  • ranged from 2mm-30mm
  • whitish or yellow
324
Q

Nabothian Cysts

mnx if diagnosis is clear

A

reassure pt, no trx

325
Q

Nabothian Cysts

mnx if diagnosis is uncertain

A
  • refer for colposcopy

- occasionally they may be excised or biopsied

326
Q

Pelvic Organ Prolapse

what causes it

A

weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

327
Q

Pelvic Organ Prolapse

name 4 types

A
  • uterine prolapse
  • vaginal vault prolapse
  • rectocele
  • cystocele
328
Q

Pelvic Organ Prolapse

what is a uterine prolapse

A

the uterus itself descends into the vagina

329
Q

Pelvic Organ Prolapse

what is a vault prolapse

A

occurs in women that have had a hysterectomy

the top of the vagina (vault) descends into the vagina

330
Q

Pelvic Organ Prolapse

what is a rectocele

A

rectum prolapses forward into the vagina

because of a defect in the posterior vaginal wall

331
Q

Pelvic Organ Prolapse

presentation of rectocele

A

faecal loading –> constipation, urinary retention, palpable lump in vagina

332
Q

Pelvic Organ Prolapse

which type is it if woman uses finer to press lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels

333
Q

Pelvic Organ Prolapse

what is a cystocele

A

caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina

prolapse of the urethra is also possible (urethrocele)

334
Q

Pelvic Organ Prolapse

what is a prolapse of both bladder and urethra called

A

cystourethrocele

335
Q

Pelvic Organ Prolapse

RFs

A
  • multiple vaginal deliveries
  • Instrumental, prolonged or traumatic delivery
  • Advanced age and postmenopause status
  • Obesity
  • Chronic respiratory disease causing coughing
  • Chronic constipation causing straining
336
Q

Pelvic Organ Prolapse

presentation

A
  • “something coming down” in the vagina
  • dragging or heavy sensation in the pelvis
  • Urinary sx: incontinence, urgency, freq, weak stream, retention
  • Bowel sx: constipation, incontinence, urgency
  • Sexual dysfunction: pain, altered sensation, reduced enjoyment
337
Q

woman identifies lump and often pushes it back up. Worse on straining or bearing down. What is t

A

pelvic organ prolapse

338
Q

Pelvic Organ Prolapse

what should pts do before examination

A

empty bladder and bowels

339
Q

Pelvic Organ Prolapse

When examining, what various positions may be attempted

A

the dorsal and left lateral position.

340
Q

Pelvic Organ Prolapse

what special speculum can be used for examination

A

Sim’s speculum

  • U-shaped, single-bladed speculum
  • supports the anterior or posterior vaginal wall while the other vaginal walls are examined.
341
Q

Pelvic Organ Prolapse

how can the severity of the uterine prolapse be graded

A

the pelvic organ prolapse quantification (POP-Q) system

342
Q

Pelvic Organ Prolapse

POP-Q: grade 0

343
Q

Pelvic Organ Prolapse

POP-Q: grade 1

A

lowest part is >1cm above the introitus

344
Q

Pelvic Organ Prolapse

POP-Q: grade 2

A

lowest part is within 1cm of the introitus (above or below)

345
Q

Pelvic Organ Prolapse

POP-Q: grade 3

A

lowest part is >1cm below the introitus, but not fully descended

346
Q

Pelvic Organ Prolapse

POP-Q: grade 4

A

Full descent with eversion of the vagina

347
Q

Pelvic Organ Prolapse

what is the term for a prolapse extending beyond the introitus

A

uterine procidentia

348
Q

Pelvic Organ Prolapse

what are the 3 options for mnx

A
  1. conservative
  2. vaginal pessary
  3. surgery
349
Q

Pelvic Organ Prolapse

who is conservative mnx suitable for

A
  • able to cope with mild sx
  • do not tolerate pessaries
  • not suitable for surgery
350
Q

Pelvic Organ Prolapse

conservative mnx

A
  • physio: pelvic floor exercises
  • weight loss
  • lifestyle: reduce caffeine, incontinence pads
  • vaginal oestrogen cream
  • treat related sx: eg anticholinergics for stress incontinence
351
Q

Pelvic Organ Prolapse

how do vaginal pessaries work

A

inserted into the vagina to provide extra support to the pelvic organs

352
Q

Pelvic Organ Prolapse

types of pessaries

A
  • ring
  • shelf + Gellhorn
  • cube
  • donut
  • hodge (rectangular)
353
Q

Pelvic Organ Prolapse

advice to give about pessaries

A
  • try the right one for you
  • remove + clean or change every 4m
  • can cause vaginal irritation + erosion over time
  • oestrogen cream helps protect vaginal wall from irritation
354
Q

Pelvic Organ Prolapse

what is the definitive trx option

355
Q

Pelvic Organ Prolapse

complications of pelvic organ prolapse surgery

A
  • Pain, bleeding, infection, DVT and risk of anaesthetic
  • Damage to the bladder or bowel
  • Recurrence of the prolapse
  • Altered experience of sex
356
Q

Pelvic Organ Prolapse

complications of mesh repairs

A
  • chronic pain
  • altered sensation
  • dyspareunia
  • abnormal bleeding
  • urinary or bowel problems
357
Q

Urinary Incontinence

what are the types

A
  • urge
  • stress
  • mixed
358
Q

Urinary Incontinence

what is urge incontinence caused by

A

overactivity of the detrusor muscles of the bladder

359
Q

Urinary Incontinence

urge incontinence is aka?

A

overactive bladder

360
Q

Urinary Incontinence

presentation of urge incontinence

A
  • suddenly feeling the urge to pass urine

- having to rush to the bathroom and not arriving before urination occur

361
Q

Urinary Incontinence

what are the 3 canals through the centre of the female pelvic floor

A

urethral, vaginal and rectal canals

362
Q

Urinary Incontinence

what is stress incontinence due to

A

weakness of the pelvic floor and sphincter muscles

which allows urine to leak at times of increased pressure on the bladder

363
Q

Urinary Incontinence

presentation of stress incontinence

A

urinary leakage when laughing, coughing or surprised

364
Q

Urinary Incontinence

what is mixed incontinence

A

combination of urge and stress

identify which is having more significant impact

365
Q

Urinary Incontinence

when can overflow incontinence occur

A

when there is chronic urinary retention due to an obstruction to the outflow of urine

incontinence occurs without the urge to pass urine

366
Q

Urinary Incontinence

causes of overflow incontinence

A
  • anticholinergic meds
  • fibroids
  • pelvic tumours
  • neuro: MS, diabetic. spinal cord
367
Q

Urinary Incontinence

mnx for women with suspected overflow incontinence

A

referred for urodynamic testing and specialist management

368
Q

Urinary Incontinence

RFs

A
  • Increased age
  • Postmenopausal status
  • Increase BMI
  • Previous pregnancies and vaginal deliveries
  • Pelvic organ prolapse
  • Pelvic floor surgery
  • Neuro conditions: MS
  • Cognitive impairment and dementia
369
Q

Urinary Incontinence

modifiable lifestyle factors that can contribute to symptoms

A
  • caffeine
  • alcohol
  • medications
  • BMI
370
Q

Urinary Incontinence

what to ask for when assessing severity

A
  • Frequency of urination
  • Frequency of incontinence
  • Night time urination
  • Use of pads and changes of clothing
371
Q

Urinary Incontinence

what to examine for

A
  • Pelvic organ prolapse
  • Atrophic vaginitis
  • Urethral diverticulum
  • Pelvic masses
  • ask pt to cough and assess leakage
372
Q

Urinary Incontinence

how to assess strength of the pelvic muscle contraction on examiantion

A

asking the woman to squeeze against the examining fingers in bimanual examination

373
Q

Urinary Incontinence

what grading system can be used to assess the strength of the pelvic muscle contraction

A

modified Oxford grading system:

374
Q

Urinary Incontinence

modified Oxford grading system

A

0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards

375
Q

Urinary Incontinence

inx

A
  • bladder diary
  • urine dipstick
  • bladder scan
  • urodynamic testing
376
Q

Urinary Incontinence

what does a bladder scan measure

A

Post-void residual bladder volume to assess for incomplete emptying

377
Q

Urinary Incontinence

when can urodynamic testing be used

A

to investigate patients with:

  • urge incontinence not responding to 1st line meds
  • difficulties urinating
  • urinary retention
  • previous surgery
  • unclear diagnosis
378
Q

Urinary Incontinence

what do urodynamic tests do

A

objectively assess the presence and severity of urinary symptoms

379
Q

Urinary Incontinence

what do pts need to do before urodynamic tests

A
  • stop taking any anticholinergic and bladder related med 5d before
380
Q

Urinary Incontinence

what happens in urodynamic tests

A
  • thin catheter inserted into bladder
  • another inserted into rectum
  • they measure the pressures in the bladder and rectum for comparison
  • bladder filled with liquid
  • various outcome measures are taken
381
Q

Urinary Incontinence

urodynamic tests: what does cystometry measure

A

the detrusor muscle contraction and pressure

382
Q

Urinary Incontinence

urodynamic tests: what does uroflowmetry measure

A

the flow rate

383
Q

Urinary Incontinence

urodynamic tests: what is leak point pressure

A

the point at which the bladder pressure results in leakage of urine.

pt asked to cough, move or jump when the bladder is filled to various capacities.

This assesses for stress incontinence.

384
Q

Urinary Incontinence

urodynamic tests: what does post-void residual bladder volume test for

A

incomplete emptying of the bladder

385
Q

Urinary Incontinence

urodynamic tests: what does video urodynamic testing involve

A

filling the bladder with contrast and taking xray images as the bladder is emptied.

(not part of routine part of urodynamic testing

386
Q

Urinary Incontinence

conservative mnx for stress incontinence

A
  • avoid caffeine, diuretics + overfilling of bladder
  • avoid excessive or restricted fluid intake
  • weight loss
  • supervised pelvic floor exercises
387
Q

Urinary Incontinence

how long should pelvic floor exercises be done before surgery

388
Q

Urinary Incontinence

what should women aim for in pelvic floor exercises

A

at least 8 contractions TDS

389
Q

Urinary Incontinence

medical mnx for stress incontinence

A

Duloxetine (SNRI antidepressant)

used 2nd line where surgery is less preferred

390
Q

Urinary Incontinence

surgical options for stress incontinence

A
  • tension-free vaginal tape
  • autologous sling procedures
  • colposuspension
  • intramural urethral bulking
391
Q

Urinary Incontinence

what is tension-free vaginal tape

A

mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.

392
Q

Urinary Incontinence

what is Autologous sling procedures

A

Similar to TVT but a strip of fascia from the patient’s abdominal wall is used rather than tape

393
Q

Urinary Incontinence

what it colposuspension

A

stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra

394
Q

Urinary Incontinence

what it intramural urethral bulking

A

injections around the urethra to reduce the diameter and add support

395
Q

Urinary Incontinence

Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, what operation may be done

A

artificial urinary sphincter: pump inserted into labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.

396
Q

Urinary Incontinence

conservative mnx (1st line) for urge incontinence

A

bladder retraining for at least 6w

397
Q

Urinary Incontinence

medical mnx for urge incontinence

A
  • anticholinergics: oxybutynin, tolterodine, solifenacin

- or mirabegron

398
Q

Urinary Incontinence

side effects of anticholinergics like oxybutynin, tolterodine, solifenacin

A

dry mouth, dry eyes, urinary retention, constipation and postural hypotension

399
Q

Urinary Incontinence

why should anticholinergics be problematic in older, more frail pts

A

they can lead to cognitive decline, memory problems and worsening of dementia,

400
Q

Urinary Incontinence

Mirabegron is CI’d in?

A

uncontrolled HTN

401
Q

Urinary Incontinence

how does mirabegron lead to a hypertensive crisis

A

works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure

402
Q

Urinary Incontinence

invasive mnx of urge incontinence

A
  • botulinum toxin type A
  • percutaneous sacral nerve stimulation
  • augmentation cystoplasty
  • urinary diversion
403
Q

Urinary Incontinence

what is percutaneous sacral nerve stimulation

A

implanting a device in the back that stimulates the sacral nerves

404
Q

Urinary Incontinence

what is augmentation cystoplasty

A

using bowel tissue to enlarge the bladder

405
Q

Urinary Incontinence

what is urinary diversion

A

redirecting urinary flow to a urostomy on the abdomen

406
Q

Bartholin’s Cyst

what are the Bartholin’s glands

A

a pair of glands located either side of the posterior part of the vaginal introitus

they produce mucus to help with vaginal lubrication

407
Q

Bartholin’s Cyst

what is it

A

when the ducts of the Bartholin’s glands become blocked, they can swell and become tender

408
Q

Bartholin’s Cyst

presentation

A

a fluid filled cyst between 1-4cm

unilateral

409
Q

Bartholin’s Cyst

presentation of a Bartholin’s abscess (infected cysts)

A

hot, tender, red and potentially draining pus.

410
Q

Bartholin’s Cyst

dx

A

clinically with a history and examination

411
Q

Bartholin’s Cyst

mnx

A
  • good hygiene
  • analgesia
  • warm compressions
  • incision generally avoided as cyst will reoccur
412
Q

Bartholin’s Cyst

inx if vulval malignancy needs to be excluded

413
Q

Bartholin’s Cyst

inx for Batholin’s abscess

A
  • swab of pus for culture

- send specific swabs for chlamydia + gonorrhoea

414
Q

Bartholin’s Cyst

what is the most common cause of Bartholin’s abscess

415
Q

Bartholin’s Cyst

mnx of Bartholin’s abscess

A
  • abx
  • or surgery may be required:
    Word catheter
    Marsupialisation
416
Q

Bartholin’s Cyst

Word catheter procedure

A
  • local
  • incision to drain pus
  • inflate catheter with saline into abscess space
  • fluid can drain around catheter, preventing cyst or abscess reoccurring
  • tissue heals around catheter leaving a permanent hole
  • catheter deflated and carefully removed at a later date once epithelisation of the hole has occurred
417
Q

Bartholin’s Cyst

what does Marsupialisation involve

A
  • GA in a surgical theatre
  • incision to drain
  • sides of abscess are sutured open
  • allowing continuous drainage
418
Q

Female Genital Mutilation

what is it

A

surgically changing the genitals of a female for non-medical reasons

a form of child abuse + safeguarding issue

419
Q

Female Genital Mutilation

Female genital mutilation is illegal as stated in ____

A

the Female Genital Mutilation Act 2003

legal requirement for healthcare professionals to report cases of FGM to the police

420
Q

Female Genital Mutilation

which countries have high rates

A
  • Somalia
  • Ethiopa
  • Sudan
  • Eritrea
421
Q

Female Genital Mutilation

how many types are there

422
Q

Female Genital Mutilation

Type 1

A

Removal of part or all of the clitoris

423
Q

Female Genital Mutilation

Type 2

A

Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.

424
Q

Female Genital Mutilation

Type 3

A

Narrowing or closing the vaginal orifice (infibulation).

425
Q

Female Genital Mutilation

Type 4

A

All other unnecessary procedures to the female genitalia.

426
Q

Female Genital Mutilation

2 key RFs to bear in mind

A
  • from a community that practise FGM

- having relatives affected by FGM.

427
Q

Female Genital Mutilation

scenarios where it is worth considering the risk of FGM

A
  • Pregnant women with FGM with a possible female child
  • Siblings or daughters of women or girls affected by FGM
  • Extended trips with infants or children to areas where FGM is practised
  • Women that decline examination or cervical screening
  • New patients from communities that practise FGM
428
Q

Female Genital Mutilation

immediate complications

A
  • Pain
  • Bleeding
  • Infection
  • Swelling
  • Urinary retention
  • Urethral damage and incontinence
429
Q

Female Genital Mutilation

long term complications

A
  • Vaginal infections e.g. BV
  • Pelvic infections
  • UTIs
  • Dysmenorrhea
  • Sexual dysfunction and dyspareunia
  • Infertility and pregnancy-related complications
  • psychological issues
  • Reduced engagement with healthcare and screening
430
Q

Female Genital Mutilation

mnx if U18

A
  • mandatory to report all cases to the police

contact

  • social serves + safeguarding
  • paediatrics
  • specialist gynae or FGM services
  • counselling
431
Q

Female Genital Mutilation

mnx if >18

A
  • careful consideration about whether to report cases to the police or social services
  • risk assessment tool on gov.uk
432
Q

Female Genital Mutilation

surgical mnx for type 3

A

de-infibulation

- aims to correct the narrowing or closure of the vaginal orifice

433
Q

Female Genital Mutilation

what is re-infibulation

A

(re-closure of the vaginal orifice) could be requested after childbirth. Performing this procedure is illegal.

434
Q

Congenital Structural Abnormalities

where do the upper vagina, cervix, uterus and fallopian tubes develop from

A

the paramesonephric ducts (Mullerian ducts)

435
Q

Congenital Structural Abnormalities

in a male fetus, what is produced which suppresses the growth of the Mullerian ducts

A

anti-Mullerian hormone

436
Q

Congenital Structural Abnormalities

what is bicornuate uterus

A

where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance

437
Q

Congenital Structural Abnormalities

dx of bicornuate uterus

438
Q

Congenital Structural Abnormalities

complications of bicornuate uterus

A

Miscarriage
Premature birth
Malpresentation

439
Q

Congenital Structural Abnormalities

what is imperforate hymen

A

where the hymen at the entrance of the vagina is fully formed, without an opening.

440
Q

Congenital Structural Abnormalities

typical presentation of imperforate hymen

A

discovered when girl starts to menstruate

cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding

441
Q

Congenital Structural Abnormalities

trx of imperforate hymen

A

surgical incision

442
Q

Congenital Structural Abnormalities

what could imperforate hymen lead to

A

retrograde menstruation could occur leading to endometriosis.

443
Q

Congenital Structural Abnormalities

what is transverse vaginal septae

A

an error in development, where a septum (wall) forms transversely across the vagina.

444
Q

Congenital Structural Abnormalities

in transverse vaginal septae, the septum can either be ____

A

perforate (with a hole) or imperforate (completely sealed).

445
Q

Congenital Structural Abnormalities

presentation of transverse vaginal septae (perforated)

A

girls will still menstruate, but can have difficulty with intercourse or tampon use

446
Q

Congenital Structural Abnormalities

presentation of transverse vaginal septae (imperforated)

A

present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation

447
Q

Congenital Structural Abnormalities

complications of transverse vaginal septae

A

infertility and pregnancy-related complications

448
Q

Congenital Structural Abnormalities

dx of transverse vaginal septae

A

examination, ultrasound or MRI

449
Q

Congenital Structural Abnormalities

trx of transverse vaginal septae

A

surgical correction

450
Q

Congenital Structural Abnormalities

main complication of surgery for a transverse vaginal septae

A

vaginal stenosis and recurrence of the septae

451
Q

Congenital Structural Abnormalities

what is vaginal hypoplasia

A

abnormally small vagina

452
Q

Congenital Structural Abnormalities

what is vaginal agenesis

A

absent vagina

453
Q

Congenital Structural Abnormalities

why does vaginal hypoplasia and agenesis occur

A

due to failure of the Mullerian ducts to properly develop

and may be associated with an absent uterus and cervix.

454
Q

Congenital Structural Abnormalities

in vaginal hypoplasia and agenesis, are the ovaries affected

A

no, so normal female sex hormones (except AIS where they are testes)

455
Q

Congenital Structural Abnormalities

mnx of vaginal hypoplasia and agenesis

A
  • vaginal dilator over a prolonged period to create an adequate vaginal size
  • or vaginal surgery

Finals (47 decks)

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