Gynae Flashcards
1
Q
What is PMS?
A
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.
2
Q
When do PMS symptoms resolve?
A
When menstruation begins
3
Q
What causes PMS?
A
Fluctuation in oestrogen and progesterone. May be due to increased sensitivity to progesterone.
4
Q
PMS presentation (7)
A
Low mood Anxiety Fatigue Mood swings Irritability Breast pain Reduced Libido
5
Q
Can PMS symptoms occur after hysterectomy/endometrial ablation/Mirena Coil? and Why?
A
Yes, since ovaries continue to function and hormonal cycle continues.
6
Q
PMS diagnosis?
A
Symptom diary spanning 2 menstrual cycles.
Definitive diagnosis may be made with GnRH analogues to halt menstrual cycle and see if symptoms resolve.
7
Q
PMS management? (4)
A
Lifestyle: Diet, exercise, alcohol, sleep
COCP
SSRI antidepressants
CBT
8
Q
What COCP is recommended by RCOG?
A
COCP containing drospirenone (i.e. Yasmin), it contains anti-mineralocorticoid effects, similar to spironolactone
9
Q
What is menorrhagia?
A
Heavy menstrual bleeding
10
Q
What are some causes of menorrhagia? (7)
A
Dysfunctional uterine bleeding, Extremes of reproductive age, Fibroids, Endometriosis and Adenomyosis, Contraceptives (*copper coil), PCOS
11
Q
Menorrhagia investigations? (4)
A
Pelvic examination with speculum and bimanual examination
FBC
Outpatient Hysteroscopy
Pelvic and transvaginal ultrasound
12
Q
Menorrhagia management? (3)
A
Remove the cause
Tranexamic acid/Mefenamic acid
Mirena coil->COCP->Cyclical oral progestogens
Endometrial ablation and Hysterectomy
13
Q
What are fibroids?
A
Benign smooth muscle tumours of uterus
14
Q
What is the relationship between fibroids and oestrogen
A
Oestrogen sensitive -> grow in response to oestrogen
15
Q
What are the types of fibroids
A
Intramural, Subserosal, Submucosal, Pedunculated
16
Q
Fibroids presentation? (6)
A
Menorrhagia Prolonged menstruation Abdominal pain Bloating Urinary/bowel Deep Dyspareunia Reduced Fertility
17
Q
Fibroids investigation? (4)
A
Abdominal and bimanual examination (palpable pelvic mass/ enlarged non-tender uterus)
Hysteroscopy (submucosal fibroids)
Pelvic ultrasound
MRI (size, shape and supply to fibroids - before uterine artery embolisation)
18
Q
Fibroids management <3cm ? (7)
A
Mirena coil
NSAIDs and Tranexamic acid
COCP
Cyclical oral progestogens
Endometrial ablation
Resection
Hysterectomy
19
Q
Fibroids management >3cm? (3)
A
Uterine artery embolisation
Myomectomy
Hysterectomy
20
Q
Name 2 GnRH
A
Goserelin, leuprorelin
21
Q
What is red degeneration?
A
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply
22
Q
Red degeneration presentation? (4)
A
Severe abdominal pain, Low grade fever, tachycardia, vomiting
23
Q
Red degeneration management?
A
Rest, Fluids, analgesia
24
Q
What is endometriosis?
A
Condition where endometrial tissue present outside uterus
25
Endometriosis causes?
Unknown, theory is retrograde menstruation where endometrial lining flows backwards through fallopian tubes and into pelvic and peritoneum. Endometrial tissue seeds itself in pelvis and peritoneal cavity.
26
Pathophysiology of Endometriosis
Ectopic endometrial tissue responds similarly to regular endometrial tissue. During menstruation ectopic tissue also sheds and bleeds causing irritation and inflammation at sites
27
Endometriosis presentation (7)
```
Cyclical abdominal/pelvic pain
Deep dyspareunia
Dysmenorrhea
Infertility
Haematuria
Urinary symptoms
Bowel Symptoms
```
28
Endometriosis investigations
Pelvic speculum and bimanual examination (vagina, cervix, adnexa tenderness, fixed cervix on BM examination, endometrial tissue visible on speculum examination)
Pelvic ultrasound (large endometriomas and chocolate cysts)
Laparoscopic surgery and biopsy
29
Endometriosis Staging?
S1-> small superficial lesions
S2->mild but deeper lesions than S1
S3-> Deeper lesions with lesions on ovaries and mild adhesions
S4-> Deep and large lesions affecting ovaries with extensive adhesions
30
Endometriosis management
Analgesia (NSAIDs, Paracetamol)
COCP, Mirena coil, Progesterone only pill, GnRH agonists, Medroxyprogesterone acetate injection (depo-Provera)
Laparoscopic excision/ablation, Hysterectomy and bilateral salpingo-ophrectomy
31
What is adenomyosis?
Endometrial tissue inside myometrium
32
Adenomyosis presentation
Dysmenorrhoea, Menorrhagia, Dyspareunia, potential infertility
33
Adenomyosis Investigation
Pelvic examination
Transvaginal ultrasound
MRI and transabdominal ultrasound
Histological examination through hysterectomy
34
Adenomyosis management
Tranexamic acid/Mefenamic acid
Mirena coil, COCP, COP
GnRH analogues, Endometrial ablation, Uterine artery embolisation, Hysterectomy
35
Complications of Adenomyosis (6)
Infertility, Misscarriage, preterm birth, Small gestational age, PROM, malpresentation
36
Menopause?
point at which menstruation stops
37
Age for menopause normally?
51.2 years
38
Menopause cause
Lack of ovarian follicular function so oestrogen, progesterone low /and FSH and LH high
39
Pathophysiology of menopause
Decline in development of ovarian follicles. Without growth, there is reduced oestrogen.
40
Perinmeopausal symptoms
Hot flushes, Irregular periods, joint pain, vaginal dryness and atrophy, reduced libido, emotional lability/low mood
41
Risks after menopause?
Cardiovascular disease and stroke, Osteoporosis, Pelvic organ prolapse, urinary incontinence
42
How is menopause diagnosed?
Made only in women over 45, using FSH
43
Depo-Provera side effects
Weight gain, osteoporosis
44
Perimenopausal management
HRT, Tibolone (steroid), Clonidine (alpha-adrenergic agonist), CBT, SSRI, Vaginal oestrogen
45
Premature ovarian insufficiency?
Menopause before the age of 40 years
46
Premature Ovarian Insufficiency causes
Idiopathic (50%), iatrogenic (chemo, radio, oophrectomy) , autoimmune, genetic, infections
47
Presentation of premature ovarian insufficiency
Irregular menstrual period, hot flushes, night sweats, vaginal dryness
48
Diagnosis of Premature ovarian insufficiency
FSH persistently raised on 2 consecutive samples 4 weeks apart (>25IU/L)
49
Management of Premature ovarian insufficiency
HRT
50
Clonidine side effects
dry mouth, headaches, dizziness and fatigue
51
PCOS?
condition causing metabolic and reproductive problems in women
52
What criteria used to diagnose PCOS and what are they?
Rotterdam Criteria - oligoovulation, anovulation + hyperandrogenism + Polycystic ovarians on ultrasound (ovarian volume >10cm3)
53
PCOS Presentation?
```
Oligomenorrhoea/amenorrhoea
Infertility
Obesity
Hirsutism
Acne
Male pattern hair loss
```
54
PCOS investigations
Blood tests : Testosterone, SHBG, LH, FSH, Prolactin, TSH
raised LH:FSH, raised testosterone, raised insulin
Pelvic ultrasound: 12> follicles in one ovary/ >10cm3 ovary volume
55
PCOS management?
```
Weight loss. orlistat,
Mirena coil (for endometrial protection
metformin
Ovarian drilling (infertility)
Co-Cyprindiol (for hirsutism)
COCP (acne)
```
56
Ovarian torsion?
Condition where ovary twists in relation to surrounding connective tissue, fallopian tube and blood supply
57
Cause of ovarian torsion
Usually due to ovarian mass >5cm e.g. cyst, tumour
58
Ovarian torsion presentation
Sudden onset severe unilateral pelvic pain (constant, progressively worse)
Nausea, vomiting
59
Investigation Ovarian torsion?
Localised tenderness, palpable mass in pelvis
Pelvic ultrasound (possible whirlpool sign-free fluid and oedema in ovary)
Laparoscopy
60
Ovarian torsion management
Un-twist
| Remove affected ovary
61
Ovarian torsion complication
Loss of function -> infertility, menopause
Infection->abscess->sepsis
Possible rupture->peritonitis and adhesions
62
Asherman's syndrome?
Adhesions form within uterus following damage
63
Causes of asherman's syndrome
Pregnancy related dilation and curettage (placental removal)
Uterine surgery
Pelvic infection
64
Asherman's syndrome presentation (4)
Secondary amenorrhoea
Significantly lighter periods
Dysmenorrhoea
Infertility
65
Asherman's syndrome diagnosis
Hysteroscopy (gold standard)
Hysterosalpingography
Sonohysterography
MRI scan
66
Management Asherman's syndrome
Dissection of adhesions during hysteroscopy
67
Cervical ectropion?
When columnar epithelium of the endocervix has extended out to the ectocervix.
68
Epidemiology of cervical ectropion
Common in younger women, use of COCP and pregnancy due to association with higher oestrogen levels
69
Endocervix histology?
Columnar epithelium
70
Ectocervix histology?
Stratified squamous epithelium
71
Cervical ectropion presentation?
Increased vaginal discharge, vaginal bleeding, dyspareunia
72
Cervical ectropion investigation?
Cervical examination (well demarcated border between redder, columnar and pink squamous epithelium)
73
Cervical ectropion management?
Asymptomatic - no treatment required
Problematic bleeding -> cauterisation of ectropion using silver nitrate during colposcopy
74
Nabothian cysts?
Fluid filled cysts seen on surface of the cervix
75
Which epithelium produces cervical mucus?
Columnar epithelium of the endocervix
76
Nabothian cysts presentation?
No symptoms normally. Might cause feeling of fullness in the pelvis.
77
Nabothian cysts investigation
Smooth rounded bumps on cervix
78
Nabothian cysts management
No treatment required if diagnosis clear, If unclear, refer to colposcopy to examine. Excision and biopsy may be required to rule out other pathologies.
79
Pelvic organ prolapse?
Descent of pelvic organs into vagina
80
What causes Pelvic organ prolapse
Weakness and lengthening of ligaments and muscles surrounding uterus, rectum and bladder
81
Types of pelvic organ prolapse
Uterine, Vault, Rectocele, Cystocele
82
Risk factors for pelvic organ prolapse (6)
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
83
Presentation of pelvic organ prolapse
```
something coming down feeling in vagina, dragging/heavy sensation in pelvis, Urinary symptoms (incontinence, urge, frequency, retention)
Bowel symptoms (constipation, incontinence, urgency)
Sexual dysfunction (pain, altered sensation, reduced enjoyment)
```
84
Procedure Examination of pelvic organ prolapse?
Empty bladder/bowel - women asked to cough
85
Grades of uterine prolapse
```
G0: Normal
G1: Lowest part > 1cm above introitus
G2: Lowest part within 1cm of introitus
G3: Lowest part >1cm below introitus, but not fully descended
G4: Full descent with eversion of vagina
```
86
Pelvic organ prolapse management
Conservative management
Vaginal pessary
Surgery (hysterectomy)
87
Urinary incontinence
Loss of control of urination
88
Types of urinary incontinence
Urge incontinence, stress incontinence
89
Cause of urge incontinence
Overactivity of detrusor muscle of bladder
90
Cause of stress incontinence
When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis.
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles.
91
Mixed incontinence?
Combination of urge incontinence and stress incontinence
92
Risk factors for Urinary Incontinence (8)
```
Increased age
Postmenopausal status
Increased BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions i.e. MS
Cognitive impairment and dementia
```
93
How to distinguish between the types of incontinence?
Medical history
94
Examination for incontinence
Examination should assess for pelvic tone and examine for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic masses
95
Investigation for urinary incontinence?
A bladder diary, urine dipstick, post-void residual bladder volume, urodynamic testing
96
Urinary stress incontinence management
Avoid caffeine, diuretics, overfilling of bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises
Surgery
Duloxetine (SNRI depressant used second line where surgery is less preferred)
97
Management of Urge incontinence
Bladder retraining for at least 6 weeks (first line)
Anticholinergic medication (oxybutynin, tolterodine)
Mirabegron (alternative to anticholinergic medications)
Invasive procedures (botulinum toxin type A, percutaneous sacral nerve stimulation)
98
Atrophic vaginitis
Dryness and atrophy of the vaginal mucosa related to lack of oestrogen
99
Relationship of oestrogen with incontinence and prolapse
Oestrogen helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence
100
Atrophic vaginitis presentation
Itching, dryness, dyspareunia, bleeding due to localised inflammation
101
Examination of atrophic vaginitis
Pale mucosa, thin skin, reduced skin folds, erythema and inflammation, dryness, sparse pubic hair
102
Atrophic vaginitis management
```
Vaginal lubricants (Sylk, Replens and YES)
Topical oestrogen
```
103
Bartholin's glands? Function?
Glands located either side of the posterior part of the vaginal introitus (vaginal opening)
They produce mucus to help with vaginal lubrication
104
How does a Bartholin's cyst happen?
When the ducts of the Bartholin glands become blocked, the glands can swell and become tender -> Bartholin's cyst
105
How is Bartholin's cyst diagnosed?
Made clinically with history and examination
106
Management of Bartholin's cyst
Will usually resolve with good hygiene, analgesia, warm compresses.
Avoid incision as cyst will often reoccur.
Biopsy may be required if vulva malignancy needs to be excluded
107
Management of Bartholin's abscess
Antibiotics. A swab for culture (e.coli most common cause)
Surgery potentially (word catheter, marsupialisation)
108
Lichen sclerosus?
Chronic inflammatory skin condition that presents with patches of shiny "porcelain white" skin.
109
Lichen sclerosus association with aloplecia and hypothyroid?
It is associated with other autoimmune diseases such as type 1 diabetes, aloplecia, hypothyroid, vitiligo
110
How is lichen sclerosus diagnosed
Clinically, based on history and examination findings.
Vulval biopsy where doubts
111
Lichen Sclerosus presentation (6)
```
Itching
Soreness and pain possibly worse at night
Skin tightness
Superficial dyspareunia
Erosions
Fissures
```
Koebner phenomenon (symptoms worse by friction to skin)
112
Lichen Sclerosus appearance
```
Porcelain white in colour
Shiny
Tight
Thin
Slightly raised
May be papules/plaques
```
113
Lichen Sclerosus management
Cannot be cured
Potent topical steroids (clobetasol propionate 0.05%) aka dermovate.
Emollients
114
Lichen Sclerosus complications
5% risk of SCC of vulva
Pain/discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal/urethral openings
115
FGM?
Surgically changing the genitals for non-medical reasons.
116
FGM common where?
African countries i.e., Somalia, Ethiopia, Sudan, Eritrea
117
Types of FGM
T1: Removal of part or all of clitoris
T2: Removal of part of all of clitoris and labia minora. Labia majora may also be removed
T3: Narrowing/Closing of vaginal orifice (infibulation)
T4: All other unnecessary procedures to female genitalia
118
FGM complications
Immediate: pain, bleeding, infection, swelling, urinary retention, urethral damage and incontinence
Long term: Vaginal, pelvic, UT infections, Dysmenorrhoea, Dyspareunia, Infertility, psychological issues and depression
119
FGM management
De-infibulation surgical procedure in cases of type 3
120
Cervical cancer types
Squamous cell carcinoma (80%)
Adenocarcinoma
Small cell cancer (rare)
121
Cause of Cervical Cancer
HPV (16,18)
122
Risk factors of Cervical Cancer
```
Increased risks of catching HPV
Later detection of precancerous and cancerous changes
Smoking
HIV
Combined contraceptive pill
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol
```
123
Cervical Cancer presentation
Abnormal vaginal bleeding, vaginal discharge, pelvic pain, dyspareunia
124
Cervical cancer investigation
Colposcopy and biopsy with some
CT/MRI for staging
Urine pregnancy test, Vaginal swabs
125
Staging for cervix
FIGO
```
1 Cervix
2 Upper 2/3 vagina
3 Lower 1/3 vagina
4 Bladder of rectum
4b Beyond
```
126
Cervical screening program when?
```
3 yrs (25-49)
5 yrs (50-64)
```
127
Cervical cancer management?
CIN to early stage 1A - LLETZ/cone biopsy
Stage 1B-2A - Radical hysterectomy and removal of lymph nodes with chemotherapy,radiotherapy
Stage 2B-4A - Chemotherapy and radiotherapy
Stage 4B - combination of surgery, radiotherapy, chemotherapy and palliative
128
Endometrial cancer main type?
Around 80% are adenocarcinoma
129
Risk factors endometrial cancer
Unopposed oestrogen
```
increased age,
early onset menstruation
late menopause,
oestrogen only HRT
No pregnancies
Obesity
PCOS
Tamoxifen
```
130
Protective factors for endometrial cancer
COCP
Mirena coil
Increased pregnancies
Cigarette smoking
131
Endometrial cancer presentation
```
Postmenopausal bleeding
Postcoital bleeding
intermenstrual bleeding
menorrhagia
abnormal vaginal discharge
haematuria
anaemia
```
132
Referral criteria endometrial cancer
Postmenopausal bleeding
133
Endometrial cancer investigations
```
TVUS (<4mm)
Pipelle biopsy (endometrial hyperplasia/cancer)
Hysteroscopy with endometrial biopsy
```
134
FIGO staging endometrial cancer
1 Uterus
2 Cervix
3 Ovaries, tubes, vagina, lymph nodes
4 Bowel, bladder, rectum, beyond pelvis
135
Endometrial cancer management
Stage 1-2 -> total abdominal hysterectomy with bilateral salpino-oophrectomy
Radiotherapy, Chemotherapy
Progesterone may be used to slow progression of cancer
136
Ovarian cancer types (4)?
Epithelial cell tumours, dermoid cysts/ germ cell tumours, sex cord-stromal tumours, metastasis
137
Risk factors ovarian cancer
Age (60), BRCA1/2 genes, Increased number of ovulation, obesity, smoking, recurrent clomifene use
138
Protective factors ovarian cancer
COCP
Breastfeeding
Pregnancy
139
Presentation ovarian cancer
```
Abdominal bleeding
Early satiety
Pelvic pain
Urinary symptoms
Weight loss
Abdominal mass
Ascites
```
140
Ovarian mass complication
Mass may press on obturator nerve causing referred hip/groin pain
141
Referral criteria ovarian cancer
Ascites, Pelvic mass, Abdominal mass
142
Investigation ovarian cancer
CA125 (>35IU/mL)
Pelvic ultrasound
CT
Histology using CT guided biopsy/laparoscopy/laparotomy
Paracentesis to test for cancer cells in ascitic fluid
IF <40 yrs check for germ cell tumour markers i.e. AFP and HCG
143
FIGO staging ovarian cancer
1. Ovaries only
2. Pelvis
3. Past Pelvis but inside abdomen
4. Distant metastasis
144
Management ovarian cancer
Surgery and Chemotherapy
145
Vulval cancer main type
90% SCC, less common is malignant melanomas
146
Risk factors Vulval cancer
Advanced age > 75
Immunosuppression
HPV infection
Lichen sclerosus
147
Vulval cancer presentation
vulval lump, ulceration, bleeding, pain, itching, lymphadenopathy in the groin
148
Where does vulval cancer most frequently affect
labia majora
149
Investigation of vulval cancer
Biopsy of lesion
Sentinel node biopsy
Further imaging for staging
150
Management of vulval cancer
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
