Gynae Flashcards
What is adenomyosis? What are some features and mx?
Presence of endometrial tissue within the myometrium . Dysmenorrhoea, menorrhgia, enlarged boggy uterus
Tx: GnRH agonist hysterectony
What is primary amenorrhoea?
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
What is secondary amenorrhoea?
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Causes of primary amenorrhoea
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
Testicular feminisation
Congenital malformations of the genital tract
Functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
Congenital adrenal hyperplasia
Imperforate hymen
Causes of secondary amenorrhoea?
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
What Ix would you carry out for amenorrhoea?
Urinary HcG - exclude preg
All bloods
Gonadotrophins (FSH, LH)
Prolactin
androgen levels - high in PCOS
Oestradiol
What can gonadotrophin levels tell you about amenorrhoea?
gonadotrophins
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
How would you manage primary amenorrhoea?
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
What is atrophic vaginitis?
Atrophic vaginitis often occurs in women who are post-menopausal women. It presents with vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry.
What is the tx for atrophic vaginitis?
Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
What are some worsening reasons that suggest an ectopic pregnancy?
If a woman has a positive pregnancy test and any of the following she should be referred immediately to an early pregnancy assessment service:
pain and abdominal tenderness
pelvic tenderness
cervical motion tenderness
What are the main differentials for bleeding in the first trimester?
- Misscarriage/ ectopic
- Implantation bleeding
- Cervical ectropion, vaginitis, trauma and polyps
Bleeding if greater than 6 weeks gestation in preg women?
refer
Less than 6 weeks gestation and bleeding?
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried
What are the common types of cervical cancer?
squamous cell cancer (80%)
adenocarcinoma (20%)
What are the features of a cervical cancer?
may be detected during routine Cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
What are the main rfs for cervical cancer?
HPV!!!!!!!!!!!!!!!!!!
smoking , HIV, early sex, multiple partners, high parity, Lower ses, COCP
How often do you test for cervical cancer?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
In pregnancy delay 3 months post partum,
What is the HPV first system?
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Positive hrHPV (high risk HPV) cytology abnormal?
if the cytology is abnormal → colposcopy
this includes the following results:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
Positive hrHPV and cytology is normal?
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What if the cytology or cervical cancer sample is inadequete?
If the sample is ‘inadequate’
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
What is the staging used in cervical cancer?
FIGO staging- do we have to learn it?
Stage 1 - confined to cervix
2- tumor beyond the cervix but not into pelvic wall
3- beyond cervix and into the vaginal wall
4- Extension beyond the pelvis involvement of bladder or rectum and beyond for extreme stages
Mx of cervical cancer?
Gold standard for 1a is hysterectomy +- lymph node clearance
If wishing to maintain fertility - cone biopsy with negative margins
for advanced tumors radiotherapy with concurrent chemo is advised
What is a cervical ectropion?
This means cervical ectropion often presents with postcoital bleeding.
Cervical ectropion is associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.
Mx od cervical ectropion
Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
Causes of delayed puberty with a short stature?
Delayed puberty with short stature
Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome
Delayed puberty with a normal stature?
Delayed puberty with normal stature
polycystic ovarian syndrome
androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome
What do you know about primary dysmenorrhoea?
affects 50% of women and no cause- usually appears 1-2 years after menarche
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
Management
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
What are some causes of secondary dysmenorrhoea?
Secondary dysmenorrhoea typically develops many years after the menarche
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
What bHCG levels point to an ectopic in case of preg of unknown location?
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Typical hx of a woman with ectopic Hx?
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
* Lower abdo pain
* Vaginal bleeding
* Hx of recent amenorrhoea (6-8 weeks from last period)
* peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
Examination findings in an ectopic?
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
Rfs for an ectopic?
0.5% of all pregnancies
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
What is the ix of choice for ectopics?
TVS
What is ‘expectant mx’ of ectopic pregnancy?
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed
When would you manage an ectopic using expectant mx?
aize <35mm, unruptured, no foetal bpm,hcg 1000
also when asympx
When would you mx ectopics medically?
Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow-up.
<35mm, unruptured, not sig pain, HCG<1500
When would you mx an ectopic surgically?
> 35 mm, sig pain , HCG >5000
Salpingectomy (removal of fallopian) or salpingotomy (preserving the tube but removing the ectopic)
All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically
What are the most common sites for an ectopic and which one is the most dangerous?
97% are tubal and mostly in the ampulla
Most dangerous in the isthmus
What is the risk of unopposed oestrogen to HRT?
Endometrial cancer
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
Who is affected by endometrial cancer?
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
Rf’s for endometrial cancer?
Obesity, nulliparity, early periods, late menopause, unopposed oestrogen
Tamoxifen!!!1
PCOS
What are the features of endometrial cancer?
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
What ix would you do for endometrial cancer?
Investigation
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
What is protective for endometrial cancer?
the combined oral contraceptive pill and smoking are protective
Mx of endometrial cancer
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
What is endometrial hyperplasia ?
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
What are the features of emndometrial hyperplasia?
Endometrial hyperplasia may present with intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding
aNY ABNORMAL vaginal bleeding
How would you manage endometrial hyperplasia?
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
What is endometriosis?
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
What are the clinical features of endometriosis?
chronic pelvic pain
secondary dysmenorrhoea (pain days before bleeding)
deep dyspareunia
subfertility
non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix
What Ix would you use for endometriosis?
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Treatment for endometriosis?
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
GnRH analogues if fertility is priority
Effect of pregnancy on fibroids?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Whats the pattern of abdominal pain for ovarian torsion?
Usually sudden onset of deep seated colicky abdominal pain.
Associated with vomiting and distress.
Vaginal examination may reveal adnexial tenderness.
Pattern of pain and sx for PID?
Bilateral lower abdominal pain associated with vaginal discharge.
Dysuria may also
How do you diagnose menorrhagia?
Womans word - if she feels its different or problematic it is
How would you ix menorrhagia?
a full blood count should be performed in all women
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.
Non contraceptive approach to menorrhagia?
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Contraceptive mx of menorrhagia?
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
What are the side-effects of HRT?
Side-effects
nausea
breast tenderness
fluid retention and weight gain
Potential complications of HRT?
Increased risk of breast cancer (increased if you add progestogen dose)
Increased risk of endometrial cancer - progestogen on and off reduces risk and continuous progestogen takes away the risk completely
VTE- patches however do not increase risk
What is the diagnostic triad of hyperemesis gravidarum?
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
What is protective against hyperemesis gravidarum?
SMOKING
What is associated with hyperemesis graviu?
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
Associations
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
When would you refer someone for hyperemesis gravidarum?
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
How can you classify the severity of hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
Mx of hyperemesis gravidarum?
antihistamines should be used first-line
oral cyclizine or oral promethazine is recommended by Clinical Knowledge Summaries (CKS)
oral prochlorperazine is an alternative
ondansetron and metoclopramide may be used second-line
metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days
ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate.
What is the recommended period of the use of contraception in menopausal women?
The average women in the UK goes through the menopause when she is 51 years old.
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
What is the mx of menopause?
- Lifestyle modifications
*HRT - advise of risks of cancer etc (Ovarian is given) - Use your common sense about dryness etc
Symptoms of HRT?
*change in perids
*Vasomotor symptoms - hot flushes and night sweats
*urogenital - vag dryness and atrophy, urinary freq
*psychological- anxiety and depression
Causes of menorrhagia?
Fibroids, hypo/hyperthyroidism, IUD’s - only copper coil, PID, bleeding disorders, idiopathic,
How do you differentiate between a threatened, missed and inevitable miscarriage?
Threatened - cervical os closed painless vag bleeding
Missed - light vaginal bleeding, closed cervical os and a gestational sac with a dead foetis without symptoms of expulsion
Inevitable: Cervical os open with heavy bleeding clots and pain
Incomplete: Cervical os is open, pain and vaginal bleeding - not all products have been expelled
