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Phase 3a > Gynae > Flashcards

Gynae Flashcards

1
Q

Menopause

A

Retrospective diagnosis - no periods for 12 months - permanent end to menstruation

Usually at ~51 years

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2
Q

Premature ovarian insufficiency + diagnostic test

A

Menopause before 40 y/o
- aka premature menopause

Diagnosis confirmed with 2 raised FSH levels 4-6 weeks apart (+ clinical presentation and ruling out hypothyroidism, hyperprolactinaemia, and pcos)

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3
Q

Menopause pathophys

A
  1. Declining devlopment of ovarian follicles
  2. Reduced production of oestrogen + progesterone
  3. Normally, Oestrogen has negative feedback to pituitary -> reduced LH and FSH produce.
    • In menopause there is less negative feedback as oestrogn is low so LH and FSH keep getting higher
  4. Ovulation doesn’t occur (anovulation) -> irregular menstrual cycle
  5. Endometrium doesn’t develop without enough oestrogen so AMENORRHOEA
  6. Perimenopausal Sx
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4
Q

Perimenopausal Sx

A

Vasomotor:

  • Hot flushes
  • Night sweats

Sexual dysfunction:

  • Vaginal dryness and atrophy
  • Reduced libido
  • Problems with orgasm
  • Dyspareunia

Psych:

  • Emotional lability or low mood
  • Anxiety
  • Lethargy
  • Reduced conc.

Other:

  • Premenstrual syndrome (tender breasts, fatigue, irritibality, cravings)
  • Irregular periods
  • Joint pains
  • Heavier or lighter periods

-

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5
Q

Complications of menopause

A
  • CVD + Stroke
  • Osteoporosis
  • Pelvic organ prolapse
  • Urinary incontinence

Caused by reduced oestrogen

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6
Q

Menopause/perimenopause Dx

A
  • Women OVER 45 YEARS
  • Typical Sx
    Clinical Dx

FSH blood test in:

  • Women UNDER 40 with SUPSECTED Early menopause
  • Women 40-45 with Sx / change in menstrual cycle
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7
Q

Menopause Mx

A

No treatment may be needed

  • HRT (both oestrogen + progesterone (for endometrial protection from oestrogen))
    - cyclically if still having periods; otherwise continuous
    - Increased risk of breast + endometrial cancer if only taking oestrogen; VTE
  • Testosterone - can improve libido

Non-hormonal:

  • Lifestyle measures: activity, avoiding triggers, sleep
  • SSRIs / SNRIs
  • Clonidine (Alpha-2 adrenergic receptor agonist)
  • CBT
  • Vaginal moisturisers
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8
Q

Polycystic Ovarian Syndrome (PCOS)

A

Heterogenous endocrine disorder characterised by:

  • Hyperandrogenism (oligomenorrhoea, hirsutism, acne)
  • Ovulation disorders
  • Polycystic ovarian morphology
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9
Q

PCOS epid

A

Affects 1/3 of females of childbearing age

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10
Q

PCOS aet

A

Unkown.

Hyperandrogenism, Insulin resistance, HIgh LH + Raised oestrogen - implicated

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11
Q

PCOS Sx

A
  • Oligomenorrhoea
  • In/Subfertility
  • Hirsutism + Acne
  • Obesity (in ~ 70% of ppl)
  • Mood changes
  • MALE PATTERN BALDNESS
  • Acanthosis nigricans (from INSULIN RESISTANCE)
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12
Q

PCOS DDx

A
  • Menopause
  • Congenital adrenal hyperplasia
  • Hyperprolactinoma
  • Androgen secreting tumours
  • Cushing’s
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13
Q

PCOS Dx criteria

A

ROTTERDAM CRITERIA - at least 2 of the following are needed to Dx:

  • Oligo / Anovulation
  • Hyperandrogenism
  • Polycystic ovaris on USS - >12 cysts / ovaries >10cm^3

+ need to exclude other causes

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14
Q

PCOS Ix

A

Bloods:

  • Testosterone (normal / raised)
  • Sex hormone-binding globulin
  • Luteinizing Hormone (raised)
  • Follicle-stimulating Hormone (LH:FSH ratio = high - >2 ; FSH is lower than LH)
  • Prolactin (may be slightly raised in PCOS too)
  • TSH / TFTs
  • Fasting + oral glocuse tolerance to check for Insulin resistance (Raised)
  • DHEA-S + free androgen index (androgen secreting tumours)
  • 24hr urine cortisol (Cushing’s)

Scan = TRANSVAGINAL USS OF PELVIS (Transabdominal is also fine)

  • Increased ovarian volume + multiple cysts
    • Follicles arranged around edge of ovary -> ‘string of pearls’
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15
Q

Dx criteria for PCOS on scan

A
  • 12 or more developing follicles in one ovary
  • Ovarian volume > 10cm3
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16
Q

PCOS Mx

A

Advice:

  • Weight loss + exercise
  • Education on Increased risk of CVD, DIABETES + ENDOMETRIAL CANCER
  • Encourage low sugar, calorie-coltrolled diet
  • Smoking ceassation
  • Statins + anti-HTN if needed

Asses for complication

Pharm (if not planning preg):

  • cOCP - decreases irregular bleeding + reduce risk of endometrial cancer
  • Metformin - helps regularise menstruation, hirsutism + acne
  • 2nd line - Co-cyprindrol - reduces hirsutism + promotes regular menstruation (VTE risk so can’t use any other hormonal contraception alongside - same as with most oral contraception)

Preg promoting pharm:

  • Clomiphene (ovulatory stimulant) - induces ovulation + enhances conception rates
  • Metformin (esp in combination with clomiphene) - improves conception rates
  • Ovarian drilling - 2nd line (laproscope to damage ovarian hormone-producing cells)
  • Gonadotrophins - 2nd line to induce ovulation
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17
Q

Significance of weight loss for PCOS Mx

A
  • Can result in ovulation + restore fertility + regular menstruation
  • Improves insulin resistance
  • Reduces hirsutism
  • Reduces risk of associated conditions

If obese (BMI > 30) - may use Orlistat
- A lipase inhibitor (stops fat being absorbed in intestines)

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18
Q

Pathphys of why PCOS can lead to Endometrial cancer

A
  • Usually the CORPUS LUTEUM releases PROGESTERONE AFTER OVULATION
  • In PCOS there is no/irregular ovulation so reduced progesterone to counteract effects of systemic oestrogen
  • Oestrogen continues to be released -> Uncontrolled endometrial prolifereation -> hyperplasia + significant risk of cancer
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19
Q

When should a pelvic USS for endometrial thickness be done? What needs to be done prior to the USS?

A
  • If there are extended gaps (> 3 months) between periods
  • Give Cyclical progesterones before scan to induce a period

Endometrial thickness >10mm -> refer for biopsy

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20
Q

Tx to reduce risk of endometrial cancer in menopause

A
  • Mirena coil - releases progesterone so acts as continuous protection in HRT (must be replaced after 6 yrs if used for HRT)
  • Inducing withdrawal bleed - just need to have at least 3 a year (1 every 3-4 months)
    - cOCP (go off it for the week you want the period)
    - Cyclical progesterones (need 10mg once a day for 14 days)
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21
Q

RFx for endometrial cancer

A
  • Obesity
  • Diabetes
  • Insulin resistance
  • Amenorrhoea
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22
Q

What is the main side effect of co-cyprindiol

A

Significantly rised risk of VENOUS THROMBOEMBOLISM as it is anti-androgen

  • Usually stopped after 3 MONTHS
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23
Q

Fibroids

A

Benign smooth muscle tumours in uterus (uterine leiomyomas) - OESTROGEN SENSITIVE (contain more ostrogen receptors than normal uterine cells)

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24
Q

Fibroid epid

A
  • affect 40-60% in later reproductive years
  • esp in 40s
  • Esp in BLACK women
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25
Q

Types of fibroids

A
  • Intramural (distort shape of uterus with growth)
    - most common
  • Subserosal (just beneath outer layer - grow out; get very large)
  • Submucosal (just below endometrium)
  • Pedunculated (any of the above but on a stalk)

Remember all are within the myometrium

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26
Q

Fibroids Px

A

Oft asymp

  • Menstrual dysfunction - typically HEAVY +/- PROLONGED (mc)
  • Abdo pain (worse during period)
  • Bloating / fullness in abdo
    - subsequent urinary / bowel Sx
  • Deep dyspareunia
  • Reduced fertility
  • Occasionally acute pelvic pain due to fibroid degen during preg or peduculated fibroid torsion (rare)

May feel palpable mass on abdo / bimanual palpation (tho uterus is non-tender)

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27
Q

RFx for developing fibroids

A
  • Obesity
  • Early menarche
  • Increasing age
  • FHx (2.5x risk if 1st degree relative)
  • Ethnicity (3x more likely in African-Americans than Caucasians)
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28
Q

Fibroid Ix

A

IMAGING:

  • Pelvic US - typically for larger
  • MRI uncommonly - typically to get more info before surgery

HYSTEROSCOPY if HEAVY BLEEDING - typically submucosal fibroids

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29
Q

Fibroid Mx

A

For smaller fibroids (< 3cm) with menorrhagia:

  • MIRENA COIL - not if uertrine distorsion
  • Sx Mx e.g. Tranexemic acid + NSAIDs
  • cOCP OR Cyclical oral progesterones
  • Selective Progesterone Receptor Modulators
  • Surgical:
    • Endometrial ablation
    • Resection
    • Hysterectomy

(Basically works in a similar way to trying to reduce endometrial proliferation to avoid endometrial cancer)

If > 3cm REFER to GYNAE. Med management is same as above but consider following surgical:

  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
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30
Q

What meds can be used to reduce size of fibroids before surg

A

GnRH AGONISTS (goserelin / leuprorelin) - induces menopause-like state -> reduced oestrogen

Only temporarily used

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31
Q

Uterine Artery Embolisation

A

Catheter inserted into (usually) Femoral artery -> go to uterine artery guided by x-ray -> inject particles causing blockage to fibroid blood supply (once in right place) -> ischaemic fibroid shrinks

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32
Q

Complications of Fibroids

A
  • Anaemia from bleeding
  • Compression of pelvic organs
    - Bladder / bowel dysfunction: UTI, Incont, Hydroneph, Retention
  • Sub/INFERTILITY +/- preg complications
  • Red Degeneration -> necrosis of fibroid, typically in 2nd/3rd trimester of preg
  • Torsion of pedunculated
  • Malignant change
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33
Q

What causes Red Degeneration of Fibroids

A
  • Fibroid rapidly enlarges + outgrows blood supply
  • Blood vessels kink as uterus expands

Typically in large fibroids > 5cm

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34
Q

Red degeneration of fibroids Px

A

Preg woman in 2nd/3rd trimester with:

  • SEVERE ABDO PAIN
  • Low-grade FEVER
  • TACHYCARDIA
  • VOMITING
  • Hx of fibroids
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35
Q

Red degen of fibroids tx

A

Supportive: Rest, fluids + analgesia

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36
Q

Ovarian cyst

A

Fluid filled sac within ovary - common esp in premenopause (functional)

Benign

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37
Q

Ovarian cyst Px

A

Usually ASYMP + found incidentally on USS

Otherwise still vague:

  • Pelvic pain
  • Bloating
  • Fullness in abdo
  • Palpable mass (if v large)

Acute pain only in torsion, haemorrhage or rupture of a cyst
- Acute UNILATERAL pain +/- intra-peritoneal haemorrhage with Haemodynamic compromise = cyst RUPTURE

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38
Q

Types of ovarian cysts

A

NON-NEOPLASTIC

Functional (main):

  • Follicular cysts (most common)
  • Corpus luteal cysts

Pathological:

  • Endometrioma (from endometriosis)
  • Polycystic
  • Theca leutin cyst (temporarily caused by raised hCG)

BENIGN NEOPLASTIC:

Epitehlial:

  • Serous cystadenoma (Benign epithelial tumour)
  • Mucinous cystadenoma (also benign epithelial but can get very big)
  • Brenner tumour (unilateral solid grey/yellow)

Germ cell tumours:

  • Dermoid cysts / Germ Cell Tumours (benign teratomas)
  • Sex Cord-Stromal Tumours (stromal/sex cells - malig or benign)
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39
Q

Ovarian cyst Assessment

A

Assess if benign or malig

  • Abdominal bloating
  • Reduce appetite
  • Early satiety
  • Weight loss
  • Urinary symptoms
  • Pain
  • Ascites
  • Lymphadenopathy
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40
Q

RFx for ovarian cancer

A

Big thing is that risk is increased the more times you’ve ovulated:

  • Age
  • Nulliparity
  • Early menarche + Late menopause

Also:

  • Oestrogen only HRT
  • SMOKING
  • Obesity
  • FHx +/- BRCA1 + BRCA2 genes OR HNPCC (Lynch syndrome)
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41
Q

Protective features for ovarian cancer

A
  • Later menarche / Earlier menopause
  • PREG esp miltiparity
  • cOCP
  • Breastfeeding
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42
Q

Ovarian cancer Px

A

Oft in Post-menopausal females + vague:

  • Bloating
  • Change in bowel habit + urinary frequency (due to pressure from tumour)
    - chronic pressure can lead to chronic pelvic pain
  • Weight loss / loss of appetite
  • IBS
  • Vaginal bleeding
  • Ascites
  • Palpable mass
  • LUTS

May press on obturator nerve + cause reffered HIP / GROIN pain

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43
Q

Meig’s syndrome

A

Triad of:

  • Ovarian fibroma
  • Pleural effusion
  • Ascites
  • uncommon but ~40% of people with Sex-cord stromal tumours / FIbromas present with this
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44
Q

Complications of ovarian cysts

A
  • Torsion
  • Haemorrhage
  • Rupture + bleeding into peritoneum
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45
Q

What is the tumour marker for ovarian cancer

A

CA125

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46
Q

Causes of Raised CA125

A
  • Epithelial cell ovarian cancer
  • Endometriosis
  • Fibroids
  • Adenomyosis
  • Pelvic infection
  • Liver disease
  • Preg
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47
Q

Ovarian mass/cyst Ix

A
  • Preg test to rule out ectopic
  • If pre-menopausal + simple ovarian cyst <5cm on US - DOESN’T NEED FURTHER Ix
  • Under 40 with COMPLEX OVARIAN MASS - requires tumour markers for a possible germ cell tumour
    - LACTATE DEHYDROGENASE (LDH)
    - Alpha-fetoprotein (a-FP)
    - human CHORIONIC GONADOTROPIN (HCG)
  • Diagnostic laparoscopy e.g. if patient unstable
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48
Q

What is the risk of Malignancy Index

A

Estimates the risk of an ovarian mass being malig:

  • Menopausal status
  • USS FINDINGS
  • CA125 LEVEL
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49
Q

Ovarian cyst Mx

A

Check guidelines + get advice from collegue

  • If suspecting cancer (complex cyst or raised CA125)
    - TWO-WEEK WAIT REFERRAL (gynae oncology)
  • Suspected dermoid cysts -> gynae Ix + consider surgery
  • Simple ovarian cysts in premenopausal
    - < 5cm = self resolve
    - 5-7cm = routine gynae referral + yearly USS
    - >7cm = consider MRI or surgiccal evaluation (hard to characterise with USS)
  • Postmenopausal -> check CA125
    - raised -> 2 week referral
    - small + norm Ca125 -> USS monitor 4-6 months
  • Surgical resection/oophorectomy if enlarging/persistent
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50
Q

Endometriosis

A

Endometrial tissue located outside of uterine cavity

  • ovaries
  • pouch of douglas
  • uterosacral ligaments
  • pelvic peritoneum
  • bladder
  • umbilicus
  • diaphragm (rarely)
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51
Q

Staging of endometriosis

A
  1. Small Superficial lesions (may not even have visible endometrioma - just the associated blood vessels visible)
  2. Mild but deeper lesions
  3. Deeper + Ovarian endometriosis (chocolate cysts) + mild adhesions
  4. Deep infiltrating endometriosis (invades into organs/ovaries) + extensive adhesions
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52
Q

Endometriosis Sx

A

Cyclical Sx - typically get Sx (/gets worse) during periods

  • Pelvic Pain (due to irritation + inflam of tissue surrounding endometriomas - particularly as can bleed into abdo cavity during periods)
    • Heavy / burning / dull
  • Menorrhagia
  • Deep dyspareunia
  • Sub-fertility

Bladder Sx:

  • Cystitis (oft mistaken for UTIs - but NITRITES -VE)
  • Haematuria

Bowel Sx:

  • Rectal bleeding
  • Change in bowel habit
  • Dyschaesia (difficulty pooping)

Lung Sx:

  • Haemothorax
  • Haemotptysis
  • Dyspnoea
  • Chest pain

Over time nerves get more sensitised -> pain -> low mood -> makes the pain feel worse
- Also general pain due to muscle spasm (due to chronic inflam)

Extent of disease doesn’t correlate with severity of Sx

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53
Q

What can cause CHRONIC, NON-CYCLICAL pain in endometriosis

A

ADHESIONS formed due to localised bleeding + inflammation -> damage + scar tissue
- possible cause of reduced fertility

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54
Q

What may vaginal examination show in Endometriosis

A
  • Visible endometrial tissue in vagina (esp in posterior fornix)
  • Fixed cervix on BIMANUAL examination
    - uterus fixed + retroverted
  • Tenderness of vagina, cervix + adnexa
    - N/B: enlarged, tender + BOGGY UTERUS = ADENOMYOSIS
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54
Q

Endometriosis Dx

A
  • PELVIC USS
    - superficial endomet can’t bee seen on scan and USS isn’t diagnostic, but it’s much safer than blindly doing laproscopy
  • Laproscopic surg (gold standard) + BIOPSY (diagnostic)
    - can remove any lesions they find during this
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55
Q

SE/Risks of surgery

A
  • Visceral injury (may need stoma)
  • Perforation of IVC or aorta
  • Death
  • Chronic pain
  • May not find anything (50% of endometriosis is diff to identify on surg)
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56
Q

RFx for endometriosis

A
  • Early menarche
  • Short menstrual cycles
  • Long duration of bleeding
  • Heavy bleeding
  • Defects in uterus / fallopian tubes
  • FHx
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57
Q

Endometriosis Mx

A
  • Explain, Educate, Discuss + ANALGESIA
  • HORMONES (can be given even without definitive Dx)
    - cOCP
    - progesterone only (mini pill)
    - Medroxyprogesterone acetate injection
    - Nexplanon
    - MIRENA coil
    - GnRH agonists (induces menopause-like Sx so must regularly check DEXA and change if osteoporotic changes)
    - goserelin
  • SURGERY
    - excise (ovarian cystectomy), ablate (diathermy) or adhesiolysis
    - may be done if trying to get preg but poor outcomes for deep infiltrating
    - Hysterectomy + bilateral salpingo-opherectomy (induces menopause so endometriomas don’t respond to menstrual cycle - still may not resolve Sx)
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58
Q

Adenomyosis definition

A

Endometrial tissue inside the myometrium - hormone dependant

More common in older age / in multiparosity - BUT - Sx tend to resolve after menopause

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59
Q

Adenomyosis Px

A
  • Dysmenorrhoea
  • Menorrhagia
  • Dyspareunia
  • Potentially infertility / preg related complications

1/3 ppl asymp

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60
Q

Findings on examination of adenomyosis

A

ENLARGED + TENDER uterus but typically softer than with fibroids

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61
Q

Adenomyosis Dx

A
  • **Transvaginal USS*
    - Alt = MRI + transabdo USS
  • Best way to determine is actually histology post-hysterectomy - but not practical
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62
Q

Adenomyosis Mx

A
  • CONTRACEPTION:
    1. MIRENA
    2. cOCP
    3. Cyclical oral progestogens
    4. or any progesterone only meds
  • If contreception not wanted - Sx relief DURING periods:
    1. Tranexemic acid (if no pain - antifibrolynitic only)
    2. Mefenamic acid (if YES pain - this is an NSAID)
  • Other:
    • GnRH anologues (goserelin)
    • Endometrial ablation
    • Uterine artery embolisation
    • Hysterectomy
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63
Q

Preg related complications of Adenomyosis

A
  • Infertility
  • Miscarriage
  • Prem birth
  • Small for gestational age
  • Prem rupture of membranes
  • Malpresentation
  • need for C-section
  • Postpartum Haemorrhage
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64
Q

Menorrhagia definitions

A

Technically - Blood loss > 80 ml during period is considered heavy
(norm = ~40ml)

In practice it is mainly from self reporting / going through a pad every 1-2 hrs or passing large clots

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65
Q

Causes of menorrhagia

A
  • DYSFUNCTIONAL UTERINE BLEEDING (ie idiopathic)
  • Extremes of reproductive age
  • FIBROIDS
  • Endometriosis / Adenomyosis
  • Endometrial polyps
  • PID
  • Contraception - esp COPPER COIL
  • Endometrial HYPERPLASIA / CANCER (think esp if post menopausal)
  • PCOS

Systemic:

  • ANTICOAG meds
  • BLEEDING DISORDERS
  • Hypothyroidism
  • Liver/Kidney disease
  • Obesity
  • Connective tissue disorders
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66
Q

Key aspects of Hx to consider for any gynae problem

A
  • Age at menarche
  • Cycle length + variation
  • INTERMENSTRUAL BLEEDING + POST COITAL bleeding
  • CONTRACEPTIVE Hx
  • SEXUAL Hx
  • PREG - possibility, future plans
  • Cervical screening Hx
  • MIGRAINES if on pill

+ all usual stuff:
- PMHx + DHx
- Smoking + alcohol
- Fhx

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67
Q

Menorrhagia Ix

A

FBC (anaemia)

PELVIC EXAMINATION -> SPECULUM + BIMANUAL palpation - to assess for fibroids, ascites + cancer

  • Not necessary if young + not sexually active; or striaght forward Hx with no other Rfx/Sx

Other:

  • Swab (infection suspected)
  • Coag screen (FHx of clotting disorder)
  • FERRITIN (if clinically anaemic)
  • TFTs (if hypothyroid features) / other endocrine tests as indicated
  • Transvaginal USS
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68
Q

When would you arrange an outpatient hysteroscopy

A
  • Suspect SUBMUCOSAL fibroids
  • Suspect endometrial pathology (hyperplasia/cancer)
  • Persistent INTERMENSTRUAL bleeding
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69
Q

When should you arrange a pelvic / transvaginal USS

A
  • You feel a pelvic mass (possible large fibroids)
  • They have menorrhagia AND pelvic tenderness (Possible adenomyosis)
  • Examination was difficult to interpret (e.g. due to obesity)
  • They were recommended a hysterscopy but declined
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70
Q

Menorrhagia Mx

A
  1. Exclude underlying pathology + Tx anything identified (e.g. remove copper coil, tx hypothyroid etc)
  2. CONTRACEPTION
  3. If contraception not needed/wanted -> TRANEXEMIC / MEFANEMIC ACID
  4. Refer to 2NDRY care if:
    • Tx unsuccessful
    • Sx severe
    • FIBROIDS > 3CM
  5. If all medical fails:
    • Endometrial ablation
    • Hysterectomy
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71
Q

Types of endometrial ablation

A
  1. 1st gen = hysteroscopy + direct endometrial destruction (now replaced with…)
  2. 2nd gen non-hysteroscopic techniques - Safer + Faster
    - e.g. Balloon thermal ablation
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72
Q

Primary amenorrhoea define

A

Not starting menstruation:

  • By 13 y/o if no other signs of puberty
  • By 15 y/o if other signs of puberty
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73
Q

Hypogonadism definition

A

Lack of sex hormones - oestrogen or testosterone

Can be:

  • hypOgonadotropic hypodonadism (low LH + FSH)
  • hypERgonadotropic hypogonadism (gonads not responding to LH/FSH so LH+FSH high to try and compensate)
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74
Q

Causes of primary amenorrhoea

A
  • hypogonadotropic hypogonadism
    • Damage to hptothalamus/pituitary
      • Reduced nutrition intake
        • Significant CHRONIC CONDITIONS (e.g. CF or IBD - only temporarily tho)
        • Excessive exercise / dieting
      • Extreme physical / psych STRESS
    • CONSTITUTIONAL DELAY in gowth + development (temporary)
  • **ENDOCRINE DISORDERS **(including adrenal hyperplasia)
  • Genetic syndromes e.g.
    • Kallman syndrome
    • Turner syndrome
    • Androgen insensitivity syndrome
  • Imperforate hymen -> haematocolpos
  • Uterine agenesis
  • Pregnancy
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75
Q

Causes of hypergonadotropic hypogonadism

A
  • Damage to gonads (torsion, mumps, cancer)
  • Congenital absence of ovaries
  • TURNER’S SYNDROME
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76
Q

Examples of structural pathology which can prevent menstruation

A
  • Imperforate hymen
  • Transverse vaginal septae
  • vaginal agenesis (vagina doesn’t develop)
  • Absent uterus
  • Female genital

May get cyclical abdominal pain if getting periods but the menses

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77
Q

Ix for delayed menarche

A

Initial:

  • FBC + Ferritin
  • U+E (?CKD)
  • Anti-TTG / Anti-EMA (?coeliac)

Hormonal:

  • FSH + LH
  • TFTs
  • Insulin-like growth factor (?GH deficiency)
  • Prolactin
  • Testosterone

Genetic microarray test
- Turner’s

Imaging:

  • X-ray wrist (?constitutional delay)
  • Pelvic US (assess ovaries + pelvic organs)
  • MRI brain (pit gland pathology / olfactory dysfunction -?kallman)
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78
Q

Endometrial cancer

A

Oestrogen dependent cancer - most commonly adenocarcinoma (glandular)

Consider in any post-menopausal woman with bleeding - more common in postmenopausal group

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79
Q

Endometrial cancer RFx

A

Anything that increases exposure to unopposed oestrogen

  • Increased age
  • Earlier onset of menstruation / Late menopause
  • Oestrogen only HRT
  • No / fewer preg
  • OBESITY
  • PCOS (due to reduced ovulation -> less corpus leuteums to release progesterone + linked )
  • Tamoxifen (blocks oestrogen receptors in breast but oestrogenic in uterus)

Also:

  • DIABETES (insulin / insulin-like growth factor -> pro-proliferative effect)
  • Hereditary nonpolyposis colorectal cancer
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80
Q

How does obesity increase endometrial cancer risk

A
  • Adipose makes oestrogen
    - it contains AROMATASE -> converts androgens into oestrogen
  • more fat = more aromatase + more oestrogen
    • in post-menopause - no corpus luteum to make progesterone to oppose
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81
Q

Ovarian torsion

A

Ovary twists in relation to surrounding structures (the adnexa)

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82
Q

Causes of ovarian torsion

A

Usually due to ovarian MASS > 5 cm
- More likely to occur with benign tumours
- esp in preg

Sometimes occurs in pre-pubertal girls when infundibulopelvic ligaments are longer and can twist more easily (sort of mirroring testicular torsion in boys)

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83
Q

Ovarian torsion Px

A
  • SUDDEN onset SEVERE, UNILATERAL pelvic PAIN
    - constant + progressive
    - associated N+V
  • sometimes intermittant
  • sometimes milder + prolonged course

LOCALISED TENDERNESS + potentially PALPABLE mass on examination

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84
Q

Ovarian torsion Dx

A
  1. Pelvic US
    • ideally transvaginal but transabdo works too
    • ‘whirlpool sign’ - FREE FLUID in pelvic cavity
    • Ovarian OEDEMA
  2. US Doppler -> lack of blood flow

Dx = Laproscopic SURGERY

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85
Q

Ovarian torsion Mx

A
  • Emergancy admission
  • LAPROSCOPIC SURGERY to do either:
    • Detorsion
    • Oophrectomy
  • Laprotomy (big cut surgery) if large mass / malig
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86
Q

Complications of ovarian torsion

A
  • Loss of function of ovary
    - usually not infertility + early menopause because there is usually another ovary that can compensate

If necrotic ovary not removed -> infection -> abscess -> sepsis
- can rupture -> peritonitis + adhesions

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87
Q

Protective factors for endometrial cancer

A
  • cOCP
  • Mirena coil
  • Increased preg
  • Cigarette smokin
    - in post menopause as it is ANTI-OESTROGENIC (despite increasing risk in breast cancer)
    - potentially oestrogen metabolised differently in smokers; or because smokers have less adipose tissue / smoking induces earlier menopause (destroys eggs)
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88
Q

Endometrial cancer Px

A

POSTMENOPAUSAL BLEEDING

  • Postcoital bleeding
  • Intermenstrual bleeding
  • Unusual MENORRHAGIA
  • Abnormal vaginal discharge
  • Haematuria
  • ANAEMIA
  • Raised platelets
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89
Q

Referal criteria for endometrial cancer 2 wk wait

A

POST MENOPAUSAL BLEEDING

Also - refer for transvaginal US in women > 55 y/o if:

  • Unexplained vaginal discharge
  • Visible haematuria + raised plts / anaemia / high glucose
90
Q

Endometrial cancer Ix

A
  • Transvaginal US (endometrial thickness > 4mm post menopausal = abnormal)
  • Pipelle biopsy (highly sensitive for endometrial Ca)
  • Hysterectomy + endometrial biopsy (if high risk / last resort)

If 1st 2 are normal - v low risk

91
Q

Pipelle biopsy

A
  • Speculum exam
  • Insert pipelle (thin tube) through cervix into uterus
  • Fill with sample of endometrium
  • Examine for hyperplasia / cancer
92
Q

Stages of endometrial cancer

A

International federation of gynae and obs (FIGO) staging system:

  1. confined to uterus
  2. Invades cervix
  3. Invades ovaries, fallopian tubes, vagina OR lymph nodes
  4. Invades bladder, rectum OR BEYOND pelvis
93
Q

Endometrial cancer Mx

A
  • Stage 1 = TOTAL abdominal HYSTEROECTOMY with BILATERAL salpingo-oophrectomy + peritoneal washing

Other:

  • Radical hysterectomy (remove pelvic lymph nodes, surrounding tissue + top of vagina (from stage 2 onwards) / maximal debulking where possible
  • Chemo/Radiotherapy (usually in that order)
  • PROGESTERONE may SLOW PROGESSION
94
Q

DDx for post-menopausal bleeding

A
  • Vulval:
    - Atrophy
    - Malignancy / pre-malig
  • Cervical polyps OR cancer
  • Endometrial:
    - Hyperplasia +/- cancer
    - Benign endometrial polyps
    - Endometrial atrophy
95
Q

Types of ovarian cancer

A
  • Epithelial cell tumours
    - Serous tumours (main)
    - Endometrioid carcinomas
    - Clear cell tumours
    - Mucinous tumours
    - Undifferentiated
  • Dermoid cysts / Germ cell tumours (benign teratomas)
    - (higher association with torsion
  • Sex Cord-Stromal tumours
    - Sertoli-Leydig cell tumours
    - Granulosa cell tumours
  • Mets
    - Krukengerg tumour = ‘signet ring’ cells; usually from GI cancer
96
Q

Referral criteria for ovarian cancer

A

Direct to 2-wk wait if:

  • ASCITES
  • PELVIC MASS (not clearly due to fibroids)
  • ABDO MASS

Further Ix first (CA125 bloods) esp in women > 50 y/o with:

  • Change in bowel habit
  • Abdo BLOATING
  • Early SATIETY
  • Pelvic PAIN
  • Urinary frequency / urgency
  • WEIGHT LOSS
97
Q

Ovarian cancer Ix

A

Initial (can be done in primary / seondary care):

  • CA125 blood test
  • Pelvic US

Further (only in 2ndry):

  • CT (Dx + staging)
  • Biopsy + HISTOLOGY
  • PARACENTESIS if ascitic

If under 40 with complex ovarian mass -> may be teratoma:

  • Alpha-Fetoprotein
  • Human chorionic gonadotropin
98
Q

Ovarian cancer staging

A

FIGO staging:

  1. Ovary only
  2. Outside ovary but still inside pelvis
  3. Outside pelvis but still inside abdo
  4. Distant mets (spread outside abdo)
99
Q

Ovarian cancer Mx

A

Specialist gynae oncology MDT

Usually = Surgery + chemo

100
Q

Cervical cancer epid

A
  • peaks in reproductive years
  • Most commonly squamous cell carcinoma
  • strong association with HPV (pretty much always related to HPV infection)
101
Q

RFx for cervical cancer

A

Increased risk of catching HPV

  • Early sexual activity / increased no. of sexual partners
  • Sexual partners who have had more partners
  • No condoms

Not engaging with cervical screening

Other:

  • SMOKING
  • HIV (get annual smears instead of every 3/5 years)
  • cOCP use for > 5 years
  • FHx
  • Increased number of full term preg
  • Exposure to dithylstilbesterol
102
Q

Cervical cancer Px

A

Can just detect through screening (asymp)

  • Abnormal vaginal bleeding
  • Abnormal vaginal discharge
  • Pelvic pain
  • Dyspareunia

(all non-specific)

103
Q

Referal criteria for 2-wk wait colposcopy

A
  • HPV +ve + Abnormal cytology on pap smear
  • Abnormal appearance of cervix on speculum examination:
    • Ulceration
    • Inflammation
    • Bleeding
    • Visible tumour
104
Q

Colposcopy

A

Inserted into vagina through speculum -> MAGNIFIES cervix + examine epithelium in detail

Can use stains to differentiate abnormal areas:

  • Acetic acid -> abnormal cells = WHITE (acetowhite)
    - caused by INCREASED nuclear to cytoplasmic ratio
  • Schiller’s iodine test -> only healthy areas stain brown

Can also do PUNCH BIOPSY or LARGE LOOP EXCISION of TRANSFORMATIONAL ZONE

105
Q

Complications of loop biopsy of cervix

A
  • Bleeding (tho the diathermy from the fact the loop is electric should cauterise it)
  • Abnormal discharge
    - Both potentially for severel weeks after

Potential increase risk of pre-term labour depending on depth of tissue removed

NB: AKA Large Loop Excision of Transformation Zone

106
Q

Cone biopsy

A

Tx for CERVICAL INTRAEPITHELIAL NEIPLASIA + early stage cervical cancer

  • Remove cone-shaped piece of cervix with scalpel -> Histology
107
Q

Main risks of cone biopsy

A
  • Pain
  • Bleeding
  • Infection
  • Scar formation leading to cervical stenosis
  • Increased risk of miscarriage / prem labour
108
Q

FIGO staging of cervical cancer

A
  • Stage 1: Confined to the cervix
    - A = only microscopic
    - B = Gross lesions
  • Stage 2: Invades the uterus or upper 2/3 of the vagina
    - A = No parametrial involvement (connective tissue around uterus)
    - B = Obvious parametrial involvement
  • Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
    - A = No sidewall involvement
    - B = Extension to sidewall / hydronephrosis
  • Stage 4: Invades the bladder, rectum or beyond the pelvis (ie mets)
    - A = Involves BLADDER / RECTUM
    - B = DISTANT ORGANS
109
Q

Cervical Intraepithelial Neoplasia

A

Grading system for level of dysplasia (baso pre-cancerous)
- Dx at colposcopy

  • CIN 1= Mild dysplasia (1/3 thickness of epithelial layer - will probs return to normal by itself)
  • CIN 2 = Mod (2/3 of thickness + likely to progress without Tx)
  • CIN 3 = Severe (very likely to progress to Ca without Tx)
110
Q

Dysplasia vs dyskaryosis

A

Dysplasia can only be Dx on colposcopy

Dyskaryosis can be determined from smear test

(both are interchangeable words for cell changes)

111
Q

Cervical cancer screening (when is it done)

A

Routine:

  • Every 3 years 25-49
  • Every 5 years 50-64

Other:

  • HIV +ve = ANNUAL screening
  • If >65 can request one if not had one since 50
  • Previous CIN needs further testing
  • More screening if on cytotoxic drugs, dialysis, organ transplant etc (immunocompromise)

Don’t do routine smear while peripartum (min = 12wks post-partum)

112
Q

Cervical screening method

A
  • Speculum exam + small brush to collect cells
  • Deposit cellls into perservation fluid
  • (Transport via liquid-based cytology)
  • Microscopy
    - 1st high-risk HPV infection
    - 2nd IF high-risk HPV present THEN -> cells exam for dyskaryosis

Can also detect:
- bacterial vaginosis
- Candidiasis
- Trichomoniasis
- Actinomyces-like organisms in ppl with IUDs (no Tx required unless Sx)

113
Q

Mx of cervical smear results

A
  • Normal = back to routine testing
  • Inadequate sample = repeat smear after at least 3 months
  • HPV +ve but NORMAL cytology = Repeat for HPV after 1 YEAR
  • HPV +ve with ABNORMAL cytology = COLPOSCOPY
114
Q

Cervical cancer Tx

A
  • CIN and Early stage 1A = Loop biopsy / cone biopsy
  • 1A = can do trachelectomy (cervix + upper vagina only) -> fertility preservation
  • Stage 1B - 2A = RADICAL HYSTERECTOMY + removal of local LYMPH nodes +/- chemo/radio
  • Stage 2B-4A = CHEMO + RADIO
  • Stage 4B = Combination of surg, chemo/radio + palliative
115
Q

Pelvic exenteration

A

Remove most/all of pelvic orgams (femal reporoductive, bladder + rectum)

  • in severe / recurrent cancer
116
Q

HPV vaccination

A
  • given ideally before kid becomes sexually active
  • Gardasil (current NHS version) protects against strains 6, 11, 16, 18

6+11 -> genital warts
16+18 -> cervical cancer

117
Q

Follow-up after cervical cancer Tx

A
  • every 4 MONTHS after Tx completion for FIRST 2 YRS
  • every 6-12 MONTHS for NEXT 3 YRS

Must do vag/cervical exam each time if they haven’t been removed

118
Q

Vulval cancer epid

A

Rarer

  • 90% SQUAMOUS cell carcinomas
  • Sometimes malignant melanoma
119
Q

RFx for vulval cancer

A
  • AGE esp >75 yrs
  • ImmunoSUPPRESS
  • HPV INFECTION
  • Lichen sclerosis
120
Q

Vulval cancer Px

A

Oft incidental e.g. found during catheterisation

  • Vulval LUMP
  • Ulcers
  • Bleeding
  • Pain
  • Itching
  • LYMPHADENOPATHY

Most commonly in LABIA MAJORA
- IRREGULAR mass
- FUNGATING lesion
- ULCER
- Bleeding

121
Q

Vulval Intraepithelial Neoplasia

A

Premalig affecting squamous epithelium

  • High grade squamous intraepithelial lesion is associated with HPV (typically in 35-50 y/o)
  • Differentiated VIN associated with LICHEN SCLEROSUS (typically in 50-60 y/o)

Can only be Dx with BIOPSY

122
Q

Tx for VIN

A
  • Watch + wait (cloe follow-up)
  • Wide LOCAL EXCISION
  • IMIQUIMOD CREAM
  • Laser ablation
123
Q

Mx of vulval cancer

A

2-WK WAIT if suspected

  • BIOPSY
  • Sentinal NODE biopsy
  • CT abdo + pelvis for staging

Tx:

  • Wide local EXCISION
  • Lymph node dissection (groin)
    • ideally removing deeper femoral nodes as superficial only = higher risk of recurrance
  • CHEMO / RADIO
124
Q

FIGO staging of vulval cancer

A
  1. vulval only
  2. lower 1/3 of vagina, uterus / anus
  3. upper 2/3 of vagina / urethra OR bladder/rectal mucosa OR non-ulcerated lymph nodes
  4. Ulcerated lymph nodes, fixation to pelvic bone OR distant mets
125
Q

Complications of groin lymphadenectomy (for vulval cancer)

A
  • Wound dehiscence (seperation of previously approximated wound edges due to failure of proper healing)
  • Infection
  • LymphoCYSTs
  • LymphOEDEMA
  • Immobility
  • Prolonged hospitalisation
126
Q

Lichen sclerosus define + epid

A

Inflam skin condition - mainly affecting GENITAL / ANAL areas
- more common in women

Vulvar lichan sclerosus involves inner vulva

127
Q

Lichen sclerosus aet

A

Possibly autoimmune - associated with:

  • T1DM
  • Alopecia
  • Hypothyroid
  • Vitiligo

Possible link with previous skin damage

128
Q

Lichen sclerosus Px

A

Porcelain White patches which may scar
- Shiny, tight, thin, slightly raised
- Possibly papules / plaques

Sx (can be asymp):

  • Itching
  • sometimes pain
  • May be worse on urination / sexual intercourse
  • Tightness
  • Erosions / Fissures

KOEBNER PHENOMENON (made worse by friction on skin)

129
Q

DDx for lichen sclerosus

A
  • Lichen planus (purplish, itchy, bumpy, white lacy, can be in mouth)
  • Psoriasis
  • Vitiligo
130
Q

Lichen sclerosus Mx

A

No cure - follow up every 3-6 months (gynae or derm specialist)

  • POTENT TOPICAL STEROIDS
    - Clobetasol propionate 0.05% (dermovate)
    - OD for 4 WKS then reduce in freq every 4 WKS till only using TWICE WEEKLY
    - Increase ti daily during flare-ups
    - Reduces risk of malig
  • EMOLLIENTS
  • Avoid soaps in affected areas
131
Q

Lichen sclerosus Ix

A

Mainly just clinical exam

  • can sometimes do biopsy to confirm
  • Bloods to rule out AI conditions
132
Q

Complications of lichecn sclerosus

A
  • 5% risk of Squamous cells carcinoma
  • Sexual dysfunction
  • Bleeding
  • Narrowing of vaginal / urethral openings
133
Q

Hydatidiform mole ie molar pregnancy

A

Gestational trophoblastic disease

  • caused by imbalance in no. of chromosomes from mother / father during conception

basically forms a tumour

134
Q

RFx fro molar preg

A

Extremes of age:

  • < 16 Y/O
  • > 45 Y/O
135
Q

What are the 2 types of molar preg

A
  • Complete mole
    - ie has no foetal tissue
    - But does have proliferation of chorionic villi
    - Only paternal DNA (the ova is empty)
    - either 2 sperm or 1 sperm which replicates (ends with 46 paternal chromosomes)
  • Partial mole:
    - some foetal tissue
    - 2 sperm + normal egg -> haploid cell with 3 SETS of chromosomes
136
Q

Molar preg Px

A
  • Vaginal bleeding
  • Nausea
  • Hyperemesis gravidarum
  • Thyrotoxicosis (due to hCG activating TSH receptors)
  • Enlargement of uterus beyond expected gestational size (excessive trophoblast growth + retained blood)
137
Q

Molar preg DDx

A
  • Normal preg
  • Ectopic
  • Miscarriage
138
Q

Molar preg Ix

A
  • B-hCG levels
    - HIGHER than in normal pregs
  • TRANS-VAGINAL US
    - Snow storm appearance if complete molar
    - Low resistance of blood vessel flow
    - Absence of foetus

Confirm Dx retroscpectively from biopsy after mole removed

139
Q

Molar preg Mx

A

Specialist referral (gestational trophoblastic disease centre) to avoid complications (choriocarcinoma / invasion)

  • SUCTION CURETTAGE to Evacuate then Histology
  • Can do hysterectomy if not wanting to preserve fertility
  • SURVAILLANCE
    - Bimonthly serum + urine hCG until levels normal
    - 1st follow-up should be 4 wks after if a partial mole then can stop surrvailance if norm
    - if complete mole -> remeat monthly for 6 months even if normal levels

It is possible for it to metastesise

140
Q

Atrophic vaginitis

A

Inflammation, thinning of genital tissue after menopause due to LOW OESTROGEN

141
Q

Aet of atrophic vaginitis

A

Normally oestrogen stimulates vagina + urinary tract to become thicker, more elastic + producing secretions

Low oestrogen -> thinner, less elastic, drier mucosa
- becomes more prone to inflammation
- causes change in vaginal pH + microbes -> contribute to localised infection

Oestrogen also helps maintain pelvic connective tissue so postmenopausal people more prone to pelvic organ prolapse + stress incontinence

142
Q

Atrophic vaginitis Sx / Px

A
  • Thinning of vaginal mucosa
  • Narrowing of opening
  • Loss of vaginal rugae (folds)
  • Vaginal dryness + itching
  • Dyspareunia
  • Post-coital bleeding
  • Vaginal discharge (due to inflam)
  • Dysuria / recurrent UTIs / other urinary Sx
  • (associated incontinence, prolapse)
  • Loss of pubic hair
143
Q

Atrophic vaginitis Ix

A
  • Clinical examination
    - Pale, dry mucose +/- erythema; inflam
    - Thin skin + sparse pubic hair
    - Reduced skin folds
  • Infection screen if itching + discharge

If needed:

  • Transvaginal US + endometrial biopsy to exclude endometrial cancer
  • Biopsy abnormal skin
144
Q

Atrophic vaginitis Mx

A
  • Lubricants (short term for e.g. dyspareunia)
  • Moisterisers (regularly)
  • HORMONES (needs annual monitoring for endometrial complications):
    - Systemic HRT OR
    - TOPICAL OESTROGEN
    - Estriol cream (syringed in at bedtime)
    - Estriol PESSARIES (overnight)
    - Estradiol TABLETS (OD)
    - Estradiol ring (only replaced every 3 months)
145
Q

Contraindications of oestrogen

A
  • Breast cancer
  • Angina
  • VTE
146
Q

Summary of main DDx in gynae

A

https://zerotofinals.com/obgyn/gynaecology/differentialdiagnosis/

147
Q

Endometrial polyps

A

Abnormal growth of glands, stroma + vasculature affecting only endometrial layer - mainly in fundus (sometimes also cervix and rarely vagina)
- usually immature endometrium so no menstrual cycle changes

Can get during reproductive / postmenopausal years (esp in 40s)

Potential link to oestrogen (higher incidence in ppl on HRT or TAMOXIFEN)

148
Q

Endometrial polyps Px

A

Usually asymp

  • Bleeding
  • Infertility
  • Sometimes may progress to malig
149
Q

Endometrial polyps Ix

A
  • Transvaginal US
    - +/- Colour Doppler
  • SALINE INFUSION SONOGRAPHY (gold)
  • Can check histology
150
Q

Endometrial polyps Mx

A

Conservative - usually self-resolving

If infertility -> Surgical excision e.g. hysteroscopic polypectomy; lilation + curettage

Consider Post surgical progesterone therapy or just progesterone HRT in general

151
Q

Asherman’s syndrome

A

When adhesions form WITHIN the Uterus following damage
- Only considered Asherman’s syndrome if SYMPTOMATIC

Usually iccurs after pregnancy- related dilation + curettage (as it can damage basal layer causing scarring)
- or uterine surgery or multiple pelvic infections

these physical abnormalities cause obstructions / distortion

152
Q

Asherman’s syndrome Sx

A

Typically after recent uterine procedure

  • 2ndry amenorrhoea
  • Lighter periods
  • Dysmenorrhoea

Or infertility / recurrent miscarriages

153
Q

Asherman’s syndrome Dx

A
  • HYSTEROSCOPY (gold)
  • Hysterosalpingography
  • Sonohysterography (saline infusion sonography)
  • MRI scan
154
Q

Asherman’s syndrome Tx

A
  • dissect during hysteroscopy
    • commonly reoccur
155
Q

Pelvic inflammatory disease epid

A

Highest prevalence in sexually active women 15-24 (YOUNG SEXUALLY ACTIVE WOMEN)

156
Q

PID pathophys / causative organisms

A

Caused by spread of infection through cervix

Most common causes = STIs

  • Neisseria gonorrhoeae tends to produce more severe PID
  • Chlamydia trachomatis
  • Mycoplasma genitalium

Less commonly:

  • Gardnerella vaginalis (associated with bacterial vaginosis)
  • Haemophilus influenzae
  • Escherichia coli
157
Q

PID RFx

A
  • Sexually active:
    • No barrier contraception
    • Multiple sexual partners / recent new partner
    • existing / previous STIs
  • Younger age (15-24)
  • PMHx of PID
  • INTRAUTERINE DEVICE

Can also get vis INSTRUMENTATION (e.g. in gynae surgery / insertion of IUD etc)

158
Q

Presentation of PID

A
  • Pelvic / lower abdo PAIN
  • Abnormal vaginal DISCHARGE
  • Abnormal BLEEDING
  • Deep DYSPAREUNIA
  • Dysuria

If severe:
- severe pain, FEVER, N+V

159
Q

Examination findings indicative of PID

A
  • Pelvic TENDERNESS
  • Cervical motion tenderness (cervical excitation)
  • Cervicitis
  • Purulent discharge

Signs of sepsis if severe

160
Q

PID Ix

A
  • ENDOCERVICAL SWABS (chlamydia + gonnorhoea) / HIGH VAGINAL SWAB (trichomoniasis + vaginosis)
    - NAAT
    - microscopy for PUS CELLS
  • Full STI screen (esp HIV, SYPHILIS)
  • Urine dipstick +/- MSU (to exclude UTI)
  • Preg test (to exclude)
  • Transvaginal US (if severe / uncertainty)
  • Laparoscopy (+ peritoneal biopsy) - only if severe AND uncertainty
  • Bloods (RAISED INFLAM MARKERS)
161
Q

PID Mx

A

GUM referral

  • EMPIRICAL ABx (before swab comes back)
    • e.g. combination of cefriaxone, doxy + metranidazole for broad cover (check local guidelines)
  • Consider analgesia
  • Rest + avoid sex
    - CONTACT TRACING - everybody in LAST 6 MONTHS
162
Q

When should ppl be admitted to hospital for PID

A
  • If PREG - esp if risk of ECTOPIC
  • Severe Sx: N+V + FEVER (sepsis)
  • Signs of PERITONITIS
  • UNRESPONSIVE TO ORAL ABx (as will then need IV)
  • Need emergancy surg
    - e.g. PELVIC ABCESS drainage
  • Suspicion of other diagnosis
163
Q

Complications of PID

A
  • Sepsis
  • Abscess
  • Infertility / Ectopics
  • Chronic pelvic PAIN
  • Fitz-Hugh-Curtis syndrome (perihepatic adhesions due to infalm of liver capsule -> RUQ pain -> Laparoscopy + adhesiolysis)

esp if prolonged / recurrent

164
Q

Amenorrhoea / oligomenorrhoea summary

A

https://teachmeobgyn.com/gynaecology/menstrual/oligomenorrhoea/

165
Q

Prolactinoma

A

Tumour of anterior pituitary gland -> excessive prolactin secretion from LACTOTROPHS

  • can be associated with multpiple endocrine neoplasia type 1 (autosomal dominant)

Can be:

  • Micro = <10mm
  • Macro = >10mm
166
Q

Prolactinoma Px

A

If macro -> raised ICP / headaches + bitemporal hemianotopia etc

Also:

  • High prolactin -> negative feedback to hypothalamus -> reduced GnRH -> reduced LH + FSH -> Reduced oestrogen / testosterone
     - Inhibits ovulation / spermatogenesis
        - a/oligomenorrhoea
  - Erectile dysfunction
  - Low oestrogen also leads to OSTEOCLAST PROLIFERATION (oestrogen usually inhibits osteoclasts)
          - Osteoporosis / frax
  - Vaginal dryness
  - Gynecomastia
  • GLACTORRHOEA
  • Low LIBIDO + INFERTILITY

Microprolactinomas are often asymp

167
Q

Prolactinoma Dx

A
  • Raised prolactin in blood
  • Raised Thyrotropin- releasing hormone (if 2ndry prolactinoma)
  • MRI BRAIN (classify)
168
Q

Prolactinoma Tx

A

Medical = DOPAMINE AGONISTS (oft enough to make tumour regress)

  • Bromocriptine
  • Cabergoline

Surgery if macro / not responsive to dopamine
+/- Radiotherapy

169
Q

Examples of congenital abnormalities of female reproductive tract

A
  • Bicornate uterus
  • Imperforate hymen
  • Transverse Vaginal septae
  • Vaginal hypoplasia + agenesis
170
Q

Bicornate uterus

A
  • uterus has 2 ‘horns’
  • Dx on USS
  • ADVERSE PREG outcomes tho USUALLY SUCCESSFUL PREG
    - Miscarriage
    - Prem birth
    - Malpresentation

Usually no specific Mx needed

171
Q

Imperforate hymen

A
  • no hole in hymen at entrance of vagina
  • Oft discovered when menstruation starts but menses unable to be expelled
    - Cyclical pelvic pain + cramping but NO bleeding
  • Dx with EXAMINATION
  • Tx = Surgical incision

If not treated - could lead to retrograde menstruation + endometriosis

172
Q

Transverse vaginal septae

A
  • Septum transversely across vagina
  • If perforate:
    - Menstruation can occur but difficulty with sex / tampons
  • If imperforate:
    - Similar to imperforate hymen
  • Associated with INFERTILITY / PREG COMPLICATIONS

Dx via exam, US / MRI
Tx = SURGICAL
- complications = vaginal stenosis / recurrance

173
Q

Vaginal hypoplasia / agenesis

A
  • Abnormally small vagina / NO vagina respectively
  • due to failure of Mullarian duct development
  • Can be associated with absent uterus / cervix as well
    • BUT OVARIES USUALLY NORMAL
      • Except in androgen insensitivity syndrome (internal testes)
  • Mx -> vaginal dilater over prolonged period; vaginal surgery etc
174
Q

Pelvic organ prolapse

A

Descent of one/more pelvic structures from normal anatomical position -> moving towards/through vaginal opening

  • common condition esp in postmenopausal + post childbirth
175
Q

RFx for pelvic organ prolapse

A

Anything that cuases stretched muscles / ligaments

  • Multiple vaginal delivaries
  • Instrumental, traumatic / prolonged delivery
  • Advanced age / postmenopausal
  • OBESITY
  • COPD -> Coughing OR Chronic constipation + straining (Chronic RAISED ABDOMINAL PRESSURE)
  • Hysterectomy
  • Heavylifting
  • Connective tissue disorders
176
Q

Pelvic organ prolapse Px

A
  • Feeling of ‘something coming down’
    - Dragging / Heavy sensation
    - Visible protrusion
  • LUTS / recurrent UTIs
  • Defecatory Sx e.g. constipation / tenesmus
  • Sexual dysfunction (pain altered sensation)
177
Q

Examination of pelvic organ prolapse

A
  • attempt various positions INCLUDING DORSAL + LEFT LATERAL
  • SIM’S SPECULUM
  • Ask to cough / bear down to assess full descent
178
Q

Types of pelvic organ prolapse

A

Anterior vaginal wall:

  • Cystocele (may lead to stress incontinence)
  • Urethrocele
  • Cystourethrocele

Posterior wall:

  • Enterocele (small intestine)
  • Rectocele

Apical wall:

  • Uterine prolapse
  • Vault prolapse (roof of vagina - common after hysterectomy)
  • (cervical prolapse?)
179
Q

Rectocele

A
  • associated with CONSTIPATION
  • Can develop faecal loading in prolapsed part
    -> Constipation, urinary retention (due to compression), palpable lump (women may push lump back themselves)
180
Q

Grades of uterine prolapse

A

Pelvic organ prolapse quantification (POP-Q):

  • 0 = Normal
  • 1 = Lowest part >1cm above interoitus (opening)
  • 2 = Lowest part within 1 cm of interoitus (above OR below)
  • 3 = Lowest part >1cm below interoitus but not full descended
  • 4 = Full descent + EVERSION of vagina

Anything extending beyond interoitus = uterine procidentia

181
Q

Mx of pelvic organ prolapse

A
  1. Conservative (if mild OR can’t tolerate other options)
    • Physio (PELVIC FLOOR EXERCISES)
    • Weight loss
    • Lifestyle changes (e.g. reduced caffine intake / incontinence pad for associated stress incontinence)
    • Treat associated Sx e.g. anticholinergics for stress incont
    • Vaginal oestrogen cream
  2. Vaginal pessaries (-> extra support + easily removed if needs)
    • Ring pessaries (around cervix)
    • Shelf + Gellhorn (flat disk with stem)
    • Cube
    • Donut
    • Hodge pessaries (almost rectangular - hooks around posterior cervix then extends into vagina)
      +/- Oestrogen cream to protect vaginal walls from irritation / erosion
  3. Surgery (e.g. hysterectomy)
182
Q

Possible complications of pelvic organ prolapse surgery

A
  • Pain, bleeding, infection, DVT, anaesthesia risk
  • Damage to bladder / bowel
  • Recurrance
  • Altered experience of sex
183
Q

Why are mesh repairs of pelvic organ prolapses no longer recommended

A

Many associated complications:

  • Chronic pain
  • Altered sensation
  • Dyspareunia
  • Abnormal bleeding
  • Urinary / bowel problems
184
Q

Types of miscarriage

A
  • Threatened (mild bleeding, pain may be absent, cervical is closed, foetus visible on uss)
  • Inevitable (heavy bleeding and pain, cervical os open, but foetus still currently inside)
  • Complete (all products of conception now fully expelled and cervical os usually closed again)
  • Missed miscarriage (foetus has died but cervical os remained closed so no symptoms)
185
Q

Causes of miscarriage

A

Foetal causes:

  • genetic disorder
  • abnormal development
  • placental failure

Maternal causes:

  • Physical uterine abnormality
  • Cervical incompetence
  • PCOS
  • Poorly controlled diabetes
  • Poorly controlled thyroid disease
  • Anti phospholipid syndrome
186
Q

Miscarriage definition

A

Loss of pregnancy before 24 weeks gestation

187
Q

Miscarriage Sx

A
  • Vaginal bleeding
  • pain (potentially more than with normal period)
  • Vaginal tissue loss
188
Q

Miscarriage Vs ectopic pregnancy

A

In ectopics, pain is usually the initial and dominant feature and any bleeding that occurs is less so than in miscarriages

Miscarriages are characterised by heavy bleeding and pain

189
Q

Miscarriage Ix

A
  • Transvaginal USS to check for any interuterine foetal components and check for foetal heartbeat
  • if not present start doing serial serum hCG measurements 48 hours apart
    • falling hCG = no more foetal development / miscarriage
    • plateau / small rise = possibly ectopic
    • normal rise = foetus growing normally but may still be ectopic
190
Q

Miscarriage Mx

A

Cannot be reversed so need to get rid of pregnancy

  • Expectant management = allow it to naturally expel
  • Medical = ** Misoprostol - synthetic prostaglandin** which stimulates expulsion of products of conception
    • Mifepristone is a progestérone receptor antagonist that is used to terminate pregnancy but it is also needed for a missed miscarriage
  • Surgical - dilation and curettage

Anti-D prophylaxis if mother is rhesus negative

191
Q

Recurrent miscarriages definition

A

Loss of 3 or more consecutive pregnancies

192
Q

Recurrent miscarriages definition

A

Loss of 3 or more consecutive pregnancies

193
Q

Investigating recurrent miscarriages

A
  • Bloods
    • Anti phospholipid antibodies
    • Thrombophilia screen
  • Cytogenic analysis of products of conception
    • karyotype the parents if this is abnormal
  • Pelvic USS (check for uterine abnormalities)
194
Q

Managing recurrent miscarriages

A

Depends on underlying cause

  • Genetic = genetic counseling, consider prénatal diagnosis or donor egg/sperm if still trying for kids
  • structural abnormality = some can be surgically treated
  • cervical incompetence = regular USS monitoring; can use cervical cerclage
  • PCOS - Unsure of best treatment, follow local guidelines
  • Anti phospholipid syndrome = heparin / low dose aspirin
  • thrombophilia = try heparin
  • Diabetes = improve glycaemic control
195
Q

Lifestyle factors affecting infertility

A
  • increasing age
  • obesity
  • smoking
  • excessive alcohol
  • illicit drug use
  • anabolic steroids and tight underwear more so in men
196
Q

Lifestyle factors affecting infertility

A
  • increasing age
  • obesity
  • smoking
  • excessive alcohol
  • illicit drug use
  • anabolic steroids and tight underwear more so in men
197
Q

Causes of infertility

A
  • Genetic (Turner’s / Kleinfelter’s)
  • Ovulation / Endocrine (pcos, pituitary tumor, Sheehan’s, hyperprolactinaemia, Cushing, premature ovarian failure)
  • Tubal abnormalities (congenital or adhesions)
  • Uterine abnormality
  • Endometriosis
  • Cervical abnormality
  • Testicular disorder
  • Ejaculatory disorder
198
Q

Infertility Ix

A
  • Serum progesterone 7 days before end of menstrual cycle (usually day 21)
  • assess TFTs, prolactin, androgens
  • semen analysis
  • Imaging studies (uss, hysterosalpingography, laproscopy)
199
Q

Examples of gonadotrophin releasing hormone analogues

A
  • Leuprorelin
  • Triptorelin

Works by activating GnRH receptors for prolonged period till they get desensitized - eventually leading to suppression of gonadotrophin (FSH and LH) secretion

Can be used to stimulate a menopausal state and switch off the ovaries e.g. to treat endometriosis (tho this is not the first line)

200
Q

How long do you need to wait to do a pap smear after giving birth / having a miscarriage

A

3 months

201
Q

Define pre-menstrual syndrome

A

Cluster of psychological, physical + behavioural Sx occuring in the LEUTEAL pahase of the menstrual cycle which causes DITRESS / DISRUPTION to patient’s life

202
Q

PMS Sx

A

Varies widely but common Sx include:

  • Mood swings + irritability
  • Depression + anxiety
  • Fatigue + sleep problems
  • Change in appetite + food cravings
  • Difficulty concentrating
  • Physical Sx e.g. bloating, breast tenderness, headaches, joint / muscle pain
203
Q

PMS DDx

A
  • Tyroid disease
  • Chronic fatigue syndrome
  • Depression / anxiety disorders
204
Q

PMS Dx

A

Clinical Dx
- Sx diary for at least 2 menstrual cycles can be helpful

Do further investigations if uncertain / suspect other conditions

205
Q

PMS Mx

A

Conservative:

  • Dietary modification
    • LESS fat, sugar, caffeine, alcohol
    • MORE fibre, fruit + more frequent snacks
  • Increase exercise
  • Vitamin supps (vit B)
  • Relaxation techniques to reduce stress
  • CBT

Pharm:

  • cOCP (with short / no pill free interval to avoid progestogenic side effects)
  • Danazol (synthetic steroid + pituitary GnRH inhibitor)
  • Transdermal oestrogen
  • GnRH analogues (menopausal state)
  • Antidepressants (esp SSRIs / SNRIs)
206
Q

Investigations for overactive bladder syndrome

A
  • Urinalysis + culture to rule out infection
  • Frequency/volume chart - to assess severity
  • Urodynamics - to evaluate bladder muscle function (e.g. cystometry, pressure flow study / voiding pressure study)
207
Q

Overactive bladder syndrome Mx

A
  • Behavioural modifications:
    • reduce oral intake, avoid caffeine + alcohol
  • Bladder retraining
  • ANTICHOLINERGICS
    • Oxybutynin
    • Solifenacin
  • Vaginal oestrogens if urogenital atrophy is a likely factor
  • Botulism toxin if REFRACTORY
208
Q

Gravidity definition

A

Number of times person has been pregnant REGARDLESS of outcome, INCLUDING current pregnancies.

Mutliple pregnancies are counted as 1 event.

209
Q

Parity definition

A

Number of times person has given birth to a pregnancy with gestational age at least 24+0 weeks, regardless of if they were alive or still born, or method of delivery.

Multiple pregnancies are counted as 1 event.

NB if they have had terminations/miscarriages before 24wks, can write it as
- number or of births (+ terminations/miscarriages)

210
Q

Termination of pregnancy legal time frame + Act

A

Less than 24 wks gestation

Can be more if meets certain criteria:

  • continuing preg would cause grave permanent injury to physical + mental wellbeing of woman
  • Continuing preg would involve greater risk to the life of the woman
  • Substantial risk child would suffer from physical or mental abnormalites and be seriously handicapped (e.g. spina bifida, Down’s)
211
Q

Medical termination of pregnancy

A
  • Mifepristone (progesterone antagonist) blocks progesterone needed for preg to continue
    • oft 200 mg orally
  • Misoprostol (prostaglandin analogue) causes smooth muscle contraction to expel uterine contents
    • oft 800 micrograms vaginal, buccal, or siblingual

Given within 24-48 hours of each other

212
Q

Surgical termination of pregnancy

A
  • Suction termination
    • can be done if less than 14 wkjs preg
  • Dilation + evacuation / Curettage
213
Q

Risk factors for prelabour rupture of membranes at term

A
  • infection
  • inflam
  • stress
  • mechanical stress
214
Q

Prelabour rupture of membranes at term Sx

A
  • Foul smelling / greenish amniotic fluid
  • Maternal fever
  • Reduced foetal movements
215
Q

DDx for PROM

A
  • Urinary incontinence
  • Vaginal discharge / infection (can be ruled out if no other infective sx / no infected seeming discharge)
216
Q

Forms of emergency contraception

A

Oral progesterone receptor modulators

  • Levonorgestrel (1.5mg)
    • Needs to be taken within 72 hours after unprotected sex (efficacy decreases with time)
    • One-off tablet; can’t be used long-term
      • but can start hormonal contraception immediately after
    • Safe and well tolerated - can disrupt menstrual cycle; sometimes causes vomiting
      • If vomiting within 3 hours of taking pill -> repeat dose
  • Ulipristal (EllaOne) - (30mg)
    • Needs to be taken within 5 days after unprotected sex
    • One off tablet; can’t be used long-term
      • can disrupt effectiveness of hormonal contraception so need to use barrier contraception for 5 days after
    • Can cause side effects in patients with ASTHMA
    • also need to stop breastfeeding for a week after taking ulipristal (don’t have to with levonorgestrel)

Copper Intrauterine device

  • most effective
  • Needs to be inserted within 5 days of unprotected sexual intercourse OR up to 5 days after estimated ovulation date (whichever comes later)
  • Can be left in situ to provide long-term contraception
  • can give Abx if patient at high risk of STI
217
Q

From which day post-partum is contraception required

A

day 21 after giving birth

218
Q

Exmples of post-partum contraception

A

Progesterone only pill

  • Can be started at any point post-partum
    • need to use additional contraception for 2 days after day 21
  • only a small amount of progesterone enters breastmilk so it is safe to breastfeed while on POP

cOCP

  • ABSOLUTELY CONTRAINDICATED if BREASTFEEDING less than 6 wks post-partum (UKMEC cat 4)
  • Some risk present if using while breastfeeding between 6wks - 6 months but generally advantages outweigh risk (UKMEC cat 2)
    • can potentially reduce breast milk production
  • CONTRAINDICATED in FIRST 21 DAYS for all mothers due to VTE RISK
  • If using after 21 days - need to use additional contraception for 7 days

IUD

  • needs to be inserted EITHER within 48 HOURS post-partum OR postponed till 4 WKS post-partum (can’t insert from 2 days till 4 weeks)

Lactational amenorrhoea

  • less effective
  • only 98% effective if:
    • FULLY breastfeeding
    • AMENORRHOIC
    • less than 6 months post-partum
219
Q

Examples of UKMEC 3 conditions for using cOCP

A
  • more than 35 years old and smoking less than 15 cigarettes/day
  • BMI > 35 kg/m^2*
  • family history of thromboembolic disease in first degree relatives < 45 years
  • controlled hypertension
  • immobility e.g. wheel chair use
  • carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
  • current gallbladder disease
  • DM diagnosed > 20 years ago (tho if more severe = cat 4)
220
Q

UKMEC 4 conditions for cOCP use

A
  • more than 35 years old and smoking more than 15 cigarettes/day
  • migraine with aura
  • history of thromboembolic disease or thrombogenic mutation
  • history of stroke or ischaemic heart disease
  • breast feeding < 6 weeks post-partum
  • uncontrolled hypertension
  • current breast cancer
  • major surgery with prolonged immobilisation
  • positive antiphospholipid antibodies (e.g. in SLE)
221
Q
A
222
Q

Recurrent thrush definition, ix and mx

A
  • 4 or more per year
  • check if compliant with treatment
  • HIGH VAGINAL SWAB MS+C +/- blood glucose to check for diabetes
  • exclude differentials e.g. lichen sclerosus
  • try INDUCTION MAINTENANCE RÉGIME
    • Oral FLUCONAZOLE every 3 days for 3 doses
    • oral FLUCONAZOLE every week for 6 months

Phase 3a (26 decks)

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