Gynae Flashcards
Adenomyosis tx
(commonly multiparous women near end of reproductive age)
symptomatic - tranaxamic acid for menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy - definitive tx!!
Amenorrhoea definition
primary: by 15yrs if normal secondary sexual characteristics (breasts), 13 if not
secondary: cessation for 3-6 if normal & regular, 6-12 if hx of oligomenorrhoea
cervical cancer RFs?
HPV, serotypes 16,18,33 !!
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill
Cervical ca screening for who?
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
pregnancy- delayed until 3 months post-partum, unless missed screening or previous abnormal smears.
HPV screening pathway?
HPV?
negative -> return to recall
Positive -> cytology
- abnormal -> colposcopy
- normal -> repeat at 12mos -> repeat at 12mos
- if negative HPV at anypoint = normal recall
- If cytology abnormal = colposcopy
- If +ve HPV, -ve cytology even at 24mos = colposcopy
Inadequate
- repeat at 3 mos
- 2 consecutive inadequate = colposcopy
If colposcopy shows cervical intraepithelial neoplasia = Large loop excision of transformation zone (LLETZ)
cervical ca staging
FIGO staging
1A - cervix only: microscopic visibility and <7mm wide
1b - cervix only: clinically visibile or >7mm wide
2 - beyond cervix, not to the pelvic wall
3 - to the pelvic wall
4 - beyond the pelvis/ bladder or rectum involvement
if causing hydronephrosis or a non-functioning kidney -> automatically stage 3
cervical ca mx
1a
- gold standard = hysterectomy +/- lymph node clearance
- if wanting to maintain fertility = cone biopsy with negative margins
- node clearance and evaluation
—
1b
- & radiotherapy with concurrent chemotherapy
- radical hysterectomy with pelvic lymph node dissection
2 & 3
- Radiation with concurrent chemotherapy
4 - Radiation and/or chemotherapy, maybepalliative
Delayed puberty causes
(short v normal stature)
short
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome
Normal
- polycystic ovarian syndrome
- androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome
Dysmenorrhoea Management
- NSAIDs such as mefenamic acid and ibuprofen
- combined oral contraceptive pills
If secondary Dysmenorrhoea (develops after a couple years) -> refer to gynae for ix
Ectopic pregnanacy mx
ix: TVUSS
Mx
Expectant (monitoring over 48hrs)
- <35mm, no fetal HB, hcG <1000 , unruptured, asymptomatic
Medial (methotrexate)
- <35mm, hCG <1500, no fetal hb, minimal pain
Surgical (salpingectomy, salpingostomy if infertility RFs)
- >35mm, fetal HB, hCG >5000, ruptured, pain
endometrial ca RFs
excess oestrogen: (nulliparity, early menarche, late menopause, unopposed oestrogen)
metabolity syndrome (obesity, DM, PCOS)
tamoxifen
hereditary non-polyposis colorectal carcinoma (Lynch syndrome)
(protective factors: multiparty, COCP, smoking)
endometrial ca 2ww?
All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
endometrial ca ix & mx
TVUSS
- if endometrial thickness is < 4 mm -> hysteroscopy with endometrial biopsy
Mx
- total abdominal hysterectomy with bilateral salpingo-oophorectomy
- if high risk - postoperative radiotherapy also
- Progestogen therapy -> frail elderly women
endometrial hyperplasia mx
simple endometrial hyperplasia without atypia: high dose progestogens (IUS) with repeat sampling in 3-4 months.
atypia: hysterectomy is usually advised
Endometriosis ix & mx
ix
- gold standard = laparoscopy
Mx (depends on clinical severity rather than laparoscopy)
- NSAID/ paracetamol - 1st line
- COCP or progesterones - 2nd line
- GnRH analogues
- laparoscopic excision / endometriosis ablation & adhesiolysis = improve conception chance
- endometrioma
classification of FGM
T1 - clitoris and/or the prepuce (clitoridectomy).
T2 - clitoris and the labia minora, with or without labia majora (excision).
T3 - Narrowing of the vaginal orifice
T4 - All other harmful procedures
menorrhagia mx
No contraception required
- Mefenamic acid or tranexamic acid
Requires contraception
- 1st line: IUS (mirena)
- COCP
- long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
admission criteria for Hyperemesis gravidarum
continued N&V & unable to keep down liquids or oral antiemetics
continued N&V w ketonuria/weight loss >5% despite oral antiemetic tx
confirmed or suspected comorbidity
Hyperemesis gravidarum dx
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
Pregnancy-Unique Quantification of Emesis (PUQE) -> severity scoring systems
Hyperemesis gravidarum mx
simple: rest, no triggers, plain food, ginger, acupuncture
- 1st line: antihistamines: oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine
- drug doxylamine/pyridoxine (vB6)
- 2nd - oral ondansetron (small risk of cleft lip/palate)
- oral metoclopramide or domperidone - must not be used for more than 5 days due to extrapyramidal SEs
- admission for IV hydration
Infertility ix
semen analysis
serum progesterone 7 days prior to expected next period
<16 - repeat, refer to specialist
16-30- repeat
>30nmol/l - ovulation
Key counselling points
- folic acid
- BMI 20-25
- regular sexual intercourse every 2 to 3 days
- smoking/ drinking advice
Perimenaupausal contraception duration?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Contraindications to HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Medical mx of miscarriage
oral mifepristone - progesterone receptor antagonist: weakens attachment to endometrial wall & cervical softening and dilation & induction of uterine contractions
48 hours later -> misoprostol (vaginal, oral or sublingual) - prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
If bleeding not stopped w/in 48hrs of misprostol - contact healthcare professional
incomplete miscarriage- single dose misoprostol
antiemetics & painrelief
pregnancy test at 3wks
Ovarian ca RFS
FH: BRCA1 or the BRCA2 gene
many ovulations: early menarche, late menopause, nulliparity
FIGO staging for ovarian cancer
I - limited to 1 or both ovaries
II - limited to pelvis
III - limited to abdomen (including regional lymph nodes)
IIII - distant metastases outside the abdomen (eg lungs)
which ovarian cysts are suspicious of ca
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
types of physiological cysts?
follicular - commonest type, non-rupture of dominant follicle or no atresia of non-dominant. Regress after several menstrual cycles
corpus luteum cyst - corpus luteum doesn’t break down & fills w blood/fluid. more likely to present with intraperitoneal bleeding than follicular cysts
most common benign ovarian tumour in under 30?
Dermoid cyst a.k.a mature cystic teratomas -> it is a Benign germ cell tumour
(immature teratoma is malignant)
lined with epithelial tissue and hence may contain skin appendages, hair and teeth
usually asymptomatic. Torsion is more likely than with other ovarian tumours
(Serous cystadenoma is most common in all)
Benign epithelial tumours types
Arise from the ovarian surface epithelium
Serous cystadenoma - most common benign epithelial tumour , resembles ovarian cancer (serous carcinoma), lined by ciliated cells (similar to Fallopian tube)
Mucinous cystadenoma - large and may become massive. ruptures may cause pseudomyxoma peritonei
Brenner tumor - Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
sandstorm vs whirlpool sign
USS findings
sandstorm - Complete hydatidiform mole
whirlpool - Ovarian torsion
Malignant epithelial tumours types
Serous cystadenocarcinoma - Often bilateral
Psammoma bodies seen (collection of calcium)
Mucinous cystadenocarcinoma - May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
Malignant germ cell tumour types
more common in adolescent girls
Immature teratoma (Mature teratoma is benign)
Dysgerminoma - Most common malignant germ cell tumour
Histological appearance similar to testicular seminoma. RF: Turner’s syndrome. Secrete hCG and LDH
Yolk sac tumour - secrete AFP
Schiller-Duval bodies on histology are pathognomonic
Choriocarcinoma - Rare tumour, spectrum gestational trophoblastic disease, increased hCG levels, early haematogenous spread to the lungs
Sex cord-stromal tumour types benign & malignant
Granulosa cell tumour - malignant - Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults. Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
Benign:
Sertoli-Leydig cell tumour- Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome
Fibroma - Associated with Meigs’ syndrome (ascites, pleural effusion). Solid tumour consisting of bundles of spindle-shaped fibroblasts. Occur around the menopause, classically causing a pulling sensation in the pelvis
Krukenberg tumour?
Malignant Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma in ovary
three main categories of anovulation/ ovulatory dysfunction
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). (ovarian induction will not work & ivf w doner eggs is needed)
Types of ovarian inductions
- exercise & weight loss- 1st line if PCOS & overweight
- Letrozole - aromatase inhibitor -> less eostrogen -> less pituitary neg feedback -> increased FSH & follicular development - 1st line medical therapy for PCOS
- Clomiphene citrate - selective estrogen receptor modulator
- Gonadotropin therapy- usually for hypogonadotropic hypogonadism. In PCOS, try is others fail
Pelvic inflammatory disease (PID) causes
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
PID ix & mx
high vaginal swab - usually negative tho so doesn’t have to be +ve
screen for Chlamydia and Gonorrhoea
Mx
- oral ofloxacin + oral metronidazole OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Remove IUD but in mild may be left in
Ix & dx PCOS
- pelvic ultrasound: multiple cysts on the ovaries
- raised LH:FSH ratio is a ‘classical’ feature but not always
- prolactin may be normal or mildly elevated
- testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
- sex hormone-binding globulin (SHBG) is normal to low in women with PCOS
check for impaired glucose tolerance
Dx: Rotterdam criteria
Rotterdam criteria ?
diagnosis of PCOS can be made if 2 of the following 3 are present:
infrequent or no ovulation- oligomenorrhoea
clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
PCOS mx
general
- weight loss if appropriate
- if needs contraception - COCP may help cycle regulation
Hirsutism and acne
- COCP: usually 3rd gen or co-cyprindiol
- eflornithine
- spironolactone, flutamide and finasteride may be used under specialist supervision
Infertility
- weight reduction
- Letrozole, metformin, clomifene or a combination
- gonadotrophins
endometrial cancer 2ww
women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer
Premature ovarian insufficiency def & ix
onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
Premature ovarian insufficiency mx
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes
PMS tx
mild - usual lifestyle -sleep, exercise, smoking and alcohol,
regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate - new-generation combined oral contraceptive pill (COCP) - e.g. Yasmin
severe - selective serotonin reuptake inhibitor (SSRI)
Semen analysis requirements
should be performed after a minimum of 3 days and a maximum of 5 days abstinence.
who can authorise abortion
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
must agree that:
- pregnancy has not exceeded its 24th week
- greater harm than risk to woman or unborn child
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
Abortion procedure?
under 24 weeks
Medical
- mifepristone & 48 hrs after- misoprostol. pregnancy test w hcg level (multi-level) in 2 wks
Surgical
- use of transcervical procedures - manual vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E) & cervical priming with misoprostol +/- mifepristone
- following a surgical abortion, an intrauterine contraceptive can be inserted
- women are offered a choice between medical or surgical abortion up to and including 23+6 weeks’ gestation
- after 9 weeks medical abortions become less common
- before 10 weeks medical abortions are usually done at home
urge incontinence mx
bladder retraining - 6 wks
bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) - in frail elderly patients because anticholinergic side-effects
stress incontinence mx
pelvic floor muscle training- 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine ( noradrenaline and serotonin reuptake inhibitor) - if they decline surgical procedures
fibroids mx
asymptomatic - nothing, periodic review
menorrhagia
- IUS - not if distortion of uterine cavity
- NSAIDs- mefamicn acid
- tranexamic acid
- COCP
- oral progesterons
- injectable progesterone
to shrink/ remove
medical - GnRH agonists (only used short term due to menopausal symptoms & loss of bone mineral density)
surgical - myomectomy, esp if fertility needs to be preserved
- hysteroscopic endometrial ablation, hysterectomy
uterine artery embolization
Vaginal candidiasis tx
high vaginal swab is not routinely indicated if clinical features
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
If recurrent - 4 or more episodes per year -> confirm w high vaginal swab & blood glucose test to exclude diabetes. rule out lichen sclerosus
- consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Urinary incontinence (UI) ix
- bladder diaries - minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
