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PM Finals > Gynae > Flashcards

Gynae Flashcards

1
Q

Adenomyosis tx

A

(commonly multiparous women near end of reproductive age)

symptomatic - tranaxamic acid for menorrhagia

GnRH agonists

uterine artery embolisation

hysterectomy - definitive tx!!

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2
Q

Amenorrhoea definition

A

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

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3
Q

cervical cancer RFs?

A

HPV, serotypes 16,18,33 !!
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill

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4
Q

Cervical ca screening for who?

A

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.

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5
Q

HPV screening pathway?

A

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)

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6
Q

cervical ca staging

A

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

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7
Q

cervical ca mx

A

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

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8
Q

Delayed puberty causes
(short v normal stature)

A

short
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome

Normal
- polycystic ovarian syndrome
- androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome

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9
Q

Dysmenorrhoea Management

A
  1. NSAIDs such as mefenamic acid and ibuprofen
  2. combined oral contraceptive pills

If secondary Dysmenorrhoea (develops after a couple years) -> refer to gynae for ix

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10
Q

Ectopic pregnanacy mx

A

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

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11
Q

endometrial ca RFs

A

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)

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12
Q

endometrial ca 2ww?

A

All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway

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13
Q

endometrial ca ix & mx

A

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

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14
Q

endometrial hyperplasia mx

A

simple endometrial hyperplasia without atypia: high dose progestogens (IUS) with repeat sampling in 3-4 months.

atypia: hysterectomy is usually advised

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15
Q

Endometriosis ix & mx

A

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

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16
Q

classification of FGM

A

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

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17
Q

menorrhagia mx

A

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.

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18
Q

admission criteria for Hyperemesis gravidarum

A

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

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19
Q

Hyperemesis gravidarum dx

A

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

Pregnancy-Unique Quantification of Emesis (PUQE) -> severity scoring systems

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20
Q

Hyperemesis gravidarum mx

A

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
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21
Q

Infertility ix

A

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

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22
Q

Perimenaupausal contraception duration?

A

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

23
Q

Contraindications to HRT

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

24
Q

Medical mx of miscarriage

A

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

25
Q

Ovarian ca RFS

A

FH: BRCA1 or the BRCA2 gene

many ovulations: early menarche, late menopause, nulliparity

26
Q

FIGO staging for ovarian cancer

A

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)

27
Q

which ovarian cysts are suspicious of ca

A

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

28
Q

types of physiological cysts?

A

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

29
Q

most common benign ovarian tumour in under 30?

A

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)

30
Q

Benign epithelial tumours types

A

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.

31
Q

sandstorm vs whirlpool sign

A

USS findings

sandstorm - Complete hydatidiform mole

whirlpool - Ovarian torsion

32
Q

Malignant epithelial tumours types

A

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)

33
Q

Malignant germ cell tumour types

A

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

34
Q

Sex cord-stromal tumour types benign & malignant

A

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

35
Q

Krukenberg tumour?

A

Malignant Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma in ovary

36
Q

three main categories of anovulation/ ovulatory dysfunction

A

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)

37
Q

Types of ovarian inductions

A
  1. exercise & weight loss- 1st line if PCOS & overweight
  2. Letrozole - aromatase inhibitor -> less eostrogen -> less pituitary neg feedback -> increased FSH & follicular development - 1st line medical therapy for PCOS
  3. Clomiphene citrate - selective estrogen receptor modulator
  4. Gonadotropin therapy- usually for hypogonadotropic hypogonadism. In PCOS, try is others fail
38
Q

Pelvic inflammatory disease (PID) causes

A

Chlamydia trachomatis
+ the most common cause

Neisseria gonorrhoeae

Mycoplasma genitalium

Mycoplasma hominis

39
Q

PID ix & mx

A

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

40
Q

Ix & dx PCOS

A
  • 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

41
Q

Rotterdam criteria ?

A

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)

42
Q

PCOS mx

A

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

43
Q

endometrial cancer 2ww

A

women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer

44
Q

Premature ovarian insufficiency def & ix

A

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

45
Q

Premature ovarian insufficiency mx

A

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

46
Q

PMS tx

A

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)

47
Q

Semen analysis requirements

A

should be performed after a minimum of 3 days and a maximum of 5 days abstinence.

48
Q

who can authorise abortion

A

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

49
Q

Abortion procedure?

A

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
50
Q

urge incontinence mx

A

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

51
Q

stress incontinence mx

A

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

52
Q

fibroids mx

A

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

53
Q

Vaginal candidiasis tx

A

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

54
Q

Urinary incontinence (UI) ix

A
  • 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

PM Finals (21 decks)

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