Gynae Flashcards
Investigations for abnormal uterine bleeding
Bedside
- General examination looking for signs of anaemia and abdominal masses
- Urine pregnancy test
- Bimanual examination
- Speculum
General
- Observations:
- BP
- HR
Bloods
- FBC – anaemia
- U&Es – dehydration
- Coag screen
Imaging:
- TVUSS
Ddx for abnormal uterine bleeding
- Dysfunctional uterine bleeding
- Fibroids
- Endometriosis
- Endometrial cancer
- Miscarriage
Mx of Fibroids/Endometriosis/DUB
- Medical:
- 1st line: LNG-IUS (if endometrial cavity not distorted)
- Tranexamic acid + mefenamic acid if dysmenorrhoea
- COCP or cyclical oral progestogens
- Ferrous Sulphate
- Surgical:
- Myomectomy (+/- GnRH agonist)
- Uterine artery embolization
- Laparoscopic ablation in endometriosis
Differentials for postmenopausal bleeding
- Endometrial cancer
- Atrophic vaginitis
- Cervical/vulval cancer
- Cervical polyps
Investigations for postmenopausal bleeding
GP
- Abdominal examination looking for masses
- Bimanual examination
- Speculum
- 2 week wait referral:
- TVUSS
- Hysteroscopy and biopsy
Management of endometrial cancer
- Localised disease:
- TAH +BSO
- Progesterone therapy if unable to tolerate surgery
- Severe disease:
- Adjuvant radiotherapy
RF for endometrial cancer
- Obesity
- Nulliparity
- Early menarche and late menopause
- Unopposed oestrogen therapy
- Diabetes mellitus
- Tamoxifen
- PCOS
- HNPCC
Subtypes of endometrial cancer
- Endometrioid
- Mucinous
- Secretory
Type 2
* Serous
* Clear Cell
Figo staging of endometrial cancer
Differentials for chronic pelvic pain
- Endometriosis
- PID
- Adenomyosis
Investigations for chronic pelvic pain
- Bedside:
- Abdominal examination
- Bimanual looking for cervical excitation and adnexal tenderness
- Speculum
- High vaginal swabs
- Endocervical swabs
- Urine dipstick and MC&S
- Bloods:
- WCC
- CRP
- HIV serology
- Imaging:
- TVUSS
- Adenomyosis – venetian blind appearance
- MRI
- Gold standard adenomyosis
- TVUSS
- Laparoscopic exploration - endometriosis
Endometriosis Management
- Medical:
- 1st line: LNG-IUS
- Tranexamic acid + mefenamic acid if dysmenorrhoea
- COCP or cyclical oral progestogens
- Ferrous Sulphate
- Surgical:
- Laparoscopic ablation in endometriosis
- Hysterectomy in adenomyosis
PID Management
PID management
- Medical:
- IM ceftriaxone 1g stat
- 2 weeks PO doxycycline 100mg BD and metronidazole 400mg BD
- Surgical:
- USS guided drainage of abscess
- Laparoscopic adhesiolysis
Complications of PID
- Fitz-Hugh-Curtis syndrome
- Ectopic pregnancy in future
- Tubal infertility
- Chronic pelvic pain
Investigations for discharge
- Bedside:
- Abdominal examination
- Bimanual looking for cervical excitation and adnexal tenderness
- Speculum – strawberry cervix?
- High vaginal swabs
- Endocervical swabs
- Urine dipstick and MC&S
- Bloods:
- WCC
- CRP
- HIV serology
- Imaging:
- TVUSS
Management of chlamydia, gonorrhoea, BV, TV and syphilis
- Chlamydia and gonorrhoea:
- IM ceftriaxone 1g stat
- 2 weeks PO doxycycline 100mg BD and metronidazole 400mg BD
- BV and TV
- Metronidazole 500mg PO for 7 days
- Syphilis
- IM benzylpenicillin
Investigations for urinary incontinence
- Examination – abdominal masses and calculate BMI
- Bimanual
- Speculum
- Urine dipstick and MC&S
- Urinary studies:
- Bladder diary
- Urodynamic studies
Management of urogenital prolapse
- conservative: weight loss, pelvic floor muscle exercises, stop smoking, avoid heavy lifting
- ring pessary
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
Management of stress incontinence
- Pelvic floor exercises
- Duloxetine
- Retropubic mid-urethral tape procedures
Management of urge incontinence:
- Bladder retraining
- Oxybutynin/tolterodine
- Mirabegron
Which complex of muscles makes up the bulk of the perineum?
Levator ani which is made of the:
- Puborectalis
- Pubococcygeus
- iliococcygeus
What are the four stages of uterine prolapse?
- Stage 1: cervix is in the upper half of the vagina
- Stage 2: cervix is at the introitus
- Stage 3: cervix protrudes out of the introitus
- Stage 4: procidentia – uterus is outside the vagina
Risk factors for urinary incontinence
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
Investigations for ovarian cancer
- Examination: abdominal mass
- Speculum
- Bloods:
- FBC – anaemia
- U&Es – obstruction and renal failure
- LFTs
- Clotting factors
- CA-125
- Imaging:
- TVUSS
- MRI for surgical planning
- Calculate RMI and if >250 refer to MDT
Management of ovarian cancer
- Surgical:
- Staging laparotomy à TAH/BSO and assessment of pelvic lymph nodes
- Advanced disease à TAH/BSO + primary debulking of omentum
- Adjunctive platinum based chemotherapy
Risk factors for ovarian cancer
- Family history: mutations of the BRCA1 or the BRCA2 gene
- Age
- HRT
- Endometriosis
- Smoking
- Overweight
- Potentially PCOS
- Many ovulations
- Early menarche
- Late menopause
- Nulliparity
Most common histological subtype of ovarian cancer
Serous cystadenocarcinoma
Describe the FIGO staging of ovarian cancer
- Confined to ovaries
- Confined to pelvis
- Confined to abdominal peritoneum/positive retroperitoneal or inguinal lymph nodes
- Distant mets
Causes of secondary amenorrhoea
*
- Anorexia/low BMI
- Hypo or hyperthyroidism
- PCOS
- Post hormonal contraceptive especially progesterone injection
- Asherman’s syndrome or cervical stenosis
Investigations for secondary amenorrhoea
- Examination: signs of anorexia e.g. muscle wasting and lanugo hair
- Urine pregnancy test
- Bloods:
- FBC – anaemia
- Hormone profile
- Low gonadotrophins à premature ovarian failure
- Prolactin à prolactinoma
- Raised androgens/testosterone à PCOS
- Oestradiol
- TFTs
How do you manage PCOS for patients trying to get pregnant?
- Weight loss
- Clomiphene citrate
- +/- metformin
- Letrozole
- Laparoscopic ovarian drilling
- Gonadotrophins
Management of subfertility caused by tubal disease?
- Salpingography + tubal catheterisation
- Hysteroscopic tubal cannulation
- Hysteroscopic adhesiolysis
Causes of infertility
- male factor 30%
- unexplained 20%
- ovulation failure 20%
- tubal damage 15%
- other causes 15%
Who would you offer intrauterine insemination to?
- People who can’t have vaginal intercourse due to physical or psychosexual disability
- Same sex couples
- Conditions that require specific consideration in relation to method of conception e.g. after sperm washing of HIV+ man
What is prediction of IVF success based off?
- Female age
- Number of previous Tx cycles
- Previous pregnancy history
- BMI
- Lifestyle
- Alcohol
- Smoking
- Caffeine
Symptoms of menopause
- Vasomotor symptoms:
- Hot flushes
- Night sweats
- Palpitations
- Urogenital symptoms:
- Vaginal dryness/itching
- Dyspareunia
- Urinary frequency, urgency, dysuria and frequent UTIs
- Psychological symptoms:
- Mood fluctuations
- Insomnia
- Depression
Diagnosis of hyperemesis gravidarum
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
