Gynae Flashcards
What are the branches of the internal iliac artery?
Posterior branch:
- iliolumbar
- lateral sacral(s)
- superior gluteal
Anterior branch
- umbilical (to superior vesical)
- obturator
- vaginal
- uterine
- middle rectal
- inferior gluteal
- internal pudendal
What is the most common cause of vaginal discharge in prepubertal girls?
Vulvovaginitis (often non-specific secondary to poor hygiene)
Also vulval dermatoses and foreign bodies
Management of vulvovaginitis in prepubertal girls?
Hygiene measures (avoid irritants, loose clothing, cotton underwear, wiping front to back), emollients and barrier creams.
Penicillin / erythro for GAS.
Definition of precocious puberty
Onset of pubertal development < 8years
Onset of menarche before 9 years
Causes of precocious puberty?
Central (80%) - idiopathic 75%, brain tumour/cyst/hydroceph
Brain trauma/malformations
Peripheral (pseudo) 20% - Hormone producing tumour, CAH, hypothyroid, exogenous estrogen, McCune Albright
Management of central precocious puberty
Only treat if young with rapid progression (shortened predicted height)
- GnRH analogues, eg zoladex Q3monthly
- monitor 3-6m with pubertal staging, annual bone age XR
Definition of delayed puberty
Absence of sexual characteristics by age 13
No menstruation by 15
Causes of hypogonadotrophic hypogonadism (for delayed puberty)
Constitutional delay
Chronic illness / suppression of the HPO axis (anorexia, exercise etc)
Kallman’s syndrome
Hydrocephalus, CNS tumours, adenoma
Panhypopituitarism
Can treat with pulsatile GnRH via pump
Causes of hypergonadotrophic hypogonadism (for delayed puberty)
Abnormal gonadal development
Turners or Swyers syndrome
Premature ovarian failure
Chemo/radiation
Autoimmune
Infections
Management: Administer small doses of oestradiol and increase 6m until BTB, then add progesterone
What is Swyers syndrome?
46 XY with genetic mutation in SRY gene in 10%
- phenotypically female
- failure of testes to develop, therefore no testosterone or AMH (tubes + uterus present)
- 30% risk of gonadal malignancy
Classical features of Turners syndrome
- appearance
- associated conditions
Short, low hairline, neck folds, widely spaced nipples, elbow deformity, naevi, lymphoedema
Aortic coarctation, renal anomalies, rudimentary ovaries and poor breast development (delayed puberty).
Insulin resistance, hypothyroidism
Management of Turners syndrome
Growth hormone to improve height
Induction of puberty with oestradiol + progesterone once bleeding
Long term HRT
Childbearing possible with ovum donation
Gonadectomy if any Y material
What is the Rotterdam Criteria?
For PCOS - 2 out of 3 of:
1. Oligo or anovulation (<21 to >35 days, or less than 8 cycles per year)
2. Clinical and/or biochemical signs of hyperandrogenism (acne/hirsutism, elevated free and total testosterone)
3. PCO morphology on USS (>20 follicles 2-9mm per ovary and/or ovarian volume >10ml)
4. Exclusion of thyroid disease, hyperprolactinaemia, non-classic CAH, and androgen secreting tumours
Biochemical findings in PCOS
Increased free testosterone
DHEAS/androstenedione may be elevated
Decreased SHBG
Increased LH to FSH ratio
Mildly increased prolactin
Increased oestrogen and decreased progesterone.
Goals of management for PCOS (4)
- Correct hyperandrogenism
- Correct cycles
- Manage fertility problems
- Improve long term health - risk of depression/anxiety, diabetes, CVD, and endometrial hyperplasia
+/- cosmetic symptoms
Causes of hypergonadotrophic hypogonadism (for male infertility)
High FSH, low/normal testosterone
Congenital:
- Androgen insensitivity
- Klinefelters (XXY)
- Y chromosome microdeletions
Acquired:
- Infection (mumps)
- Trauma / torsion
- Chemoradiation
- Drugs, lifestyle + exposure to heat
Normal semen analysis (6)
Volume >1.5ml
Count > 40 million
Concentration >16mill/ml
Motility >40%
Normal morphology >4%
pH > 7.2
Investigations for male infertility
Semen analysis
If semen analysis abnormal - FSH/testosterone +/- karyotype.
Post-ejaculatory urine sample (retrograde ejaculation), TSH/prolactin.
Hep B, C and HIV screening if contemplating IVF
What are the absolute and relative contraindications for MHT?
Absolute:
1. Breast, endometrial or other hormone dependent cancer (past or present)
2. Undiagnosed abnormal vaginal bleeding
3. Current / untreated VTE
Relative:
1. Established CVD / high risk CVD
2. Previous VTE
3. Active liver disease or active SLE
4. Untreated HTN
5. Possibly migraine with aura
What is a T score?
How your BMD compares to your expected BMD (for age/ethnicity/gender) - reported as no. of SD from the mean
-1 to +1 is normal
-2.5 to -1 is osteopenia
Less than -2.5 is osteoporosis
What is Stage 1a endometrial cancer?
Tumour confined to corpus, no or less than 1/2 myometrial invasion
What is Stage 1b endometrial cancer?
Tumour confined to corpus, equal or more than 1/2 myometrium involved.
What is Stage II endometrial cancer?
Tumour invades the cervical stroma but not beyond the uterus
What is Stage III endometrial cancer?
Local and/or regional spread of the tumour
IIIa = Invades serosa and/or the adnexa
IIIb = Vaginal involvement and/or parametrial involvement
IIIc = Positive nodes
What is Stage IVa Endometrial cancer
Invasion of the bladder or bowel
Radiological staging for Endometrial cancer?
MRI pelvis + CXR for grade 1-2 endometrioid
CT CAP or PET scan for high grade
What is the adjuvant therapy recommended for Endometrial Ca with intermediate/high risk factors (e.g stage 1b)
Adjuvant vaginal brachytherapy - excellent vaginal control without impacting QoL
Definition of endometrial hyperplasia
Disordered proliferation of endometrial glands with increased gland to stromal ratio
What are the risks of co-existent Ca and risk of progression with hyperplasia with and without atypia?
Hyperplasia without atypia: <1% risk of co-existent Ca, <5% risk of progression over 20 years
Hyperplasia with atypia: ~40% of coexistent Ca, ~30% risk of progression
Management of endometrial hyperplasia without atypia?
Mirena 1st line (resolution in 89-96%)
Oral progestins
Resample in 6m intervals
Discharge after 2x consecutive normal samples
What are the indications for hysterectomy in the management of endo hyperplasia without atypia?
No resolution after 12m
Relapse of hyperplasia
Non-resolution of bleeding
Non-compliance with treatment and/or sampling
What is the management of endometrial hyperplasia with atypia?
Hysterectomy
If post-menopausal: TLH + BSO
If pre-menopausal: TLH + BS
What are the fertility sparing options for managing endometrial hyperplasia with atypia?
Rule out cancer (Hysteroscopy D+C, MRI, + consider Ca125)
Thorough counselling about risks
Mirena 1st line, or high dose progestins (Provera 100-600mg daily)
3m sampling until 2x consecutive are negative
Then sample 6-12m until hysterectomy
Surgery indicated when:
1. Patient request / fertility no longer required
2. Progression to cancer
3. Persistence at 12 months
Types of germ cell tumours (4)
- Dysgerminoma
- exquisitely sensitive to chemo, equivalent to serminoma in testicular cancer) - Teratoma (mature vs immature)
- Yolk sac / endodermal sinus tumour
- secretes AFP, aggressive - Choriocarcinoma - secrete HCG
All are highly sensitive to chemo and so conservative surgery (USO) is standard
What are two types of sex cord stromal cells tumours of the ovary?
What is their management?
Granulosa - secrete oestrogen and inhibin
- can be Juvenile or Adult
Sertoli-Leydig - secrete testosterone
Treatment is USO unless post-menopausal
What is Stage 1a Ovarian cancer?
One ovary with capsule intact
What is Stage 1b ovarian cancer?
Both ovaries involved, with capsules intact
What is Stage 1c ovarian cancer?
- 1c1
- 1c2
- 1c3
One or both ovaries affected
1c1 = surgical spill
1c2 = capsule ruptured pre-surgery or tumour on surface
1c3 = malignant cells in ascites or washings
What is stage II ovarian cancer?
Involves one or both ovaries / tubes with pelvic extension (below pelvic brim) or peritoneal cancer
IIa = Extension and/or implants on uterus and/or tubes and/or ovaries
IIb = Extension to other pelvic intraperitoneal tissues
What is Stage III ovarian cancer?
Involves one or both ovaries or tubes (or primary peritoneal ca) with spread to peritoneum outside the pelvis +/- mets to retroperitoneal LNs
What is Stage IIIb ovarian cancer?
Macroscopic peritoneal mets beyond the pelvis up to 2cm. With or without retroperitoneal lymph nodes.
What is Stage IIIc ovarian cancer?
Macroscopic peritoneal mets beyond the pelvis >2cm diameter, with or without mets to retroperitoneal LNs
What is Stage IVa ovarian cancer?
Stage IV = Distant mets
Stage IVa = Pleural effusion with positive cytology
What is Stage IVb ovarian cancer
Parenchymal mets, and mets to extra-abdominal organs (including inguinal lymph nodes, and lymph nodes outside the abdominal cavity)
When is adjuvant chemo recommended for ovarian Ca?
Stage 1c and above
What are the types of cervical cancer?
Squamous cell carcinoma 70-80%
Adenocarcinoma 15-20%
Rare = Melanoma, sarcoma, lymphoma, small cell carcinoma
What is Stage Ia1 cervical cancer?
Strictly confined to cervix
Microscopic with deepest invasion <3mm invasion and <7mm wide
Stage Ia2 cervical cancer?
Strictly confined to cervix
Microscopic 3-5mm invasion and <7mm wide
What is Stage 1b cervical cancer?
Strictly confined to cervix
Clinically visible or pre-clinical lesion larger than Ia
Ib1 = <2cm wide
Ib2 = 2-4cm wide
Ib3 = >4cm wide
What is stage II cervical cancer?
Invades beyond the cervix but not to the pelvic wall or lower 1/3rd of the vagina
What is stage IIa1 and IIa2 cervical cancer?
Stage IIa = No parametrial invasion
IIa1 = Clinically visible lesion <4cm diameter
IIa2 = Clinically visible >4cm diameter
What is Stage IIb cervical cancer?
Obvious parametrial invasion
What is Stage III cervical cancer?
Extends to the pelvic side wall and/or involves the lower 1/3 of the vagina and/or is causing hydronephrosis
IIIa = Lower third of vagina
IIIb = Pelvic side walls or hydronephosis
IIIc = Lymph nodes (pelvic then para-aortic)
What is Stage IV cervical cancer?
Spread beyond the true pelvis and/or involves the mucosa of the bladder or bowel (biopsy proven)
Treatment of Stage Ia1 cervical cancer
Lletz or Cone with adequate margins
Consider simple hysterectomy if no desire for ongoing fertility
Treatment of Stage Ia2 and Ib1 cervical cancer
Modified simple hysterectomy + PLND or SNLB
If fertility desired consider large cone vs trachelectomy + lap PLND
Treatment of Ib2 and IIa1 cervical cancer
Radical hysterectomy + PLND
Treatment of Ib3, IIa2 (and above) cervical cancer
Surgery is feasible but not encouraged due to size of lesions and likelihood of needing adjuvant chemorad (surgery + chemorad increases morbidity)
Recommend primary chemorad
What is the management of glandular abnormalities on smear (AGC or AIS) / cervical biopsy?
Refer straight to colposcopy
Type 3 excision (Cone) + Hysteroscopy D&C recommended
Management of AIS on Type 3 excision?
Depends on age and fertility expectations + status of excisional margins.
Once family complete -> Hysterectomy
- recurrence after cone is high (up to 20%)
- difficult reliable cytology f/u as disease is often multi-focal
What is the transformation zone?
The area between mature squamous epithelium distally and columnar epithelium proximally
- the site of active squamous metaplasia
What are abnormal findings you might see at colposcopy?
- Mosaicism (abnormal vessel pattern)
- CIN1 = fine, CIN2-3 = coarse - Punctation (abnormal dilated blood vessels)
- CIN1 = fine, CIN 2-3 = coarse, large - Abnormal branching of vessels - suggests microinvasion
Describe high grade changes on colposcopy (4)
Oyster grey, rapid change with acetic acid
Relatively small, smooth and flat
In upper TZ or near the new SCJ
Border: Straight, raised or rolled and prominent
(c.f low grade changes: large ad geographic throughout ectocervix, slow to change with acetic acid, irregular and indistinct border)
What is the risk of progression to malignancy with uVIN?
4-6%
Causes 20% of SCC of the vulva
22% also have high grade CIN
What is the risk of progression to malignancy with dVIN?
60%, and shorter time to progression
Causes 80% of SCC of the vulva
Higher risk of recurrence - excision is the treatment of choice
What is the risk of recurrence of VIN after CO2 ablation?
40% risk recurrence
What is the risk of recurrence of VIN after topical immune modulator therapy (imiquimod 5%)?
50% short term recurrence
What is Stage Ia vulvar cancer
Site <2cm and stromal invasion </=1mm
Treat with WLE
- no lymph node dissection needed
Aim surgical margins of 2cm, pathological margins of 8mm
What is Stage Ib vulvar cancer
> 2cm or >1mm invasion
Treat with vulvectomy + LND
What is Stage II vulvar cancer
Any size, with extension to the lower 1/3rd of the urethra, vagina or anus, with negative nodes
Resection with adjuvant CCRT, vs Definitive CCRT
When is adjuvant radiotherapy required after excision of vulvar cancer?
If extra-capsular spread
2+ positive groin nodes
<5mm pathological margins (and unable to re-excise)
What is the risk of ovarian cancer with BRCA1?
2-3% by age 40, 10-20% by age 50
Overall risk of 44% (by age 80)
What is the risk of ovarian cancer with BRCA 2?
<3% by age 50, 17% by age 80
What are the lifestyle modifications possible for management of urinary incontinence (5)?
And management of underlying health conditions? (5)
Weight loss
Decrease fluid intake to 1-1.5L per day
Decrease caffeine intake
Avoid ETOH
Smoking cessation
Manage diabetes, constipation, sleep apnoea, chronic cough
- Review medications e.g diuretics, ACEIs
What are the different medical management options for Urge urinary incontinence?
Topical oestrogens
Anticholinergics
- Solifenacin (Vesicare) 5mg daily, increase to 10mg if required
- Oxybutynin 5mg TDS
Intra-vesical botox injection
- risk of urinary retention
Management of vesicovaginal fistula if not recognised with 48hrs from injury?
Delay 6-12 weeks, IDC in situ for this time.
- allow reduction in granulation tissue, infection and necrosis
Surgical repair - vaginal or abdominal
- tension-free, closure in 4 layers, excision of all scar tissue
What is the most common generalised cause of male infertility?
What are 4 congenital and 4 acquired causes of this?
Hypergonadotrophic hypogonadism (primary testicular failure)
- no predisposing factors in 50% of cases
Congenital = Klinefelters (XXY), androgen insensitivity, Y chromosome microdeletions and undescended testes
Acquired = Infection (mumps), trauma / torsion, cancer / chemorad, drugs and lifestyle / environmental
What are the long term health risks with PCOS (5)?
T2DM
Heart disease
Hypercholesterolaemia / hyperlidipiaemia
Anxiety / depression
Endometrial hyperplasia and cancer
Differentials for irregular periods / secondary amenorrhoea (8)
Rule out pregnancy
PCOS
Prolactinaemia - check prolactin
Thyroid disease - check TFTs
Ovarian failure or hypothalamic amenorrhoea - check FSH and oestradiol
Late onset / non-classical CAH - check 17-OHP
Androgen secreting tumour - check DHEAS
Ovarian androgen secreting tumour - check androstenedione
Cushings - consider 24hr urinary cortisol
Classical biochemical findings with PCOS?
Elevated free and total testosterone
Elevated LH to FSH ratio
Decreased SHBG
Oestradiol may be increased
May have mildly increased DHEAS
Prolactin may be mildly increased
What is vaginismus?
Psychological conditioned reflex in the pelvic musculature with muscle spasm occurring during attempts at vaginal penetration
- may be triggered by an early painful sexual experience or by childhood sexual abuse
Treatment options for vaginismus?
MDT with sex therapist, physiotherapist and psychologist +/- vaginal dilatos
Psychodynamic / psychotherapeutic vs physical with dilators
Possible causes / triggers for Vaginismus?
Early painful encounter
Previous sexual abuse
Endometriosis
Vaginitis
Can be related to previous childbirth / epis / tear
