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Phase 3a > Gynae > Flashcards

Gynae Flashcards

1
Q

Define the different types of urinary incontinence

A

Stress: involuntary leakage of urine on effort/ exertion (e.g. coughing/ sneezing).

Urgency: involuntary leakage of urine preceded by a strong desire to pass urine. Can be caused by overactive bladder syndrome.

Mixed: a combination of these symptoms.

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2
Q

Investigations for urinary incontinence

A

Urine dipstick/ MSU - rule out infection

Frequency volume chart - record voided volume/ frequency or urination/ quantity + frequency of LUTS

Urodynamic tests e.g. cystometry - measures the detrusor muscle contraction and pressure whilst voiding, used to confirm diagnoses

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3
Q

Risk factors for stress incontinence

A

Pregnancy

Vaginal delivery

Obesity

Post-menopausal

Age

Neurological conditions e.g. multiple sclerosis

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4
Q

Pathophysiology of stress incontinence

A

Increased intra-abdominal pressure –> increased bladder pressure. Combine with weak pelvic floor support–> bladder neck slip below pelvic floor –> involuntary voiding.

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5
Q

Pathophysiology of overactive bladder

A

over activity of the detrusor muscle –> increased bladder pressure –> urgency + urge incontinence preceded by strong desire to pass urine

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6
Q

Management of stress incontinence

A

Conservative = physiotherapy + lifestyle (lose weight, reduce fluid intake)

Medical = duloxetine (SNRI)

Surgical = TVT (tension-free vaginal tape) or TOT (trans obturator tape)

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7
Q

Common finding on examination of patient with stress incontinence

A

Rectocele/ Cystocele

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8
Q

Management of urge incontinence

A

Conservative = bladder retraining

Medical = anticholinergic medication (e.g. oxybutynin), alternative = mirabegron

Surgical = botulinum toxin type A injection, augmentation cystoplasty

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9
Q

Caution for medical management of urge incontinence

A

Anticholinergic medications e.g. oxybutynin cause side effects (dry eyes, urinary retention, constipation, postural hypotension) and cognitive decline which can be problematic to the patient SO THEY SHOULD BE USED WITH CAUTION AND MIRABEGRON CAN BE CONSIDERED AS AN ALTERNATIVE.

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10
Q

Pathophysiology of pelvic organ prolapse

A

Structures of the levator ani are weakened which causes the pelvic fascia to be overstretched. As a result, the pelvic organs descend into the vagina

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11
Q

Types of pelvic organ prolapse

A

Rectocele - rectum bulges through posterior wall of the vagina

Cystocele - bladder bulges through anterior wall of the vagina

Uterine prolapse - uterus hangs down into the vagina

Vault prolapse - in patients who have had a hysterectomy, the top of the vagina (the vault) may descend into the vagina

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12
Q

Define rectocele

A

rectum bulges through posterior wall of the vagina

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13
Q

Define cystocele

A

bladder bulges through anterior wall of the vagina

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14
Q

Define uterine prolapse

A

Uterine prolapse - uterus hangs down into the vagina

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15
Q

Define vault prolapse

A

Vault prolapse - in patients who have had a hysterectomy, the top of the vagina (the vault) may descend into the vagina

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16
Q

Risk factors for pelvic organ prolapse

A

Multiple vaginal deliveries

Instrumental/ prolonged/ traumatic delivery

Obesity

Advanced age

Pelvic surgery (e.g. hysterectomy)

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17
Q

Clinical presentation of pelvic organ prolapse

A

Patient experiences dragging/ heavy sensation in their pelvis. They may have identified a lump/ mass and have to push this to initiate bowel movements.

Urinary symptoms - urgency, frequency, incontinence, retention
Bowel symptoms - constipation, incontinence, urgency
Sexual dysfunction - pain, altered sensation, reduced enjoyment

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18
Q

Management of pelvic organ prolapse

A

Conservative = physiotherapy (pelvic floor exercises) + lifestyle (weight loss, avoid high-impact exercise)

Medical = vaginal oestrogen cream + vaginal pessary

Surgical = pelvic floor repair

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19
Q

Purpose of vaginal pessary + types

A

Purpose = provide extra support to pelvic organs from within the vagina. Significantly improve symptoms non-invasively but can cause vaginal irritation and erosion long-term. Good for patients who are considering having children in the future.

Ring - sit around the cervix and hold the uterus up
Shelf/ Gellhorn - flat disc with a stem that sits below the uterus (make it challenging to have sex)

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20
Q

Define a genital tract fistula

A

Abnormal connection(s) between the bladder and vagina which creates a single, or multiple openings and causes urine to leak from the vagina

Aetiology: congenital, external trauma, radiotherapy, difficult childbirth (forceps laceration, C-section, uterine rupture), surgery (hysterectomy, ant-incontinence surgery, prolapse surgery)

CP: continuous incontinence from the vagina after a recent pelvic operation (small = watery discharge from the vagina + normal voiding)

Ix: 3 swab test, cystoscopy, urodynamics

Mx: catheter (small/ early) –> surgery

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21
Q

Aetiology of genital tract fistula

A

Congenital

Difficult childbirth (forceps laceration, uterine rupture, C-section)

Surgery (hysterectomy, anti-incontinence surgery, prolapse surgery)

External trauma

Radiotherapy

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22
Q

Clinical presentation of a genital tract fistula (vesico-vaginal fisutla)

A

CP: continuous incontinence from the vagina after a recent pelvic operation (small = watery discharge from the vagina + normal voiding)

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23
Q

Investigations for a genital tract fistula

A

3 swab test (gauze @ top/ middle/ bottom of vagina, insert catheter and blue dye into bladder, blue dye on swabs = leak)

Cystoscopy and EUA (examination under anaesthetics)

Urodynamics

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24
Q

Management of a genital tract fistula

A

Small/ diagnosed early = catheter (chance to heal itself)

Definitive = surgery

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25
Q

Aetiology of cervical cancer

A

> 70% of cases caused by HPV-16 or HPV-18.

HPV infection –> inhibition of tumour suppressors p53 + pRb by E6 + E7 oncoproteins –> uncontrolled proliferation of cells

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26
Q

Risk factors for cervical cancer

A

Increased risk of HPV (early sexual activity, not using condoms, numerous sexual partners, sexual partner with increased no. of sexual partners)

Non-engagement with screening programme

Others: smoking, HIV, FHx, COCP (>5yrs)

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27
Q

Define cervical intraepithelial neoplasia (CIN)

A

Premalignant dysplasia of cervical epithelium, often at squamocolumnar junction, driven by HPV infection

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28
Q

Grading of CIN

A

Done using colposcopy

CIN-1 = low-grade cervical lesions (LSIL): dysplasia in the basal 1/3rd of epithelium
CIN-2 = high-grade cervical lesions (HSIL): dysplasia in the basal 2/3rd of epithelium
CIN-3 = carcinoma-in-situ (CIS): dysplasia of more than 2/3rd of the epithelium, without invasion of the basement membrane

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29
Q

Clinical presentation of cervical cancer

A

Detected in asymptomatic women at cervical screening

Symptomatic = abnormal vaginal bleeding (intermenstrual, postcoital, post-menopausal), vaginal discharge, dyspareunia

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30
Q

Investigations for suspected cervical cancer

A

Cytology - look at cervical cells under a microscope to detect cellular abnormalities

Colposcopy - visualise cervix in detail + use stains to differentiate abnormal areas + perform biopsy
(Acetic acid - abnormal cells turn white, highlights CIN and cervical cancer cells with more nuclear material
Schiller’s iodine test - abnormal areas will not stain
LLETZ - local anaesthetic administered, use diathermy to remove abnormal epithelial tissue + cauterise tissue
Cone biopsy - treatment for CIN/ early-stage cervical cancer, performed under GA, use scalpel to excise piece of cervix)

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31
Q

Stains/ procedures conducted during colposcopy

A

Acetic acid - abnormal cells turn white, highlights CIN and cervical cancer cells with more nuclear material

Schiller’s iodine test - abnormal areas will not stain

LLETZ - local anaesthetic administered, use diathermy to remove abnormal epithelial tissue + cauterise tissue

Cone biopsy - treatment for CIN/ early-stage cervical cancer, performed under GA, use scalpel to excise piece of cervix

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32
Q

HPV vaccination schedule + target groups

A

Girls + boys aged 11-14YO, 2 doses 6/24 months apart, aim = protect before the onset of sexual activity

Other eligible groups (2 doses 6 months apart): MSM aged 15-45YO, high-risk individuals (e.g. sex workers)

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33
Q

NHS cervical screening programme

A

3 investigations: high-risk HPV testing, cytology, colposcopy

Program: every 3yrs aged 25-49/ 5yrs if aged 50-64
HIV +ve = annual, immunocompromised people may have additional screening, pregnant women wait until 12/52 postpartum

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34
Q

Management of cervical cancer

A

Stage IA1 = manage conservatively
Stage IA-IIA (early-stage disease) = radical hysterectomy w/ lymphadenectomy
Stage IIb-IVa (locally advanced) = chemoradiation
Stage IVb (metastatic disease) = combination chemotherapy

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35
Q

Management of CIN

A

CIN-1 = watch and wait
CIN-2/3 = consider excision/ ablation

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36
Q

HPV types associated with cervical cancer

A

Type 16
Type 18

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37
Q

Drug used to prevent miscarriage up until 1971 that causes an increased risk of cervical cancer

A

Diethylstilboestrol (DES)

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38
Q

Types of cervical cancer

A

Squamous cell carcinoma (80%)
Adenocarcinoma
Small cell cancer (v. rare)

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39
Q

Differential for cervical cancer

A

Ectropion (benign growth of columnar epithelium on the outside of the cervix) - can cause vaginal discharge/ bleeding/ dyspareunia

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40
Q

What is ectropion?

A

benign growth of columnar epithelium on the outside of the cervix

can cause vaginal discharge/ bleeding/ dyspareunia

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41
Q

Define endometrial cancer

A

(mostly) oestrogen-dependent cancer affecting the lining of the uterus (endometrium)

mainly affects post-menopausal individuals

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42
Q

Aetiology of endometrial cancer

A

Unopposed oestrogen due to endogenous/ exogenous lack of progesterone

Endogenous - PCOS, obesity, nulliparity, early menarche + late menopause
Exogenous - HRT (oestrogen-only), tamoxifen

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43
Q

Endogenous causes of endometrial cancer

A

PCOS, obesity, nulliparity, early menarche + late menopause

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44
Q

Exogenous causes of endometrial cancer

A

HRT (oestrogen-only), tamoxifen

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45
Q

Risk factors for endometrial cancer

A

Obesity + T2DM

HTN, hypothyroidism, nulliparity, early menarche + late menopause, tamoxifen use, PCOS

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46
Q

Protective factors against endometrial cancer

A

smoking, caffeine, exercise, aspirin use, parity, COCP

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47
Q

Clinical presentation of endometrial cancer

A

Post-menopausal bleeding, heavy/ irregular periods in younger individuals

Other: vaginal discharge, advanced = pelvic pain/ oedema/ rectal bleeding/ weight loss/ fatigue, metastatic = cough/ abdo pain/ bone pain/ jaundice

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48
Q

Investigations for endometrial cancer

A

Transvaginal ultrasound + pipelle biopsy (v. specific for endometrial cancer)

Consider hysteroscopy w/ endometrial biopsy

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49
Q

Staging of endometrial cancer

A

Stage 1a = endometrium only
stage 1b = <1/2 myometrium
stage 1c = >1/2 myometrium
stage 2a = cervical glands
stage 2b = cervical stoma
stage 3 = invades through uterus
stage 4 = further spread (e.g. in bowel/ bladder/ distant metastases)

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50
Q

Management of endometrial cancer

A

Laparoscopic hysterectomy + bilateral salpingoophrectomy (BSO) = most common

Adjuvant = external beam radiotherapy (indications= high risk of extrauterine disease, proven extrauterine disease, inoperable/ recurrent disease, palliation for symptoms)

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51
Q

Define ovarian cancer

A

malignant neoplasm of the ovary with a vague and insidious onset, often causing patients to present with a pelvic mass + late stage disease

most commonly affects older women 60-70YO

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52
Q

Risk factors for ovarian cancer

A

Incessant ovulation - nulliparity, early menarche + late menopause, use of HRT>5yrs

Other: FHx (BRCA1/ BRCA2), occupational carcinogen exposure (asbestos), obesity/ diabetes/ sedentary lifestyle

((Protective = lactating, pill, parity))

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53
Q

Protective factors for ovarian cancer

A

lactating
pill
parity

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54
Q

Clinical presentation of ovarian cancer

A

Non-specific symptoms: abdominal bloating, early satiety, loss of appetite, pelvic pain, urinary symptoms (frequency/ urgency), weight loss, abdominal/ pelvic mass, ascites

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55
Q

Investigations for ovarian cancer

A

Raised CA125 blood test (>35IU/mL) = indication for ultrasound
Raised CA125 = non-specific, can also be caused by: endometriosis, fibroids, adenomyosis, pregnancy etc.

Ultrasound/ physical examination find pelvic/ abdominal mass OR ascites = urgent secondary-care referral

Woman <40YO with complex ovarian mass = check tumour markers for germ cell tumour (alpha-fetoprotein + hCG)

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56
Q

What can cause a raised CA125, aside from ovarian cancer?

A

Endometriosis
Fibroids
Adenomyosis
Pregnancy
Liver disease

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57
Q

Management of ovarian cancer

A

Exploratory laparotomy (may feature TAH + BSO, omentectomy, lymph node sampling)

Adjuvant chemotherapy (first-line = carboplatin + paclitaxel)
Second-line = pegylated liposomal doxorubicin (PLDH) + topotecan

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58
Q

First-line chemotherapy drugs for ovarian cancer

A

carboplatin + paclitaxel

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59
Q

Staging of ovarian cancer

A

Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)

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60
Q

Epidemiology of ovarian cancer

A

Older women (60-70YO), <40YO = extremely rare

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61
Q

Most common type of vulval cancer

A

squamous cell carcinoma (>90%)

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62
Q

What conditions are commonly associated with vulval cancer?

A

VIN - vulval intraepithelial neoplasia (pre-malignant condition affecting squamous epithelium of the skin)

Lichen sclerosus - 5% of patients with lichen sclerosus develop vulval cancer

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63
Q

What is VIN?

A

Vulval intraepithelial neoplasia (VIN) = pre-malignant condition affecting squamous epithelium of skin that precedes vulval cancer

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64
Q

Risk factors for vulval cancer

A

Lichen sclerosus

Advanced age (>70YO)

Immunosuppression

HPV

VIN

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65
Q

Clinical presentation of vulval cancer

A

Often an incidental finding in an older woman, most frequently affects labia majora

Vulval lump, ulceration, bleeding, pain, itching

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66
Q

Investigating vulval cancer

A

Biopsy of the lesion - establish histological type

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67
Q

Management of vulval cancer

A

Wide local excision +/- inguinal lymphadenectomy. Radiotherapy if lymph nodes are involved.

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68
Q

Risk factors for vaginal cancer

A

HPV infection, CIN/ vaginal intraepithelial neoplasia (VAIN), SLE, HIV/ AIDs, PMHx of gynae cancer

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69
Q

Clinical presentation of vaginal cancer

A

Unexplained palpable mass in/ at entrance to the vagina

Other: smelly/ bloodstained vaginal discharge, IMB, post-menopausal bleeding, post-coital bleeding, mass/ ulcer in the vagina, pruiritus, painful urination

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70
Q

Diagnosis of vaginal cancer

A

Colposcopy with biopsy

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71
Q

Management of vaginal cancer

A

Intravaginal radiotherapy

Radical surgery

72
Q

Define menarche

A

The first occurrence of menstruation, resulting from the hypothalamic pituitary axis ‘waking up’ the ovaries

73
Q

The physiology of menarche

A

Hypothalamic GnRH pulses increase –> FSH + LH release (pituitary) –> secretion of oestrogen from ovaries –> development of secondary sexual characteristics (breast development, pubic hair, menarche)

74
Q

Typical ages of the development of secondary sexual characteristics in girls

A

9-11YO = breast development
111-12YO = pubic hair
13-16YO = menarche

75
Q

Define the menstrual cycle

A

hormonal changes → ovulation + inducing change in endometrium to prepare for implantation (should fertilisation occur)

76
Q

Normal parameters of the menstrual cycle

A

Menarche <16YO + menopause > 45YO

3-8 days of menstruation

<80mL blood loss

24-38 day cycle

No intermenstrual bleeding

77
Q

The phases of the menstrual cycle

A

Menstruation (Day 1-4): get rid of it all
Endometrium sheds, aided by myometrial contractions (cramps)

Proliferative phase (Day 5-13): create one follicle + oocyte
GnRH (hypothalamus) → LH + FSH release (pituitary) → follicular growth
Follicles produce oestradiol + inhibin → FSH suppression → one follicle + oocyte mature
Oestradiol reaches maximum → i) endometrial proliferation + ii) LH surge (–> ovulation within 36hrs)

Ovulation (Day 14): egg released from follicle (now known as corpus luteum)

Luteal/ secretory phase (Day 14-28): implantation or menstruation
Corpus luteum produces oestradiol + progesterone → secretory changes in endometrium (stromal cells enlarge/ glands swell/ blood supply increases)
Day 21 = progesterone peak
Corpus luteum fails if egg not fertilised → oestrogen + progesterone fall (hormonal support withdrawn) + endometrium breaks down

78
Q

Describe the menstruation phase of the menstrual cycle

A

Menstruation (Day 1-4): get rid of it all
Endometrium sheds, aided by myometrial contractions (cramps)

79
Q

Describe the proliferative stage of the menstrual cycle

A

Proliferative phase (Day 5-13): create one follicle + oocyte
GnRH (hypothalamus) → LH + FSH release (pituitary) → follicular growth
Follicles produce oestradiol + inhibin → FSH suppression → one follicle + oocyte mature
Oestradiol reaches maximum → i) endometrial proliferation + ii) LH surge (–> ovulation within 36hrs)

80
Q

Define ovulation

A

Ovulation (Day 14): egg released from follicle (now known as corpus luteum)

81
Q

Describe the luteal/ secretory phase of the menstrual cycle

A

Corpus luteum produces oestradiol + progesterone → secretory changes in endometrium (stromal cells enlarge/ glands swell/ blood supply increases)
Day 21 = progesterone peak
Corpus luteum fails if egg not fertilised → oestrogen + progesterone fall (hormonal support withdrawn) + endometrium breaks down

82
Q

Day of menstrual cycle (if 28 days) when progesterone peaks

A

day 21

83
Q

Day of menstrual cycle (if 28 days) when ovulation occurs

A

day 14

84
Q

Secretory changes in endometrium caused by progesterone (+ oestradiol)

A

Stromal cells enlarge

Glands swell

Blood supply increases

85
Q

What drives ovulation?

A

LH surge in the proliferative phase of the menstrual cycle

86
Q

Define menopause

A

retrospective diagnosis of last menstrual period made after 12 months of amenorrhoea, typically occurring @ 51YO, premature = <40YO

87
Q

Define perimenopause

A

The time leading up to the last menstrual period and 12 months after. Characterised by vasomotor symptoms + irregular periods.

88
Q

Define premature menopause

A

menopause <40YO, the result of premature ovarian insufficiency

89
Q

Describe the physiology of menopause

A

Caused by a lack of ovarian follicular function

↓ in development of ovarian follicles → ↓ production of oestrogen → ↑ LH+FSH release from pituitary → anovulation + amenorrhoea + menopausal symptoms

90
Q

Clinical features of menopause

A

Early - hot flushes, night sweats, poor sleep, irritability, insomnia, psychological

Late - skin + breast atrophy, hair loss, atrophic vaginitis, prolapse, urinary symptoms, osteoporosis, cardiovascular disease, sexual problems (e.g. decreased libido), urogenital problems (e.g. dyspareunia, burning, dryness)

91
Q

Regimens of HRT

A

No uterus = oestrogen-only pill (Elleste Solo/ Premarin)/ patch (Evorel)

Perimenopausal w/ periods = cyclical combined tablets (Elleste-Duet/ Femoston)/ patches (Evorel Sequi)
OR mirena coil + oestrogen-only pills/ patches

Postmenopausal w/ uterus = continuous combined tablets (Elleste-Duet Conti/ Femoston Conti)/ patches (Evorel Conti)
OR mirena coil + oestrogen-only pills/ patches

92
Q

HRT Regimen for patient with no uterus

A

oestrogen-only pill (Elleste Solo/ Premarin)/ patch (Evorel)

93
Q

HRT Regimen for postmenopausal patient with a uterus

A

Postmenopausal w/ uterus = continuous combined tablets (Elleste-Duet Conti/ Femoston Conti)/ patches (Evorel Conti)
OR mirena coil + oestrogen-only pills/ patches

94
Q

HRT Regimen for perimenopausal patient with periods

A

Perimenopausal w/ periods = cyclical combined tablets (Elleste-Duet/ Femoston)/ patches (Evorel Sequi)
OR mirena coil + oestrogen-only pills/ patches

95
Q

Risks of HRT

A

increased risk of breast/ endometrial cancer, VTE, and cardiovascular events

BUT risk not increased in women < 50YO AND no risk of endometrial cancer if people w/o uterus

96
Q

Symptomatic relief, apart from HRT, available for menopause

A

Testosterone - low libido

CBT/ SSRI - psychological symptoms

Vaginal oestrogen/ moisturiser - vaginal dryness/ atrophy

97
Q

What is atrophic vaginitis?

A

dryness and atrophy of vaginal mucosa due to oestrogen deficiency, occurs as most women enter menopause

CP: pruritus, dryness, dyspareunia, bleeding (localised inflammation), redness, raised pH of vagina

Mx: if symptomatic → oestrogen (topical options OR systemic HRT if postmenopausal)
Estriol cream/ pessaries/ tablets (Vagifem OD)/ ring (Estring)

98
Q

Management of atrophic vaginitis

A

Mx: if symptomatic → oestrogen (topical options OR systemic HRT if postmenopausal)
Estriol cream/ pessaries/ tablets (Vagifem OD)/ ring (Estring)

99
Q

How do the female organs form?

A

upper vagina/ cervix/ uterus/ fallopian tubes develop from paramesonephric ducts (Mullerian ducts) along the outside of the urogenital region. They fuse/ mature at 9wks to become reproductive structures + errors in development → congenital structural abnormalitie

100
Q

What is a bicornate uterus?

A

uterus has two horns (heart-shaped appearance)
Dx: pelvic ultrasound
Complications: miscarriage, premature birth, malpresentation

101
Q

What is an imperforate hymen? CP? Mx?

A

hymen at entrance of vagina fully formed
CP: cyclical pelvic pain + cramping w/o vaginal bleeding (menses sealed in vagina)
Mx: surgical incision to create opening

102
Q

What is a transverse vaginal septae? Complications? Mx?

A

septum forms transversely across the vagina, can be perforate (hole allows for menstruation) or imperforate (similar to imperforate hymen)
Complications: infertility, pregnancy-related complications
Mx: surgical correction

103
Q

What is vaginal hypoplasia/ agenesis? Mx?

A

failure of Mullerian ducts to develop → abnormally small or absent vagina, may be associated w/ absent uterus/ cervix
Mx: vaginal dilator or vaginal surgery

104
Q

Causes of abnormal uterine bleeding (gynae)

A

PALM-COEIN

Structural = polyps, adenomyosis, leiomyoma (fibroids), malignancy + hyperplasia

Non-structural = coagulapathy, ovulatory dysfunction (e.g. PCOS), endometriosis, iatrogenic (e.g. 2ry to anticoagulant Tx), not yet identified (systemic cause e.g. liver disease)

105
Q

Structural causes of abnormal uterine bleeding

A

polyps

adenomyosis

fibroids

malignancy + hyperplasia

106
Q

Non-structural causes of abnormal uterine bleeding

A

Coagulopathy (e.g. VWD)

Ovulatory dysfunction (e.g. PCOS)

Endometriosis

Iatrogenic (e.g. 2ry to anticoagulant therapy)

Not yet specified (e.g. systemic causes = liver disease)

107
Q

Define polyps

A

Small benign tumours that grow into the uterine cavity, common in women 40-50YO (high oestrogen levels)

CP: asymptomatic, menorrhagia, IMB, prolapse through cervix

Dx: ultrasound/ hysteroscopy

Mx: resection of polyp w/ cutting diathermy or avulsion

108
Q

Clinical presentation of polyps

A

common in women 40-50YO (high oestrogen levels)

CP: asymptomatic, menorrhagia, IMB, prolapse through cervix

109
Q

Mx of polyps

A

resection of polyp w/ cutting diathermy or avulsion (if symptomatic)

110
Q

Define adenomyosis

A

Presence of endometrium + underlying stroma within myometrium, >40YO, associated w/ endometriosis + fibroids, symptoms subside after menopause

((CP: asymptomatic, painful/ irregular/ heavy menstruation, uterus mildly enlarged/ tender on examination

Ix: ultrasound/ MRI

Mx: medical (progesterone IUS/ COCP) for symptoms, hysterectomy often necessary))

111
Q

Clinical presentation of adenomyosis

A

asymptomatic, painful/ irregular/ heavy menstruation, uterus mildly enlarged/ tender on examination

> 40YO, associated w/ endometriosis + fibroids, symptoms subside after menopause

112
Q

Management of adenomyosis

A

medical (progesterone IUS/ COCP) for symptoms, hysterectomy often necessary

113
Q

Define fibroids (leiomyomas)

A

Benign tumours of myometrium, growth = oestrogen + progesterone dependent (regress after menopause/ change during pregnancy)

((CP: asymptomatic, dysmenorrhoea, pressure effects (urinary symptoms), subfertility

Ix: ultrasound, hysteroscopy

Mx: if symptomatic
Selective progesterone receptor modulators (SPRMs, e.g. ulipristal acetate) - reduce heavy menstrual bleeding (HMB) and shrink fibroids
Surgical - hysteroscopic resection (if intrauterine/ <3cm), myomectomy (fertility preserving, if medical treatment failed), embolization, radical hysterectomy))

114
Q

Clinical presentation of fibroids

A

asymptomatic, dysmenorrhoea, pressure effects (urinary symptoms), subfertility

oestrogen + progesterone dependent (regress after menopause/ change during pregnancy)

115
Q

Management of symptomatic fibroids

A

Selective progesterone receptor modulators (SPRMs, e.g. ulipristal acetate) - reduce heavy menstrual bleeding (HMB) and shrink fibroids

Surgical - hysteroscopic resection (if intrauterine/ <3cm), myomectomy (fertility preserving, if medical treatment failed), embolization, radical hysterectomy

116
Q

Medication used to shrink fibroids

A

Selective progesterone receptor modulators (SPRM) e.g. ulipristal acetate

117
Q

Define PCOS

A

common (5% of women) condition causing metabolic and reproductive problems in women. Characterised by multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.

118
Q

Clinical presentation of PCOS

A

obesity, acne, hirsutism, oligomenorrhoea/ amenorrhoea, miscarriage

119
Q

Diagnostic criteria for PCOS

A

Two or more out of…

Ovaries polycystic morphology on ultrasound - >12 small (2-8mm) follicles in an enlarged (>10mL in volume) ovary, present in 20% of women (most will have regular menstrual cycles)
Irregular periods 5wks or more apart
Hirsutism (clinical and/or biochemical)

120
Q

Management of PCOS

A

lifestyle (weight loss) + COCP (regulate periods + treat hirsutism) + fertility treatment

121
Q

Complications associated with PCOS

A

increased risk of developing T2DM/ gestational diabetes + endometrial cancer (unopposed oestrogen action w/ amenorrhoea)

122
Q

Define endometriosis

A

presence and growth of ectopic endometrial tissue outside the uterus causing pelvic pain and often subfertility

123
Q

Clinical presentation of endometriosis

A

Can be asymptomatic

Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility

Urinary/ bowel symptoms - endometriosis affects other sites

124
Q

Investigating Endometriosis

A

Pelvic ultrasound

Laparoscopy = gold-standard

125
Q

Definitive diagnosis of endometriosis

A

Laparoscopy w/ biopsy

126
Q

Surgical management of endometriosis

A

Depends on whether fertility is a priority

If not: laparoscopic hysterectomy +/- oophorectomy

If it is: excision/ ablation of endometriosis, adhesiolysis + removal of endometriomas may improve chance of spontaneous pregnancy

127
Q

Medical management of endometriosis

A

Analgesia - paracetemol/ NSAIDs

Hormonal - COCP/ progesterone, mirena coil, GnRH analogue injections (e.g. Prostap + Zoladex)

128
Q

Define Heavy menstrual bleeding

A

Excessive menstrual loss that interferes with physical, emotional, social and material QOL, >80mL

129
Q

Define intermenstrual bleeding (IMB)

A

any bleeding that occurs between menstrual periods. Red flag for cancers but often alternative cause.

130
Q

Define postcoital bleeding

A

vaginal bleeding following intercourse that isn’t menstrual loss. Red flag for cancers but often no cause.

131
Q

Define amenorrhoea

A

Absence of menstruation (primary = by 16YO, secondary = ceased for >3/12)

132
Q

Define oligomenorrhoea

A

Infrequent menstruation (every 35 days to 6 months)

133
Q

Aetiologies of oligmenorrhoea

A

Hypothalamus hypogonadism - due to anorexia, excessive exercise, low BMI

Hyperprolactinaemia

Hypothyroidism

PCOS, premature menopause, Turner’s syndrome

Imperforate hymen, transverse vaginal septum, cervical stenosis, Asherman’s syndrome

Iatrogenic - drugs e.g. progesterone, GnRH analogues, antipsychotics

134
Q

What is the most common type of ovarian cyst?

A

Follicular cyst - functional type of cyst that arises when a follicle fails to rupture/ release an egg –> persistent cyst

135
Q

What is an ovarian cyst?

A

A fluid-filled sac present in/ surrounding the ovaries

136
Q

Clinical presentation of an ovarian cyst

A

Often asymptomatic + found incidentally via pelvic ultrasound OR present acutely:

Rupture/ haemorrhage/ torsion

137
Q

Management of an ovarian cyst in premenopausal women

A

<5cm = leave to resolve by itself within 3 cycle
5-7cm = monitor with ultrasound
>7cm = consider MRI/ surgical evacuation

138
Q

Management of an ovarian cyst in postmenopausal women

A

Raised CA125 = 2wk-wait referral
Normal CA125 + <5cm = monitor w/ ultrasound

139
Q

Why does management for an ovarian cyst differ depending on whether they are menopausal or not?

A

Postmenopausal = more concerned RE: malignancy

140
Q

Define ovarian torsion

A

twisting of the adnexa that is most likely to occur during pregnancy and most commonly caused by an ovarian mass > 5cm. Medical emergency that will lead to necrosis if not resolved

141
Q

Pathophysiology of an ovarian torsion

A

twisting of the adnexa (contains blood supply to ovaries/ fallopian tubes/ connective tissue) → blood supply to ovaries restricted → ischemia → necrosis + loss of ovary’s function

142
Q

Clinical presentation of ovarian torsion

A

Sudden-onset severe unilateral pelvic pain, progressive worsening, N+V, tenderness/ palpable mass on examination

143
Q

What does a whirlpool sign on a transvaginal ultrasound indicate?

A

Ovarian torsion - free fluid in the pelvis/ oedema of ovary

144
Q

Management of an ovarian torsion

A

Laparoscopic surgery - detorsion or oophorectomy
Ovary removal → sub/infertility + menopause

145
Q

Complications arising from surgical management of ovarian torsion

A

Ovary removal –> sub/ infertility + menopause

If ovary not removed it can become infected –> abscess formation –> rupture/ sepsis (potentially)

146
Q

What is androgen insensitivity syndrome?

A

X-linked recessive genetic condition that causes genetically male individuals to appear phenotypically female.

Cells unable to respond to androgens e.g. testosterone –> converted into oestrogen –> female secondary sexual characteristics develop

147
Q

Inheritance of Androgen insensitivity syndrome

A

X-linked recessive genetic condition that causes genetically male individuals to appear phenotypically female.

148
Q

Clinical presentation of androgen insensitivity syndrome

A

Appear female (often w/ normal female genitalia), typically present w/ amenorrhoea
Other: lack of pubic hair/ facial hair, slightly taller than female average, infertility

Infancy: presents w/ inguinal hernias containing testes or @ puberty with 1ry amenorrhoea

149
Q

Management of androgen insensitivity syndrome

A

Bilateral orchiectomy + oestrogen therapy + vaginal dilators/ surgery (create adequate vaginal length)

150
Q

What is lichen sclerosus?

A

chronic inflammatory skin condition caused by a loss of collagen → vulval epithelium thinning + formation of shiny, porcelain-white skin, most common in postmenopausal women

151
Q

Clinical presentation of lichen sclerosus

A

Most common in postmenopausal women

Severe pruritus (worse at night), bleeding/ skin breaking, pain, dyspareunia, discomfort
Skin changes - pink-white papules coalesce
Loss of vulval architecture - inflammatory adhesions –> fusion of labia + narrowing of introitus

152
Q

Investigations in lichen sclerosis

A

Biopsy - confirm diagnosis + exclude carcinoma

153
Q

Management of lichen sclerosis

A

Long-term potential topical steroids (e.g. Clobetasol propionate 0.05% - dermovate) + emollients

154
Q

Female patient with short stature, webbed neck and widely space nipples

A

Turner’s syndrome: genetic condition that occurs when occurs a female has a single X chromosome (45XO), characterised by short stature, a webbed neck and widely spaced nipples

155
Q

What is Turner’s syndrome?

A

A genetic condition that occurs when occurs a female has a single X chromosome (45XO), characterised by short stature, a webbed neck and widely spaced nipples

156
Q

Patient presents with secondary amenorrhoea/ significantly lighter periods/ dysmenorrhoea following recent uterine surgery. What might cause this?

A

Asherman’s syndrome: formation of adhesions within the uterus, following damage to it

157
Q

What can cause Asherman’s syndrome?

A

Adhesions in the uterus can be caused by:

Dilatation + curettage procedures (e.g. Evacuation of retained products of conception, ERPC)
Uterine surgery (e.g. myomectomy)
Pelvic infection (e.g. endometritis)

158
Q

Features of Asherman’s syndrome

A

amenorrhoea
severely lighter periods
dysmenorrhoea

159
Q

Management of Asherman’s syndrome

A

Dissect adhesions present in uterus during hysteroscopy (reoccurrence common)

160
Q

What is a hydatidiform mole?

A

Type of tumour that grows like a pregnancy inside the uterus

Complete - two sperm cells fertilise ovum w/ no genetic material, no foetal material will form
Partial - two sperm cells fertilise ovum w/ genetic material, some foetal material may form

161
Q

Clinical presentation of a hydatidiform mole

A

Behaves like a normal pregnancy BUT more severe morning sickness, vaginal bleeding, increased enlargement of uterus, abnormally high hCG, thyrotoxicosis

162
Q

What pathology would show a snowstorm appearance on an ultrasound?

A

Hydatidiform mole

163
Q

Management of hydatidiform mole

A

Evacuation of uterus

164
Q

What is a prolactinoma?

A

non-cancerous tumour of the pituitary gland → excess secretion of prolactin → menstrual irregularities (oligomenorrhoea/ amenorrhoea) + galactorrhoea

165
Q

Clinical presentation of a prolactinoma

A

Menstrual irregularities - oligomenorrhoea/ amenorrhoea

Galactorrhoea

Headaches

Reduced libido

Bitemporal hemianopia (compression of optic chiasm)

166
Q

Management of a prolactinoma

A

Medical - dopamine agonist e.g. cabergoline

If fail: Surgical - trans-sphenoidal surgical removal of tumour

167
Q

What is Pelvic Inflammatory Disease?

A

inflammation and infection of organs of the pelvis caused by an infection spreading up through the cervix, significant cause of tubular infertility + chronic pelvic pain

168
Q

Most common causes of PID?

A

most = STIs - Neisseria gonorrhoea (more severe), Chlamydia trachomatis, mycoplasma genitalium

((Other (non-STIs) - Gardnerella vaginalis (associated w/ BV), Haemophilus influenzae, E. coli))

169
Q

RFs for PID

A

not using barrier contraception, multiple sexual partners, young age, existing STIs, prev. PID, intrauterine device (e.g. copper coil)

170
Q

Clinical presentation for PID

A

Pelvic/ lower abdominal pain + deep dyspareunia
Other: PCB/ IMB, fever, dysuria, abnormal vaginal discharge
Examination: cervical motion tenderness (cervical excitation), inflamed cervix, pelvic tenderness

171
Q

Management of PID

A

Outpatient: first-line = 1g IM ceftriaxone single dose, 100mg oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days

Inpatient: (systemic illness/ no response to outpatient Mx) first-line = 2g IV ceftriaxone OD, 100mg IV/ oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days

172
Q

Ix for PID

A

HVS - look for STIs, pregnancy test (exclude ectopic pregnancy), transvaginal ultrasound (exclude ovarian pathology), MSU (exclude UTI)

173
Q

What is Fitz-Hugh-Curtis syndrome?

A

Inflammation of liver as PID spreads across peritoneum.

Associated with chlamydia + RUQ pain

174
Q

Complications of PID

A

Fitz-Hugh-Curtis Syndrome

Chronic pelvic pain, increased risk of future ectopic pregnancies, subfertility, abscess in ovaries + fallopian tubes

175
Q
A

Phase 3a (5 decks)

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