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Finals > Gynae 2 > Flashcards

Gynae 2 Flashcards

1
Q

What is PID

A 
infection of the upper genital tract. Infection spreads upwards from the endocervix causing one or more of:
Endometritis.
Salpingitis.
Parametritis.
Oophoritis.
Tubo-ovarian abscess.
Pelvic peritonitis.
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2
Q

What causes PID

A 
Chlamydia trachomatis (14–35% of cases) 
Neisseria gonorrhoeae (2–3% of cases) 
Mycoplasma genitalium

Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.

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3
Q

What are some risk factors for PID

A

Factors related to sexual behaviour, such as:
<25
Early age of first coitus.
Multiple sexual partners.
New partner within least 3 months
History of STI in the woman or her partner.

Recent instrumentation of the uterus or interruption of the cervical barrier, such as due to:
TOP
Insertion of an intrauterine device
Hysterosalpingography.
IVF and intrauterine insemination.
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4
Q

What are the symptoms of PID

A 
asymptomatic
Lower abdominal pain
Deep dyspareunia
PCB
menorrhagia, dysmenorrhoea or IMB
Dysuria (painful urination)
Abnormal vaginal discharge (especially if purulent or with an unpleasant odour)

fever and N+V if severe

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5
Q

What are the signs of PID on examination

A

Lower abdominal tenderness (usually bilateral).
Adnexal tenderness
cervical motion tenderness,
or uterine tenderness
Abnormal cervical or vaginal mucopurulent discharge

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6
Q

What investigations should be considered in PID

A

Pregnancy test, urine dip
FBC, CRP, ESR, GIV, syphilis
Endocervical swabs - gonorrhea and chlamydia,
high vaginal swab - trichomonas vaginalis and bacterial vaginosis

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7
Q

How is PID managed

A

immediate start of 14-day course of broad spectrum antibiotics - Ceftriaxone 500 mg IM, oral doxycycline 100 mg BD and oral metronidazole 400 mg BD for 14 days.

avoid sexual intercourse until the antibiotic course is complete and partner(s) are treated.
All sexual partners from the last 6 months should be tested and treated to prevent recurrence and spread of infection.

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8
Q

How should a woman with diagnosed PID be followed up?

A

R/V in 72 hours
should be clinical improvement. if not, consider admission or review the diagnosis.

Check the antibiotic sensitivities from swab result and adjust antibiotics treatment if necessary.
Continue treatment even if swabs are negative.

R/V in 2-4 weeks to check:
compliance with, and response to, treatment.
Confirm that sexual contacts have been screened and treated.
Discuss the potential sequelae of PID
Ensure repeat pregnancy test, if clinically indicated

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9
Q

What are the long term complications of PID

A 
Tubal infertility.
Ectopic pregnancy.
Chronic pelvic pain.
Tubo-ovarian abscess.
Fitz-Hugh Curtis syndrome
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10
Q

What is an ovarian cyst

A

fluid filled sac within the ovary

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11
Q

What is the difference between a simple and complex ovarian cyst

A

simple - fluid only

complex - not simple! may contain blood, solids, septation or vascularity

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12
Q

Name some non-neoplastic types of ovarian cysts

A 
follicular
corpus luteal
endometriomal
PCOS
theca lutein
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13
Q

Name some benign neoplastic types of ovarian cysts

A 
serous cystadenoma
mucinous cystadenoma
benign cystic teratoma - germ cells
benign mature teratoma - germ cells
fibroma
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14
Q

What are the risk factors for ovarian cyst formation

A

obesity
tamoxifen
early menarche
infertility

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15
Q

What are the symptoms of ovarian cysts

A

dull ache or pain in lower abdomen
dyspareunia
swollen abdomen
pressure effects - frequency

if torsion - severe pain
if rupture - pain, peritonitis, shock

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16
Q

What investigations should be done in ovarian cysts

A

pregnancy test, urine dip
FBC CA125 AFP BhCG
TVUS
FNA and cytology of cyst

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17
Q

When should ca125 not be done for an ovarian cyst

A

for premenopausal women who have a simple cyst on ultrasonography

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18
Q

When should AFP and betahCG be done for an ovarian cysts

A

if it is a germ cell tumour and the woman is under 40

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19
Q

What is the RMI in relation to ovarian problems

A

risk of malignancy index

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20
Q

How is the RMI calculated

A

ultrasound score x menopausal score x CA 125 level in U/mL.

The ultrasound score is the number of the following findings on scan: multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal metastases. (0 = no abnormalities, 1 = one abnormality, 3 = two or more)

menopausal score is where 1 = premenopausal and 3 = postmenopausal).

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21
Q

How are ovarian cysts managed

A

expectant - if simple <50mm. repeat TV US in 6 weeks - if persistent then monitor with ultrasound and CA125 3-6 monthly and calculate RMI.

surgery - if persistent and 5-10cm, symptomatic or complex

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22
Q

How is the RMI used in management of ovarian cysts

A

in postmenopausal women:

Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.

Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).

High RMI (over 250): referral for staging laparotomy

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23
Q

State the different kinds of ovarian cancer

A

epithelial - 90%
germ cell
sex cord stromal

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24
Q

What are the risk factors for ovarian cancer

A

age

lifestyle:
smoking
obesity
asbestos exposure
low exercise

hormonal:
infertility, clomifene, nulliparity, early menarche, late menopause, HRT

FH
BRCA1/2
endometriosis
history of breast, ovarian or bowel cancer

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25
Q

What are the symptoms of ovarin cancer

A 
abdominal discomfort
abdo distention or bloating
frequency
dyspepsia
any new IBS if >50Y
fatigue, weight loss, anorexia, depression
pain - late sign
ascites
breathlessness - pleural effusion
PMB
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26
Q

What investigations should be done in suspected ovarian cancer

A

ca125, AFP, beta hCG
TV USS/ abdo US
CT AP
staging laparotomy

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27
Q

What can cause a raised ca-125

A 
ovarian cancer
PID
pregnancy
torsion, rupture or haemorrhage of ovarian cyst
other cancer
trauma
heart failure
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28
Q

What are the management options for ovarian cancer

A

surgery

chemo - cisplatin

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29
Q

What is chronic pelvic pain

A

Intermittent or constant pain in the lower abdomen or pelvis in women.
Lasting for at least six months.
Not occurring exclusively with menstruation or sexual intercourse.
Not being associated with pregnancy.

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30
Q

What can cause chronic pelvic pain

A 
Endometriosis:
Adhesions:
IBS.
Interstitial cystitis.
Musculoskeletal problems.
Pelvic organ prolapse.
Nerve entrapment:
Psychological and social issues
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31
Q

What investigations could be done in chronic pelvic pain

A

urine dip
FBC, CRP, ca125
endocervical swab - gonorrheoa, chlamydia
TV US
Diagnostic laparoscopy - if results inconclusive

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32
Q

How is menopause defined

A

12 months of amenorrhoea due to the loss of ovarian follicular activity

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33
Q

What is premature menopause

A

menopause occurring before the age of 40 years

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34
Q

What is the perimenopause

A

the period of change leading up to the last period.

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35
Q

What is early menopause

A

menopause between 40-45 years.

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36
Q

State the hormonal changes that occur in the menopause

A

reduced sensitivity of the ovary to circulating FSH and LH - due to reduction in follicle numbers.

leads to reduction in oestrogen secretion

leads to increased levels of FSH and LH

The decrease in developing follicles also reduces the amount of inhibin released causing an enhanced rise of FSH.

37
Q

What are the key symptoms of the perimenopause

A 
irregular menstrual bleeding
hot flushes - affect the face, head, neck and chest and last for a few minutes
depression and mood change
joint and muscle aches and pains
vaginal discomfort and dryness, dyspareunia
Loss of libido
recurrent lower urinary tract infection.
sleep disturbance
38
Q

Why does amenorrheoa occur in the menopause

A

Estradiol production, which occurs in the granulosa and thecal cells surrounding the oocyte, becomes insufficient to stimulate the endometrium, and amenorrhoea occurs.

39
Q

What causes the urogenital problems associated with menopause

A

loss of the trophic effect of oestrogen.

there is atrophy of the vagina, thinning of vaginal walls and dryness

40
Q

What causes the sleep disturbance in menopause

A

hot flushes and night sweats

may also be due to mood disorders

41
Q

What investigations are needed in menopause

A

clinical diagnosis!

only done in premature ovarian failure;
FSH
to exclude other diagnoses: TFT Blood glucose
A pelvic scan - may be considered for those women with atypical symptoms

42
Q

How does the menopause affect bone metabolism

A

Oestrogen protects bone mass and density through reducing the activity of oesteoclasts.

Decreased oestrogen leads to an increase in bone reabsorption

leads to loss of bone density and increased frequency in fractures e

43
Q

How does the menopause affect cardiovascular health

A

Oestrogen offers a protective effect against heart disease. It is thought that oestrogen reduces levels of LDL cholesterol whilst raising HDL cholesterol.

After the menopause women experience the same frequency of cardiovascular disease as men.

44
Q

What are the management options for the menopause

A

HRT
non hormonal
lifestyle

45
Q

Give some lifestyle interventions for the management of symptomatic menopause

A

Hot flushes and night sweats — regular exercise, weight loss, wearing lighter clothing, sleeping in a cooler room, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).
Sleep disturbances — avoiding exercise late in the day and maintaining a regular bedtime.
Mood and anxiety disturbances — adequate sleep, regular physical activity, and relaxation exercises.
Cognitive symptoms — exercise and good sleep hygiene.

46
Q

Give some non-hormonal interventions for the management of symptomatic menopause

A

For vasomotor symptoms, consider a 2-week trial of fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine (37.5 mg twice a day). (off label)

For vaginal dryness, prescribe a vaginal lubricant or moisturizer, such as Replens MD®.

For psychological symptoms consider self-help groups, cognitive behavioural therapy (CBT), or antidepressants.

47
Q

Which symptoms of menopause is HRT effective in treating

A

Vasomotor symptoms (hot flushes/night sweats).
Mood swings.
Vaginal and bladder symptoms.

48
Q

Which women should be prescribed combined or oestrogen only HRT

A

In woman with a uterus - combined (oestradiol plus progestogen) HRT

without a uterus - oestrogen-only preparation.

49
Q

How can urogenital symptoms of menopause be managed with HRT

A

if urogenital atrophy (including those already using systemic HRT) - low-dose vaginal oestrogen.

if vaginal dryness - moisturisers and lubricants can be used alone or in addition to vaginal oestrogen.

50
Q

What are the risks of HRT

A

VTE - more so for oral than transdermal

Coronary heart disease (CHD) and stroke -combined associated with small increase in risk

Breast cancer - combined increases risk

Endometrial cancer - oestrogen-only increases the risk of endometrial cancer in women with a uterus.

51
Q

What are the benefits of HRT

A 
reduction in vasomotor symptoms
improvement in QOL
improvement in mood changes
improvement of urogenital symptoms
reduction in osteroporosis risk`
improvement in muscle mass and strength
52
Q

How long is contraception required for after the menopause

A

Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period.

Those over the age of 50 require only 1 year of contraception.

53
Q

What does cervical screening look for?

A

Liquid based cytology (LBC) to detect early abnormalities of the cervix, which if untreated could lead to cancer of the cervix.
- abnormalities in the appearance of the nucleus and other aspects of cell morphology (dyskaryosis)

54
Q

Who is screened for cervical cancer

A

First invitation for screening at age 25

Routine recall three-yearly recall between ages 25-49, then five-yearly recall until aged 65.

Women over the age of 65 are only screened if they have not been screened since the age of 50 or have had recent abnormal tests.

55
Q

How is the smear test carried out?

A

A speculum made from disposable plastic inserted vaginally to view the squamocolumnar junction of the cervix.

A brush is rotated against the squamocolumnar junction (usually in the cervical canal).

Brush top broken off into preservative or rinsed in preservative. Sent off for testing

56
Q

What can be the histological result of cervical smear test

A

Negative - . Endocervical cells with normal nuclei are seen.

Inadequate

Borderline - Cells are seen with abnormal nuclei, but the pathologist cannot say for certain that they are indicative of dyskaryosis

Mild dyskaryosis -usually equates to CIN 1. Cancer is very unlikely.

Moderate dyskaryosis - usually equates to CIN 2 a pre-cancerous condition with an intermediate probability of developing into cancer.

Severe dyskaryosis - equates to CIN 3. It is at the higher risk end of the cancer spectrum.

Glandular neoplasia - suggestive of adenocarcinoma in situ, adenocarcinoma of the cervix, endometrial adenocarcinoma, or adenocarcinoma of an organ outside the uterus.

57
Q

What can cause a cervical smear to come back as inadequate

A

insufficient or unsuitable material sampled (vaginal cells, endocervical cells, insufficient cells)
unlabelled specimens
inadequate fixation/poor spreading of the material on the slide in the laboratory.

58
Q

What should be done if the smear comes back inadequate

A

Repeat sample as soon as possible

If persistent (three inadequate samples), advise assessment by colposcopy.

59
Q

What should be done if the smear comes back borderline or mild dyskaryosis

A

tested the sample for HPV

If HPV is negative, women are returned to normal recall.

If the HPV test is inadequate or unreliable, they are advised to have a repeat smear/HPV test in six months time.

If HPV is positive, women are referred for colposcopy within 6 weeks

60
Q

What should be done if the smear comes back moderate or severe dyskaryosis

A

refer for colposcopy within 2 weeks

61
Q

What happens at colposcopy

A

Look for any abnormal changes in the cervix which may indicate CIN or the presence of cancer.

Apply acetic acid is applied to the cervix, abnormal areas (such as CIN) tend to turn white (sometimes referred to as acetowhite).

May take a biopsy to confirm the diagnosis.

62
Q

What types of cervical cancer are there

A

Squamous cell carcinoma - more common

Cervical adenocarcinoma

63
Q

What causes cervical cancer

A

HPV16 and HPV18 are responsible for about 75% of cervical cancers.

integration of viral DNA into the host genome, interference of HPV E6 and E7 proteins with the normal cell regulatory functions

64
Q

How long between infection with HPV and cervical cancer

A

10 years at least

65
Q

What are the risk factors for HPV

A

Heterosexual women.
Women with multiple sexual partners, or partners of promiscuous males.
Smoking.
Lower social class.
Immunosuppression - eg, HIV and post-transplant.
There is a slight increase in risk with use of a combined oral contraceptive.
Non-attendance at the cervical screening programme

66
Q

What are the symptoms of cervical cancer

A

asymptomatic - picked up on screening!

IMB
PCB
PMB
Blood-stained vaginal discharge.
Mucoid, or purulent vaginal discharge.
Pelvic pain/dyspareunia.
67
Q

What is seen on examination in cervical cancer

A

The cervix may appear inflamed or friable and bleed on contact
visible ulcerating or fungating lesion
foul-smelling serosanguineous vaginal discharge.

68
Q

Give some differentials for cervical cancer

A 
Cervicitis.
Cervical erosion (ectropion).
PID
Endometrial cancer.
Side-effects of intrauterine contraceptive device (IUCD) use.
Endometrial hyperplasia.
Fibroids.
Atrophic vaginitis.
69
Q

What is the difference between CIN and invasive cervical cancer

A

CIN does not breach the basement membrane

invasive breaches the basement membrane

70
Q

What are the subclassifications within CIN

A

CIN I: disease confined to the lower third of the epithelium.
CIN II: disease confined to the lower and middle thirds of the epithelium.
CIN III: affecting the full thickness of the epidermis.

71
Q

What is the difference between microinvasive and invasive cervical cancer

A

micro-invasive carcinoma = the deepest invasive element is <5 mm from the surface of the epithelium

invasive = extends beyond 5 mm or is wider than 7 mm

72
Q

What investigations should be done in suspected cervical cancer

A

FBC, U+E, LFTs
endocervical swab - chlamydia
colposcopy and core biopsy
CXR and CT CAP for mets

73
Q

How is cervical cancer managed

A

radical hysterectomy and lymphadenectomy

chemoradiation

74
Q

What causes a pelvic prolapse

A

weakness of the supporting structures

allows the pelvic organs to protrude within the vagina

75
Q

What increases the risk of prolapse

A 
prolonged labour, 
trauma from instrumental delivery, 
lack of postnatal pelvic floor exercise, 
obesity, 
chronic cough and constipation. 
Poor perineal repair
76
Q

What is a cystocoele

A

the anterior wall of the vagina, and the bladder attached to it, bulge.

77
Q

What symptoms can a cystocele cause

A

Residual urine within the cystocele may cause frequency and dysuria.

78
Q

What is a rectocele

A

The lower posterior wall, which is attached to rectum, may bulge through weak levator ani.

79
Q

What might a woman with a rectocele need to do to aid defecation

A

reduce herniation prior to defecation by putting a finger in the vagina, or pressing on the perineum.

80
Q

What is an enterocele

A

Bulges of the upper posterior vaginal wall may contain loops of intestine from the pouch of Douglas.

81
Q

What is a uterine prolapse

A

Protrusion of the uterus downwards into the vagina, taking with it the cervix and upper vagina.

82
Q

What is the difference between first, second and third degree prolapses

A

First degree: The lowest part of the prolapse descends halfway down the vaginal axis to the introitus.

Second degree: The lowest part of the prolapse extends to the level of the introitus, and through the introitus on straining.

Third degree: The lowest part of the prolapse extends through the introitus and outside the vagina.

83
Q

What are the symptoms of prolapse

A 
Dragging sensation, 
discomfort, 
feeling of a lump ‘coming down,’ 
dyspareunia, 
backache.

With cystocele, urinary urgency and frequency, incomplete bladder emptying, urinary retention if the urethra is kinked.

With rectocele, constipation and difficulty with defecation.

84
Q

How is a prolapse examined

A

Bimanual to exclude pelvic masses.

Examine for prolapse with the woman in left lateral position using a Sims speculum.

Inspect anterior and posterior walls for atrophy and descent.

If no obvious prolapse, ask the woman to strain or stand.

85
Q

How is prolapse managed

A

Conservative:
lose weight, stop smoking, and stop straining.
Improve muscle tone with exercises or physiotherapy. Pessaries - should be changed every 6 months and if the woman is post-menopausal, topical oestrogen is useful to prevent vaginal erosion.

Surgery:
Repair operations excise redundant tissue and strengthen supports, but may reduce vaginal width.

86
Q

How do pessaries for prolapse work?

A

Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.
Most are ring shaped.

87
Q

When is surgery for pevic organ prolapse useful?

A

if symptoms are severe,
the woman is sexually active,
and pessaries have failed

88
Q

What are the different surgical options for prolapse

A

vaginal vault prolapse = sacrocolpoplexy to suspen the vaginal apex to the sacral promontory.

cystocele = Anterior colporrhaphy to repair vaginal wall or colposuspension

rectocele: posterior colporrhaphy

uterine prolapse: hysterectomy, sacrohysteropexy

Finals (32 decks)

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