Gynae 2017 Flashcards
GnRH pulses come from?
Where does stimulation of FSH/LH release come from?
Oestrogen is produced by the folllicle but has a negative feedback on FSH, why?
What stimulates the LH surge?
What is progesterone then produced by?
What does progesterone do in pregnancy?
Hypothalamus Anterior pituitary So only one egg matures High levels of oestrogen Corpus luteum Maintains the lining of the womb
Amenorrhea ix?
Bloods - FSH/LH, oestrogen, progesterone, prolactin, testosterone, TFTs
Pregnancy test
TVUS
US adrenals
MRI pituitary
Karyotyping
Give at least 1 primary and 1 secondary cause of amenorrhea for each category Central Endocrine Ovarian Genital tract Other
Central
1-hypothalamic hypogonadism, hyperprolactinaemia, kallmans syndrome
2-hypothalamic hypogonadism, hyperprolactinaemia, Sheehan syndrome
Endo
1- Thyroid, CAH, adrenal tumour
2-Thyroid, adrenal tumour
Ovarian
1-PCOS, androgen insufficiency, Turner syndrome
2-PCOS, androgen insufficient, premature failure
Genital tract
1- imperforate hymen, transverse vaginal septum
2- cervical stenosis, ashermans syndrome
Other
1-constitutional delay, childhood radiotherapy
2- pregnancy, lactation, menopause, progesterone
Common sites of endometriosis tissue?
Uterosacral ligaments
Ovaries - chocolate cyst
Also can get tissue in rectum, bladder, vagina and lungs
PCOS management of Insulin resistance? Hirtuism Irregular ovulation Infertility
Metformin
COCP, spironolactone
COCP
Clomifene
How long after last period before menopause?
12 months
Some early, medium and late Sx of menopause?
Early
Irregular periods, vaginal dryness, poor concentration, headaches, reduced libido, joint pain, vasomotor (flushes, night sweats)
Medium
GU - frequency, urgency, nocturia, UTIs
Atrophic vaginitis, PMB
Late
Osteoporosis, dementia, CVD
What are and what can help with vasomotor sx of menopause?
Hot flushes, night sweats
Progesterone
Benefits of HRT? Risks?
Symptom management, osteoporosis prevention, colorectal cancer prevention
Breast cancer risk if combined
Endometrial cancer if oestrogen only
Gallbladder disease
A married couple in their thirties presents to the gynaecologist. They are struggling to conceive
The lady has a BMI of 32 and drinks 12 units/week. The man smokes 10/day and drinks 15 units/week. What pre-conception advice do you give them?
You ask the man for a sperm sample. What are you looking for? What might reduce his sperm quality?
What test can you do to check for ovulation? What are ovulatory factors for infertility? (hint, think amenorrhoea)
You suspect it might be tubal factors. What can cause this? What investigations can you do?
How many cycles of IVF can this couple have on the NHS? What are the risks associated?
Start folic acid, female stop drinking, man stop smoking, lose weight
COUNT, MORPHOLOGY, MOTILITY
Smoking, obesity, klinfelters, varicocele, prolactin, hypothalamic hypogonadism
Day 21 progesterone
PCOS, hypothalamic hypogonadism, hyperprolactinaemia, premature ovarian failure, adrenal tumour, thyroid
PID, surgical adhesions, endometriosis
Laparoscopy and methylene blue dye, hysterosalpingogram
3 as they are aged under 40
Multiple pregnancy, ectopic, infection from egg collection, ovarian hyperstimulation syndrome, miscarriage
What is methylene blue dye used for?
Injected into cavity of uterus -> fills the tubes and then they become distended as fill with dye then it spills out into the abdomen though the open ends
Checks for tubal patency
What do you se a hysterosapingogram for?
Test for tubal infertility
X-ray after uterus and Fallopian tubes filled with contrast (fluoroscopy)
Difference between miscarriage and intrauterine death?
24 weeks gestation is the cut off
Risk factors for miscarriage ?
Previous Age BV Uterine anatomy Medical Eg antiphospholipid
Difference between complete and incomplete GTD
C- sperm plus empty egg
I- 2 sperm 1 egg
Molar pregnancy What is it termed if it becomes invasive and metastasises? Are hCG levels low or high? What is seen on US scan? What is the management?
Choriocarcinoma
Very high
Snowstorm
Suction curettage, monitor hCG
Ectopic pregnancy Most common location? Risk factors? Why do you get shoulder tip pain? Characteristic sign on pelvic examination? What happens to hCG levels?
Most common location?
Ampulla of fallopian tube
Risk factors?
PID, age, IUD, Pelvic surgery, smoking , previous ectopic
Why shoulder tip pain?
Diaphragmatic irritation from blood if ruptures
What is the characteristic sign on pelvic examination?
Cervical excitation
What happens to the HCG?
Doesn’t increase by 2/3 in 24 hours
Ectopic
Initial mx steps?
Surgical procedure?
When can you use a medical procedure and what is it?
What is your initial management?
ABCDE, NBM, FBC and crossmatch, anti-D
What is the surgical procedure?
Laparoscopy and salpingectomy (or salpinostomy)
When can you use medical management and what is it?
Methotrexate injection if HCG<3000, stable, no foetal cardiac activity, unruptured
Characteristic appearance of a fibroid cut transversely?
Whorled
-each one is monoclonal in origin
What is cervical ectropion?
Associated with?
Sx?
Mx?
Columnar epithelium of endocervix visible as erythema around external os Increased oestrogen (ovulation, pregnancy, COCP)
Asx, PV discharge, post-coital bleeding
Mx - exclude carcinoma (colposcopy), and ablate if sx
What happens in a smear?
Speculum examination, brush rotated around external os and rinsed in preserving fluid for liquid based cytology
Drawback of smear test?
High false negative rate
What is dyskaryosis? What would you see under a microscope ?
Abnormal cytoligic changes of squamous epithelial cells characterised by hyperchromatic nuclei and/or irregular nuclear chromatin
Smear test result is suspected invasive cancer, what is next step?
Urgent colposcopy within 2 weeks
±hysteroscopy
Cervical cancer Ix?
Colposcopy and biopsy
±cystoscopy and MRI to stage
Management of stages in cervical cancer ?
1ai: loop excision cone biopsy (LLETZ)
1aii-1bi: fertility preserving sergery
1aii-2a LN-: hysterectomy or chemoradio
1aii-2a LN+ or >2b: chemoradio w/o surg
Endometrial ca
Ix?
Mx?
What if unfit for surgery?
Ix:
Transvaginal US (measure endometrial thickness)
Hysteroscopy (if >4mm or multiple episodes) and pipelle biopsy
Mx: (depends on stage)
Surgery: total abdominal or laparoscopic hysterectomy + BSO +/- pelvic LN removal
Radiotherapy: locally to LNs, adjuvant to surgery
Medical: progesterone (only if unfit for surg)
FIGO staging of endometrial ca
1a-endometrium only
B- <1/2 of myometrium
C >1/2 of myometrium
2a cervical glands
2b cervical stroma
3a ovary
B vagina
C lymph nodes
4 a local organs
B regional organs
Which cancer often presents as new onset IBS sx in older women?
Ovarian
Why is the prognosis of ovarian cancer poor
Vague sx -> late presentation
Vulval ca Aetiology Rf? Presentation? Ix? Mx?
Predisposing condition Eg VIN, oncogenic HPV
Lichen sclerosis, immunosupresion, smoking, Paget’s disease of vulva
V non specific Eg vulval pain, persistent lump, bleeding, discharge
±dysuria / dyspareunia
Examination and biopsy
Surgical - conservative or radical excision
What is a prolapse?
Protrusion of the uterus/vagina beyond the normal anatomical confines
Two types of anterior wall prolapse and description
Urethrocoele
Prolapse of the lower vaginal anterior wall
Involves urethra only
Cystocoele
Prolapse of the Upper vaginal anterior wall
Involves bladder ± urethra
What is a genital prolapse of the apex called? Description?
Apical prolapse
Prolapse of the uterus (or vault if hysterectomy), cervix and upper vagina
2 types of posterior wall prolapse and description
Rectocoele
Prolapse of the Lower vaginal posterior wall
Involves anterior wall of rectum
Enterocoele
Prolapse of upper vagina posterior wall
Involving bowel loops or pouch of douglass
Grading of prolapse
0 - no degree of decent of pelvic organs while straining
1- leading surface >1cm above hymenal ring
2- leading surface 1cm above - 1cm below hymenal ring
3- extends >1cm below hymenal ring without complete vaginal eversion
4- complete vaginal eversion
Prolapse RFs
Multiparity
Vaginal delivery
Menopause
Iatrogenic - Eg pelvic surgery
Pelvic mass
Increased intraabdominal pressure - obesity, chronic cough, constipation
Congenital abnormality of collagen - Eg ehlers danlos
Prolapse sx
May be ASx
“something coming down…”
Dragging sensation
Dysparunia
Backache
If anterior: urinary frequency, urgency, retention
If posterior: constipation +/- digital reduction
Prolapse Ix / MX
Biannual examination and sims speculum vaginal examination
Mx
General: lose weight, pelvic floor exercises, treat cough/stop smoking
Pessaries: cones, ring or shelf pessaries (changed every 6-9 months)
Surgical: hysteroplexy/vaginal hysterectomy for uterine prolapse anterior repair for cystocoele posterior repair for rectocoele sacrospinous fixation for vault prolapse
Stress urinary incontinence
Definition?
Predisposing factors?
Involuntary leakage of urine on exertion/coughing/sneezing due to urethral sphincter weakness which leads to social or hygiene problems and is objectively demonstrable
Postmenopausal
Vaginal delivery - esp prolonged / forceps
Muliparity
Obesity
Stress urinary incontinence
Ix?
Mx?
Urine dipstick – check for signs of UTI
Urine diary – for at least 3 days, shows leaks
Cystometry – to exclude OAB
Management:
Conservative: physiotherapy for pelvic floor muscle training (for ≥ 3 months)Decrease weight, caffeine, smoking and constipation
Reassurance and support
Medical: SNRI e.g. duloxetine
Surgical: mid-urethral sling procedure e.g. tension-free vaginal tape
What is Urge urinary incontinence often termed? What is it? Features?
Overactive bladder
Uncontrolled increase in detrusor pressure leading to increased bladder pressure, beyond that or normal urethra, leading to social or hygiene problem
Urinary urgency and urge incontinence Urinary frequency Nocturia/nocturnal enuresis May have triggers e.g. key in the door May have Hx of childhood enuresis or fecal urgency
Urge incontinence
Ix?
Mx?
Investigations:
Urine diary – frequent voiding of small volumes +/- high caffeine intake
Cystometry – detrouser contractions on filling or provocation (not indicated initially)
Management:
Conservative: decrease fluid intake esp. caffeine, review diuretic usebladder retraining (education, timed voiding, positive reinforcement)
Medical: anticholinergic e.g. oxybutinin
vaginal oestrogens if post-menopausal
botox injections into detrusor
Surgery: ileocystoplasty if severe
Other: neuromodulation and sacral nerve stimulation
What is PID? RF?
Infection of the upper female genital tract
may be due to ascending infection from endocervix e.g. STI
or decending infection from enteric organs e.g appendix
Age <25 Previous STI Post-partum endometriosis Multiple partners Uterine instrumentation - Eg Surgical TOP / IUCD
PID presentation
Lower abdo pain – may be constant or intermittent, unilateral or bilateral
Deep dysparunia
Vaginal discharge
Fever
Changes to bleeding e.g. oligomenorrhoea, dysmenorrhoea, IMB or PMB
Tenderness in adnexal area +/- cervical excitation on PV examination
n.b. may be asymptomatic and retrospective diagnosis e.g on investigation of subfertility
PID Ix? Mx?
Investigations:
Bloods: ↑WCC and ↑CRP, chlamydia and gonorrhoea NAAT
Gonorrhoea cervix culture
? USS or laparoscopy
Management:
Multiple abx to cover all potential causative organisms e.g. ceftriaxone, azithromycin, doxycline and metronidazole
Contact tracing and treatment of sexual partners
