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Sheff 3a > Gynae 24th Nov > Flashcards

Gynae 24th Nov Flashcards

1
Q

What is endometriosis? Presentation ? O/e?

A

When endometrial tissue grows outside of the uterine cavity
1 - cyclical pain (often triple- before, during and after menstruation)
2- deep dyspareunia
3- sub fertility

O/e- Adnexal tenderness, palpable nodule in posterior fornix (not always)

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2
Q

Investigation and management for endometriosis

A

Gold - diagnostic laparoscopy
(Endometrial tissue seen on an ovary is called a ‘chocolate cyst’)

Mx- OCP - back to back, no breaks -> Mirena / depot
Surgical -> ablation and fulguration or excision
(Need to take into account fertility - pregnancy improves Sx as no ovulation)

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3
Q

Painless ulcer on vulva - probable? Ix? Causative organism? MX?

A

Primary syphilis
Swab, HIV test, Treponemal enzyme immunoassay (EIA)
Treponema pallidum

Bezathine penicilin IM

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4
Q

In PCOS what does the term ‘polyfollicular’ mean? Basic pathophysiology ?

A

Each month the follicle is expelled onto the surface of ovary and turns into a cyst

Ovaries are overstimulated (GnRH-LH) and produces an excess of testosterone which causes an increase in insulin levels and dyslipidaemia

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5
Q

Classic triad of PCOS? Presentation? Ix and Rotterdam criteria ?

A

Obesity, hirsutism, anovulation

±acne, subfertility, male pattern balding, acanthosis nigricans (darkened thickened skin around armpit/groin/neck) , psychological distress

Rot - USS -> 12 peripheral follicles >10cm3
Oligo/anovulation
Clinical/biochemical signs of hyperandrogenism

Testosterone, TFT, prolactin, glucose, lipid

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6
Q

When do you give metformin in PCOS ? Fertility mx? Sx control? Hirtuism mx?

A

Metformin if BMI >25
Fertility BMI >25 -> clomiphene, BMI <25 -> ovarian drilling
Sx - OCP
Hirtuism - Cyproterone (anti-androgen) ± cosmetic

Treat HTN, DM, lipids as normal

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7
Q

PCOS complications?

A

DM -> do a GTT
CHD (lipids and obesity)
HTN
Ovarian / endometrial Ca

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8
Q

RF for primary dysmenorrhea? Mx?

A

Smoking, obese, early monarch, alcohol

Lifestyle, NSAIDs, mefanamic acid
2nd line - OCP

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9
Q

Clamyda tachomatis Ix? What is important with Ix? Mx? How long should you abstain? When would you check treatment success?

A

Vulvovaginal swab / urine NATT testing
Normalise testing in at risk groups

Stat dose of azithromycin, Doxycyline 100mg BD for 1 week

Avoid sex for 1week after end of treatment

Only test if pt was pregnant

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10
Q

Menorrhagia Ix? Mx 1/2/3 line?

A

Vaginal exam
FBC (treat if Fe deficiency), TFT, clotting (if indicated)
US and biopsy if persistent after Tx, Abnormal Examination or RF for Ca

1- mirena
2- tranexamic acid / mefenamic acid (this can be first line if want to get pregnant, OCP
3- norethisterone

Surgical - hysterectomy / endometrial ablation

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11
Q

Turners syndrome genetic? Features? Key ix? Mx?

A

45x (common) / 46xx
Neck webbing, short stature, obesity, primary amenorrhea, cardiovascular problems
-> ECG and Echo

Combine supplementary oestrogen and progesterone (start at normal age of puberty)

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12
Q

Usual cause of PID ? RF? Presentation?

A

Ascending infection from the cervix (chlamydia / gonorrhoea)

Young, no barrier protection, multiple partners, BV (helps infection ascend), previous gynae surgery, IUD

Can be ASx and does not present until fertility issues

Cervicitis - PV bleed ± deep dyspareunia, abdo pain, post coital bleed , discharge
Salpingitis ( more common with gonorrhoea)
Pain , fever >38, abdo muscle spasm, O/E - cervical excitation, adnexal tenderness ± peritonitis

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13
Q

PID ix? Mx inpatient / outpatient ? Complications?

A

Triple swab, hCG
If very unwell (likely gonorrhoea -> admit for cultures and IV Abx

Inpatient - IV ceftriaxone + doxy PO
Outpatient - IM ceftriaxone stat dose + PO Doxy and metronidazole 14days

Ectopics, chronic pelvic pain, subfertility

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14
Q 
Mrs Smith (45y/o) presented to her GP complaining of increased bleeding during her periods and has been going on for the past 4 months. She also complains of intermittent lower pelvic pain that is in relation to her periods. On examination, she looks slightly pale but has not lost weight. She also complains of increased urinary frequency. Abdomen was SNT, pelvic examination shows evidence of bleeding and a mass can be felt on bimanual palpation. 
DDs?
A 
Menorrhagia 
Fibroids 
Dysmenorrhea 
Endometriosis 
Malignancy
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15
Q

Menorrhagia is subjective and varies between women, what is the objective definition?

A

> 80ml blood loss

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16
Q

What effect can HRT have on fibroids?

A

Prolong their growth - as they are oestrogen dependent and would shrink after menopause

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17
Q

Mx of menorrhagia?

A

Medical
1- IUS
2- antifibrinolytics (tranexamic acid), NSAIDS (mefanamic acid), COCP
3- Pogesterones, GnRH agonists

Surgical 
Endometrial ablation 
Poppy removal / trans cervical resection of fibroid 
Myomectomy 
Hysterectomy 
Uterine artery embolisation
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18
Q

Mx of fibroids?

A

Medical
Tranaxemic acid acid, NSAIDS, progesterone - useful for fibroid induced menorrhagia
GnRH agonists -> temporary amenorrhea and fibroid shrinkage by inducing a temporary menopausal state

Surgical 
Hysteroscopic surgery 
Myomectomy 
Radical hysterectomy 
Uterine artery embolisation
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19
Q

Side effects of GnRH agonists? How to avoid?

A

Reduced bone density

-> limit use to 6 months

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20
Q 
Ectropion eversion 
Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? NO 
Discharge colour? Clear 
PH? Normal 
Redness? Yes 
Odour?normal 
Treatment? Cryotherapy
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21
Q 
Bacterial vaginosis 
Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? No 
Discharge colour? Grey-white  
PH? Raised 
Redness? No
Odour? Fishy 
Treatment? Antibiotics
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22
Q 
Candidiasis
Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? Yes 
Discharge colour? White  
PH? Normal 
Redness? Yes
Odour? Normal 
Treatment? Imidazoles
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23
Q 
Trichomoniasis Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? Yes 
Discharge colour? Grey-green 
PH? Raised 
Redness? Yes
Odour? Yes
Treatment? Abx
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24
Q 
Malignancy 
Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? No
Discharge colour? Red-brown 
PH? Variable 
Redness? No
Odour? Yes
Treatment? Biopsy
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25
Q 
Atrophic vaginitis 
Itching?
Discharge colour? 
PH?
Redness?
Odour?
Treatment?
A 
Itching? No
Discharge colour? Clear  
PH? Raised 
Redness? Yes
Odour? No
Treatment? Oestrogen
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26
Q

56 y/o lady coming in complaining of post-coital bleeding. She had her menopause when she was 52. She has noticed some weight loss. Cardio, respi, GI examination was normal. Pelvic examination was normal. Speculum examination revealed a small ulcer at the base of the cervix.
DDx? Ix and why?

A

Atrophic vaginitis secondary to menopause
Cervical CA
Endometrial CA

Bloods - FBC, tumour markers (Ca125, CEA, AFP, b-HCG, LDH, inhibit)
->tumour burden, baseline (in case of infection)

Imaging - TV ultrasound, CT abdo / pelvis / chest
-endometrial thickness >5mm, identify extent of disease for operative staging

Biopsy - endometrial biopsy, cervical smear / biopsy / colposcopy
-> diagnosis of endometrial / cervical CA

27
Q

MX of atrophic vaginitis secondary to menopause

A

Topical oestrogen

HRT

28
Q

Mx of endometrial ca

A

Medical
High dose progesterone for palliative sx
Adjuvant radiotherapy with chemo

Surgical
Total abdominal hysterectomy with bilateral salpingo-oophorectomy

29
Q

What is cervical CIN? Mx?

A

Cervical intraepithelial neoplasia (premalignant)

Surgical
Large loop excision of transformation zone
Cone biopsy

30
Q

Cervical CA mx?

A

Medical
Cisplatin based chemo with adjuvant radiotherapy

Surgical
Cone biopsy
Laparoscopic hysterectomy
Total pelvic exenteration

31
Q

Sx of menopause? Usual age?

A

Average age 51

Menstural irregularity 
Hot flushes and sweats 
Dyspareunia, vaginal discomfort and dryness 
Sleep disturbance 
Mood changes
32
Q

Staging of CIN ? Rf?

A

1 - confined to lower third of epithelium, mild dysplasia
2 - lower and middle thirds - moderate dysplasia
3 - full thickness of epidermis - severe dysplasia

Sexually active
HPV 16 & 18
Smoking
Immunosuppression

33
Q

When dos CIN become cervical Ca ? Staging?

A

When invasive squamous/mixed/adenocarcinoma extends beyond 5mm from the surface epithelium or is wider than 7mm

1 - confined to cervix
2 - tumour into uterus
3 -into pelvic wall and/or lower third of vagina and/or causes hydronephrosis / impacts on kidney function
4 -further spread

34
Q

When is cervical screening in uk ?

What cytological markers?

A

Every 3 years age 25-49
Every 5 years 50-64

1 - increased nuclear/cytoplasmic ratio
2- shape / density of nucleus
3- inflammation, infection, mitosis

35
Q

2 vaccines for HPV? When are they given?

A

Cervarix - HPV 16&18
Gardasil - HPV 16, 18, 6, 11
-2 dose between age 11-14

36
Q

Wilson and jugner criteria for screening

A

Knowledge of the disease
The condition should be important.
There must be a recognisable latent or early symptomatic stage.
The natural course of the condition, including development from latent to declared disease, should be adequately understood.

Knowledge of the test
Suitable test or examination.
Test acceptable to population.
Case finding should be continuous (not just a ‘once and for all’ project).

Treatment
Accepted treatment for patients with recognised disease.
Facilities for diagnosis and treatment available.
Agreed policy concerning whom to treat as patients.

Cost considerations
Costs of case finding (including diagnosis and treatment of patients diagnosed) economically balanced in relation to possible expenditures on medical care as a whole.

37
Q

What should be measured in all women under 40 with complex ovarian mass? Why?

A

Lactate dehydrogenase LDH
Alpha-fetoprotein AFP
HCG

Possibility of germ cell tumours

38
Q

Endometrial ca is oestrogen dependent. What are the risk factors and how are some of them related to this fact?

A

HRT (especially tibolone -> selective oestrogen receptor modulator)
Obesity - peripheral conversion of adipose tissue -> oestrone
Diabetes
HNPCC (genetics)
PCOS

39
Q

Stages of endometrial ca ? Mx at each stage?

A

1 - confined to a)endometrium b)more than half of myometrium
Total abdominal hysterectomy with bilateral salpingo-oophorectomy

2- involves corpus and cervical stroma
Radical hysterectomy with pelvic node clearance

3- local spread beyond uterus
De bulking surgery with chemo and radio - sentinel node biopsy may be taken

4- bladder / bowel mucosa

40
Q

50 y/o lady presented to her GP with increased abdominal swelling. She has noticed that her tummy was getting bigger. She describes herself as getting fatigued more recently and has episodes of bloating. She also reports a change in her appearance of her breast. FH: Her mother passed away from bowel CA. SH: She smokes 20 cigarettes a day and drinks 14 units a week.
Examination of her abdomen showed a smooth pelvic abdominal mass that is palpable below the umbilicus. Examination of her breast showed dimpling of the skin. No erythema around the breast was noted.
DDx? Ix and why?

A

Ovarian cyst / cA
Breast Ca

Bloods - FBC, LFT, U&E, tumour markers (Ca125, CEA, AFP, b-HCG, inhibit, oestradiol)
-tumour burden, baseline (in case of surgery)

Imaging - transvaginal US, CT abdo / pelvis / chest
-identify any abnormality in overlies an confirm if cyst is benign

Breast triple assessment
-genetic profiling / grading

41
Q

Parts of the breast triple assessment

A 
Examination 
Fine needle aspiration (cytology) 
Imaging 
-if >35 can do mammogram 
If <35 USS 
-> MRI if either are not definitive
42
Q

Mx of ovarian cyst

A

Conservative
Watch and wait if <50mm
50-70mm -> annual follow up

Surgical
Persistent simple cyst 5-10cm or complex cysts can have surgical removal to prevent torsion

43
Q

What is oligomenorrhea?

A

Periods occur between 35days and 6 months

44
Q

Mnemonic to remember pathological causes of amenorrhea?

A 
A THOOP 
Adrenal 
Thyroid 
Ovary 
Outflow tract obstruction 
Pituitary
45
Q

Diagnosis of PCOS needs?

A

2/3 of

1- polycistic ovaries on US (12 or more follicles on enlarged ovary)

2- irregular periods (over 35 days appart)

3- Hirsutism

  • clinical - acne or excess body hair
  • biochemical - raised testosterone
46
Q

Features of PCOS

A 
Subfertility 
Oligo/amorhorrea 
Hirsutism / Acne 
Obesity 
Miscarriage
47
Q

PCOS ix?

A 
Bloods
FSH - usually normal 
Prolactin - exclude prolactinoma 
TSH 
Serum testosterone 
LH - usually raised

Ultrasound - pelvic / trans vaginal

Screening for diabetes

Check lipids

48
Q

Management of PCOS ? Specific drug for facial Hirsutism

A

Advice diet and exercise
Treat with oral contraceptive if fertility not required

Hirsutism
Cyproterone acetate / sprironolactone (antiandrogens)
[must avoid conception on these]

Metformin - insulin sensitiser

  • reduces insulin
  • reduces Hirsutism / androgens

Eflorthinine (topical androgen)
-for facial hirtuism

49
Q

Protective factors for fibroids

A

Parity
COCP use
IM progesterone use

50
Q

How many fibroids are sx? What are the sx?

A

50%

Menorrhagia, dysmenorrhea
Bladder compression -> frequency / retention
Ureter compression -> hydronephrosis
Fertility impairment due to mechanical reasons

51
Q

Complications of fibroids?

A

Torsion

Degeneration
Red degeneration - common in pregnancy due to inadequate blood supply
-> pain and uterine tenderness
-haemorrhage and necrosis occur

Hyaline degeneration
Cystic degeneration

They can cause premature labour, malpresentation, transverse lie, obstructed labour, PPH

52
Q

When does CIN become malignant?

A

When it invades the basement membrane

53
Q

Clinical symptoms of cervical Ca

A

PCB, IMB,PMB
Offensive vaginal discharge

Later - sx of compression/invasion 
Uraemia - ureters 
Haematuria - bladder 
Rectal bleeding - rectum 
Pain - nerves
54
Q

Stages of Cervical Ca? What is the classification called?

A

FIGO classification (international federation of gynae and obs)

Stage 0 - CIS

Stage 1 - Ca confined to CERVIX only (a-microscopy only, 1b-visible macroscopically)

Stage 2- confined to cervix and UTERUS

Stage 3 - invades the PELVIC WALL
And/or LOWER 1/3 of vagina
And/or causes KIDNEY problems

Stage 4 - ca extended beyond PELVIS
And/or involves BLADDER/RECTUM

55
Q

What is parametrium

A

Fibrous tissue that separate the supravaginal portion of the cervix from the bladder -> informs of cervix and extends laterally between layers of broad ligaments

56
Q

Management of cervical ca based on stage….
1a?
Lymph node negative?
Lymph node positive ?

A

1a - cone biopsy or simple hysterectomy

LN-ve
Desire fertility -> radical trachelectomy
If don’t require fertiliy or already at stage 2a -> Radical abdominal hysterectomy (hysterectomy, pelvic node clearance, removal of parametrium, + upper 1/3 of vagina)

LN+ve or stage 2b+
Chemoradiotherapy -> also used if older / medically unfit

57
Q

What happens in radical trachelectomy?

A

80% of cervix and upper vagina removed

58
Q

What is adenomyosis? Symptoms?Older or younger population than endometriosis? Seen O/E? Investigation for diagnosis? Mx?

A

Endometrial tissue disperses within myometrium

Can be ASx menorrhagia, pain (constant but worse on periods)
~40yrs (older and often after children)

Mildly enlarged, tender uterus

MRI for diagnosis

Hysterectomy
-mirena / COCP for sx relief

59
Q

What hormone reduces risk of endometrial ca?

A

Progesterone

Unopposed oestrogen causes excessive proliferation of endometrial cells

60
Q

Where is the most common place for recurrence of endometrial ca?

A

Vaginal vault usually within 3 yrs

-> radiotherapy of vaginal vault after TAHBSO surgery

61
Q

Types of ca of ovarian epithelium?

Unique features?

A

Serous adeonoCa
Endometrioid
Mucinous
Clear cell

Most common type of ovarian cyst

62
Q

2 Germ cell tumours in ovarian Ca unique feautres

A

Teratomas
Grow hair / teeth
Smal bilateral often asx

Dysgerminoma
Teens / young adults
Particularly sensitive to radiotherapy

63
Q

Type of stromal ovarian ca? Unique feature?

A

Sex cord tumours

Secrete inhibin -> used as tumour marker for recurrence

64
Q

Parts of bloods for tumour markers?

A

tumour markers (Ca125, CEA, AFP, b-HCG, inhibit, oestradiol)

Sheff 3a (30 decks)

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