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Obs & Gynae > Gynae > Flashcards

Gynae Flashcards

1
Q

Symptoms of cervical ectropions

A

Normally asyx

PCB, vaginal discharge

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2
Q

Treatment of ectropion

A

Cryotherapy w/out anaesthesia once smear/colposcopy -ve for malignancy

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3
Q

Causes of cervicitis (acute and chronic)

A

Acute: STD, ulceration and infection often prolapsed
Chronic: inflammation/infection ie of ectropion

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4
Q

Treatment of cervicitis

A

Inflammatory smear + discharge

Tx with avulsion but still investigate bleeding

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5
Q

Cervical polyps: epi, syx and tx

A

Common after 40, usually

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6
Q

What is a nabothian follicle?

A

Squamous epithelium over columnar = blocks glands –> white glands and opaque swelling on ectocervix
Tx if syx

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7
Q

Definition and Classification of CIN

A

Definition: atypical cells in Sq epi - larger nuclei + dyskaryosis (atypia)
I - mild - lower 1/3 of epithelium
II - moderate - lower 2/3
III - severe - full thickness (malignant like cells without invasion)
Malignancy = invasion of Basement membrane

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8
Q

Epi of CIN

A

1/3 of III will get cervical cancer within 10 years
Peak 25-29
HPV 16, 18, 31, 33 - (16+18 vaccinated now before first sex)
OCP and smoking
Immunodef ie steroids or HIV

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9
Q

Pathology of CIN

A

Columnar to Sq in TZ
HPV turns off tumour suppressor genes and hides cells from immune system
NB CIN is premalignant and predicts risk of developing cervical cancer

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10
Q

Screening schedule for CIN

A

Smear every 3 years from 25-49, 5 years 50-64, >65 if no smear since 50 or previously abnormal

80% acception rate

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11
Q

Smear test procedure

A

Cusco speculum and brush –> liquid based cytology (only 2.5% failure) + HPV test

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12
Q

Smear test results (mild/CGIN)

A

Detects atypical cells not histo abnormalities
Mild = HPV test –> high risk HPV = colposcopy, low/no HPV = back to normal schedule of 3/5y
CGIN = cone biopsy

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13
Q

Smear test results (II/III)

A

Colposcopy w/ tx - TZ excised w/diathermy/LLETZ = dx and tx

Risk of haemorrhage and preterm delivery

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14
Q

Cervical cancer: Epidemiology

A

Peak 30s/80s esp 25-29
90% SCC, 10% adenocarcinoma (worse prognosis)
All have HPV - same risks as CIN as it’s premalignant
Inadequate screening and FHx are common

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15
Q

What is a cervical ectropion and what is the cause?

A

Columnar epithelium visible around the os caused by eversion in pregnancy or puberty

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16
Q

Epidemiology of cervical cancer

A

Peak 30s and 80s (25-49, esp 25-29)

90% SCC 10% adeno from columnar: worse prognosis

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17
Q

Aetiology of cervical cancer

A

HPV in ALL cervical cancer
HIV/immunodef
smoking
inadequate screening

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18
Q

Clinical features of cervical cancer: Hx and Ex

A

Occult: asyx but dx on biopsy/LLETZ
Hx: PCB, IMB, PMB, offensive discharge. PAIN is UNCOMMON
Late: uraemia and haematuria, rectal bleeding and pain (ureters, bladder, rectum and nerves)
Ex: ulcer or mass on cervix or may look normal

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19
Q

Staging of cervical cancer

A

1ai: dx on microscopy: invasion 4cm diameter
2ai: upper 2/3 vagina w/o parametrial involvement 4cm
2b: parametrium
3: lower vagina or pelvic wall or ureteric obstruction
4: bladder or rectum or pelvis

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20
Q

Anatomy of uterus

A

Myometrium (smooth muscle) and Endometrium (glandular)
Supported by uterosacral and cardinal (like cervix)
Broad = continuous with pelvic side wall and F tubes
Round = little support but holds blood supply
EM responds to oestrogen and progesterone, basal + spiral arterioles

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21
Q

Fibroids Pathology and Epidemiology

A

25% of women, esp near menopause, decreased in nulliparous + OCP - oestrogen driven, regress postmenopausally

Benign tumour of the myometrium
Variable size, intramural, subserosal, submucosal (polyp)

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22
Q

Fibroid syx

A

50% asyx - syx due to size
30% get HMB, IMB if submucosal/polypoid
Pain is rare unless torsion, sarcoma or red degeneration
Urinary if pressure on tract
Reduced fertility esp implantation and tube blocking

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23
Q

Progression of fibroids

A

Slow growing, calcify post menopausally, HRT increases growth
Degenerate if poor blood supply - red = haemorrhage and necrosis, hyaline = fluid filled

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24
Q

Fibroids in pregnancy

A

Red degeneration, premature, malpresentation, abnormal lie, obstruction, PPH

Don’t remove at section due to bleeding

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25
Q

Investigation of fibroids

A

USS
MRI/lap may be needed (MRI sees adenomyosis)
Hysterectomy = visualise change - esp fertility
Hb - bleed = decrease, EPO secretion by fibroids = increase

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26
Q

Tx of fibroids

A

Asyx = none (monitor for malignancy if large)
Medical: tranexamic acid, NSAIDs and progestogens (often not enough if HMB) but try 1st line
GnRH = decreased fibroid size (menopausal state) - 6m only, 2y with add-back HRT
Surgical: Up to 3cm - remove via hysteroscopy if polypoid/submucosal
Pretreat with GnRH
Myomectomy if medical fails and fertility needed (heavy blood loss)
Complications: section in future due to rupture risk, adhesions

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27
Q

Adenomyosis Pathology

A

EM and stroma in myometrium
Common around 40y, assoc with EMosis and fibroids
Syx subside after menopause
EM blood can pool in MyoM - chocolate cyst

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28
Q

Clinical features and diagnosis of adenomyosis

A

May be asyx
Painful, regular HMB common
Uterus enlarged and tender
MRI is dx

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29
Q

Treatment of adenomyosis

A

IUS or COCP +/- NSAIDs to control HMB
Hysterectomy often required
GnRH trial to see if hysterectomy will work

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30
Q

EM polyps Epidemiology, dx and tx

A

Benign, common 40-50y, increased oestrogen= cause
Esp tamoxifen postmenopausally
Can contain hyperplasia/carcinoma = HMB/IMB
Dx = hysteroscopy/USS
Tx = avulsion/ resection

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31
Q

Haematometra Path and Syx

A

Blood accumulation in the uterus
Causes: fibroids, post EM resection, carcinoma, cone biopsy
Congenital imperforate hymen, blind horn - primary amenorrhea

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32
Q

Congenital uterine malformations causes and tx

A

Failure or mullerian duct fusion @9wk
Renal and pregnancy problems
Malpresenation, transverse lie, preterm, miscarriage, retained placenta
Hysteroscopic tx = septa, lap/open = horns, bicorn = not opened

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33
Q

EM carcinoma Epidemiology

A

Most common genital tract cancer

60y, 15% premenopausal (1%

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34
Q

Aetiology of EM carcinoma

A

High oestrogen: progesterone ratio ie unopposed oestrogen
Exogenous oest without prog
Obesity
PCOS/ prolonged amenorrhea, nulliparous, late menopause
tamoxifen = oestrogen agonist in postmen uterus

COCP is protective

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35
Q

Premalignant EM epi and clinical

A

Epi: 1st cystic then atypical glandular
Rare in reproductive age women - tx with progestogens if uterus needed + 6m EM biopsy
Clinical: PMB (10% risk carcinoma), increasing with age, Premen IMB or recent HMB, CGIN smear and Ex normal

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36
Q

EM carcinoma staging

A 
Stage 1 - confined to uterus
a - EM only, b - 1/2
Stage 2 - cervix also
a - cervical glands, b - cervical stromal invasion
Stage 3 - through uterus
a - serosa or adnexae, b - vag/parametrium, c - pelvic nodes, d - paraaortic
Stage 4 - distant
a - bowel/bladder, b - distant
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37
Q

Ix of EM carcinoma

A

Abnormal vaginal bleed as for pre/postmen bleed
USS/biopsy EM depending on risk
Staging only possible post-hysterectomy
MRI in those @ risk and suspected spread

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38
Q

Management of EM carcinoma

A

Surgery: 75% present Stg1 = hysterect + oophrec
Estimate further risk for radio (may be stg 3)
Radio if high risk of LN involvement
High risk LN +ve: deep myometrial invasion, poor histology, grade, stg 2+

39
Q

Prognosis of EM carcinoma

A

Recurrence usually in vault in 1st 3y

Poor prog factors: old, advanced, deep myometrial invasion in stg 1/2, adenosquamous

40
Q

Uterine sarcoma Types, syx and Tx

A

Leiomyo - malignant fibroids
EM stromal - perimenopausal
Mixed mullerian - from embryo elements - old age
Presents: IMB PMB and rapid painful enlargement of fibroid
Tx: hysterec +/- chemo + radio
30% survival at 5y

41
Q

Vaginal support anatomy

A

cervix and upper 1/3 - cardinal and uterosacral
mid - endofascial condensation
lower 1/2 - lev ani and perineal body

42
Q

Types of prolapse

A 
Urethocele
Cystocele
Apical - cervix and upper vagina/vault
enterocele
rectocele
43
Q

Grading of prolapse

A 
0 - no decent of viscera on straining
1 - leading surface >1cm above hymenal ring
2 - 1cm above to 1cm below
3 - >1cm below
4 - vagina everted (complete procidenta)
44
Q

Epi and Aetio of prolapse

A

Epi: 1/2 of all parous women to some degree (10-20% present)
Aetio: Vaginal delivery, pregnancy, prolonged 2nd stage, instrumental, congenital connective tissue disease (ehler danlos), menopause (decreased oestrogen) = tissue deterioration, obesity, cough, constipation (increased IAPressure), surgery/continence procedures

45
Q

Clinical presentation of prolapse

A

Asyx or dragging/lump at end of day or standing
Back pain and intercourse problems
Ulcer and bleeding/ discharge
Cele specific ie urinary
May need to reduce before urination/defecation

Ex: abdo and bimanual for masses, sims for vag wall, rectocele exam

46
Q

Ix and prevention of prolapse

A

Pelvic USS for mass/urodynamic test for incontinence

Prevented by avoiding obstructed labour and XS long 2nd stage, doing pelvic floor exercises

47
Q

Management of prolapse

A

General: weight loss, stop smoking, physio
Pessaries, rings (cones/shelves), topical oestrogen/HRT to stop ulcers, Pain, infection and retention can occur
Surgical: hysteropexy - fix cervix and uterus to sacrum with mesh, sacropexy - vault to sacrum or sacrospinous ligament (less effective)
Urinary incontinence = tension free vag tape or TOT

48
Q

Risk factors for STIs

A

Young, single, >2 partners in 6m, new partner, non-barrier C, inner city, syx in partner, current STI, Hx STI, ethnicity, MSM/contact with MSM

49
Q

Chlamydia Epi, Clinical features, Complications, Dx and Tx

A

5-10% women aged 20-30 have been infected
Usually asyx
Pelvic inf (can be silent), tubal damage, Reiters triad: urethritis, arthritis and conjunctivitis
Dx: NAAT ie PCR on urine
Tx: doxy/azithro

50
Q

Gonorrhea Clinical, Dx and Tx

A

Asyx in women normally, may have, vag discharge, cervicitis, urethritis, pelvic inf, Bartholinitis, systemic bacteraemia/monoarthritis/septic arth
Men get urethritis
Dx = culture endocervical swab
Tx = cephtriaxone (pen and cipro res increasing), partner notification

51
Q

Genital warts virus, Clinical, Tx

A

HPV - common, 16+18 assoc with CIN
Clinical: variable size, usually multiple vesicles on cervix
Tx: topical podophylin or imiquimod cream for external, cryo/electrocautery if resistant

52
Q

Genital herpes virus, clinical, Dx and Tx

A

HSV2 (and 1 increasing)
Clinical: small, painful vesicles and ulcers around introitus, local lymphadenopathy, dysuria and systemic inf, secondary bacterial infections ie acute aseptic meningitis
75% reactivate; less painful, less severe, preceded by tingling
Dx: vag swab and exam
Tx: aciclovir if severe infection

53
Q

Trichomoniasis protozoa clinical, Dx and Tx

A

Offensive grey green discharge, vulval irritatino and superficial dyspareunia, can be asyx
Dx: wet film microscopy
Tx: metronidazole

54
Q

Syphilis Clinical, Complications, Dx and Tx

A

Primary: solitary painless vulval ulcer (chancre)
Secondary (untreated): rash, flu-like sex, warty genital/perioral growth (condylomata lata)
Both 1o and 2o can cause congenital infection in preg
Complications: aortic regurge, dementia, tabes dorsalis, gumata in skin and bone
Dx: enzyme immunoassay, venerial disease research lab tests
Tx: IM penicillin (parenteral)

55
Q

HIV Epi, Risks, Clinical, Tx

A

80% heteros dx in UK contracted it abroad
Risk: STI risk factors and Africa
Clinical: Asyx then flulike on seroconversion
Dx of AIDS: Opportunistic inf or CD4

56
Q

Non-infectious DD for vaginal discharge

A

Physiological (most common) - usually non-offensive: esp in ovulation, preg and COCP use
Ectropion
Atrophic vaginitis: (dec oest esp cervical carcinoma/other genital tract malignancy

57
Q

Infectious DD of vaginal discharge

A

Bacterial vaginosis: fishy odour, grey white discharge. NOT red/itchy, clue cells, increased vag pH. Tx metro/clinda, Dx +ve whiff test
Candidiasis: cottage cheese, itch+vulval irritation, Dx by culture. Tx canestan/fluconazole
Chlamydia/Gon/tric can all cause discharge

58
Q

DD of urethral discharge

A

Gonococcal: 2-5d incubation, purulent discharge (95%), anal inf, epididymal spread late
Non-gonococcal (NSUrethritis): most common - chlamydia or mycoplasma, may not have had sexual contact, blamed on soap/irritants

59
Q

DD of pelvic pain

A

PID, UTI, miscarriage,m ectopic, torsion/rupture of ov. cyst, red degen of fibroid

60
Q

DD of scrotal pain

A 
Testicular torsion: acute pain
Epididymitis: Gradual
Fourniers gangrene: aggressive perineal inf, fever, intense pain
Inguinal hernia
Hydrocele/varicocele
61
Q

Causes of genital lumps

A

Inf: warts, syphilis, HSV
Neoplastic
Benign: cyst, angioma, mollusca

62
Q

Ix of STIs

A 
Screen for concurrent disease (can have >1)
Urine dip and culture
Preg test
Swab for microscopy and culture
HIV/Hep B bloods
63
Q

7 steps of STI management

A
  1. Tx with correct Abx/Antivirals
  2. Screen for concurrent inf + awareness of pregnancy risk
  3. Tx partner
  4. Partner notification (with permission)
  5. Maintain confidentiality
  6. Educate risks of STIs
  7. Promote barrier contraception
64
Q

Pelvic inflammatory Disease Path and Epi

A

STI, assoc with endometritis, bilat salpingitis, parametritis
Epi: 2% women. Young, poor, sex active, nulliparous increase risk

65
Q

Causes of PID

A

Ascending: 80% sexual (increased risk if GUM risk present) COCP protective. Chlamydia and gon common - non-STIs seldom spread into pelvis
Descending: from visceral ie appendicitis or blood

66
Q

Clinical features of PID

A

Usually silent if chlamydia

Bilateral abdo pain and deep dyspareunia, vag discharge, fever, erratic bleeding

67
Q

Ix, Tx and Complications of PID

A

Ix: swab, FBC, CRP, lap if doubt/poor tx response, preg test
Tx: analgesia + Abx (metronidazole and ciprofloxacin
Complications: abscess, chronic PID, CPP, subfertility, ectopic

68
Q

Endometritis definition, causes, presentation, Ix and Tx

A

Inf of uterine cavity only - spread if untreated
Causes: instrumental, preg comp ie RPOC (chlam, gon, E.coli, staph, clostridium)
Present: HVagB, persistent pain, tender uterus, open os, fever
Ix: swab and FBC
Tx: Broad Abx, ERPC if needed

69
Q

DD of colicky abdo pain

A

Obstetric: labour (uterine contractions), torted ovary/cyst (uterus relaxed)
Urinary: colic - loin to groin and haematuria
GI: sigmoid volvulus, billiary colic

70
Q

DD of peritonism, fever and abdo pain

A

Obstetric: Chorioamnionitis: Hx ROM +/- discharge, tender uterus, maternal and fetal tachycardia
Urinary: pyelonephritis: loin pain and fever, cloudy urine
GI: appendix, cholecystitis, pancreatitis (inc amylase)

71
Q

Other causes of abdo pain

A

Abruption: constant pain + bleed PV + abnormal CTG
Uterine rupture: fetal parts felt, abnormal CTG
HELLP: hep tender, blood indices abnormal
Splenic aneurysm rupture: sudden pain and hypovolaemia

72
Q

Ix of abdo pain

A

Blood: UE, LFT, FBC, amylase, glucose, clotting
Urine: analysis and preg test
Culture: swab + blood
Radio: USS AXR CXR IV pyelogram CT
Other: ECG, cardiac enz, peritoneal lavage

73
Q

Presentation of chronic ovarian cyst

A

May be asyx
Pain, discomfort, bloating, swelling in abdomen
Irreg periods, frequency due to pressure on bladder
Breast tenderness and hair growth
N+V, subfertility

74
Q

Presentation of ovarian cysts acutely

A

Rupture: sudden unilateral pain, usually disappears after 6h
Heavy menstrual loss - USS normal
Fluid seen in pouch of Douglas
Haemorhagic cyst: acute v severe pain, persists longer
Torted ovarian cyst: cutting off blood supply to ovary! - acute severe pain, urgent surgery and detorsion to save ovary

75
Q

Ix and Diagnosis of ovarian cysts

A

Hx: pain, duration, menstrual cycle relationship, age (malig rare in young), assoc bowel and urinary syx, Breast or GI (mets), FHx
Ex: palpable mass, liver enlargement or ascites
Ix: Bloods in hCG to exclude choriocarcinoma/yolk sac tumour, CA125
Radio: USS: risk features are:
multilocular, solid/separate, bilateral, ascites, abnormal dopplers
MRI: LN
Lap if >5cm, persistent or rapid growth —> laparotomy if malig

76
Q

What is RMI and how is it calculated?

A

RMI = CA125 x USS points x menstrual status
USS: multilocular, solid, bilateral, ascites, IA masses (0=0, 1=1, >1=3)
Menstrual status: pre=1, post=3

> 200=high risk, 25-200 = monitor

77
Q

Classification of ovarian masses

A

Physiological: Follicular and luteal (persistence) - COCP protective
Benign:
Epi: serous cystadenoma (uniloc, straw coloured fluid filled), mucinous cystadenoma (90% benign, multiloc, unilat, mucin filled)
Sex cord: Granulosa (slow growing malig, release oest and inhibin), thecoma (benign, release oest and androgen), fibroma (rare benign, Meig syndrome - pleural effusion + small ovarian masses)
Germ cell: teratoma/dermoid: young, premen, bilat, small asyx, rupture = pain
EMoma: chocolate cysts due to EMosis: rupture = v painful

78
Q

Malignant Ovarian Tumours types

A

Epi: serous cystadenocarcinoma: most common (50%)
Mucinous CAC: 10% - pseudomyxoma = mucin throughout peritoneum)
EMoid (25%): hist similar to EM carcinoma
Clear cell: 10% but aggressive and poor prognosis

Sex cord: granulosa - slow growing, inhibin to monitor, oestrogen secreting

Germ cell: dysgerminoma - most common in younger women, radiosensitive

79
Q

Bartholin cyst definition, path and tx

A

Defintion: blockage of mucus secreting gland behind lab minora
abscess if infected - v painful and tender swelling
Tx: incision and drainage, suture open = stop reaccumulation

80
Q

Endometriosis definition and epi

A

EM tissue outside uterus
1-2% women (more as asyx often)
30-45 nulliparous most common

81
Q

Endometriosis Pathology

A 
Oestrogen dependent (regress postmen and in preg)
Most common behing ovaries and in uterosacral ligaments but can be anywhere even lungs
Accumulated blood = choc cysts and EMosis in ovaries
Causes inflammation, fibrosis and adhesions (frozen pelvis if bad)
82
Q

Aetiology of EMosis

A

Retrograde menstruation, inherited predisposal + retro men may not cause EMosis

NB: Syx don’t = severity of disease

83
Q

Clinical features of EMosis

A

Hx: asyx or cyclical pelvic pain, dysmenorrhea before menstruation, deep dyspar, subfertility, pain on defecation. Choc cyst rupture = v painful
Cyclical haematuria, rectal/umbilical bleed if severe
Ex: Tender, thick behind uterus and adnexae, retroverted, immobile uterus if bad, rectovaginal felt on DRE, normal if mild

84
Q

Ix of EMosis

A

visualise and biopsy for dx
active lesions = red, less active = brown powder burn
extensive adhesions seen on TVUSS, MRI for adenomyosis and bowel infiltration

85
Q

Medical Management of EMosis

A

Asyx = don’t tx, 50% regress or don’t progress - common incidental finding

Medical: NSAIDs, paracetamol, opiates + ovary suppressors (pill, GnRH or androgen danazol)
COCP: NB CIs - continuous 2-3 back to back
Progestogen: Continuous/cyclical: good by premen syndrome + erratic bleeding, weight gain
GnRH: overstimulate pit = decrease GnRH receptors = decreased ov. hormones 6m/2y with add back HRT due to bone demineralisation
IUS: decreased pain and control syx for 5y

86
Q

Surgical Management of EMosis

A

See and tx @ lap - laser, dia, scissors
Better fertility but hard surgery as anatomy distorted
Radical surgery if ovary involved - strip away/ablate
70% syx better and longer lasting
Hystero + BSO last resort (HRT needed) - support with COCP to stop unopposed oestrogen
F tubes affected = need IVF, F tubes not = surgery effective for treating subfertility

87
Q

CPP definition and presentation

A

> 6m intermittent or continuous lower abdo pain not cyclical or intercourse related
Presents as migrain/lower back pain, 15% women
Exclude non-gynae causes first - detailed hx of ideas from pt - psych assoc

88
Q

Causes of CPP

A

EMosis/adenomyosis if varying with cycle
Oestrogen activity vital: postmen = cancer or adhesions with ov tissue stuck in them causing pain - tx oophrectomy + adhesiolysis
IBS/Icystitis
Depression, psych/ abuse causes

89
Q

Management of CPP

A

IBS style: analgesics and antispasmodics
Cyclical - COCP, GnRH + addback, IUS
Lap, counselling, psychotherapy
Gabapentin/TCAs used if neuropathic

90
Q

EMosis syx

A 
Pelvic pain
Dysmenorrhea
Dyschezia
Dyspareunia
Subfertility
91
Q

EMosis tx

A

Medical: ov suppression: COCP, progestogens, GnRH + HRT
Surgical: Lap ablation +- adhesiolysis, ovarian cystectomy, HBSO

92
Q

Tx of cervical cancer

A

Stage 1ai - cone biopsy
Other 1&2 - LN involvement - radiochemo and LN excision - radical Hysterectomy and BSO (unless young and SCC) if -ve nodes
Radical trachelectomy for fertility retention
>2b - radiochemo and look for mets
recur - pelvic exeneration - take everything possible
Review at 3m, 6m then 6mthly

93
Q

Staging of ovarian cancer

A

Stage 1 - confined to ovaries (a - 1ovary, capsule intact, b - 2 bilateral, capsule intact, c - capsule not intact/cells in abdo cavity - ascites)
2 - beyond ovaries, confined to pelvis
3 - beyond pelvic, confined to abdomen (most common)
4 - beyond abdomen

94
Q

Management of ovarian cancer

A

Midline lap - total BSO and hysterectomy with omentectomy and biopsy any deposits/LN
Stg 1 - retroperitoneal LN
Stg 2 - block dissection
Borderline = ovary alone removed
Chemo once dx confirmed on biopsy (no chemo if 1a/b)
1c - 6 cycles of carboplatin
2+ add in paclitaxel to cis/carboplatin - monitor with CA125

Obs & Gynae (3 decks)

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