Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

O&G > Gynae 4 > Flashcards

Gynae 4 Flashcards

1
Q

What is cervical cancer?

A

Malignancy of the uterine cervix

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the types of cervical cancer?

A
  • 80% squamous (from CIN)
  • 20% adenocarcinoma (from CGIN)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the aetiology of cervical cancer?

A

HPV (types 16 and 18) in most cases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the RFs for cervical cancer?

A

Major = HPV

Minor…

  • Smoking
  • Early first intercourse
  • Many sexual partners
  • Immunosuppression / HIV
  • COCP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the S/S of cervical cancer?

A

May be asx and detected during routine cervical cancer screening

  • PV discharge (offensive or bloodstained)
  • Abnormal vaginal bleeding - PCB, IMB, PMB
  • Dyspareunia (deep)
  • Pelvic or back pain
  • Symptoms of late metastasis - lower limb oedema, haematuria, rectal bleeding, signs of fistulae, pressure symptoms, SoB, DIC
  • FLAWS

> Metastasises to iliac LNs (not para-aortic)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the investigations for cervical cancer?

A

1st line:

  • Vaginal or speculum examination - may show cervical mass or bleeding
  • HPV testing + cytology
  • Colposcopy - punctated blood vessels, mosaics, white rings around the gland openings, acetic white epithelium, leukoplakia and atrophic changes
  • Biopsy - Confirms diagnosis histologically and identifies subtype

Consider:

  • MRI > CT-CAP
  • Bloods – FBC (anaemia), U&Es (obstructive picture / elevated creatinine), LFTs (metastasis - elevated ALP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe the difference in imaging for cervical / endometrial / ovarian cancer

A

MRI > CT-CAP = cervical cancer

CT-CAP > MRI = ovarian cancer, endometrial cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe HPV screening

A

Main aim of cervical screening is to detect pre-malignant changes rather than to detect cancer (cervical adenocarcinomas are frequently undetected by screening)

HPV first system i.e. a sample is tested for high-risk strains of HPV (hrHPV) first and cytological examination is only performed if this is positive

  • It is said that the best time to take a cervical smear is around mid-cycle.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Describe the follow-up of HPV screening

A

Negative hrHPV: Return to normal recall
Unless:

  • TOC pathway (treated for CIN = repeat sample in 6m)
  • Untreated CIN1 pathway = repeat sample in 12m
  • Follow-up for incompletely excised CGIN / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
  • Follow-up for borderline changes in endocervical cells

Positive hrHPV: Samples examined cytologically

If cytology abnormal = colposcopy <2w
Includes the following results:

  • Borderline changes in squamous or endocervical cells
  • CIN I / II / III
  • Invasive squamous cell carcinoma
  • Glandular neoplasia

If cytology normal = test repeated at 12 months:

  • If repeat test hrHPV -ve → return to normal recall
  • If repeat test still hrHPV +ve and cytology still normal → further repeat test 12 months later:
  • If hrHPV -ve at 24 months → return to normal recall
  • If hrHPV +ve at 24 months → colposcopy

If the sample is ‘inadequate’:

  • Repeat sample within 3 months
  • If 2 inadequate samples → colposcopy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the management of Stage IA1 cervical cancer?

A

Microinvasive Disease

Cone Biopsy:

  • If fertility preservation is desired
  • Cold knife cone biopsy is preferred method
  • LLETZ may be acceptable

OR Simple Hysterectomy

  • If fertility preservation not desired

±lymphadenectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the management of stage IA2 to IIa cervical cancer?

A

(Early stage):

  • Radical hysterectomy (resection of the cervix, uterus, parametria, and cuff of upper vagina) with bilateral pelvic lymphadenectomy
  • Radical trachelectomy (removal of the cervix) and lymphadenectomy may be considered instead for smaller tumours
  • Consider adjuvant chemotherapy or radiotherapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the management of stage IIb to IVa cervical cancer?

A

(Locally advanced disease):

  • Chemoradiotherapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the management of stage IVb cervical cancer?

A

(Metastatic disease):

  • 1st line = Combination chemotherapy (e.g. Cisplatin) with or without bevacizumab
  • 2nd line = Single agent therapy and palliative care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What types of radiotherapy are used for cervical cancer?

A
  • External beam radiotherapy (10 minutes of delivery, completed over 4 weeks)
  • Internal radiotherapy (brachytherapy; rods of radioactive selenium is inserted into the affected area)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the management of cervical cancer if pregnant?

A

MDT care

  • Surgery is typically avoided
  • Radiotherapy absolutely contraindicated as it would result in pregnancy termination and foetal death.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the complications of the management of cervical cancer?

A

Surgical risk (Wertheim’s hysterectomy):

  • Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
  • Bladder dysfunction (atony) > common, may require intermittent self-catheterisation
  • Sexual dysfunction (due to vaginal shortening)
  • Lymphoedema (due to pelvic lymph node removal) > leg elevation, good skin care and massage

Radiotherapy (more often used than chemotherapy, which is used for later stage cancer):

  • Short-term: diarrhoea, vaginal bleeding, radiation burns, dysuria, tiredness/weakness, urgency, incontinence
  • Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe FIGO staging for cervical cancer

A

IA:
Confined to cervix, only visible by microscopy and <7mm wide

  • A1 = <3mm deep
  • A2 = 3-5mm deep

IB:
Confined to cervix, clinically visible or larger than 7mm wide

  • B1 = <4cm diameter
  • B2 =>4cm diameter

II:
Extension of tumour beyond cervix but not to the pelvic wall

  • A = upper 2/3 of vagina
  • B = parametrial involvement

III:
Extension of tumour beyond the cervix and to the pelvic wall

  • A = lower 1/3 of vagina
  • B = pelvic side wall

IV:
Metastatic

  • A = involvement of bladder or rectum
  • B = involvement of distant sites outside pelvis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is dysfunctional uterine bleeding?

A

Abnormal uterine bleeding in the absence of organic pathology

  • Diagnosed by excluding pregnancy, iatrogenic causes, systemic conditions, and genital tract pathology
  • Affects ~10% of women
19
Q

What are the RFs for DUB?

A

Extremes of reproductive age, obesity

20
Q

What are the types of DUB?

A

Anovulatory (90%)

  • Failure of follicular development > no increase in progesterone > cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation
  • Shedding of this may be prolonged or long-term

Ovulatory (10%)

  • Prolonged progesterone secretion > irregular shedding
21
Q

What is menorrhagia?

A

Menorrhagia is defined as what the individual woman believes is menorrhagia – there is no need to quantify it

22
Q

What are the causes of DUB?

A
  • Polyps
  • Adenomyosis
  • Malignancy
  • Coagulopathy
  • Endometriosis
  • Iatrogenic
23
Q

What are the S/S of DUB?

A
  • Bleeding (menorrhagia, IMB, dysmenorrhoea)
  • Anaemia signs/symptoms

S/S of the cause:

  • Relation to the menstrual cycle
  • Fertility issues
  • Compression symptoms
  • Cervical screening history
  • DHx, FHx, sexual history (fevers, previous STIs, sexual contacts)
    Coagulopathy disorders (von Williebrand disease)
24
Q

What are the investigations for DUB?

A

If menorrhagia without other related symptoms (i.e. persistent IMB, pelvic pain, pressure symptoms), consider starting management without any physical examination (unless LNG-IUS)

  • Examination: Speculum (i.e. ectropion), bimanual (i.e. bulky, fibroids)

1st line:

  • FBC (anaemia), TFTs (hypothyroid)
  • Clotting screen (if primary menorrhagia or FHx)

2nd line

  • TVUSS (PCOS, fibroids, malignancy)

3rd line

  • OPD hysteroscopy / laparoscopy ± biopsy (endometriosis)
25
Q

What is the management of DUB?

A

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis:

  • 1st line (contraception required; hormonal): LNG-IUS (may not be possible in large fibroids distorting uterus)
  • 2nd line (fertility required; 1st line declined/unsuitable):
    BLEED = Tranexamic acid (contraindications: renal impairment, thrombotic disease)
    PAIN = Mefenamic acid (NSAIDs; contraindications: IBD)
  • 2nd line (contraception required; 1st line declined/unsuitable):
    1st = COCP
    2nd = cyclical oral progestogens
  • Norethisterone 5 mg TDS for 10 days can be used to arrest bleeding acutely
  • When you stop taking this, it causes a heavy bleed

Surgical: (last resort)

  • Endometrial ablation (will need continued contraception)
  • Hysterectomy

If fibroids >3cm = see fibroids management

26
Q

What is endometrial hyperplasia?

A

An abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle

A minority of patients with endometrial hyperplasia may develop endometrial cancer

EH without atypia = cells are normal
EH with atypia = cells are abnormal

27
Q

What are the RFs for EH?

A
  • Increasing age
  • Excess oestrogen (early menarche, late menopause, nulliparous, tamoxifen, HRT without progesterone, COCP, obesity)
  • Sex-cord stromal ovarian tumours are functional I.E. Granulosa cell tumour > oestrogen > EH
  • High insulin levels (T2DM, PCOS)
  • FHx ovarian, bowel (HNPCC, Lynch Syndrome – same as per Ovarian Cancer) or uterine cancer
28
Q

What are the S/S of EH?

A
  • Heavy PV bleeding
  • IMB
  • PMB
  • Secondary changes in periods
29
Q

What are the investigations for EH?

A

Same as endometrial cancer pathway

1st: TVUSS (if PMB, otherwise must be matched with ovulatory cycle)

  • <4mm = endometrial cancer unlikely (<10mm if pre-menopausal)
  • > 4mm = 2nd line investigations: hysteroscopy ± biopsy (>10mm if pre-menopausal)

2nd: Biopsy [Diagnostic Gold-Standard]:

  • Either Hysteroscopy with biopsy (performed as outpatient under LA) or pipelle biopsy
  • Complex hyperplasia with atypia is a premalignant condition that often co-exists with low-grade endometrioid tumours of the endometrium (25-50% risk of progression to endometrial cancer)
  • Sonohysterography = replacing hysteroscopy as a method of visualisation
30
Q

What is the management of EH?

A

EH without Atypia:
<5% risk of becoming malignant in 20 years

  • 1st line = high dose progesterone (IUS > continuous oral)
  • +Reverse risk factors (e.g. obesity, HRT)
  • +Endometrial surveillance (ie repeat biopsy) every 6 months
  • Can discharge once 2x consecutive negative biopsies but encourage to continue progesterone treatment
  • 2nd line / if does not regress / recurs = Hysterectomy

EH with Atypia:

  • 1st line = Hysterectomy +/- BSO

If wishes to preserve fertility:

  • MRI to exclude malignancy
  • 1st line: LNG-IUS
  • 2nd line: PO progestogens
  • Until 2x negative biopsies (ideally every 6m, if keen to start family then can be every 3m)
  • Once regressed, consider assisted reproduction
  • Once family complete = hysterectomy
31
Q

What is endometrial cancer?

A

Malignancy arising from endometrial tissue

  • Classically seen in post-menopausal women (~25% before menopause)
  • Uncommon in <40yo (mean age 54yo)
  • If PMB, diagnosis is endometrial cancer until proven otherwise
  • Usually carries a good prognosis due to early detection
  • 2nd most common gynae malignancy in UK (1% lifetime risk)
  • 90% = adenocarcinoma
32
Q

What are the RFs for endometrial cancer?

A

Excess oestrogen:

  • Nulliparity
  • Early menarche / late menopause
  • Obesity
  • Unopposed oestrogen (HRT without progesterone)

Also:

  • Diabetes mellitus
  • PCOS
  • Tamoxifen (breast cancer drug)
  • Hereditary non-polyposis colorectal carcinoma / Lynch syndrome
33
Q

What are protective factors for endometrial cancer?

A
  • Multiparity
  • COCP
  • Smoking (the reasons for this are unclear)
34
Q

What are the types of endometrial cancer?

A

Type 1 = SEM - secretory, endometrioid, mucinous carcinoma (85%)

  • Younger patients; oestrogen-dependent; superficially invade; low-grade
  • ≥4 mutations must accumulate to cause this…
    -PTEN
    -PI3KCA
    -K-Ras
    -CTNNB1
    -FGFR2
    -P53

Type 2 = SC - uterine papillary serous carcinoma (UPSC), clear cell carcinoma (15%)

  • Older patients; less oestrogen-dependent; deeper invasion, higher grade
  • Mutations associated:

Serous Carcinoma: p53 (90%), PI3KCA (15%), Her 2 amplification

Clear Cell Carcinoma: PTEN, CTNNB1, Her-2 amplification

35
Q

What are the S/S of endometrial cancer?

A
  • PMB (as opposed to ovarian cancer which is more associated with palpable masses)
  • Bulky uterus
  • Metastasises to para aortic LNs
36
Q

Describe the FIGO staging of endometrial cancer

A

I = limited to uterus
II = spread to cervix
III = spread adjacent
IV = distant spread

37
Q

What are the investigations for endometrial cancer?

A

All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway (2ww)

  • Vaginal examination (speculum and bimanual)

1st: TVUSS (if PMB, otherwise must be matched with ovulatory cycle)
Looking at endometrial thickness

  • <4mm = endometrial cancer unlikely
  • > 4mm = requires further investigation

2nd: Hysteroscopy + biopsy

  • Hysteroscopy under GA as outpatient or pipelle biopsy
38
Q

What is the management of endometrial cancer?

A

Stage 1:

  • Total hysterectomy + bilateral salpingoopherectomy (BSO)
  • +Peritoneal washings
  • Curative in most cases

Stage 2+:

  • Radical hysterectomy + BSO with radiotherapy
  • Can be brachytherapy or external

> > Chemotherapy is of limited use and used if a cancer is not amenable to radiotherapy

Hormone treatments:

  • High-dose oral or intrauterine progestins (LNG-IUS)
  • Indication: women with complex atypical hyperplasia + low-grade stage 1A endometrial tumours
  • Relapse rates are high but may be suitable for those not fit for surgery or for fertility reasons
39
Q

What is the prognosis of endometrial cancer?

A

5-year survival = 80% (dependent on type, stage and grade)

Bad prognostic features:

  • Age
  • Grade 3 tumours
  • T2 histology
  • Distant metastasis
  • Deep invasion
  • Lymphovascular space invasion
  • Nodal involvement

Hormone receptor expression may influence a better prognosis/treatment (Her2)

40
Q

What is endometriosis?

A

Presence/growth of endometrial tissue outside the uterus

Affects 1 in 10 women (of reproductive age), mainly 30-45y

41
Q

What are the RFs for endometriosis?

A
  • Early menarche
  • FHx
  • Nulliparity
  • Prolonged menstruation (>5 days)
  • Short menstrual cycles

Sampson’s theory – retrograde menstruation and implantation may be the cause

Associations = clear cell ovarian carcinoma > endometroid ovarian carcinoma

42
Q

What are the S/S of endometriosis?

A
  • Cyclical or chronic pelvic pain occurring before or during menstruation
  • Dyspareunia (deep), dyschezia (pain on defecation)
  • Dysmenorrhoea (N.B. no menorrhagia differentiates this from fibroids)
  • Symptoms of extra-uterine endometriosis (i.e. rectal pain, bleeding)
  • Subfertility
43
Q

What are the investigations for endometriosis?

A

Bimanual & speculum examination:

  • Findings: reduced mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions, fixed retroverted uterus= ectopic tissue on utero-sacral ligament

1st line = TVUSS

  • May show endometrioma, may show nothing
  • Other = HSG or HyCoSy
  • Association to clear cell (20%) and endometroid (<20%) ovarian carcinoma

Diagnostic laparoscopy (GOLD-STANDARD):

  • Red vesicles or punctate marks on peritoneum = active lesions
  • White scars / brown spots = less active endometriosis
44
Q

What is the management of endometriosis?

A

Medical treatment of presumed endometriosis can begin if clinical examination / TVUSS normal (without need for laparoscopy). However, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:

1st line (3m trial) = Paracetamol ± NSAIDs

  • Adjunct: Tranexamic acid

If analgesia doesn’t help then hormonal treatments should be tried:

2nd line (3m trial) = COCP or progesterone (POP, implant, injectables or LNG-IUS)

  • COCP can provide cycle control and contraception whilst alleviating symptoms of endometriosis
  • Continue until pregnancy required
  • Progesterone used to induce amenorrhoea in those where COCP contraindicated

If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include:

Laparoscopic ablation

  • If mild endometriosis superficially
  • Recurrence rate is high at 30% so supplement with medical therapy (COCP)

Hysterectomy with BSO

GnRH analogues (e.g. leuprorelin) can induce a ‘pseudo-menopause’

  • Used to shrink endometriosis in the approach to surgery
  • Inhibits oestrogen release > don’t use for longer than 6 months (osteoporosis risk)
  • Menopause-like side effects (hot flushes, night sweats)

Subfertility

  • Laparoscopic ablation ± endometrioma cystectomy (no hormonal treatment if trying to conceive)

O&G (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions