Gynae Flashcards
List the 4 stages of female pubertal development and the hormone(s) which control it
1a. Growth acceleration (GH and gonadal steroids)
1b. Breast development (subareolar; thelarche) (ovarian oestrogen)
2. Pubic and auxiliary hair (adrenarche) (ovarian and adrenal androgens)
3. Menarche
Describe the physiological process behind the change in the hypothalamic-pituitary ovarian axis in puberty
Hypothalamo-pituitary-ovarian axis reactivates (been dormant since 3-4m old)
Loses sensitivity to suppression by low gonadal steroid levels during childhood
Describe the endocrine events in the onset of puberty
- Sleep pulsatile FSH + LH release, eventually becomes 247
2. → ovarian oestrogen production
What is delayed puberty defined as ?
Absence of pubertal features by 13y/o
What is primary amenorrhoea defined as ?
No menarche by 14y/o + no sexual characteristics
OR
No menarche but other sexual characteristics developed
Which days in the menstrual cycle are the menstruation/proliferative/secretory (luteal) phase?
Day 1-4: menstruation
Day 5-13: proliferative
Day 14-28: secretory
Describe the endocrine events occur in the proliferative phase (3)
GnRH pulses from hypothalamus stimulate pituitary FSH/LH release ⇒ follicle development + follicle production of oestradiol + inhibin (-ve feedback on FSH so only 1 follicle/oocyte matures)
Oestradiol continues to increase + at maximum acts as +ve feedback ⇒ sharp LH rise
Oestradiol also ⇒ endometrium reform / proliferation
What endocrine changes occur in the luteal/secretory phase (2)
Follicle (egg released) becomes corpus luteum which produces oestrodiol + progesterone
If egg not fertilised, CL fails to continue producing oestrogen/progesterone ⇒ hormonal withdrawal ⇒ cycle starts again (endometrium sheds)
What cellular changes happen in the secretory phase? (3)
Enlarged stromal cells
Glands swell
Increased blood supply
What is the menopause defined as? (+ median age)
What age is classed as premature?
What time period does the perimenopause consist of?
= Permanent cessation of menstruation due to loss of ovarian follicular activity; median age 51
<40yrs = premature
Perimenopause = from 1st features to 12m post-LMP
What are the early effects of the menopause (3)
Irregular periods
Vasomotor (hot flushes, night sweats ⇒ sleep disturbance/irritability)
Psychological (memory loss)
What are the intermediate effects of the menopause? (3)
Skin atrophy (wrinkles)
Genital tract atrophy (dryness/dyspareunia)
Urinary tract atrophy (UTI/freq/urge/noct/incontinence)
What are the late effects of the menopause? (3)
Cerebrovascular accident
Cardiac disease
Bone fractures / osteoporosis
What 2 types of investigations can be done for ovarian failure in menopause?
When are they each measured?
FSH + LH ⇒ high = suggests less oocytes in ovary
FSH measured b/wn d2-5 - avoids normal cycle changes (FSH high pre-ov + low luteal)
Anti-Muillerian Hormone = low levels consistent with ovarian failure
Measurable any day (stable throughout cycle)
What is the incidence of osteoporosis in menopausal women?
What BMD is classed as osteopenia / osteoporosis?
1/3rd of >50s
-1 to -2.5 = osteopenia
less than -2.5 = osteoporosis
What common fractures are seen in osteoporosis? (3)
Wrist (Colle’s)
Hip
Spine
What drugs are used for osteoporosis ? (4)
Vit D supplements
Strontium
Raloxifene
Bisphosphonates
What are the genetic RFs for osteoporosis? (2)
Female FH fractures (esp 1st degree w/ hip fracture)
What are some environmental RFs for osteoporosis? (2)
Smoking
Alcohol abuse
What are some constitutional (physical) RFs for osteoporosis? (2)
Low BMI Early menopause (<45)
What types of drug is a RF for osteoporosis?
Corticosteroids (high-dose > 5mg/d)
What other conditions are RFs for osteoporosis? (7)
RA
Sedentary lifestyle
Low Ca intake
Malabsorption
Chronic liver disease
Hyperthyroidism /hyperparathyroidism
Hypergonadism
What different types (+names) of hormones are used in HRT? (4)
Oestrogens (oestradiol/oestrone/oestriol)
Progesterones (levonogesterol/norethisterone)
Androgens (testosterone)
Tibolone
What is tibolone? How does it work / its actions?
What beneficial effects for the pt? (5)
= synthetic steroid
converted in vivo into metabolites
oestrogenic/progesterogenic/androgenic)
Period-free
Treats vasomotor + psychological + libido + conserves bone mass
What HRT regimen would be used for a women who’s had a hysterectomy?
Oestrogen alone (unopposed)
How is concern for a subtotal hysterectomy (endometrial/cervical remnants) Dx?
Presence/absence bleeding in sequential HRT
What HRT regimen is used in women with a uterus?
Progesterones combo w/ oestrogens (to reduce risk of endometrial cancer)
Sequential (withdraw bleed every 2m)
Continuous (no bleeds) - only >55 and LMP>2yrs
When + which topical oestrogen’s are used?
For urogenital symps (long term as return on cessation)
Low-dose naturals used:
Oestradiol creams/pessaries
Oestriol tablet/ring
What are the risks of HRT?
Breast cancer (with combined) - Endometrial cancer (unopposed) VTE (oral) Gallbladder disease (oral)
List some causes of menorrhagia (6 anatomical; 2 medical)
Fibroids (30%) Polyps (10%) (cervical/endometrial) Malignancy (cervical/endometrial) Ovarian tumour Pelvic inflammatory disease Adenomyosis
Thyroid disease
Von Willebrands / anticoagulation
What symptoms(2) / signs (4) seen in menorrhagia?
Flooding
Passing clots
Anaemia
Irregular enlarged uterus (fibroids)
Tenderness w/o enlargement
Ovarian mass
What 5 investigations can be done for menorrhagia? (+ assessing what?)
Hb (anaemia) Thyroid (if Hx suggestive) Coag (if Hx suggestive) Transvaginal USS (fibroid/polpys/mass) Hysteroscopy (endometrial biopsy)
When is an endometrial biopsy (by hysteroscopy) indicated for menorrhagia? (4)
Endometrial thickness >10mm or suggestive of polyps
>40yrs
Menorrhagia w/ IMB
No response to treatment
What is the 1st line pharmacological treatment for menorrhagia?
What is 2nd line? (3)
What is 3rd line? (2)
1st line = IUS
2nd line = COC, fibrinolytics (tranexamic acid), NSAIDs (mefanamic acid) (last 2 are 1st line if trying to conceive)
3rd line = progesterones (oral/IM), GnRH analogues
What surgical treatments can be done (if medical fails)? (6)
Hysteroscopic:
polyp resection,
endometrial ablation (inc basal),
transcervical fibroid resection (submucosal),
myomectomy (conserve fertility) - use GnRH agonist b4
Uterine aa embolisation
Hysterectomy
What is the incidence + cause + treatment of primary dysmenorrhoea?
50% with menarche (severe in 10%)
No organic cause
NSAIDs (mefanamic) / COC (ovulation suppression)
What is dysmenorrhoea due to? (3)
High levels of prostaglandins in endometrium
Uterine contraction
Uterine ischaemia
List 5 pelvic pathological causes of secondary dysmenorrhoea
PID Fibroids Ovarian tumours Adenomyosis Endometriosis
What other conditions/symptoms is secondary dysmenorrhoea assoc w.?
Menorrhagia
Deep dyspareunia
Oligomenorrhoea
What is 1st line management for dysmenorrhoea (2)
+ 2nd line (2)
NSAIDs / COC
Pelvic USS / Laparoscopy
What are the possible causes of anovulatory cycles
Early/late reproductive years
PCOS
What pelvic pathologies may cause irregular/intermenstrual bleeding? (6)
Fibroids Polyps (uterine/cervical) Adenomyosis Ovarian cysts Chronic pelvic inflammation Malignancy (endomet/cervical/ovarian) - esp if older/ recent change
What investigations are done for irregular / intermenstrual bleeding? (2+3)
Same as menorrhagia:
Transvaginal USS
Hysteroscopy
Bloods: testoserone, FSH/LH, cortisol (cushings)
What is the medical management of irregular periods (when no anatomical cause detected)
COC (1st line)
Progesterones
HRT (for perimenopausal erratic bleeding)
List 4 causes of post-coital bleeding + how each managed?
Cervical carcinoma (not covered in healthy squamous + bleeds after mild trauma: important to exclude) → smear/colposcopy
Cervical ectropion → cryotherapy
Cervical polyps → remove + to histo
Cervicitis / vaginitis
List the causes for post-menopausal bleeding (6)
Cervical carcinoma / polyps Endometrial carcinoma / polyps Ovarian carcinoma Cervicitis Atrophic vaginitis Sequential HRT
List 2 causes for purulent bloody discharge
Endometrial carcinoma Diverticular abscess (rare)
What investigations are done for post-menopausal bleeding? (3)
Check up-to-date smear
Pelvic Examination (bimanual + speculum)
Transvag USS
What does increased thickness / fluid filled cavity on transvaginal USS suggest
Risk of malignancy / hyperplasia / polpys
What is the criteria for biopsy in PMB?
How is it done as outpatient?
Why would an inpatient admission be required ?
> 4mm OR >1 PMB episode
Paracervical local anaesthetic
If local not tolerated / endometrial polyp / restricted vaginal access (atrophic) - hysteroscopy under GA
Define primary amennorhoea
Define secondary
Defone oligomenorrhoea
Primary = not started by 16yrs Secondary = normal menstruation for 6m+ Oligomenorrhoea = menstruation b/wn 35d-6m
List some non-pathological causes of amenorrhoea (2 primary + 4 secondary)
Constitutional delay
Drugs
Lactation
Pregnancy
Menopause
Drugs
List some pathological causes of amenorrhoea (both primary and secondary) (8)
Psychological
Anorexia nervosa
Athleticism
Hyper/hypothyroidism
Hyperprolactinaemia
Adrenal tumour/hyperplasia
PCOS
Premature ovarian failure
List some pathological causes of amenorrhoea specific to primary (4)
Transvaginal septum
Imperforate hymen
Turners / gonadal dysgeneses
Androgen insensitivity
List some pathological causes of amenorrhoea specific to secondary (2)
Ashermans syndrome
Cervical stenosis
What investigations can be done to confirm Dx of physiological (constitutional) delay of menarche
Maternal FH
Progesterone challenge test
USS (confirms normal structures)
What is the incidence of endometriosis
Who is it more common in
Where does it occur
1-20%
Nulliparous
Throughout pelvis (anywhere) - esp uterosacral ligaments/ovaries
Describe the pathophysiology of endometriosis spread
Indiv factors (e.g. genetic predispo)
Retrograde menstruation
Lymph/blood etc for more distal foci
What are the complications/associated effects of endmetriosis
Progressive fibroids
Chocolate cyst (endometrioma)
Adhesions
What are the symptoms of endometriosis (6)
Asymptomatic
Acute pain (choc cyst rupture)
Chronic pelvic pain (pre-menstrual dysmen / deep dyspareunia)
Subfertility
Menstrual problems
Cyclical bladder/bowel probs during period (pain ± bleeding)
What may be seen O/E in endometriosis (4)
Normal pelvic exam (in mild)
Tenderness/thickening behind uterus/andexa
Uterus poss retroverted
Uterus poss immobile (adhesions)
How is endometriosis Dx?
Laparascopy ± biopsy
What are some DDx for endometriosis (5)
Adenomyosis PID Chronic pelvic pain Pelvic mass IBS
What are the medical management options for endometriosis (5) How do (most of them) work?
Analgesics (NSAIDs, paracetamol, opiates) GnRH analogues (pituitary overstim - menopausal SEs)
COC
Progesterone pill
Mirena IUS
What are the surgical management options for endometriosis? (3)
Laparoscopic laser ablation/diathermy/scissors ± adhesiolysis
Ovarian cystectomy
Hx-tomy + bilat salp-oo (BSO) - for severe/older
What is adenomyosis?
Who is it seen in
What conditions is it assoc w.?
Endometrium within myometrium
Common around 40y/o
Assoc w. endometriosis + fibroids
What are the clinical features of adenomyosis (3)
+ How is it Dx?
Asymp
Painful/heavy menstruation
Mildly enlarged + tender uterus
Dx - MRI
How is adenomyosis managed?
COC/IUS ± NSAIDs (for menorrhagia/dysmen)
Hx-tomy often required
What is the prevalence of fibroids?
25% women
What are the RFs (3) + avoidance factors (2) for fibroids
RFs:
Near menopause
Afro-Caribbean
FH
Avoidance factors:
Parity
COC/Depo
What are the 6 possible structural sites/types of fibroids?
Subserous polyp Subserous Intramural Intra-cavity polyp Subserous Cervical
Fibroids: symptoms (5)
Menorrhagia Dysmenorrhoea Intermenstrual bleeding Pressure effects Subfertility
List some possible complications of fibroids normally (3)
+ in pregnancy (3)
Torsion of pedunculated fibroid (postpartum)
Malignancy (0.1% risk leiomyosarcoma)
Degeneration from ↓ blood supply (haemorrhage/necrosis/tenderness)
Preterm labour
Abnormal/transverse lie
Obstructed labour
What investigations (3) can be done for fibroids?
USS
MRI (distinguish b/wn ovarian mass + fibroid)
Laparoscopy
When is treatment done for fibroids?
What treatments are available for fibroids? (3)
Only if symptoms / fast-growing
Hysterectomy
Myomectomy
Uterine aa embolisation
What are the risks of a myomectomy
Peri-op haemorrhage
Adhesions
Uterine rupture during labour
What 3 acute things may occur with an ovarian cyst?
Rupture
Haemorrhage (into cyst)
Torsion
What is a bartholin cyst? + abscess
How is it treated?
Blockage of bartholin gland (lubrication for coitus)
Infection (staph/E.Coli) = abscess
Incision / Drainage / Suture open (prevent reformation)
What USS findings in a polycystic ovary (PCO)
Transvaginal USS shows multiple (12+) small (2-8mm) follicles
What are the criteria for PCOS (2 of 3)
+ List some other features (non-criteria)
PCO on USS
Hirsutism (clinical/biochem)
Irregular cycle (>35d)
Obesity
Asymptomatic
Anovulatory infertility
How is PCOS caused (describe the physiology)
Mainly genetic
↑ Ovarian androgen production, due to:
disordered LH production
+ peripheral insulin resistance/↑
What investigations can be done for PCOS (scans/bloods/other)
USS
Testosterone ↑
Progesterone ↓
FSH - normal
Prolactin - normal
Diabetes screening
Abnormal lipids
What may ↑↑↑ testosterone levels indicate? (rather than PCOS)
Androgen secreting tumour / congenital adrenal hyperplasia
List the long-term risks of PCOS (3)
Gestational DM (30% PCOS pts) Diabetes (50% PCOS pts) Endometrial malignancy (persistent anov)
List the possible complications of PCOS
Obesity
Infertility
Miscarriage
What are the treatment options for PCOS?
None if incidental find
Wt loss if needed
Infertility: clomifene/ ov diathermy/ metformin/ gonadotrophins/ IVF
Hirsutism: pill / spironolactone / eflornithine face cream
Menstrual: COC/IUS
Cervical ectropion: What is it? Who seen in? What clinical features (3) What seen O/E
Eversion of columnar epithelium (∴ visible)
Young girls on pill
Asymp / vaginal discharge / PCB
Red area around cervical os
How do Acute + Chronic Cervicitis occur?
+ List 1 complication of acute
Acute - STI (Complication: prolapse/ulceration)
Chronic - inflamm/infection of ectropion
Cervical polyps:
Where originate from
Who seen in
What clinical features (3)
From endocervix
Common >40yrs
Asymp / IMB / PCB / PMB
How do nabothian cysts form?
Metaplastic squamous grows over endocervical columnar secretions
What histological features would be seen in:
CIN1-2
CIN3
CIN4
CIN I-II: abnormal cells w/ larger nuclei proliferating in lower 1-2/3rds
CIN III: abnormal cells occupying entire epithelium
CIN IV: abnormal cells penetrated basement memb
List some causes/RFs of CIN (5)
HPV Low vaginal pH Oral contraceptive Smoking Immunocompromise (HIV/long-term steroids)
What management is done if smear result shows:
Normal
Mild dyskaryosis (borderline)
Moderate / severe dyskaryosis
Cervical glandular intraepithelial neoplasia
Normal - repeat every 3yrs (5yrs if >50) Mild - HPV-ve: back to routine recall Mild - HPV+ve: colposcopy Mod/Severe: colposcopy (/urgent) CGIN: colposcopy/hysteroscopy
How is CIN treated?
What are the poss complications of this treatment
Loop diathermy of abnorm transformation zone (LLETZ)
Post-op haemorrhage / Subsequent pre-term delivery
List some features/symptoms of cervical carcinoma (5)
+ List some later stage features (4)
Asymp PMB IMB PCB Offensive vaginal discharge
Pain
Uraemia
Haematuria
Rectal bleeding
What investigations can be done for cervical carcinoma?(5)
Biopsy (Dx) Vaginal/rectal Ex (to stage) Cystoscopy (bladder involvement) MRI (TMN) Pts fitness for surgery (FBC/crossmatch/U&E/CXR)
List the diff stages of cervical carcinoma (1-4 dependant on invasion sites)
- Uterus + cervix
- Upper vagina
- Lower vaginal / ureteric obstruction / pelvic wall
- Bladder / rectum / beyond pelvis
What are the different managements for the different stages of cervical cancer? (1a i; 1a ii-2a; 2b+)
1a. i) Cone biopsy ± Simple Hx-tomy
1a. ii - 2a.) LN biopsy
LNs -ve → Wertheim’s (total Hx-tomy + connectives + LNs)
2b+ / LNs +ve → Chemo-radio w/o surgery
What are some of the symps that should be asked about in vulval conditions? (5)
Pruritis Superficial dyspareunia Soreness / Burning Discharge / Bleeding Lumps
What are some causes for Pruritis Vulvae? (I D-No)
Infection: Thrush / Warts / Lice / Scabies
Dermatological: Eczema / Contact dermatitis/ Psoriasis / Lichen simplex-sclerosis-planus
Neoplasia: Carcinoma / Pre-Malig
What are the features of Lichen simplex? (2)
What triggers? (3)
Severe pruritis (esp night) Hyper-po-pigmentation + thickening of major
Assoc w. irritants, stress, low Fe
What happens in lichen sclerosis?
What conditions is it assoc w.? (3)
What may it →?
Loss of collagen in vulval tissue
Menopausal / Autoimmune / Thyroid
5% → vulval cancer
List 2 features of lichen planus
How is it treated?
Flat papular purple lesions
Pain (>pruritis)
Potent steroids (poss autoimmune)
What are some causes of vaginal discharge? (6)
Physiological
BV
Thrush
Atrophic vaginitis
Cervical eversion/ectropion
Foreign body
List some RFs for vulval cancer (4)
Lichen sclerosis
Immunosuppression (skin cancer type)
Smoking
Paget’s
How does vulval cancer usually present? 5 features
Presents late Pruritis Bleeding Discharge Mass (majora/clit) Enlarged LNs (femoral → ext iliac)
How is vulval cancer managed? (3)
Wide local excisional biopsy
Groin LN dissection biopsy
Radiotherapy if LNs involved
What is the normal epithelium type in the vagina?
Normal flora?
Normal pH?
What is the normal pH prepubertal/postmenopausal? What does this change in pH mean?
Squamous
Lactobacillus
pH < 4.5 (acidic)
Atrophic + pH 6.5-7.5 (less resistance to infection)
What are some features of candidiasis? (4)
Vulval irritation/itching
Superficial dyspareunia
Dysuria
‘Cottage cheese’ discharge
What are the RFs for candidiasis infection? (3)
Pregnant
Abx
Diabetes
What are the features of bacterial vaginosis? (3)
What is a complication of BV
Grey/white fishy discharge
Vagina not red / itchy
pH high
Complication: secondary PID or preterm labour
What are some features of Chlamydia STI? (3)
How Ix/managed?
What complications? (2)
Asymp (usually)
Urethritis
Vaginal discharge
NAAT/PCR
Doxy/azithro
PID
Reiter’s syndrome (urethritis/conjunctivitis/arthritis)
What type of bacteria is gonorrhoea?
What features? (4)
What problems when managing it?
G-ve diplococcus
Asymp (women)
Vaginal discharge
Bartholinitis/cervicitis
Urethritis (men)
Abx resistance
What pathogen involved in genital warts (condylomata acuminata)
HPV (may affect cervix + 16/18 oncogenic)
What are the symptoms of primary genital herpes infection? (4)
Systemic symptoms
Lymphadenopathy
Multiple painful ulcers
Dysuria
What are the features of trichomoniasis vaginalis (parasite) infection? (3)
Offensive green discharge
Vulval irritation
Superficial dyspareunia
What are the features of syphilis primary (1) + secondary (3) infection?
And complications of tertiary infection (rare) (3)
Primary: painless vulval ulcer
Secondary: Rash, Flu-like symptoms, genital warty-like (condylomata lata)
Tertiary: neurosyphilis, aortic regurg, dementia, locomotor ataxia
What are the RFs for HIV infection? (4)
Sub-saharan migration
IVDU
Lack of barrier contraception
Sex w. high-risk males
What CD4 count is classed as AIDS
CD4<200 = AIDS
What ob/gynae complications can occur with HIV? (4)
Vertical transmission
CIN (cervical neoplasia) higher risk (yrly smears)
Candidiasis
Menstrual disturbances
What groups of people would you suspect PID in? (3)
Young
Sexually active
Nulliparous
What anatomical areas can be involved / inflamed in PID? (4)
Endometritis
Parametritis
Bilateral salpingitis
Perihepatitis (Fitz-High-Curtis adhesions)
List the clinical features that may be seen in PID? (5S + 5S)
Symptoms: Asymp Abdo pain (pelvic / RUQ in perihepatitis) Deep dyspareunia Abnormal bleeding Vaginal discharge
Signs: Fever Tachycardia Bilateral lower abdo tenderness / peritonism Cervical excitation* Adnexal tenderness*
What things may be seen in PID in laparoscopy? (4)
Filmy adhesions
Ovary buried beneath adhesion
Ovary adherent to fallopian tube
Swollen/blocked fallopian tube
What are some complications of PID? (3)
Chronic PID/ pelvic pain
Subfertility (tubal obstruction)
Ectopic pregnancy
What are the DDx of PID? (3) + what features determine between
Appendicitis (no cervical excitation)
Ovarian cyst (would be unilateral)
Ectopic pregnancy
What Ix are done if suspect PID? (2)
How is it managed? (2)
WCC / CRP raised
Laparoscopy Dx
IV Abx + analgesics (acute/chronic)
What are some causes of endometritis? (3)
Pregnancy complication
Uterus instrumentation (C-Sec/ToP/SMM)
Infection (Chlamydia/Gono/BV/E.Coli)
What are the clinical features of endometritis? (4)
Persistent heavy vaginal bleeding + pain O/E: Uterus tender Os open Poss fever/septicaemia
Where is the superior part of uterus lymph drained to?
+ the inferior part?
Superior → common iliac nodes
Inferior → internal iliac nodes
List the RFs for endometrial cancer (8)
High oestrogen (production/oestrogen-secreting tumours) Obesity PCOS Prolonged amenorrhoea Unopposed HRT Late menopause Nulliparity Tamoxifen (agonist in postmeno uterus but antag in breast)
What are the clinical features of endometrial cancer? (3 symps + 2 O/E)
Post-Menopausal bleeding
Irregular / IMB
Menorrhagia (recent onset)
Poss abnormal smear
O/E: normal pelvis
What 3 factors determine level of investigations for endometrial cancer?
What Ix can be done? (5)
Age
Menopausal status
Endometrial cancer symptoms
USS +/or Biopsy (Pipelle/hysteroscopy)
CXR / MRI (detect spread)
Fitness assessment in elderly (FBC/Renal func/Gluc/ECG)
What is the management of endometrial cancer? (2)
Hysterectomy + BSO (abdo/lap) (unless pt unfit/disseminated)
Radiotherapy (if high-risk LN involvement)
What are some common causes of ovarian masses in:
Premenopausal (4)
Post-menopausal (2)
Premeno: Follicular/lutein cysts Dermoid cysts Endometriomas Benign epithelial tumour
Postmeno:
Benign epithelial tumour
Malignancy
What are some primary types of neoplasm in the ovary? (4)
Which are benign/malig
Epithelial tumours:
Adenocarcinoma (Malignant: serous > mucinous)
Endometroid carcinoma (malignant)
Germ cell tumours (young):
Teratoma / dermoid cyst (benign)
Dysgerminoma (malignant)
What secondary metastases may → ovarian malignancy?
Breast cancer GI tract (inc. Krukenberg)
What are the RFs of ovarian tumours? (What are they related to) (3)
What are the protective factors? (3)
RFs (related to no. ovulations):
Early menarche
Late menopause
Nulliparity
Protective factors:
COC
Pregnancy
Lactation
What are some possible features of an ovarian tumour? (4)
How may it present similarly to?
Abdo distension / mass Pain uncommon Urinary frequency/urgency PV bleeding Breast/GI symps (metastases)
May present similarly to IBS (but IBS usually presents in younger)
Usually presents late
What features may indicate the mass is more likely to be malignant? (6)
Older
Rapid growth
Bilateral masses
Ascites
Solid/septate on USS
Vascular
Define the stages (1-4) of ovarian cancer
- Confined to ovary
- Confined to pelvis
- Confined to abdo (e.g. omentum, SI, peritoneum)
- Beyond abdo (lungs, liver)
What Ix done in ovarian cancer? (4)
How is the risk of malignancy estimated? (RMI)
CA125 + if raised → USS pelvis/abdo
Also AFP + hCG (raised in germ cell tumours)
RMI = U (USS score) x M (meno status) x CA125
How is ovarian cancer normally managed? + if wanting to preserve fertility? (3)
What is the prognosis for ovarian malignancy?
Chemo if 1c+ (+ response monitored by CA125)
+
Assess fitness for surg
Total Hx-tomy + BSO + partial omentectomy
LN biopsy/removal
To preserve fertility can leave uterus + unaffected ovary
<35% 5yr survival due to late presentation
What structures make up
Level 1 of the pelvic floor (2) + Level 2 (1) + Level (2)
Level 1: cardinal + uterosacral ligaments
Level 2: endopelvic fascia (→ lateral pelvic walls)
Level 3: perineal body + legator ani
What factors determine urinary filling? (2)
What factors determine urinary voiding? (2)
How much can a normal bladder hold?
At what ml will you normally get the 1st urge to void?
Filling: bladder capacity + urethral sphincter competency
Voiding: detrusor contractility + urethral relaxtion
Normal = 500ml
1st urge = 200ml
What is the micturition reflex?
Bladder distension → parasymp afferents to pons
→ Modified by cortex (relax/contracts pelvic floor)
→ Efferent parasymp contracts detrusor (+ symp eff inhib)
What factors/ areas of pressure determine urinary continence?
Depends on: urethral pressure > bladder
Urethral: sphincter tone / pelvic floor / intra-abdo pressure
Bladder: detrusor tone + intra-abdo pressure
What are some causes of prolapse? (5) think KITTENS
Congenital Iatrogenic (pelvic surg) Pregnancy / vaginal delivery Chronic predispo (obesity/cough/constipation/heavy lifting) Menopause (collagen deterioration)
What are some features of prolapse? (6)
Asymp
Dragging/lump sensation (somethings coming down)
Worse end of day / standing
Back pain (rare)
Severe - interferes with SI
Severe - ulcerate/bleed
What Ix can be done if suspect prolapse? (3)
Ex: Sims speculum (allows separate inspection of ant/post walls)
Urodynamic testing (if urinary symptoms main prob)
Assess fitness for surg (FBC/Renal/ECG/CXR)
How is prolapse managed? (6)
Wt loss
Smoking cessation (cough)
Physio
Pessaries (shelf/ring - replace every 6-9m)
Hx-tomy (40% → vaginal vault prolapse)
Hysteropexy
What are the causes of urinary incontinence? (4)
Detrusor instability (overactive bladder - OAB) Stress incontinence (raised intra-abdo pressure) (50%) Neurogenic/obstructive overflow incontinence Bypass thru fistula
How does stress incontinence occur? (what physical changes)
List the causes (6)
Weak pelvic floor support → Bladder neck slips below → Neck not compressed with raised intra-abdo pressure
Preg/ vaginal delivery
Prolonged labour
Forceps
Age
Obesity
Prev Hx-tomy
What features may stress incontinence co-exist with? (3)
What may be seen O/E in stress incontinence? (3)
Urinary urge / freq
Faecal urge
O/E:
Sims speculum leakage on cough
Poss urethro/cystocele
Normal abdo palp (exclude distended bladder)
How is stress incontinence managed? (7)
Which management strategy is 1st line
Conservative: Wt loss Smoking cessation Avoid excessive fluid intake Physio pelvic floor muscle training (PFMT) - 1st line for 3m
Medical: SNRI drugs (enhance urethral sphincter but many SEs)
Surgical:
Tension-free vag tape / trans-obturator tape
Injectable periurethral bulking agents (for elderly, less invasive)
What is the difference b/wn urodynamic stress incontinence + just stress incontinence?
Urodynamic = Dx disorder from cystometry
Stress incontinence = a symptom
What are the different urinary investigations and the indications for each? (6)
Urine dipstick:
Nitrites - infection
Glucose - diabetes
Blood - carcinoma/calculi
Urinary diary (assess bladder capacity)
Post-micturition USS / catheterisation (exclude chronic retention)
Cystometry (before SI surgery / failure of lifestyle changes / failed OAB therapy)
List the causes of overactive bladder (4)
I - idiopathic
I - iatrogenic post-USI surgery
T - provocation with cough (confused with SI)
N - detrusor overactivity from underlying neuropathy (e.g. MS)
List some features of overactive bladder (6)
Frequency Urgency / urge incontinence Nocturia Nocturnal enuresis / at orgasm H/o childhood enuresis Stress incontinence
What are the conservative measures of an overactive bladder? (4)
And pharmacological management? (3)
Conservative: Avoid excessive fluid intake Avoid caffeine Review bladder altering drugs (e.g. diuretics, anti-psychotics) Bladder training
Pharmacological:
Anticholinergics - 1st line (suppress detrusor activity)
Oestrogen (most symps develop after menopause)
Botox - 2nd line
What are the general risks in gynae surgery? (4)
+ how prevented
VTE - thromboprophylaxis
Infection - prophylactic Abx for major abdo/vaginal surg
Bladder damage - routine catheterisation
Bowel damage
Describe what VTE prophylaxis measures are taken in gynae surgery
What categorises Low/Mod/High risk
COC usually stopped 4wks prior to major abdo surg
HRT stopped / if not, LMWH used
Low risk: minor/major <30mins, no RFs
Mod risk: >30mins, obesity, varicose vv’s, immobility → stocking ± LMWH
High risk: ≥3RFs → LMWH 5d
