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Gynae Flashcards

1
Q

List the 4 stages of female pubertal development and the hormone(s) which control it

A

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

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2
Q

Describe the physiological process behind the change in the hypothalamic-pituitary ovarian axis in puberty

A

Hypothalamo-pituitary-ovarian axis reactivates (been dormant since 3-4m old)

Loses sensitivity to suppression by low gonadal steroid levels during childhood

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3
Q

Describe the endocrine events in the onset of puberty

A
  1. Sleep pulsatile FSH + LH release, eventually becomes 247

2. → ovarian oestrogen production

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4
Q

What is delayed puberty defined as ?

A

Absence of pubertal features by 13y/o

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5
Q

What is primary amenorrhoea defined as ?

A

No menarche by 14y/o + no sexual characteristics
OR
No menarche but other sexual characteristics developed

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6
Q

Which days in the menstrual cycle are the menstruation/proliferative/secretory (luteal) phase?

A

Day 1-4: menstruation
Day 5-13: proliferative
Day 14-28: secretory

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7
Q

Describe the endocrine events occur in the proliferative phase (3)

A

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

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8
Q

What endocrine changes occur in the luteal/secretory phase (2)

A

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)

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9
Q

What cellular changes happen in the secretory phase? (3)

A

Enlarged stromal cells
Glands swell
Increased blood supply

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10
Q

What is the menopause defined as? (+ median age)
What age is classed as premature?

What time period does the perimenopause consist of?

A

= Permanent cessation of menstruation due to loss of ovarian follicular activity; median age 51

<40yrs = premature

Perimenopause = from 1st features to 12m post-LMP

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11
Q

What are the early effects of the menopause (3)

A

Irregular periods
Vasomotor (hot flushes, night sweats ⇒ sleep disturbance/irritability)
Psychological (memory loss)

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12
Q

What are the intermediate effects of the menopause? (3)

A

Skin atrophy (wrinkles)
Genital tract atrophy (dryness/dyspareunia)
Urinary tract atrophy (UTI/freq/urge/noct/incontinence)

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13
Q

What are the late effects of the menopause? (3)

A

Cerebrovascular accident
Cardiac disease
Bone fractures / osteoporosis

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14
Q

What 2 types of investigations can be done for ovarian failure in menopause?
When are they each measured?

A

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)

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15
Q

What is the incidence of osteoporosis in menopausal women?

What BMD is classed as osteopenia / osteoporosis?

A

1/3rd of >50s

-1 to -2.5 = osteopenia
less than -2.5 = osteoporosis

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16
Q

What common fractures are seen in osteoporosis? (3)

A

Wrist (Colle’s)
Hip
Spine

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17
Q

What drugs are used for osteoporosis ? (4)

A

Vit D supplements
Strontium
Raloxifene
Bisphosphonates

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18
Q

What are the genetic RFs for osteoporosis? (2)

A 
Female
FH fractures (esp 1st degree w/ hip fracture)
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19
Q

What are some environmental RFs for osteoporosis? (2)

A

Smoking

Alcohol abuse

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20
Q

What are some constitutional (physical) RFs for osteoporosis? (2)

A 
Low BMI
Early menopause (<45)
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21
Q

What types of drug is a RF for osteoporosis?

A

Corticosteroids (high-dose > 5mg/d)

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22
Q

What other conditions are RFs for osteoporosis? (7)

A

RA

Sedentary lifestyle
Low Ca intake

Malabsorption
Chronic liver disease

Hyperthyroidism /hyperparathyroidism
Hypergonadism

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23
Q

What different types (+names) of hormones are used in HRT? (4)

A

Oestrogens (oestradiol/oestrone/oestriol)
Progesterones (levonogesterol/norethisterone)
Androgens (testosterone)
Tibolone

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24
Q

What is tibolone? How does it work / its actions?

What beneficial effects for the pt? (5)

A

= synthetic steroid
converted in vivo into metabolites
oestrogenic/progesterogenic/androgenic)

Period-free
Treats vasomotor + psychological + libido + conserves bone mass

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25
Q

What HRT regimen would be used for a women who’s had a hysterectomy?

A

Oestrogen alone (unopposed)

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26
Q

How is concern for a subtotal hysterectomy (endometrial/cervical remnants) Dx?

A

Presence/absence bleeding in sequential HRT

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27
Q

What HRT regimen is used in women with a uterus?

A

Progesterones combo w/ oestrogens (to reduce risk of endometrial cancer)

Sequential (withdraw bleed every 2m)
Continuous (no bleeds) - only >55 and LMP>2yrs

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28
Q

When + which topical oestrogen’s are used?

A

For urogenital symps (long term as return on cessation)

Low-dose naturals used:
Oestradiol creams/pessaries
Oestriol tablet/ring

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29
Q

What are the risks of HRT?

A 
Breast cancer (with combined) - 
Endometrial cancer (unopposed)
VTE (oral)
Gallbladder disease (oral)
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30
Q

List some causes of menorrhagia (6 anatomical; 2 medical)

A 
Fibroids (30%)
Polyps (10%) (cervical/endometrial)
Malignancy (cervical/endometrial)
Ovarian tumour
Pelvic inflammatory disease
Adenomyosis

Thyroid disease
Von Willebrands / anticoagulation

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31
Q

What symptoms(2) / signs (4) seen in menorrhagia?

A

Flooding
Passing clots

Anaemia
Irregular enlarged uterus (fibroids)
Tenderness w/o enlargement
Ovarian mass

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32
Q

What 5 investigations can be done for menorrhagia? (+ assessing what?)

A 
Hb (anaemia)
Thyroid (if Hx suggestive)
Coag (if Hx suggestive)
Transvaginal USS (fibroid/polpys/mass)
Hysteroscopy (endometrial biopsy)
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33
Q

When is an endometrial biopsy (by hysteroscopy) indicated for menorrhagia? (4)

A

Endometrial thickness >10mm or suggestive of polyps
>40yrs
Menorrhagia w/ IMB
No response to treatment

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34
Q

What is the 1st line pharmacological treatment for menorrhagia?

What is 2nd line? (3)
What is 3rd line? (2)

A

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

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35
Q

What surgical treatments can be done (if medical fails)? (6)

A

Hysteroscopic:
polyp resection,
endometrial ablation (inc basal),
transcervical fibroid resection (submucosal),
myomectomy (conserve fertility) - use GnRH agonist b4

Uterine aa embolisation

Hysterectomy

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36
Q

What is the incidence + cause + treatment of primary dysmenorrhoea?

A

50% with menarche (severe in 10%)
No organic cause
NSAIDs (mefanamic) / COC (ovulation suppression)

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37
Q

What is dysmenorrhoea due to? (3)

A

High levels of prostaglandins in endometrium
Uterine contraction
Uterine ischaemia

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38
Q

List 5 pelvic pathological causes of secondary dysmenorrhoea

A 
PID
Fibroids
Ovarian tumours
Adenomyosis
Endometriosis
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39
Q

What other conditions/symptoms is secondary dysmenorrhoea assoc w.?

A

Menorrhagia
Deep dyspareunia
Oligomenorrhoea

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40
Q

What is 1st line management for dysmenorrhoea (2)

+ 2nd line (2)

A

NSAIDs / COC

Pelvic USS / Laparoscopy

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41
Q

What are the possible causes of anovulatory cycles

A

Early/late reproductive years

PCOS

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42
Q

What pelvic pathologies may cause irregular/intermenstrual bleeding? (6)

A 
Fibroids
Polyps (uterine/cervical)
Adenomyosis
Ovarian cysts
Chronic pelvic inflammation
Malignancy (endomet/cervical/ovarian) - esp if older/ recent change
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43
Q

What investigations are done for irregular / intermenstrual bleeding? (2+3)

A

Same as menorrhagia:
Transvaginal USS
Hysteroscopy

Bloods: testoserone, FSH/LH, cortisol (cushings)

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44
Q

What is the medical management of irregular periods (when no anatomical cause detected)

A

COC (1st line)
Progesterones
HRT (for perimenopausal erratic bleeding)

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45
Q

List 4 causes of post-coital bleeding + how each managed?

A

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

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46
Q

List the causes for post-menopausal bleeding (6)

A 
Cervical carcinoma / polyps
Endometrial carcinoma / polyps
Ovarian carcinoma
Cervicitis
Atrophic vaginitis
Sequential HRT
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47
Q

List 2 causes for purulent bloody discharge

A 
Endometrial carcinoma
Diverticular abscess (rare)
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48
Q

What investigations are done for post-menopausal bleeding? (3)

A

Check up-to-date smear
Pelvic Examination (bimanual + speculum)
Transvag USS

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49
Q

What does increased thickness / fluid filled cavity on transvaginal USS suggest

A

Risk of malignancy / hyperplasia / polpys

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50
Q

What is the criteria for biopsy in PMB?

How is it done as outpatient?
Why would an inpatient admission be required ?

A

> 4mm OR >1 PMB episode

Paracervical local anaesthetic

If local not tolerated / endometrial polyp / restricted vaginal access (atrophic) - hysteroscopy under GA

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51
Q

Define primary amennorhoea
Define secondary
Defone oligomenorrhoea

A 
Primary = not started by 16yrs
Secondary = normal menstruation for 6m+
Oligomenorrhoea = menstruation b/wn 35d-6m
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52
Q

List some non-pathological causes of amenorrhoea (2 primary + 4 secondary)

A

Constitutional delay
Drugs

Lactation
Pregnancy
Menopause
Drugs

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53
Q

List some pathological causes of amenorrhoea (both primary and secondary) (8)

A

Psychological
Anorexia nervosa
Athleticism

Hyper/hypothyroidism
Hyperprolactinaemia

Adrenal tumour/hyperplasia

PCOS
Premature ovarian failure

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54
Q

List some pathological causes of amenorrhoea specific to primary (4)

A

Transvaginal septum
Imperforate hymen
Turners / gonadal dysgeneses
Androgen insensitivity

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55
Q

List some pathological causes of amenorrhoea specific to secondary (2)

A

Ashermans syndrome

Cervical stenosis

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56
Q

What investigations can be done to confirm Dx of physiological (constitutional) delay of menarche

A

Maternal FH
Progesterone challenge test
USS (confirms normal structures)

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57
Q

What is the incidence of endometriosis
Who is it more common in

Where does it occur

A

1-20%
Nulliparous

Throughout pelvis (anywhere) - esp uterosacral ligaments/ovaries

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58
Q

Describe the pathophysiology of endometriosis spread

A

Indiv factors (e.g. genetic predispo)
Retrograde menstruation
Lymph/blood etc for more distal foci

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59
Q

What are the complications/associated effects of endmetriosis

A

Progressive fibroids
Chocolate cyst (endometrioma)
Adhesions

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60
Q

What are the symptoms of endometriosis (6)

A

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)

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61
Q

What may be seen O/E in endometriosis (4)

A

Normal pelvic exam (in mild)
Tenderness/thickening behind uterus/andexa
Uterus poss retroverted
Uterus poss immobile (adhesions)

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62
Q

How is endometriosis Dx?

A

Laparascopy ± biopsy

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63
Q

What are some DDx for endometriosis (5)

A 
Adenomyosis
PID
Chronic pelvic pain
Pelvic mass
IBS
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64
Q 
What are the medical management options for endometriosis (5) 
How do (most of them) work?
A 
Analgesics (NSAIDs, paracetamol, opiates)
GnRH analogues (pituitary overstim - menopausal SEs)

COC
Progesterone pill
Mirena IUS

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65
Q

What are the surgical management options for endometriosis? (3)

A

Laparoscopic laser ablation/diathermy/scissors ± adhesiolysis
Ovarian cystectomy
Hx-tomy + bilat salp-oo (BSO) - for severe/older

66
Q

What is adenomyosis?
Who is it seen in
What conditions is it assoc w.?

A

Endometrium within myometrium
Common around 40y/o
Assoc w. endometriosis + fibroids

67
Q

What are the clinical features of adenomyosis (3)

+ How is it Dx?

A

Asymp
Painful/heavy menstruation
Mildly enlarged + tender uterus

Dx - MRI

68
Q

How is adenomyosis managed?

A

COC/IUS ± NSAIDs (for menorrhagia/dysmen)

Hx-tomy often required

69
Q

What is the prevalence of fibroids?

A

25% women

70
Q

What are the RFs (3) + avoidance factors (2) for fibroids

A

RFs:
Near menopause
Afro-Caribbean
FH

Avoidance factors:
Parity
COC/Depo

71
Q

What are the 6 possible structural sites/types of fibroids?

A 
Subserous polyp
Subserous
Intramural
Intra-cavity polyp
Subserous
Cervical
72
Q

Fibroids: symptoms (5)

A 
Menorrhagia
Dysmenorrhoea
Intermenstrual bleeding
Pressure effects
Subfertility
73
Q

List some possible complications of fibroids normally (3)

+ in pregnancy (3)

A

Torsion of pedunculated fibroid (postpartum)
Malignancy (0.1% risk leiomyosarcoma)
Degeneration from ↓ blood supply (haemorrhage/necrosis/tenderness)

Preterm labour
Abnormal/transverse lie
Obstructed labour

74
Q

What investigations (3) can be done for fibroids?

A

USS
MRI (distinguish b/wn ovarian mass + fibroid)
Laparoscopy

75
Q

When is treatment done for fibroids?

What treatments are available for fibroids? (3)

A

Only if symptoms / fast-growing

Hysterectomy
Myomectomy
Uterine aa embolisation

76
Q

What are the risks of a myomectomy

A

Peri-op haemorrhage
Adhesions
Uterine rupture during labour

77
Q

What 3 acute things may occur with an ovarian cyst?

A

Rupture
Haemorrhage (into cyst)
Torsion

78
Q

What is a bartholin cyst? + abscess

How is it treated?

A

Blockage of bartholin gland (lubrication for coitus)
Infection (staph/E.Coli) = abscess

Incision / Drainage / Suture open (prevent reformation)

79
Q

What USS findings in a polycystic ovary (PCO)

A

Transvaginal USS shows multiple (12+) small (2-8mm) follicles

80
Q

What are the criteria for PCOS (2 of 3)

+ List some other features (non-criteria)

A

PCO on USS
Hirsutism (clinical/biochem)
Irregular cycle (>35d)

Obesity
Asymptomatic
Anovulatory infertility

81
Q

How is PCOS caused (describe the physiology)

A

Mainly genetic
↑ Ovarian androgen production, due to:
disordered LH production
+ peripheral insulin resistance/↑

82
Q

What investigations can be done for PCOS (scans/bloods/other)

A

USS

Testosterone ↑
Progesterone ↓
FSH - normal
Prolactin - normal

Diabetes screening
Abnormal lipids

83
Q

What may ↑↑↑ testosterone levels indicate? (rather than PCOS)

A

Androgen secreting tumour / congenital adrenal hyperplasia

84
Q

List the long-term risks of PCOS (3)

A 
Gestational DM (30% PCOS pts)
Diabetes (50% PCOS pts)
Endometrial malignancy (persistent anov)
85
Q

List the possible complications of PCOS

A

Obesity
Infertility
Miscarriage

86
Q

What are the treatment options for PCOS?

A

None if incidental find
Wt loss if needed

Infertility: clomifene/ ov diathermy/ metformin/ gonadotrophins/ IVF
Hirsutism: pill / spironolactone / eflornithine face cream
Menstrual: COC/IUS

87
Q 
Cervical ectropion:
What is it?
Who seen in?
What clinical features (3)
What seen O/E
A

Eversion of columnar epithelium (∴ visible)
Young girls on pill
Asymp / vaginal discharge / PCB
Red area around cervical os

88
Q

How do Acute + Chronic Cervicitis occur?

+ List 1 complication of acute

A

Acute - STI (Complication: prolapse/ulceration)

Chronic - inflamm/infection of ectropion

89
Q

Cervical polyps:
Where originate from
Who seen in
What clinical features (3)

A

From endocervix
Common >40yrs
Asymp / IMB / PCB / PMB

90
Q

How do nabothian cysts form?

A

Metaplastic squamous grows over endocervical columnar secretions

91
Q

What histological features would be seen in:
CIN1-2
CIN3
CIN4

A

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

92
Q

List some causes/RFs of CIN (5)

A 
HPV
Low vaginal pH
Oral contraceptive
Smoking
Immunocompromise (HIV/long-term steroids)
93
Q

What management is done if smear result shows:
Normal
Mild dyskaryosis (borderline)
Moderate / severe dyskaryosis
Cervical glandular intraepithelial neoplasia

A 
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
94
Q

How is CIN treated?

What are the poss complications of this treatment

A

Loop diathermy of abnorm transformation zone (LLETZ)

Post-op haemorrhage / Subsequent pre-term delivery

95
Q

List some features/symptoms of cervical carcinoma (5)

+ List some later stage features (4)

A 
Asymp
PMB
IMB
PCB
Offensive vaginal discharge

Pain
Uraemia
Haematuria
Rectal bleeding

96
Q

What investigations can be done for cervical carcinoma?(5)

A 
Biopsy (Dx)
Vaginal/rectal Ex (to stage)
Cystoscopy (bladder involvement)
MRI (TMN)
Pts fitness for surgery (FBC/crossmatch/U&amp;E/CXR)
97
Q

List the diff stages of cervical carcinoma (1-4 dependant on invasion sites)

A
  1. Uterus + cervix
  2. Upper vagina
  3. Lower vaginal / ureteric obstruction / pelvic wall
  4. Bladder / rectum / beyond pelvis
98
Q

What are the different managements for the different stages of cervical cancer? (1a i; 1a ii-2a; 2b+)

A

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

99
Q

What are some of the symps that should be asked about in vulval conditions? (5)

A 
Pruritis
Superficial dyspareunia
Soreness / Burning
Discharge / Bleeding
Lumps
100
Q

What are some causes for Pruritis Vulvae? (I D-No)

A

Infection: Thrush / Warts / Lice / Scabies
Dermatological: Eczema / Contact dermatitis/ Psoriasis / Lichen simplex-sclerosis-planus
Neoplasia: Carcinoma / Pre-Malig

101
Q

What are the features of Lichen simplex? (2)

What triggers? (3)

A 
Severe pruritis (esp night)
Hyper-po-pigmentation + thickening of major

Assoc w. irritants, stress, low Fe

102
Q

What happens in lichen sclerosis?
What conditions is it assoc w.? (3)
What may it →?

A

Loss of collagen in vulval tissue
Menopausal / Autoimmune / Thyroid
5% → vulval cancer

103
Q

List 2 features of lichen planus

How is it treated?

A

Flat papular purple lesions
Pain (>pruritis)

Potent steroids (poss autoimmune)

104
Q

What are some causes of vaginal discharge? (6)

A

Physiological
BV
Thrush

Atrophic vaginitis
Cervical eversion/ectropion
Foreign body

105
Q

List some RFs for vulval cancer (4)

A

Lichen sclerosis
Immunosuppression (skin cancer type)
Smoking
Paget’s

106
Q

How does vulval cancer usually present? 5 features

A 
Presents late
Pruritis
Bleeding
Discharge
Mass (majora/clit)
Enlarged LNs (femoral → ext iliac)
107
Q

How is vulval cancer managed? (3)

A

Wide local excisional biopsy
Groin LN dissection biopsy
Radiotherapy if LNs involved

108
Q

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?

A

Squamous
Lactobacillus
pH < 4.5 (acidic)

Atrophic + pH 6.5-7.5 (less resistance to infection)

109
Q

What are some features of candidiasis? (4)

A

Vulval irritation/itching
Superficial dyspareunia
Dysuria
‘Cottage cheese’ discharge

110
Q

What are the RFs for candidiasis infection? (3)

A

Pregnant
Abx
Diabetes

111
Q

What are the features of bacterial vaginosis? (3)

What is a complication of BV

A

Grey/white fishy discharge
Vagina not red / itchy
pH high

Complication: secondary PID or preterm labour

112
Q

What are some features of Chlamydia STI? (3)
How Ix/managed?
What complications? (2)

A

Asymp (usually)
Urethritis
Vaginal discharge

NAAT/PCR
Doxy/azithro

PID
Reiter’s syndrome (urethritis/conjunctivitis/arthritis)

113
Q

What type of bacteria is gonorrhoea?
What features? (4)
What problems when managing it?

A

G-ve diplococcus

Asymp (women)
Vaginal discharge
Bartholinitis/cervicitis

Urethritis (men)

Abx resistance

114
Q

What pathogen involved in genital warts (condylomata acuminata)

A

HPV (may affect cervix + 16/18 oncogenic)

115
Q

What are the symptoms of primary genital herpes infection? (4)

A

Systemic symptoms
Lymphadenopathy
Multiple painful ulcers
Dysuria

116
Q

What are the features of trichomoniasis vaginalis (parasite) infection? (3)

A

Offensive green discharge
Vulval irritation
Superficial dyspareunia

117
Q

What are the features of syphilis primary (1) + secondary (3) infection?
And complications of tertiary infection (rare) (3)

A

Primary: painless vulval ulcer
Secondary: Rash, Flu-like symptoms, genital warty-like (condylomata lata)

Tertiary: neurosyphilis, aortic regurg, dementia, locomotor ataxia

118
Q

What are the RFs for HIV infection? (4)

A

Sub-saharan migration
IVDU
Lack of barrier contraception
Sex w. high-risk males

119
Q

What CD4 count is classed as AIDS

A

CD4<200 = AIDS

120
Q

What ob/gynae complications can occur with HIV? (4)

A

Vertical transmission

CIN (cervical neoplasia) higher risk (yrly smears)
Candidiasis
Menstrual disturbances

121
Q

What groups of people would you suspect PID in? (3)

A

Young
Sexually active
Nulliparous

122
Q

What anatomical areas can be involved / inflamed in PID? (4)

A

Endometritis
Parametritis
Bilateral salpingitis
Perihepatitis (Fitz-High-Curtis adhesions)

123
Q

List the clinical features that may be seen in PID? (5S + 5S)

A 
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*
124
Q

What things may be seen in PID in laparoscopy? (4)

A

Filmy adhesions
Ovary buried beneath adhesion
Ovary adherent to fallopian tube
Swollen/blocked fallopian tube

125
Q

What are some complications of PID? (3)

A

Chronic PID/ pelvic pain
Subfertility (tubal obstruction)
Ectopic pregnancy

126
Q

What are the DDx of PID? (3) + what features determine between

A

Appendicitis (no cervical excitation)
Ovarian cyst (would be unilateral)
Ectopic pregnancy

127
Q

What Ix are done if suspect PID? (2)

How is it managed? (2)

A

WCC / CRP raised
Laparoscopy Dx

IV Abx + analgesics (acute/chronic)

128
Q

What are some causes of endometritis? (3)

A

Pregnancy complication
Uterus instrumentation (C-Sec/ToP/SMM)
Infection (Chlamydia/Gono/BV/E.Coli)

129
Q

What are the clinical features of endometritis? (4)

A 
Persistent heavy vaginal bleeding + pain
O/E: 
Uterus tender
Os open
Poss fever/septicaemia
130
Q

Where is the superior part of uterus lymph drained to?

+ the inferior part?

A

Superior → common iliac nodes

Inferior → internal iliac nodes

131
Q

List the RFs for endometrial cancer (8)

A 
High oestrogen (production/oestrogen-secreting tumours)
Obesity
PCOS
Prolonged amenorrhoea
Unopposed HRT
Late menopause
Nulliparity
Tamoxifen (agonist in postmeno uterus but antag in breast)
132
Q

What are the clinical features of endometrial cancer? (3 symps + 2 O/E)

A

Post-Menopausal bleeding
Irregular / IMB
Menorrhagia (recent onset)

Poss abnormal smear
O/E: normal pelvis

133
Q

What 3 factors determine level of investigations for endometrial cancer?

What Ix can be done? (5)

A

Age
Menopausal status
Endometrial cancer symptoms

USS +/or Biopsy (Pipelle/hysteroscopy)
CXR / MRI (detect spread)
Fitness assessment in elderly (FBC/Renal func/Gluc/ECG)

134
Q

What is the management of endometrial cancer? (2)

A

Hysterectomy + BSO (abdo/lap) (unless pt unfit/disseminated)

Radiotherapy (if high-risk LN involvement)

135
Q

What are some common causes of ovarian masses in:
Premenopausal (4)
Post-menopausal (2)

A 
Premeno:
Follicular/lutein cysts
Dermoid cysts
Endometriomas
Benign epithelial tumour

Postmeno:
Benign epithelial tumour
Malignancy

136
Q

What are some primary types of neoplasm in the ovary? (4)

Which are benign/malig

A

Epithelial tumours:
Adenocarcinoma (Malignant: serous > mucinous)
Endometroid carcinoma (malignant)

Germ cell tumours (young):
Teratoma / dermoid cyst (benign)
Dysgerminoma (malignant)

137
Q

What secondary metastases may → ovarian malignancy?

A 
Breast cancer
GI tract (inc. Krukenberg)
138
Q

What are the RFs of ovarian tumours? (What are they related to) (3)
What are the protective factors? (3)

A

RFs (related to no. ovulations):
Early menarche
Late menopause
Nulliparity

Protective factors:
COC
Pregnancy
Lactation

139
Q

What are some possible features of an ovarian tumour? (4)

How may it present similarly to?

A 
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

140
Q

What features may indicate the mass is more likely to be malignant? (6)

A

Older
Rapid growth
Bilateral masses
Ascites

Solid/septate on USS
Vascular

141
Q

Define the stages (1-4) of ovarian cancer

A
  1. Confined to ovary
  2. Confined to pelvis
  3. Confined to abdo (e.g. omentum, SI, peritoneum)
  4. Beyond abdo (lungs, liver)
142
Q

What Ix done in ovarian cancer? (4)

How is the risk of malignancy estimated? (RMI)

A

CA125 + if raised → USS pelvis/abdo
Also AFP + hCG (raised in germ cell tumours)

RMI = U (USS score) x M (meno status) x CA125

143
Q

How is ovarian cancer normally managed? + if wanting to preserve fertility? (3)

What is the prognosis for ovarian malignancy?

A

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

144
Q

What structures make up

Level 1 of the pelvic floor (2) + Level 2 (1) + Level (2)

A

Level 1: cardinal + uterosacral ligaments
Level 2: endopelvic fascia (→ lateral pelvic walls)
Level 3: perineal body + legator ani

145
Q

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?

A

Filling: bladder capacity + urethral sphincter competency
Voiding: detrusor contractility + urethral relaxtion

Normal = 500ml
1st urge = 200ml

146
Q

What is the micturition reflex?

A

Bladder distension → parasymp afferents to pons
→ Modified by cortex (relax/contracts pelvic floor)
→ Efferent parasymp contracts detrusor (+ symp eff inhib)

147
Q

What factors/ areas of pressure determine urinary continence?

A

Depends on: urethral pressure > bladder

Urethral: sphincter tone / pelvic floor / intra-abdo pressure
Bladder: detrusor tone + intra-abdo pressure

148
Q

What are some causes of prolapse? (5) think KITTENS

A 
Congenital
Iatrogenic (pelvic surg)
Pregnancy / vaginal delivery
Chronic predispo (obesity/cough/constipation/heavy lifting)
Menopause (collagen deterioration)
149
Q

What are some features of prolapse? (6)

A

Asymp
Dragging/lump sensation (somethings coming down)
Worse end of day / standing
Back pain (rare)

Severe - interferes with SI
Severe - ulcerate/bleed

150
Q

What Ix can be done if suspect prolapse? (3)

A

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)

151
Q

How is prolapse managed? (6)

A

Wt loss
Smoking cessation (cough)
Physio

Pessaries (shelf/ring - replace every 6-9m)
Hx-tomy (40% → vaginal vault prolapse)
Hysteropexy

152
Q

What are the causes of urinary incontinence? (4)

A 
Detrusor instability (overactive bladder - OAB)
Stress incontinence (raised intra-abdo pressure) (50%)
Neurogenic/obstructive overflow incontinence
Bypass thru fistula
153
Q

How does stress incontinence occur? (what physical changes)

List the causes (6)

A

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

154
Q

What features may stress incontinence co-exist with? (3)

What may be seen O/E in stress incontinence? (3)

A

Urinary urge / freq
Faecal urge

O/E:
Sims speculum leakage on cough
Poss urethro/cystocele
Normal abdo palp (exclude distended bladder)

155
Q

How is stress incontinence managed? (7)

Which management strategy is 1st line

A 
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)

156
Q

What is the difference b/wn urodynamic stress incontinence + just stress incontinence?

A

Urodynamic = Dx disorder from cystometry

Stress incontinence = a symptom

157
Q

What are the different urinary investigations and the indications for each? (6)

A

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)

158
Q

List the causes of overactive bladder (4)

A

I - idiopathic
I - iatrogenic post-USI surgery
T - provocation with cough (confused with SI)
N - detrusor overactivity from underlying neuropathy (e.g. MS)

159
Q

List some features of overactive bladder (6)

A 
Frequency
Urgency / urge incontinence
Nocturia
Nocturnal enuresis / at orgasm
H/o childhood enuresis
Stress incontinence
160
Q

What are the conservative measures of an overactive bladder? (4)
And pharmacological management? (3)

A 
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

161
Q

What are the general risks in gynae surgery? (4)

+ how prevented

A

VTE - thromboprophylaxis
Infection - prophylactic Abx for major abdo/vaginal surg
Bladder damage - routine catheterisation
Bowel damage

162
Q

Describe what VTE prophylaxis measures are taken in gynae surgery
What categorises Low/Mod/High risk

A

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

Obs & Gyn (4 decks)

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