Gynae Flashcards
1
Q
Define primary and secondary amenorrhoea
A
1- Failure to start mensturation by 16 (14 if no signs of puberty)
2- Previous menses, then no menstruation for >6months and NOT pregnant
2
Q
Causes of primary amenorrhoea
A
Constitutional delay (familial)
GU malformation
Hypothalamic failure - anorexia, Kallman’s syndrome (low GnRH and lack of sense of smell)
Gonadal failure - Turners syndrome (45x) - neck webbing, short stature, obesity, CV problems ->(ECG/Echo)
3
Q
Causes of secondary amenorrhoea
A
Premature ovarian failure
H-P-O axis failure - stress, exercise, weight
Hyperprolactinaemia (suppresses ovulation)
Ovarian - PCOS, tumours, menopause
Iatrogenic - depot, implant, Post COCP
Obstruction
4
Q
Features of Kallmans
Management
A
Delayed puberty, lack of sense of smell
Some - cleft lip/palate, absence of 1 kidney, deafness, shortened digits, eye movement problems
Hormone replacement (testosterone in males / FSH/LH) -> puberty
or GnRH -> fertile
5
Q
Investigations in amenorrhoea ? What changes if its secondary?
A
FSH/LH, hCG, prolactin, karyotype, TFT, USS
Less likely to do karyotype / USS
Check day 21 progesterone, serum free androgen (PCOS)
6
Q
With amenorrheoa when are FSH/LH raised? Low?
A
Raised - ovarian failure (premature menopause)
Low - Hypothalmic (constitutional delay, weight loss, anorexia, exercise, hypothalamic/ pituitary tumour)
7
Q
What causes increased prolactin? Drug to lower?
A
Stress, hypothyroid, prolactinomas, drugs
Bromocriptine (D agonist)
8
Q
What causes an increase in testosterone?
A
Androgen secreting tumour
Congenital adrenal hyperplasia / cushings
Moderate increase in PCOS
9
Q
What is ashermans? Sheehan’s?
A
A- adhesions of the endometrium Eg after surgery
S- necrosis of the pituitary gland after significant PPH
10
Q
A 37 year old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative.
What is the most likely diagnosis? Definition? Sx? Risk factors?
A
Premature ovarian failure
Cessation of menses for 1 year before the age of 40
Can be preceded by irregular cycles
Sx - Hot flushes, night sweats, vaginal dryness, vaginal atrophy, sleep disturbance, irritability
Risk - FH, exposure to chemo / radiotherapy, autoimmune disease
11
Q
14 - no periods, but gets cyclical pain
Looks well O/E
Diagnosis?
A
Imperforate hymen
12
Q
Difference between 1 / 2 dysmenorrhoea ? Cause of 1? 2?
A
1- absence of underlying pelvic pathology - Fall in progesterone ->Prostaglandin release -> myometrium contract -> ischemia and pain
2- Endometriosis, adenomyosis, PID, fibroids, endometrial polyps, malignancy
13
Q
30 yr old complaining of cyclical abdo pain
What else do you want to know?>
A
Dysparenuia, PCB, IMB, menorrhagia, bowel / urinary Sx, IBS sx
14
Q
Cyclical pain
Deep dyspareunia, menorrhagia
No PCB / IMG, not on contraception
No urinary / bowel Sx
Diagnosis? 3 theories of cause?
A
Endometriosis
Sampson’s - retrograde mensturation
Meyers - metaplasia
Halbans - lymphatic / haematogenous spread
15
Q
Endometriosis and pain on defecation Where is it? What is seen on ovaries during a scan generally in endometriosis?
A
Pouch of Douglass
Chocolate cysts - altered blood
16
Q
Investigations in endometriosis ?
A
Exclude others
Abdo exam / pelvic exam , triple swabs, TVUS, abdo US
17
Q
Gold standard for endometriosis diagnosis?
Management ?
A
Laparoscopy
Suspected - NSAIDs (iboprofen, mefanamic acid), Paracetamol
Medial - Suppress mensturation - COCP, IUS, implant, depot / refer to gynae
Specialised - GnRH analogues
Surgery - Laparoscopic (improves fertility), or radical surgery if severe disease
18
Q
How do GnRH alalouges work?
A
LH agonists - initial stimulation of pituitary secretion of gonadotrophins then rapidly inhibitors secretion due to down regulation
19
Q
Mrs P (60yo) attends her GP practice complaining of cyclical abdominal pain.
No dyspareunia, menorrhagia
No PCB or IMB, not on contraceptive
No urinary/bowel symptoms
Diagnosis? What is it? Investigation?
MX?
A
Adenomyosis - invasion of myometrium by endometrial tissue
MRI
Same as endometriosis
20
Q
Define menorrhagia? How often is no cause found and what is this termed? Underlying causes
A
Excessive, regular Menstural loss (>80ml and/or >7days bleeding)
50% - dysfunctional uterine bleeding
Uterine - Fibroids, endometriosis/adenomyosis, polyps / malignancy, Systemic - coagulation disorders, hypothyroidism, diabetes, liver/kidney disease
Iatrogenic - Anticoagulant treatment / chemo
21
Q
Most common benign tumour in women? Sx? Risk factors?
A
Fibroids
Menorrhagia, pelvic pain, secondary dysmenorrhea, urinary tract problems (frequency, urgency, incontinence, hydronephrosis), bowel problems (bloating / constipation)
Age, early puberty, obesity, black ethnicity, FHx
22
Q
Investigation of fibroids ? Mx?
A
Bulky non tender uterus
Goserelin (GnRH agonist) -> suppresses oestrogen
<3cm - IUS, Tranexamic acid, NSAID, COCP
>3cm- trans cervical resection of fibroids (TCRF), myomectomy, hysterectomy, Uterine fibroid embolisation (UFE)
23
Q
What sx of menorrhagia suggest underlying pathology (Eg PID, endometriosis, endometrial Ca)?
Investigations ?
A
Persistent post coital /intermenstural bleeding, dysparenuria, dysmenorrhea, pelvis pain, Urinary/bowel Sx, vaginal discharge
Detailed hx Abdo / biannual examination Speculum exam of cervix Blood test - iron deficiency Other appropriate dependent on Sx - Eg ultrasound....
24
Q
What are fibroids also called?
A
Leiomyomas - Smooth muscle and fibroblasts
25
Bar fibroids, Eg of other benign ovarian tumours and a bit about them
Functional Cysts
Enlarged persistent follicle or corpus luteum. Normal < 5cm, resolve after 2/3 cycles. Can cause pain and peritonitis sx if they bleed. COCP inhibits.
Mucinous Cystadenomas
Massive. Unilateral, Appear solid, common in 30-40 yr old, 15% malignant
Serous Cystadenomas
Most common epithelial tumour, commonly bilateral, 30-50yr old, 25% malignant
Dermoid cyst
‘mature cystic teratoma’, contain skin/hair/teeth most common cyst in < 30s. Bilateral 20/30%. Torsion most likely in dermoid cyst.
26
Ovarian cysts usually rupture mid cycle
| Presentation? Investigations? Mx?
Acute abdo pain, PV bleed, nausea & vomiting, circulatory collapse ± weakness / syncope
Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
Laparoscopy is diagnostic but usually get USS first
Stable -> analgesia
Bleeding / unstable -> surgery
27
Ovarian torsion occurs unilaterally in combination with a pathologically enlarged ovary
RF? Presentation? Ix?Mx?
Rf - pregnancy, malformations, tumours, previous surgery
P- Acute abdo pain (often unilateral) radiates to back, thigh, pelvis
N&V
Fever - indicates necrotic ovary
Ix: Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
USS with colour Doppler analysis is diagnostic
Management:
Laparoscopy
+ Analgesia; NSAIDs, opiates
28
```
Ovarian Ca
Most common histological
RF
Presentation
Common differential
Ix
Mx
Staging
What would you think if a young (<30yr)
```
; Epithelial Serous adenocarcinoma (50%)
increased risk with increased number of ovulations – early menarche and late menopause, null parity. BRCA1 (40% lifetime risk) BRCA2 (25% lifetime risk) and HNPCC. (Protective: COCP + having children, anovulation, pregn, lactation, POP/Mirena
Presentation: (typically vague and non specific – therefore most present late e.g with ascites)
Persistent abdo bloating
Early satiety, anorexia
Urinary urgency / frequency
PV bleed
Lower abdo pain/ back pain or dyspareunia
Common differential? IBS but any over 50 presenting with new IBS type symptoms must have Ca125 done
Ca125, US scan (take these combined with menopausal status to calculate risk score)
CT scan
If younger = afp and hcg – germ cell tumours
Management: refer to MDT if U x M x CA125. Refer to Gyn Onco if 250 or more
Platinum based chemo, oophorectomy, bevacizumab
CT scan and laparoscopy for staging
Staging 1 = limited to ovaries, 2 = limited to pelvis, 3 = limited to abdomen, 4 = distant mets outside abdomen
80% of cases in over 50s -> think germ cell line if under 30y/o
29
```
Endometrial ca
Most common histological type?
Risk factors?
Presentation?
Investigations?
Management?
Factors associated with a poor prognosis?
```
Most cmn gynae Ca: 90% adenoCa, 10% adenosquamous
Risk factors: Oestrogen dependent ca |(causes excess proliferation of endometrial cells)so at increased risk when endometrium is exposed to unopposed oestrogen e.g. Oestrogen only HRT, Tamoxifen, PCOS, obesity, diabetes, HTN, oestrogen secreting tumours, nulliparity, late menopause,
Presentation:
Post menopausal bleeding (have to exclude endometrial cancer)
Watery discharge
Investigations:
US
Hysteroscopy with endometrial biopsy is definitive diagnostic ix
(CXR and MRI for spread)
Management:
Limited to uterus or cervix (stages 1 and 2) = total hysterectomy and bilateral salpingo-oophrectomy
Stage 3 - post op radiotherapy
Unsuitable for surgery -> radiotherapy and progestogens e.g. medroxyprogesterone
Poor progn if: older age, advanced clinical stage, deep myometrial invasion in Stage 1 or 2, high grade, adenosquamous histology
30
What is strange about tamoxifen and receptors
Antagonist in breast but agonist in uterus
31
```
Cervical Ca
Most common histological type?
Risk factors?
Preventative measure?
Presentation?
Screening? When do you refer for colposcopy?
Treatment?
```
SCC, 90% squamous cell Ca, 10% adenoCa from columnar epithelium
Rf - HPV 16, 18, (31,33, 45) early age intercourse, multiple partners, STIS,multiparity, smoking, COCP, immuno-suppressed pts, previous CIN, other genital tract neoplasia
Prevention - Gardasil HPV vaccine to 12/13 yr old girls
Presentation:
Vaginal discharge (offensive)
PV bleed – postcoital/micturating/defecating PCB/IMB/PMB, dyspareunia
Late sx – painless haematuria, chronic urinary freq, altered bowel habit, leg oedema, pelvic pain.
Smear - Targets transformation zone (squamous-columnar jct) and HPV testing from age 25 – 50 every 3 years, age 50 – 65 every 5 years or yearly if at high risk e.g. HIV
Refer to colposcopy IF:
Borderline dyskaryosis AND HPV +ve
OR Moderate or severe dyskaryosis
Treatment
Dysplasia -> laser therapy/ cryotherapy -> LLETZ/ cone biopsy
Stage 1B+ (ca at opening of womb) -> surgery with chemo therapy
Stage 2B+ (vagina)-> ?chemoradiation
3 (surrounding structures)
4(spread outside vagina and womb)
[chemo and radio in any stage above 1b]
32
What is subfertility? % of couples who conceive in 1yr? 2yr? Usual causes?
Failure to conceive in 1 year or regular unprotected sex
80%, 90%
```
Unexplained 25%
Male factors 30%
Ovulatory disorders 25%
Tubal damage 20%
Uterine disorders 10%
```
40% - factors in both partners
33
A 27 y/o lady attends your practice complaining of inability to get pregnant despite regular unprotected intercourse for the past year…
…You can’t help but notice she is obese, has acne, and an unusual amount of hair on her upper lip and chin
Diagnosis?
Other sx they may get?
PCOS
| Oligomenorrhoea, alopecia (male pattern), sleep apnea, psych problems
34
Assuming other causes have been excluded what is the diagnosis to criteria for PCOS ?
Rotterdam criteria
Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
Oligo-ovulation or anovulation.
Clinical and/or biochemical signs of hyperandrogenism.
Two of the three following criteria are diagnostic of the condition, assuming other causes have been excluded (Rotterdam criteria):
35
PCOS - DD? Ix? Mx if wish to conceive? If don’t wish to conceive?
Thyroid disorder (particularly hypothyroidism).
Hyperprolactinaemia.
Cushing's syndrome.
Acromegaly.
Side-effects of medication (medication causing hirsutism, weight gain or oligomenorrhoea as side-effects, for example).
Late-onset congenital adrenal hyperplasia (CAH). – 21 hydroxylase deficiency
Androgen-secreting ovarian or adrenal tumours.
Investigations
Total testosterone: Normal to slightly raised in PCOS.
Free testosterone levels may be raised but if total testosterone is >5 nmol/L, exclude androgen-secreting tumours and CAH.
Sex hormone-binding globulin. Normal or low in PCOS.
LH may be elevated
Ultrasound scan
Other blood tests, where indicated from the clinical picture, to exclude other potential causes - eg, TFT (thyroid dysfunction), 17-hydroxyprogesterone levels (CAH), prolactin (hyperprolactinaemia), DHEA-S and free androgen index (androgen-secreting tumours), and 24-hour urinary cortisol (Cushing's syndrome).
Fasting glucose and oral glucose tolerance tests are useful in assessing insulin resistance/diabetes. Women who are overweight or have other risk factors for diabetes should have an oral glucose tolerance test on diagnosis of PCOS.[6]
Fasting lipid levels should be checked.
Weight control and exercise
No pregnancy planning - co-cyprindrol, COCP, metformin
Planning - clomifene, metformin, laparoscopic ovarian drilling
36
Causes of female infertility
Ovarian - PCOS, pituitary tumours, Sheehan’s, hyperprolactinaemia, premature ovarian failure, turners syndrome
Tubes / uterus / cervix - PID, sterilisation, ashermans, fibroids, endometriosis, uterine malformation , surgery
Thyroid
Adrenal - cushings, CAH
Chronic disease
37
Causes of primary ammenhorea when secondary sexual characteristics are present
Usually GU malformation - Imperforate hymen, Transverse vaginal septum , Absent uterus
Androgen insensitivity syndrome
Endocrine - thyroid, hyperprolactinaemia, cushings, PCOS (rare primary)
38
Primary amenorrhea with absent secondary sexual characteristic?
Ovarian failure - gonadal dysgenesis (turners 46XO), prematurity ovarian failure, chemo, pelvic irradiation
Hypothalamic dysfunction - decrease GnRH -> decreased LH/FSH
-Chronic system illness, eating disorders, weight loss, exercise, stress, depression
Tumours, head injury, infection, tumours, kallman’s syndrome
39
What happens in 5a-reductive deficiency? Why might they be classed as primary amenorrhea
People are genetically male (46XY) but do not produce enough dihydrotestosterone
-> genitalia appear ambiguous / female at birth
40
How would an androgen secreting tumour present ?
Extreme virilisation - deep voice, extreme hirtuism
41
What is the cause of congenital adrenal hyperplasia in 95% of cases? 3 severities?
21-hydroxylase (21-OH) deficiency
Reduces the efficiency of cortisol synthesis -> hyperplasia of adrenal cortex -> increase ACTH -> increase progesterone + DHEA + testosterone
Severe - life threading salt wasting crisis in first month of life
Simple virilising CAH - mineral corticospinal deficiency is less -> no salt wasting but genital ambiguity does occur
Late onset - even less - may be taller and appearance of pubic hair mid childhood the common presentation
42
Physiological causes of secondary amenorrhea
Pregnancy
Lactation
Menopause
43
Iatrogenic causes of secondary amenorrhea
Contraception — depot takes a while to recover
Chemo
Radiotherapy
Surgery - oophorectomy, hysterectomy
Drugs causing hyperprolactinaemia - antipsychotics, methyl dopa, opiates, cocaine, metoclopramide
44
```
Amenorrhea indications if
Increased serum free androgen?
Increased FSH/LH
Decreased FSH/LH
Raised prolactin?
Raised testosterone?
```
PCOS
Ovarian failure
Hypothalamic - Eg delay, weight loss....
Prolactin -> stress, hypothyroid, prolactinomas, drugs
Testosterone - androgen secreting tumour, CAH, Cushing, androgen insensitivity, PCOS
45
A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an 'early menopause'. How is premature ovarian failure defined?
Causes?
Sx?
Change in hormones?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of: 40
Causes: idiopathic (commonest), chemo, autoimmune, radiation
Symptoms: hot flushes, night sweats
Infertility, secondary amenorrhoea
Raised FSH, LH
46
```
A 35-year-old woman presents as she has not had a period for six-months. Prior to this time she had a 28 day cycle with a five day bleed. Which one of the following investigations is least helpful initially?
Thyroid function
Serum gonadotrophins
Serum prolactin
Urinary beta-HCG
Serum progesterone
```
Progesterone -> doesn’t point towards a diagnosis
47
A 37 year old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative.
What is the most likely diagnosis?
Premature ovarian failure
Cessation of menses for 1 year before the age of 40
Can be preceeded by irregular menstrual cycles
Symptoms: hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, irritability
Strong risk factors
FH, exposure to chemo/radiotherapy, autoimmune disease
48
```
A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis?
Mullerian agenesis
Constitutional delay
Turner syndrome
Pregnancy
Imperforate hymen
```
Imperforate hymen - cyclical pain but no evidence of mensturation
49
Vaginal ca RF? Sx? Tx?
In-utero exposure to diethylstilbestrol (clear cell), HPV
Sx- bleeding, mass, pain on sex, pelvic pain, dysuria
Surgery
50
Drugs causing female infertility? Occupational?
Spironolactone, chemotherapy / cytotoxic, neuroleptic, recreational
Pesticides, solvents
51
Causes of primary spermatic failure?
Testis - chemo, maldescent, absence
Chromosome - klinfelters - 47 XXY
Varicoceles
52
Male factors infertility
Obstructive azoospermia
- epididymal obstruction (infection/surgery)
- vas deferens obstruction , ejaculatory duct obstruction
Hypogonadism
-deficient androgen secretion Eg Kallmans, hyperprolactinaemia from pituitary adenoma, anabolic steroids
Drugs
- sulfasalazine, chemo, anabolic steroids
Other
Stress, ejaculation disorders, erectile dysfunction
53
First thing to discuss in infertility?
| What would the next step be?
Talk about - stress, sex, smoking, weight
```
Mid luteal phase progesterone (7 days before expected period [day 21 if 28 day cycle]
FSH/LH
Thyroid
Prolactin
Chlamydia screen!
```
Men - semen analysis, chlamydia screen
54
Couple decides to do assisted conception. What problem might the GP see after assisted conception (eg clomifene and gonadotrophin ovulation induction)?
Ovarian hyperstimulation syndrome
Ectopic pregnancy
Pelvic infection (from egg extraction)
Multiple pregnancy
55
Usual cause of ovarian hyperstimulation syndrome? RF? What happens? Sx / signs?
Iatrogenic
RF - young, lean physique, PCOS
Hyperstimulated ovaries produce vasoactive products – can thrombosis, renal/liver dysfunction, resp distress syndrome
```
Sx -
Mild - abdo bloating and mild pain
Moderate - N&V and more pain
Severe - oliguria, generalised oedema
Critical - oligo/Anuria, large hydrothroax, thromboembolism , acute RDS
```
56
Managment of PCOS ? First line ovulatory drug? How does the drug work and what do you need to look out for?
Weight loss advice
Regulate mensturation and hirtuism - COCP
Metformin
Gonadotrophin - Give FSH/LH sc daily -> follicular growth
Clomifene - watch out for Ovarian hyperstimulation syndrome (OHSS)
57
A couple in their 20s come into their GP after failing to conceive despite having regular sexual intercourse for 6 months, and ask you for advice. What is the most appropriate course of action for you to take?
Wait until they have been trying for 12 months
58
A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant. She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill. Despite stopping the pill 6 months ago she is still not having regular periods. Her body mass index is 28 kg/m^2. Apart from advising her to lose weight, which drug would be the most effective in increasing her chances of conceiving
Clomifene
59
During a subfertility clinic you are asked to take a menstrual cycle history from a 30-year-old in order to establish on what day her mid-luteal progesterone level needs to be done. You clarify that the woman has a regular 35 day cycle. On which day would you carry out mid-luteal progesterone level?
28
60
A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely spaced nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear? Why? Syndrome? Genetic?
Systolic - loudest over aortic valve
Bicuspid aortic valve, aortic valve stenosis ± aortic coarctation
Turners (45XO)
61
```
Menorrhagia causes...
Structural?
Endocrine?
Iatrogenic?
Coagulopathy?
Malignancy?
Infective
```
Structural: fibroids, bicornate uterus/ uterine abnormality, endometriosis, adenomyosis
Endocrine: Thyroid, adrenal
Age: Beginning or end of reproductive life
Iatrogenic: Copper coil (IUD), anticoagulants
Coagulopathy: clotting disorder e.g. haemophilia, VW
Malignancy: endometrial carcinoma
Infective: PID
62
1st, 2nd, 3rd line for menorrhagia
1 - mirena coil
2- tranexamic acid, mefanamic acid, NSAIDS, COC
3- prostaglandins, GnRH analogue
Surgical - endometrial ablation, embolisation, hysterectomy
63
Only way to improve fertility in endometriosis ?
Ablation
64
Treatment options for endometriosis ?
NSAIDs, COC, progesterones (eg medroxyprogesterone acetate)
GnRH analogues
IUS Mirena
Endometrial ablation
65
Treatment of fibroids?
Mirena
Tranexamic acid, COC
GnRH -> short term shrinkage prior to surgery
Surgery - myomectomy, ablation, hysterectomy, embolisation
66
What is an ovarian cyst?
3 main types with Eg?
General complications?
Sac with liquid / semiliquid material in the ovary
1- functional ovarian cyst (24%) - follicular cyst, corpus luteal cysts, theca lutein cysts
2- benign ovarian cysts (70%) - benign epithelial cyst, benign cystic teratoma, fibromo,
3-malignant ovarian -> ovarian ca
Torsion, rupture, haemorrhage
67
Usual causes of follicular cysts ?
Lack of ovum release due to excessive FSH stimulation or lack of LH surge at mid cycle
68
Cause of corpus luteal cysts
Failure of dissolution to occur -> corpus luteal cyst
| [defined as a corpus luteum which grows up to 3cm]
69
Cause of theca-lutein cysts? When do they often occur? What is more likely with these cyst?
Luteinisation and hypertrophy of the theca Interna cell layer due to excessive stimulation from hCG.
Occur in setting of
- gestational trophoblastic disease (hydatiform mole / choriocarcinoma)
- multiple gestation
- exogenous ovarian hyperstimulation
70
What is meigs syndrome?
Triad of
| Benign fibroma, ascites, and pleural Effusion
71
Ovarian ca related to which genes?
BRAC1 BRAC2
| HNPCC
72
3 main types of ovarian CA and Egs ?
Epithelial ovarian tumours - serous, clear cell, mucinous
Germ cell - teratomas,
Sex cord stromal - granulosa cell tumour, sertoli-leydig cell tumour
73
Epithelial ovarian ca from where.
Serous?
Mucinous?
Clear cell?
Serous - epithelial from Fallopian tube
M - cervix
Cc - mesonephros
74
Signs and sx of ovarian Ca
Pain or discomfort in the lower abdomen
Severe pain from torsion (twisting) or rupture - Cyst rupture is characterized by sudden, sharp, unilateral pelvic pain; this can be associated with trauma, exercise, or coitus
Discomfort with intercourse, particularly deep penetration
Desire to defecate - This can occur if pressure develops
Micturition - This can occur frequently, due to pressure on the bladder
Irregularity of the menstrual cycle and abnormal vaginal bleeding - The intermenstrual interval may be prolonged, followed by menorrhagia
Bloating; abdominal distention or discomfort
Pressure effects on the bladder and rectum
Constipation
Vaginal bleeding
Indigestion and acid reflux
Cervical motion tenderness
Tiredness
Weight loss
Early satiety
75
What score system used to assess ovarian mass? Who should it not be used in?
How is it scored? When do you get a referral?
RMI - risk of malignancy index
Should not be used in pre-menopausal
RMI = ultrasound score x menopause status x CA125 IU/ml
Post menopause = 3
US score = solid areas, metastases, ascities, bilateral lesions, multilocular cysts
(1=1, 2-5=3 points)
RMI >200 referred to a centre with ovarian cancer surgery experience
76
Staging of ovarian ca
1 - tumour confined to ovaries
2 - both ovaries / pelvic extension / primary peritoneal cancer
3- spread to peritoneum ± metastasis to retroperitoneal lymp nodes
4 -distant mets
77
Types of breast ca - by management
Oestrogen and/or progesterone +, HER2-
Luminal A
ER and/or PR +, HER2+
Luminal B
ER-, HER2+
Triple negative
Basal like
78
Histological classification of breast Ca
```
Invasive duct all adenocarcinoma - 75%
Invasive lobar adenocarcinoma - 15%
Medullary carcinoma 5%
Paget’s disease of the breast 1-4%
Papillary carcinoma - 1%
```
79
What is the most common breast ca subtype? Aggressive? Prognosis? Hormone response? Younger or older?
```
Luminal A
Less aggressive
Good prognosis
Hormone responsive
Increasing age
```
80
Basal like breast ca histological grade? Younger or older? Which group most at risk?
High grade histology
Aggressive
Younger age <40
Pre menopausal African American
81
Luminal A / B better prognosis?
A
82
ER-, HER2+ aggressive? Histology? Older or younger? Risk group?
Less common, highly aggressive
High grade histology
Younger age <40 - more than luminal
African American is risk factor
83
Signs and sx of breast ca
```
Lump or contour change
Skin tethering
Nipple inversion
Dilated veins
Ulceration
Peau d’orange
```
84
How would you describe breast lump ?
Harness
Irregularity
Focal nodularity
Fixation to skin / muscle
85
What is recommended after conservative breast ca surgery?
Whole breast radiotherapy
86
What can be offered to BRAC1/2 or TP53 carriers?
Prophylactic bilateral mastectomy
87
Hormonal therapy drugs for ER+? HER2+?
ER - tamoxifen / anastrozole
HER2 - Herceptin (trastuzumab)
88
What do you need to remember with tamoxifen complication/.
Pro-oestrogenic effect on uterus -> increases risk of endometrial ca
89
What is heceptin? Also called?
Trastuzumab
| Humanised monoclonal antibody specific for HER2
90
Important drug interaction with herceptin?
Cardiotoxic if combined with doxorubicin (chemo drug -> liver dysfunction, heart damage and radiation burn)
91
Advanced ER positive breast ca treatment options ?
Endocrine therapy as first line
Systemic chemo should be given in order
A) single agent docetaxel
B) single agent vinorelbine or capecitabine
c) the other of V/C
92
Mx of advanced ER negative breast ca
```
Palliative chemo and radio
Supportive
-physical
-psychological
-social
-financial
-spiritual
```
93
A 37 year old woman presents to her general practitioner having identified a mass in her right breast on self examination. She reports no history of trauma and is taking no medication. She is worried because her mother died of breast cancer at the age of 54 years and her sister has recently been diagnosed with breast cancer.
1. What is the most common malignant neoplasm to affect the breast?
The patient tells you that both her mother and her maternal grandmother died from breast cancer.
2. State the names of two genes responsible for familial causes of this disease?
Upon examination the patient is found to have a hard fixed 2 x 2 x 2cm mass adjacent to the right nipple. The right nipple is inverted. Mammography confirms the presence of a stellate mass in the breast with association microcalcification.
3. What is the site to which such a tumour will most commonly first metastasise?
A chest radiograph reveals the presence of several lytic lesions within the ribs
4. State four other common tumours (excluding breast) which typically metastasise to bone.
5. State two special laboratory tests which should be carried out on the originally excised tissue in order to plan the patient’s therapy.
A few months later you are the F1 doctor on call and receive a telephone call from the patient’s GP. He tells you that over the last two weeks the patient has become increasingly confused and now is confined to bed as she has difficulty getting about her home.
6. State one possible complication of her condition that you would immediately consider as a result of this telephone call.
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Most common neoplasm- Adenocarcinoma
Gene- BRAC1 BRAC2
First site- axillary lymph nodes
KTBB- kidney, thyroid, brain, bone
ER +/ HER2 +
Hypercalcaemia/ cerebral mets
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94
Ovarian malignancy
List 4 features on USS suggestive of malignancy
4x blood tests that should be performed prior to surgery, and rationale for each
At surgery, the ovary looks malignant.
What operation does she now require?
What intraoperative test could be carried out to confirm that it is malignant?
multilocular cysts, solid areas, metastases, ascites and bilateral lesions
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Blood test
CA125- Tumour burden for ovarian cancer
Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) should be measured in all women under the age of 40 with a complex ovarian mass because of the possibility of germ cell tumours.
FBC- Patient’s constitutional status for surgery, correct any abnormality before surgery
U&E- Kidney function test before surgery due to risk of anaesthesia
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Operation- total abdominal hysterectomy and bilateral salpingo-oophorectomy
Test to confirm- examination of all peritoneal surfaces, an infracolic omentectomy, biopsies of pelvic and para-aortic lymph nodes and clinically uninvolved areas and peritoneal washings.
95
CAH Ix?
17a- hydroxyprogesterone
