Gynae Flashcards
What to do in borderline/mild dyskaryosis? Moderate? Severe? Suspected invasive cancer? Inadequate?
The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis Consistent with CIN II. Refer for colposcopy
Severe dyskaryosis Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks**)
Suspected invasive cancer Refer for urgent colposcopy (within 2 weeks)
Inadequate Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy
Mechanism of HPV causing cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
Primary secondary causes of amenorrhea?
Initial ix?
Causes of primary amenorrhoea Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital trac
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Initial investigations
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
Endometriosis 1st? 2nd? 3rd? If not wanting to conceive
COCP back to back
Progesterone only - depot / POP OR mirena
GnRH analogues
Mefanamic acid / NSDAISs are good for dysmenorrhea.
How do they work? What is the second line?
Inhibit prostaglandin production
COCP
An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates a voiding detrusor pressure of 90 cm H20 (normal value < 70 cm H2O) and peak flow rate of 5 mL/second (normal value > 15 mL/second). What is the most likely diagnosis?
Overflow incontinence
What happens to Women with a cervix that cannot be visualised
Refered to colposcopy
What happens to women who have cervical stenosis
referred to the colposcopy clinic for consideration of cervical dilatation.
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC?
Higher sensitivity and specificity
Less inadequate smears
Most likely location of ectopic? RF?
Ampulla of Fallopian tube
Risk factors (anything slowing the ovum's passage to the uterus) damage to tubes (salpingitis, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic)
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
What should be done?
Urinary dye studies
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
A 56-year-old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive.
What should be done
Urodynamic studies
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
In urge incontinence bladder stabilising drugs are used after 6 weeks of bladder retraining
What needs to be avoided in ‘frail older women’
Immediate release oxybutin
-use darifenacin
[bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’]
Initial ix in incontinence ?
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
Management of urge incontinence ?
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
Management of stress incontinence
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain. The pain came on gradually and has been getting progressively worse for 3 days. She is nauseated and has vomited twice this morning. She has a temperature of 38.4ºC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute. The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler. On speculum examination the cervix is closed and there is no blood. She has a history of menorrhagia due to uterine fibroids. This is her first pregnancy. What is the most likely diagnosis?
Why? Mx?
Fibroid degeneration
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Mx of fibroids
symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
other options include tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy
uterine artery embolization
A 25-year-old female student was brought in to the Emergency Department. She complains of a severe abdominal pain. The pain started suddenly 3 hours ago while she was shopping .Further questioning reveals that she has not had her periods for 7 weeks and is currently sexually active. She also reported a history of pelvic inflammatory disease 5 years ago. Abdominal examination reveals generalised guarding and signs of peritonism. An urgent ultrasound scan was ordered and showed free fluid in the pouch of Douglas with an empty uterine. Urine βhCG was positive. Other basic bloods are sent.
While in the emergency department, she suddenly became very ill. Her observations were; Blood pressure 85/50 mmHg, Heart Rate -122/min, Respiratory Rate-20/min, O2 saturation 94%.
What is the next appropriate action?
Resuscitate and arrange for emergency laparotomy
A 30-year-old woman is 24 weeks pregnant and she receives a letter about her routine cervical smear. She asks her GP if she should make an appointment for her smear. All her smears in the past have been negative. What should the GP advise?
smear 12 weeks after delivery
If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first?
Second?
Management? What if they are old and frail?
TVUS
2- Hysteroscopy with endometrial biopsy
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
A 17-year-old female comes to your GP clinic. She has recently travelled to Egypt to see her family, and now has come to visit as she is suffering with per vaginal bleeding and urinary incontinence.
She consents to examination with a chaperone present and you identify signs that suggest there have been recent trauma to the genitalia. You suspect this is a case of female genital mutilation.
What is the most appropriate course of action?
Report to the police as <18
Long term complications of PCOS ?
Subfertility Diabetes mellitus Stroke & transient ischaemic attack Coronary artery disease Obstructive sleep apnoea Endometrial cancer
PCOS increases risk of endometrial Ca. Why?
How can you limit this?
Oligo/amenorrhea with pre-menopausal levels of oestrogen
Induce withdrawal bleed every 1-3 months using COCP or insertion of mirena coil
Ix in PCOS
USS - Multiple cysts on ovaries
FSH, LH, prolactin, TSH, testosterone
-if Prolactin / testosterone are markedly raised -> consider other causes
Impaired glucose tolerance
Predisposing factors for thrush?
Diabetes mellitus
Drugs - Abx / steroids
Pregnancy
Immunosuppression
Mx of candiasis? What if pregnant?
Local - clotrimazole pessary
Oral - itraconazole / fluconazole
Pregnant -> only local
What to do if recurrent vaginal candiasis?
Make sure compliance with treatment
Rule out DD eg lichen sclerosis
Exclude predisposing factors
Mx of ovarian cyst in Premenopausal?
Post menopausal?
Pre
Conservative approach - Re do USS in 12 weeks -> referral if persists
Post
Less likely to be physiological
-Refer to gynae
Side effects of HRT?
Nausea
Breast tenderness
Fluid retention and weight gain
HRT and breast / endometrial Ca ?
Breast - increased with a progesterone
Endometrial - increased without progesterone
Complications of HRT
Breast / endometrial ca
VTE risk
Risk of stroke
Ischemic heard disease if longer than 10 years post menopause
Mx of menorrhagia if
Does not require contraception?
Can have contraception?
No contraception - Tranexamic acid, or NSAIDS (eg mefanamic acid)
Contraception
1- Mirena
2 - COCP
3 - Long acting progesterone Eg Depo Provera
What can be used as short term option to rapidly stop heavy menstural bleeding?
Norethisterone 5mg
A 15-year-old comes in with right iliac fossa pain. She describes the pain as starting a few hours earlier when she was playing hockey and the pain has progressively got worse. She is Rovsing’s sign negative. An USS is done and free pelvic fluid is seen with a whirlpool sign. What is the most likely diagnosis?
Ovarian torsion - whirlpool sign
[also seen in volvuls]
What is Rosvigs sign?
palpation of the left iliac fossa causes increased tenderness in the right iliac fossa.
-> appendicitis
history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain [why?] and cervical excitation may be seen
Diagnosis?
Ectopic
Rupture -> peritoneal irritation and phrenic
Typical Hx of torsion?
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Type of epithelium on cervix / cervical canal?
What increased risk of cervical ectropion?
What are features?
Mx if troublesome?
Squamous / Columnar with a transformation zone
Elevated oestrogen levels - ovulatory phase, pregnancy, COCP
-> Larger area of columnar epithelium present on ecto cervix
Vaginal discharge
Post-coital bleeding
Ablative treatment Eg ‘cold coagulation’
Endometrial Ca Ix?
1- TV US
Hysteroscopy with endometrial biopsy
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.
Mx?
Cause?
Oral metronidazole
Trichomonas vaginalis
[strawberry cervix]
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus.
Mx?
Cause?
Chlamydia
IM ceftriaxone + oral azithromycin
What is premenstrual syndrome? Mx?
Physical , psychological and behavioural sx in the absence of organic disease
-usually occur near end of menstruation cycle and stop after menstruation
Mx
Lifestyle - healthy diet, exercise, reduction in stress levels and regular sleep.
Moderate/severe -> COCP / SSRIs
Management of PID
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Complications of PID
Infertility
Chronic pelvic pain
ectopic pregnancy
Drug taken pre-surgery for fibroids?
GnRH analogue
Markers for what?
CA-125
CA19-9
CEA
Ovarian Ca
Pancreatic Ca
Bowel Ca
What has to be done prior to abortion ? Who can perform/>
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
Medical method of abortion <9weeks?
mifepristone (an anti-progestogen, often referred to as RU486)
followed 48 hours later by prostaglandins to stimulate uterine contractions
When should CIN screening be done after treatment for CIN?
6 months
Ovarian cysts in post menopausal ?
Physiological are unlikely
Urgent gynae referral
Long term complications of vaginal hysterectomy? Acute?
Enterocoele
Vaginal vault prolapse
Urinary retention
Why is oxybutynin not recommended in old and frail?
Increased risk of falls
Eg of a bisphosphonate?
alendronic acid
Syndrome with 3 features including a benign ovarian tumour? What are the features?
Meig’s syndrome are:
a benign ovarian tumour
ascites
pleural effusion
A 16-year-old female presents to the emergency department with a 12 hour history of pelvic discomfort. She is otherwise well and her last normal menstrual period was 2 weeks ago. On examination she has a soft abdomen with some mild supra pubic discomfort.
Diagnosis?
Mittelschmerz - normal period pain
-small amount of fluid is often released
25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia.
Diagnosis?
PID
2 conditions where cervical excitation is found?
PID
Ectopics
Staging of ovarian Ca
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
Pathology of OHSS
the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF).
This results in increased membrane permeability and loss of fluid from the intravascular compartment
Fluid can fill abdo cavity -> bloating
Severe can -> chest
