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3a obs and gynae > Gynae > Flashcards

Gynae Flashcards

PID, prolapse, endometriosis, fibroids, cancers, ovarian cysts

1
Q

Define acute pelvic pain

A

short duration of pain lasting less than 3 months

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2
Q

Define chronic pelvic pain

A

intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6 months duration, at least 1 in 7 days a week

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3
Q

List the gynaecological causes of acute pelvic pain

A

early pregnancy complications - ectopic, miscarriage
PID
endometriosis
adenomyosis
ovarian cyst torsion, haemorrhage or rupture
primary dysmenorrhoea
torsion of the fallopian tube

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4
Q

List the non gynaecological causes of acute pelvic pain

A 
UTI 
steric stones
diverticular disease
peritonitis 
appendicitis 
aortic aneurysm
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5
Q

List the gynaecological causes of chronic pelvic pain

A 
adenomyosis 
endometriosis
adhesions - from previous surgery 
chronic PID
pelvic organ prolapse
fibroids
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6
Q

List the non gynaecological causes of chronic pelvic pain

A 
IBS
constipation
hernia
fibromyalgia
psychological - depression
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7
Q

What are the red flags for someone presenting with pelvic pain?

A 
weight loss
reduced appetite 
post coital bleeding
pelvic mass
new bowel symptoms >50 y/o
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8
Q

Define Pelvic Inflammatory Disease

A

infection of the upper genital tract - either ascending infection from endocervix or descending infection from other organs

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9
Q

What are the risk factors for pelvic inflammatory disease?

A

age <25
previous STI
new sexual partner /multiple sexual partner
uterine instrumentation e.g. intrauterine contraception, laparoscopy, termination of pregnancy
post partum endometritis
complications of child birth and miscarriage

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10
Q

What are the common causative factors for PID?

A

chlamydia trachomatis (60%)
neisseria gonorrhoea
anaerobes

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11
Q

How does PID clinically present?

A 
asymptomatic 
bilateral pelvic pain 
deep dyspareunia 
vaginal discharge 
irregular or more painful menses 
fever
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12
Q

What are the signs seen in PID?

A

cervical motion pain
adnexal tenderness
elevated temp -> sign of fever
bilateral lower abdominal tenderness

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13
Q

How does chronic pelvic inflammatory pain occur and what are the main symptoms?

A

persisting infection resulting my non treatment or inadequate treatment of an acute PID

chronic pelvic pain, dysmenorrhoea, deep dyspareunia, sub fertility

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14
Q

Which investigations are necessary for diagnosing PID?

A

Laparoscopy with fimbrial biopsy **- gold standard but only done when diagnosis uncertain
pelvic ultrasound

FBC and blood cultures if fever
endocervical swabs to check for STIs

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15
Q

How is pelvic inflammatory disease managed as an inpatient and outpatient?

A

Inpatient: IV ceftriazone 2g od + IV doxycycline 100mg bd / oral doxycycline 100mg bd 14 days + oral metronidazole 400mg bd 14 days

outpatient: IM ceftriaxone 500mg stat + oral doxycycline 100mg bd 14 days + oral metronidazole 400mg pd 14 days

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16
Q

Define endometriosis

A

endometrial tissue outside the endometrium cavity

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17
Q

What are the possible locations of endometriosis?

A 
pelvis ** - pouch of douglas, uterosacral ligaments, bladder, peritoneum 
lungs
brain
muscle
eye
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18
Q

describe the signs O/E of endometriosis

A

fixed retroverted uterus
tenderness in posterior vaginal fornix
adnexal mass
tenderness of uterosacral ligaments

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19
Q

What are the symptoms of endometriosis

A

Dyspareunia
Dysmenorrhoea - cyclical, pain worse on periods
Dyschezia - pain in passing stools during menses
Dysuria - if endometriosis in bladder

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20
Q

How is endometriosis caused?

A

retrograde menstruation

family history

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21
Q

Describe endometriosis’s appearance

A

peritoneal endometriotic lesions
ovarian endometriotric cysts - >10cm, brown coloured fluid
fibrosis and adhesions

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22
Q

List the differentials for endometriosis

A 
fibroids 
polyps 
pelvic inflammatory disease 
ovarian cancer 
adenomyosis
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23
Q

What examinations would you appropriate for a diagnosis of endometriosis?

A

1st line = transvaginal ultrasound scan

gold standard = laparoscopy with biopsy* - resect >3cm to rule out malignancy - MRI and CA125

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24
Q

What is the medical management for endometriosis

A
  1. abolish cyclicality
    1st line = COCP triphasing- 3 months continuous back to back pill, but do NOT give to women who want to get pregnant
  2. Glandular atrophy
    oral progestogens, depot provera , mirena
    aromatase inhibitors

if after 6 months of care, refer to gynaecology

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25
Q

What is the surgical management for endometriosis

A

surgery for women who want children and cannot take the medication: ablation and excision

surgery for women who have had their family: oophorectomy or pelvic clearance

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26
Q

What are fibroids

A

** benign tumours of the myometrium **

vary in size from mm -> large tumours
can be intramural, subserousal (extend into peritoneal cavity) or submucosal (extend into uterine cavity)
oestrogen dependent so regress after menopause, grow in pregnancy

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27
Q

What are the risk factors for fibroids?

A

pre menopausal
afro caribbean women
family history

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28
Q

What are the protective factors for fibroids?

A

porous women
COCP
injectable progestogens

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29
Q

How does someone with fibroids present?

A

asymptomatic (50%)
pain - dysmenorrhoea, usually causes pain when complications occur
bleeding problems - menorrhagia, miscarriages, anaemia
sub fertility

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30
Q

What are the potential complications with fibroids?

A
  1. torsion of fibroid
  2. enlargement which puts pressure on other organs
  3. progress to malignancy in 0.1% - leiomyosarcoma
  4. degeneration - during pregnancy , fibroids grow due to the oestrogen and cause degeneration = fever + pain + vomiting
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31
Q

Which investigations are necessary for fibroids?

A

Imaging - ultrasound**

examination - solid knobbly mass palpable , “whorled appearance histologically”

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32
Q

How are fibroids managed?

A

Conservative - if asymptomatic no treatment, analgesia if necessary

Medical - transexamic acid, NSAIDs, progestogens +/- GnRH agonists

Surgical - hysteroscopic surgery or open laparoscopic myomectomy

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33
Q

Define prolapse

A

protrusion of the uterus +/- vagina beyond normal anatomical confines

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34
Q

What is the aetiology of a prolapse?

A

pregnancy and vaginal delivery - big babies, instrumental delivery, prolonged labour, multiparous women

congenital factors - Ehlers Danlos syndrome

menopause - age

iatrogenic - pelvic surgery, hysterectomy, continence procedures

chronic factors - obesity, chronic cough, constipation, heavy lifting

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35
Q

How is the vagina supported at 3 levels from the side walls of the pelvis?

A

Level 1: cervix and upper 1/3 vagina supported by cardinal and uterosacral ligaments

Level 2: middle of vagina attached by endofascialg fascia laterally of pelvic side walls

Level 3: the lower 1/3 of vagina supported by levator and muscles and perineal body

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36
Q

What is the clinical presentation of a prolapse?

A 
dragging sensation, discomfort
feelings of a "lump coming down"
backache
dyspareunia 
symptoms worse at the end of the day
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37
Q

How might a cyst-urethrocele present?

A

urinary urgency and frequency
incomplete bladder emptying
urinary retention or reduced flow

38
Q

How might a rectocele present?

A

constipation

difficulty with defection

39
Q

How are prolapses classified?

A

cystocele = prolapse of the upper anterior vaginal wall involving the bladder

urethrocoele = prolapse of the lower anterior vaginal wall, involving the urethra

apical/uterine = prolapse of the uterus, cervix and upper vagina

enterocoele = prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel

rectocele= prolapse of the lower posterior was of the vagina, involving anterior wall of the rectum

40
Q

How are prolapses investigated?

A

abdominal and bimanual examination
vaginal examination with speculum - examine anterior and posterior vaginal walls
assessment of pelvic floor strength

41
Q

How is pelvic organ prolapse prevented?

A

reduction of prolonged labour
reduction of trauma by instrumental delivery
weight reduction
treat chronic constipation, chronic cough

42
Q

How is prolapse managed?

A

CONSERVATIVE

  1. weight reduction
  2. stop smoking
  3. physiotherapy - pelvic floor muscle exercises, vaginal cones
  4. intravaginal devices (pessaries) - ring pessary, shelf pessary, doughnut pessary
43
Q

What are some of the possible causes of ovarian cancer?

A

Gene mutations - HNPCC and BRCA1/2
increased risk by multiple ovulations e.g. nulliparity, late menopause, early menarche
ovarian cyst

44
Q

What is the prognosis for ovarian cancer?

A

poor prognosis - 5 year survival at 35%

leading cause of death from gynaecological malignancy

45
Q

How is ovarian cancer commonly presented?

A

non specific/vague/common symptoms resulting in misdiagnosis…

IBS/ bowel changes in older women*
abnormal vaginal bleeding
detection of pelvic mass
urinary symptoms - late

46
Q

How is ovarian cancer diagnosed?

A

CA125 - tumour marker - measure in >50 y/o with vague symptoms

abdominal/ pelvic ultrasound +/- CT

47
Q

How is ovarian cancer treated?

A

SURGERY - staging laparotomy**, TAH, bilateral salpino-oophorectomy

NEOADJUTANT CHEMOTHERAPY

48
Q

What are the risk factors for cervical cancer?

A

HPV exposure (16,18,33) *** e.g. multiple sexual partners, early first sexual experience, non barrier contraception
COCP
smoking
immunosuppressed e.g. HIV, transplant patients

49
Q

How is cervical cancer prevented?

A

HPV vaccine

attending screening

50
Q

What is the most common type of cancer in cervical cancer?

A

squamous cell carcinoma = 90%

adenocarcinoma = 10%

51
Q

How does cervical cancer present?

A

asymptomatic - incidental finding or picked up in screening
bleeding - post coital**, during intercourse, post menopausal
offensive vaginal discharge

52
Q

Who qualifies for cervical cancer screening?

A

25- 50 y/o = every 3 years

50-64 y/o =every 5 years

53
Q

What is involved in cervical cancer screening?

A

smear = speculum examination

brush around the external os and rinsed in preserving fluid for liquid cytology

54
Q

Define dyskaryosis

A

abnormal cytological changes of squamous epithelial cells

characterised by hyper chromatic nuclei +/- irregular nuclei chromatin

55
Q

What happens if cervical cancer screening comes back abnormal?

A 
95%= normal
5%= dyskaryosis

if HPV +ve, then need colposcopy

if severe dyskaryois/ suspect invasive cancer, need colposcopy within 2 weeks +/- hysteroscopy

if HPV -ve and borderline, return to normal routine callback

56
Q

How is cervical cancer diagnosed?

A

colposcopy + biopsy **

+ MRI/ cystoscopy to stage

57
Q

How is cervical cancer managed, depending on its stage?

A

1a (i) = cone biopsy / simple hysterectomy = LARGE LOOP EXCISION OF TRANSFORMATIONAL ZONE
1a (ii) - 1b = laparoscopic lymphadenectomy
1a (ii)-2a = Wertheims hysterectomy or chemo-radiotherapy

58
Q

Define cervical intraepithelial neoplasia

A

histologically abnormality of the cervix in which abnormal epithelial cells occupy

59
Q

What is the most common type of vulval cancer?

A 
90%= squamous cell carcinoma 
10% = melanomas, basal cell, sarcomas, bartholins gland carcinoma
60
Q

How is vulval cancer caused?

A

de novo = lichens sclerosis, smoking, pages disease, immunosuppression

predisposing conditions = oncogenic HPV, vulval intraepithelial neoplasia

61
Q

How does vulval cancer present?

A

non specific symptoms = lump, ulcer, bleeding, irritation, pain

62
Q

How is vulval cancer diagnosed?

A

clinical examination

biopsy and histology = squamous cell carcinoma

63
Q

How is vulval cancer managed?

A

surgery

radiotherapy +/- chemotherapy

64
Q

What is endometrial cancer caused by?

A

presence of unopposed oestrogen (high ratio of oestrogen to progesterone):

ENDOGENOUS - obesity, PCOS, nulliparity, late menopause, oestrogen producing tumour

EXOGENOUS - oestrogen only HRT, tamoxifen

MISC. - type 2 diabetes, hypertension, HNPCC gene, breast cancer

65
Q

What is the most common type of endometrial cancer

A

endometrial adenocarcinoma = 87%

66
Q

How does endometrial cancer commonly present?

A

post menopausal bleeding **
menstrual disturbance
PV diacharge

67
Q

How is endometrial cancer diagnosed?

A

transvaginal ultrasound
if <4mm endometrial thickness = low risk fo pathology
if >4mm endometrial thickness = endometrial biopsy and hysteroscopy

68
Q

How is endometrial cancer treated?

A

surgery - TAH + BSO
total abdominal hysterectomy and bilateral salpingo oophorectomy

adjuvant radiotherapy

hormonal - high dose progestogens

69
Q

What is an ovarian cyst?

A

> 3cm fluid filled cyst
benign ovarian tumour
very common

70
Q

What are the two types of physiological cysts?

A

physiological cysts form during menstrual cycle

  1. Follicular (<3cm) : form due to failure of Graafian follicle to rupture, regress in subsequent cycles
  2. Corpus luteal (<5cm) : may fill with blood or fluid, expanding to cause a cyst
71
Q

What are non -gynaecological causes of a pelvic mass?

A

bladder tumour
intestinal tumour
diverticular disease

72
Q

How does an ovarian cyst present?

A

asymptomatic
chronic pain - dull ache
pressure on other organs - e.g. urinary frequency, bowel disturbance
abdominal uterine bleeding

73
Q

When do you get acute pain with an ovarian cyst and describe the pain?

A

During an ovarian accident (rupture of the contents of the ovarian cyst into the peritoneal cavity) e.g. torsion, haemorrhage, rupture

acute pain - intense, hypovolaemic shock

74
Q

How is the “modified risk of malignant index (RMI)” calculated?

A

RMI = U x M x CA125

U= ultrasound score (1pt for solid area, ascites, multi locular cysts, bilateral lesions, mets)

M= menopausal status (1pt = premenopausal, 3= post menopausal)

CA125= serum cancer antigen 125 level

75
Q

How are ovarian cysts investigated?

A

transvaginal ultrasound
CA125
risk of malignancy index

76
Q

What is a serous cystadenoma?

A

most common ovarian epithelial neoplasm

20-25% malignant

77
Q

What is a mutinous cyst adenoma

A

often multinucleate

also found in appendix, pancreas and liver

78
Q

What is an endometrioma?

A

due to endometrial tissue in ovaries that haemorrhages

“chocolate cyst”

79
Q

What is a dermoid cyst?

A

common, benign neoplasm in pre menopausal women

may contain fully differential tissue, classically hair, teeth and skin

80
Q

How are ovarian cysts managed?

A

exclude malignancy
rescan in 6 weeks - monitor with ultrasound and CA125 at 3 and 6 months
transvaginal cyst aspiration or laparoscopic cystectomy if persist

81
Q

what can cause CA125 to raise?

A 
ovarian cancer
endometriosis
fibroids 
pregnancy 
menstruation
PI
82
Q

Define adenomyosis

A

presence of endometrium within the myometrium (oestrogen dependent)

83
Q

Describe the features of adenomyosis?

A

menorrhagia + dysmenorrhoea

84
Q

How is adenomyosis diagnosed?

A

MRI

85
Q

How is adenomyosis treated?

A
  1. IUS or COCP +/- NSAIDs
86
Q

define intrauterine polyps

A

small benign tumours that grow into the uterine cavities

- arise due to to disordered cycles of apoptosis and regrow in the endometrium

87
Q

How do intrauterine polyps present?

A

menorrhagia and IMB

88
Q

How are intrauterine polyps diagnosed?

A

USS + hysteroscopy

89
Q

how does lichen sclerosus present?

A

itch ** - worse at night, uncontrollable scratching causing bleeding
white papules/ plaques

90
Q

How is lichen sclerosis diagnosed?

A

clinical examination and history - biopsy

91
Q

How is lichen sclerosis treated?

A

topical steroids and emollients

92
Q

List the differentials for post coital bleeding?

A

cervical cancer * - must be ruled out

cervical ectropion * cervical polyps

3a obs and gynae (5 decks)

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