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Phase 3a > Gynae > Flashcards

Gynae Flashcards

1
Q

What is menarche?

+ when is normal

A

Onset of menstruation

Around 13 usually

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2
Q

At what age would you class puberty as being early in females / males?

A

Females <8

Males <9

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3
Q

At what age would you class puberty as being late in females / males?

A

Females >13

Males >14

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4
Q

What is the first sign of puberty in females?

A

Breast budding

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5
Q

What is the first sign of puberty in males?

A

Testicular enlargement

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6
Q

What stimulates the production of secondary sexual characteristics in females?

A

FSH + LH –> oestrogen

This is thelarce

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7
Q

What is menorrhagia?

A

Heavy menstrual bleeding
Over 80ml loss in one cycle
Affecting quality of life - physical, emotional, social

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8
Q

What would be classed as irregular periods?

A

Period outside of 23-35 day cycle with variability of more than 7 days between shortest and longest cycle

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9
Q

What is primary amenorrhoea?

A

Never had a period by 16

Or by 14 if no development of secondary sexual characteristics either

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10
Q

What is secondary amenorrhoea?

A

Previously had periods but no period for 6 months or more

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11
Q

What is oligomenorrhoea?

A

Infrequent periods - between 35 and 6 months between periods

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12
Q

What is post-menopausal bleeding?

A

Bleeding more than 1 year after menopause

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13
Q

What is dysmenorrhoea?

A

Painful periods

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14
Q

What are the causes of menorrhagia?

A 
primary - unknown
secondary;
- uterine fibroids
- polyps
Less common:
- PID
- endometrial / cervical cancers
- coagulopathies - very rare
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15
Q

What would you ask for in the history of a patient with menorrhagia (to establish its existence)?

A

flooding - flooding sanitary towels / having to change tampons excessively / using both
passing clots bigger than a 10p piece

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16
Q

How would you investigate a patient with menorrhagia?

A

Look for signs of anaemia
Masses - uterine (fibroids), ovarian (cancer)
Tenderness on examination - adnomyosis
Bloods - anaemia, coag screen, TFTs
TVUS (endometrial thickness / fibroids / ovarian mass) - biopsy if indicated

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17
Q

When would you biopsy a patient with menorrhagia who has had a TVUS?

A

POST MENOPAUSAL
Endometrial thickening of more than 4mm if symptomatic
More than 11mm if asymptomatic

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18
Q

How would you treat a patient presenting with menorrhagia?

A

First line = IUS
Second line = Tranexamic acid / Mefanamic acid
Third line = progestogens or GnRH agonists
Last resort = surgery

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19
Q

What are the differentials for dysmenorrhoea?

A 
Primary - at the start of menstruation = common
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumours
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20
Q

How would you treat primary dysmenorrhoea?

A

NSAIDs, COCP

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21
Q

What are the causes of IMB?

A

Non-malignant:

  • Fibroids
  • Polyps
  • Adenomyosis
  • Ovarian cyst
  • PID

Malignant - endometrial cancer

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22
Q

How would you investigate a patient with IMB?

A

Assess blood loss
FBC, coag screen, TFTs
TVUS - endometrial thickness - biopsy if needed

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23
Q

How would you manage a patient with IMB?

A

IUS or COCP
High dose progesterone to cause amenorrhoea - but withdrawal bleed occurs
HRT in perimenopause

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24
Q

CASE

A patient with pain that starts a few days before menstruation and ends 1-2 days after bleeding starts
+ pain during sex

A

Endometriosis

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25
Q

What is endometriosis?

A

Presence / growth of endometrial tissue outside the uterus

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26
Q

Where are the common sites of endometriosis?

A 
Uterosacral ligaments
Ovaries
Vagina
Rectum
Bladder
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27
Q

What are the complications of endometriosis?

A

Chocolate cysts

Fibrosis and adhesions

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28
Q

What are the typical features of endometriosis?

A

Cyclical pain with menstruation (starts a few days before)
Deep dyspareunia
Subfertility
Acute pain if rupture of chocolate cyst
Can be haematuria or rectal bleeding if tissue on bladder or rectum

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29
Q

How would you investigate a patient with suspected endometriosis?

A

O/E - tender and thickened adnexa
TVUS to exclude ovarian endometrioma (remove in case ovarian malignancy)

Gold standard = laparoscopy to see the lesions

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30
Q

How would you treat a patient with endometriosis?

A

NSAID - ibuprofen, naproxen, mefanamic acid

If don’t want to get preggo:

  • Tricyclic COCP
  • Oral progesterone pill / depot / IUS

NSAID + analgesia

GnRH analogue

Surgical - diathermy, dissection of adhesions, removing endometriomas, hysterectomy

31
Q

What might you find on examination of a patient with endometriosis?

A

Tenderness and thickening in the adnexae
Adnexal masses - endometriomas
Retroverted / immobile uterus - adhesions
Rectovaginal nodule on digital exam

32
Q

What are the risk factors for endometriosis?

A

Nulliparous

Family history?

33
Q

What are the complications of endometriosis?

A

Subfertility

Frozen pelvis

34
Q

What are fibroids?

A

Benign growths of the endometrium

35
Q

What are the risk factors for fibroids?

A

Afro-Caribbean

Family history

36
Q

What are the protective factors for fibroids?

A

COCP
Parity
+ are oestrogen dependent so regress after menopause

37
Q

What are the possible locations for fibroids?

A 
Subserous polyp
Subserous
Intracavity polyp
Intramural
Submucosal
Cervical
38
Q

What are the complications of fibroids in pregnancy?

A 
Can grow (1/3)
Premature labour
Malpresentation (transverse lie)
Obstructed labour
PPH
Red degeneration
Torsion of pedunculated fibroid after birth - pain
39
Q

What are the complications of fibroids?

A 
Pregnancy stuff
Torsion
Calcification after menopause
Red degeneration
Malignancy (0.1%)
40
Q

What symptoms can fibroids cause?

A

Menorrhagia
Dysmenorrhoea
Depending on location - urinary frequency, infertility

41
Q

How would you investigate a patient with suspected fibroids?

A 
Abdo / bimanual exam for masses
TVUS
MRI
Laparoscopy
Hysteroscopy or hysterosalpingogram
42
Q

How would you manage a woman with fibroids?

A

If asymptomatic - just annual check up to see size and growth

If menorrhagia + less than 3cm with no distortion of the uterine cavity:

  • 1st line IUS
  • 2nd line tranexamic acid (anti-fibrinolytic)
  • 3rd line norethisterone from day 5-26

Surgical - resection, ablation, myomectomy, uterine artery ablation

43
Q

What are the differentials for cervical excitation?

A

PID

Ectopic pregnancy

44
Q

CASE

Obese lady who has always had irregular periods, bad acne, issues with facial hair and is now trying to get pregnant with difficulty.

Differential?

A

PCOS

Polycystic ovary syndrome

45
Q

What are the pathophysiological features of PCOS?

A

Disordered LH production
Peripheral insulin resistance (so raised insulin levels)

Increased androgens

46
Q

What are the clinical features of PCOS?

A

Oligo/amenorrhoea
Obesity
Acne
Hirsutism

47
Q

What would you see on examination of a patient with PCOS?

A 
High BMI
Hirsutism
Acne
Alopecia
Acanthosis nigrans
48
Q

How would you investigate a patient with suspected PCOS?

A

Day 2-5 LH and FSH for ovulation
TFTs - exclude hyper/hypothyroidism
Prolactin - exclude hyperprolactinaemia
Testosterone

If hyperandrogenism - DHEAS (dihydroepiandosterone sulfate), SHBG (sex hormone binding globulin)

Exclude other causes of primary oligo/amenorrhoea

Pelvic USS

49
Q

How would you make a diagnosis of PCOS?

A

Rotterdam criteria
2 of:
- Oligo/anovulation
- Hyperandrogenism - hirsutism, acne, alopecia, or biochemical
- Polycystic ovaries on USS - >12 antral follicles on one ovary, 2-8mm in size, in enlarged ovary >10mm

50
Q

How would you treat a patient with PCOS (not wanting to get pregnant)?

A

Weight loss + exercise

COCP
Antiandrogens

51
Q

How would you treat a patient with PCOS (wanting to get pregnant)?

A

Metformin

Clomiphene

52
Q

How would you treat a patient with severe PCOS not responding to treatment?

A

Laparoscopic ovarian drilling

53
Q

CASE

A 29 year old presents having collapsed at home following severe abdominal pain and bleeding.

Diagnosis?

A

Ectopic pregnancy until proven otherwise

54
Q

What is ectopic pregnancy?

A

Implantation of the embryo outside the uterine cavity

55
Q

What are the risk factors for ectopic pregnancy?

A 
PID
Previous pelvic / tubal surgery
Assisted conception
Previous ectopic
Smoking

+ rule out in a woman with an IUD - prevents intrauterine pregnancies but not tubal ones

56
Q

What are the clinical features of ectopic pregnancy?

A

Abnormal vaginal bleeding - dark
Abdominal pain ± collapse
Amenorrhoea of 4-10 weeks
Shoulder tip pain

57
Q

What would you see on examination of a woman with ectopic pregnancy?

A 
Tachycardia (blood loss)
Abdominal / rebound tenderness
Cervical excitation
Adnexal tenderness
Closed os
58
Q

How wold you investigate a woman with a suspected ectopic pregnancy?

A

Pregnancy test - urine bhCG
TVUS
Serum hCG >1000IU/ml (declining / slow rising levels)

Diagnostic laparoscopy

59
Q

What would you see on a TVUS in an ectopic pregnancy?

A

Empty uterus
Free fluid
Mass - tubal / elsewhere

60
Q

From beta hCG levels, how would you distinguish between a viable uterine pregnancy and an ectopic pregnancy?

A

Raising = viable uterine

Declining / slow rising = ectopic or non-viable intrauterine

61
Q

What is incontinence?

A

Involuntary leakage of urine

62
Q

What can cause incontinence?

A 
Stress incontinence
Detrusor overactivity
Fistula
Neurological
Overflow
Functional
Mixed Incontinence
63
Q

What are the symptoms associated with detrusor overactivity?

A

Urge incontinence

Frequency
Nocturia
Nocturnal enuresis
‘Key in the door’
‘Handwash’
Intercourse
64
Q

What are the symptoms associated with stress incontinence?

A 
Involuntary leakage with increased intra-abdominal pressure
Cough
Laugh
Lifting
Exercise
Movement
65
Q

How would you investigate a patient with urinary incontinence?

A

Bladder diary - frequency volume chart
Urinalysis
Residual urine measurement
Questionnaire - ePAQ

+ assess pelvic floor muscles, prolapse
+ residual urine volume (post-void volume) - cystometry

+ urodynamic testing after conservative management

66
Q

How would you manage stress incontinence?

A

Conservative = Kegel exercises
SNRI - duloxetine - enhances the urethral sphincter
Surgery = sling / suspension

67
Q

How would you manage overactive bladder (detrusor overactivity)?

A 
Bladder drills
Anticholinergic drugs - oxybutynin
Botox
Augmentation
Bypass
68
Q

What lifestyle measures would you give to someone with urinary incontinence?

A 
Avoid caffeine 
Modify fluid intake
Weight loss
Avoid straining
Stop smoking
69
Q

What medication would you use to treat detrusor overactivity?
+ side effects

A

Anti-cholinergic eg Oxybutynin, Tolterodine

SE = dry mouth, constipation, drowsiness, blurred vision

70
Q

What are the options for incontinence before surgery?

A 
Lifestyle 
Containment options:
- Catheters
- Leakage barriers - pads and pants
- Vaginal support devices
- Skin care
- Odour control
71
Q

What are the symptoms of utero-vaginal prolapse?

A

Feeling like something is coming down / dragging sensation
Lump
Discomfort
Pelvic floor + sexual symptoms

72
Q

How would you investigate a patient with suspected prolapse?

A

Sims speculum examination

73
Q

What are the treatment options for uterovaginal prolapse?

A

Lifestyle - lose weight etc
Conservative = pessaries
Surgical (eg hysteroplexy, sacroplexy, anterior or posterior wall repair)
Oestrogen replacement - adds turgor to the vagina

74
Q

What are the types of prolapse?

A 
Frontal = urethrocoele or cystocoele
Apical = uterine prolapse
Back = enterocoele (small bowel) or rectocoele (rectum)

Phase 3a (11 decks)

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