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Year 4 Family and Children ANNA > Gynae > Flashcards

Gynae Flashcards

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1
Q

How are “heavy periods” defined?

A
  • losing 80ml or more in each period,
  • having periods that last longer than 7 days,
  • or both.
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2
Q

What questions can elicit a heavy bleeding complaint?

A
  • Do you have to change sanitary products more frequently than every 2 hours?
  • Do you double up pads or types of protection?
  • Do you soak through to your clothes?
  • Pass blood clots?
    • How large? (large = bigger than 10p)
  • Do you avoid work / school / exercise on a period?
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3
Q

What questions should be included in an abnormal vaginal bleeding history?

A
  1. Age? (>45 high risk)
  2. Regular?
  3. Other symptoms that may be associated with fibroids? -
    1. A heaviness in the pelvis
    2. urinary symptoms
    3. fibroids seen on a previous scan
  4. Other -
    1. Bleeding disorder such as von Willebrands?
    2. Symptoms of thyroid dysfunction?
    3. Anti-coagulants?
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4
Q

When is menstrual bleeding always abnormal?

A
  1. IMB (inter-menstrual bleeding)
  2. PCB (post-coital bleeing)
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5
Q

What aspects of the history are important in dysmenorrhoea?

A
  1. Timing and severity of pain (including degree of functional loss): commonly premenstrual pain in the first 1– 2 days of bleeding, then eases
  2. Pelvic pain and deep dyspareunia (may signify pelvic pathology)
  3. Previous history of PID (pelvic inflam disease) or STIs
  4. Previous abdominal or genital tract surgery (may cause adhesions).
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6
Q

What is the endometrial thickness:

  1. During menstruation
  2. Early Proliferative phase
  3. Late proliferative phase
  4. Secretory phase
A
  1. during menstruation: 2-4 mm 1,4
  2. early proliferative phase (day 6-14): 5-7 mm
  3. late proliferative / preovulatory phase: up to 11 mm
  4. secretory phase: 7-16 mm
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7
Q

What are the investigations for Heavy Menstrual Bleeding (after history)?

A

Bedside: Examination: Bimanual exam, looking for masses, palpable uterus etc.

Urine?

Bloods: Anaemia (FBC), Bleeding disorders - esp. if always had heavy bleeding (Von Willebrands etc), thyroid, PCOS?

Imaging: USS

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8
Q

What is the acronym for causes of abnormal uterine bleeding?

A

PALM COEIN (S)

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9
Q

What does PALM COEIN (S) Stand for?

A
  • P - Polyp / Pregnancy
  • A - Adenomyosis (endometrial tissue in muscle of uterus wall)
  • L - Leiomyomas = fibroids
  • M - Maligancy
  • C - Coagulopathy
  • O - Ovulatory dysfunction e.g. PCOS
  • E - Endometrial Process / Estrogen
  • I - Iatrogenic e.g. heparin
  • N - Not yet classified
  • S - STI e.g. gonorrhoea / chlamydia
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10
Q

What is Post-ablation tubal sterilisation syndrome?

A

PATSS is a complication that potentially occurs following a global endometrial ablation in women with previous tubal sterilization.

PATSS presents as cyclic pelvic pain caused by tubal distention from occult bleeding into the obstructed tubes.

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11
Q

which synthetic hormone does the Mirena coil contain?

A

Progesterone (synthetic name is progestin)

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12
Q

What is the first line, non-hormonal pharmaceutical treatment for heavy menstrual bleeding?

A

Transexamic acid + NSAID (e.g. mefenamic acid)

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13
Q

what is the first line treatment for heavy menstrual bleeding?

A

Mirena coil

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14
Q

Iliac fossa pain associated with shoulder tip pain indicates what?

A
  • This is highly suggestive of peritoneal irritation due to intra-peritoneal bleeding.
  • Shoulder tip pain occurs because of diaphragmatic irritation from blood.
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15
Q

What features on ultrasound scan would raise your concern about an ovarian malignancy?

A

Ovarian cysts that are large, bilateral, appear “complex” (i.e. have both solid and cystic areas) should be treated as suspicious.

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16
Q

What are the risk factors for ovarian cancer?

A

family history: mutations of the BRCA1 or the BRCA2 gene

many ovulations: early menarche, late menopause, nulliparity

(protective factors are the reverse)

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17
Q

What are the symptoms of ovarian cancer?

A

Clinical features are notoriously vague

  1. abdominal distension and bloating
  2. abdominal and pelvic pain
  3. urinary symptoms e.g. Urgency
  4. early satiety
  5. diarrhoea
18
Q

What is the initial investigation for ovarian cancer?

A

Ca125 (>35ml indicates urgent USS)

NB/ endometriosis and ovarian cysts also raise CA125

19
Q

What is the risk of malignancy index for ovarian cancer?

A

RMI = U (USS) x M (Menopause) x CA125

refer all women with an RMI I score of 250+

20
Q

What other things (other than CA125) do you measure in women under 40 with supsected ovarian cancer?

A

alpha fetoprotein (AFP) + beta human chorionic gonadotrophin (beta-hCG)

21
Q

What is the surgery offered for ovarian cancer?

A

“Debulking”, or cytoreduction, means removing as much macroscopic disease as possible.

= total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO), unless you have very low grade cancer (may be able to leave a tube)

Common complications:

  • Colostomy (surgery to bowel)
  • Catheter (surgery to bladder)
22
Q

What type of ovarian cancer is 95% of all ovarian cancer?

A

Epithelial ovarian cancer

23
Q

What are the 4 stages of ovarian cancer?

A
  1. Stage 1 – only affecting one or both of the ovaries
  2. Stage 2 – has spread outside the ovaries but not outside the pelvis
  3. Stage 3 – has spread outside the pelvis to the lining of the abdomen and bowel
  4. Stage 4 – has spread to other parts of the body such as liver, spleen, lungs
24
Q

What are the 3 most common subtypes of epithelial ovarian cancer?

A
  1. Serous (68%)
    1. High grade
    2. Low grade
  2. Clear Cell (12%)
  3. Endometroid (9%)
25
Q

What % of high grade serous ovarian cancer is associated with a germline mutation in either BRCA1 or BRCA2?

A

15%

26
Q

Why would BRACA testing be offered for women with ovarian cancer?

A

2 reasons:

  1. if the patient is a carrier then it allows other members of the family to undergo testing to see whether they are at risk too - Asymptomatic carriers may elect to undergo prophylactic surgery to reduce their risk of breast and ovarian cancer.
  2. can tailor treatment with PARP inhibitors
27
Q

What non-urological questions are important to ask in a urological history? (x6)

A
  1. Bowel symptoms (incontinence, constipation)
  2. Affect on sexual function
  3. Obstetric Hx (full and detailed all past pregs)
  4. Surgical Hx - pelvic and abdo
  5. PMHx
    1. DM
    2. Neurological
    3. DHx
    4. Hx of UTIs?
  6. Effect on quality of Life
28
Q

What does ICI-Q questionairre do?

A

validates symptoms and evaluates which pelvic floor symptoms a patient has

29
Q

how much does a normal bladder hold?

A

400-600ml

30
Q

How much is a normal fluid intake?

A

1500-2000mls

31
Q

How much is a normal voided volume?

A

Voided volumes 250-500mls

32
Q

What is the POP-Q system?

A

Pelvic Organ Prolapse Quantifications System

33
Q

What are the 4 types of prolapse?

A
  1. Cystocele / anterior wall prolapse
    • Partial
    • Complete
  2. Rectocele / posterior wall prolapse
  3. Uterine prolapse
  4. Vaginal vault prolapse
34
Q

What is conservative management for stress incontinence?

A
  1. Pelvic floor exercises
  2. Change medications e.g. alpha blockers (for BP) to ACE inhibitors or others
  3. Stop smoking
35
Q

How is smoking related to incontience?

A
  1. chronic cough, which can put pressure on the pelvic muscles, causing them to weaken and increasing the chance of stress incontinence.
  2. smoking is an irritant to the bladder.
  3. smoking can also lead to bladder cancer.
36
Q

What diagnoses can urodynamics aid in making?

A

stress incontinence, detrusor overactivity (DO) and voiding dysfunction.

37
Q

OSCE: Explain stress incontinence to me!

A
  • Small amounts of urine leaks when there is raised intrabdominal pressure (sneezing, coughing, laughing)
  • It is common (1 in 3 women)!
  • Chilbirth is biggest riskfactor. It is also associated with obesity, chronic cough, chronic constipation or heavy lifting on a regular basis.
  • draw picture!
  • e.g. When woman gives birth the pelvic floor muscles are overstretched and can no longer support the external sphincter as well.
  • Good news is that by strengthening the pelvic floor muscles you can regain control!
  • Surgical options too
38
Q

What are the surgical options for stress incontinence?

A
  1. Urethral Bulking agents
  2. Mid-urethral slings (MUS)
  3. Colposuspension
  4. A fascial sling
39
Q

What are the advantages and disadvantages of using urethral bulking agent to treat stress incontinence?

A

Advantages:

  1. Can be done under local
  2. No surgery/incisions - for those unfit or unwilling
  3. Less risks to fertility
  4. 60-70% successful

Disadvantages:

  1. Reduces efficacy over time - 1/3 will need 2nd bulking
40
Q

What are the advantages and disadvantages of using a mid-urethral sling to treat stress incontinence?

A

Advantages:

  1. Just as effective as more invasive operations but with quicker recovery
  2. less chance of needing surgery for prolapse in the first two years after the surgery
  3. Theoretically can be done under spinal
  4. Long term success rate

Disadvantages:

  1. The operation is less likely to be a success if you have had previous surgery to your bladder
  2. Pregnancy may complicate surgery in future (complete family 1st)

Complications:

  1. Difficulty voiding due to swelling of urethra
  2. Bleeding
  3. UTI
  4. Rare: Damage to the bladder
  5. Rare: Sling becomes palpable in vagina years later
  6. Rare: worsened urge incontinence
  7. Rare: Pain not settling
41
Q

What are some common complications for many of these surgeries?

A

Complications:

  1. Difficulty voiding due to swelling of urethra
  2. Bleeding
  3. UTI
  4. Rare: Damage to the bladder
  5. Rare: worsened urge incontinence
  6. Rare: Pain not settling

Year 4 Family and Children ANNA (23 decks)

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