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Year 4 GOSH > Gynae > Flashcards

Gynae Flashcards

1
Q

Physiology of FSH?

A

Causes maturation of the ovum, and hence the increase in production of oestrogen.

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2
Q

Physiology of LH?

A

Causes the corpus luteum to form (release of egg- ovulation!), and hence the production of progesterone.

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3
Q

How does the cervix change during the menstrual cycle? (follicular phase + luteal phase)

A

Follicular phase –> ^ mucus production by cervix. Around ovulation, becomes more stringy + runny to facilitate sperm access.
Luteal phase –> becomes thicker + more elastic to protect the foetus from any microbes coming up vagina (mucus plug).

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4
Q

Purpose of the corpus luteum? (which marks the Luteal Phase- 14days)

A

Corpus Luteum continuously produces progesterone –> stabilises endometrium, makes more viable for embryo to implant, ^endometrium’s secretions, lipids, glycogen + blood supply.

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5
Q

What is the current classification of Abnormal Uterine Bleeding?

A

FIGO classification (PALM-COEIN) for causes of AUB in non-gravid women of reproductive age.

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6
Q

What is adenomyosis and what are the key characteristics?

A

Ectopic endometrial tissue WITHIN the uterus (embedded in the myometrium).
Therefore- uterus will be bigger (symmetrical lumps on bimanual), painful ‘vague pain’ and heavy bleeding!

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7
Q

What are the 3 types of leiomyoma (fibroid) and most common type?

A

Intramural (inside uterus muscle).
Subserous (fibroid out of uterus cavity- most common!)
Submucous (fibroid coming out of uterus cavity)

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8
Q

If a woman of CBA presents with heavy bleeding, what investigations would you do?

A

FBC
Coagulation screen
TFTs
Offer OPH/ US as 1st line (outpatient hysteroscopy- esp if Hx suggestive of endometrial pathology)

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9
Q

If no cause of heavy menstrual bleeding identified… Dysfunctional Uterine Bleeding! Management of this?

A

1st line= Mirena IUS

If doesn’t want hormones/severe pain too= Mefenamic/Tranexamic Acid.

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10
Q

IMB + PCB in WoCBA is suggestive of what?

A

Cervix: polyps, cervicitis, ectropion (v common!), cancer.
Endometrium: polyp, submucosal fibroid.

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11
Q

Post-menopausal bleeding- what are the 3 main causes and how do you manage women who present with PMB in GP?

A 
Vaginal Atrophy (70%!)
Endometrial hyperplasia/polyp (consider hysterectomy/ progesterones)
Malignancy (10%)

Mx- must be sent for 2wk wait referral! Urgent USS + endometrial biopsy should be arranged.
(remember- women on combined HRT- bleeding during progesterone free period is normal)

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12
Q

What causes vaginal atrophy, and how can it be managed?

A

Reduced oestroen levels cause thinning of vaginal epithelium. Infection associated with this.
Reassure- can be normal!
Lube during sex/ estradiol creams if necessary.

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13
Q

In PMB, investigating the endometrial thickness with USS- what are the cut off points for biopsy?

A

If >3mm (or >5mm on HRT!) then biopsy required! (as ^likelihood of endometrial ca.)
This DOESNT apply to women on Tamoxifen who have a thickened endometrium and require a hysteroscopy.

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14
Q

Examination/Investigations of women who comes in with Abnormal Uterine Bleeding??

A
  1. Anaemia! (FBC!!!)
  2. Thyroid signs! (TFTs!!!)
  3. Check breast symptoms- as prolactin can be an important cause.
  4. Abdo exam for any masses (PCOS/fibroids may be felt).
  5. Pelvic exam for symmetry in uterus.
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15
Q

Reasons for Primary Amenorrhoea?

A

Normal sexual characteristics:

  • Physiological (constitutional delay)
  • Mullerian agenesis
  • Imperforate hymen
  • Androgen insensitivity syndrome

No sexual characteristics:

  • Hypothyroidism (stress, exercise, low BMI)
  • Primary ovarian insufficiency
  • Chemo-radio
  • Turner’s
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16
Q

Reasons for Secondary Amenorrhoea?

A
  • Contraception
  • Lactation
  • Hypothyroidism
  • Premature ovarian failure
  • Hyperprolactinaemia
  • Menopause
  • Asherman’s
  • Features of androgen excess: PCOS, Cushing’s, androgen secreting tumour.
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17
Q

Management of Primary Dysmenorrhoea? (onset usually within 2yrs of menarche)

A

(^ levels of prostaglandins - ^contractility of myometrium)

  • NSAIDS: Mefenamic Acid + Ibuprofen (reduce production of uterine PGs)
  • COCP/DEPOT progesterones (suppress ovulation)
  • IUS
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18
Q

How do you diagnose PCOS?

A

Rotterdam Diagnostic Criteria! 2 out of 3:

  1. Irregular menstruation
  2. Signs/sx of ^ systemic androgens
  3. USS criteria of PCOS which is >12mm cycts, <9mm
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19
Q

Pathophysiology of PCOS?

A

Increased GnRH causes a basal increase in LH.
Compensatory insulin increase results in insulin resistance + hyperinsulinaemia.
Increased LH + hyperinsulinaemia causes ^output of ovarian androgens
Results in acne + hirsutism!

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20
Q

What do raised/normal/low levels of FSH show?

A

Raised- ovarian failure
Normal- PCOS
Low- hypothalamic disease

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21
Q 
Markers of PCOS:
FSH
LH
Prolactin
Testosterone
TSH
A 
FSH- normal
LH- often raised (but not diagnostic)
Prolactin- exclude prolactinoma (pituitary tumour)
Testosterone- raised
TSH- to exclude thyroid dysfunction
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22
Q

Management of PCOS?

A

COCP- to regulate menstruation (need 3-4 bleeds/year to protect endometrium)
Metformin- for hyperinsulinaemia/ CVD risk
Clomiphene- used to induce ovulation when subfertility
Ovarian drilling
Lifestyle advice (BMI<30)

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23
Q

Physiology of the Menopause?

A

(usually- developing follicles in ovaries produce estradiol)
As menopause approaches - ^anovulation, so progesterone levels drop.
Therefore, ^FSH +LH levels (as less estradiol, so less -ve feedback to anterior pituitary)

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24
Q

What are measured to identify menopause?

A

Serum FSH >30IU/L (not reliable)

Anti-Mullerian hormone (better indicator of follicular reserve)

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25
Q

What is the basis of HRT?

A

Oestrogen replacement!! Oral oestrogens are usually given for 2-3 years.

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26
Q

When would you use Continuous Combined HRT?

A

Postmenopausal!
>1yr without a period.
(No bleed HRT)

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27
Q

Difference between Combined Cyclical, and Long Combined Cyclical HRT?

A

Combined- women with menopausal sx but still have regular periods. (withdrawal bleed every month)
Long combined- women with menopausal sx but have irregular periods. (withdrawal bleed every 3months)

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28
Q

What can be used for hot flushes/ vasomotor sx of the menopause?

A

Clinidine (acts directly on hypothalamus) and Gabapentin

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29
Q

What are the big risks of HRT?

A
  • Breast carcinoma (risk ^ every year, but effect not sustained once HRT stopped)
  • Endometrial carcinoma (^risk with unopposed oestrogen)
  • VTE (also a contraindication of HRT)
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30
Q

Acute causes of Pelvic Pain?

a) Gynaecological
b) Non-gynaecological

A

a) Gynae:
- Ectopic pregnancy
- Ovarian cyst accident (grad onset, exclusively unilateral dysparaenia/palpation pain)
- Primary dysmenorrhoea
- Mittelschmerz
b) Non-gynae:
- Appendicitis
- IBS/IBD
- Strangulated hernia
- UTI

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31
Q

Chronic causes of Pelvic Pain?

a) Gynae
b) Non-gynae

A

a) Gynae:
- Pelvic adhesions
- Fibroids
- Cervical stenosis
- Asherman’s syndrome
b) Non-gynae:
- GI (constipation, hernia, IBS/IBD)
- Urological (interstitial cystitis, calculi)

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32
Q

Core symptoms of Endometriosis?

A
  • Severe cyclical non-collicky pelvic pain (around time of menstruation)
  • Pain on passing stool during menses (dyschezia)
  • Deep dyspareunia (indicates endometriosis in Pouch of Douglas)
  • Subfertility
  • Chocolate cyst
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33
Q

What is Asherman’s syndrome?

A

Acquired condition, refers to the existence of scar tissue in uterus.
Sx include having light/no periods + subfertility.

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34
Q

What is a chocolate cyst?

A

An endometrial cyst on ovary that when ruptures, secretes blood resembling melted chocolate.
Rupture causes acute pain.

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35
Q

What is the GOLD STANDARD investigation for endometriosis?

A

Exploratory Laparoscopy:

  • Active lesions (red vesicles/ punctuate marks on peritoneum)
  • Less active (white scars/brown spots)
  • Severe disease (ovarian endometriomas (cysts) )
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36
Q

Endometriosis management?

a) Medical?
b) Surgical?

A

a) Medical- mx mimics pregnancy (COCP/progesterone) OR menopause (GnRH). GnHR use limited to 6months.
b) Surgical:
- Laporascopic: ablation + excision of endometrial areas, combined with medical mx. This has become standard!
- Definitive surgery: hysterectomy + salpingo-oopherectomy.

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37
Q

What are the common infections associated with PID?

A 
-Chlamydia trachomatis (20-30%)
–Neisseria gonorrhoea (10-15%)
–Mycoplasma genitalium (15%)
–BV associated organism
–Mycobacterium tuberculosis
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38
Q

What is a late complication of PID?

A

A tubo-ovarian abscess! Presents with a swinging fever.

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39
Q

Examination findings of PID?

A
  • Lower abdo tenderness (usually bilateral)
  • Adnexal tenderness on bimanual
  • Cervical motion tenderness
  • Fever >38 in moderate-severe
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40
Q

Investigations in PID?

A
  • NAAT (chlam/gonorrhoea)
  • Serology (HIV/syphilis)
  • MSU + Urine Dip
  • Endocervical swab (gonorrhoea)
  • Pregnancy test
41
Q

Treatment of PID?

A

1) Ceftriaxone 500mg IM (+1g azithro if gonorrhoea)
2) + Doxycline 100mg BD 14days
3) + Metronidazole 400mg BD 14days

If mycoplasma genitalium = Moxifloxacin.

NO SEX until woman + partner investigated/treated.

42
Q

Complications of PID?

A
  • Tubal factor infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Peri-Hepatitis (inflam around liver= Fitz-High-Curtis Syndrome)
  • Tubo-ovarian abscess
43
Q

Women, <30yrs with RUQ pain what should you always consider?

A

Fitz-High-Curtis Syndrome (inflammation around liver).

Also- cholecystitis (but this is more common in older women).

44
Q

Risk factors for Leiomyomas? (Fibroids)

A
  • African descent
  • FHx: MED12 gene
  • Nulliparous
  • Obesity
  • Early puberty
45
Q

Management of Leioyomas?

A
  • Asymptomatic then LEAVE!
  • GnHR (switch off ovarian oestrogen production, shrinking fibroids)
  • Ulipristic acid (short course before surgery)
  • Hysterectomy
  • Myomectomy (only option for women wanting to conceive)
46
Q

What are the 2 types of Inflammatory Ovarian Cyst?

A

(usually associated with PID)

  1. Tubo-Ovarian abscess (complication of PID, abscess forms between ovary + fallopian tube. Rupture -> sepsis!)
  2. Endometrioma (aka chocolate cyst. Associated with endometriosis)
47
Q

What are the most common ovarian tumour in young women?

A

Benign teratoma (germ cell cysts, aka DERMOID CYST!)

48
Q

What is the risk of a Thecoma?

A

(Type of Sex Cord Stromal Cyst)
Benign oestrogen-secreting tumours (often present post-menopausal with symptoms of excessive oestrogen). May induce endometrial ca.

49
Q

What investigations would you conduct for Ovarian Cysts?

A
  1. Bimanual + TVUSS
  2. Ca-125
  3. LDH (lactate dehydrogenase), aFP (alpha fetoprotein) and hCG
50
Q

When does the cervical screening program run?

A

Every 3yrs from 25-50yrs, then every 5yrs up to 61yrs.

51
Q

OSCE cervical smear process?

A
  1. Easy, not painful but may be uncomfortable.
  2. Speculum inserted into vagina, cervix visualised.
  3. Swab (like small brush) inserted into external os + rotated 5x clockwise.
  4. Swab sent for liquid cytology.
  5. Calls assessed for dyskariosis (abnormal nucleus).
52
Q

(cervical smear) management of:

a) Women with low-grade abnormalities + no presence of high-risk HPV?
b) Women with low-grade abnormalities + presence of high-risk HPV?
c) Women with high-grade abnormalities?

A

a) Regular 3/5 year recall.
b) Colposcopy 6wks.
c) Colposcopy 2wks.

53
Q

OSCE Colposcopy process?

A

Uses histology to diagnose CIN.

  • Speculum, Dr looks at cervix through colposcope.
  • Cervical biopsy: small tissue samples.
  • Painless as cervix has no nerves.
  • ACETIC ACID: abnormal cells turn white (so CIN cells appear white)
  • IODINE: normal stains brown!
54
Q

Management of an Ectropion?

A

AgNO3 ablation (silver nitrate rods can be used to ablate around the area of the ectropion)

55
Q

Aetiology of CIN? (premalignant at the transformational zone)

A
  • HPV (16, 18, 31 and 33)
  • COCP
  • Smoking
56
Q

What do you do if CIN I/ II or III?

A

CIN I: mild dysplasia.
CIN II: moderate dysplasia (treat- LLETZ)
CIN III: severe dysplasia (treat- LLETZ)
If CIN II/III then specimen is examined histologically.

57
Q

Symptoms for Cervical Cancer? (most common cancer in women <35yrs/ 75-85yrs)

A
  • PCB, IMB or PMB
  • Persistent, offensive, blood-stained discharge
  • Lower back pain
  • Painful, swollen leg (thrombosis in pelvis)
58
Q

Investigations for Cervical Cancer?

A
  • Spec + bimanual
  • PR
  • Examine inguinal lymph nodes
  • FBCs, U&Es (kidney commonly affected by stage 3 cervical cancer), LFTs.
  • Colposcopy
  • MRI for local invasion
  • CT CAP for metastatic spread (most likely: vagina, bladder, bowel, nodes, bloodborne–>liver&lung!)
59
Q

Management of Cervical cancer? (FIGO staging!)

A

Stage 1a (microinvasive): LLETZ
Stage 1b/2a: Hysterectomy + pelvic node resection, pelvic radiotherapy)
Stage 2b/4: RT + chemo.

60
Q

How do you manage cervical cancer if you want to preserve fertility?

A

Radical trachelectomy- known as Wertheim’s.

61
Q

FIGO staging of cervical cancer in terms of extent of the tumour?

A

1: confined to cervix.
2: disease beyond cervix, not to pelvic wall or lower 1/3 vagina.
3: disease to pelvic wall or lower 1/3 vagina.
4: invades bladder rectum or metastasis.

62
Q

Staging of Endometrial cancer? (most common type of uterine + gynae cancer!)

A

Stage I – confined to body of uterus (endometrium/ myometrium)
Stage II - involving cervix
Stage III - spread outside uterus (ovary… vagina..)
Stage IV - with bowel, bladder or distant organ involvement

63
Q

What are some risk factors for endometrial cancer?

A

(increased oestrogen, decreased progesterone)

  • Obesity!
  • Nulliparity
  • Early menarche, late menopause
  • Tamoxifen (oestrogen antagonist in breast, but agonist in uterus)
  • Oestrogen-only HRT (safest is the oestrogen-only patch)
  • HNPCC (FHx of breast, ovarian or colon)
64
Q

Symptoms of endometrial cancer?

A
  • PMB (>1yr after cessation of periods)

- In premenopausal women: irregular bleeding, IMP, heavy periods (esp. recent onset)

65
Q

Investigations of endometrial cancer?

A
  • Spec + bimanual
  • Transvaginal USS (uterine thickness >5mm postmenopausal women requires biopsy)
  • Hysteroscopy + biopsy
  • MRI (if biopsy comes back +ve)
  • CT CAP (mets- liver+lung)
66
Q

Management of endometrial cancer?

A

-Anastrazole
-Mirena
-Radical Hysterectomy + BSO (BILATRAL SALPINGO-OOPHERECTOMY) (+lymph node excision)
+ Adjacent RT

67
Q

Some risk factors for Ovarian cancer?

A
  • Nulliparity/early menarche/late menopause (continuous ovulation causes repeated trauma to ovarian epithelium)
  • BRCA1 50%, BRCA2 20%, HNPCC 5%.
  • Obesity
  • Smoking
  • Endometriosis
68
Q

What are some protective factors of endometrial cancer? (weird)

A
  • Smoking
  • COCP, mirena, POP
  • Pregnancy
69
Q

What is the Risk Of Malignancy Index (RMI)?

A

For ovarian cancer- calculates the chances of having a malignancy:

  • Ca125
  • US findings
  • Whether they’ve been through menopause.
70
Q

Symptoms of Ovarian cancer? (vague sx- so women often present late)

A
  • Persistent abdo distention + pain + loss of appetite (basically, suspect ovarian ca in >50yrs and IBS sx)
  • Ascites
  • Bleeding
  • Urinary urgency/frequency
71
Q

What are the cancer markers for ovarian ca.?

A

Ca-125: serous, endometrioid!
Ca-19.9: mucinous!

(These are epithelial tumours- others include germ cell and sex cord stromal)

72
Q

Mode of action of Tamoxifen in pre and post menopausal women?

A
  • Premenopausal: anti-oestrogenic effect (PROTECTIVE on breast + endometrial tissue)
  • Postmenopausal: still anti-oestrogenic effect on breast, however OESTROGENIC effect on endometrium, therefore ^risk endometrial ca.
73
Q

What is the largest risk for a woman developing cancer?

A

OBESITY!!!

NOT HRT

74
Q

Management of an unwanted pregnancy?

A
  • hCG to confirm
  • USS (gestational age, viability, exclude molar/ectopic)
  • Bloods: Hb, ABO + Rhesus (women who are rh-ve will require anti-D)
  • Azithromycin 1g (prevents infection)
  • Counselling
75
Q

Counselling before TOP ? (OSCE)

A
  • Weighing up physical + emotional implications
  • Give the woman the time she needs.
  • Depression NOT increased after abortion
  • (at end) Jointly put together a contraceptive plan.
76
Q

Medical management of TOP?

A

MIFEPRISTONE + MISOPROSTOL!

77
Q

Surgical mangement of TOP?

A
  • Manual Vacuum Aspiration
  • Surgical Evacuation
  • Dilation/evacuation (method recmmended for pregnancies >14wks)
  • Surgical evacuation without fetocide
  • Surgical with fetocide
78
Q

What are some complications of TOP?

A
  • Retained products of conceptions (persistent bleeding)
  • Failure: so importance of follow up.
  • Infection: prophylactic abx + advise warning signs.
  • Haemorrhage: more in later gestation.
  • Perforation of uterus/ cervical trauma: reduced by prostaglandins before to soften cervix.
  • Future fertility: not affected.
  • Psychological sequelae: no evidence, may need support.
79
Q

When to refer for subfertility?

A

<36 and 1 yr of trying

>36 or abnormal Hx (amenorrhoea/PID)/ Ix in primary care and <1 year of trying.

80
Q

What is the leading cause of subfertility in women?

A

Ovulatory problems.

81
Q

What are some male causes of subfertility?

A
  • Idiopathic (most common)
  • Hypogonadism (the only medically treatable cause)
  • Testicular trauma/surgery
  • Obstruction
  • Anabolic steroid induced
82
Q

General subfertility investigations in women?

A
  • Midluteal progesterone (7 days before period- confirms presence of ovulation)
  • Chlamydia/STI test
  • USS of area
  • FSH, LH + oestrodiol levels
  • Thyroid + prolactin levels
  • Hysteroscopy (if expecting structural problems/ polyp on USS)
  • Rubella immune or not
83
Q

General subfertility investigations in men?

A
  • Sperm sample (collected after 2-7days of abstinence) sperm count/motility/morphology.
  • Chlamydia/STI test
  • Total serum testosterone
84
Q

What do you look at in a sperm sample?

A

Volume, count, concentration, vitality, progressive motility, total motility, normal morphology.

85
Q

How do you test to see if a woman is ovulating?

A

Mid-luteal progestrone (7 days before menstruation)

86
Q

What are the 3 main types of anovulation disorder?

also what is another cause?

A

Type 1: Hypothalamic pituitary failure (low oestrogen, low FSH)
Type 2: Hypothalamic pituitary ovarian disorder (PCOS!!) (normal oestrogen + FSH)
Type 3: Ovarian Failure (low oestrogen, high FSH)

87
Q

What is the gold standard to test Tubal Infertility?

A

Laparoscopy: Lap + Dye !

can also do hysterosalpingography

88
Q

What is the management for anovulation?

A

Clomifene Citrate! (anti-oestrogen, causes release of FSH +LH. Trues to stimulate monthly ovulation)
If also PCOS –> give Metformin too!!

89
Q

Obs/Gynae Hx taking in urinary incontinence?

A
  • Premenopausal (more likely URGE), or postmenopausal (more likely STRESS/ bigger issue like prolapse)
  • Vaginal atrophy causes urinary freq + UTIs
  • Problems with sex? (pain=endometriosis, prolapse etc)
  • Vaginal deliveries? (hints at more stress)
90
Q

PMHx taking in urinary incontinence?

A
  • Prolapse sx (mass/pain during sex)
  • Constipation
  • Chronic cough
  • Diabetes?
  • Neuro problems
91
Q

Investigations in urinary incontinence?

A
  • BMI
  • Urine dip
  • Abdo exam for any obvious masses
  • Cough whilst lying (look for leakage/prolapse)
  • Speculum (vaginal atrophy/fibroids)
  • Do smear if appropriate
92
Q

How do anticholinergics and vaginal oestrogens work? (urge incontinence)

A

Anticholinergics: relax the bladder by blocking vagus nerve.

Vaginal oestrogens: post-menopausal women (if vaginal atrophy as the problem)

93
Q

What physio can be used in urinary incontinence?

A

Pelvic floor exercises. At least 8 contractions 3xday, for 3months.

94
Q

What is a medical treatment for stress incontinence?

A

Duloxetine ! (helps with tightening sphincter)

Also can use Bulkamid as urethral bulking agent (not as bad as surgery but still not great)

95
Q

Percutaneious posterior nerve stimulation (PPNS)?

A

Posterior tibial nerve L4-S3, once a week for 12wks.

96
Q

What if there is a mixture between stress and urge incontinence?

A

Always treat urge incontinence first because treating stress can make the symptoms of urge worse.

97
Q

What does the Baden-Walker System grade?

A

It grades the extent of prolapse.

max possible descent: procidentia

98
Q

Treatment for prolapse?

A
  • Conservative mx: weight loss, avoid heavy lifting, pelvic floor exercises.
  • Pessary (reinforces position of everything)
  • Surgery (anterior/post repair, vaginal hysterectomy, sacrosponous fixation)
99
Q

What is the risk of surgery for prolapse or stress incontinence?

A

It can just make urge incontinence worse !!!

Year 4 GOSH (3 decks)

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