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Year 4 GOSH > Gynae > Flashcards

Gynae Flashcards

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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
What is the basis of HRT?
Oestrogen replacement!! Oral oestrogens are usually given for 2-3 years.
26
When would you use Continuous Combined HRT?
Postmenopausal! >1yr without a period. (No bleed HRT)
27
Difference between Combined Cyclical, and Long Combined Cyclical HRT?
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)
28
What can be used for hot flushes/ vasomotor sx of the menopause?
Clinidine (acts directly on hypothalamus) and Gabapentin
29
What are the big risks of HRT?
- Breast carcinoma (risk ^ every year, but effect not sustained once HRT stopped) - Endometrial carcinoma (^risk with unopposed oestrogen) - VTE (also a contraindication of HRT)
30
Acute causes of Pelvic Pain? a) Gynaecological b) Non-gynaecological
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
31
Chronic causes of Pelvic Pain? a) Gynae b) Non-gynae
a) Gynae: - Pelvic adhesions - Fibroids - Cervical stenosis - Asherman's syndrome b) Non-gynae: - GI (constipation, hernia, IBS/IBD) - Urological (interstitial cystitis, calculi)
32
Core symptoms of Endometriosis?
- 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
33
What is Asherman's syndrome?
Acquired condition, refers to the existence of scar tissue in uterus. Sx include having light/no periods + subfertility.
34
What is a chocolate cyst?
An endometrial cyst on ovary that when ruptures, secretes blood resembling melted chocolate. Rupture causes acute pain.
35
What is the GOLD STANDARD investigation for endometriosis?
Exploratory Laparoscopy: - Active lesions (red vesicles/ punctuate marks on peritoneum) - Less active (white scars/brown spots) - Severe disease (ovarian endometriomas (cysts) )
36
Endometriosis management? a) Medical? b) Surgical?
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.
37
What are the common infections associated with PID?
``` -Chlamydia trachomatis (20-30%) –Neisseria gonorrhoea (10-15%) –Mycoplasma genitalium (15%) –BV associated organism –Mycobacterium tuberculosis ```
38
What is a late complication of PID?
A tubo-ovarian abscess! Presents with a swinging fever.
39
Examination findings of PID?
- Lower abdo tenderness (usually bilateral) - Adnexal tenderness on bimanual - Cervical motion tenderness - Fever >38 in moderate-severe
40
Investigations in PID?
- NAAT (chlam/gonorrhoea) - Serology (HIV/syphilis) - MSU + Urine Dip - Endocervical swab (gonorrhoea) - Pregnancy test
41
Treatment of PID?
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
Complications of PID?
- Tubal factor infertility - Chronic pelvic pain - Ectopic pregnancy - Peri-Hepatitis (inflam around liver= Fitz-High-Curtis Syndrome) - Tubo-ovarian abscess
43
Women, <30yrs with RUQ pain what should you always consider?
Fitz-High-Curtis Syndrome (inflammation around liver). | Also- cholecystitis (but this is more common in older women).
44
Risk factors for Leiomyomas? (Fibroids)
- African descent - FHx: MED12 gene - Nulliparous - Obesity - Early puberty
45
Management of Leioyomas?
- 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
What are the 2 types of Inflammatory Ovarian Cyst?
(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
What are the most common ovarian tumour in young women?
Benign teratoma (germ cell cysts, aka DERMOID CYST!)
48
What is the risk of a Thecoma?
(Type of Sex Cord Stromal Cyst) Benign oestrogen-secreting tumours (often present post-menopausal with symptoms of excessive oestrogen). May induce endometrial ca.
49
What investigations would you conduct for Ovarian Cysts?
1. Bimanual + TVUSS 2. Ca-125 3. LDH (lactate dehydrogenase), aFP (alpha fetoprotein) and hCG
50
When does the cervical screening program run?
Every 3yrs from 25-50yrs, then every 5yrs up to 61yrs.
51
OSCE cervical smear process?
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
(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) Regular 3/5 year recall. b) Colposcopy 6wks. c) Colposcopy 2wks.
53
OSCE Colposcopy process?
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
Management of an Ectropion?
AgNO3 ablation (silver nitrate rods can be used to ablate around the area of the ectropion)
55
Aetiology of CIN? (premalignant at the transformational zone)
- HPV (16, 18, 31 and 33) - COCP - Smoking
56
What do you do if CIN I/ II or III?
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
Symptoms for Cervical Cancer? (most common cancer in women <35yrs/ 75-85yrs)
- PCB, IMB or PMB - Persistent, offensive, blood-stained discharge - Lower back pain - Painful, swollen leg (thrombosis in pelvis)
58
Investigations for Cervical Cancer?
- 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
Management of Cervical cancer? (FIGO staging!)
Stage 1a (microinvasive): LLETZ Stage 1b/2a: Hysterectomy + pelvic node resection, pelvic radiotherapy) Stage 2b/4: RT + chemo.
60
How do you manage cervical cancer if you want to preserve fertility?
Radical trachelectomy- known as Wertheim's.
61
FIGO staging of cervical cancer in terms of extent of the tumour?
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
Staging of Endometrial cancer? (most common type of uterine + gynae cancer!)
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
What are some risk factors for endometrial cancer?
(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
Symptoms of endometrial cancer?
- PMB (>1yr after cessation of periods) | - In premenopausal women: irregular bleeding, IMP, heavy periods (esp. recent onset)
65
Investigations of endometrial cancer?
- 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
Management of endometrial cancer?
-Anastrazole -Mirena -Radical Hysterectomy + BSO (BILATRAL SALPINGO-OOPHERECTOMY) (+lymph node excision) + Adjacent RT
67
Some risk factors for Ovarian cancer?
- Nulliparity/early menarche/late menopause (continuous ovulation causes repeated trauma to ovarian epithelium) - BRCA1 50%, BRCA2 20%, HNPCC 5%. - Obesity - Smoking - Endometriosis
68
What are some protective factors of endometrial cancer? (weird)
- Smoking - COCP, mirena, POP - Pregnancy
69
What is the Risk Of Malignancy Index (RMI)?
For ovarian cancer- calculates the chances of having a malignancy: - Ca125 - US findings - Whether they've been through menopause.
70
Symptoms of Ovarian cancer? (vague sx- so women often present late)
- Persistent abdo distention + pain + loss of appetite (basically, suspect ovarian ca in >50yrs and IBS sx) - Ascites - Bleeding - Urinary urgency/frequency
71
What are the cancer markers for ovarian ca.?
Ca-125: serous, endometrioid! Ca-19.9: mucinous! (These are epithelial tumours- others include germ cell and sex cord stromal)
72
Mode of action of Tamoxifen in pre and post menopausal women?
- 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
What is the largest risk for a woman developing cancer?
OBESITY!!! | NOT HRT
74
Management of an unwanted pregnancy?
- 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
Counselling before TOP ? (OSCE)
- 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
Medical management of TOP?
MIFEPRISTONE + MISOPROSTOL!
77
Surgical mangement of TOP?
- Manual Vacuum Aspiration - Surgical Evacuation - Dilation/evacuation (method recmmended for pregnancies >14wks) - Surgical evacuation without fetocide - Surgical with fetocide
78
What are some complications of TOP?
- 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
When to refer for subfertility?
<36 and 1 yr of trying | >36 or abnormal Hx (amenorrhoea/PID)/ Ix in primary care and <1 year of trying.
80
What is the leading cause of subfertility in women?
Ovulatory problems.
81
What are some male causes of subfertility?
- Idiopathic (most common) - Hypogonadism (the only medically treatable cause) - Testicular trauma/surgery - Obstruction - Anabolic steroid induced
82
General subfertility investigations in women?
- 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
General subfertility investigations in men?
- Sperm sample (collected after 2-7days of abstinence) sperm count/motility/morphology. - Chlamydia/STI test - Total serum testosterone
84
What do you look at in a sperm sample?
Volume, count, concentration, vitality, progressive motility, total motility, normal morphology.
85
How do you test to see if a woman is ovulating?
Mid-luteal progestrone (7 days before menstruation)
86
What are the 3 main types of anovulation disorder? | also what is another cause?
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
What is the gold standard to test Tubal Infertility?
Laparoscopy: Lap + Dye ! | can also do hysterosalpingography
88
What is the management for anovulation?
Clomifene Citrate! (anti-oestrogen, causes release of FSH +LH. Trues to stimulate monthly ovulation) If also PCOS --> give Metformin too!!
89
Obs/Gynae Hx taking in urinary incontinence?
- 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
PMHx taking in urinary incontinence?
- Prolapse sx (mass/pain during sex) - Constipation - Chronic cough - Diabetes? - Neuro problems
91
Investigations in urinary incontinence?
- 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
How do anticholinergics and vaginal oestrogens work? (urge incontinence)
Anticholinergics: relax the bladder by blocking vagus nerve. | Vaginal oestrogens: post-menopausal women (if vaginal atrophy as the problem)
93
What physio can be used in urinary incontinence?
Pelvic floor exercises. At least 8 contractions 3xday, for 3months.
94
What is a medical treatment for stress incontinence?
Duloxetine ! (helps with tightening sphincter) | Also can use Bulkamid as urethral bulking agent (not as bad as surgery but still not great)
95
Percutaneious posterior nerve stimulation (PPNS)?
Posterior tibial nerve L4-S3, once a week for 12wks.
96
What if there is a mixture between stress and urge incontinence?
Always treat urge incontinence first because treating stress can make the symptoms of urge worse.
97
What does the Baden-Walker System grade?
It grades the extent of prolapse. | max possible descent: procidentia
98
Treatment for prolapse?
- Conservative mx: weight loss, avoid heavy lifting, pelvic floor exercises. - Pessary (reinforces position of everything) - Surgery (anterior/post repair, vaginal hysterectomy, sacrosponous fixation)
99
What is the risk of surgery for prolapse or stress incontinence?
It can just make urge incontinence worse !!!

Year 4 GOSH (3 decks)

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