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NV - Phase 3A > Gynae > Flashcards

Gynae Flashcards

1
Q

What are some causes of promary amenorrhoea?

A 
Turner's syndrome
imperforate hymen 
anorexia nervosa, stress, exercise
constituitional delay 
Kallmann syndrome 
prolactinoma 
gonadal dysgenesis 
Swyer syndrome - XY but look like a girl 
Late onset CAH
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2
Q

What is the definition of secondary amenorrhoea?

A

absence of periods for >6m in someone who is not pregnant

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3
Q

What are some causes of secondary amenorrhoea?

A 
marathon runners - excessive exercise 
PCOS
premature ovarian failure 
iatrogenic (pill)
?pregnancy 
Sheehan's syndrome 
Asherman's syndrome 
hyperthyroidism
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4
Q

What biochemical findings would be present in someone with premature ovarian failure?

A

hypergonadotrophism
hypooestrogenism
raised FSH

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5
Q

How would you investigate secondary amenorrhoea?

A

Full hx
pregnancy test
thyroid function
FSH and LH - high in ovarian failure, low in hypothalamic causes
mid luteal progesterone to check for ovulation
prolactin levels
free androgen (increased in PCOS)

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6
Q

How is secondary amenorrhoea treated?

A

Cyclic progesterone
bromocriptin/cabergoline - tx for hyperprolactinaemia
GnRH replacement - if due to hypothalamic failure
thyroid replacement
tx underlying cause

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7
Q

What is the triad of features in PCOS?

A

Rotterdam criteria - 2 out of 3 must be present:

  1. 12 cysts on ovary or an ovary >10 mL
  2. signs of clinical (excess hair) or biochemical (blood test) raised testosteron/hyperandrogenism
  3. oligo or amenorrhoea
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8
Q

How would you investigate ?PCOS?

A 
serum testosterone/free androgen levels 
thyroid function
prolactin 
sex hormone binding globulin 
test for diabetes - random plasma glucose, fasting, HbA1c 
USS
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9
Q

What are some long-term complications of PCOS?

A

gestational diabetes
T2DM
CVD
Endometrial cancer

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10
Q

What are some ddx fo PCOS? / Other causes of irregular menstrual bleeding?

A 
thyroid dysfunction 
hyperprolactinaemia 
CAH
androgen secreting tumours
Cushing's syndrome
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11
Q

How is PCOS treated?

A

Weight loss
smoking cessation
tx any diabetes, HTN, dyslipidaemia, sleep apneoa

clomifene - induces ovulation 
metformin 
ovarian drilling to help fertility 
COCP with regular withdrawal bleeds 
hair removal cream for hirsuitism
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12
Q

What is the name for menorrhagia with no identifiable underlying cause?

A

dysfunctional uterine bleeding

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13
Q

What are some causes of menorrhagia?

A 
FIBROIDS
bleeding disorder 
hypothyroidism 
unknown - dysfunctional uterine bleeding 
polyps
adenomyosis 
endometriosis 
cancer
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14
Q

How would you investigate menorrhagia?

A 
FBC - look for anaemia 
Physical examination - bulky, non-tender uterus if fibroids 
TSH levels 
cervical smear if due 
STI screen 
TVUS - look for fibroids, polyps, endometrial thickness
endometrial biopsy 
hysteroscopy
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15
Q

How do you medically treat menorrhagia?

A

mirena coil - first line if no intention to get pregnant
anti-fibrinolytics - tranexamic acid taken during bleeding
NSAIDs - mefanamic acid taken during bleeding
triphasing COCP
progestogens
norethisterone - when they don’t want to bleed e.g. on holiday

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16
Q

What are some surgical treatments for menorrhagia?

A

endometrial ablation - if no desire to be pregnant again
uterine artery embolisation
hysterectomy

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17
Q

What are some causes of dysmenorrhoea?

A 
endometriosis 
adenomyosis 
fibroids
PID
Cancer
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18
Q

How is dysmenorrhoea treated?

A

NSAIDs - mefenamic acid during menstruation
paracetamol
COCP
smooth muscle anti-spasmodics (anticholinergics) - hyoscine butylbromide or dicyclomine

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19
Q

What is the main diagnosis to rule out if someone presents with post-coital bleeding? What are some other causes?

A

CERVICAL CANCER

others - polyps, cervical trauma, cervicitis, vaginitis, chlamydia

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20
Q

What is the main diagnossi to rule out when someone presents with post-menopasual bleeding? What are some other causes?

A

Endometrial cancer until proven otherwise!!

others - vaginitis, foreign bodies (pessaries), vulval/cervical cancer, polyps, oestrogen withdrawal.

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21
Q

Which route of HRT gives the highest increased risk of DVT and how is this risk reduced?

A

Oral HRT poses highest risk
reduced by giving transdermal patch instead
transdermal shoudl always be offered to people with BMI>30

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22
Q

What is the definition of premature ovarian failure?

A

When periods stop before the age of 40
FSH>25 in 2 samples more than 4 weeks apart
plus 4 months of amenorrhoea

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23
Q

What are the causes of premature ovarian failure??

A

idiopathic

iatrogenic - chemotherapy, radiotherapy, surgery

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24
Q

How is premature ovarian failure treated?

A

oestrogen replacement - HRT, COCP.
Andorgen replacement - testosterone gel
fertility- donor egg

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25
Define miscarriage.
loss of a pregnnacy before 24 weeks' gestation. | After = stillbirth
26
What are the risk factors for miscarriage?
``` increased maternal age smoking in pregnancy alcohol drugs high caffeine intake obesity infections and food poisoning severe hypertension cervical incompetency ```
27
What are the most common causes for one-off miscarriages?
``` unknown chromosomal abnormalities abnormal foetald evelopment maternal illness infection trauma cervical weakness SLE in mum ```
28
What is the definition of recurrent miscarriage?
loss of >3 consecutive pregnancies before 24 weeks' with the same biological father
29
What are some causes of recurrent miscarriage?
antiphospholipid syndrome uterine abnormalities thrombophilia - Factor V Leiden, protein C or S deficiencies parental chromosomal abnormality - unbalanced Robertsonian translocation infection - bacterial vaginosis associated with 2nd trimester loss
30
What are the features of a threatened miscarriage?
mild symptoms - mild abdo pain, mild vaginal bleeding cervical os is CLOSED
31
What are the features of an inevitable miscarriage?
severe abdo pain vaginal bleeding cervical os is OPEN
32
What are the 3 main causes of PV bleeding in early pregnancy?
ectopic pregnancy miscarriage molar pregnancy
33
What are the risk factors for ectopic pregnancy?
``` damage to tubes - PID, surgery previous ectopic endometriosis copper coil IVF smoking ```
34
What are the features of ectopic pregnancy?
LMP 8 weeks ago vaginal bleeding pain - generalised abdo or iliac fossa shoulder tip pain from haematoperitoneum
35
How would you investigate someone with suspected ectopic pregnancy?
USS - intrauterine? foetal heartbeat? serial hCG measurements pelvic exam - cervical excitatio on speculum exam
36
How is an ectopic pregnancy surgically managed?
salpingectomy if other fallopian tube is viable salpingotomy if other tube is not viable
37
What are the clinical features of a molar pregnancy?
``` vaginal bleeding pain uterus larger that should be for expected dates very very high levels of BhCG clinical hyperthyroidism hyperemesis gravidarum ```
38
How is a molar pregnancy managed?
remove by suction
39
When are women offered cervical screening?
sexually active women aged 25-64 every 3 years from 25-50 every 5 years from 50-64
40
How is CIN managed?
large loop excision of the transformational zone
41
What is the cell type usually seen in cervical cancer?
squamous cell carcinoma
42
What staging tool is used to stage cervical cancer and endometrial cancer?
FIGO staging (international federation of gynaecology and obstetrics)
43
What is stage 1 cervical cancer?
Confined to the cervix
44
What is stage 2 cervical cancer?
spread into top part of vagina
45
What is stage 3 cervical cancer?
spread into other nearby organs such as the ureter
46
What is stage 4 cervical cancer?
distant metastases
47
What are some risk factors for cervical cancer?
``` HPV infection early age intercourse (<16 yrs) STIs cigarette smoking - encourages persistence of HPV previous CIN/abnormal smear multiparity hx of other GUM neoplasia ```
48
Which types of HPV are oncogenic?
16 and 18
49
Which types of HPV cause genital warts?
6 and 11
50
Which oncoprotein do types 16 and 18 HPV contain and why does this cause cancer?
Contain E6 and E7 oncoproteins E6 prevents p53 tumour suppressor gene working E7 attacks retinoblastoma tumour suppressor gene leads to overstimulation of growth of the cells of the cervix
51
What are the symptoms of cervical cancer?
POST COITAL BLEEDING post-menopausal bleeding watery vaginal discharge
52
Which histological cell type is usually seen in endometrial cancer?
adenocarcinoma
53
Who is more at risk of endometrial cancer?
post-menopausal women
54
What histological cell trype would be seen in vulval cancer and what causes it?
squamous cell younger women - HPV older women - lichen sclerosis
55
What cell type is seen mainly in ovarian cancer?
epithelial cell tumours
56
What are the causes of ovarian cancer?
gene mutation - BRCA 1 and 2, HNPCC (Lynch syndrome) more ovulation - early menarche, late menopause, never been pregnant, never taken the pill
57
How does ovarian cancer present?
bloating/IBS-like symptoms abdominal pain/discomfort change in bowel habit urinary frequency
58
How do you investigate ovarian cancer?
Ca125 levels transabdominal ultrasound scan menopausal status calculate risk malignancy index
59
What are the ultrasound findings suggestive of ovarian malignancy?
``` bilateral multiocular ascites solid areas metastasis ```
60
What score on the risk malignancy index warrants a referral to gynae?
250 or above
61
Where are some sites that endometriosis can occur and what symptoms can this cause?
Pouch of Douglas - rectal bleeding during period lungs or pharynx - coughing up blood during period nose - epistaxis during period umbilicus points of previous scarring - appendix scar endometrioma - bleeding into ovaries dueing period
62
What are the 3 theories of how endometriosis develops?
Sampson's - retrograde menstruation Meyer's - metaplasia of mesothelial cells Halban's - via the blood or lymphatic systems
63
What are the symptoms of endometriosis?
PAIN + SUBFERTILITY dysmenorrhoea menorrhagia
64
What are the features of the pain in endometriosis?
``` cyclical pain worse 2-3 days before periods gets better after period deep dyspareunia dysuria pain on defecation ``` IMPOVES during pregnancy
65
What is the gold standard diagnosis for endometriosis?
Laparoscopy
66
What is the main differential for endometriosis and how does it differ?
Adenomyosis endometriosis - younger women who have not had children adenomyosis - older women who have had lots of children + cyclical pain that can last for 2 weeks after period stops (longer than endo)
67
What is the gold standard diagnosis for adenomyosis?
MRI scan
68
How are fibroids investigated?
``` abdominal examination bimanual pelvic examination transvaginal ultrasound transabdominal ultrasound hysteroscopy ```
69
What would be felt on a pelvic exam in someone with fibroids?
bulky non-tender uterus
70
How are fibroids managed?
<3cm - IUS, tranexamic acid, NSAID (mefenamic acid) or COCP >3cm - trans-cervical resection of fibroids (TCRF), myomectomy, hysterectomy, uterine artery embolisation
71
What are the main types of benign ovarian tumours?
1. functional cysts - enlarged persistent follicle or corpus luteum. Normal <5cm, resolve after 2/3 cycles. Can cause pain and peritonitis if they bleed. COCP inhibits. 2. mucinous cystadenomas - massive, unilateral, appear solid. common in 30-40 yr olds. can be malignant - cause mucus ascites (pseudomyoxma peritonei) if rupture. 3. serous cystadenomas - most common epithelial tumours, commonly bilateral, 30-50 yr olds, some can be malignant 4. dermoid cyst - mature cystic teratoma - contain skin/hair/teeth - most common cyst in under 30s. Some bilateral. torsion is most likely in dermoid cyst.
72
How does ovarian torsion present?
``` acute unilateral abdo pain often during exercise radiates to the back, thighs and pelvis nausea and vomiting fever indicates necrotic ovary ```
73
How do you investigate ovarian torsion?
rule out ectopic - pregnancy test | USS with colour Doppler --> gold standard investigation
74
What are some signs you would see on examination in someone with PID?
``` cervical excitation (motion tenderness) on vaginal examination vaginal discharge adnexal tenderness ```
75
What are some complications of PID?
``` tubo-ovarian abscess Fitz-Hugh-Curtis syndrome --> liver capsule inflammation recurrent PID ectopic pregnancy subfertility from tubal blockage ```
76
What are the different subtypes of incontinence?
overactive bladder (detrusor overactivity) stress incontinence caused by sphincter weakness fistula between urinary tract and vagina/bowel neurological overflow incontinence due to retention/prostate enlargement functional mixed
77
What is the clinical presentation of an overactive bladder?
``` urgency urge incontinence frequency nocturia noctural enuresis key in the door and hand wash can act as triggers intercourse ```
78
How does stress incontinence present?
``` involuntary leakage when: cough laugh lifting exercise movement ```
79
What is the first-line investigation for incontinence?
History + bladder diary AKA frequency volume chart
80
What other investigations can you do for incontinence?
MSU - infections, nephritis, cancer, stones, diabetes, renal disease residual urine measurement ePAQ questionnaire - urinary, vaginal, bowel and sexual symptoms urodynamics - pressure differences cystogram with contrast to view the bladder
81
What is the first line tx for overactive bladder?
bladder training + use of pads
82
What is the first-line tx for stress incontinence?
pelvic floor exercises
83
What medications can be used in overactive bladder?
Anticholinergics - oxybutynin, solifenacin Because parasympathetic is for pissing so decreases the need to urinate Mirabegron - Beta-3-adrenergic recptor agonist (sympathetic for storage) - relaxes detrusor and increases bladder capacity Botox injection - paralyses detrusor to stop it from being overactive
84
What are the side effects of anti-cholinergics such as oxybutynin?
``` dry mouth blurred vision drowsiness constipation tachycardia ```
85
What are some surgical options for managing overactive bladder?
augmentation cystoplasty indwelling catheters bypass (urostomy)
86
What are some ovarian causes of subfertility?
``` PCOS pituitary tumours Sheehan's syndrome hyperprolactinaemia premature ovarian failure Turner's syndrome hypothyroidism previous chemo or radiotherapy ```
87
What are some tubal/uterine causes of subfertility in women?
``` PID sterilisation Asherman's syndrome (adhesions) fibroids polyps endometriosis uterine malformation ```
88
What are some causes of male infertility?
``` use of anabolic steroids high prolactin cystic fibrosis - even carriers can have absence of vas deferens hx of undescended testes childhood measles working with a lot of heat - chefs ```

NV - Phase 3A (7 decks)

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