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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
Q

Define miscarriage.

A

loss of a pregnnacy before 24 weeks’ gestation.

After = stillbirth

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26
Q

What are the risk factors for miscarriage?

A 
increased maternal age 
smoking in pregnancy 
alcohol 
drugs
high caffeine intake
obesity 
infections and food poisoning 
severe hypertension
cervical incompetency
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27
Q

What are the most common causes for one-off miscarriages?

A 
unknown
chromosomal abnormalities
abnormal foetald evelopment 
maternal illness
infection
trauma
cervical weakness
SLE in mum
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28
Q

What is the definition of recurrent miscarriage?

A

loss of >3 consecutive pregnancies before 24 weeks’ with the same biological father

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29
Q

What are some causes of recurrent miscarriage?

A

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

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30
Q

What are the features of a threatened miscarriage?

A

mild symptoms - mild abdo pain, mild vaginal bleeding

cervical os is CLOSED

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31
Q

What are the features of an inevitable miscarriage?

A

severe abdo pain
vaginal bleeding
cervical os is OPEN

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32
Q

What are the 3 main causes of PV bleeding in early pregnancy?

A

ectopic pregnancy
miscarriage
molar pregnancy

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33
Q

What are the risk factors for ectopic pregnancy?

A 
damage to tubes - PID, surgery
previous ectopic
endometriosis
copper coil
IVF
smoking
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34
Q

What are the features of ectopic pregnancy?

A

LMP 8 weeks ago
vaginal bleeding
pain - generalised abdo or iliac fossa
shoulder tip pain from haematoperitoneum

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35
Q

How would you investigate someone with suspected ectopic pregnancy?

A

USS - intrauterine? foetal heartbeat?
serial hCG measurements
pelvic exam - cervical excitatio on speculum exam

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36
Q

How is an ectopic pregnancy surgically managed?

A

salpingectomy if other fallopian tube is viable

salpingotomy if other tube is not viable

37
Q

What are the clinical features of a molar pregnancy?

A 
vaginal bleeding
pain
uterus larger that should be for expected dates
very very high levels of BhCG
clinical hyperthyroidism 
hyperemesis gravidarum
38
Q

How is a molar pregnancy managed?

A

remove by suction

39
Q

When are women offered cervical screening?

A

sexually active women aged 25-64
every 3 years from 25-50
every 5 years from 50-64

40
Q

How is CIN managed?

A

large loop excision of the transformational zone

41
Q

What is the cell type usually seen in cervical cancer?

A

squamous cell carcinoma

42
Q

What staging tool is used to stage cervical cancer and endometrial cancer?

A

FIGO staging (international federation of gynaecology and obstetrics)

43
Q

What is stage 1 cervical cancer?

A

Confined to the cervix

44
Q

What is stage 2 cervical cancer?

A

spread into top part of vagina

45
Q

What is stage 3 cervical cancer?

A

spread into other nearby organs such as the ureter

46
Q

What is stage 4 cervical cancer?

A

distant metastases

47
Q

What are some risk factors for cervical cancer?

A 
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
Q

Which types of HPV are oncogenic?

A

16 and 18

49
Q

Which types of HPV cause genital warts?

A

6 and 11

50
Q

Which oncoprotein do types 16 and 18 HPV contain and why does this cause cancer?

A

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
Q

What are the symptoms of cervical cancer?

A

POST COITAL BLEEDING
post-menopausal bleeding
watery vaginal discharge

52
Q

Which histological cell type is usually seen in endometrial cancer?

A

adenocarcinoma

53
Q

Who is more at risk of endometrial cancer?

A

post-menopausal women

54
Q

What histological cell trype would be seen in vulval cancer and what causes it?

A

squamous cell

younger women - HPV
older women - lichen sclerosis

55
Q

What cell type is seen mainly in ovarian cancer?

A

epithelial cell tumours

56
Q

What are the causes of ovarian cancer?

A

gene mutation - BRCA 1 and 2, HNPCC (Lynch syndrome)

more ovulation - early menarche, late menopause, never been pregnant, never taken the pill

57
Q

How does ovarian cancer present?

A

bloating/IBS-like symptoms
abdominal pain/discomfort
change in bowel habit
urinary frequency

58
Q

How do you investigate ovarian cancer?

A

Ca125 levels
transabdominal ultrasound scan
menopausal status

calculate risk malignancy index

59
Q

What are the ultrasound findings suggestive of ovarian malignancy?

A 
bilateral
multiocular
ascites
solid areas
metastasis
60
Q

What score on the risk malignancy index warrants a referral to gynae?

A

250 or above

61
Q

Where are some sites that endometriosis can occur and what symptoms can this cause?

A

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
Q

What are the 3 theories of how endometriosis develops?

A

Sampson’s - retrograde menstruation

Meyer’s - metaplasia of mesothelial cells

Halban’s - via the blood or lymphatic systems

63
Q

What are the symptoms of endometriosis?

A

PAIN + SUBFERTILITY
dysmenorrhoea
menorrhagia

64
Q

What are the features of the pain in endometriosis?

A 
cyclical pain 
worse 2-3 days before periods
gets better after period
deep dyspareunia
dysuria
pain on defecation

IMPOVES during pregnancy

65
Q

What is the gold standard diagnosis for endometriosis?

A

Laparoscopy

66
Q

What is the main differential for endometriosis and how does it differ?

A

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
Q

What is the gold standard diagnosis for adenomyosis?

A

MRI scan

68
Q

How are fibroids investigated?

A 
abdominal examination
bimanual pelvic examination
transvaginal ultrasound
transabdominal ultrasound
hysteroscopy
69
Q

What would be felt on a pelvic exam in someone with fibroids?

A

bulky non-tender uterus

70
Q

How are fibroids managed?

A

<3cm - IUS, tranexamic acid, NSAID (mefenamic acid) or COCP

> 3cm - trans-cervical resection of fibroids (TCRF), myomectomy, hysterectomy, uterine artery embolisation

71
Q

What are the main types of benign ovarian tumours?

A
  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
Q

How does ovarian torsion present?

A 
acute unilateral abdo pain
often during exercise
radiates to the back, thighs and pelvis
nausea and vomiting
fever indicates necrotic ovary
73
Q

How do you investigate ovarian torsion?

A

rule out ectopic - pregnancy test

USS with colour Doppler –> gold standard investigation

74
Q

What are some signs you would see on examination in someone with PID?

A 
cervical excitation (motion tenderness) on vaginal examination
vaginal discharge 
adnexal tenderness
75
Q

What are some complications of PID?

A 
tubo-ovarian abscess
Fitz-Hugh-Curtis syndrome --> liver capsule inflammation 
recurrent PID
ectopic pregnancy 
subfertility from tubal blockage
76
Q

What are the different subtypes of incontinence?

A

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
Q

What is the clinical presentation of an overactive bladder?

A 
urgency 
urge incontinence
frequency
nocturia 
noctural enuresis 
key in the door and hand wash can act as triggers 
intercourse
78
Q

How does stress incontinence present?

A 
involuntary leakage when:
cough
laugh
lifting
exercise
movement
79
Q

What is the first-line investigation for incontinence?

A

History + bladder diary AKA frequency volume chart

80
Q

What other investigations can you do for incontinence?

A

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
Q

What is the first line tx for overactive bladder?

A

bladder training + use of pads

82
Q

What is the first-line tx for stress incontinence?

A

pelvic floor exercises

83
Q

What medications can be used in overactive bladder?

A

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
Q

What are the side effects of anti-cholinergics such as oxybutynin?

A 
dry mouth
blurred vision
drowsiness
constipation
tachycardia
85
Q

What are some surgical options for managing overactive bladder?

A

augmentation cystoplasty
indwelling catheters
bypass (urostomy)

86
Q

What are some ovarian causes of subfertility?

A 
PCOS
pituitary tumours
Sheehan's syndrome
hyperprolactinaemia 
premature ovarian failure
Turner's syndrome
hypothyroidism 
previous chemo or radiotherapy
87
Q

What are some tubal/uterine causes of subfertility in women?

A 
PID
sterilisation
Asherman's syndrome (adhesions)
fibroids 
polyps
endometriosis
uterine malformation
88
Q

What are some causes of male infertility?

A 
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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