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Phase 3a Medicine > Gynae > Flashcards

Gynae Flashcards

1
Q

What are the 2 main types of incontinence, their causes, diagnosis, and the steps in their management?

A

Stress: urethral sphincter weakness.
Urodynamic studies (cystometry) to confirm stress incontinence.
- 1st: Pelvic floor exercises 3/12.
- 2nd: surgery (vaginal tape.)
- 3rd: decline or can’t have surgery = Duloxetine.

Urge: overactive bladder (detrusor muscle.)

  • 1st: bladder drill.
  • 2nd: drugs = oxybutinin.
  • 3rd: surgery.
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2
Q

Define early menopause.

Define premature ovarian insufficiency.

Ix and findings for menopause?

Risks of HRT?

What should contraception use around the menopause be?

A
  • 40-45.
  • <40.
  • Day 2 and 5 FSH high (>40).
  • Breast cancer, VTE, IHD and stroke (if over 60!!) T2DM.
  • Use contraception for 2 years if menopause <50, or 1 if menopause >50.
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3
Q

Which cancers do oestrogen and progesterone increase the risk of?

A

Oestrogen: endometrial and ovarian.

Progesterone: breast and cervical.

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4
Q

Explain the pathology in hypothalamic causes of amenorrhoea and list the causes.

A

Reduction in GnRH release due to anorexia, dieting, athletes, stress.
Kallmann’s syndrome: GnRH secreting neurones fail (+anosmia.)

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5
Q

Explain the pathology in pituitary causes of amenorrhoea and list the causes.

A
  • Hyperprolactinaemia inhibits GnRH release: anti-psychotic meds, pituitary adenoma.
  • Sheehan’s syndrome: massive PPH = necrosis of ant. pituitary = no LH and FH is released from it.
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6
Q

Explain the pathology in thyroid causes of amenorrhoea and list the causes.

A

Hyper or hypothyroidism.

Low T3 and T4 leads to negative feedback and increased TRH (hypothalamus) and so TSH (anterior pituitary).

The increased TRH = more prolactin = supress GnRH.

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7
Q

Explain the pathology in adrenal causes of amenorrhoea and list the causes.

A
  • CAH.

- Tumours = increased androgen production.

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8
Q

Explain the pathology in ovarian causes of amenorrhoea and list the causes.

A

PCOS (not true.)

Premature ovarian syndrome.

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9
Q

Explain the pathology in genetic causes of amenorrhoea and list the causes.

A

Turner’s (45XO) = underdeveloped gonads (dysgenesis) = normal GnRH, FSH, LH, but no oestrogen from ovaries.

Idiopathic gonadal dysgenesis.

Androgen insensitivity syndrome: XY resistant to androgens so develops female characteristics.

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10
Q

Explain the pathology in structural causes of amenorrhoea and list the causes.

A

Imperforate hymen.
Transverse vaginal septum.

Asherman’s = 2ndary

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11
Q

List the commonest causes of menorrhagia

A

Fibroids.
Polyps.
Adenomyosis.

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12
Q

List the Tx options for primary menorrhagia.

A
  1. Mirena IUS.
  2. Tranexamic acid.
  3. Mefenamic acid (NSAID.)
  4. COCP.
  5. Progestogens.
  6. Endometrial ablation/ hysterectomy.
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13
Q

Mx of primary dysmenorrhoea

A
  1. Lifestyle.
  2. Analgesia (NSAIDS +/- paracatemol.)
  3. IUS/COCP 3-6 month trial.
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14
Q

Sx and Tx or fibroids

A

Menorrhagia.
Pressure Sx.
Subfertility.
Red degeneration in pregnancy.

Tx:
1. Mirena IUS.
2. Tranexamic acid. Mefenamic acid (NSAID.)
3. GnRH and transcervical resection of fibroids (TCRF).
or myomectomy
or hysterectomy.

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15
Q

Define polyps, when are they common, Sx, Ix and Tx.

A

Benign tumours that grow into uterine cavity.

Common in post-menopausal women.

Menorrhagia, IMB.

USS/hysteroscopy for Ix of bleeding

Recetion by cutting diathermy or avulsion due to carcinoma risk.

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16
Q

When investigating menorrhagia, when should you a) not offer Ix and just treat, b) offer hysteroscopy and c) offer TVUS?

A

a) if no other Sx.
b) if other Sx but suspect they are small.
c) palpable uterus, pelvic mass, difficult e.g. obese.

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17
Q

Diagnosis of adenomyosis?

A

TVUS.

MRI.

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18
Q

List the causes of recurrent miscarriage

A

Antiphospholipid antibodies (thrombosis in uteroplacental circulation.)

Chromosomal abnormalities.

Anatomical issues such as uterine abnormalities or cervical incompetence.

Infection.

19
Q

What happens in antiphospholipid Ab?, and what is the Tx?

A

thrombosis in the uteroplacental circulation. Tx is Aspirin and LMWH.

20
Q

What are the types of management for miscarriage and when would they be used?

A
  1. Refer to early pregnancy assessment unit.
  2. Give anti-D if >12 weeks or severe and painful bleeding.
  • Expectant: as long as mother happy and no signs of infection. Has 24/7 access to gynae services.
  • Medical: Vaginal Misoprostol.
  • Surgical: ERPC under anaesthetic. If preferred by Px, heavy bleeding, signs of infection (add Abx if so.)

Repeat scans 2/3 weeks later.

21
Q

What blood test should be done in suspected miscarriage and what would the results be?

A

Serum b-hCG: increase bu >66% in 48hrs if viable intrauterine pregnancy.

22
Q

What are the investigations for a suspected ectopic?

A
  1. Pregnancy test in any woman of childbearing age.
  2. TVUS: intrauterine pregnancy? If none = pregnancy of unknown location.
  3. Repeat serum hCG 48 hours apart. If <1500 IU/mL:
    - Increase of 66% in 48hrs = early viable.
    - Decrease >50% in 48 hrs = complete miscarriage.
    - Between this = ectopic.
23
Q

What would high hCG levels, but an empty uterine sac be suggestive of?

A
  • <5 weeks viable intrauterine pregnancy.
  • Complete miscarriage.
  • Ectopic pregnancy.
24
Q

What is the management for a suspected ectopic and the criteria for each?

A

Expectant:

  • hCG <1000 and falling.
  • Small and unruptured.
  • No heartbeat.

Medical:

  • Unruptured and no pain.
  • No heartbeat.
  • hCG <1500.
  • IM Methotrexate.

Surgical:

  • Ruptured.
  • Large.
  • Lot of pain.
  • Visible heartbeat.
  • hCG >1500.
  • Perform laparoscopic salpingectomy.
  • Or salpingostomy to remove just the ectopic if other tube is damaged, to preserve fertility.
25
Q

What is the triad of endometriosis Sx, the diagnostic Ix, and Tx pathway?

A
  • Infertility, dysmenorrhoea, dyspareunia.
  • Laparoscopy.

Medical:

  • Analgesia.
  • COCP, or Mirena IUS.
  • Progestogens.
  • GnRH analogue to induce temporary menopause.

Surgical:

  • Laparoscopic diathermy.
  • Hysterectomy with BSO.
26
Q

What is the Tx pathway for PID?

A

IM Ceftriaxone.
Doxycycline and Metronidazole.

After 24 hours if no improvement = laparoscopy.

27
Q

Commonest type of endometrial cancer?

Risk factors?

Clinical features?

Ix?

A

Adenocarcinoma.

Unopposed oestrogen (i.e. anovulation.)

PMB, rarely IMB in younger.

TVUS, thickness >5mm (or >4mm if postmenopausal) = biopsy.

28
Q

Describe the staging for endometrial cancer

A

1: confined to uterus
a = less than half myometrial invasion.
b - more than half myometrial invasion.

2: extend to cervix.

3: beyond uterus but confined to pelvis.
a - ovaries.
b - vaginal.
c - lymph nodes.

4a - bladder/bowel b - distant mets.

29
Q

Describe the Tx for endometrial cancer

A

Total hysterectomy with bilateral salpingo-oophorectomy.

Adjunct chemo then radio.

30
Q

Commonest type of ovarian cancer?

Risk factors?

Clinical features?

A

Epithelial subtype.

More ovulations = increased risk.

Non-specific, bloating, change in bowel/urinary habits (IBS), dyspareunia.

31
Q

What are the investigations for ovarian cancer?

A
  • Under 40 = rule out germ cell tumour with lactate, alphafetoprotein, hCG.

RMI (risk of malignancy index)
USS * Menopause * CA125

USS: cysts, solid areas, metastases, ascites, bilateral lesions. 1 point if 1, 3 points if 2+.

Menopause: 1 for pre, 3 for post.

CA125 (cancer antigen.)

RMI >250 = refer.

32
Q

Describe the staging of ovarian cancer.

A

1: confined to ovaries.
a - one effected.
b - 2 effected.
c - 1 or 2, but capsule not intact.

2: beyond ovaries, confined to pelvis.
3: beyond pelvis, confined to abdomen.
4: distant mets.

33
Q

Treatment of ovarian cancer?

A
  • Midline laparotomy for staging.
  • Total hysterectomy with BSO and omentectomy.
  • 2+ = remove retroperitoneal LN.
  • 1c+ = chemo.
34
Q

Define CIN.

What are the types and peak age?

What causes it?

A

Cervical intraepithelial neoplasia.
Presence of dyskaryotic cells within squamous epithelium of the ectocervix.

Types 1, 2 and 3, peak age for 3 in <45.

Caused by HPV (16 and 18 commonly associated with cervical cancer.)

35
Q

What age and frequency for cervical screening?

If first is inadequate?

If 2 are inadequate?

If HPV -ve?

If HPV +ve? Possible outcomes?

Treatment?

A

25-49 = every 3 years.
50 - 64 = every 5 years.
65+ if no smear since 50.

Repeat in 3 months.

Refer to colposcopy.

Return to routine screening.

Do cytology.
Changes seen = refer to colp.

Normal = repeat after 1 year.
-ve HPV = return to normal.
+ve = repeat in 1 year.

-ve = return to nromal.
\+ve = refer.

LLETZ (large loop excision of transformation zone.)

36
Q

What is the majority of cervical cancer?

Cause and risk Fx?

Clinical features?

Investigation?

A

Squamous cell carcinoma.

Persistent HPV infection:

  • early intercourse.
  • multiple sexual partners.
  • STDs.
  • smoking.

Abnormal vaginal bleeding.

STI tests. Colposcopy referral + biopsy.

37
Q

Staging for cervical cancer?

A

0 - in-situ carcinoma.

1 - confined to cervix.

a: microscopic.
b: macroscopic.

2 - beyond cervix but no pelvic wall or lower 1/3 of vagina.

a: upper 2/3 vagina.
b: parametrial involvement.

3 - pelvic side wall, lower 1/3 of vagina, hydronephrosis.

a: lower 1/3 of vagina.
b: pelvic side wall and/or hydronephrosis.
c: pelvic LN or para-aortic LN.

4a - bladder/rectum
b - distant mets.

38
Q

Cervical cancer Tx?

A

1a - cone biopsy.

1b - Laparoscopic radical hysterectomy. (trachelectomy to preserve fertility.)

2 onwards = with chemoradiation.

39
Q

List and explain the types of prolapse.

A

Urethrocele.

Cystocele - bladder bulges into front (anterior) wall of vagina.

Uterine - uterus, cervix, vagina prolapse.

Enterocele - upper posterior vaginal wall, creates a pouch containing loops of small bowel.

Rectocele - lower posterior vaginal wall, rectum pushes through.

40
Q

Management of prolpase?

A

Pessary, esp if unfit for surgery, changed every 6-9 months.

Surgery

41
Q

Describe the aetiology of PCOS.

A

Excess LH = more androgens.

Insulin resistance = supresses sex hormone binding globulin = higher levels of free androgens.

Both leads to supressed LH surge and anovulation, so follicles remain in ovary as cysts. Also leads to the Sx seen.

42
Q

What are the criteria for PCOS? Name and list them.

A

Rotterdam Criteria: 2/3 = diagnosis.

  • Oligo or amenorrhoea.
  • Clinical and/or biochemical signs of hyperandrogenism.
  • PCO on US (12+)
43
Q

What are the important Ix in PCOS?

A

LH:FSH ratio = raised.

44
Q

Management of PCOS?

A
  • Reduce weight.
  • COCP.
  • Want to conceive:
    Clomifene and metformin.
    Laparoscopic ovarian drilling (diathermy.)

Phase 3a Medicine (4 decks)

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