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*year 4 additions > Gynae > Flashcards

Gynae Flashcards

1
Q

Definition amennorrhoea

A

no periods for 6 months in women of reproductive age

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2
Q

categories of:
dysmenorrhoea? (2)
dyspareunia? (2)
incontinence? (2)

A
  • primary or secondary
  • superficial or deep
  • urge or stress
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3
Q

Who must be present for all examinations? (1)
what must you check before starting? (3)
where do you start the exam? (1)
what else do you feel? (2)

A

FEMALE chaperone

check patient warm enough and comfortable
in any pain
empty bladder
“let me know if you’re uncomfortable”

  • start with hands–> anaemia
    -BP
  • lymph nodes: feel for Virchow’s node (abdo malignancy)
  • breast exam
    (important as breast often metastasizes to ovaries (Krukenburg tumours)
  • abdo exam (inspect, palpate, percuss, auscultate)

pleural effusion may also be elicited as a consequence of abdominal ascites
BP and BMI (relevant to surgical and medical management)

THEN
- pelvic exam- verbal consent and female chaperone
- insepct genitalia/skin surrounding, FGM
- cough/bear down (incontinence and prolapse)
- speculum: Sims for proplase, Cusco’s for normal visualization of cervix (depends on presenting problem)
- bimanual exam: palpate uterus then adenexal either side
don’t use lubricant if doing a smear as messes with the analysis
- rectal exam to differentiate rectocele or enterocele or palpapte uterosacral ligaments more thoroughly

non-sterile gloves if patient pregnant, sterile if pregnant

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4
Q

When might ultrasound visualization be a problem?

A

obese patient

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5
Q

mid-luteal phase progesterone tests… day 21 and 28 in cycle or 7 days before mensturation in longer cycle shows.

A

confirmation of ovulation

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6
Q

All women trying to concieve should…

A

take folic acid

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7
Q

hydrosalpinx

A

blocked fallopian tube

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8
Q

what is Asherman’s syndrome?

A

endometrial scaring
from surgery or infection

can result in lighter periods of reduce chance of conception

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9
Q

endometrial polyps:

which decrease fertility the most?

A 
submucosal polyps
(intramural if >5cm)
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10
Q

Which hormone is released in a pulsatile fashion?

A

GnRH from the hypothalamus (triggers anterior pituitary)

–> increase in LH and FSH

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11
Q

How does eostrogen interact with LH? (1)
how does this work with the menstural cycle LH surge? (1)
how does COCP work to use this system? (1)
how does progesterone differ? (1)

A

low oestrogen –> decrease LH production (negative feedback)
(directly acting on pituitary)

high oestrogen –> LH increase
(via increasing GnRH)
but for POSITIVE oestrogen feedback it has to reach a certain threshold to cause the LH surge

as oestrogen increases in hthe FOLLICULAR phase, it stimulates the periovulatory LH surge from the pituitary

COCP artificially creases a constant serum oestrogen level in the negative-feedback range, so low GnRH release

progesterone has positve-feedback on pituitary LH and FSH secretion (seen immediately prior to ovulation) –> high levels of progesterone (e.g. the LUTEAL phase) inhibit LH and FSH production
- causes decreased GnRH AND
- decreased sensitivity to the GnRH in the pituitary
(which causes deceased LH and FSH)

ESSENTIALLY THEY DO OPPOSITE THINGS

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12
Q

When in the menstrual cycle is FSH high? (1)

what does surge in FSH cause? (1)

A

The FOLLICULAR stage (and first few days)
when everything else is low
to stimulate the follicles to grow

as the follicles grow they increase oestrogen synthesis

as oestrogenincreases, negative feedback causes FSH to drop so that no other folicules are stimulated
(MAKES SENSE!)

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13
Q

which cells are present in the ovaries that make steroids/LH/FSH? (2)
How does progesterone interact with the endometrium? (1)
what effect does this also have on hormone feedback? (1)
how long does the luteal phase last? (1)

A 
LH= theca
FSH= granulosa

stabilizes the endometrium(highestin Luteal phase then when drps the endometrium sheds)

-high progesterone –> LH and FSH suppressed to stop extra follicular development

-14 days THE FIXED PART!
(in absence of BhCG the corpus leuteum goes through luteolysis and disappear

at the end of the cycle oestrogen and progesterons decrease and hence FSH is surged to restart the whole thing again

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14
Q

The three endometrial phases? (3)

A

MENSTURATION
shedding

PROLIFERATIVE
endometrium grows from single later of columnar to pseudostratified epithelium with frequent mitoses
increase frm 0.5mm to 3.5mm-5

SECRETORY
endometriual glandular secretory activity -

endometrium doesn’t thicken any further but glands become more tortuous, spiral arteries will grow, and fluid is secreted into glandular cells and into the uterine lumen

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15
Q 
Puberty:
what happens to the HPO axis? (1)
what age does GnRH start being pulsated out? (1)
what are is precocious pubery? (1)
what influences puberty onset? (4)
the technical name for breast development and axillary hair growth? (2)
how are these staged? (1)
first signs of puberty? (1)
A
  • suppressed
  • at 8-9years old, pulsations inrease in amplitude and frequency
  • initially sleep related but progress and extend throughout the day
  • <8 in a girl, <9 in a boy = prevovious puberty
    (can be central or peripheral and 25% caused by CNS malformation or brain tumour)
  • stimualted FSH n dLH then in term triggers follicular growth
factors influencing puberty are unknown  but influenced by:
- race
- hereditary
- body weight
- exercise
Leptin plays a massive role
  • thelarche (breast)
  • adrenarche
  • the Tanner’s staging

breast budding usually 2-3 years before menarche, it is usually the first signs

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16
Q

Delayed puberty:
name for central defect? (1)
name for failure of gonad function? (1)
what are disorders of sexual development? (1)

A
  • hypogonadotrophic hypogonadism
    anorexia/ exercise/ Kalmans dynrome (pituitary tumour), diabetes/ renal failure
  • hypergonadotrophic hypogonadism
    high gonadotrophins but doesnt function –> Turner syndrome, XX gondaal dysgenesis, premature ovarian failure (can be post chemo/radio/autoimmune/idiopathic)

when normal development doesn’t happen - may have abnormal genitalia or primary amenorrhea or increasing virilization

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17
Q

Disorders of sexual developent:

genetic casues?

A
  • Turner syndrome (45X); variable presentation so for 10% presentation made at puberty
    most common genetic problem in women, require ovum donation
    short stature, webbing of neck, wide carriy angle, coarctation of the aorta, IBD< sensorineural and conduction deafness, renal abnormalities, endocrine dysfunction, autoimmune thyroid disease
  • 46XY gonadal dysgenesis
  • 5 alpha reductase deficiency
  • 46XX
  • 46XY DSD

investigate by doing KARYOTYPING

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18
Q

Primary ammenorrhoea:
what age?
definition?

A

no periods at 16

6 months no periods in woman of fertile age who isn’t pregnant, lactatin or in mennopause

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19
Q

Kallman’s syndrome

A

X-linked recessive condition resulting in GnRH causing underdeveloped genitelia

hypogonadotrophic hypogonadism

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20
Q

Ancathosis nigricans - what does it indicate? (1)

What is it seen in?

A

insulin resistance

  • type 2 diabetes
  • PCOS!
  • stomach cancer
    conditions that affect hormone levels – such as Cushing’s syndrome, polycystic ovary syndrome or an underactive thyroid
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21
Q 
Diagnosis of PCOS? (3)
management:
to regular mensuration? 
induce withdrawal?
clomiphene?
lifestyle?
A

2/3 of:

  • oligo/amenorrhea
  • clinical or biochemical hyperandrogenism
  • polycystic ovaries on US: 8+ subcapsular follicular cysts <10mm and increased ovarian stroma
  • COCP
  • progesterone cyclical
  • clomiphene: induce ovulation if subfertility
  • BMI, weight reduction
  • ovarian drilling sometimes used

can get different creasm

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22
Q

PMS:

If COCP and stress management/lifestyle advice fail, what theraplies can help?

A
  • GnRH analogues (but add back HRT to prevent osteoperosis)
  • St Johns wart (drug interactions but actualy supposed to help!?)
  • other complementary oils but limited evidence
  • vitamins B6, magnesium, calcium, Vit D

hysterectomy andbilateral salpingo-oophorectomy + HRT
last ditch attempt

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23
Q

Haavy menstrual bleeding causes?
what is important to establish? (1)
extra questions to ask in history? (2)
what to check for in exam?

A

PALM COIEN

TIMING
if it started at menarche it is much less likely to be associated with pathology!

  • symptoms of anaemia
  • bruise easily or bleed (clotting problem)

timing of cycle also important as irregular timings associated with PCOS and perimenopause

  • are their families complete?

EXAM:

  • signs of anaemia
  • then abdo and pelvic exam
  • cervical smear
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24
Q

Endometrial ablation: consequences for future pregnancies? (2)

A
  • induce prematurity
  • morbidly adherent placenta

used for heavy menstrual bleeding after medical management/ reassurance has failed

used as an alternative to hysterectomy
(although some people prefer hysterectomy anyway)

hysterecctomy also used if pressure symptoms due to large fibroids or those who have smaller uterus and associated with uterine prolapse

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25
Q

Surigical managment of HMB options? (5)

A
  • endometrial ablation
    (destroy endometrium to dept to prevent regeneration) used over hysterectomy if small fibroids (3cm)
  • uterine artery embolization
  • hysterectomy
  • myomectomy (used if pressure symptoms but want kids)
  • transcervical resection of fibroid
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26
Q

Managemnt of acute HMB:
what drugs to give?
bloods to take?

A
  • tranexamic acid IV
  • IV access and transfusion if needed
  • high dose progesterones toarrest bleeding
  • consider GnRH or ulipristol acitate
  • FBC, coagulopathy screen, transfusion
  • find cause
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27
Q 
Dysmenorrhoea:
definition? (1)
secondary causes? (3)
what vital clue indicates endometriosis? (1)
another important thing to ask? (2)
A

PAINFUL

PRIMARY vs SECONDARY

  • endometriosis/ adenomyosis
  • PID
  • cervical stenosis and haematometra (rare)

pain preceeds the period in endometriosis

  • passage of CLOTS - medication to reduce flow may be effective
  • dyspareunia
  • how much impacting ADLs= will alter treatment!! youre not going to just reassure and let her go if shes not going into work/school!

only do investigative laporoscopy if all normal but symptoms persist and patient really wants to

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28
Q

woman aged 47 with HMB, what is the most important investiation?

A

endometrial biopsy for endometrial malignancy/hyperpasma if >45 and HMB

wouldn’t do thyroid function unless symptoms of abnormla thryoid

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29
Q

What does the corpus luteum secrete? (1)
why? (1)
what does the implanted blastocyst secrete? (1)
why? (1)
from what point can gestatonal sac be identified on TVUS? (1)

A
  • progesterone
  • stops endometrium shedding to prepare for baby
  • B-hCG
  • stops thecorpous luteum from going through luteolysis and thus maintains progesterone secretone
  • the CL supports the pregnancy for the first 8 weeks thenafter that the placenta is grown and takes over
  • 5 weeks
  • foetal heartbeat at 6 weeks
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30
Q

Groups of causes of misscarraiage? (5)
what blood tests to do? (2) and why? (2)
management options for misscarriage? (3)

A 
drugs
chromosonal
medical/endocrine
uterine abnormalities
infections
drugs/chemicals

FBC - to assess amount of vaginal loss
Group and Save - to see Rhesus status

  1. EXPECTANT –> Pt after3 weeks, may require unplanned surgery if start to bleed heavily
  2. MEDICAL –> prostglandin E analogue misoprostol, 10% faillure rate so may need surgical
  3. SURGICAL –> if haemodynamically unstable/ patient wants this, manual vacuum aspiration under local anaesthetic or under GA . Risks= perforation/ pelvic infection/ cervical trauma/ cervical incmpetence
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31
Q

Psychosocial management of misscarriage

A
  • explain they are not to blame
  • misscarriages occur in 10-20% of all pregnancies
  • most miscarriages are not recurrent (3+)
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32
Q

What is given in antiphopsolipid syndrome to reduce miscarriage rate by 50%?

A

aspirin and low-dose heparin can reduce miscarriage rate by 50%

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33
Q 
Ectopic pregnancy:
What is heterotopic pregnancy? (1)
risk factors for ectopic? (6)
why do ectopics cause shoulder tip pain? (1)
what happens with hCG in ectopics ? (1)
A

simultaneous development of 2 pregnancies: one invasive the uterine cavity and one outside
(in these cases TVUS doesn’t exclude them! as they see a viable pregnancy but dont see the ectopic, but it is ratre )

(larger incidence in IVF)

  • PID
  • previous ectopic
  • previous tubal surgery
  • alterations to fucntion of fallopian tube due to smoking or icnreased maternal age
  • previous abdo surgery (c-section, appendectomy), subfertility, IVF, use of intrauterine devices, endometriosis, conception on OCP)

If RUPTURE irritate the diaphragm –> shoulder pain

hCG raises slowly but not as much as viable pregnancies (nornmally doubles every 48 hours)

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34
Q

Ectopic managment options (3)

what must you advise women with medical managemetn using methotrexate? (1)

A
  1. EXPECTANT
  2. MEDICAL –> methotrexate (stops DNA syntehesis fur to folate antagonist), calculated on body surface area of patient, routinely measure serum hCG days 4, 7 and 11then weekly until undetctable
  3. SURGICAL –> laparoscopy - salpingectomy (only recomended if tube damaged asassociated with higher subsequent EP risk)

avoid sex up to 3 months after as it is teratogenic!

and alcohol and prolonged sunlight

35
Q

When is a Kleihauer test not needed? (1)

what miscarriages are anti-D not needed in? (1)

A

to determine fetomaternal haemorrahge in first trimester of pregnancy

  • threatened, incomplete or complete natural miscarriage
36
Q

What should be avoided in women with a molar pregnancy?

A

oestrogens

all patient who have moles should also have to be registered at a nationally recognised centre for treatment of gestational trophoblastic dsiease

37
Q

Examination:
how can the cervix look? (2)
reasons you wouldn’t be able to feel a uterus on bimanual? (3)

A

parous (via vaginal devliery) = —-
nuliparous = o

  1. posterior uterus
  2. fetus in it (i.e. its larger)3. 3. hysterectomy!
38
Q

cervical ectropion

A

Cervical ectropion (also known as cervical erosion and ectopy) is a common condition caused when cells from inside the cervical canal, known as glandular cells (soft cells), are present on the outside surface of the cervix (neck of the womb).

39
Q

When would you not do a smear on speculum exam?

A

if pregnant as –> stimualtes them!

40
Q

Bleeding in pregnancy, where do you send if:
<6 weeks? (1)
6-14 weeks? (1)
14+ weeks? (1)

A
  • home: no point doing a TVUS if <6 weeks as you might not see it anyway and the fetus wont have a heartbeat yet so normally wait untila after 6 weeks to see it the pregnancy is viable
    explain that if anything happens before 6 weeks there is nothing they can do- just means the pregnancy was never viable
  • 6-14= early pregnancy unit
  • > 14= maternity assessment
41
Q

Contraception:
definition of a LARC? (1)
benefits of LARCs over short acting? (2)
what contraindications to check before starting a contraceptive? (1)
what are the levels of this? (4)
which contraceptives are affected by enzyme inducers? (4)
most commonly used contracpetive worldwide? (1)
two main contraindications of this method? (2)

A

administration <1 per month (so injection counts)

in some countries injectable is considered medium-acting though

  1. COMPLIANCE- 50% stop using short acting within 1 year
    for LARCS 80% are still on them after a year
  2. ‘typical’ use same as ‘perfect’ use
  3. more effective anyway
UKMEC 
1=fine
2=adv>disadvantages
3=disadvantages>adv --> avoid if possible
4=no
  • if women gets a condition whilst on it, then stop the contraceptive as it may have contributed to them getting the condition
  • CHC (pills, patch, ring)
  • progesterone only implant
  • progesterone only pill
  • Levonelle moring after pill (as progesterone!)
    BUT NOT progesterone injectable or either IUD
  • IM or SC injectable depot most popular
  • weight gain
  • loss of bone mineral density in first few years of use
42
Q

Which contraceptive makes you put on weight? (1)
main side effect of COCP? (1)

COCP cancer risk-
increased? (2)
decreased? (3)

A

injectable - think of Immy

bleeding 15%
if >3 months then start investigations for polyps/fibroids/ cervical conditions/infection etc

COCP overall 12% reduction in cancer risk!
reduced risk
-colorectal, endometrial, ovarian
(possibly as you’re not stimulating the ovaries each month!?, progesterone may also stabilize the endometrium and stop the mitogenic effects of oestrogen on it)

increased risk
-breast and cervical
(cervical cytology can pick up early –> just tell them to go to smears and breast risk decreases to normal levels after stopping for 10 years–> tell them to check breasts)
could be because women dont use condoms

43
Q

CHC:

why contraindicated in migraine? (1)

A

if migrane with aura then increased chance of cerebral vasospasm and –> stroke

(homonomyous hemianopia, unilateral paraesthesia, weakness, aphasia)

44
Q

Progesterone-only pills:
how do they work? (1)
how often to take them? (1)
what to do if miss a pill? (1)

A

inhibit ovulation
but
lower-dose methods inhibit ovulation inconsistently –> also THICKING CERVICAL MUCUS so reduce sperm penetrability and transport

take CONITNOUSLY unlike CHC

continue taking POP and abstain/use condoms for 48 hours until progestogen effects on mucus have built up again

45
Q

fertility awareness-based methods (FABs):
who cant do these? (1)
types? (5) -don’t learn

A

if you don’t have regular periods (e.g. extremes of reproductive age)

calendar/rhythm method, temperature method, cervical mucus method, cervical palption, personal feriltiy monitor (LH and oestrogne in urine to see midfollicular phase)

46
Q

both emergency contraceptive pills work by…

A

delaying ovulation

if need another emergency contraceptive in this cycle then 2-3* less likely to work so START ON A LARC!

47
Q

Most common reason for abortion? (1)
investigations to do before abortion? (2)
when can you start contraceptives post abortion? (1)

A

UK Reason C = 95% of abortions
the pregnancy has not exceeded 24th week and continuing the pregnancy will invovle risk, greater than if the pregnancy were terminated, of injury to the physical or mental heatlh of the pregnant woman
(as 24th week is considered fetal viability)

  1. gestational assessment - US (consider STI testing)
  2. Rhesus status (consider FBC)

can start them all ASAP ! insert a LARC when you do the surgical exam if possible

48
Q

Abortion:
medical contains what drugs? (2)
how long will they bleed for? (2)
where are abortions done <9 weeks and >9 weeks? (2)
what has to be done if between 22 and 24 weeks? (2)
what are the two surgical abortion techniques used? (2)
are antibiotics given? (1)

A

2*pills, mifepristone (progesterone modulator) + misoprostol

  • if <9 weeks not long
  • if >9 weeks gestation on average 2 weeks bleeding
  • > 9 weeks in hospital as expulsion of larger fetus
  • misoprostol has to be repeated every 3 hours until the expulsion occurs
  • after 21 completed weeks (21 weeks 6 days) –> feticide
    use digoxicn or potassium chloride into the heart
    baby doesn’t feel pain until 24 weeks
  1. vacuum aspiration (<14 weeks)
  2. dilation and evacuation >14 weeks

Ax given for SURGICAL but not medical abortions

49
Q

If a sperm sample is abnormal, what do you do? (1)

what other tests do you do? (3)

A

repeat in 3 months

may below because of a viral infection so allow 3 months for spermatogenesis to occur

  • if low sperm count or azoospermia do FSH, LH and testosterone to identify if testicular failure due to low testosterone
  • Cystic fibrosis test
  • karyotyping
50
Q

most significant complication from IVF (1)
what can you do in azoospermia? (2)
who might you want to preserve sperm/eggs in? (1)
options for fertility treatment? (4)

A

ovarian hyperstimulation syndrome )OHSS) in 1-3% of cases

  • surgical sperm retrieval (under sedation/GA) use fine needle to insert into epididymis and testicular tissue and obtain sperm - then do ICSI
  • OR sperm donation
  • if chemotherapy/radiotherapy do it BEFORE (family preservation)
  • ovarian induction
  • surgery
  • IUI
  • IVF

there is now preimplantation genetic diagnosis for IVF where you can test embryos for the disease but obviously not allowed in UK

51
Q

what is the cervix made of?
junction between the two types of cells is where? what is it called?
when does an ectopion develop and what does it look like? (4)

A

collagen

squamocolumnar junction- joins simple columnar and non-keratinized stratified squamous epithelium

red area around the external cervical os is an ectropion in women of reproductive age

puberty, pill, pregnancy

52
Q

Endometral polyp:
risk factors? (4)
symptoms? (2)

A
  • obesity
  • late menopause
  • tamoxiden
  • HRT
  • subferility
  • bleeding: HMB, IMB, `PMB

don’t have the same cells as the endometrium–> not cyclical increase/decrease with period

  • small ones self resolve but some don’t–> polypectomy to remove AUB and optimize fertility and exclude cancer/hyperplasia
  • remove via hysteroscope and instruments through the operating channel

can also get cervical polyps which are smooth, reddish protrusions. asymptomatic.

53
Q

Cervical stenosis:
when did you see it? (1)
risk factors?

A

lady in colposcopy

  • treatment of premalignant disease of cervix using cone/loop
54
Q

Ashermans syndrome:
causes? (1)
main complication? (1)
treatment? (1)

A
  • procedures e.g. treratment of miscarriage or following secondary postpartum haemorrhage
  • endometritis
  • inferility
  • adhesiolysis to artificially break down the intrauterine adhesiosn
55
Q

Whatis the myometrium? (1)

two main conditions affecting the myometrium? (2)

A
  • middle layer of the uterine wall
  • fibroids/’leiomyoma’
  • adenomyosis
56
Q 
Fibroid:
other name for a fibroid? (1)
describe?
when do they get bigger/smaller? (1)
risk factors? (4)
symptoms? (5)
can you remove fibroids to treat infertility? (1)
complications in pregnancy?(2)
A

leiomyoma

fim, well-demarcated, whorled tumour that is oestrogen-dependent

  • -> enlarge in pregnancy due to hyperoestrogenic state
  • shrink at menopause as oestrogen decreases

nulliparous, obese women, FHx, African

can increase size of uterus

  • asymptomatic(mainly)
  • AUB
  • reproductive failure
  • subfertility
  • recurrent pregnancy loss
  • bulk effects on other structures in pelvis e.g bowel or bladder dysfunction
  • pressure/pain
  • abdo distension
    mainly asymptomatic but when they do cause symptoms its really annoying and often –> hysteroscopy
  • yes, can remove submucosal and is just as affective as IVF, but the effectiveness of the other types to be surgically removed is less clear and –>1% hysteroscopy because of intraoperatuve bleeding

can undergo degenerative change–> red/ hyaline/ cystic (rarely –> malignant but v rare <1%)

  • abnormal lie of baby
  • postpartum haemorrhage due to inefficient uterine contraction
  • FBC always if HMB
  • TVUSS
57
Q 
Fibroid:
medical treatment? (2)
surgical  treament (2)
what is done before surgery? (1)
why? (2)
A
  • tranexamic acid
  • mefanamic acid
  • OCP
  • Mirena
    ineffective if submucous fibroid or enlarged tuers
  1. inject GnRH agonists –> induce menopausal state as stops all oestrogen
    (and thus –>menopausal symptoms)

2.- selective progesterone receptor modulator (ULIPRISAL ACETATE) been shown to be as effective as GnRH agonists in reducing fibroid volume and alleviating HMB symptoms although not widely used yet
BUT neither GnRH or ulipristal are long term solutions! (and when stopped the fibroids grow back to same size as before)

  • hysterectomy
  • myomectomy(if want to preserve fertility)

give GnRH agonist pretreamt over 3 month period to reduce bulk and vascularity
- mean suprapubic rather than midline abdominal incision
(less complications and quicker recover)
can obscure tissue planes though but this is minor compared to the positives

  • uterine artery embolization also performed by international radiology –> embolise both uterine arteries
    reduces volume to 50%
    painful - admission overnight,
    complications: fever, infection, fibroid expulsion, potential ovarian failure
58
Q

investigation of choice for adenomyosis?

treatment of choice? (1)

A

MRI

poor treatment availability
give progesterone containing LARCs to try to enduce amenorrhea
but Sx return after stopping

59
Q 
Malignancy:
how common are cervical and vagina/vuval cancers in the UK (1)
what social factor linked to cervical cancer? (1)
ectocervix and cervix cell type? (2)
where does cancer normally form? (1)
low grade CIN? (1)
high grade CIN? (2)
what to do in low grade CIN? (1)
A

cervical rare due to screening
vaginal rare anyway (only 1% of vaginal cancers)

- smoking
immune response has the clear the HPV --> in smoking that response dampened
- HIV
- transplant recipient
- long term immunosuppressive therapy

persistent HPV is what causes the chance

endocervic= columnar, ecto=squamocolumnar

nabothian follicle= normal, develops on the transformation zone of the cervix

cancers grow in transformational zone as this is where metaplasia occurs
first –>CIN

low grade= CIN1
high grade= CIN2 and 3

sometimes spontaneously regressed due to cell-mediated immunity
high grade less likely to progress–> treat (about 20% go on to develop cancer)

60
Q

how to explain smear to the patient? (1)

what happens if you get an abnormal smear? (1)

A
  • does NOT pick up cancers
  • picks up abnormal growth of cells
  • we are looking for CIN
    draw on paper CIN 1,2,3
    1 is low grade, 2 and 3 are high grade and require treatment

often regress by themselves, can take years to grow into cancer

go to CYTOLOGY to have a proper look at the cervix

61
Q

Colposcopy:
what is it? (1)
what is put on cervix to highlihght dyscariosis(1)
what is done if they find high/low grade looking cervix? (2)
treatment options? (3)

A

the examination of teh magnified cervis using a light source

aceitic acid turns dyscariosis white
the colposcopist writes down what she thinks it is (low or high grade)
- ‘see and treat’ so they treat it that day
- subsequent colposcopy 6 month later

  • if low grade/unsure –>biopsy

treatment options:

  • diatherpy (but you dont get a biopsy then_
  • loop diathermy (LLETZ)
  • cone biopsy (but mainly just do LLETZ)
62
Q

Cervical cancer:
what are under 25s not treated of low grade (CIN1)?

symptoms of cervical cancer? (3)
what does it look like? (1)
how is it staged? (1)

A

avoid overtreatment as can affect fertility and body deals with this by itself

  • AUB
  • anaemia
  • pain (infiltration to spinal cord)
  • incontinence (vasicovaginal fistulae)
  • renal failure (ureteric blockage)

mass on cervix that is red on contact (may be ENDOcervical therefore you cant see it

  • squamous cell carcinoma is most common but the sfreeninghas decreased this and adenocarcinomas are not rising
  • MRI of abdomen and pelvis - CXR to exclude lung metastases
    may need to do n examination under anaesthetic if unsure if operable

IA, IB, II, III, IV

63
Q

what is trachelectomy?
when used? (1)
other than surgery, what else is used to treat this type of cancer (1)

A

trachelectomy is removal of the cervix, upper vagina and parametrium (tissue surrounding the cervix)

early stages of cervical cancer in those who wish to keep families

although radical hysterectomy is the mainstay

mainly RADIOTHERAPY in cervical cancer- can use brachytherapy or external radiotherapy
chemo can be given in conjunction

but radiotherapy not conducive with having a family as radiation causes early menopause in the ovaries as they are very sensitive to it

64
Q 
Vaginal cancer:
risk factors? (3)
staging?
Vulval cancer:
two main groups? (2)
(both look like lump/ulcer)
A

previous HPV
vaginal intraepithelial neoplasia
pelvic radiotherapy

staged I-IV again

Vulval:

  1. young women: HPV linked–> VIN–>cancer
  2. older women- non-HPV linked, associated with premalignant vulval condition lichen sclerosis which–> cancer
65
Q

Cervical cancer:

which can be treated with LLETZ only?

A

Stage I A only..

Stage 1B+ needs radical tachelectomy/hysterectomy

66
Q

Inhibin A:
Inhibin A is produced where?
when does it decline?

A

by ovarian follicles
as the number of follicles decline so does inhibin A
postmenopause inhibin is undetectable

in perimenopause i.e. time time before menopause diagnosis is made (that 1 year period), small declines in inhibin drives an increase in pulsatility of GnRH and thus FSH and LH to try to maintain folicle production and oestrogen levels
(so in perimenopause you get increased FSH and LH)

67
Q

Androgens:

where are they made in a woman? (3)

A
  • peripheral adipose tissie
  • ovaries
  • adrenal glands
68
Q 
POI:
primary causes (3)
secondary causes (3)
A
  • chromosoma (tuerns, fagile x)
  • autoimmune (hypothyroidism, addisons, myasthenia gracis)
  • enzyme deficiencies (galactosaemai, 17a-hydroxylase deficienciy)
  • chemo
  • radio
  • infection (e.g. TB, mumps, malaria, varicella)
69
Q

Who has worse outcomes for menopausae? ie. more symptoms
Does menopause link to dementia? (1)
what’s important to ask about in women with menopause? (1)

A

obese women

no evidence linking menopause to dementia but can decrease memory and concentration but this may be due to the vasomotor symptoms causing night sweats and poor sleep quality (causes tiredness, low energy and concentration problems)

ASK ABOUT SEX AND DRYNESS - they may not tell you
ask about CVD and BONE risk factors - KEY OPPORTUNITY to modify risk factors and improve overall health

70
Q

risk factors oestoperosis? (8)

when does peak bone mass occur? (1)

A
  • FHx osteoperosis or hipfracture
  • smoking
  • alcoholism
  • long-term steroids
  • POI/ hypogonadism
  • medical treatments that induce menopause
  • thrpoid/parathyoroid disorders
  • immobility
  • disorders of gut absorption, malnutrition, liver disease

NB oestrogen also stops atherogenesis and cholesterol buildup –> lack of it increases CVD

71
Q

menopause:

management

A

aim to improve bone health and prevent CVD and reduce vasomotor symptoms

  • stop smoking
  • reduce alcohol
  • maintain normal BMI
  • alternative/complementary treatment
  • non-hormonal prescription treatments
    used to reduce symptoms, e.g. bisphosphonates, beta blockers, a-adronergic agonists (clonidine)
  • hormonal treatments
    given PO, vaginally, patch, ring etc
  • testosterone given if fail to respond to HRT
72
Q

Risks of hormone therapy

A

cancer;
CVD/stroke (benefits are at younger age then as use it later stroke rate increase)
VTE

73
Q

Can women at menopause get pregnant?

A

THEY CAN so council them on contraceptives

74
Q

Dyschezia:
what is it? (1)
what is it seen in? (1)
other symptoms you may get?

A

pain on defication

endometriosis

  • cyclical rectal bleeding
  • obstruction

Lung: cyclical hymoptysis, haemopneumothoraxi (rare but can get here due to blood vessel linkages)

Urinary tract: cyclical haematuria/dysuria
- loin/flank pain/obstruction

Female reporductive tract: infertility, low back pain, torisoon, dsypareunia, pelvc pain, dysmonorrhoea

30-40% have trouble conceiving - surgical ablation may help

75
Q

What is chronic pelvic pain

A

intermittend orconstant pain in lower abdomen or pelvis of a woman at least 6 months in duration, not occuring exclusively with mensuration or intercourse and not associated with pregnancy

76
Q

Cervical smears:

if treated for CIN 1/2 when do they get recalled?

A

6 months for test of cure

77
Q

most common complication following TOP

A

INFECTION
nfection can happen in up to 10% of TOP cases. Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.

Retained tissue pregnancy occurs in less than 1% of cases.

Haemorrhage occurs in less than 1% of cases, but is more likely to occur in pregnancies greater than 20 weeks gestation.

Failure occurs in less than 1% of cases.

Injury to the cervix occurs in less than 1% of cases.

78
Q

TOP methods

A

less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

so if you have aminocentesis (15th-20th week of pregnancy) you have to have mini labour

79
Q

when is TOP allowed up until

A

24 weeks (unless going to save the life of mum/ extreme cases)

80
Q

most common cause 1st trimester misscarraige

A

antiphospholipid syndrome

81
Q

when is contraception no longer needed after menopause?

A

12 months after the last period in women > 50 years
24 months after the last period in women < 50 years

but advise not prevented against STIs!

82
Q

medical management of missed misscarriage

A

viaginal MISOprostol
MISoprostol= MIScarriage

MIFEpriston=ME FED up of prengnacy=termniantion

83
Q

Cervical smears if HIV positive

A

at diagnosis then annually

as decreased immune system

84
Q

when in pregnancy would large cervical cone biopsy cause miscarriage

A

2nd trimester

think about pressure on cervix

*year 4 additions (12 decks)

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