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Y4 Reproductive Health > Gynae Passmed 1 > Flashcards

Gynae Passmed 1 Flashcards

1
Q

What is adenomyosis?

A

presence of endometrial tissue within the myometrium, more common in multiparous women towards the end of their reproductive years

Features:
dysmenorrhoea
menorrhagia
enlarged, boggy uterus

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2
Q

Give some risk factors for adenomyosis

A

High parity
Uterine surgery e.g. any endometrial curettage, endometrial ablation
Previous caesarean section

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3
Q

How should adenomyosis be investigated? Mx?

A

Ix:
transvaginal ultrasound first-line investigation
MRI is an alternative

Mx:
tranexamic acid to manage menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy = ‘definitive’ treatment

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4
Q

Define primary amenhorrhea

A

the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics

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5
Q

Define secondary amenorrhea

A

cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

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6
Q

How should amenorrhea be investigated?

A

exclude pregnancy with urinary or serum bHCG
FBC, U&Es, coeliac screen, TFTs
FSH and LH (low = hypothalmic cause, high = ovarian cause)
androgen levels (high = ?PCOS) , oestradiol
prolactin

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7
Q

What is androgen insensitivity syndrome?

A

X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype

Features:
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur

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8
Q

How is androgen insensitivity diagnosed?

A

buccal smear or chromosomal analysis to reveal 46XY genotype
after puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys

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9
Q

How is androgen insensitivity managed?

A

counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy

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10
Q

What are the main differentials for bleeding in the first trimester?

A

miscarriage
ectopic pregnancy
implantation bleeding (dx of exclusion)
cervical ectropion
vaginitis
trauma
polyps

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11
Q

If a woman has a positive pregnancy test and any of the following she should be referred immediately to an early pregnancy assessment service:

A

pain and abdominal tenderness
pelvic tenderness
cervical motion tenderness

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12
Q

How should bleeding in early pregnancy be managed?

A

> 6 weeks gestation (or of uncertain gestation) + bleeding = referral to early pregnancy assessment service, transvaginal USS to identify the location of the pregnancy and whether there is a fetal pole and heartbeat

< 6 weeks gestation + bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly.

These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried

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13
Q

What are the two types of cervical cancer?

A

squamous cell cancer (80%)
adenocarcinoma (20%)

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14
Q

How may cervical cancer present?

A

may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge

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15
Q

What are the risk factors for developing cervical cancer?

A

HPV (particularly serotypes 16,18 & 33) is by far the most important factor

smoking
HIV
early first intercourse, many sexual partners
high parity
lower socioeconomic status
COCP

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16
Q

What is the mechanism by which HPV can cause cervical cancer?

A

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene

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17
Q

What staging determines the management of cervical cancer?

A

FIGO staging (alongside wish of patient to maintain fertility)

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18
Q

What is FIGO stage 1A?

A

Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep

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19
Q

What is FIGO stage 1B?

A

Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter

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20
Q

What is FIGO stage 2?

A

Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement

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21
Q

What is FIGO Stage 3?

A

Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall

NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

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22
Q

What is FIGO stage 4?

A

Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis

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23
Q

How should stage 1A cervical tumours be managed?

A

Gold standard of treatment is hysterectomy +/- lymph node clearance
For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed

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24
Q

How should stage 1B cervical cancer be managed?

A

B1: radiotherapy + chemotherapy (cisplatin)
B2: radical hysterectomy with pelvic lymph node dissection

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25
Q

What are the possible complications of surgical cervical cancer tx?

A

Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies

Radical hysterectomy may result in a ureteral fistula

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26
Q

What are the possible complications of radiotherapy for cervical cancer?

A

Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness

Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

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27
Q

Who gets screened for cervical cancer? How are the samples tested?

A

A smear test is offered to all women between the ages of 25-64 years

25-49 years: 3-yearly screening
50-64 years: 5-yearly screening

HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive

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28
Q

What are the ‘special situations’ in cervical cancer screening?

A

cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears

women who have never been sexually active have a very low risk of developing cervical cancer therefore they may wish to opt out of screening

women with HIV or significant immuncompromise should have annual smears

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29
Q

What is the test of cure (TOC) pathway for cervical cancer screening?

A

individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community

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30
Q

hrHPV +ve and cytologically abnormal =

A

patient referred for colposcopy

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31
Q

hrHPV +ve but cytologically normal =

A

the test is repeated at 12 months

if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:

If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy

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32
Q

What should be done if the smear sample for cervical cancer screening is inadequate

A

repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy

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33
Q

What is the most common treatment for cervical intraepithelial neoplasia?

A

Large loop excision of transformation zone (LLETZ)

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34
Q

What is a cervical ectropion?

A

In a cervical ectropion, elevated oestrogen levels (ovulatory phase, pregnancy, COCP use) result in larger area of columnar epithelium (that lines the cervical canal) being present on the ectocervix.

Can be asymptomatic or present with vaginal discharge / post-coital bleeding.

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35
Q

What tx can be used if a cervical ectropion causes troublesome sxs?

A

Ablative treatment (for example ‘cold coagulation’)

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36
Q

Causes of delayed puberty with short stature?

A

Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome

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37
Q

Causes of delayed puberty with normal stature?

A

PCOS
androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome

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38
Q

What is primary dysmenorrhea?

A

Excessive pain during menstruation with no underlying pelvic pathology, potentially due to excessive endometrial prostaglandin production

pain typically starts just before or within a few hours of the period starting

suprapubic cramping pains which may radiate to the back or down the thigh

39
Q

What is secondary dysmenorrhea?

A

Excessive pain during menstruation that typically develops many years after the menarche and is the result of an underlying pathology.

The pain usually starts 3-4 days before the onset of the period

40
Q

Mx of primary dysmenorrhea?

A

NSAIDs such as mefenamic acid and ibuprofen
COCP are used second line
can advise heat pads and exercise

41
Q

Causes of secondary dysmenorrhea?

A

endometriosis
adenomyosis
fibroids
PID
IUD

42
Q

What are the examination findings in ectopic pregnancy?

A

abdominal tenderness

cervical excitation (also known as cervical motion tenderness) : found on pelvic examination

adnexal mass: do NOT examine for an adnexal mass due to an increased risk of rupturing the pregnancy

43
Q

In the case of pregnancy of unknown location, what test can indicate presence of ectopic pregnancy?

A

serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

44
Q

Give some risk factors for ectopic pregnancy?

A

Anything slowing the ovum’s passage to the uterus

damage to tubes (PID, surgery)
previous ectopic
IVF
endometriosis
contraceptives: IUCD, POP

45
Q

What is the investigation of choice for ectopic pregnancy?

A

transvaginal USS

46
Q

How should ectopic pregnancies be managed?

A

<35mm, unruptured = Expectant management - closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed

<35mm, ruptured = Medical management - methotrexate

> 35mm = Surgical management - salpingectomy first line or salpingotomy for women with other risk factors for infertility e.g. contralateral tube damage

47
Q

In which anatomical location are ectopic pregnancies at higher risk of rupture?

A

the isthmus

48
Q

What is the natural history of an ectopic pregnancy?

A

tubal abortion
tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
tubal rupture

49
Q

What are the main risk factors for endometrial cancer?

A

excess oestrogen
* nulliparity
* early menarche
* late menopause
* HRT

metabolic syndrome
* obesity
* diabetes mellitus
* PCOS

tamoxifen
hereditary non-polyposis colorectal carcinoma

50
Q

Give some protective factors against endometrial cancer

A

multiparity
COCP
smoking (the reasons for this are unclear)

51
Q

How does endometrial cancer present?

A

postmenopausal bleeding
usually light and intermittent initially before becoming heavier

premenopausal women may develop menorrhagia or intermenstrual bleeding
pain is not common and typically signifies extensive disease
vaginal discharge is unusual

52
Q

What are the investigations for suspected endometrial cancer?

A

All women >= 55 years who present with postmenopausal bleeding should be referred using suspected cancer pathway

trans-vaginal USS - a normal endometrial thickness (< 4 mm) has a high negative predictive value

hysteroscopy with endometrial biopsy

53
Q

How is endometrial cancer managed?

A

mainstay is surgery

localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy

patients with high-risk disease may have postop radiotherapy

54
Q

What is endometrial hyperplasia?

A

abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle

may present w intermenstrual bleeding

55
Q

How should endometrial hyperplasia be managed?

A

without atypia: high dose progestogens with repeat sampling in 3-4 months, can use IUS

with atypia: hysterectomy is usually advised

56
Q

What is endometriosis?

A

the growth of ectopic endometrial tissue outside of the uterine cavity

57
Q

Give some risk factors for endometriosis

A

Family history of endometriosis
Early menarche
Short menstrual cycles
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in the uterus or fallopian tubes

58
Q

Give some symptoms of endometriosis

A

chronic pelvic pain
dysmenorrhoea (pain often starts days before bleeding)
deep dyspareunia
subfertility

non-gynaecological: urinary symptoms (e.g. dysuria, urgency, haematuria) , dyschezia (painful bowel movements)

59
Q

Give some signs of endometriosis on examination

A

reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen on laprascopy

60
Q

How should endometriosis be investigated and managed?

A

laparoscopy is the gold-standard investigation

Mx:

NSAIDs / paracetamol for symptomatic relief
COCP or progestogens e.g. medroxyprogesterone acetate can be added

Secondary treatments:
GnRH analogues - induce a ‘pseudomenopause’
surgery

61
Q

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.

Outline the WHO FGM classification.

A

Type 1: removal of the clitoris / the prepuce

Type 2: removal of the clitoris and the labia minora +/-excision of the labia majora

Type 3 : Narrowing of the vaginal orifice with creation of a covering seal

Type 4: all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization

62
Q

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If they grow faster than their blood supply this can cause fibroid degeneration.

How does this present?

A

low-grade fever, pain and vomiting

managed conservatively with rest and analgesia and should resolve within 4-7 days

63
Q

Give some gynaecological causes of abdominal pain

A

Mittelschmerz
Endometriosis
Ovarian torsion
Ectopic pregnancy
PID

64
Q

How does Mittleschmerz present?

A

mid cycle ovulation pain, sharp, little systemic disturbance, may see free fluid on USS

65
Q

How does ovarian torsion present?

A

sudden onset of deep seated colicky abdominal pain
Associated with vomiting and distress
Vaginal examination may reveal adnexial tenderness

66
Q

How may PID present?

A

Bilateral lower abdominal pain associated with vaginal discharge +/- dysuria
Peri-hepatic inflammation (Fitz Hugh Curtis Syndrome) may produce RUQ discomfort
Fever >38
Raised WCC and may have raised amylase

67
Q

Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it was difficult to quantify, so the mx has therefore shifted towards what the woman considers to be excessive

How should menorrhagia be investigated and managed?

A

Ix: FBC, transvaginal USS if symptoms suggest structural abnormality

Mx:

Does not require contraception =

  • mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period

Requires contraception =

  • IUS (Mirena) should be considered first-line
  • COCP
  • long-acting progestogens
68
Q

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

What are the potential side effects?

A

nausea
breast tenderness
fluid retention and weight gain

69
Q

What are the risks of HRT?

A

increased risk of breast cancer
increased risk of ovarian cancer

increased risk of endometrial cancer
(oestrogen by itself should not be given as HRT to women with a womb, reduced by the addition of a progestogen but not eliminated completely)

increased risk of VTE (unless transdermal)

increased risk of stroke

increased risk of IHD if taken more than 10 years after menopause

70
Q

What is Hyperemesis gravidarum? What are the risk factors?

A

Extreme N+V during pregnancy, thought to be due to raised b-HCG levels

increased levels of beta-hCG
- multiple pregnancies
- trophoblastic disease
nulliparity
obesity
family or personal history of NVP

71
Q

When should admission be considered for Hyperemesis gravidarum?

A

unable to keep down liquids or oral antiemetics

Continued nausea and vomiting with ketonuria / weight loss (> 5% of body weight), despite treatment with oral antiemetics

A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

72
Q

The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis of hyperemesis gravidarum:

A

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

73
Q

How should hyperemesis gravidarum be managed?

A

rest and avoid triggers e.g. odours
bland, plain food, particularly in the morning
ginger
P6 (wrist) acupressure
antihistamines: oral cyclizine or promethazine
phenothiazines: oral prochlorperazine or chlorpromazine

if admitted: 0.9% NaCl with 20mmol KCl

74
Q

Women with hyperemesis gravidarum may develop dehydration, weight loss and electrolyte imbalances.

Other complications include:

A

AKI
Wernicke’s encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism

75
Q

Complications of hysterectomy?

A

urinary retention (short term)
enterocoele
vaginal vault prolapse

76
Q

How can suspected infertility be investigated?

A

semen analysis (repeat 3 months later if abnormal)
serum progesterone 7 days prior to expected next period

77
Q

What key points can be given when counselling couples struggling with infertility?

A

folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

78
Q

For how long should contraception be used in relation to the menopause?

A

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

79
Q

Menopause is defined as the permanent cessation of menstruation caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

What lifestyle modifications can be suggested to relieve symptoms?

A

regular exercise, weight loss, stress reduction
good sleep hygiene
light, loose layers of clothing

80
Q

What are the absolute contraindications to HRT?

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

81
Q

What non HRT medical mx is available for menopausal symptoms?

A

Vasomotor symptoms
fluoxetine, citalopram or venlafaxine

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, CBT or antidepressants

Urogenital symptoms
urogenital atrophy = vaginal oestrogen can be prescribed
vaginal dryness = moisturisers and lubricants

82
Q

Give some causes of menorrhagia

A

dysfunctional uterine bleeding: menorrhagia in the absence of underlying pathology.
anovulatory cycles
uterine fibroids
copper IUD
PID
bleeding disorders, e.g. von Willebrand disease
hypothyroidism

83
Q

In which cases does NICE recommend medical or surgical mx for miscarriage?

A

increased risk of haemorrhage
- late first trimester
- coagulopathies or is unable to have a blood transfusion

previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)

evidence of infection

84
Q

Give some risk factors for ovarian cancer

A

family history: mutations of the BRCA1/ BRCA2 gene
many ovulations: early menarche, late menopause, nulliparity

85
Q

How may ovarian cancer present? How is it investigated?

A

abdominal distension and bloating
abdominal and pelvic pain
early satiety
urinary symptoms e.g. Urgency
diarrhoea

CA125 and USS

86
Q

Which ovarian cysts should be biopsied to exclude malignancy?

A

complex - multi loculated

87
Q

Give the two types of functional ovarian cysts

A

Follicular cysts (commonest )
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles

Corpus luteum cyst
more likely to present with intraperitoneal bleeding than follicular cysts

88
Q

Give an example of a benign germ cell tumour that can form on the ovary

A

Dermoid cyst (mature cystic teratoma)

lined with epithelial tissue and hence may contain skin appendages, hair and teeth
usually asymptomatic
torsion is more likely than with other ovarian tumours

89
Q

Give an example of benign epithelial tumours that can form on the ovary

A

Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)

Mucinous cystadenoma
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei

90
Q

How should ovarian cysts be managed?

A

Premenopausal women
a conservative approach can be taken for younger women (esp < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and ‘simple’ then it is likely to be benign. A repeat USS should be arranged for 8-12 weeks

Postmenopausal women
physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst should be referred to gynaecology for assessment

91
Q

What is Ovarian hyperstimulation syndrome (OHSS)?

A

a complication seen in some forms of infertility treatment

Mild
Abdominal pain and bloating

Moderate•
Nausea and vomiting
Ultrasound evidence of ascites
•
Severe
Clinical evidence of ascites
Oliguria

Critical
Anuria
Tense ascites
Thromboembolism
ARDS

92
Q

What is ovarian torsion? How does it present?

A

partial or complete torsion of the ovary on it’s supporting ligaments that may compromise the blood supply

If the fallopian tube is also involved then it is referred to as adnexal torsion

sudden onset deep-seated colicky abdominal pain
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness

93
Q

What are the risk factors for ovarian torsion?

A

ovarian mass: present in 90% of cases
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome

94
Q

What may you see on USS for ovarian torsion?
How would you investigate and manage further?

A

free fluid or a whirlpool sign

Laparoscopy is usually both diagnostic and therapeutic - surgical detorsion

Y4 Reproductive Health (13 decks)

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