Gynae stuff you forget Flashcards
Which cancer’s have oestrogen as RF for, and therefore what are these RF?
Endometrial cancer (if unopposed by progesterone)
Breast cancer
For breast cancer - Alcohol, obesity, smoking. HRT. cOCP, nulliparity, not breastfeeding, early menarche/late menopause.
NB endometrial ca, anything increasing no. of menstruations is RF, therefore COCP is protective (smoking protective too). Tamoxifen, whilst anti-oestrogen in breast, has pro-oestrogen effects in other areas.
Adding progesterone to HRT protects endometrium but increases risk of breast ca. Risk is minimal.
RF for ovarian cancer
Anything which increases the number of ovulations - early menarche, late menopause, nulliparity, clomifene.
Also BRCA1/2, increased age.
Protective factors therefore breastfeeding (nhibits ovulation), OCP, multiparity.
RF for ovarian cancer
Anything which increases the number of ovulations - early menarche, late menopause, nulliparity, clomifene.
Also BRCA1/2, increased age.
Protective factors therefore breastfeeding (nhibits ovulation), OCP, multiparity.
Urgent 2week referrals:
Any women >55 with postmenopausal bleeding (i.e. >12months after menstruation has stopped)
For ovarian cancer, any women with RMI >250. Ascites in women at risk = 2 week wait
Any ovarian mass in a post-menopausal women needs 2wk referral to gynaecology.
Stages 1a/b, 2a/b, 3, 4 for cervical cancer and their treatment
1 - confined to cervix (A =<7mm, B = >7mm wide or clinically visible)
2 - extension beyond cervix but not to pelvic wall (A - upper 2/3rds of vagina, B - parametrial involvement)
3 - extension to pelvic wall (A - lower 1/3 of vagina, B - pelvic side wall). Any tumour causing hydronephrosis/non-functioning kidney = stage 3
4 - extension to involve bladder or rectum (A) or other sites (B)
CIN - LLETZ/Cone biopsy
1a1 - hysterectomy gold std, trachelectomy/cone biopsy if fertility desired.
1a2 - hysterectomy + lymphadenectomy
1b/2a+ radio/chemo/palliative
(if hydronephrosis - nephrostomy)
Things which cause CA125 to rise
- Ascites
- Ovarian torsion
- Menstruation
- Adenomyosis, endometriosis
- Liver disease
- Cancer (ovarian, breast, endometrial, metastatic lung)
Which Ix do and not do in ovarian cancer?
Ca 125 >35 => TV US, if mass/ascites 2 week referral to gynae.
Do not do fine needle aspiration as can spread. Surgery required for definitive diagnosis.
Describe classification of ovarian tumours:
Primary neoplasms:
1. Epithelial (serous adenocarcinoma most common)
- Serous cystadenoma or adenocarcinoma (70% of ovarian malignancies.
- Endometrioid carcinoma - 10% of ovarian malignancies
- Clear cell carcinoma - 10% of ovarian malignancies
- Mucinous cystadenoma - 3% of ovarian malignancies
2. Germ cell tumours - originate from undifferentiated germ cells of the gonad and account for 3% of ovarian malignacies.
- Teratoma/dermoid cyst - common BENIGN TUMOUR in younger women.
- Yolk sac tumours - highly malignant in children/young
- Dysgerminoma - like a seminoma, most common ovarian malignancy in younger women.
3. Sex cord tumours (<2% of ovarian malignancies), include granulosa cell and thesomas, both relatively benign.
Secondary malignancies - mets from breast and GI tract.
Classification of breast cancer:
Most epithelial - ductal (70%) or lobular (epithelium of terminal ducts of lobules - 10%).
Difference between WLE and total mastectomy (indications)
WLE HAS TO HAVE RADIOTHERAPY afterwards.
Mastectomy may be preferred over lumpectomy if tumour is large relative to size of breast, if multiple tumours, patient preference.
OR/PR +ve cancer difference in treatment if pre/post menopausal?
Pre-menopausal - Tamoxifen (anti-oestrogen)
Post-menopausal - Anastrozole (an aromatase inhibitor)
If Her2 positive - Trastuzumab.
How does vulval cancer present?
Pruritus, bleeding, discharge, mass, ulcer. If is more common if >60.
May be lichen sclerosis beforehand - premalignant.
Treatment of vulval cancer (stage 1a and others)
Stage 1a treated with WLE, without inguinal lymphadenectomy.
If positive SNLB, triple incision radical vulvectomy, radiotherapy, reconstructive surgery.
Which TOP clauses have 24 week limit?
C and D.
A, B and E have no time limit.
Which contraception can you give straight after misoprostol TOP? Which do you have to wait until next cycle?
Straight after misoprostol - oral pills, condoms, injectables, implants.
Next menstrual cycle - IUD/S, sterilisation.
Makes sense because misoPROSTol is a prostaglandin which would cause contractions - not good for surgery or a coil in place.
Which method of TOP is indicated when, and what are the methods?
Suction curettage - between 7-14wks. NB cervix can be ripened with vaginal misoprostol.
Medical can be used at any gestation but most effective <7wks. Mifepristone (antiprogesterone, sensitises to PG) then 36hrs later misoprostol (PGE1)
> 22wks feticide (KCl into umbilical vein)
What are the 3 methods of managing inevitable/incomplete/missed miscarriage and when can they be used (not time, conditions)?
If pregnancy tissue in vagina/cervical os - manual evacuation
- Expectant - No signs of infection. Not bleeding heavily. Repeat TVS at 2wks. If failed then medical.
Med/surg if increased risk of haemorrhage (late 1st trimester), infection, previous traumatic experience.
- Medical - oral PG (misoprostol), Preg test 3wks later. Only mifepristone if inevitable miscarriage (not missed/incomplete). Also no infection/bleeding.
- Surgical (ERPC/SMM), preferred if heavy bleeding/signs of infection. IM ergometrine reduces bleeding by contracting.
NB also need to give anti-D ig if medical/surgical Tx or if bleeding after 12wks gestation.
If threatened miscarriage consider progesterone, anti-D but mainly counselling
What is Asherman’s syndrome?
Where surgical evacuation partially removes endometrium, leading to adhesions and smaller uterus.
Can cause dysmenorrhoea, infertility, 2o amenorrhoea (as can Sheehan)
How to manage PID just after inserting a coil?
Start abx immediately (doxycycline, metronidazole, IM ceftriaxone)
Leave in recently coil in, if no response to abx within 48hrs, remove coil and prescribe other contraceptives
What is Fitz-Hugh-Curtis syndrome?
Chronic Cx of PID - RUQ pain due to adhesions between liver CAPSULE and anterior abdominal wall.
Usually resolves after infection
How does PID present?
Bilateral lower abdo pain with deep dyspareunia, usually with abnormal vaginal bleeding or discharge.
Fever, back pain, adnexal tenderness, cervical excitation
Gold std for PID Ix?
Laparoscopy with fimbrial biopsy, but not commonly performed.
Usually Swabs, bloods and NAAT.
How does endometritis differ to PID?
Infection of uterus alone, usually the result of instrumentation (CS, miscarriage, TOP) rather than ascending infection.
Tx and Ix similar. ERPC if products in uterus at US.
What is the bacteria causing BV? What is discharge like? Diagnosis? Tx?
Loss of lactobacilli and increase in anaerobic bacteria (G.vaginalis, Atpobium vaginae.
Vaginal discharge is fishy smelling, thin, grey/white and homogenous with pH >4.5. can be itching.
Raised pH, positive Whiff test, clue cells on microscopy
Tx - metronidazole (think anaerobes) or clindamycin cream.
Discharge in thrush? Diagnosis? Tx?
Odourless, white, curdy (cottage cheese), with pH <4.5 and itching. Vagina may be inflamed/red.
Diagnosis - culture
Tx - NICE recommends:
* stat PO fluconazole.
* 2nd line - clotrimazole pessary.
May add topical imidazole if vulval sx.
In pregnancy - systemic Tx CI, so clotrimazole cream/pessary.
Describe CT organism, diagnosis, treatment
Gram negative, intracellular
NAAT (vaginal swab, first void urine in males)
1st line - Doxycyclin 5 days but contraindicated in pregnancy (erythromycin in pregnancy)
2nd line - stat Azithromycin (better if breast feeding).
NB CT is generally more asymptomatic than Gon.
Describe NG organism, diagnosis, treatment
Gram negative diplococci
NAAT, microscopy (culture for confirmation)
Stat IM ceftriaxone
Describe Syphilis organism, Px, diagnosis, treatment
Gram negative spiroschaete (technically, stain better on Ryus), species pallidum
Single chancre, painless (primary syphilis) on genitals, nipples or mouth. Heals untreated. Secondary syphilis is rash, flu-like Sx 6-8wks later (condylomata), any organ can be involved.
Diagnosed on serology (VDRL looks for active infection - cardiolipin; and TPHA - looks for IgG immmunity).
1st line Benzanthine penicillin IM, 2nd line is azithromycin/Doxy
Trichomoniasis, describe organise, discharge, diagnosis and Tx
Flagellate protozoan.
Offensive grey/green discharge, vulval irritation, dysuria
NAAT
Systemic metronidazole
Describe discharge for BV, Thrush, Trichomoniasis, Chlamydia, Gonorrohoea
BV - fishy smell, grey/white, homogenous, pH >4.5
Thrush - odourless, white/curdy (cottage cheese), pH <4.5
Trichomoniasis - fishy smell, green, frothy, pH >4.5
Chlamydia - fishy smell, yellow discharge
Gonorrhoea - odourless, green/yellow/white discharge
RF and PF for endometriosis
RF - increased periods (early menarche/late menopause, nulliparity). also short cycles.
PF - multiparity and COCP.
Tx for endometriosis, preserving fertility and not.
Non-fertility sparing:
- 1st line - analgesia (NSAIDs, paracetamol)
- 2nd line - hormonal treatment to stop cycles (stops it sheading). COCP triphasing (taken back to back) 1st, then Mirena coil or POP 2nd line.
- 3rd line, refer to 2o care. GnRH analogues (Goserelin) but SE of menopause + osteopenia. Can add HRT to prevent this.
Surgery - laparoscopy -> ablation/ligation, or hysterectomy
Preserving fertility - just pain relief and laparoscopy. NB pregnancy will stop periods.
Tx of adenomyosis
Similar to endometriosis - try NSAIDs, COCP, coil but hysterectomy often required. Can try GnRH.
RF for ectopic pregnancy
Age >35, lower social class (smoking, age <18 at first sex), black race. IVF, previous pelvic surgery, IUCD in situ.
Describe conditions and methods of expectant, medical and surgical management of ectopic pregnancy
Expectant - size <35mm, bhCG <1000 no foetal heartbeat and asymptomatic. Need to monitor over 48hrs and intervene if bhCG starts to rise.
Medical - same as above but hCG <5000. Give stat dose methotrexate, if patient willing to follow-up (hCG levels)
Surgical - required if any of above conditions not met. Laparoscopy preferred to laparotomy (open). 2 options:
- Salpingectomy - removal of tube (preferred), done unless RF for fertility (e.g. contralateral tube damage), as it is only surgery that improves fertility
- Salpingostomy - removal of ectopic, can get ectopics in scar
Triad of HG and what makes you admit?
Dehydration, 5% pre-pregnancy weight loss, electrolyte disturbance
Admit if above, ketonuria, malnutrition and trial of oral antiemetics.
Triad of HG and what makes you admit?
Dehydration, 5% pre-pregnancy weight loss, electrolyte disturbance
Admit if above, ketonuria, malnutrition and trial of oral antiemetics.
Why is there a link between hyperthyroidism and HG?
bhCG has TSH-like effects.
Tx of HG
1st line - antihistamines (cyclizine, promethazine, prochlorperazine)
2nd line - Ondansetron (slight risk of cleft palate), metoclopramide (may cause extrapyramidal SE, no more than 5 days use).
Failure of these indicates Hospital and IV rehydration and thiamine.
Look for Cx - Mallory Weiss, Wernicke’s, Central pontine myelinolysis, foetal (pre-eclampsia, IUGR)
Describe forms of GTD
GTD is pregnanct related tumours from trophoblast.
- Premalignant = hydatidiform/vesciular mole - most common and benign.
- Complete = empty oocyte so paternal doubles (46XX with NO foetal tissue, hCG very raised)
- Partial = 2 sperms (69XXX, XXY or XYY), some foetal tissues and slightly raised hCG.
- Malignant = GTN. Can be invasive mole (only in uterus) choriocarcinoma (most dangerous one), PSTT - rare.
GTD presentation, ix and treatment
Presents with vaginal bleeding/spotting and severe HG, uterus often large and hyperthyroidism (due to hCG effects)
US w/ snowstorm appearance, but can only be confirmed histologically at ERPC. hCG may be very raised (T4 raised)
Tx with suction dilation curettage (ERPC), monitor bhCG
Tx of PCOS symptoms (fertility not desired)
1st line - weight loss / diet (restores ovulation in up to 80%)
2nd line - COCP will regulate menstruation and treat hirsutism (3-4bleeds a year to protect endometrium)
Antiandrogens (cyproterone acetate/spironolactone) can be used to treat hirsutism.
Metformin will also help. IUS will not as hormones not around body.
Tx of PCOS if fertility desired - 3 options, explain MoA.
Clomifene - antioestrogen (blocks R in hypothalamus), causes hyperstimulation of Hypo/Pitui. Only given at start of cycle to initate follicular maturation. Monitor w/ TV US to make sure not 0 or 3+ follicles develop where does reduction. However, antioestrogen thins the endometrium so low birth rate. RF for ovarian cancer.
Metformin - insulin sensitizer so reduces insulin. Doesn’t need scans. More effective if BMI <30. Can be added to clomifene. Does treat hirsutism and reduces GDM risk.
Letrozole - oral aromatase inhibitor (stops androgens to oestrogens), indces ovulation. Not widely used.
2ndn line options - laparoscopic ovarian diathermy, clomifine + metformin as dual therapy, Gonadotropins (in hypothalamic hypogonadism - SC FSH/LH).
Criteria for ovarian cysts to be managed conservatively
Assymptomatic, simple unilocular and <10cm with Ca125 <135 - serial us (even haemorrhagic)
Otherwise laparoscopy/laparotomy (increasing size or suspicious for malignancy)
Oral contraceptives do not effect benign ovarian cysts.
Causes of menorrhagia and Ix
Fibroids, polyps, thyrod disease, haemostatic disease
To TV US. If endometrial thickness >10mm (>4mm in postmenopausal) or other Sx of malignancy (IMB) then endometrial biopsy.
Tx of menorrhagia
1st line IUS (Progestogens), NB copper may make bleeding worse.
2nd line / fertility desired - tranexamic acid taken during menstruation only (SE leg cramps/feeling sick) or NSAIDs (mefenamic acid) - these inhibit prostaglandin synthesis and help dysmenorrheoa.
3rd line = progestogens high dose/orally, GnRH
Surgical - polyp removal, endometrial ablation, myomectomy for fibroids.
PMS Sx and Tx (mild, moderate, severe)
Emotional and physical Sx in the luteal phase, only if having ovulatory menstrual cycles.
Emotional Sx - anxiety, stress, fatigue, mood swings
Physical - bloating, breast pain
Mild - lifestyle advice (carb diet)
Moderate - COCP
Severe - SSRI
4 groups of RF for prolapse
1) Vaginal delivery
2) collage metabolism (EDS etc.)
3) Menopause
4) Any increase in intra-abdo pressure (obesity, chronic cough - smoking, constipation, pelvic mass, heavy lifting)
Mx of prolapse
If asymptomatic, reassure/avoid treatment. Lifestyle = weight reduction/smoking cessation
Pessaries, ring more common, shelf more effective. Changed 6-9m. Can fall out, cause pain, infection, urinary retention.
Surgical treatment - synthetic meshes, hysteropexy
Which blood test diagnoses early (<40) menopause?
FSH should be significantly elevated on 2 samples 4-6wks apart.
Otherwise, cessation of menses >12 consecutive months without reason.
Symptoms of menopause are due to low oestrogen, what are the symptoms?
Urogenital atrophy - vaginal thinning, decreased secretions, increase pH => dryness, itching, dyspareunia, PMB, recurrent UTIs
Bone resorption accelerates
CV risk increases
How to manage menopause general and vasomotor sx symptoms
Oestrogen helps symptoms of menopause, transdermal has less SE. If a uterus, must add progestin to protect against endometrial hyperplasia.
If wants to avoid hormones, Paroxetine is an SSRI, clonidine (a2 agonist 2nd line).
What are the 5 categories of infertility and some causes
Male factors (30%) - bad sperm (varicocele, abs, drug exposure, other)
Ovulatory (25%) - gonadal (PCOS, ovarian failure), hypothalamic hypogonadism, hyperprolactinaemia, CAH
Tubal (20%) - PID, endometriosis, iatrogenic
Uterine (10%) - polyps, fibroids
Unknown (25%) - e.g. sex problems/impotence
When do you consider early referral (before 1yr of trying to conceive) for infertility?
Mum >35
Menstrual disorder
Previous PID/STI
Abnormal exam
Systemic illness
Ix for infertility
Hormone profile (mid-luteal progesterone, 7 days prior to next expected period - usually (but not always) day 21). Elevated serum progesterone indicates ovulation has occurred.
Sperm count
Further - tubal patency (hysterosalpingogram, HyCoSy, laparoscopy)
Mx for male infertility if mild/moderate/severe abnormalities
Preconception advice - 2-3times/week, folic acid, smears, smoking/alcohol cessation, BMI20-25.
Mild - intrauterine insemination
Moderate - IVF
Severe - intra-cytoplasmic sperm injection
What are fibroids cell and describe classification
Leiomyomata (benign smooth muscle tumours of uterus)
Submucosal (can form intracavity polyps), intramural (most common, confined to myometrium), subserosal
Growth is oestrogen/progesterone dependent
How do fibroids present? Ix?
Asymptomatic
HMB or IMB if submucosal
Pain - dysmenorrhea or torsion
Pressure Sx:
- Bladder/bowel - frequency, retention, constipation
- Ureters - hydronephrosis
- Tubes - fertility
O/E - central pelvic mass.
May present with red degeneration
US diagnoses, hysteroscopy gold std.
Tx of fibroids
First line - can try NSAIDs, tranexamic acid but often not good.
Progesterone IUS is first line for fibroids <3cm (any larger, cannot put a coil in)
GnRH agonists/SPRMS (ulipristal) can reduce the size.
2nd line for <3cm - endometrial ablation.
If symptomatic hysterectomy or myomectomy (to preserve fertility). May give GnRH agonists before surgery to shrink them.
Mastitis/Breast abscess bacteria, RF, Px, Tx
Abscess usually S.aureus. Mastitis can be lactational or non-lactational (infection).
Smoking is key risk factor, also entry (piercings, breastfeeding.
Mastitis has nipple changes, discharge, pain, warm/red.
Breast abscess is tender lump, fluctuant.
Lactational mastitis - conservatively
Infective - fluclox 1st line, Co-amox 2nd line, drainage.
Fibroadenoma describe Px and Tx
Benign tumours of stromal/epithelial breast tissue.
20-40yrs (respond to oestrogen and progesterone hence regress after menopause) Painless, smooth, round, well circumscribed, mobile (breast mouse)
Left alone as not increased risk of breast cancer
Describe fibrocystic changes to breast
General lumpiness, not a disease. Change with menstrual cycle (pain prior to menstruating), mastalgia, tenderness
Tx w/ supportive bra, NSAIDs, avoid caffeine, apply heat.
Lichen sclerosus and lichen simplex describe
Lichen sclerosus is AID loss of collagen, usually post-menopausal with severe pruritus at night - can lead to excoriation. Pink white papules forms. Ix w/ biopsy to exclude Ca and Tx w/ steroid cream over 12wks.
Lichen simplex is like eczema of the vagina. Presents similar (itchy) but hyper/hypopigmentation.
Tx with moderately potent steroid creams/antihistamines
What ages do women have 3yearly and 5yearly smears?
25 - 49 every 3 years
50 - 64 - every 5 years
>65 only if not had a screen since age 50
What do you do if positive hrHPV and then:
- cytology normal once
- cytology normal twice
Cytology abnormal at any point?
What if tests are inadequate
- repeat at 12m
- repeat another 12m later (24m) (if HrHPV still positive then colposcopy). 3 tests over 3 years all HrHPV positive = colposcopy
If hrHPV becomes negative at any point discharge to normal
If cytology becomes abnormal then colposcopy required
If first inadequate, repeat in 3m. If 2consecutive inadequate samples then colposcopy
What is CIN1, 2, 3 and how are they managed?
CIN1 = mild dysplasia, atypical cells in only lower 1/3 of epithelium
CIN2 = moderate dysplasia, as above but 2/3rds
CIN3 = severe, full thickness of epithelium, carcinoma in situ
CIN1 - no treatment but follow up after 12m
CIN2 or 3 - LLETZ or DLE (allows diagnosis and treatment
Describe cervical ectropion and Px, Mx
Elevated oestrogen (ovulatory phase, pregnancy, COCP) causes larger area of columnar epithelium present on ectocervix (transformation zone shifts) which can bleed etc.
Normally asymptomatic or postcoital bleeding (DDx for cervical ca)
Often left alone but can do cryotherapy
Which abortion patients should anti-D be offered too?
Rh-ve and if pregnancy lasted over 10+0 wks gestation
First line Tx for menorrhagia and dysmenorrhoea
Menorrhagia - Progesterone IUS
Dysmemorrhoea - Mefenamic acid/NSAIDs (if no CIs - ulcers, renal impairment)
