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
