Gynaecological Conditions Flashcards
What is an ectropion?
A benign condition of the cervix where the columnar epithelium which normally lines the inside surface of the cervix, protrudes outwards and can be seen on the vaginal surface of the cervix. Gives a ‘raw’ appearance to the cervix and can present with increased discharge.
What age-group of women are more commonly affected by functional ovarian cysts?
Young girls, adolescents, women of reproductive age
What is the treatment for a functional ovarian cyst?
If symptomatic, laparoscopic cystectomy. If no symptoms, observe by repeat ultrasound but doesn’t require immediate treatment.
Which type of ovarian cyst is associated with pregnancy?
Theca luteal cyst
List some medical management choices for increased menstrual bleeding
Mefanamic acid and NSAIDs Tranexamic acid Combined oral contraceptive pill Norethisterone Mirena coil GnRH agonist
Give 2 contraindications for using mefanamic acid and NSAIDs as treatment for heavy menstrual bleeding.
Severe asthma
Hx of duodenal ulcer
Why are GnRH agonists only used short-term (max. 6 months) for heavy menstrual bleeding?
They act on the pituitary to stop production of oestrogen. Long-term action predisposes to osteoporosis due to hypo-oestrogenic state.
Give 2 surgical options for management of heavy menstrual bleeding.
Endometrial ablation
Hysterectomy
What is meant by ‘dysmenorrhoea’?
Painful menstruation
List some management options for dysmenorrhoea
Lifestyle changes Heat NSAIDs e.g. ibuprofen, naproxen Oral contraceptives Mirena coil GnRH analogues
What is ‘dyspareunia’?
Pain on intercourse
What is the definition of urinary incontinence?
Involuntary leaking of urine that is objectively demonstrable and is a social and/or hygienic problem.
What are the 3 types of urinary incontinence?
Stress
Urge
Mixed
What is stress incontinence?
Involuntary leakage of urine during times of increased abdominal pressure e.g. coughing, laughing, exercise, etc.
Why does stress incontinence occur?
Physical changes to the pelvic floor e.g. after pregnancy/childbirth, atrophy resulting from menopause, pelvic floor weakening etc.
What is urge incontinence?
Overactivity of the detrusor muscle
What might cause the overactivity of the detrusor muscle seen in urge incontinence?
Loss of inhibitory mechanisms from the CNS, bladder irritation e.g. in UTI, bladder outlet obstruction e.g. in enlarged prostate
What is uroflowmetry?
Non-invasive procedure which allows observation of the rate of flow of urine. Patient will full bladder passes urine over a commode attached to a urodynamics machine. Allows objective measurement of amount of urine passed and the flow rate. Subsequent scan performed to observe any residual volume.
What age group of women are invited to have a cervical screening test?
25 - 64
How often do women aged 25 - 49 have a cervical smear test?
Every 3 years
How often do women ages 50 - 64 have a cervical smear test?
Every 5 years
What action is taken if a cervical smear test shows ‘low grade (borderline) dyskaryosis’?
It is tested for HPV…if positive for HPV patient is referred to colposcopy…if negative there is very little chance of development into abnormality so patient rejoins normal 3-5 year smear tests (depending on age).
What is pelvic inflammatory disease?
PID occurs when infection spreads from lower genital tract (vagina) through the cervix to the upper genital tract. Organisms causing PID are usually spread sexually although it may be that no organism is identified.
What might you find on internal examination of a patient with pelvic inflammatory disease?
Adnexal tenderness
Lower abdominal pain
Cervical excitation
How might you investigate possible PID?
- Pregnancy test
- STI screen
- Bloods, especially WCC and inflammatory markers
- Laparoscopy not often indicated unless e.g. fallopian tube blocked
- Trans-vaginal ultrasound scan may show free fluid in the pelvis
- Endometrial biopsy (although NB this can induce infection!)
How long must a women be free of periods to have, by definition, gone through the menopause?
12 months
What is the key investigation for a patient with post-menopausal bleeding, and why?
Transvaginal ultrasound scan - shows the endometrial thickness which can be an indicator of malignant pathology (anything over 5mm considered raised)
List some key causes of uterine / vaginal prolapse
Vaginal delivery
Menopause (lack of oestrogen)
Surgery
Congenital abnormalities including collagen problems
Chronic raised intra-abdominal pressure e.g. heavy lifting, coughing, etc.
What are the symptoms of uterine / vaginal prolapse?
Pelvic pain / pressure - feeling of a ‘dragging’ sensation
Feeling of a ‘lump’ or something coming down
Back pain
Urinary dysfunction
Bowel problems
What is endometriosis?
A relatively common condition in which endometrial tissue lies outside the uterine cavity.
What is the medical management for endometriosis?
Analgesia
COCP
Progestogens
GnRH analogues
What is a Nabothian cyst?
Common finding of the cervix, caused by metaplasia of squamous epithelium over the endocervical columnar epithelium. This traps the secretions of the columnar epithelium below it and causes white cysts to appear on the cervix. Treatment is not required.
Give 3 skin conditions which may affect the vulva
Lichen simplex chronicus
Lichen sclerosis
Lichen planus
What is lichen simplex chronicus and how might it present on the vulva?
A chronic, inflammatory skin disease - presents with chronic itching, especially at night. Patient is likely to be affected by eczema elsewhere on the body.
Which condition out of lichen simplex chronicus, lichen sclerosis, and lichen planus does NOT cause itching
Lichen planus
What is a Bartholin’s abscess?
Infected cyst affecting the vulva caused by blockage of the mucous secreting glands behind the labia minora
What 4 conditions must be met for conception to be successful?
Ovulation
Adequate sperm production
Fertilisation
Implantation
What is the first-line medical management for patients with an overactive bladder and what is their mechanism of action?
Anti-muscarinics e.g. solifenacin, tolteradone, oxybutinin. These block the muscarinic receptors on the bladder detrusor muscle to dampen its contractility.
What is the triad associated with polycystic ovarian syndrome?
Polycystic ovaries - confirmed on ultrasound
Hyperandrogenism symptoms e.g. hirsutism
Ovarian dysfunction e.g. oligomenorrhoea
What might be the LH:FSH ratio in PCOS?
Raised (>2.5-3:1)
What will be the level of mid-luteal phase progesterone in polycystic ovarian syndrome?
Low - Ovulation has not occurred so there is no corpus luteum to produce progesterone so level is low
Give some key features of the menopause:
- Absence of periods
- Vasomotor symptoms: Hot flushes, night sweats
- Cardiovascular disease increased risk (due to removed protection from oestrogen)
- Urogenital symptoms: Urinary frequency / incontinence, vaginal atrophy
- Sexual dysfunction: Loss of libido, dyspareunia, anorgasmia
- Osteoporosis
- Psychological symptoms: Loss of memory, poor concentration
What age is described as ‘early menopause’?
Onset of menopause below age 40
What are the risks of using HRT?
- Increased risk of breast cancer with combined regimen
- Increased risk of endometrial cancer with oestrogen-only regimen
- Increased risk of BTE
- Increased risk of gallbladder disease
What are the 3 types of functional ovarian cyst?
Follicular cyst
Corpus luteal cyst
Theca luteal cyst
What is a ‘chocolate cyst’?
Endometriosis where the ectopic endometrial tissue is found on the ovaries
True / False: Endometriosis is common in post-menopausal women
False - It resolves after the menopause as the tissue is under oestrogen control
Give some presenting features of endometriosis
Pelvic pain - intermittent (cyclical), worst just before and at the onset of a period
Sub fertility
Dyspareunia
Menorrhagia and dysmenorrhoea
What might you find on examination of a patient with endometriosis?
Adnexal pain
There may be a fixed, retroverted uterus (especially if the utero-sacral ligament is involved as this pulls the uterus back)
What is the investigation of choice for diagnosis of endometriosis?
Laparoscopy - ‘Red lesions’ or adhesions present
What are the different categories of ovarian cyst?
Functional Inflammatory Germ cell Epithelial Sex cord stromal
Give an example of a germ cell benign ovarian tumour
Dermoid cyst (teratoma)
What is the most common type of being tumour in young women?
Dermoid cyst (teratoma)
Does a dermoid cyst (teratoma) need remove;?
Yes - cystectomy is performed as there is a 2% risk of malignant transformation. Oophorectomy may be done if there is torsion (more common occurrence than with other types of ovarian cyst)
Give 3 types of benign epithelial ovarian tumours
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
What is the most common type of benign epithelial ovarian tumour?
Serous cystadenoma
Give 2 types of sex cord stromal benign ovarian tumour
Fibroma
Thecoma
What is the most common type of sex cord stromal benign ovarian tumour?
Fibroma
What is the most common type of ovarian pathology associated with Meigs’ syndrome?
Fibroma (a type of sex cord stromal benign ovarian tumour)
What are the different types of uterine fibroid?
Submucosal
Pedunculate
Intramural
Subserosal
What are the risk factors for fibroids?
Nulliparity
Obesity
Afro-Caribbean ethnicity
Family history
What is the key clinical feature of fibroids?
Menorrhagia
When deciding upon management for fibroids, what is it important to ask the patient?
Whether they have any plans to become pregnant. If they do, this rules out medical management.
What are the management options for fibroids?
Conservative - Watch and wait
Medical - COCP, progestins, Mirena coil
Surgical - Uterine artery embolisation, myomectomy (hysteroscopic or laparoscopic), hysterectomy
What investigations might you do if menopause is suspected? What would they show?
FSH increases (due to absence of inhibition by oestrogen) Anti-Mullerian hormone reduced (it is released by ovarian follicles)
NB investigations are not always required as diagnosis made clinically
What regimen of HRT is given to menopausal women without a uterus?
Oestrogen only regimen
What regimen of HRT is given to post-menopausal women with a uterus?
Combine regimen (oestrogen and progesterone)
Why are post-menopausal women with a uterus given the combined regimen of HRT?
Oestrogen alone can cause endometrial hyperplasia in women with a uterus, contributing to malignancies. Progesterone protects the uterus from the unopposed oestrogen.
Give some benefits of HRT
Symptomatic relief for menopausal symptoms - vasomotor, urogenital (and to a variable extent, neuropsychiatric)
Reduces risk of osteoporosis
What is the mechanism of action of tranexamic acid?
An antifibrinolytic - Inhibits production of plasmin and thus causes increased clots (it stabilises smaller clots) and stops vessels from bleeding
Is mefanamic acid taken continuously for menorrhagia?
No - Mefanamic acid and other NSAIDs are only taken on days of bleeding
If tranexamic acid taken continuously for menorrhagia?
No - Tranexamic is only required on days of particularly heavy bleeding
What is primary amenorrhoea?
Absence of menses by 16 years old
What is secondary amenorrhoea?
Absence of menstruation for more than 6 months, when not due to pregnancy, lactation or menopause
What is premature ovarian failure?
Ceasing of menstrual cycles before age 40
List some causes of menorrhagia
Copper coil Fibroids Endometrial polyps Malignancy - endometrial, cervical, ovarian Idiopathic (Dysfunctional uterine bleeding) Hypothyroidism Coagulation disorder Pelvic inflammatory disorder
What is Kallman’s syndrome?
X-linked recessive disorder where there is GnRH deficiency which results in underdeveloped genetalia - causes amenorrhoea and also anosmia
List some pituitary causes of amenorrhoea
Pituitary tumour - commonly prolactinoma
Pituitary necrosis i.e. Sheehan’s syndrome
What is Sheehan’s syndrome?
Pituitary necrosis caused by profound hypotension and ischaemia resulting from obstetric haemorrhage
What might a raised FSH suggest in the context of amenorrhoea?
Premature ovarian failure
What investigations might be reasonable in amenorrhoea?
Pregnancy test
Bloods: FSH, LH, testosterone, prolactin, TFTs
Pelvic ultrasound scan
Pituitary MRI
Chronic pelvic pain with an enlarged, ‘boggy’ uterus, mildly tender to bimanual palpation may suggest which condition?
Adenomyosis
What is the management of endometrial polyps?
In younger people they are often left alone unless irregular bleeding is causing severe problems. Polyps are removed in post-menopausal women as there is risk they are due to malignancy.
Is prolactin low, normal or raised in polycystic ovarian syndrome?
Normal
What happens to LH in polycystic ovarian syndrome?
It is constantly high, due to positive feedback from raised peripheral oestrogen, and also raised GnRH production
What is the management of polycystic ovarian syndrome?
Weight reduction - reduces risk of insulin resistance
Clomifene - aids ovarian function
COCP - reduces androgen symptoms
Metformin - increased levels of sex hormone binding globulin which helps to ‘mop up’ excess androgens, and also helps insulin resistance
Surgical interventions e.g. ovarian drilling
Which inflammatory skin condition of the vulva may predispose to malignancy?
Lichen sclerosis
What is the treatment for lichen sclerosis of the vulva?
Long-term topical steroids e.g. Dermovate
