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Gynaecology 1 Flashcards

1
Q

What days is menstruation during the menstrual cycle?

A

1-4

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2
Q

What is the first half of the menstrual cycle called? What days is it? What hormone predominates?

A

Proliferative (follicular) phase days 5-13
Oestrogen predominates to thicken the endometrium
FH > LSH

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3
Q

What hormonal change marks oocyte release from a follicle and what day is this?

A

LH surge on 14 days (matches up with oestrogen bump)

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4
Q

What is the second half of the menstrual cycle called? What days is it? What hormone predominates?

A

Proliferative (luteal) phase days 14-28
Progesterone dominates to form a secretory endometrium
LH > FSH relatively

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5
Q

Define irregular periods?

A

Outside normal range of 23-35 days, variability of >7 days between shortest and longest

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6
Q

What is oligomenorrhoea?

A

Infrequent periods, between 35 days - 6m

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7
Q

What is primary amenorrhea?

A

Periods never start by age 16

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8
Q

What is secondary amenorrhea?

A

Periods stop for > 6m

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9
Q

What is Postmenopausal bleeding?

A

Bleeding that occurs >1 year after LMP

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10
Q

What is the objective definition of menorrhagia but what is normally considered?

A

> 80ml blood loss in one normal period, which could lead to an IDA
Normally just when heavy enough to interfere with everyday life

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11
Q

Most common causes of menorrhagia?

A

Idiopathic
Fibroids
Polyps

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12
Q

What does tenderness when examining for menorrhagia indicate?

A

More likely adenomyosis

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13
Q

3 most appropriate investigations for menorrhagia?

A

TVUSS +/- endometrial pipelle biopsy +/- hysteroscopy

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14
Q

First line management for menorrhagia if patient not wanting to get pregnant?

A

Mirena coil IUS

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15
Q

What drugs are second line for menorrhagia after IUS/if fertility desired?

A

Tranexamic acid, an antifibrinolytic

NSAIDs

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16
Q

What is third line management for menorrhagia?

A

Progestogens to induce artificial amenorrhea
GnRH analogues to induce artificial menopause

If fail, surgery

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17
Q

Most common causes of irregular periods and IMB?

A

Fibroids, adenomyosis
Polyps
Ovarian cysts
PID

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18
Q

What are more likely causes of IMB and irregular menses in older women?

A

Endometrial, ovarian and cervical cancer

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19
Q

What drugs can be given to induce artificial amenorrhea and are therefore used for menorrhagia, IMB, irregular menses and occasionally dysmenorrhea?

A

Progestogens and CoCP

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20
Q

First line management for menstrual disturbance when fertility not required?

A

IUS or CoCP

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21
Q

Physiological causes of amenorrhea?

A

Pregnancy

Lactation

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22
Q

6 areas of causes of amenorrhea/oligomenorrhoea?

A 
Drugs e.g. Progestogens, GnRH agonists, antipsychotics
Hypothalamic hypogonadism
Pituitary - hyperprolactinaemia 
Adrenals/thyroid - hypothyroidism
Ovary - PCOS, prem menopause, Turners
Outflow tract disturbance
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23
Q

3 most common causes of amenorrhea/oligomenorrhoea? Which most commonly causes oligomenorrhoea?

A

PCOS - normally oligo
Premature menopause
Hyperprolactinaemia

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24
Q

What can hypothalamic hypogonadism be caused by?

A

Losing loads of weight, anorexia, exercise

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25
Is PCB ever 'normal'? What are the most common causes?
No Most commonly cervical e.g. Ectropion, polyps, Cancer Can be atrophic vaginitis in older women
26
Why does dysmenorrhea happen and what are the 2 types?
High prostaglandins causing contraction and uterine ischaemia Primary = no organic cause Secondary = secondary to pelvic pathology
27
Characteristics of primary dysmenorrhea?
No organic cause Normally at start of menstruation Often responds to NSAIDs or ovulatory suppression (COCP)
28
Most common causes of secondary dysmenorrhea?
Fibroids Adenomyosis, endometriosis PID
29
Characteristics of secondary dysmenorrhea?
Often precedes menstruation Commonly coexists with deep dyspareunia, menorrhagia, irregular menses Requires PUS and laparoscopy
30
What is the premenstrual syndrome?
Sx worsening in luteal phase of cycle, resolve by end of menstruation Tension, irritability, aggression, depression IBS like symptoms, breast pain
31
Management of premenstrual syndrome?
SSRIs (duloxetine) are useful | Cycle ablation - COCP, GnRH analogues with add back HRT
32
What is the relationship between fibroids and adenomyosis?
Fibroids (leiomyomata) are benign myometrial tumours Adenomyosis is endometriosis which deposits within the myometrium Both can cause menorrhagia, irregular/IMB, dysmenorrhea
33
What effect does progesterone have on the endometrium and how does it relate to menstruation?
Causes gland swelling and vascularisation | Falls at the end of the cycle causing decrease in blood supply, ischaemia and menstruation
34
What do fibroids depend on for growth and therefore what is protective against them?
Oestrogen and progesterone (so common just pre-menopause and normally regress during pregnancy, post-menopause) Pregnancy, COCP, Progestogens are protective
35
3 types of fibroids and how do they relate to polyps?
``` Subserous fibroids Intramural fibroids Submucosal fibroids Intracavity polyps Subserous polyps ```
36
What polyps and fibroids are related in terms of location and symptomlogy?
Intracavity polyps and submucosal fibroids both push into uterine cavity Subserous fibroids and subserous polyps both push out of uterus and make the outside of it bumpy
37
When can fibroids grow during pregnancy and what problems can arise?
Can grow mid-pregnancy second trimester -> preterm labour, malpresentation, transverse lie, PPH Red degeneration (severe pain) Pedunculated fibroid torsion
38
What is the cancerous change that arises from fibroids?
Leiomyosarcoma
39
Why can Hb be high with fibroids?
They can secrete erythropoietin
40
Investigations for fibroids?
TVUS +/- MRI +/- laparoscopy
41
Medical management of fibroids if not trying to conceive?
GnRH agonists to induce temporary menopause with add back HRT
42
Alternative surgical management for fibroids if wanting to preserve fertility?
Pretreatment GnRH agonists followed by hysteroscopy and TCRF for submucosal/intracavity polyp Myomectomy - open laparotomy or laparoscopic for intramural/subserous
43
What is umbilical artery embolization UAE used for?
Fibroids shrinkage in those that don't want kids
44
What can haematometra occur as a result of?
Fibrosis post-endometrial resection, cone biopsy Carcinoma Congenital malformation or imperforate hymen (1* amenorrhea)
45
What is the commonest genital tract cancer in women?
Endometrial cancer
46
Who does endometrial cancer occur most commonly in?
Older women > 60
47
What histological type are the majority of endometrial cancers?
Adenocarcinoma of columnar endometrial gland cells
48
What is the major risk factor for endometrial cancer and what 2 types can this broadly be split into?
Unopposed oestrogen/high oestrogen:prog ratio | Split into exogenous and endogenous oestrogen excess
49
Exogenous oestrogen RFs for endometrial cancer?
Tamoxifen for breast cancer | Unopposed oestrogen therapy
50
Endogenous oestrogen sources as risk factors for endometrial cancer?
``` Obesity (androgen->oestrogen conversion) PCOS Nulliparity Late menopause Oestrogen secreting (ovarian) tumours ```
51
What is Lynch type II syndrome?
Hereditary Non-Polyposis Colorectal Cancer | Risks of colorectal, endometrial and ovarian cancer
52
What is the premalignant disease for endometrial cancer?
Endometrial hyperplasia with atypia | Requires hysterectomy if possible
53
What is the biggest presenting picture for endometrial cancer?
PMB - increasing likelihood of cancer with age | If pre-menopausal - rare but IMB/irregular menses or oligomenorrhoea
54
What cervical pathology may coexist with endometrial cancer?
Cervical Glandular Intraepithelial Neoplasia CGIN
55
How is FIGO staging for endometrial cancer carried out?
USS + endometrial pipelle biopsy +/- hysteroscopy | Staging can only be done post-hysterectomy
56
Stages for endometrial cancer?
Stage 1 - uterus only (75% at presentation) Stage 2 - uterus and cervix Stage 3 - invasive through uterus into adnexae, vagina, LNs Stage 4 - bowel or bladder spread or distant mets
57
Stage 1 management for endometrial cancer?
H+BSO | If turns out subsequently to be stage 3 -> ?radiotherapy
58
Recurrence for endometrial cancer?
Most commonly vaginal vault - VGIN
59
Moist Smelly Stuff is Gynae Basics of gynae history?
``` Menstrual questions Sexual Hx Smear Hx Genitourinary Sx incl discharge Bowel Sx ```
60
What is cervical ectropion?
Visible endocervical columnar epithelium as redness around external os More common during pregnancy, COCP
61
Other than asymptomatic, how can cervical ectropion present?
Discharge | Post-coital bleeding
62
Management of cervical ectropion?
Cryotherapy after exclusion of carcinoma by smear/colposcopy
63
What is chronic cervicitis?
A common cause of discharge, often due to chronic STI of cervical ectropion
64
What are cervical polyps?
Benign endocervical epithelial tumours most common in older women
65
Apart from asymptomatic, how can cervical polyps present?
Post-coital bleeding, Intermenstrual bleeding
66
Management of cervical polyps?
Avulsion + histological analysis
67
What are Nabothian follicles?
Columnar cell secretions trapped under squamous epithelium leading to white/opaque swellings in ectocervix. Commonly asymptomatic
68
What is the most common histological type of cervical cancer?
Squamous cell carcinoma
69
What are CIN I-III and what do they represent?
Dysplasia of cervical intraepithelial cells; I is atypical cells at lower 1/3 of epithelium only, II is 2/3 and III is full thickness
70
What is another term form CIN III and how does it progress to malignant disease?
Carcinoma in situ -> invasion through basement membrane
71
What HPV serotypes are most implicated in cervical cancer?
16, 18, 31 and 33
72
Besides HPV RFs, RFs for cervical cancer?
Smoking | Immunocompromise
73
What is the screening programme for cervical cancer?
3 yearly from 25-49 | 5 yearly from 49-64
74
What is the lowest level of dyskaryosis in CIN which, when combined with a positive HPV titre, should prompt a colposcopy?
CIN I + positive HPV -> colposcopy
75
What is HPV screening used for in CIN?
As HPV triage and also test of cure
76
What can presence of CGIN indicate?
Cervical/endometrial adenocarcinoma so should prompt colposcopy and endometrial biopsy
77
What do confirmed CIN II and III have to be treated with? What risk does this hold for future pregnancies?
LLETZ | Slight risk of preterm labour in future
78
Other than asymptomatic, how can cervical cancer present?
PCB, IMB, PM, offensive discharge | Pain, GI/GU Sx
79
FIGO stage 1-4 for cervical cancer?
1 - cancer confined to cervix 2 - local spread into vagina but not pelvic side wall 3 - spread to lower vagina or pelvic walls or ureteric obstruction 4 - invasion of bladder, rectum or beyond
80
Management of cervical cancer with increasing grade at presentation?
Come biopsy/hysterectomy -> radical hysterectomy -> chemo/radiotherapy
81
What are common ovarian symptoms?
None! Often silent | With increasing size, can eventually cause abdominal distension and bloating
82
What is an ovarian accident?
Acute rupture, haemorrhage, torsion or infarct of an ovarian mass (usually cyst)
83
What is PCO?
Term descriptive of the characteristic TVUS appearance: >12 small follicles in an enlarged ovary
84
What can prompt a woman with PCO to develop PCOS?
Weight gain
85
Major diagnostic features of PCOS?
Anovulation Hirsutism either clinically or as high serum testosterone Oligomenorrhoea/irregular periods PCO on TVUS
86
What is the pathophysiological background of PCOS?
Genetic susceptibility leading to increased LH production and peripheral insulin resistance LH and insulin act on PCO causing ovarian androgen production and disruption of folliculogenesis
87
What FH condition is common with PCOS?
DM2
88
3 long term risks of PCOS?
Endometrial cancer (anovulation leading to unopposed oestrogen) DM2 GDM and miscarriage during pregnancy
89
First line management of PCOS?
Lifestyle - weight loss
90
Management of PCOS if wanting fertility?
Clomifene Metformin Gonadotrophins, IVF
91
Management of PCOS if fertility not desired?
``` Symptomatic relief - COCP or Mirena to regulate menstruation and treat hirsutism Anti androgens (systemic or topical) ```
92
What is premature menopause defined as?
Menopause before age of 40
93
What is the most common congenital cause of gonadal dysgenesis?
Turners syndrome 45XO
94
What are the 3 major types of primary ovarian carcinoma?
Epithelial tumours Germ cell tumours Sex cord tumours
95
What are the most common malignant primary ovarian cancers?
Epithelial cell cancers - serous cystadenoma/adenocarcinoma
96
What are the 5 types of ovarian epithelial carcinoma?
``` Serous cystadenoma Mucinous cystadenoma Endometrioid carcinoma Clear cell carcinoma Brenner tumour ```
97
From what ovarian tumour can pseudomyxoma peritonei originate?
Borderline mucinous cystadenoma
98
In whom are germ cell ovarian tumours more common?
Women under 30
99
2 types of germ cell ovarian tumour? What is the most common malignant ovarian cancer in younger women?
Teratoma/dermoid cyst | Dysgerminoma (most common)
100
3 types of ovarian sex cord tumour?
Granulosa cell tumours Thecomas Fibromas
101
What do granulosa cell tumours secrete?
Oestrogen and inhibin | Thus causing endometrial hyperplasia/cancer or precocious puberty
102
What is Meig's syndrome?
Fibroma, ascites and right sided pleural effusion
103
What are the 2 most common primary sites for ovarian secondary malignancies?
Breast | GI cancers
104
2 major cyst conditions of ovaries?
Endometriotic (chocolate) cysts | Functional cysts - follicular/lutein cysts
105
What is protective vs functional ovarian cysts?
COCP
106
RFs for ovarian cancer?
Related to increasing number of ovulations: Early menarche Late menopause Nulliparity
107
Protective factors against ovarian cancer?
Pregnancy Lactation COCP
108
Familial links for ovarian cancer?
BRCA 1+2 | HNPCC (lynch syndrome type II)
109
What 3 cancers is lynch II (HNPCC) implicated in?
Ovarian Endometrial Colorectal
110
What common GI disease manifestation does ovarian cancer often mimic?
IBS
111
What is used to assess ovarian cancer possibility in secondary care? How is it calculated?
Risk of Malignancy Index | RMI = Ca125 x US x Menopausal Status
112
What specific bloods may be useful to investigate ovarian cancer in women under 40 at increased risk of germ cell tumours?
Alpha feto-protein | hCG
113
Cut off RMI value for referral to specialist MDT?
250
114
FIGO staging for ovarian cancer?
1 ovarian only 2 beyond ovaries but pelvis only 3 beyond pelvis but abdomen only 4 beyond abdomen
115
3 general areas of causes of pruritis vulvae?
Infection Dermatological Neoplasia
116
Which of the lichen conditions most mimics dermatitis or eczema?
Lichen simplex
117
Which of the lichen conditions mostly affects mucosa (mouth and genital)?
Lichen planus - causing painful, erosive flat papules
118
Which of the lichen conditions has an autoimmune link and may be associated with thyroid disease and vitiligo?
Lichen sclerosus
119
Who does lichen sclerosus mostly affect and how does it present?
Postmenopausal women Severe pruritis -> thinning skin, adhesions, fissures Labial fusion and introital narrowing
120
Which of the lichen conditions carries a risk of vulval carcinoma?
Lichen sclerosus
121
What do Bartholin's glands normally do? How do they form cysts/abscesses?
Normally secrete lubricant for vulva | Blockage leads to cyst formation, can become infected with staph/E coli etc.
122
How do bartholin's gland abscesses present?
Acute pain, large red tender swelling
123
What is the drainage method for bartholin's gland cysts called?
Incise, drain and leave open (marsupialisation)
124
In what age is primary dysmenorrhea most common? When does it tend to recede?
15-25, symptoms decrease with age and tend to stop after childbirth
125
Pain associated with primary dysmenorrhea?
Crampy pains starting within 24 hours of menstruation, stop within 2-3 days
126
In what age is secondary dysmenorrhea most common?
Over 30s
127
What device can cause secondary dysmenorrhea within first few months of insertion?
IUD
128
Pain associated with secondary dysmenorrhea?
Starts at least 2 days before menstruation and continues whole way through Associated with other Sx e.g. Dyspareunia
129
Metabolic cause of menorrhagia?
Hypothyroidism
130
What is the general cause of physiological leucorrhoea? Relation to causes of increased discharge?
High oestrogen | So increased in pregnancy, CoCP, around time of ovulation
131
What medical procedure can encourage growth of follicular ovarian cysts?
Clomiphene ovulatory induction
132
What ovarian benign ovarian cysts can secrete lots of oestrogen?
Follicular cysts
133
What 3 item criteria is used to define PCOS? What are they?
Rotterdam criteria PCO as defined by at least 12 follicles or increased ovarian size Oligo/anovulation Clinical or biochemical evidence of hyperandrogenism
134
What is co-cyprindol?
Drug used for symptom management of PCOS
135
2 drugs suitable for PCOS in women wanting to get pregnant?
Metformin | Clomiphene
136
What cancer is PCOS a risk factor for?
Endometrial
137
Large doughy uterus, uterine contractions with persistent bleeds and expulsion of grape like material. Diagnosis?
Molar pregnancy
138
What is ptyalism?
Excessive salivation
139
What does an unsatisfactory cervical smear result mean?
Incorrect processing or not enough cells | Repeat in 4 weeks
140
What does an inconclusive cervical smear result suggest?
Infection - treat and repeat
141
What happens if woman has normal smear but is positive for HPV?
Retest every 6m til negative Then yearly for 2 years Then 2 yearly
142
With what infection is strawberry cervix associated with?
Thrichomoniasis
143
Differentials for cervical motion tenderness/cervical excitation?
Classical of PID | To a lesser extent ectopic pregnancy
144
Boggy, tender uterus on Bimanual exam?
``` Adenomyosis Uterine atony (postpartum) ```
145
Differentials for an adnexal mass on bimanual?
Ovarian - cysts, tumours, PCOS Ectopic pregnancy Abscess
146
Which of gonorrhoea and chlamydia in women typically causes malodourous, purulent discharge?
Chlamydia
147
4 infections detectable via high vaginal swab?
BV Trichomonas Candida Group B Strep
148
2 infections detected by endocervical swab? Which uses charcoal media?
Gonorrhoea (charcoal media) | Chlamydia
149
What is more suggestive of PID than endometriosis?
Fever | Vaginal discharge
150
What type of cervical cancer is associated with COCP use?
CGIN
151
What is virilisation?
Mega high androgens (e.g. From adrenal hyperplasia or androgen secreting tumour) causing irreversible male changes in women e.g. Clitoromegaly and vocal deepening
152
What is the difference between virilisation and hirsutism?
Both hyperandrogenism but hirsutism is milder and reversible | Virilisation mega and irreversible
153
What is acanthosis nigricans?
Darkly pigmented velvety skin in skin flexures (nape of neck, skin folds, elbow creases) associated with PCOS and DM
154
What skin change may be associated with DM and PCOS?
Acanthosis nigricans
155
What is the progestogen challenge test used for?
5 day course of prog should induce withdrawal bleed when stopped - used for detecting patency of connection between uterus cervix and vagina and an oestrogenised uterus
156
What 2 conditions can progestogen challenge test highlight?
Asherman's syndrome | Cervical stenosis
157
What heart auscultation findings are common in pregnancy?
Ejection systolic murmur and S3 gallop due to hyperdynamic circulation
158
What does uterine fibroid embolization herald a risk of in future?
Premature ovarian failure - 1%
159
What pregnancy interval is a RF for pre-eclampsia?
10 years (likely nulliparity)
160
How can vaginal pH be used to differentiate between causes of vaginal discharge?
BV and trichomonas have alkaline pH (>4.5) | Candida has acidic or normal
161
What pH do BV and trichomonas share?
Over 4.5 alkaline
162
What does asymmetric IUGR suggest?
Placental insufficiency
163
What is granuloma inguinale?
Painless slow growing ulcerative lesions with no regional lymphadenopathy caused by Klebsiella granulomatis
164
Painless, slow growing genital ulcer with no associated regional lymphadenopathy?
Granuloma inguinale
165
Sx associated with lymphogranuloma?
Unilateral tender inguinal or femoral lymphadenopathy | Self limiting, papule like ulcer
166
Unilateral tender inguinal and femoral lymphadenopathy with papule-like ulcer?
Lymphogranuloma
167
What Ix is best for detecting early Syphillis infection from lesion exudate or tissue?
Darkfield examination
168
What is Darkfield examination used for?
Early Syphillis infection isolate from tissue exudate
169
Sx of chancroid?
Painful general ulcer with tender suppurative lymphadenopathy
170
Painful genital ulcer plus tender suppurative lymphadenopathy?
Chancroid
171
7 steps of vertex delivery?
``` Engagement Descent Flexion of head Internal rotation Extension and restitution External rotation Expulsion ```
172
Describe complete hyatid moles?
Diploid (46 chromosomes) with paternal origin only No Fetal tissue Higher risk of need for chemo
173
Describe partial hyatid moles?
Triploid - 69 chromosomes with full paternal and half maternal Identifiable Fetal tissue
174
3 early pregnancy Sx of hyatid moles?
Early hyperthyroidism, pre-eclampsia and hyperemesis
175
What 2 Sx typify Kallmans syndrome?
Hypothalamic (hypogonadotrophic) hypogonadism | Anosmia
176
Is smoking a RF for placenta praevia?
Nope
177
Most common oestrogen secreting ovarian tumour? How does this present?
Mucinous cystadenoma - young woman with PV bleed

Revision Qs (28 decks)

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