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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 5-13Oestrogen predominates to thicken the endometriumFH > 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 14-28Progesterone dominates to form a secretory endometriumLH > 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 IDANormally just when heavy enough to interfere with everyday life

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11
Q

Most common causes of menorrhagia?

A

IdiopathicFibroidsPolyps

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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 antifibrinolyticNSAIDs

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16
Q

What is third line management for menorrhagia?

A

Progestogens to induce artificial amenorrheaGnRH analogues to induce artificial menopauseIf fail, surgery

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17
Q

Most common causes of irregular periods and IMB?

A

Fibroids, adenomyosisPolypsOvarian cystsPID

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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

PregnancyLactation

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22
Q

6 areas of causes of amenorrhea/oligomenorrhoea?

A

Drugs e.g. Progestogens, GnRH agonists, antipsychoticsHypothalamic hypogonadismPituitary - hyperprolactinaemia Adrenals/thyroid - hypothyroidismOvary - PCOS, prem menopause, TurnersOutflow tract disturbance

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23
Q

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

A

PCOS - normally oligoPremature menopauseHyperprolactinaemia

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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
Q

Is PCB ever ‘normal’? What are the most common causes?

A

NoMost commonly cervical e.g. Ectropion, polyps, CancerCan be atrophic vaginitis in older women

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26
Q

Why does dysmenorrhea happen and what are the 2 types?

A

High prostaglandins causing contraction and uterine ischaemiaPrimary = no organic causeSecondary = secondary to pelvic pathology

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27
Q

Characteristics of primary dysmenorrhea?

A

No organic causeNormally at start of menstruationOften responds to NSAIDs or ovulatory suppression (COCP)

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28
Q

Most common causes of secondary dysmenorrhea?

A

FibroidsAdenomyosis, endometriosis PID

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29
Q

Characteristics of secondary dysmenorrhea?

A

Often precedes menstruationCommonly coexists with deep dyspareunia, menorrhagia, irregular mensesRequires PUS and laparoscopy

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30
Q

What is the premenstrual syndrome?

A

Sx worsening in luteal phase of cycle, resolve by end of menstruationTension, irritability, aggression, depressionIBS like symptoms, breast pain

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31
Q

Management of premenstrual syndrome?

A

SSRIs (duloxetine) are usefulCycle ablation - COCP, GnRH analogues with add back HRT

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32
Q

What is the relationship between fibroids and adenomyosis?

A

Fibroids (leiomyomata) are benign myometrial tumoursAdenomyosis is endometriosis which deposits within the myometriumBoth can cause menorrhagia, irregular/IMB, dysmenorrhea

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33
Q

What effect does progesterone have on the endometrium and how does it relate to menstruation?

A

Causes gland swelling and vascularisation Falls at the end of the cycle causing decrease in blood supply, ischaemia and menstruation

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34
Q

What do fibroids depend on for growth and therefore what is protective against them?

A

Oestrogen and progesterone (so common just pre-menopause and normally regress during pregnancy, post-menopause)Pregnancy, COCP, Progestogens are protective

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35
Q

3 types of fibroids and how do they relate to polyps?

A

Subserous fibroidsIntramural fibroidsSubmucosal fibroidsIntracavity polypsSubserous polyps

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36
Q

What polyps and fibroids are related in terms of location and symptomlogy?

A

Intracavity polyps and submucosal fibroids both push into uterine cavitySubserous fibroids and subserous polyps both push out of uterus and make the outside of it bumpy

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37
Q

When can fibroids grow during pregnancy and what problems can arise?

A

Can grow mid-pregnancy second trimester-> preterm labour, malpresentation, transverse lie, PPHRed degeneration (severe pain)Pedunculated fibroid torsion

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38
Q

What is the cancerous change that arises from fibroids?

A

Leiomyosarcoma

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39
Q

Why can Hb be high with fibroids?

A

They can secrete erythropoietin

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40
Q

Investigations for fibroids?

A

TVUS +/- MRI +/- laparoscopy

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41
Q

Medical management of fibroids if not trying to conceive?

A

GnRH agonists to induce temporary menopause with add back HRT

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42
Q

Alternative surgical management for fibroids if wanting to preserve fertility?

A

Pretreatment GnRH agonists followed by hysteroscopy and TCRF for submucosal/intracavity polypMyomectomy - open laparotomy or laparoscopic for intramural/subserous

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43
Q

What is umbilical artery embolization UAE used for?

A

Fibroids shrinkage in those that don’t want kids

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44
Q

What can haematometra occur as a result of?

A

Fibrosis post-endometrial resection, cone biopsyCarcinomaCongenital malformation or imperforate hymen (1* amenorrhea)

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45
Q

What is the commonest genital tract cancer in women?

A

Endometrial cancer

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46
Q

Who does endometrial cancer occur most commonly in?

A

Older women > 60

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47
Q

What histological type are the majority of endometrial cancers?

A

Adenocarcinoma of columnar endometrial gland cells

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48
Q

What is the major risk factor for endometrial cancer and what 2 types can this broadly be split into?

A

Unopposed oestrogen/high oestrogen:prog ratioSplit into exogenous and endogenous oestrogen excess

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49
Q

Exogenous oestrogen RFs for endometrial cancer?

A

Tamoxifen for breast cancerUnopposed oestrogen therapy

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50
Q

Endogenous oestrogen sources as risk factors for endometrial cancer?

A

Obesity (androgen->oestrogen conversion)PCOSNulliparityLate menopauseOestrogen secreting (ovarian) tumours

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51
Q

What is Lynch type II syndrome?

A

Hereditary Non-Polyposis Colorectal CancerRisks of colorectal, endometrial and ovarian cancer

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52
Q

What is the premalignant disease for endometrial cancer?

A

Endometrial hyperplasia with atypia Requires hysterectomy if possible

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53
Q

What is the biggest presenting picture for endometrial cancer?

A

PMB - increasing likelihood of cancer with ageIf pre-menopausal - rare but IMB/irregular menses or oligomenorrhoea

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54
Q

What cervical pathology may coexist with endometrial cancer?

A

Cervical Glandular Intraepithelial Neoplasia CGIN

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55
Q

How is FIGO staging for endometrial cancer carried out?

A

USS + endometrial pipelle biopsy +/- hysteroscopyStaging can only be done post-hysterectomy

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56
Q

Stages for endometrial cancer?

A

Stage 1 - uterus only (75% at presentation)Stage 2 - uterus and cervixStage 3 - invasive through uterus into adnexae, vagina, LNsStage 4 - bowel or bladder spread or distant mets

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57
Q

Stage 1 management for endometrial cancer?

A

H+BSOIf turns out subsequently to be stage 3 -> ?radiotherapy

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58
Q

Recurrence for endometrial cancer?

A

Most commonly vaginal vault - VGIN

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59
Q

Moist Smelly Stuff is Gynae Basics of gynae history?

A

Menstrual questionsSexual HxSmear HxGenitourinary Sx incl dischargeBowel Sx

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60
Q

What is cervical ectropion?

A

Visible endocervical columnar epithelium as redness around external osMore common during pregnancy, COCP

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61
Q

Other than asymptomatic, how can cervical ectropion present?

A

DischargePost-coital bleeding

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62
Q

Management of cervical ectropion?

A

Cryotherapy after exclusion of carcinoma by smear/colposcopy

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63
Q

What is chronic cervicitis?

A

A common cause of discharge, often due to chronic STI of cervical ectropion

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64
Q

What are cervical polyps?

A

Benign endocervical epithelial tumours most common in older women

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65
Q

Apart from asymptomatic, how can cervical polyps present?

A

Post-coital bleeding, Intermenstrual bleeding

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66
Q

Management of cervical polyps?

A

Avulsion + histological analysis

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67
Q

What are Nabothian follicles?

A

Columnar cell secretions trapped under squamous epithelium leading to white/opaque swellings in ectocervix. Commonly asymptomatic

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68
Q

What is the most common histological type of cervical cancer?

A

Squamous cell carcinoma

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69
Q

What are CIN I-III and what do they represent?

A

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

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70
Q

What is another term form CIN III and how does it progress to malignant disease?

A

Carcinoma in situ -> invasion through basement membrane

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71
Q

What HPV serotypes are most implicated in cervical cancer?

A

16, 18, 31 and 33

72
Q

Besides HPV RFs, RFs for cervical cancer?

A

SmokingImmunocompromise

73
Q

What is the screening programme for cervical cancer?

A

3 yearly from 25-495 yearly from 49-64

74
Q

What is the lowest level of dyskaryosis in CIN which, when combined with a positive HPV titre, should prompt a colposcopy?

A

CIN I + positive HPV -> colposcopy

75
Q

What is HPV screening used for in CIN?

A

As HPV triage and also test of cure

76
Q

What can presence of CGIN indicate?

A

Cervical/endometrial adenocarcinoma so should prompt colposcopy and endometrial biopsy

77
Q

What do confirmed CIN II and III have to be treated with? What risk does this hold for future pregnancies?

A

LLETZSlight risk of preterm labour in future

78
Q

Other than asymptomatic, how can cervical cancer present?

A

PCB, IMB, PM, offensive dischargePain, GI/GU Sx

79
Q

FIGO stage 1-4 for cervical cancer?

A

1 - cancer confined to cervix2 - local spread into vagina but not pelvic side wall3 - spread to lower vagina or pelvic walls or ureteric obstruction4 - invasion of bladder, rectum or beyond

80
Q

Management of cervical cancer with increasing grade at presentation?

A

Come biopsy/hysterectomy -> radical hysterectomy -> chemo/radiotherapy

81
Q

What are common ovarian symptoms?

A

None! Often silentWith increasing size, can eventually cause abdominal distension and bloating

82
Q

What is an ovarian accident?

A

Acute rupture, haemorrhage, torsion or infarct of an ovarian mass (usually cyst)

83
Q

What is PCO?

A

Term descriptive of the characteristic TVUS appearance: >12 small follicles in an enlarged ovary

84
Q

What can prompt a woman with PCO to develop PCOS?

A

Weight gain

85
Q

Major diagnostic features of PCOS?

A

AnovulationHirsutism either clinically or as high serum testosteroneOligomenorrhoea/irregular periodsPCO on TVUS

86
Q

What is the pathophysiological background of PCOS?

A

Genetic susceptibility leading to increased LH production and peripheral insulin resistanceLH and insulin act on PCO causing ovarian androgen production and disruption of folliculogenesis

87
Q

What FH condition is common with PCOS?

88
Q

3 long term risks of PCOS?

A

Endometrial cancer (anovulation leading to unopposed oestrogen)DM2GDM and miscarriage during pregnancy

89
Q

First line management of PCOS?

A

Lifestyle - weight loss

90
Q

Management of PCOS if wanting fertility?

A

ClomifeneMetformin Gonadotrophins, IVF

91
Q

Management of PCOS if fertility not desired?

A

Symptomatic relief - COCP or Mirena to regulate menstruation and treat hirsutismAnti androgens (systemic or topical)

92
Q

What is premature menopause defined as?

A

Menopause before age of 40

93
Q

What is the most common congenital cause of gonadal dysgenesis?

A

Turners syndrome 45XO

94
Q

What are the 3 major types of primary ovarian carcinoma?

A

Epithelial tumoursGerm cell tumoursSex cord tumours

95
Q

What are the most common malignant primary ovarian cancers?

A

Epithelial cell cancers - serous cystadenoma/adenocarcinoma

96
Q

What are the 5 types of ovarian epithelial carcinoma?

A

Serous cystadenomaMucinous cystadenoma Endometrioid carcinomaClear cell carcinomaBrenner tumour

97
Q

From what ovarian tumour can pseudomyxoma peritonei originate?

A

Borderline mucinous cystadenoma

98
Q

In whom are germ cell ovarian tumours more common?

A

Women under 30

99
Q

2 types of germ cell ovarian tumour? What is the most common malignant ovarian cancer in younger women?

A

Teratoma/dermoid cystDysgerminoma (most common)

100
Q

3 types of ovarian sex cord tumour?

A

Granulosa cell tumoursThecomasFibromas

101
Q

What do granulosa cell tumours secrete?

A

Oestrogen and inhibinThus causing endometrial hyperplasia/cancer or precocious puberty

102
Q

What is Meig’s syndrome?

A

Fibroma, ascites and right sided pleural effusion

103
Q

What are the 2 most common primary sites for ovarian secondary malignancies?

A

BreastGI cancers

104
Q

2 major cyst conditions of ovaries?

A

Endometriotic (chocolate) cystsFunctional cysts - follicular/lutein cysts

105
Q

What is protective vs functional ovarian cysts?

106
Q

RFs for ovarian cancer?

A

Related to increasing number of ovulations:Early menarcheLate menopauseNulliparity

107
Q

Protective factors against ovarian cancer?

A

PregnancyLactationCOCP

108
Q

Familial links for ovarian cancer?

A

BRCA 1+2HNPCC (lynch syndrome type II)

109
Q

What 3 cancers is lynch II (HNPCC) implicated in?

A

OvarianEndometrialColorectal

110
Q

What common GI disease manifestation does ovarian cancer often mimic?

111
Q

What is used to assess ovarian cancer possibility in secondary care? How is it calculated?

A

Risk of Malignancy IndexRMI = Ca125 x US x Menopausal Status

112
Q

What specific bloods may be useful to investigate ovarian cancer in women under 40 at increased risk of germ cell tumours?

A

Alpha feto-protein hCG

113
Q

Cut off RMI value for referral to specialist MDT?

114
Q

FIGO staging for ovarian cancer?

A

1 ovarian only2 beyond ovaries but pelvis only3 beyond pelvis but abdomen only4 beyond abdomen

115
Q

3 general areas of causes of pruritis vulvae?

A

InfectionDermatologicalNeoplasia

116
Q

Which of the lichen conditions most mimics dermatitis or eczema?

A

Lichen simplex

117
Q

Which of the lichen conditions mostly affects mucosa (mouth and genital)?

A

Lichen planus - causing painful, erosive flat papules

118
Q

Which of the lichen conditions has an autoimmune link and may be associated with thyroid disease and vitiligo?

A

Lichen sclerosus

119
Q

Who does lichen sclerosus mostly affect and how does it present?

A

Postmenopausal womenSevere pruritis -> thinning skin, adhesions, fissuresLabial fusion and introital narrowing

120
Q

Which of the lichen conditions carries a risk of vulval carcinoma?

A

Lichen sclerosus

121
Q

What do Bartholin’s glands normally do? How do they form cysts/abscesses?

A

Normally secrete lubricant for vulvaBlockage leads to cyst formation, can become infected with staph/E coli etc.

122
Q

How do bartholin’s gland abscesses present?

A

Acute pain, large red tender swelling

123
Q

What is the drainage method for bartholin’s gland cysts called?

A

Incise, drain and leave open (marsupialisation)

124
Q

In what age is primary dysmenorrhea most common? When does it tend to recede?

A

15-25, symptoms decrease with age and tend to stop after childbirth

125
Q

Pain associated with primary dysmenorrhea?

A

Crampy pains starting within 24 hours of menstruation, stop within 2-3 days

126
Q

In what age is secondary dysmenorrhea most common?

127
Q

What device can cause secondary dysmenorrhea within first few months of insertion?

128
Q

Pain associated with secondary dysmenorrhea?

A

Starts at least 2 days before menstruation and continues whole way throughAssociated with other Sx e.g. Dyspareunia

129
Q

Metabolic cause of menorrhagia?

A

Hypothyroidism

130
Q

What is the general cause of physiological leucorrhoea? Relation to causes of increased discharge?

A

High oestrogen So increased in pregnancy, CoCP, around time of ovulation

131
Q

What medical procedure can encourage growth of follicular ovarian cysts?

A

Clomiphene ovulatory induction

132
Q

What ovarian benign ovarian cysts can secrete lots of oestrogen?

A

Follicular cysts

133
Q

What 3 item criteria is used to define PCOS? What are they?

A

Rotterdam criteriaPCO as defined by at least 12 follicles or increased ovarian sizeOligo/anovulationClinical or biochemical evidence of hyperandrogenism

134
Q

What is co-cyprindol?

A

Drug used for symptom management of PCOS

135
Q

2 drugs suitable for PCOS in women wanting to get pregnant?

A

MetforminClomiphene

136
Q

What cancer is PCOS a risk factor for?

A

Endometrial

137
Q

Large doughy uterus, uterine contractions with persistent bleeds and expulsion of grape like material. Diagnosis?

A

Molar pregnancy

138
Q

What is ptyalism?

A

Excessive salivation

139
Q

What does an unsatisfactory cervical smear result mean?

A

Incorrect processing or not enough cellsRepeat in 4 weeks

140
Q

What does an inconclusive cervical smear result suggest?

A

Infection - treat and repeat

141
Q

What happens if woman has normal smear but is positive for HPV?

A

Retest every 6m til negativeThen yearly for 2 yearsThen 2 yearly

142
Q

With what infection is strawberry cervix associated with?

A

Thrichomoniasis

143
Q

Differentials for cervical motion tenderness/cervical excitation?

A

Classical of PIDTo a lesser extent ectopic pregnancy

144
Q

Boggy, tender uterus on Bimanual exam?

A

AdenomyosisUterine atony (postpartum)

145
Q

Differentials for an adnexal mass on bimanual?

A

Ovarian - cysts, tumours, PCOSEctopic pregnancyAbscess

146
Q

Which of gonorrhoea and chlamydia in women typically causes malodourous, purulent discharge?

147
Q

4 infections detectable via high vaginal swab?

A

BVTrichomonasCandidaGroup B Strep

148
Q

2 infections detected by endocervical swab? Which uses charcoal media?

A

Gonorrhoea (charcoal media)Chlamydia

149
Q

What is more suggestive of PID than endometriosis?

A

FeverVaginal discharge

150
Q

What type of cervical cancer is associated with COCP use?

151
Q

What is virilisation?

A

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
Q

What is the difference between virilisation and hirsutism?

A

Both hyperandrogenism but hirsutism is milder and reversibleVirilisation mega and irreversible

153
Q

What is acanthosis nigricans?

A

Darkly pigmented velvety skin in skin flexures (nape of neck, skin folds, elbow creases) associated with PCOS and DM

154
Q

What skin change may be associated with DM and PCOS?

A

Acanthosis nigricans

155
Q

What is the progestogen challenge test used for?

A

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
Q

What 2 conditions can progestogen challenge test highlight?

A

Asherman’s syndromeCervical stenosis

157
Q

What heart auscultation findings are common in pregnancy?

A

Ejection systolic murmur and S3 gallop due to hyperdynamic circulation

158
Q

What does uterine fibroid embolization herald a risk of in future?

A

Premature ovarian failure - 1%

159
Q

What pregnancy interval is a RF for pre-eclampsia?

A

10 years (likely nulliparity)

160
Q

How can vaginal pH be used to differentiate between causes of vaginal discharge?

A

BV and trichomonas have alkaline pH (>4.5)Candida has acidic or normal

161
Q

What pH do BV and trichomonas share?

A

Over 4.5 alkaline

162
Q

What does asymmetric IUGR suggest?

A

Placental insufficiency

163
Q

What is granuloma inguinale?

A

Painless slow growing ulcerative lesions with no regional lymphadenopathy caused by Klebsiella granulomatis

164
Q

Painless, slow growing genital ulcer with no associated regional lymphadenopathy?

A

Granuloma inguinale

165
Q

Sx associated with lymphogranuloma?

A

Unilateral tender inguinal or femoral lymphadenopathy Self limiting, papule like ulcer

166
Q

Unilateral tender inguinal and femoral lymphadenopathy with papule-like ulcer?

A

Lymphogranuloma

167
Q

What Ix is best for detecting early Syphillis infection from lesion exudate or tissue?

A

Darkfield examination

168
Q

What is Darkfield examination used for?

A

Early Syphillis infection isolate from tissue exudate

169
Q

Sx of chancroid?

A

Painful general ulcer with tender suppurative lymphadenopathy

170
Q

Painful genital ulcer plus tender suppurative lymphadenopathy?

171
Q

7 steps of vertex delivery?

A

EngagementDescentFlexion of headInternal rotationExtension and restitutionExternal rotationExpulsion

172
Q

Describe complete hyatid moles?

A

Diploid (46 chromosomes) with paternal origin onlyNo Fetal tissueHigher risk of need for chemo

173
Q

Describe partial hyatid moles?

A

Triploid - 69 chromosomes with full paternal and half maternalIdentifiable Fetal tissue

174
Q

3 early pregnancy Sx of hyatid moles?

A

Early hyperthyroidism, pre-eclampsia and hyperemesis

175
Q

What 2 Sx typify Kallmans syndrome?

A

Hypothalamic (hypogonadotrophic) hypogonadismAnosmia

176
Q

Is smoking a RF for placenta praevia?

177
Q

Most common oestrogen secreting ovarian tumour? How does this present?

A

Mucinous cystadenoma - young woman with PV bleed

O+G Year 5 (8 decks)

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