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Women's health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

How common are pelvic floor disorders?

A

20% adult women experience regular incontinence
10% will have surgery for prolapse
< 10% anal incontinence
Increase with age, parity, obesity, smoking

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2
Q

What should you also consider with pelvic floor disorders?

A

Sexual dysfunction linked to lower urinary tract, vaginal and bowel
Can’t be considered in isolation

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3
Q

What is incontinence?

A

Involuntary leakage of urine
Social or hygiene problems
Can be objectively demonstrable

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4
Q

What happens with an overactive bladder/detrusor overactivity?

A

Involuntary bladder contractions

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5
Q

What are the symptoms of overactive bladder?

A

Urgency and urgency incontinence
Frequency
Nocturia
Nocturnal enuresis
‘Key in door’
Sound of running water
Intercourse

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6
Q

What happens with stress urinary incontinence?

A

Sphincter weakness

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7
Q

What are the symptoms of stress incontinence?

A

Involuntary leaking due to anything that increases intraabdominal pressure as sphincter not working properly
Cough
Laugh
Lifting
Exercise
Movement
Walking/running downhill
Intercourse
Stumble/choking/vomiting

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8
Q

Name 3 different types of incontience

A

Sphincter weakness - stress incontinence
Detrusor overactivity - overactive bladder
Mixed
Fistula
Neurological and functional eg dementia - can cause reflux into kidneys as bladder pressure so high
Overflow and retention

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9
Q

What assessments can you do for incontinence?

A

Urinalysis - MSU
Frequency and volume chart
Residual urine measurement
Questionnaire - ePAQ

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10
Q

What is recorded on a frequency volume chart?

A

Bladder diary
- Voided volume
- Frequency of urination
- Quantity and frequency of leakage
- Fluid intake
Diurnal variation
Initial assessment and clinical diagnosis
Planning treatment
Adjunct to cystometry

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11
Q

How is residual urine measurement done?

A

In and out catheter - CISC
- Post-surgical voiding dysfunction
- Post-natal retention
- Neuropath
Indwelling - suprapubic/urethral
USS

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12
Q

What are the different sections of the ePAQ questionnaire?

A

Urinary
- Pain
- Voiding
- Overactive bladder
- Stress incontinence
- QoL
Vaginal
- Pain
- Capacity
- Prolapse
- QoL
Bowel
- IBS
- Constipation
- Evacuation
- Continence
- QoL
Sexual
- Urinary
- Bowel
- Dyspareunia
- Overall sex life

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13
Q

What lifestyle adaptations can help with incontinence?

A

Weight loss including bariatric surgery
Smoking cessation - smoking damages collagens of pelvic organs, chronic cough
Reduced caffeine intake - stimulant
Avoidance of straining and constipation

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14
Q

How can you manage incontinence via containment?

A

Bladder bypass (catheters) - indwelling, clean intermittent self-catheterisation (CISC)
Leakage barriers (pads/pants)
Vaginal support (pessaries)
Skin care (barrier creams) to protect skin
HRT (vaginal oestrogen)
- Oestrogen and progesterone receptors - bladder dome, trigone, urethra, bladder neck, vagina, vesico-vaginal fascia
- Local vaginal oestrogen less frequency, urgency and incontinence
- Very little gets absorbed into system, fewer s/e
- Topical oestrogen
Lifestyle adaptation

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15
Q

How can you manage incontinence with treatment?

A

Overactive bladder
- Bladder drill
- Drugs (anti-cholinergic)
- Botox
- Augment
- Bypass
Stress incontinence
- Conservative (physio and lifestyle adaptation)
- Surgery (sling, suspension)
Reassurance, support, lifestyle adaptation, containment

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16
Q

What is the detrusor muscle?

A

Smooth muscle, transitional epithelium, normally contracts only during micturition

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17
Q

What innervates the detrusor muscle?

A

Sacral parasympathetic (S2-4) - reflex
Neurotransmitter - Ach
Receptors - muscarinic M2 and 3
T11 and 12 maintain relaxation of bladder for urine storage, reflex bladder contractions suppressed, brain will remove inhibition when goes to toilet

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18
Q

Name an Ach antagonist

A

Atropine

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19
Q

What are the S/E of atropine?

A

CNS - cognitive impairment
Constipation
Dry mouth
Blurred vision
Tachycardia

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20
Q

What are anticholinergics?

A

Atropine like agents M2 and 3 receptor antagonists
Antimuscarinic

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21
Q

Name an anti-cholinergic drug and it’s dose

A

Oxybutynin 2.5-5mg BD-TDS
PRN as effective, less S/E

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22
Q

What are the S/E of oxybutynin?

A

Dry mouth, blurred vision, drowsiness, constipation
Can’t see, can’t pee, can’t spit, can’t shit

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23
Q

What is the success rate of treatment with anti-cholinergics?

A

7% cured in one year
Large placebo effect

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24
Q

Name 2 other anti-cholinergics

A

Tolterodine
Propiverine
Trospium - doesn’t cross BBB so lower risk for CNS s/e - consider in older patients
Solifenacin

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25
Q

What is mirabegron?

A

Beta-3 adrenergic receptor agonist
Relaxes smooth muscle detrusor
Increased bladder capacity

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26
Q

How is stress incontinence treated?

A

Emphasis on conservative treatment before surgery
Self-help and lifestyle adaptation
- Weight, smoking, oestrogen
Physio, pelvic floor exercises, biofeedback, electrical stimulation, vaginal cones
Surgery
- Colposuspension, sling
- May be unsuitable due to medical conditions, mild/intermittent symptoms, personal circumstances

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27
Q

What are the principles of surgery for stress incontinence?

A

Restore pressure transmission to urethra
Support/elevate urethra
Increase urethral resistance

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28
Q

What history might you get for someone with uretero-vaginal prolapse?

A

Something coming down lump, discomfort, pelvic floor and sexual dysfunction

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29
Q

How would you examine someone with suspected uretero-vaginal prolapse?

A

Bimanual and sims speculum

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30
Q

What investigations should you do for uretero-vaginal prolapse?

A

Usually none

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31
Q

What is the treatment for uretero-vaginal prolapse?

A

Reassurance and advice, treat pelvic floor symptoms, pessary (holds vagina in place, can insert themselves), surgery

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32
Q

When do you repair a uretero-vaginal prolapse?

A

Symptomatic - dyspareunia, discomfort, obstruction, bothersome
Severe - outside vagina, ulcerated, failed conservative measures

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33
Q

How does an ovarian cyst present?

A

Presents with pain in the quadrant that the cyst is

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34
Q

What investigations should you do when someone presents with pain that could be an ovarian cyst?

A

Pregnancy test
Bloods
If in L lower quadrant then USS for appendicitis

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35
Q

Why do ovarian cysts cause pain?

A

○ Haemorrhage into cyst with sudden increase in size and/or rupture into peritoneal cavity with spillage of blood
If twists blood supply reduced, can be intermittent initially as it untwists, can stop hurting if necrotic

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36
Q

What are the treatment options for ovarian cysts?

A

Remove ovary - reduced fertility, may subsequently have cyst on other ovary
Remove cyst - spillage of dermoid contents may cause chemical peritonitis or at least untwist it with view to later surgery
Do nothing for now - pain unresolved, risk of torted ovary becoming necrotic and dying

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37
Q

What surgery can be done for ovarian cysts?

A

Laparotomy - cystectomy most easily achieved successfully, more pain, prolonged hospital stay, longer recovery, more wound infections, greater risk of thrombosis
Laparoscopy - less painful, shorter hospital stay, more difficult to shell out cyst and conserve ovarian tissue, longer procedure, increased risk of damage to major blood vessels and bowel

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38
Q

How common are miscarriages?

A

Occurs in 20% pregnancies

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39
Q

When is a miscarriage inevitable?

A

Once cervical os open enough to admit a finger

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40
Q

How can you diagnose a delayed miscarriage?

A

Ultrasound scan, empty gestation sac seen or foetal pole with no heart beat

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41
Q

How many early pregnancies complicated by vaginal bleeding will remain viable?

A

Approximately 60%

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42
Q

What management should you do when miscarriage incomplete and not associated with heavy bleeding or at early gestation < 8 weeks?

A

Expectant management

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43
Q

What is surgical treatment of miscarriage associated risks?

A

Uterine perforation

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44
Q

How quickly can medical management of delayed miscarriage be complete?

A

24 hours
Depends upon size on scan if > 12 weeks size

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45
Q

How common are ectopic pregnancies?

A

Approx 1% pregnancies

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46
Q

What is the most common site of an ectopic pregnancy?

A

Fallopian tube most common site (85-90%) of which cornual (interstitial) are 10% then ovary, cervix, and abdomen

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47
Q

When should you consider an ectopic pregnancy?

A

When empty uterus found on USS in patient with positive pregnancy test

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48
Q

What is the risk of a ruptured ectopic pregnancy?

A

Death

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49
Q

What is the maternal mortality rate with ectopic pregnancies?

A

Maternal mortality rate 10.12 per 100,000

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50
Q

How can ectopic pregnancies be treated?

A

Fallopian tube doesn’t need to be removed to remove ectopic pregnancy - salpingotomy - open fallopian tube and remove ectopic pregnancy, risk of incomplete removal so monitor hCG levels
Can treat medically using methotrexate
- Beta hCG level criteria (< 3000)
- Satisfactory LFTs and U&Es
- Needs to attend hospital for regular monitoring in pregnancy resolved

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51
Q

How common is vomiting in early pregnancy?

A

80%

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52
Q

What is hyperemesis gravidarum?

A

Excessive vomiting associated with dehydration and ketosis

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53
Q

In whom is hyperemesis gravidarum most common in?

A

Women with high beta hCG levels - such as twin pregnancies

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54
Q

How is hyperemesis gravidarum treated?

A

Rehydrate IV fluids
Vitamin supplements
NBM until oral fluids tolerated
Small, frequent meals recommended once easting recommenced
Anti-emetics

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55
Q

What is the menopause?

A

Cessation of menstruation
Average age 51
Diagnosed at 12 month of amenorrhoea
Onset of symptoms if hysterectomy

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56
Q

What is the perimenopause?

A

Period leading up to menopause
Characterised by irregular periods and symptoms eg hot flushes, mood swings, urogenital atrophy
Decreased oestrogen levels

57
Q

What are the central effects of decreased oestrogen during the perimenopause?

A

Vasomotor symptoms - hot flushes, sweats
MSK symptoms - joint and muscle pain
Low mood and sexual difficulties - low sexual desire

58
Q

What are the local effects of decreased oestrogen during the perimenopause?

A

Urogenital symptoms - vaginal dryness due to vaginal atrophy

59
Q

What are the short term impacts of the menopause?

A

Vasomotor symptoms
- Experienced by 60-80% women
- Last on average 2-7 years
- Impact on sleep, mood, and QoL
General symptoms
- Mood change/irritability
- Loss of memory/concentration
- Headaches, dry and itchy skin, joint pains
- Loss of confidence, lack of energy

60
Q

What are the medium term impacts of the menopause?

A

Urogenital atrophy
- Dypareunia
- Recurrent UTIs
- PMB
- Peak incidence of urinary incontinence and prolapse in 55-65

61
Q

What are the long term impacts of the menopause?

A

Osteoporosis
Cardiovascular disease- adverse changes in lipid
Dementia - increased prevalence with early menopause
Risk reduction strategies start at time of menopause

62
Q

How can you manage menopausal symptoms?

A

Holistic approach
Lifestyle advice
Reduce modifiable risk factors
Inform about options
- Hormonal - HRT, vaginal oestrogens
- Non-hormonal eg clonidine
Non-pharmaceutical eg CBT

63
Q

What are the benefits of HRT?

A

Relief of menopause symptoms
Bone mineral density protection
Possibly prevent long term morbidity

64
Q

What are the risks of HRT?

A

Breast cancer
VTE
CVS disease
Stroke

65
Q

What is the breast cancer risk with HRT?

A

HRT with oestrogen alone - little or no change in risk
HRT with oestrogen + progesterone - increased risk
Increased risk related to treatment duration and reduces after stopping HRT

66
Q

What is the risk of VTE with HRT?

A

Risk increased by oral HRT
Oral > transdermal
Transdermal = baseline population
Transdermal - BMI > 30 or increased risk of VTE
High risk women eg strong FH or thrombophilia refer to haematology for assessment before starting HRT

67
Q

What is the risk of CVD with HRT?

A

HRT doesn’t increased CVS risk when started in women < 60
Baseline risk of CVD varies according to existing risk factors
Presence of CVS risk factors not CI to HRT as long as optimally managed

68
Q

What is the risk of stroke with HRT?

A

Baseline population risk of stroke 11.3 per 1000 over 7.5 years
Oral (not transdermal) increases this risk slightly

69
Q

What dose of oestrogen should you give for HRT?

A

Aim for lowest effective dose

70
Q

Who should have transdermal HRT?

A

Gastric upset eg Crohn’s
Need for steady absorption eg migraine/epilepsy
Percieved increased risk of VTE
Older women - higher risk of HRT
Medical conditions eg hypertension
Patient choice

71
Q

What is premature ovarian insufficiency?

A

Menopause < 40 years

72
Q

What can cause premature ovarian insufficiency?

A

Majority of causes - idiopathic
Natural causes
- Chromosome abnormalities
- FSH receptor gene polymorphisms
- Inhibin B mutations
- Enzyme deficiencies
- Autoimmune disease
Iatrogenic
- Surgery
- Chemotherapy
- Radiotherapy

73
Q

How is premature ovarian insufficiency diagnosed?

A

FSH > 25 - 2 samples > 4 weeks apart + 4 months amenorrhoea

74
Q

How is premature ovarian insufficiency treated?

A

Encouraged to use HRT at least until average age of menopause

75
Q

What happens with conception and the menopause?

A

Fertile for 2 years if menopause < 50
Fertile for 1 year if menopause > 50

76
Q

How do you assess someone’s need for HRT?

A

Assess severity of symptoms
Risk factors for osteoporosis

77
Q

What are the CI to starting HRT?

A

Undiagnosed abnormal PV bleeding, breast lump, active liver disease

78
Q

What are the cautions with HRT treatment?

A

Fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history
Caution in starting HRT in over 60s

79
Q

What are the most common gynaecological cancers?

A

Uterus and ovary

80
Q

How common is endometrial cancer?

A

Incidence - 9000 cased UK/year and rising

81
Q

What can increase your risk of endometrial cancer?

A

Obesity
T2DM
Nulliparity
Late menopause
Ovarian tumours
Oestrogen only HRT
Pelvis irradiation
Tamoxifen
PCOS

82
Q

What signs might you get of endometrial cancer?

A

Post-menopausal bleeding

83
Q

What investigations can you do for endometrial cancer?

A

Transvaginal USS
Endometrial biopsy
Hysteroscopy

84
Q

What type of cancer is endometrial cancer?

A

Adenocarcinoma

85
Q

What is the staging for endometrial cancer?

A

FIGO I/II/III/IV

86
Q

What is the treatment for endometrial cancer?

A

Surgery - hysterectomy, bilateral salpingo-oophorectomy +/- pelvic lymph nodes
Radiotherapy
Progesterones

87
Q

What is the prognosis of stage 1 endometrial cancer?

A

5 year survival for stage 1 disease > 90%

88
Q

What can cause endometrial cancer?

A

HPV

89
Q

How common is HPV?

A

75% population affected by HPV at some point if life pre-vaccination

90
Q

Why does HPV cause endometrial cancer?

A

Regions E6 and 7 of HPV genome cause growth stimulation
Persistent HPV infection associated with increased risk of high grade cervical intraepithelial neoplasia

91
Q

How common is cervical cancer?

A

Incidence highest in 30-34 years
Highest rates in areas of high deprivation
Majority diagnosed at stage 1

92
Q

What cell type is cervical cancer?

A

Squamous (90%)/adenocarcinoma

93
Q

What is the cervical cancer staging?

A

FIGO I/II/III/IV

94
Q

What is the prognosis for stage 1 cervical cancer?

A

Stage I > 90% 5 year survival

95
Q

How is cervical cancer treated?

A

Stage 1 treatment - surgery
Stages 2+ treatment
- Radiotherapy
- Chemotherapy
- Palliative care

96
Q

How common is vulval cancer?

A

Uncommon, 20th most common cancer in women

97
Q

What can cause vulval cancer?

A

HPV/lichen sclerosis

98
Q

What cell type is vulval cancer?

A

Squamous (90%)

99
Q

What are the symptoms of vulval cancer?

A

Vulval itching
Vulval soreness
Persistent lump
Bleeding
Pain on passing urine
Past history of VIN/lichen sclerosis

100
Q

What are the stages of vulval cancer?

A

I < 2cm (79% 5 yr survival)
II > 2cm (59% 5 yr survival)
III adjacent organs/unilateral nodes (43% 5 yr survival)
IV bilateral nodes/distant mets (13% 5 yr survival)

101
Q

What is the treatment for vulval cancer?

A

Surgery - conservative
Surgery - radical
Radiotherapy +/- chemo

102
Q

How does ovarian cancer present?

A

Bloating/IBS like symptoms
Abdominal pain/discomfort
Change in bowel habit
Urinary frequency
Bowel obstruction
No symptoms at all

103
Q

How common is ovarian cancer?

A

> 7000 cases UK/year
Highest in 75-79 years
6/10 women present with advanced disease

104
Q

What can cause ovarian cancer?

A

Ovulation - menarche, menopause, parity, breast feeding, OCP, hysterectomy, ovulation induction
Gene mutation - BRCA1/2

105
Q

What is the prognosis of stage 3 ovarian cancer?

A

Stage 3 disease up to 40% 5 yr survival

106
Q

What cell type is ovarian cancer?

A

Epithelial 85% - includes fallopian tube and primary peritoneal cancers

107
Q

What investigations should you do for ovarian cancer?

A

Symptoms and age
CA125
USS
CT
Image guided biopsy

108
Q

What is the management for ovarian cancer?

A

Surgery
Chemotherapy

109
Q

What is endometriosis?

A

Presence of endometrial tissue outside the endometrial cavity
Chronic condition
High risk of recurrence
Impact on fertility
Impact on quality of life

110
Q

What are the symptoms of endometriosis?

A

Cyclic pain
Dysmenorrhoea
Dyspareunia
Young
Low parity

111
Q

How can you treat endometriosis?

A

Abolish cyclicity
- OCP
- GnRH agonists
Glandular atrophy
- Oral progestagens
- Depot provera
- Mirena

112
Q

How do GnRH agonists work?

A

Inhibit stimulation of pituitary release of gonadotrophins - increased FSH and LH
Followed by down regulation - decreased FSH and LH

113
Q

What are the risks of GnRH agonists?

A

Prolonged treatment may be necessary
HRT - add back therapy

114
Q

How can you treat endometriosis with surgery?

A

Ablation - maintains fertility
Excision - maintains fertility
Oophorectomy - if fertility no longer desired
Pelvic clearance - if fertility no longer desired

115
Q

How can endometriosis cause infertility?

A

Immune factors
Oocyte toxicity
Adhesion
Tubal dysfunction
Ovarian dysfunction

116
Q

How common are endometrial polyps?

A

15% malignant in post-menopausal women

117
Q

What are raised nitrites in an MSU an indication of?

A

Infection

118
Q

What are raised leukocyte esterases in an MSU an indication of?

A

Infection

119
Q

What is microscopic haematuria in an MSU an indication of?

A

Glomerulonephritis
Nephropathy
Neoplasia
Calculus
Infection

120
Q

What is proteinuria in an MSU an indication of?

A

Renal disease
Cardiac disease

121
Q

What is glucosuria in an MSU an indication of?

A

Diabetes
IGT
Nephropathy
Reduced renal threshold

122
Q

What can a frequency volume chart also be used for?

A

Bladder drill/bladder training

123
Q

What is the lower end of normal for the amount of voided urine?

A

400ml

124
Q

What is urodynamics and what is it used for?

A

Measuring intravesical (bladder) and intraabdominal pressures
Helps to determine type of incontinence
Can work out detrusor pressure

125
Q

What determines bladder pressure?

A

Detrusor pressure and abdominal pressure

126
Q

What is a cystogram?

A

Visualising continence
Helps diagnose stress incontinence

127
Q

Why can spinal cord damage cause incontinence?

A

T11 and 12 control over bladder reflex lost

128
Q

How does botox treat incontinence?

A

Over active bladder
Neurotoxin
Blocks acetylcholine release - prevents muscle contraction

129
Q

Where is the uterus in a 1st degree prolapse?

A

Uterus in upper half of vagina

130
Q

Where is the uterus in a 2nd degree prolapse?

A

Uterus nearly descended into opening of vagina

131
Q

Where is the uterus in a 3rd degree prolapse?

A

Uterus prolapsed out of vagina

132
Q

Where is the uterus in a 4th degree prolapse?

A

Completely out of vagina

133
Q

What are the 2 layers of the pelvic floor?

A

Levator ani - anterior muscles
Coccygeus - posterior muscles

134
Q

What are the 3 levator ani muscles?

A

Pubococcygeus
Iliococcygeus
Puborectalis - forms a sling around rectum

135
Q

What is the nerve innervation of coccygeus?

A

S2-3

136
Q

What is the role of coccygeus?

A

Resists intraabdominal pressure

137
Q

Name 4 risk factors for getting a pelvic prolapse

A

Obesity
Previous pelvic surgery
Chronic constipation
Vaginal or instrumental births
Multiple pregnancies
Larger babies
Post-menopausal
Hysterectomy
Genetics - weak connective tissues

138
Q

What is a threatened miscarriage?

A

Associated with vaginal bleeding with/without abdo pain

Women's health (9 decks)

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