Gynaecology Flashcards by Matthew Ashman

Common features of PCOS

Excessive androgens
Hirsutism (excessive hair)
Infrequent periods
Ovarian cysts on imaging

Obesity
Acne 
Subfertility 
Chronic pelvic pain
Depression

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Investigations for PCOS

Rotterdam criteria (2/3 present):
Multiple ovaries (12 or more >10cm)
Infrequent or no periods
Clinical or biochemical signs of hyperandrogenism

Bloods - testosterone (raised), LH (raised), FSH (normal), Progesterone (low),

Imaging - US

Also - thyroid (rule out hypothyroidism), prolactin (hyperprolactinaemia)

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Management of PCOS

Infrequent periods - Induce bleeding (otherwise unopposed oestrogen will cause endometrial thickening) - using COCP or a progesterone analogue

Weight loss - can induce normal menstrual cycle. Orlistat in severe cases

Infertility - Clomifene and metformin can induce ovulation. Consider laparoscopic ovarian drilling

Hirsutism - Cosmetically, anti-androgen medication

Treat complications - diabetes, psych problems, dyslipidaemia

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Causes of menorrhagia

PALM COEIN

Polyp
Adenomyosis
Leiomyoma (fibroid)
Malignancy and hyperplasia 
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic - hormones, IUD
Not classified yet

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Investigations of menorrhagia

Bloods:
FBC - anaemia 
U+E's and LFTs - underlying liver problem? blood loss can affect electrolyte levels
Thyroid - underactive?
Other hormones - if PCOS suspected 
Coagulation and test for VWD

Imaging:
Transvaginal US (especially if palpable uterus or pelvic mass)
Cervical smear - if not up to date
High vaginal and enocervical swabs (infection)
Pipelle endometrial biopsy

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Management of menorrhagia

Treat cause

Conservative - iron supplements, analgesia
Levongestrol-releasing system (mirena)
Other pharmacological treatment - Tranexamic acid, mefanamic acid (taken during bleeding)

Surgical - Endometrial ablation or hysterectomy

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What is a threatened miscarriage? Features

Continuing pregnancy with bleeding

Some bleeding (less than menstruation) 
Cervical os is closed

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What is a delayed or missed miscarriage? Features

Gestation sack contains dead fetus, before 20 weeks
Without symptoms of expulsion
Mothers may have light vaginally bleeding
Pain usually not a feature
Cervical os closed

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What is a inevitable miscarriage? Features

Heavy bleeding with clots and pain

Cervical os is open

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What is an incomplete miscarriage? Features

Not all products expelled
Pain and bleeding
Cervical os is open

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Management of miscarriage

Expectant - wait for miscarriage. Appropriate if not much bleeding. Appropriate for incomplete. Rescan in 2 weeks

Medical - vaginally misoprostal

Surgical - heavy or persistant bleeding. Suction or gen surg

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What are predisposing factors for an ectopic pregnancy?

Anything that slows ovum's passage to the uterus.
Damage to the tubes - PID, previous surgery 
Previous ectopic
Endometriosis 
IUCD
POP
Subfertility 
IVF
Smoking

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Where are most ectopic implanted?

Ampulla of the tubes

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Management of ectopics

Expectant, medical or surgical

Stable women should be offered expectant or medical - asymptomatic, hCG <3000. Ectopic <3cm, no fetal activity. No haemoperitoneum

Expectant - must have falling hCG

Medical - methotrexate single dose

Surgical - laporoscopy, salpingectomy/otomy

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Fibroid presentation

Asymptomatic 
Menorrhagia - do not usually cause intermenstrual of postmenopausal bleeding
Anaemia 
Fertility problems 
Pain 
Mass

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Complications of fibroids

Red degeneration - their growth can outstrip blood supply - they are oestrogen sensitive and so grow in pregnancy

Pregnancy - enlargement 2nd trimester

Torsion

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Treatment or uterine fibroids

Minimal symptoms = no treatment needed
Levonogestrel-releasing IUS - first line
GnRH analogues - Goserelin
Ullipristal acetate- selective progesterone recepyor modulator
Myomectomy - only treatment to improve fertility
Uterine artery embolization
Hysterectomy

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Presentation of endometriosis

Pelvic pain - cyclical due to response from menstrual cycle 
Dysparanuia
Dysuria 
Pain of defecation
Subfertility 
No symptoms

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Investigations for endometriosis

Transvaginal US
Bowel involvement - MRI
Gold standard - laparoscopy with biopsy
Adenomyosis - mri is gold standard

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Treatment of endometriosis

Depends on symptoms severity
NSAIDs for symptoms
Empirical - COCP of progestogen if fertility not an issue (if analgesics worked)
IVF
GnRH analogues (if analgesics didn’t work)
Surgery - if medical management failed

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Causes of subfertility

Male factor
Tubular damage
Anovulation- premature ovarian failure, turners, chemotherapy, surgery, PCOS, excessive weight gain or loss 
Unexplained 
Fibroids
Endometriosis

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Investigations and advice for subfertility

Semen analysis
Serum progesterone 7 days prior to expected next period (day 21 in 28 day cycle)

Folic acid
Advise BMI 20-25
Advise regular intercourse
Smoking/drinking

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What medication is used in management of ectopic

Methotrexate

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Causes of PID

Ascending infection - chlamydia, uterine instrumentation, post-partum
Can descend - appendicitis

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Features of PID

``` Lower abdominal pain associated with vaginal discharge Fever Dyspareunia Intermenstrual or postcoital bleeding Dysmenorrhoea Cervical motion tenderness ``` Pelvic inflammation secondary to chlamydia (Fitz Hugh Curtis syndrome) - RUQ discomfort

Investigations for PID

Vulvovaginal swabs FBC CRP Blood cultures if sepsis

Management of PID

Outpatient - ceftriaxone 500 mg Station or azithromycin plus doxycycline for 14 days and metronidazole 400 mg for 14 days Inpatient - ceftriaxone IV plus doxycycline Contact tracing Oral ofloxacin and oral metronidazole or IM ceftriaxone + oral doxycycline + oral metronidazole

What is overactive bladder / urge incontinence

Due to detrusor overactivity

What is stress incontinence

Leaking small amounts when coughing or laughing

What is overflow incontinence

Due to bladder outlet obstruction (prostate enlargement)

Invesrigations of urinary incontinence

Bladder diaries Vaginally exam - rule out prolapse Urine dipstick and culture Urodynamic studies

Management or urge incontinence

Bladder retraining for minimum of 6 weeks | Anti-muscarinics - oxybutynin, tolterodine

Management of stress incontinence

Pelvic floor muscle training - 8 contractions x 3 daily for minimum 6 months Surgical procedures Duloxetine

What is high in a molar pregnancy

Ridiculously high bHCG

Causes of primary amenorrhoea

Gonadal dysgenesis (turners syndrome) Congential malformations of genital tract Functional hypothalamic amenorrhoea (secondary to anorexia) Congenital adrenal hyperplasia

Causes of secondary amenorrhoea

``` Hypothalamic amenorrhoea (secondary to stress, exercise) PCOS Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis Sheehan's syndrome ```

Investigations in amenorrhoea

``` Exclude pregnancy FBC U&Es, coeliac screen, TFTs Gonadotrophins - low levels = hypothalamic cause, raised = ovarian problem (ovarian failure) raised in turners Prolactin Androgen - raised in PCOS Oestradiol ```

Most common presenting complaint in endometrial cancer

Postmenopausal bleeding

Management of endometrial hyperplasia

Progesterones Mirena coil Levonorgestrel

Risk factors for endometrial cancer

Unopposed oestrogen ``` Obesity Diabetes Increased age Late menopause Oestrogen HRT No or few pregnancies PROS Tamoxifen Lynch syndrome ```

Presentation of endometrial cancer

``` Postmenopausal bleeding Postcoital bleeding Intermenstrual bleeding Heavy period Abnormal vaginal discharge Haematuria Anaemia Raised platelets ```

Management of endometrial cancer

Refer - urgent Surgery - radical hysterectomy with bilateral salpingo-oophorectomy Also consider radio / chemotherapy Progesterone therapy

Investigations for endometrial cancer

``` Transvaginal US (5mm cut off) Pipelle biopsy Hysteroscopy with endometrial biopsy ```

Risk factors for ovarian cancer

``` Age (peaks at 60) BRCA1 and BRCA2 Increased ovulation Obesity Smoking Late menopause No pregnancy ```

Pregnancy decreases the risk of what cancer?

Endometrial | Ovarian

Presentation of ovarian cancer

``` Non-specific symptoms IBS Abdominal bloating Loss of appetite Pelvic pain Urinary symptoms Weight loss Ascites Abdo or pelvic mass ```

Investigations of ovarian cancer

``` Urgent referral CA125 Pelvic US CT - establish diagnosis and stage Histology - CT guided biopsy Ascitic tap Diagnostic laparotomy ```

Presentation of ovarian torsion

``` Sudden onset one sided pelvic pain Gets worse Associated nausea and vomiting Tenderness Mass ```

Investigagions of ovarian torsion

Emergency admission Pelvic US Laparoscopic surgery

Causes of premature ovarian failure

``` Idiopathic - most common, may be FHx Bilateral oophorectomy Radiotherapy Chemotherapy Infection - mumps / TB Autoimmjne disorders - coeliac, adrenal insufficiency, T1DM, thyroid ```

Presentation of premature ovarian failure

Irregular menstrual periods Lack of menstrual periods (secondary amenorrhoea) Symptoms of low oestrogen levels - hot flushes, night sweats, vaginally dryness

Diagnosis of premature ovarian failure

Less than 40, menopausal symptoms, elevated FSH

Risks of premature ovarian failure

``` Related to lack of oestrogen CVD stroke Osteoporosis Cognitive impairment Dementia Parkinsonism ```

Management of premature ovarian failure

HRT until normal age of menopause

When are you called for cervical screening?

25-49 - every 3 years | 50-65 - every 5 years

How is cervical screening performed?

Screened for HPV Then looked at for cytology (cellular changes) If cytology abnormal - colposcopy

First line management of urge incontinence

Bladder retraining

First line management of stress incontinence

Pelvic floor muscle training

What is a severe complication of infertility treatment

Ovarian hyperstimulation syndrome

Someone undergoing a hysterectomy for fibroids might take what short term medication?

GnRH agonists - goserelin

Uterine fibroid <3cm and not distorting the uterine cavity can be managed how?

IUS (medical management

Pelvic pain, dysmenorrhoea, dyspareunia and subfertility should point to what diagnosis?

Endometriosis

Most common benign ovarian tumour in women <25 years old

Dermoid cyst

Most common ovarian pathology found in meigs syndrome

Fibroma

Most common cause of ovarian enlargement in reproductive age

Follicular cyst

Symptoms of ruptured ovarian cyst

Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity

Raised FSH/LH in primary amenorrhea, consider what?

Gonadal dysgenesis (turners syndrome)

Lynch syndrome is risk factor for what?

Endometrial cancer

Gold standard invesrigation for endometriosis

Laparoscopy