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Obs & Gynae > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Describe the hypothalamic-pituitary-gonadal target organ (hormone) axis)

A

-Hypothalamus secretes GnRH-> promotes LH + FSH release from anterior pituitary-> stimulates oestrogen + inhibin production from the ovaries-> negative feedback on hypothalamus + AP-> decreases GnRH + LH + FSH-> decreases oestrogen + inhibin

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2
Q

What happens on the first day of the menstrual cycle?

A

Follicle begins to grow + oestrogen is secreted (negative feed back on AP)

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3
Q

What happens in the follicular phase (day 1-14) of the menstrual cycle?

A
  • Menses (day 0-7)
  • Proliferation (day 7-14)
  • Can change length
  • Negative feedback then in the middle oestrogen flips feedback to positive
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4
Q

When does ovulation occur and why?

A

Day 14 of the cycle due to LH surge

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5
Q

What happens in the luteal phase (day 14-28) of the menstrual cycle?

A
  • Secretory phase
  • Same length for everyone
  • Progesterone increased till 7 days before end of cycle (day 21 ish ie midluteal phase- depends on cycle length)
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6
Q

What pattern does oestrogen follow during the menstrual cycle?

A
  • Day 0-14-> increases (causing spiral artery contraction + shedding of endometrium ie menses)
  • Peaks at day 14
  • Decreases from day 14
  • Small increase at day 21
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7
Q

What pattern does progesterone follow during the menstrual cycle?

A
  • Low until day 14
  • Gradual increase until day 21 (mid luteal)
  • Decreases from day 21-28
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8
Q

What is the corpeus luteum and what causes it to break down?

A
  • Follicle of released egg
  • Secretes progesterone
  • Progesterone downregulates LH so negative feedback-> breaks down in not fertilised
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9
Q

What causes the corpus luteum to persist?

A
  • Fertilisation
  • Produces b-hCG-> acts like LH + keeps CL going to produce progesterone
  • Persists for 6 months of pregnancy
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10
Q

Which embryological ducts develop + degenerate in people with XX chromosomes?

A
  • Develop-> paramesonephric (Mullerian) ducts

- Degenerate-> Mesonephric (wolffian) ducts

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11
Q

Which embryological ducts develop + degenerate in people with XY chromosomes?

A
  • Develop-> mesonephric (wolffian) ducts

- Degenerate-> paramesonephric (mullerian) ducts

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12
Q

Histology of the ectocervix?

A

Stratified non-keratinous epithelium

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13
Q

Histology of the endocervix?

A

Simple columnar epithelium

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14
Q

Histology of the vagina?

A

Stratified squamous epithelium

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15
Q

What determines which of the embryological ducts break down and develop?

A

-Leydig cells-> produce testosterone + anti-Mullerian hormone

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16
Q

What are the four parts of the fallopian tube?

A
  • Isthmus-> connection to uterus
  • Ampulla-> wide + where fertilisation usually happens
  • Infundibulum-> narrow
  • Fimbriae-> captures ovum from ovary
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17
Q

Where in the fallopian tube does fertilisation usually occur?

A

The ampulla

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18
Q

What hormones does the anterior pituitary release?

A

LH, FSH, prolactin, GH, ACTH, TSH

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19
Q

What hormones does the posterior pituitary produce?

A

Oxytocin, ADH

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20
Q

What is menorrhagia?

A
  • Heavy menstrual bleeding
  • > 80ml blood loss per cycle
  • More determines by impact on QoL
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21
Q

Investigations for menorrhagia?

A
  • History-> length of cycle, amount of bleeding etc, related symptoms (pain, pressure, urine/bowel), PMH + drugs (eg anticoagulants)
  • Examination-> not usually needed unless pain
  • Bloods-> FBC (anaemia), coag screen (FH), TSH
  • US-> transvaginal or abdominal
  • Hysteroscopy-> if persistent or suspect abnormality
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22
Q

Causes of menorrhagia?

A

PALM-COEIN

  • Polyps
  • Adenomyosis
  • Leiomyoma (fibroids)
  • Malignancy or hyperplasia
  • Coagulopathy (eg VWF)
  • Ovulatory dysfunction (PCOS or perimenopause)
  • Emdometrial disorders
  • Iatrogenic (hormone therapy, copper coil)
  • Not yet classified
  • Other-> eg hypothyroid
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23
Q

Treatments for menorrhagia?

A
  • Tranexamic acid-> 2-8 tablets TDS for <4 days/month (period)
  • NSAIDs-> inc mefanamic acid
  • Hormonal-> COCP (younger), oral progesterones (older), IUS
  • Surgical-> myomectomy (large fibroids), hysterectomy
  • Endometrial ablation-> ensure complete family + may need repeat
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24
Q

Complications of menorrhagia?

A

-Increased risk of endometrial cancer + hyperplasia-> when 50+

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25
Q

Contraindications to endometrial ablation?

A

Malignancy, acute PID, excess cavity length

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26
Q

What is primary amenorrhoea?

A

-Failure to menstruate by age 15 (when normal secondary sexual characteristics present) or 13 (without)

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27
Q

Causes of primary amenorrhoea (with secondary characteristics)?

A

Physiological, GU malformations, endocrine (hypo/hyperthyroid, hyperprolactinaemia, Cushing’s), structural (eg imperforate hymen)

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28
Q

Causes of primary amenorrhoea (without secondary characteristics)?

A

Primary ovarian insufficiency, Turner’s, HT-P dysfunction (eg illness, stress, weight loss)

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29
Q

What is secondary amenorrhoea?

A
  • Menstruation stops for 3-6 months when previously normal

- Menstruation stops for 6-12 months when previously oligomenorrhoea

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30
Q

What is oligomenorrhoea?

A

Infrequent menstrual periods (<6-8 a year)

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31
Q

Causes of secondary amenorrhoea (without androgen XS features)?

A

Pregnancy, menopause, illness, stress, ED, weight loss, primary ovarian sufficiency

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32
Q

Causes of secondary amenorrhoea (with androgen XS features)?

A

PCOS, Cushing’s, late onset CAH, androgen-secreting tumours (eg ovarian/adrenal)

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33
Q

Management of amenorrhoea?

A
  • History + examination
  • Bloods-> prolactin, LH + FSH, TSH, testosterone
  • US
  • Gynae referral-> primary, increased LH/FSH, recent surgery or infection, infertility, suspected PCOS
  • Endocrine-> secondary, high prolactin, low LH/FSH, suspect Cushing’s/late CAH
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34
Q

What is acute pelvic pain?

A

Pain in lower abdomen/pelvis for 3+ months

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35
Q

Causes of acute pelvic pain?

A
  • Ectopic-> need pregnancy test
  • Complications of pregnancy-> miscarriage, cysts, ligament stretch etc
  • Ovarian-> torsion, haemorrhage, abscess, rupture
  • Adenexal-> fallopian tube torsion, cysts, abscess
  • Mittleschmerz-> pain on ovulation
  • Haematometra/haematocolops-> blood retention in uterus/vagina
  • Other-> PID, dysmenorrhoea, exacerbation of chronic pain
  • Consider GI + urological causes
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36
Q

Investigations for acute pelvic pain?

A
  • History + examination-> abdominal + pelvic
  • Pregnancy test
  • MSU
  • Triple swabs-> high vaginal, endocervical, cervical
  • Bloods-> FBC, CRP, G+S, X match
  • Scans-> pelvic US (abdo/TV), abdo Xray +/- contrast, CT/MRI
  • Diagnostic laparoscopy-> when can’t find cause
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37
Q

What is chronic pelvic pain?

A
  • Intermittent or constant pain in the lower abdomen or pelvis for 6 months
  • Not exclusively with menstruation, intercourse or pregnancy
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38
Q

Causes of chronic pelvic pain?

A
  • Endometriosis
  • Adenomyosis
  • Adhesions-> trapped ovary syndrome (post-hysterectomy)
  • Pelvic venous congestion-> dilated veins
  • Other-> GI, urological, MSK, neurological
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39
Q

Investigations for chronic pelvic pain?

A
  • History + examination
  • Pain diary-> connect factors
  • GnRH analogue trial-> if doesn’t help then hysterectomy likely won’t help
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40
Q

What could a GnRH analogue trial in chronic pelvic pain indicate?

A

If doesn’t help with pain then can indicate that hysterectomy wouldn’t help with symptoms

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41
Q

Treatment options for chronic pelvic pain?

A
  • Analgesia-> use pain ladder, pre-emptive (eg when predictive + cyclical), pain clinic referral, neuropathic
  • Hormonal-> COCP, GnRH analogues, IUS, low dose HRT etc
  • Surgery-> hysterectomy etc
  • Other-> physio + psych
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42
Q

What is a fibroid?

A
  • Leiomyoma-> benign smooth muscle lesion

- Dependent on oestrogen

43
Q

Symptoms of uterine fibroids?

A
  • Heavy bleeds
  • Painful bleeds
  • Pressure feeling when large-> eg urinary
44
Q

What is a subserous fibroid and what are its symptoms?

A
  • Outside of the uterus

- No bleeding or pregnancy problems

45
Q

What is a submucous fibroid and what are its sub-types?

A

-Types 0, 1 (<50% in myometrium) + 2 (some in cavity)

46
Q

What is an intracavity fibroid and what are its symptoms?

A
  • In the uterine cavity
  • Can interfere with pregnancy (eg miscarriage)
  • Irregular or heavy bleeding
  • Pain-> contraction of uterus as tries to get rif of fibroid
47
Q

What is an intramural fibroid?

A

-Within the muscle layer of the uterus

48
Q

Investigation of choice for fibroids?

A

Hysteroscopy-> whitened + may have some blood vessels

49
Q

Treatment for fibroids?

A
  • Myomectomy
  • Hysterectomy
  • Uterine artery embolisation
  • Hysteroscopic resection
  • Temporary menopause using GnRH-> block FSH + LH so stop oestrogen production + shrinks fibroid
50
Q

What is a uterine polyp?

A
  • Cavity occupying lesion
  • Made of endometrium (benign)-> fibrous tissue + columnar epithelium
  • Due to disordered cycles of endometrial regrowth + apoptosis
51
Q

Symptoms of uterine polyps?

A
  • Heavy bleeding
  • Infertility
  • Miscarriages
52
Q

Investigations of uterine polyps?

A
  • Bloods (anaemia)

- Hysteroscopy-> look pink and fleshy

53
Q

What is adenomyosis?

A
  • When endometrium found in the myometrium + bleeds
  • Often from placenta getting stuck in myometrium after pregnancy
  • Not hormonal
54
Q

Symptoms of adenomyosis?

A
  • Usually older and multiparous
  • Heavy bleeding
  • Pain
55
Q

Treatment for adenomyosis?

A

Endometrial ablation

56
Q

What is endometriosis?

A

Endometrial tissue outside of cavity

57
Q

Where is endometriosis most commonly found?

A
  • In the pelvis-> especially the pouch of Douglas (lowest part of pelvis when standing)
  • retrograde menstruation (ie up to fallopian tubes)
58
Q

Other than in the pelvis, where can endometriosis be found?

A

Anywhere except the brain

59
Q

Can endometriosis spread?

A

Yes- via blood (embolism) or lymphatics

60
Q

What can put someone at an increased risk of endometriosis?

A
  • Family history
  • Immunodeficiency
  • High exposure to oestrogen + not much progesterone-> eg PCOS
61
Q

Symptoms of endometriosis?

A
  • Heavy bleeding
  • Infertility
  • Pain-> cyclical, during periods, often low parity + young
  • Dyspareunia-> when tissue in/near pouch of Douglas
  • Often have fibroids too
62
Q

Gold standard investigation for endometriosis?

A

Laparoscopy

63
Q

What is an endometrioma?

A
  • Chocolate cysts in ovaries/pelvis indicating endometriosis

- Can see/biopsy using US

64
Q

Treatments for endometriosis?

A
  • Give progesterone + take away oestrogen
  • COCP 3 months back to back-> stop cycle of oestrogen
  • Other hormonal-> mini pill, depo, IUS
  • GnRH agonists-> artificial menopause + stop cycle (give HRT for osteoporosis risk)
  • Surgical-> endometrial ablation, nodule exicsions, hysterectomy
65
Q

Complications of endometriosis?

A
  • Recurrence-> only stops completely after menopause
  • Infertility
  • Fibrosis + adhesions (can cause frozen pelvis)
  • Cyst rupture
  • Reduced quality of life
66
Q

What is polycystic ovarian syndrome (PCOS)?

A

-Common condition that causes irregular periods, excess androgens and polycystic ovaries

  • Theca cells produce excess androgens
  • Increased testosterone
  • Hyperinsulinaemia + insulin resistance
  • Low sex hormone binding protein
67
Q

How might PCOS present?

A

Acne, hirsutism, secondary amenorrhoea or oligomenorrhoea, infertility, hair loss

68
Q

Treatments for PCOS?

A
  • Weight loss if BMI is high
  • Metformin-> when lifestyle interventions not working
  • COCP
  • Clomiphine-> fertility drug
  • Infertility referral
69
Q

What is Turner Syndrome?

A
  • Person born with single X chromosome (45XO)

- Gonadal dysgenesis-> premature ovarian failure

70
Q

Features of Turner syndrome?

A

Short, webbed neck, high arching palate, downward sloping eyes + ptosis, broad chest, widely spaced nipples, underdeveloped ovaries, late/incomplete puberty, infertility, cubitus valgus

71
Q

Complications of Turner syndrome?

A

Recurrent otitis media + UTIs, coarctation of the aorta, hypothyroid, HTN, obesity, diabetes, o’porosis, LDs

72
Q

Management of Turner syndrome?

A
  • Oestrogen + progesterone replacement
  • Fertility treatment
  • Monitoring for complications
73
Q

What are tumour suppressor genes?

A
  • Genes that protect against cancer
  • ‘Brake signal’ in G1 of cell cycle
  • Eg-> p53
74
Q

What is an oncogene?

A
  • Stimulate cancer development
  • Single mutation often not enough to cause cancer
  • Eg-> HER2
75
Q

What is the most common type of endometrial cancer?

A

Adenocarcinomas (90%)

76
Q

What are some risk factors for endometrial cancer?

A
  • Unapposed oestrogen-> early menarche, late menopause, nulliparity, PCOS, oestrogen-only HRT
  • Obesity
  • T2DM
  • Tamoxifen
  • Ovarian tumours
77
Q

How might endometrial cancer present?

A

Post-menopausal bleeding

78
Q

Investigations for endometrial cancer?

A
  • TV US
  • If >4mm endometrial thickness-> hysteroscopy + biopsy
  • May need MRI (staging) + CT (mets)
79
Q

Treatment for endometrial cancer?

A
  • Usually total hysterectomy +/- pelvic lymph node removal
  • Radiotherapy-> for LNs
  • Progesterones
80
Q

What is cervical intraepithelial neoplasia (CIN)?

A

Pre-cancerous cells in the cervix

81
Q

What causes cervical intraepithelial neoplasia (CIN)?

A

HPV types 16 + 18

82
Q

What are the different types/grades of cervical intraepithelial neoplasia (CIN)?

A
  • CIN1-> 1/3 thickness of epithelium affected
  • CIN2-> up to 2/3 thickness
  • CIN3-> up to full thickness (but not cancer as only affects epithelium)
83
Q

Treatment options for cervical intraepithelial neoplasia (CIN)?

A
  • May watch + wait
  • Laser therapy, cryotherapy or cold coagulation
  • Large loop excision of transformation zone (LLETZ)-> thin heated loop to excise + seal tissue
  • Cone biopsy
84
Q

What is the most common type (histology) of cervical cancer?

A

Squamous cell (90%)

85
Q

What causes cervical cancer?

A

HPV 16 + 18 (persistent) and/or high grade CIN

86
Q

What are the stages of cervical cancer?

A
  • 1A1-> very small
  • 1B2-> >4cm in cervix
  • 2-> into surrounding tissues eg vagina
  • 3-> Into other structures or pelvic/abdominal LNs
  • 4-> spread to bladder, rectum or further
87
Q

What are some of the risk factors for cervical cancer?

A
  • COCP
  • Immunosuppression (eg HIV)
  • HPV
  • Smoking
  • Chronic illness
88
Q

Treatment options for cervical cancer?

A
  • Low grade-> surgical resection
  • Chemotherapy-> radical or palliative
  • Radiotherapy
  • Pelvic extenteration-> remove pelvic organs
89
Q

What is done (histologically) when screening for cervical cancer?

A
  • HPV testing

- Liquid based cytology if HPV +ve

90
Q

What are some of the risk factors for vulval intraepithelial neoplasia (VIN) and vulval cancer?

A
  • Lichen sclerosis

- 5% of VIN turns to cancer

91
Q

How might vulval intraepithelial neoplasia (VIN) present?

A
  • Post-menopausal itching or pain
  • Dyspareunia
  • Pink-white papules over labia
  • Lesion/ulcer on labia/clitoris
  • Adherence + fusing of labia
92
Q

Treatment options for vulval intraepithelial neoplasia (VIN)?

A
  • Topical potent steroids

- Wide local excision + histology

93
Q

Treatment options for vulval cancer?

A

-Vulvectomy +/- groin LN excision

94
Q

What are the different types of ovarian tumours?

A
  • Epithelial carcinomas (most common)
  • Serous + mucinous cystadenomas
  • Germ cell tumours-> teratoma (benign) or dysgerminoma (malignant)
  • Brenner-> benign and rare
95
Q

Risk factors for ovarian cancer?

A
  • Lots of ovulations-> early menarche, late menopause

- BRCA 1/2 genes

96
Q

Protective factors against ovarian cancer?

A
  • Breastfeeding
  • Hysterectomy
  • OCP
97
Q

How might ovarian cancer present?

A

-Vague, IBS-like abdominal symptoms-> bloating etc

98
Q

When should investigation into ovarian cancer be prompted?

A

Aged 45+ and new IBS-like symptoms

99
Q

Where is ovarian cancer likely to spread?

A

Abdomen and pelvic organs (but quite rare)

100
Q

What primary cancers is ovarian cancer a common metastasis site of?

A

Breast and GI malignancy

101
Q

Investigations for ovarian cancer?

A
  • Bloods-> AFP, hCG, LDH can all increase
  • CA125-> marker
  • US
  • CT-> if cyst looks suspicious
102
Q

What might cause a raised CA125?

A
  • Ovarian cancer
  • Periods
  • Endometriosis
  • Pregnancy
  • Heart failure
  • Liver disease
103
Q

How is the risk of ovarian cancer calculated?

A

US findings x menopause status x CA125-> over certain number prompts referral

104
Q

Treatment for ovarian cancer?

A
  • Surgery-> laparotomy

- Chemotherapy

Obs & Gynae (5 decks)

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