Gynaecology Flashcards
Describe the hypothalamic-pituitary-gonadal target organ (hormone) axis)
-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
What happens on the first day of the menstrual cycle?
Follicle begins to grow + oestrogen is secreted (negative feed back on AP)
What happens in the follicular phase (day 1-14) of the menstrual cycle?
- Menses (day 0-7)
- Proliferation (day 7-14)
- Can change length
- Negative feedback then in the middle oestrogen flips feedback to positive
When does ovulation occur and why?
Day 14 of the cycle due to LH surge
What happens in the luteal phase (day 14-28) of the menstrual cycle?
- 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)
What pattern does oestrogen follow during the menstrual cycle?
- 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
What pattern does progesterone follow during the menstrual cycle?
- Low until day 14
- Gradual increase until day 21 (mid luteal)
- Decreases from day 21-28
What is the corpeus luteum and what causes it to break down?
- Follicle of released egg
- Secretes progesterone
- Progesterone downregulates LH so negative feedback-> breaks down in not fertilised
What causes the corpus luteum to persist?
- Fertilisation
- Produces b-hCG-> acts like LH + keeps CL going to produce progesterone
- Persists for 6 months of pregnancy
Which embryological ducts develop + degenerate in people with XX chromosomes?
- Develop-> paramesonephric (Mullerian) ducts
- Degenerate-> Mesonephric (wolffian) ducts
Which embryological ducts develop + degenerate in people with XY chromosomes?
- Develop-> mesonephric (wolffian) ducts
- Degenerate-> paramesonephric (mullerian) ducts
Histology of the ectocervix?
Stratified non-keratinous epithelium
Histology of the endocervix?
Simple columnar epithelium
Histology of the vagina?
Stratified squamous epithelium
What determines which of the embryological ducts break down and develop?
-Leydig cells-> produce testosterone + anti-Mullerian hormone
What are the four parts of the fallopian tube?
- Isthmus-> connection to uterus
- Ampulla-> wide + where fertilisation usually happens
- Infundibulum-> narrow
- Fimbriae-> captures ovum from ovary
Where in the fallopian tube does fertilisation usually occur?
The ampulla
What hormones does the anterior pituitary release?
LH, FSH, prolactin, GH, ACTH, TSH
What hormones does the posterior pituitary produce?
Oxytocin, ADH
What is menorrhagia?
- Heavy menstrual bleeding
- > 80ml blood loss per cycle
- More determines by impact on QoL
Investigations for menorrhagia?
- 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
Causes of menorrhagia?
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
Treatments for menorrhagia?
- 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
Complications of menorrhagia?
-Increased risk of endometrial cancer + hyperplasia-> when 50+
Contraindications to endometrial ablation?
Malignancy, acute PID, excess cavity length
What is primary amenorrhoea?
-Failure to menstruate by age 15 (when normal secondary sexual characteristics present) or 13 (without)
Causes of primary amenorrhoea (with secondary characteristics)?
Physiological, GU malformations, endocrine (hypo/hyperthyroid, hyperprolactinaemia, Cushing’s), structural (eg imperforate hymen)
Causes of primary amenorrhoea (without secondary characteristics)?
Primary ovarian insufficiency, Turner’s, HT-P dysfunction (eg illness, stress, weight loss)
What is secondary amenorrhoea?
- Menstruation stops for 3-6 months when previously normal
- Menstruation stops for 6-12 months when previously oligomenorrhoea
What is oligomenorrhoea?
Infrequent menstrual periods (<6-8 a year)
Causes of secondary amenorrhoea (without androgen XS features)?
Pregnancy, menopause, illness, stress, ED, weight loss, primary ovarian sufficiency
Causes of secondary amenorrhoea (with androgen XS features)?
PCOS, Cushing’s, late onset CAH, androgen-secreting tumours (eg ovarian/adrenal)
Management of amenorrhoea?
- 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
What is acute pelvic pain?
Pain in lower abdomen/pelvis for 3+ months
Causes of acute pelvic pain?
- 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
Investigations for acute pelvic pain?
- 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
What is chronic pelvic pain?
- Intermittent or constant pain in the lower abdomen or pelvis for 6 months
- Not exclusively with menstruation, intercourse or pregnancy
Causes of chronic pelvic pain?
- Endometriosis
- Adenomyosis
- Adhesions-> trapped ovary syndrome (post-hysterectomy)
- Pelvic venous congestion-> dilated veins
- Other-> GI, urological, MSK, neurological
Investigations for chronic pelvic pain?
- History + examination
- Pain diary-> connect factors
- GnRH analogue trial-> if doesn’t help then hysterectomy likely won’t help
What could a GnRH analogue trial in chronic pelvic pain indicate?
If doesn’t help with pain then can indicate that hysterectomy wouldn’t help with symptoms
Treatment options for chronic pelvic pain?
- 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
What is a fibroid?
- Leiomyoma-> benign smooth muscle lesion
- Dependent on oestrogen
Symptoms of uterine fibroids?
- Heavy bleeds
- Painful bleeds
- Pressure feeling when large-> eg urinary
What is a subserous fibroid and what are its symptoms?
- Outside of the uterus
- No bleeding or pregnancy problems
What is a submucous fibroid and what are its sub-types?
-Types 0, 1 (<50% in myometrium) + 2 (some in cavity)
What is an intracavity fibroid and what are its symptoms?
- 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
What is an intramural fibroid?
-Within the muscle layer of the uterus
Investigation of choice for fibroids?
Hysteroscopy-> whitened + may have some blood vessels
Treatment for fibroids?
- Myomectomy
- Hysterectomy
- Uterine artery embolisation
- Hysteroscopic resection
- Temporary menopause using GnRH-> block FSH + LH so stop oestrogen production + shrinks fibroid
What is a uterine polyp?
- Cavity occupying lesion
- Made of endometrium (benign)-> fibrous tissue + columnar epithelium
- Due to disordered cycles of endometrial regrowth + apoptosis
Symptoms of uterine polyps?
- Heavy bleeding
- Infertility
- Miscarriages
Investigations of uterine polyps?
- Bloods (anaemia)
- Hysteroscopy-> look pink and fleshy
What is adenomyosis?
- When endometrium found in the myometrium + bleeds
- Often from placenta getting stuck in myometrium after pregnancy
- Not hormonal
Symptoms of adenomyosis?
- Usually older and multiparous
- Heavy bleeding
- Pain
Treatment for adenomyosis?
Endometrial ablation
What is endometriosis?
Endometrial tissue outside of cavity
Where is endometriosis most commonly found?
- In the pelvis-> especially the pouch of Douglas (lowest part of pelvis when standing)
- retrograde menstruation (ie up to fallopian tubes)
Other than in the pelvis, where can endometriosis be found?
Anywhere except the brain
Can endometriosis spread?
Yes- via blood (embolism) or lymphatics
What can put someone at an increased risk of endometriosis?
- Family history
- Immunodeficiency
- High exposure to oestrogen + not much progesterone-> eg PCOS
Symptoms of endometriosis?
- Heavy bleeding
- Infertility
- Pain-> cyclical, during periods, often low parity + young
- Dyspareunia-> when tissue in/near pouch of Douglas
- Often have fibroids too
Gold standard investigation for endometriosis?
Laparoscopy
What is an endometrioma?
- Chocolate cysts in ovaries/pelvis indicating endometriosis
- Can see/biopsy using US
Treatments for endometriosis?
- 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
Complications of endometriosis?
- Recurrence-> only stops completely after menopause
- Infertility
- Fibrosis + adhesions (can cause frozen pelvis)
- Cyst rupture
- Reduced quality of life
What is polycystic ovarian syndrome (PCOS)?
-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
How might PCOS present?
Acne, hirsutism, secondary amenorrhoea or oligomenorrhoea, infertility, hair loss
Treatments for PCOS?
- Weight loss if BMI is high
- Metformin-> when lifestyle interventions not working
- COCP
- Clomiphine-> fertility drug
- Infertility referral
What is Turner Syndrome?
- Person born with single X chromosome (45XO)
- Gonadal dysgenesis-> premature ovarian failure
Features of Turner syndrome?
Short, webbed neck, high arching palate, downward sloping eyes + ptosis, broad chest, widely spaced nipples, underdeveloped ovaries, late/incomplete puberty, infertility, cubitus valgus
Complications of Turner syndrome?
Recurrent otitis media + UTIs, coarctation of the aorta, hypothyroid, HTN, obesity, diabetes, o’porosis, LDs
Management of Turner syndrome?
- Oestrogen + progesterone replacement
- Fertility treatment
- Monitoring for complications
What are tumour suppressor genes?
- Genes that protect against cancer
- ‘Brake signal’ in G1 of cell cycle
- Eg-> p53
What is an oncogene?
- Stimulate cancer development
- Single mutation often not enough to cause cancer
- Eg-> HER2
What is the most common type of endometrial cancer?
Adenocarcinomas (90%)
What are some risk factors for endometrial cancer?
- Unapposed oestrogen-> early menarche, late menopause, nulliparity, PCOS, oestrogen-only HRT
- Obesity
- T2DM
- Tamoxifen
- Ovarian tumours
How might endometrial cancer present?
Post-menopausal bleeding
Investigations for endometrial cancer?
- TV US
- If >4mm endometrial thickness-> hysteroscopy + biopsy
- May need MRI (staging) + CT (mets)
Treatment for endometrial cancer?
- Usually total hysterectomy +/- pelvic lymph node removal
- Radiotherapy-> for LNs
- Progesterones
What is cervical intraepithelial neoplasia (CIN)?
Pre-cancerous cells in the cervix
What causes cervical intraepithelial neoplasia (CIN)?
HPV types 16 + 18
What are the different types/grades of cervical intraepithelial neoplasia (CIN)?
- 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)
Treatment options for cervical intraepithelial neoplasia (CIN)?
- 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
What is the most common type (histology) of cervical cancer?
Squamous cell (90%)
What causes cervical cancer?
HPV 16 + 18 (persistent) and/or high grade CIN
What are the stages of cervical cancer?
- 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
What are some of the risk factors for cervical cancer?
- COCP
- Immunosuppression (eg HIV)
- HPV
- Smoking
- Chronic illness
Treatment options for cervical cancer?
- Low grade-> surgical resection
- Chemotherapy-> radical or palliative
- Radiotherapy
- Pelvic extenteration-> remove pelvic organs
What is done (histologically) when screening for cervical cancer?
- HPV testing
- Liquid based cytology if HPV +ve
What are some of the risk factors for vulval intraepithelial neoplasia (VIN) and vulval cancer?
- Lichen sclerosis
- 5% of VIN turns to cancer
How might vulval intraepithelial neoplasia (VIN) present?
- Post-menopausal itching or pain
- Dyspareunia
- Pink-white papules over labia
- Lesion/ulcer on labia/clitoris
- Adherence + fusing of labia
Treatment options for vulval intraepithelial neoplasia (VIN)?
- Topical potent steroids
- Wide local excision + histology
Treatment options for vulval cancer?
-Vulvectomy +/- groin LN excision
What are the different types of ovarian tumours?
- Epithelial carcinomas (most common)
- Serous + mucinous cystadenomas
- Germ cell tumours-> teratoma (benign) or dysgerminoma (malignant)
- Brenner-> benign and rare
Risk factors for ovarian cancer?
- Lots of ovulations-> early menarche, late menopause
- BRCA 1/2 genes
Protective factors against ovarian cancer?
- Breastfeeding
- Hysterectomy
- OCP
How might ovarian cancer present?
-Vague, IBS-like abdominal symptoms-> bloating etc
When should investigation into ovarian cancer be prompted?
Aged 45+ and new IBS-like symptoms
Where is ovarian cancer likely to spread?
Abdomen and pelvic organs (but quite rare)
What primary cancers is ovarian cancer a common metastasis site of?
Breast and GI malignancy
Investigations for ovarian cancer?
- Bloods-> AFP, hCG, LDH can all increase
- CA125-> marker
- US
- CT-> if cyst looks suspicious
What might cause a raised CA125?
- Ovarian cancer
- Periods
- Endometriosis
- Pregnancy
- Heart failure
- Liver disease
How is the risk of ovarian cancer calculated?
US findings x menopause status x CA125-> over certain number prompts referral
Treatment for ovarian cancer?
- Surgery-> laparotomy
- Chemotherapy
