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3a > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Define primary amenorrhoea

A

-Not starting menstruation
-By 13 yrs if no other signs of pubertal development
-By 15 years if signs of puberty

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2
Q

Define hypogonadism and give 2 causes ?

A

-> Lack of sex hormones
-> Hypogonadotropic hypogonadism : deficiency of LH and FSH
-> Hypergonadotropic hypogonadism : lack of response to LH and FSH by the gonads

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3
Q

What can cause hypogonadotropic hypogonadism ?

A

-Low GnRH -> low FSH & LH -> low oestrogen

-Hypopituitarism
-Damage to hypothalamus or pituitary
-Chronic conditions : CF, IBD
-Excessive exercise or dieting
-Constitutional delay in growth and development
-Endocrine disorders : growth hormone deficiency, hyopothyroid, cushing’s or hyperprolactinaemia
-Kallman syndrome

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4
Q

What is Kallman syndrome

A

-Genetic condition causing hypogonadotropic hypogonadism
-Causes a failure to start puberty and is associated with reduced or absent sense of smell

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5
Q

What is hypergonadotropic hypogonadism and what can cause it ?

A

-The gonads failure to respond to LH and FSH.
-There is no negative feedback from oestrogen, meaning the anterior pituitary continues to produce LH and FSH

-Damage to gonads
-Congenital absence of the ovaries
-Turner’s syndrome

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6
Q

Give 5 causes of primary amenorrhoea

A

-Hypogonadotropic hypongonadism
-Hypergonadotropic hypogonadism
-Congenital adrenal hyperplasia
-Androgen insensitivity syndrome
-Structural pathology

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7
Q

What is androgen insensitivity syndrome

A

-Occurs in someone who is genetically male (XY) but the tissue are unresponsive to androgen hormones
-Causes female phenotype : normal female external genitalia and breast tissue. BUT internally there are testes and an absent uterus, upper vagina, fallopian tubes and ovaries.

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8
Q

Give 5 structural pathologies than can cause primary amenorrhoea

A

-Imperforate hymen
-Transverse vaginal septae
-Vaginal agenesis
-Absent uterus
-Female genital mutilation

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9
Q

Define secondary amenorrhoea

A

-No menstruation for more than 3 mnths after previous regular menstrual periods

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10
Q

Give 8 causes of secondary amenorrhoea

A

-Pregnancy
-Menopause & premature ovarian failure
-Hormonal contraception
-Hypothlamic or pituitary pathology
-PCOS
-Asherman’s syndrome
-Thyroid
-Hyperprolactinaemia

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11
Q

Give 4 reasons why the hypothalamus would reduce GnRH production leading to secondary amenorrhoea

A

-Excessive exercise
-Low body weight and ED
-Chronic disease
-Psychological stress

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12
Q

Give 2 pituitary causes of amenorrhoea

A

-Pituitary tumours (e.g. prolactinoma)
-Pituitary failure due to trauma, radiotherapy, surgery or sheehan syndrome (postpartum hypopituitarism caused by necrosis of the pituitary gland)

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13
Q

Why does hyperprolactinaemia cause secondary amenorrhoea ?

A

-High prolactin -> prevents GnRH release from the hypothalamus
-Most common cause = pituitary adenoma. Often galactorrea also present

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14
Q

How is a prolactinoma managed ?

A

-> CT or MRI
-> Dopamine agonists (e.g. bromocriptine/cabergoline)

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15
Q

What 5 hormone tests are done in secondary amenorrhoea

A

-HCG -> preganancy
-LH and FSH (high = primary ovarian failure)
-Prolactin -> hyperprolactinaemia (followed by MRI)
-TSH
-Testosterone (raised = PCOS, androgen insensitivity, congenital adrenal hyperplasia)

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16
Q

When and what treatment is given to reduce the risk of osteoporosis in secondary amenorrhoea

A

-> Vit D and calcium if amenorrhoea lasts >12 mnths
-> HRT or combined oral contraceptive pill due to low oestrogen levels

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17
Q

Go over menorrhagia mindmap

A

Draw out mindmap

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18
Q

How is menorrhagia managed if no contraception is wanted ?

A

-> Tranexamic acid (if no associated pain)
-> Mefenamic acid (if associated pain)

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19
Q

How is menorrhagia managed if contraception is wanted ?

A

-1st : mirena coil
-2nd : combined oral contraceptivepill
-3rd : cyclical oral progestogens
-4th : progesterone only pill or implant
-Finals : endometrial ablation and hysterectomy

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20
Q

What are fibroids and who are they more common in ?

A

-Oestrogen sensitive tumours of smooth muscle of the uterus (uterine leiomyomas)
-Black women

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21
Q

What are the 4 types of fibroid ?

A

-Intramural -> within myometrium
-Subserosal -> below outer layer of uterus
-Submucosal -> blow endometrium
-Pedunculated -> on a stalk

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22
Q

If not asymptomatic, how do fibroids present? (6)

A
  • Menorrhagia
  • > 7 days menstruation
  • Abdo pain, worse on menstruation
  • Bloating or feeling full in the abdomen
  • Urinary or bowel Sx due to pelvic pressure or fullness
  • Deep dyspareunia (pain during sex)
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23
Q

What is the initial investigation for fibroids in menorrhagia ?

A

-Hysteroscopy
-Pelvic USS may be needed in larger fibroids

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24
Q

How are fibroids of <3cm managed ?

A

Medical : same as menorrhagia
Surgical : endometrial ablation, resection of fibroids, hysterectomy

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25
Q

How are fibroids >3cm managed ?

A

-Medical : same as menorrhagia
-Surgical : uterine artery embolisation, myomectomy, hysterectomy

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26
Q

Explain the surgical options used in larger fibroids

A

-Uterine artery embolistion : catheter passed through femoral artery to uterine artery to cut of O2 supply to fibroid and shrink it
-Myomectomy : surgical removal
-Hysterectomy : removing uterus and fibroids

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27
Q

Give 3 severe complications of fibroids?

A

-Red degeneration of fibroid
-Torsion of fibroid
-Malignant change to leiomyosarcoma (very rare)

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28
Q

What is red degeneration of fibroids

A

-Ischaemia, infarction and necrosis of the fibroid occurring most commonly in the 2nd or 3rd trimester of pregnancy
-Presents with severe abdo pain, low grade fever, tachycardia and vomiting
-Manage : supportive

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29
Q

Define endometriosis

A

-Ectopic endometrial tissue outside of the uterus
-Endometrioma : lump of endometrial tissue
-‘Chocolate cyst’ : endometrioma in the ovaries

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30
Q

If not asymptomatic, how does endometriosis present? (5)

A

-Cyclical abdominal or pelvic pain
-Deep dyspareunia
-Dysmenorrhoea
-Infertility
-Cyclical bleeding from other sites (e.g. haematuria, blood in stool)

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31
Q

What is the gold standard investigation for endometriosis?

A

-Laparoscopic surgery w biopsy of lesions
-Pelvic USS is often unremarkable

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32
Q

what are the management options of endometriosis ?

A
  • 1st line : analgesia (NSAIDS, ibuprofen)
  • 2nd : hormonal treatment (COCP, progestogens)
  • 3rd : GnRH analogues
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33
Q

What surgical options can help with fertility / symptom management of endometriosis

A

-Laparoscopic surgery to excise or ablate endometrial tissue and remove adhensions
-Hysterectomy and bilateral salpingo-opherectomy (ovary removal induces menopause and so stops ectopic endometrial tissue responding to the menstrual cycle)

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34
Q

Define adenomyosis

A

Endometrial tissue inside the myometrium (muscle layer of the uterus)

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35
Q

How does adenomyosis present ?

A

-Dysmenorrhoea
-Menorrhagia
-Dyspareunia
Can present with infertility or pregnancy related complications

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36
Q

What isn the 1st line investigation for adenomyosis ?

A

-Transvaginal USS of pelvis

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37
Q

How is andenomyosis managed?

A

Same as menorrhagia and dependent on want for contraception

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38
Q

Perimenopause
Menopause
Postmenopause

A

-Perimenopause : time leading up to the last period and the 12 mnths afterwards. Vasomotor and irregular periods
-Menopause : point at which menstruation stops
-Postmenopause : period from 12 mnths after the final menstrual period onwards

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39
Q

Explain the physiology behind why menopause occurs and the hormone levels

A

-> Decline in the development of ovarian follicles
-> Reduced oestrogen production
-> Increasing FSH and LH levels due to lack of negative feedback from oestrogen
-> Anovulation resulting in irregular periods
-> Without oestrogen endometrium does not develop leading to ammenorrhoea
-> Low oestrogen causes perimenopausal symptoms

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40
Q

What 4 conditions does a lack of oestrogen increase the risk of ?

A

-Cardiovascular disease and stroke
-Osteoporosis
-Pelvic organ prolapse
-Urinary incontinence

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41
Q

What is premature ovarian insuffiency and what does it cause?

A

-> Early onset menopause (<40 yrs) : irregular periods, secondary amenorrhea and Sx of low oestrogen levels (hot flushes, night sweats, vaginal dryness)
-> Hypergonadotropic hypogonadism
-> Raised LH and FSH, low oestradiol
- > Dx : raised FSH and menopausal sx

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42
Q

Give 5 causes of premature ovarian insufficiency

A

-> Idiopathic
-> Iatrogenic (chemo,radiotherapy)
-> Autoimmune (coeliac etc)
-> Genetic (+ Fx)
-> Infections (mumps, TB, cytomegalocirus)

43
Q

What is required for a diagnosis of primary ovarian insufficiency ?

A

-> Woman, <40 yrs with typical menopausal symptoms plus elevated FSH (>25 IU/l on 2 consecutive samples separated by >4 wks)

44
Q

How is primary ovarian insuffiency managed?

A

-HRT : traditional or combined oral contraceptive pill

45
Q

What are the associations with HRT?

A

-Lower BP compared to combined pill
-Risk of VTE, reduced by using patches rather than oral

46
Q

What can be used to alleviate symptoms in perimenopausal and postmenopausal women ?

A

-HRT

47
Q

Explain the 3 steps in choosing HRT

A
  1. Do they have local or systemic Sx?
    -Local : topical treatments
    -Systemic : go to step 2
  2. Does the woman have a uterus
    -No : continuous oestorgen only HRT
    -Yes : Combined, go to step 3
  3. Have they had a period in the last 12 mnths ?
    -Yes : give cyclical combined HRT
    -No : continuous combined HRT
48
Q

Why is combined HRT given to postmenopausal women with a uterus ?

A

-> Progesterone prevents endometrial hyperplasia and endometrial cancer secondary to ‘unopposed’ oestrogen.

49
Q

Give 5 non-hormonal treatments for menopausal symptoms

A

-Lifestyle changes
-CBT
-Clonidine
-SSRI
-Venlafaxine
-Gabapetin

50
Q

Give 4 indications for HRT use

A

-.Replacing hormones in premature ovarian insufficiency
-Reducing vasomotor symptoms
-Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
-Reducing risk of osteoporosis in women under 60

51
Q

Go over menopause and HRT mindmap

A

Draw mindmap

52
Q

What criteria is used for a diagnosis of PCOS?

A

ROTTERDAM : at least 2/3 needed ->

-Oligoovulation and anovulation presenting with irregular or absent menstrual periods
-Hyperandrogenism : characterised by hirsutism and acne
-Polycystic ovaries on USS

53
Q

What do the hormal blood tests typically show in PCOS?

A

-Raised LH
-Raised LH to FSH ratio
-Raised testosterone
-Raised insulin
-Normal or raised oestrogen levels
Low sex hormone binding globulin

54
Q

What imaging is used in PCOS

A

-Pelvic USS
-Transvaginal USS is gold standard for visualising ovaries

55
Q

How may the follicles be arranged on a transvaginal USS in PCOS?

A

-> ‘String of pearls’ appearance
-> The diagnostic criteria is either :

  1. 12 or more developing follicles on one ovary
  2. Ovarian volume of more than 10cm3
56
Q

What is a common associated condition with PCOS?

A

-Insulin resistance and DM

57
Q

What are the key aspects of PCOS management ?

A

-> weight loss : fertility, and hirsutism management
-> Mirena coil : endometrial cancer risk
-> COCP : manages endometrial cancer risk due to ‘unopposed oestrogen’, acne and hirsutism

58
Q

What are the 2 kinds of functional ovarian cyst and who are they common in ?

A

-Follicular -> most common ovarian cyst
-Corpus luteum

59
Q

What is the most common benign ovarian tumour in women under 30

A

-Dermoid cyst / teratoma
-Lined with epithelial tissue and so many contain skin, hair and teeth

60
Q

What is the tumour marker for epithelial cell ovarian cancer ?

A

-CA125

61
Q

What is the risk of malignancy index and what does it take into account?

A

-Estimates the risk of an ovarian mass being malignant
-Menopausal status, USS findings and CA125 levels

62
Q

How is a simple ovarian cyst in a premenopausal woman managed ?

A
  • <5cm, usually resolves within 3 cycles. No follow up scan
  • 5cm to 7cm : routine gynae referral and yearly USS monitoring
    ->7cm : MRI or surgical evaluation
63
Q

How are ovarian cysts in postmenopausal women managed ?

A

-> Check CA125 level
-> IF raised, two week wait gynae referral

64
Q

Triad of ovarian fibroma, pleural effusion and ascites.

A

Meig’s syndrome

65
Q

If not asymptotic. what are the symptoms of an ovarian cyst ?

A

-Pelvic pain
-Bloating
-Abdo fullness
-Palpable mass

-If the is ovarian torsion, haemorrhage or rupture of the cyst = acute pelvic pain

66
Q

-Sudden onset severe unilateral pelvic pain
-N&V
-Localised tenderness and possible palpable mass

A

-Ovarian torsion

67
Q

Ovarian torsion : Ix of choice, findings and management

A

-Pelvis USS : ‘whirlpool sign’, free fluid in pelvis and oedema of ovary
-Laparoscopic surgery to un-twist ovary and fix in place (detorsion) or remove affected ovary (oophorectomy)

68
Q

Common result of pregancy-related endometrial dilatation and curettage

A

-Asherman’s syndrome
-Can also be caused by uterine surgery or pelvic infection

69
Q

What is asherman’s syndrome ?

A

-Adhesions form within the uterus following damage to the uterus

70
Q

How can asherman’s present ?

A

-> Usually following recent dilation and curettage, uterine surgery or endometritis with :

-Secondary amenorrhoea
-Significantly lighter periods
-Dysmenorrhoea

-May also present with infertility

71
Q

What is the gold standard investigation for asherman’s?

A

-Hysteroscopy : also done for dissection and treatment

72
Q

What is atrophic vaginitis and why does it occur

A

-> Dryness and atrophy of the vaginal mucosa
-> Occurs at menopause due to a lack of oestrogen causing the mucosa to become thinner, less elastric and dry

73
Q

How does atrophic vaginitis present ?

A

-> Itching, dryness, dyspareunia and bleeding
-> Older women with recurrent UTI, stress incontience or pelvic organ prolapse

74
Q

How is atropic vaginitis managed ?

A

-Vaginal lubricants
-Topical oestrogen

75
Q

-50 year old woman with vulval itching and skin changes in the vulva
-Labia, perianal and perineal skin changes : ‘Porcelain-white’ colour, shiny, tight, thin, slight raised
-Itching, soreness, erosions
-Koebner phenomenon : signs and synptoms made worse by friction -> tight underwear and scratching

A

Lichen sclerosus

76
Q

How is lichen sclerosis managed ?

A

-Potent topical steroids (clobetasol propionate 0.05%)

77
Q

What is a critical complication of lichen sclerosis

A

-Squamous cell carcinoma of the vulva

78
Q

Define the different pelvic organ prolapses

A

-Uterine : uterus into vagina
-Vault : vault of the vagina into the vagina
-Rectocele : defect in posterior vaginal wall = rectum into vagina
-Cystocele : defect in anterior vaginal wall = bladder into vagina

79
Q

What are the 3 management options in a pelvic organ prolapse ?

A
  1. Conservative
  2. Vaginal pessary
  3. Surgery
80
Q

what does the upper vagina, cervix, uterus and fallopian tubes develop from ?

A

-Mullerian ducts

81
Q

What 2 congenital structural abnormalities can lead to cyclical pelvic symptoms without menstruation ?

A

-Imperforate hymen
-Transverse vaginal septae (if imperforate)

82
Q

What is the most common causative organism of pelvic inflammatory disease?

A

-Chlamydia trachomatis

-Can also be caused niesseria gonorrhoea (severe PID) and mycoplasma genitalium

83
Q

how does PID present ?

A

-Lower abdo pain
-Fever
-Deep dyspareunia
-Dysuria and menstrual irregularities
-Vaginal or cervical discharge
-cervical excitation

84
Q

How is PID managed?

A

-Depends on guidelines
-Ceftriaxone and doxycline will cover many organisms

85
Q

Give 4 complications of PID

A

-Perihepatitis : RUQ pain
-Tubular infertility
-Chronic pelvic pain
-Fitz-Hugh-Curtis syndrome

86
Q

Give 4 signs of a complete hydatidiform mole, including USS sign

A

-Vaginal bleeding
-Uterus size greater than expected for gestational age
-Abnormally high serum hCG
-USS : ‘snow storm’ appearance

87
Q

What is Fitz-Hugh-Curtis syndrome ?

A

-> Complication of PID : inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and peritoneum
-> RUQ pain referred to the right shoulder pain

88
Q

what are the conservative management options for pelvic organ prolapse

A

Physio
Weight loss

89
Q

explain the grades of uterine prolapse

A

1 : lowest part is >1cm above introitus
2 : lowest part is within 1cm of introitus
3 : lowest part is >1cm below the introitus, but not fully descended
4 : full descent with eversion of vagina

90
Q

feeling of ‘something coming down’ in vagina
dragging or heavy sensation in pelvis
urinary sx : incontinence, urgency, frequency
bowel sx : constipation, incontinence, urgency
sexual dysfunction : pain, altered sensation

A

Prolapse

91
Q

What are the 2 types of benign epithelial ovarian cysts

A

-Serous cystadenoma
-Mucinous cystadenoma

92
Q

what are the initial investigations in incontinence

A

Bladder diary (3 days)
Vaginal examination
Urine dip and culture (if <65 urinalysis)
Urodynamic studies

93
Q

What is urge incontinence and how is is managed

A

-Overactivity of detrusor muscle
1 : Bladder retraining for 6 wks
2 : Antimuscarinis (oxybutin)
3 : Merabegron
4 : invasive surgery

94
Q

What is stress incontinence and how is it managed ?

A

-Weakness in pelvic floor and sphincter muscles
1 : Lifestyle advice
2 : Pelvic floor exercises for at 3 mnths
3 : Surgery
4 : Duloxetine if surgery declines

95
Q

cysts in premenopausal vs postmenopausal women

A

-Premenopausal : usually benign
-Postmenopausal : more concerning. Measure CA125. If raised, refer

96
Q

COCP
3 mnth inter-menstrual and occasional post-coital bleeding
26 y/o

A

Cervical ectropion

97
Q

what is cervical ectropion

A

Increased oestrogen (COCP, pregnancy) causes larger area of columnar epithelium being present on the ectocervix

98
Q

what 2 things cause cervical excitation

A

ectopic pregnancy
PID

99
Q

what is cervical ectropion

A
  • There is a larger area of columnar epithelium on the ectocervix
100
Q

how does cervical ectopion present and what is seen on examination of the cervix

A
  • Post coital bleeding
  • Vaginal discharge
  • Red and tender cervix
101
Q

what staging is used tp assess development of secondary sexual characteristics

A

Tanner

102
Q

what system is used to classify severity of a prolapse

A

Baden-walker

103
Q

what is the inheritance of CAH

A
  • Autosommal recessive
104
Q

Give 6 possible causes of menorrhagia

A
  1. Dysfunctional uterine bleeding
  2. Fibroids
  3. PID
  4. Anticoagulation
  5. Bleeding disorders (e.g. VWD).
  6. Contraception (especially copper coil).

3a (45 decks)

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