Gynaecology Flashcards
What are the 2 types of incontinence?
Stress and urge incontinence
What is Stress incontinence?
Small losses of urine due throughout the day, often caused by coughing, sneezing or exercise.
What is urge incontinence?
An overactive bladder, leading to an increasing urge to go to the toilet
What 4 pieces of lifestyle advice would you give a patient to manage stress incontinence?
Reducing caffeine intake
Weight loss
Reduce fluid intake
Stop smoking
What treatments are used alongside lifestyle advice in stress incontinence?
Pelvic floor exercises
What conditions should you refer a patient with incontinence on a 2ww?
Unexplained visible haematuria without UTI
Persistent visible haematuria that occurs after UTI has been treated.
Aged over 60 with non visible haematuria and dysuria or raised WCC
What is the non-pharmacological treatment for urge incontinence?
Referral for bladder training
What class of medication and which drug specifically should be trialled for urge incontinence?
Antimuscarinic/anticholinergic such as oxybutynin
What are the 4 main risk factors for a uterovaginal prolapse?
Vaginal delivery
Older women
High BMI
Previous surgery for prolapse
What symptoms do women tend to experience with a uterovaginal prolapse?
Feeling of pressure in the vagina
Urinary incontinence
Constipation
What is the management for a uterovaginal prolapse?
Pessary initially
Surgery if symptoms persist
What is a rectocele?
A prolapse between the posterior wall of the vagina and rectum
What are the 4 main causes of a rectocele?
Chronic constipation
Chronic cough
Repeated heavy lifting
Being overweight or obese
What is the management of a rectocele?
Treating constipation (lots of water, fibrous foods etc)
Pelvic floor exercises
Maybe pessaries if prolapse is higher up
What is a cystocele?
A prolapse between the anterior vaginal wall and the bladder
What is the management of a cystocele?
Pessaries
Pelvic floor exercises
Surgery if severe
What is a genitourinary fistula?
An abnormal connection that forms between your bladder/urethra and vagina/uterus
What can cause a genitourinary fistulae?
Labour and delivery
Gynaecological or pelvic surgery
What are the symptoms of a GU fistulae?
Continuous/intermittent leakage of urine
Vagina smelling of urine
Foul smelling discharge shortly before leaking urine
UTI’s
Voiding smaller amounts of urine as bladder never fills
What is the treatment of a genitourinary fistulae?
Usually surgical treatment
If caught early can drain bladder with catheter and it may close on its own.
At what age do fibroids typically appear?
Within the childbearing years
When do fibroids tend to regress?
After the menopause
What are fibroids?
Benign tumours of the uterus composed of smooth muscle and connective tissue
What are the 3 main risk factors for fibroids?
Increasing age
Black ethnicity
High BMI
Name 5 most common symptoms/signs of uterine fibroids.
Heavy menstrual bleeding
Pelvic pain/pressure/discomfort
Increased frequency of urination
Bloating/constipation
Subfertility/infertility
What is the typical management for uterine fibroids?
Most are asymptomatic and do not need treatment.
Mirena coil
Tranexamic acid to control bleeding
What are some possible complications of uterine fibroids?
Iron deficiency anaemia
Bladder/bowel compressive symptoms
Obstetric complications
Pedunculated fibroid
What are ovarian cysts?
A fluid filled sac within the ovarian tissue which come and go throughout the menstrual cycle.
Why are nulliparous women more likely to develop ovarian cysts and ovarian cancer?
The more you ovulate the greater the risk of developing an ovarian cyst or cancer. This is because the tumour arises from surface epithelial irritation caused by ovulation.
Name 2 symptoms of ovarian cysts.
New onset pelvic pain
Chronic bloating that does not change throughout the day.
What are the characteristic symptoms of ovarian cancer?
Bloating/abdo distention
Early satiety
Pelvic/abdo pain
Increased frequency
PV bleeding
Which investigations can be used to differentiate between ovarian cysts and tumours?
Ca 125
Transvaginal USS
Abdo USS
Name 3 risk factors for ovarian cancer.
Nulliparity
Early menarche
Smoking/obesity
Late menopause
What is ovarian torsion?
Twisting of the ovary around its ligamentous supports
What happens when the ovary is twisted around the ligaments?
Loss of blood supply to both the ovary and fallopian tube. This is a surgical emergency
What is the most common reason that ovarian torsion occurs?
Ovarian mass which causes the torsion
Why does oedema of the ovary occur in ovarian torsion?
Veins have thinner walls than arteries. Therefore venous return is occluded more so than arterial supply, leading to oedema.
What are the symptoms of ovarian torsion?
Acute pelvic/abdo pain.
N&V
Palpable mass
What investigations should be done in acute onset pelvic pain?
Pregnancy testing
Urinalysis
FBC
Transvaginal USS
Surgical visualisation
What is lichen sclerosis?
Pale white, itchy patches on the genitals or other parts of the body
Is lichen sclerosis contagious?
No, and it cannot be spread through sexual intercourse
Which age group does lichen sclerosis most commonly affect?
Females between the ages of 40 and 60.
What are the 4 most common symptoms of lichen sclerosis?
Itching
Burning
Pain
White patches on skin
How is lichen sclerosis treated during a flare up?
Potent corticosteroid creams for 2 weeks daily, then reducing based on symptoms
How is lichen sclerosis managed in the longterm?
Annual follow-up to check for squamous cell carcinoma.
Moisturise regularly
Use an emollient soap substitute
What is the most common cause of cervical cancer?
HPV
Name 3 risk factors for cervical cancer.
Multiple sexual partners
Immunosuppression (HIV)
Age 45-49
What is the biggest sign of cervical cancer?
Post coital bleeding
What are the symptoms of cervical cancer?
Abnormal PV bleeding
Post coital bleeding
Pelvic pain
Purulent vaginal discharge
What type of epithelium makes up the mucosa of the ectocervix?
Non-keratinising, stratified squamous epithelium
What is the epithelium of the endocervix?
Mucus secreting, simple columnar epithelium
When may someone have a cold coagulation treatment on their cervix?
When they have some abnormal cells on their cervix but its not carcinoma. CIN1 or CIN2
Signs and symptoms of endometrial cancer?
Post menopausal bleeding
Abnormal menstruation/bleeding
Name 4 risk factors for endometrial cancer.
Unopposed oestrogen therapy
Over 50 years
Tamoxifen use
Diabetes mellitus
A whirlpool sign is seen on USS imaging of the pelvis, after a complaint of acute pelvic pain. What is this suggestive of?
Ovarian torsion
What is PCOS?
Excess androgen production and the presence of cysts within the ovaries.
What is PCOS caused by?
Excess androgen production and insulin resistance are the driving factors behind PCOS
What are the 3 main risk factors for PCOS?
Diabetes
Irregular menstruation
FHx PCOS
What are the 5 main features of PCOS?
Oligomenorrhoea
Infertility
Hirsutism
Obesity
Chronic pelvic pain
Which hormones will show changes on blood tests in PCOS?
Testosterone raised
LH raised
Progesterone low
Sex hormone binding globulin low
What is the management of PCOS?
Use COCP to induce bleeds 3 times a year
Metformin for ovulation stimulant if wanting to get pregnant
Manage weigh if obese
What is the most common appearance of a vulval carcinoma?
Commonly ulcerated and appear on the labia majorum
How would you tell the difference between HSV and vulval cancer in terms of appearance?
HSV tends to present with smaller lesions whereas vulval carcinoma is usually ulcerated
What is a chancre?
A small lesion seen in the first place of syphilis
What is the triad of symptoms for endometriosis?
Dysmenorrhoea, dyspareunia and subfertility
A 50-year-old lady is undergoing staging for her confirmed ovarian cancer. Upon scanning, it is found that the tumour has spread beyond the ovary, but is still within the pelvis. What stage is her cancer at?
Stage 2
What is the role of the drug clomifene in PCOS?
An anti oestrogen which is first line in helping couples to conceive
What disease are clue cells seen in?
Bacterial vaginosis
What is a hydatidiform mole?
A growing mass of tissue inside your uterus that will not develop into a baby and is a result of abnormal conception.
What is a partial molar pregnancy?
This is where 2 sperm fertilise the egg, this results in too much genetic material, causing the placenta to grow too quickly and overtake the space where the foetus would normally develop.
What is a complete molar pregnancy?
A sperm fertilises an egg with no genetic material inside. Therefore all the genetic material is from the father. There is no development of the baby and only the placenta grows, forming fluid filled cysts.
Which age groups are most at risk for developing a molar pregnancy?
Under 20 and over 35.
How can you differentiate the symptoms of a molar pregnancy from hyperemesis gravidarum?
Severe nausea and vomiting as well as an abnormally high beta HCG level
What type of vaginal bleeding may be experienced with a molar pregnancy?
Red, grape like cysts, different to normal period blood
What are the signs and symptoms of a molar pregnancy?
Severe nausea and vomiting
Rapid uterine growth (looking much bigger than your dates)
PV bleeding of grape like cysts
Miscarriage symptoms such as pelvic pressure or pain and bleeding.
How are molar pregnancies managened?
They cannot survive, therefore it can be removed by suction D&E or complete hysterectomy depending on the persons wish to preserve fertility.
How long is it recommended to wait before getting pregnant again in the case of a molar pregnancy?
Recommended to wait at least 6 months before trying again.
What can a molar pregnancy develop into if the cells burrow more deeply into the uterus?
Gestational trophoblastic neoplasia. This can occur if some of the tissues from a molar pregnancy remain.
What are the signs of gestational trophoblastic neoplasia after molar pregnancy?
Beta HCG levels do not return to normal as they should.
What is endometriosis?
Growth of endometriod tissue outside of the uterus
What are the 4 main symptoms of endometriosis?
Dysmenorrhoea which affects daily life
Dyspareunia
Infertility
Chronic pelvic pain
What are the 3 main risk factors for endometriosis?
Early menarche
Nulliparity
FHx of endometriosis
What is found on bi manual exam in patients with endometriosis?
Pain in the posterior vaginal fornix
What is the management for endometriosis?
COCP back to back to manage pain
IUS
GnRH agonists to put patients into an artificial menopause
Laparoscopy
What is the difference between endometriosis and adenomyosis?
In adenomyosis endometrial tissue grows into the muscle of the uterus, not outside the uterus.
What are the symptoms of adenomyosis?
Dysmenorrhoea
Menorrhagia
Pelvic pain
Dyspareunia
How are both adenomyosis and endometriosis diagnosed?
Diagnostic laparoscopy is the only way they can be officially diagnosed.
What is the definition of a threatened miscarriage?
Any degree of light bleeding in early pregnancy is defined as a threatened miscarriage.
What is a missed miscarriage?
Non-viable fetus in the womb without the symptoms of miscarriage.
At what gestation should the fetal pole develop?
5.5 - 6 weeks
On a transvaginal scan at what gestation can you see a fetal heartbeat?
5.5 - 6 weeks from the date of last menstrual period.
What is an inevitable miscarriage?
Cervix is open. The fetus can be either viable or non viable
What is a complete miscarriage?
History of bleeding and passing clots. Symptoms have now settled and there are no POC within the uterus.
Which 2 drugs are used in the medical management of miscarriage?
Mifepristone and misoprostol
What is the recommended first line treatment for missed miscarriage in the UK?
Expectant management for 7-10 days then take a repeat pregnancy test. If still positive come for further assessment.
How is the mifepristone misoprostol medical management performed?
Oral mifepristone is given. Then vaginal misoprostol is given 24-48 hours later.
Management can be done with just misoprostol, but there is a greater risk of the miscarriage not being successful with this.
When is someone eligible for manual vacuum aspiration of POC under local anasthetic?
If under 12 weeks gestation
Where is the most common location for an ectopic pregnancy?
Fallopian tube in the ampullary and isthmic regions
What signs are found on bi manual in ectopic pregnancy?
Cervical excitation/cervical motion tenderness
What are the symptoms of ectopic pregnancy?
Guarding and abdo pain
Shoulder tip pain
PV bleeding
GI symptoms
Name 3 risk factors for ectopic pregnancy.
Previous ectopic
PID
Fallopian tube surgery
Copper IUD
What is the threshold beta hcg level for diagnosing ectopic pregnancy if no intrauterine pregnancy is found on USS?
1500
How quickly do you expect the B HCG to change in miscarriage?
It should halve in 48 hours
What is the management of ectopic pregnancy in an emergency?
A to E approach
FAST abdo scan
Site 2 IV cannulas
IV crystalloid fluids
Catheter
Bloods for crossmatch
Prepare 4 units of blood
Theatre for removal
When is medical management of an ectopic offered?
If the patient is stable and B HCG is under 1500. Foetus is unruptured and has no visible heartbeat.
What is the medical management of an ectopic?
IM methotrexate
Beta HCG must decline between days 4-7
Follow up until B HCG becomes negative
Cannot get pregnant again for 3 months.
What are the most common organisms to cause PID?
Chlamydia and gonorrhoea
What is PID?
An infection of the upper genital tract in females which can affect the uterus, fallopian tubes and ovaries.
What symptoms does PID present with?
Lower abdo pain
Unusual vaginal discharge
Fever
Can present differently in everyone.
What are the signs on bi manual of PID?
Adenexal tenderness
Cervical motion tenderness
What are the risk factors for PID?
Sexually active
Age 15-24
Recent partner change
No barrier contraception
History of STI’s
What investigations should be carried out in the case of suspected PID in primary care?
STI screen
High vaginal swab
Urine dip
Pregnancy test
What is the management of PID?
3 types of antibiotics for 2 weeks
Doxycycline
Ceftriaxone
Metronidazole
What advice should be given to the patients upon receiving diagnosis of PID?
All sexual partners in the last 6 months should be tested
At what gestation does hyperemesis gravidarum present?
Before 11 weeks gestation. If symptoms start after 11 weeks this suggests a different pathology.
What scoring system is used to assess the severity of hyperemesis gravidarum?
PUQE score
When do hyperemesis gravidarum symptoms tend to resolve?
Between 16-20 weeks gestation
When is hyperemesis gravidarum diagnosed?
Patient has lost more than 5% of initial body weight due to N&V and dehydration.
Electrolyte imbalance
Ketonuria
Which oral antiemetics should be used first line in hyperemesis gravidarum?
Oral cyclazine or oral promethazine.
Which anti emetics can be prescribed second line in hyperemesis gravidarum?
Ondansetron, metochlopromide, domperidone
There cannot be prescribed for longer than 5, 5 and 7 days respectively due to the risks.
What is the average age of the menopause in the UK?
51 years
What symptoms do women experience in the menopause and leading up to the menopause?
Irregular periods
Hot flushes
Mood swings
Urogenital atrophy
Do the levels of LH and FSH rise or decline when you are approaching the menopause?
They rise, as there is less oestrogen to supress them.
How long do symptoms of the menopause last on average?
2-7 years
What are some of the advantages of HRT?
Bone mineral density protection
Preventative for CVD
What are the risks associated with HRT?
Breast cancer
VTE
Risk of stroke
Which preparation of HRT increase the risk of VTE?
Oral, so transdermal should be given to those at higher risk
How long after a miscarriage, TOP or giving birth can you have a smear?
3 months
What is the second line treatment for infertility in PCOS?
Laparoscopic ovarian drilling
What is chorioamnionitus?
Infection of the membranes in the uterus
What are the 3 different types of ovarian cancer?
Epithelial (most common)
Germ cell tumours
Sex cord stromal tumours
When does atrophic vaginitis appear in women?
Occurs in post-menopausal women
What are the symptoms of atrophic vaginitis?
Vaginal dryness
Dyspareunia
Occasional spotting
How to treat atrophic vaginitis?
Vaginal lubricants and moisturisers
Topical oestrogen creams used second line
What is required for a diagnosis of PCOS to be made?
2 out of 3 of the following features:
Oligomenorrhoea
Clinical or biochemical signs of hyperandrogenism
Polycycstic ovaries on USS
What is the difference between primary and secondary dysmenorrhoea?
Primary - no known pelvic pathology, caused by prostaglandins
Secondary - As a result of pelvic pathology, pain often starts before the onset of menstruation.
What do investigations reveal for primary ovarian insufficiency?
FSH over 30mmol/L on 2 separate occasions 4-6 weeks apart
