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Gynaecology Flashcards

1
Q

What are the presentations of fibroids?

A

Often asymptomatic
Heavy menstrual bleeding (menorrhagia)
Prolonged menstruation
Abdominal pain (especially when menstruating)
Bloating
Urinary/bowel symptoms (due to pressure on surrounding structures)
Deep dyspareunia
Reduced fertility

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2
Q

What investigations are done with fibroids?

A

Hysteroscopy –> Initial investigation for submucosal fibroids
Pelvic ultrasound –> Larger fibroids
MRI –> Determine size, shape and blood supply before surgery

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3
Q

What is the management of fibroids less than 3cm?

A

Same as heavy menstrual bleeding:
Mirena coil (first line)
Manage symptoms –> NSAIDs, tranexamic acid
Combined oral contraceptive pill
Cyclical oral progestogens

Surgical options:
Endometrial ablation
Resection
Hysterectomy

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4
Q

What is the management of fibroids >3cm?

A

Refer to gynaecology
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil
COCP
Cyclical oral progestogens

Surgical options:
Uterine artery embolisation
Myomectomy
Hysterectomy

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5
Q

What drug can help reduce the size of a fibroid?

A

Triptorelin (GnRH agonists)

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6
Q

What are possible complications of fibroids?

A

Heavy menstrual bleeding –> anaemia
Reduced fertility
Miscarriage/premature labour
Constipation
UTI/urinary outflow obstruction
Ischaemia/infarction/necrosis of the fibroid
Malignant change to leiomyosarcoma

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7
Q

What is the difference in significant in ovarian cysts in pre- vs post-menopausal women?

A

Pre-menopausal = often benign
Post-menopausal = more concerning, potentially malignant, need further investigation

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8
Q

What is the presentation of ovarian cysts?

A

Mostly asymptomatic and found incidentally
Pelvic pain
Bloating/fullness
Palpable pelvic mass

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9
Q

What are the different types of ovarian cysts?

A

Follicular cyst = When the follicle fails to rupture and release the egg –> Often disappears after a few menstrual cycles
Corpus luteum cyst = When the corpus luteum fails to break down and fills with fluid –> Seen in early pregnancy
Serous/mucinous cystadenoma = Benign tumour of epithelium
Endometrioma = Lumps of endometrium in the ovary due to endometriosis
Dermoid cyst/germ cell tumour = Benign ovarian tumours

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10
Q

What are the risk factors for ovarian malignancy?

A

Increasing age
Post-menopausal
Increased number of ovulations (eg. early menarche, late menopause, no Mirena/COCP etc, no pregnancies, infertility treatment)
Obesity
HRT
Smoking
No breastfeeding (breastfeeding is protective)
Family history/BRCA1 and BRCA2 genes

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11
Q

What factors reduce the risk of ovarian cancer?

A

Later menarche
Early menopause
Any pregnancies
Use of COCP/Mirena
Breastfeeding

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12
Q

What is the management of ovarian cysts?

A

Raised CA125/complex cyst = 2 week wait
Dermoid cyst = Referral
Simple + <5cm = Self limiting and will most likely resolve
Simple + 5-7cm = Routine referral to gynaecology
Simple + >7cm = MRI/surgical evaluation

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13
Q

What is Meig’s syndrome?

A

Ovarian fibroma (benign ovarian tumour)
Pleural effusion
Ascites

Removal of tumour resolves symptoms

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14
Q

What is the presentation of ovarian cancer?

A

Bloating/fullness
Loss of appetite
Pelvic pain
Urinary symptoms
Weight loss
Abdominal/pelvic mass
Ascites

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15
Q

What findings on physical examination would indicate a 2-week-wait referral for suspected ovarian cancer?

A

Ascites
Pelvic mass (unless clearly due to fibroid)
Abdominal mass

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16
Q

What are the initial investigations in suspected ovarian cancer?

A

CA125 blood test
Pelvic ultrasound

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17
Q

What are the stages of ovarian cancer?

A

Stage 1 = Confined to the ovary
Stage 2 = Spread past the ovary but still in the pelvis
Stage 3 = Spread past the pelvis but in the abdomen
Stage 4 = Spread outside abdomen (distant metastasis)

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18
Q

What is the management of ovarian cancer?

A

Surgery and chemotherapy

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19
Q

What are non-ovarian cancer causes of a raised CA125?

A

Breast, endometrial and metastatic lung cancer
Adenomyosis
Ascites
Endometriosis
Menstruation
Ovarian torsion
Liver disease

NOT VULVAL CANCER

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20
Q

What is endometrial hyperplasia?

A

Precancerous condition involving thickening of the endometrium
Risk factors, presentation and investigations are the same as for endometrial cancer
Most cases return to normal over time

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21
Q

What is the management of endometrial hyperplasia?

A

IUS (Mirena)
Continuous oral progestogens

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22
Q

What are the risk factors for endometrial cancer?

A

Increase exposure to unopposed oestrogen

Increased age
Early menarche
Late menopause
Oestrogen-only HRT
No/fewer pregnancies
Obesity –> Adipose tissue is a source of oestrogen in post-menopausal women
PCOS
Tamoxifen

Also:
Type 2 diabetes
Lynch syndrome

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23
Q

What factors are protective against endometrial cancer?

A

COCP
Mirena
Increased pregnancies
Cigarette smoking

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24
Q

What is the presentation of endometrial cancer?

A

Postmenopausal bleeding –> Endometrial cancer until proven otherwise
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelets

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25
What is the referral criteria for a 2-week-wait referral for endometrial cancer?
Postmenopausal bleeding more than 12 months after last period
26
What are the investigations for endometrial cancer?
Transvaginal US --> endometrial thickness Pipelle biopsy Hysteroscopy with biopsy
27
What are the stages of endometrial cancer?
Stage 1 = Confined to uterus Stage 2 = Invades the cervix Stage 3 = Invades uterus, fallopian tubes, vagina or lymph nodes Stage 4 = Invades bladder, rectum or beyond
28
What is the management of endometrial cancer?
Stage 1 + 2 = Total abdominal hysterectomy with bilateral salpingo-oopherectomy Other options: Radical hysterectomy (also removing the pelvic lymph nodes, surrounding tissues and top of vagina) Radiotherapy Chemotherapy Progesterone to slow the progression
29
What is the most common type of cervical cancer?
Squamous cell carcinoma (80%)
30
What is the most common cause of cervical cancer?
HPV
31
What are the risk factors for cervical cancer?
Increased risk of catching HPV --> Not using condoms, early sexual activity, increased number of sexual partners Not engaging with screening Smoking HIV COCP for > 5 years Increased number of full-term pregnancies Family history
32
What is the presentation of cervical cancer?
Detected on smears in asymptomatic women Abnormal vaginal bleeding Vaginal discharge Pelvic pain Dyspareunia
33
What are the stages of cervical cancer?
Stage 1 = Confined to cervix Stage 2 = Invades uterus or upper 2/3 of vagina Stage 3 = Invades pelvic wall or lower 1/3 of vagina Stage 4 = Invades bladder, rectum or beyond
34
What is the management of cervical cancer?
Early stage 1A = Cone biopsy or large loop excision of the transformation zone (LLETZ) Stage 1B-2A = Radical hysterectomy and removal of local lymph nodes with chemo/radiotherapy Stage 2B-4A = Chemo/radiotherapy Stage 4B = Combination of surgery, chemo/radiotherapy and palliative care
35
What are the risk factors for vulval cancers?
Advanced age Immunosuppression HPV infection Lichen sclerosus
36
What is the presentation of vulval cancer?
Vulval lump Ulceration Bleeding Pain Itching Groin lymphadenopathy
37
What is the management of vulval cancer?
2 week wait Biopsy Excision to remove the cancer Groin lymph node dissection Chemo/radiotherapy
38
What is the presentation of lichen sclerosus?
Vulval itching Soreness/pain Skin tightness Superficial dyspareunia Erosions Fissures Skin changes: Porcelain white colour, shiny, tight, thin, slightly raised
39
What is the management of lichen sclerosus?
Topical steroids (dermovate) Emollients
40
What are the complications of lichen sclerosus?
Squamous cell carcinoma of the vulva
41
What is the presentation of ovarian torsion?
Sudden onset, severe, unilateral pelvic pain that is constant and gets progressively worse Nausea and vomiting
42
What is the initial investigation of choice for ovarian torsion?
Transvaginal US, or abdominal US in TV not possible "Whirlpool" sign
43
What is the management of ovarian torsion?
Emergency admission Laparoscopic surgery to untwist or remove the ovary
44
What is the diagnostic criteria for polycystic ovarian syndrome?
Rotterdam criteria At least 2 of: Oligo/anovulation --> Irregular/absent periods Hyperandrogenism --> Hirsutism and acne Polycystic ovaries on US
45
What do hormonal blood tests typically show in PCOS?
Raised LH Raised LH:FSH ratio Raised testosterone Raised insulin Normal or raised oestrogen
46
What is the management of PCOS?
Reduce risk factors --> Weight loss, smoking cessation, exercise, reduce hypertension, lower glycaemic index Treat complications eg. infertility, hirsutism, acne
47
What is endometriosis?
A condition where there is ectopic endometrial tissue outside of the uterus
48
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain (for over 6 months) Deep dyspareunia Dysmenorrhoea Infertility Cyclical bleeding from other sites eg haematuria
49
What is the gold standard way to investigate and diagnose endometiosis?
Laparoscopic surgery with biopsy
50
What is the staging of endometriosis?
Stage 1 = Small superficial lesions Stage 2 = Mild but deeper lesions than stage 1 Stage 3 = Deeper lesions with lesions on the ovaries and mild adhesions Stage 4 = Deep and large lesions affecting the ovaries with extensive adhesions
51
What is the management of endometriosis?
Analgesia (paracetamol and NSAIDs) COCP POP Depo injection Nexplanon implant Mirena GnRH agonists Surgery --> Excision or ablation of the endometrium Hysterectomy
52
What is adenomyosis?
Endometrial tissue found in the myometrium
53
What is the presentation of adenomyosis?
Painful periods Heavy periods Dyspareunia
54
What is the gold standard investigation for adenomyosis?
Histological examination after hysterectomy. However, this is obviously not always a suitable way, so instead transvaginal US (1st line) or abdominal US or MRI are performed
55
What is the management of adenomyosis?
Management without contraception: Tranexamic acid if no pain (reduce bleeding) Mefenamic acid if pain (reduces pain and bleeding) Management with contraception: Mirena (1st line) COCP Cyclical oral progestogens
56
How long after the last period can a diagnosis of menopause be given?
12 months
57
What are the symptoms of perimenopause?
Hot flushes Emotional lability/low mood Irregular periods Joint pains Heavier/lighter periods than normal Vaginal dryness Reduced libido
58
What is the physiology of the menopause?
At the start of the menstrual cycle, FSH stimulates development of secondary follicles. As these follicles grow, granulosa cells secrete increasing amounts of oestrogen. In menopause, there is a decline in the development of ovarian follicles, and therefore reduced oestrogen. Reduced follicle development means that there is no ovulation. Reduced oestrogen means that the endometrium doesn't develop and therefore there is no menstruation.
59
What conditions are consequences of low oestrogen?
Cardiovascular disease Stroke Osteoporosis Pelvic organ prolapse Urinary incontinence
60
What is the management of perimenopausal symptoms?
No treatment --> Likely to resolve after 2-5 years HRT CBT SSRIs Vaginal oestrogen
61
What is the presentation of atrophic vaginitis?
Occurs in postmenopausal women Itching Dryness Dyspareunia Bleeding
62
What are the management options for atrophic vaginitis?
Vaginal lubricants Topical oestrogen --> cream, pessary, tablets, ring
63
What is the genetic cause of androgen insensitivity syndrome?
X-linked recessive condition where androgen receptors do not form properly
64
How do patients with androgen insensitivity syndrome present?
Genetically male (XY) Female phenotype externally Normal female external genitalia but have testes in the abdomen and no uterus, cervix, fallopian tubes or ovaries
65
What are the results of a hormone test for patients with androgen insensitivity syndrome?
Raised LH Normal or raised FSH Normal or raised testosterone Raised oestrogen levels (for a male)
66
What is the management of androgen insensitivity syndrome?
Bilateral orchidectomy --> Reduce risk of testicular cancer Oestrogen therapy Vaginal dilators/surgery MDT support including counselling
67
What is the definition of primary amenorrhoea?
Not starting menstruation by 13 years old when there is no other evidence of pubertal development OR Not starting menstruation by 15 years old when there are other signs of puberty eg. breast bud development
68
What is hypergonadotropic vs hypogonadotropic hypogonadism?
Hypergonadotropic = Lack of a response to LH and FSH by the gonads Hypogonadotropic = Deficiency in LH and FSH
69
What are causes of hypogonadotropic hypogonadism (LH/FSH deficiency)?
Hypopituitarism Hypothalamus/pituitary gland damage Cystic fibrosis/inflammatory bowel disease Excessive exercise or dieting Unexplained delay in puberty GH deficiency/hypothyroidism/Cushing's Kallman syndrome
70
What are causes of hypergonadotropic hypogonadism (lack of response to LH/FSH)?
Previous damage to gonads Congenital absense of ovaries Turner's syndrome
71
What is the definition of secondary amenorrhoea?
No menstruation for more than 3 months after previous regular menstrual periods
72
What are the causes of secondary amenorrhoea?
Pregnancy Menopause Premature ovarian failure Hormonal contraception Hypothalamic or pituitary pathology PCOS Uterine pathology Thyroid pathology Hyperprolactinaemia
73
What is the management of secondary amenorrhoea?
Manage underlying cause
74
What does amenorrhoea with cyclical pain suggest?
Imperforate hymen
75
What is the management of an imperforate hymen?
Surgery
76
What are the causes of menorrhagia?
Extremes of reproductive age Fibroids Endometriosis/adenomyosis Pelvic inflammatory disease Contraceptive (eg. copper coil) Anticoagulants Bleeding disorders Endocrine disorders Endometrial hyperplasia/cancer PCOS
77
What is the management of menorrhagia?
Exclude underlying pathology Tranexamic acid --> If don't want contraception and no pain Mefenamic acid --> If don't want contraception and in pain Mirena (1st line if also want contraception) COCP Cyclical oral progestogens Endometrial ablation Hysterectomy
78
What are the presentations of premenstrual syndrome?
Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido
79
What is the management of premenstrual syndrome?
General lifestyle changes COCP SSRIs CBT Transdermal oestrogen patches
80
When can oestrogen-only HRT by used?
After hysterectomy --> Progesterone only used to prevent endometrial hyperplasia/cancer caused by unopposed oestrogen
81
What non-hormonal options are available for management of menopausal symptoms?
Lifestyle changes CBT Clonidine --> helps vasomotor symptoms and hot flushes SSRIs Venlafaxine Gabapentin
82
When is HRT indicated?
In premature ovarian insufficiency, even without symptoms To reduce vasomotor symptoms eg. hot flushes and night sweats To improve symptoms such as low mood, decreased libido, poor sleep and joint pain To reduce risk of osteoporosis in women under 60
83
What are the risks of HRT?
Increased risk of breast cancer Increased risk of endometrial cancer Increased risk of VTE Increased risk of stroke/coronary artery disease
84
What are contraindications to starting HRT?
Undiagnosed abnormal bleeding Endometrial hyperplasia/cancer Breast cancer Uncontrolled hypertension VTE Liver disease Active angina or MI Pregnancy
85
How does HRT delivery differ between women having periods and women not having periods?
Perimenopausal = cyclical HRT Postmenopausal = Continuous HRT
86
What is Asherman's syndrome?
Where adhesions form within the uterus following damage to the uterus
87
What are some precursors to Asherman's syndrome?
Removal of retained products of conception Uterine surgery Pelvic infection
88
What is the presentation of Asherman's syndrome?
Secondary amenorrhoea Lighter periods Dysmenorrhoea Infertility
89
What investigations are done for Asherman's syndrome?
Hysteroscopy (gold standard) Hysterosalpingography Sonohysterography MRI
90
What is the management of Asherman's syndrome?
Dissecting the adhesion during hysteroscopy
91
What is the presentation of cervical ectropion?
Post-coital bleeding No pain
92
What is cervical ectropion?
Where the columnar epithelium of the endocervix extends to the ectocervix
93
What are the risk factors for cervical ectropion?
High oestrogen --> COCP, pregnancy
94
What is a uterine prolapse?
When the uterus descends into the vagina
95
What is a vault prolapse?
When the top of the vagina descends into the vagina following hysterectomy
96
What is a rectocele?
A fault in the posterior vaginal wall that allows the rectum to prolapse into the vagina
97
What is a cystocele?
A defect in the anterior vaginal wall that allows the bladder to prolapse into the vagina
98
What are the risk factors for pelvic organ prolapses?
Multiple vaginal deliveries Instrumental/prolonged/traumatic delivery Advanced age Obesity Chronic respiratory disease--> Coughing Chronic constipation --> Straining
99
What are the presentations of a pelvic organ prolapse?
Feeling of something coming down Dragging/heavy sensation Urinary symptoms (eg. frequency, incontinence, urgency) Bowel symptoms (eg. constipation, incontinence, urgency) Sexual dysfunction (eg. pain, altered sensation)
100
What is the grading system for uterine prolapse?
Grade 0 = Normal Grade 1 = Lowest part is more than 1cm above the opening of the vagina Grade 2 = Lowest part is within 1cm (above or below) opening of vagina Grade 3 = Lowest part is more than 1cm below vaginal opening but not fully descended Grade 4 = Full descent and eversion of the vagina
101
What is the management of a uterine prolapse?
Conservative --> physiotherapy, weight loss, lifestyle changes for stress incontinence Vaginal pessaries --> Ring, shelf, donut etc Surgery
102
What is urge incontinence?
Overactivity of the detrusor muscle causes sudden urges to pass urine
103
What is stress incontinence?
Weakness of the pelvic floor and sphincter muscles allows urine to leak when there is increased pressure on the bladder, eg. when laughing or coughing
104
What is overflow incontinence?
Chronic urinary retention due to an obstruction to the outflow of urine results in overflow of urine without the urge to pass urine
105
What are the risk factors for urinary incontinence?
Increased age Postmenopausal Increased BMI Previous pregnancies/vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions eg. MS Cognitive impairment/dementia
106
What investigations are done for urinary incontinence?
Bladder diary Urine dipstick Post-void residual bladder volume Urodynamic testing
107
What is the management for stress incontinence?
Avoid caffeine, diuretics and overfilling bladder Avoid excessive/restricted fluid intake Weight loss Pelvic floor exercises Surgery Duloxetine
108
What is the management of urge incontinence?
Bladder retraining Anticholinergic medication eg. oxybutynin, solifenacin, tolterodine Mirabegron (alternative to anticholinergic medication) Botox injection Surgery
109
What is the recall period following different cervical smear results?
Negative and 25-49 = 3 years Negative and 50-65 = 5 years Positive = Cytological examination Positive but cytological examination normal = 12 months Insufficient test = 3 months
110
What is the definition of premature ovarian failure?
Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40
111
What are the causes of premature ovarian failure?
Idiopathic Bilateral oophorectomy Radiotherapy Chemotherapy Infection eg. mumps Autoimmune disorders
112
What are the features of premature ovarian failure?
Hot flushes Night sweats Infertility Secondary amenorrhoea Raised LH + FSH Low oestradiol
113
What is the management of premature ovarian failure?
HRT or COCP until the age of the average menopause
114
What are the risk factors for breast cancer?
Female Increased oestrogen exposure (earlier menarche and later menopause, COCP, HRT) More dense breast tissue Obesity Smoking Family history
115
What is a ductal carcinoma in situ?
Pre-cancerous/cancerous epithelial cells of the breast ducts that are localised to a single area but have the potential to spread and become invasive. Often picked up on mammogram Good prognosis if lump fully excised and adjuvant treatment used
116
What is lobular carcinoma in situ?
A pre-cancerous condition occurring typically in pre-menopausal women Usually undetectable on mammogram, diagnosed incidentally on breast biopsy Managed with close monitoring
117
What is an invasive ductal carcinoma?
Invasive cancer originating in the breast ducts Can be detected on mammograms Around 80% of invasive breast cancers
118
What is invasive lobular carcinoma?
Invasive breast cancer originating from the breast lobules Not always visible on mammogram Around 10% of invasive breast cancers
119
What is inflammatory breast cancer?
Presents similarly to abscess or mastitis with swelling, warm, tender breast with pitting skin (peau d'orange) Does not respond to antibiotics 1-3% of breast cancers Worse prognosis than other types
120
What is Paget's disease of the nipple?
Looks like eczema of the nipple/areola Erythematous, scaly rash May represent DCIS or invasive breast cancer
121
What clinical features suggest breast cancer?
Hard, irregular, painless and/or fixed lumps Lumps that are tethered to the skin or chest wall Nipple retraction Skin dimpling or oedema (peau d'orange) Lymphadenopathy, particularly in axilla
122
What are the most common locations for breast cancer to metastasise to?
Lings Liver Brain Bones Can spread to any region --> common primary carcinoma for metastasis
123
What are the symptoms of breast abscess?
Swollen, fluctuant (able to move fluid within the lump), tender lump Muscle aches Fatigue Fever Sepsis signs
124
What are the symptoms of non-lactational mastitis?
Nipple changes Purulent nipple discharge Localised pain Tenderness Warmth Erythema Hardening of the skin or breast tissue Swelling
125
What is the management of non-lactational mastitis?
Analgesia Broad spectrum antibiotics (co-amoxiclav OR erythromycin/clarithromycin + metronidazole) Treat underlying cause (eg. eczema or candidiasis)
126
What is the management of a breast abscess?
Referral to surgical team Antibiotics US Drainage Microscopy, culture and sensitivities
127
What is a fibroadenoma?
Common benign tumours of the stromal/epithelial breast duct tissue Small and mobile
128
What are the features of a breast fibroadenoma?
Painless Smooth Round Well-defined border Firm Mobile Up to 3cm diameter
129
What is the management plan for pelvic inflammatory disease?
Start broad-spectrum antibiotics (doxycycline, metronidazole and IM ceftriaxone) immediately Leave in a recently inserted coil and monitor any improvement in 48 hours --> if no improvement, remove coil and start other contraception

Phase 3A Revision (23 decks)

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