Gynaecology Flashcards

Question

Fibroids Pathophysiology Presentation Investigation Management Complications

Answer 1

**Pathophysiology** - Leiomyoma (benign tumour) - Types: intramural, submucosal (into cavity), subseroal (outside), pedunculated - RFs: Afro-Carribean, Oestrogen (uncommon before puberty + regress in menopause) **Presentation** - Asymptomatic - Menorrhagia (-> IDA) - palpabe abdominal mass, lower abdo pain, dysmenorrhoea, bloating - Pressure syptoms -> urinary frequency - Subfertility - Rare: polycythaemia secondary to autonomous EPO production **Investigations** TV USS **Management** - Asymptomatic - no tx, monitor - Menorrhagia: 1st IUS (if also wanting contraception + no distortion of uterine cavity) Other: NSAIDs, tranexamic acid, COCP, POP, injectable progesterone - Shrink/remove the fibroid - GnRH agonists pre-surgery (BUT SEs: menopausal symptoms, loss of bone density + fibroid returns once stopped) - Surgical - myomectomy, endometrial ablation, hysterectomy, uterine artery embolisation **Complications** - Red degeneration - haemorrhage into tumour - common in pregnancy

Answer 2

**Risk Factors ** - Obesity, DM, tamoxifen, PCOS, herediatry non-polyposis colorectal carcinoma - Unopposed oestrogen - More cycles: nulliparity, early menarche, late menopause **Presentation** - Post-menopausal bleeding (main one) - Pre-menopause can have intermenstrual bleeding - If pain = extensive disease **Investigations** - Women >55 w/ post-menopausal bleeding - 2ww -> TV USS (if >4mm --> hysteroscopy + biopsy) **Management** - localised disease - TAH w/ B/L salpingo-oophorectomy +/- radiotherapy - Frail elderly, not suitable for surgery - progestogen therapy

Answer 3

**Pathophysiology** - Benign metaplasia of ectocervix squamous epithelium to simple columnar - Due to high oestrogen: COCP, pregnancy, menstruating age **Presentation** - most - asymptomatic - increased PV discharge - Post-coital or intermenstrual bleeding - Exam: everted columnar epithelium - red ring around external os Differentials: Ca, CIN, Cervicitis (infection), pregnancy **Investigation** - Pregnancy test - Triple swab - Smear (to rule out CIN) OR biopsy if lesion seen **Management** Only treat if symptomatic (it is a normal variant) 1st: stop oestrogen containing meds 2nd: ablation of columnar epithelium w/ cryotherapy or electrocautery

Answer 4

Physiological - early cycle (white), midcycle (clear) Candida - RFs: DM, Abx, Steroids, Prengnacy, HIV, immunosupression - Presentation: - thick, white, cottage cheese like discharge. vulval itching/soreness +/- satellite lesions. - Superfical dyspareunia, dysuria. - Mx: *One-off episode* (swab not needed) 1st: single dose PO fluconazole (150mg) 2nd: clotrimazole pessary single-dose +/- topical imidazole if vulval symptoms (N.B. in pregnancy - topical only) *Recurrent (4 or more episodes in 1yr)* - confirm diagnosis high vaginal swab + exclude dd e.g. lichen sclerosus - Rule out DM w/ glucose testing - Induction (PO fluconazole every 3 days for 3 doses); Maintenance (PO fluconazole weekly for 6/12) Bacterial Vaginosis - overgrowth of gardenella vaginalis -> drop in lactobacilli -> raised pH - Presentation: Thin white discharge, fishy, offensive odour - Ix: clue cells on microscopy, pH >4.5, positive whiff test - Mx: PO metronidazole 7 days Trichomonas Vaginalis = parasite Presentation: offensive, yellow/green, frothy discharge, vulvovaginitis, strawberry cervix, pH >4.5 Ix: microscopy show trophozoites Mx: PO metronidazole 5-7d (or one-off 2g metronidazole) **Swabs** - External + internal examination - Swabs: - High vaginal charcoal: BV, trichomonas, candida, group B strep - Endocervical + Vulvovaginal NAAT - chlamydia + gonorrhoea

Answer 5

**Causative Organism** = gram -ve diplococci - Neisseria gonorrhoea **Presentation** - infection can occur on any mucous membrane (typically GUm but can be rectum/pharynx) - Males: urethral discharge, dysuria - Females. Cervicitis, discharge - Rectal/pharyngeal infec - asymptomatic **Investigation** - NAAT swabs **Complications** - Urethral strictures - Epididymitis - Salpingitis (-> infertility) - conjunctivitis in babies born to infected mothers (first 2-5d) - Disseminated gonococcal infection + gonococcal arthritis Initial triad: tenosynovitis, migratory polyarthritis + dermatitis (maculopapular or vesicular) Later: septic arthritis, endocarditis, Fitz-hugh-Curtis **Management** - 1st IM ceftriaxone 1g - +/- single dose PO ciprofloxacin 500mg (only if sensitivities known)

Answer 6

Causative organism: chlamydia Trachomatis (obligate intracellular) **Presentation** Asymptomatic (70% of women, 50% men) Women: cervicitis (discharge, bleeding), dysuria Men: discharge, dysuria Complications: epididymitis, PID, endmetritis, ectopic, infertility, reactive arthritis, Fitz-Hugh- Curtis), conjunctivitis in neonates (5-12d) **Investigation** - NAAT swab or urine - women 1st line: vulvovaginal swab - men: urine is 1st line - should be done 2/52 after exposure **Screening** - all men + women aged 15-24yo **Management** - 1st: Doxycycline 7 day course - pregnancy: azithromycin or erythromycin or amoxicillin Contact tracing Symptomatic men: all contacts within 4 weeks Women + asymptomatic men: last 6 months or last known partner before then Offer contacts treatment prior to test results if contact within last 2 weeks

Answer 7

Causative oranism = Trepoenma Pallidum **Presentation** Primary -Chancre (painless singular ulcer) (can be on cervix so not always visible) -Local non-tender lymphadenopathy Secondary (6-10/52 post primary) - Systemic: fever, lymphadenopathy - Rash: rough red/brown spots on trunk, palms, soles - Buccal 'snail track' ulcers - Condylomata lata (painless, warty lesions on genitalia) Tertiary (years later) - Gummatous: granulomas in skin/bone - CVS: Ascending aortic aneusrysms, aortic regurg - Neuro: Tabes Dorsalis (slow degeneration dorsal columns/senosry pathways -> areflexia, paraesthesia, ataxia); - Argyll Roberton Pupil (Accomodation Reflex Present, Pupillary Reflex Absent) - now more commonly due to DM **Complications** In pregnancy --> congenital syphilis (blunted upper incisors, keratitis, saber shins, saddle nose, deafness, rhagades (linear scars at angle of mouth) **Investigation** - Dark ground microscopy of chancre fluid (primary) - Serology: tremponemal tests and non-treponemal (RPR ot VDRL titres) - LP for neurosyphilis **Management** - Prolonged course IM penicillin (or doxy) - If CVS or neuro involvement give steroids prior to abx to avoid localised inflammatory response ( Jarisch-Hercheimer reaction _. fever, tachy, rash (supportive management)) - Contact tracing - Monitor non-treponemal titres to assess treatment response.

Answer 8

**Genital Warts** HPV (typically 6+11) - painless, small fleshy lesions +/- bleeding/itch - Management: - 1st Topical podophyllum (multiple, nonkeratinised warts) or cryotherapy (singular, keratinised warts) - 2nd: imiquimod - (often recur post-treatment, although clears within 1-2yrs) **Genital Ulcers** Genital Herpes (HSV2) - Present: painful ulceration +/- dysuria, pruritis, tender inguinal lyphadenopathy, urinary retention - Primary infection often more severe than recurrent episodes w/ headache, fever + malaise - Ix: NAAT + HSV serology - Mx: - General: saline baths, analgesia, topical anaeshtetic (lidocaine) - PO aciclovir (if frequent episodes may benefit from this long-term) - In pregnancy: C-section if primary infection >28/52. In those w/ recurrent infections give supressive therapy + advise transmission risk is low. Primary Syphilis (singular, painless chancre) Chancroid - Cause: haemophilus ducreyi - Present: Painful ulcers w/ sharply defined ragged borders. AND unilateral painful inguinal lymph node enlargement. Lymphogranuloma Venereum (LGV) Cause: chlamydia 3 stages of infection: 1. small painless pustule which develops into ulcer; 2. painful inguinal lymphadenopathy; 3. proctocolitis Treat: doxycyline Bechet's Disease - rare - mouth + genital ulcers + rash - painful ulcers in non-sexually active Carcinoma Granuloma Inguinale (klebsiella granulomatosis)

Answer 9

**Vulval Carcinoma** - 80% = SCC. - RF: HPV, VIN, immunosupression, lichen sclerosus - Features: lump or ulcer on labia majora, inguinal lymphadenaopthy +/- itching/irritation **Bartholin's cyst/abscess** - Cyst = fluid filled sac. Abscess = infection - Organisms: E.coli, MRSA, STI - RF: nulliparous, prev hx, secually active - Presentation - Cyst - small are asymptomatic. Large can cause vulval pain (esp when walking) + superficial dyspareunia. Rupture can -> sudden relief of pain. - Abscess - acute onset pain +/- difficulty passing urine - Investigation: clinical diagnosis BUT if >40 biopsy to exclude carcinoma - Management: small asymp cyst (warm baths, compress). Marsupilisation +/- antibiotics. **Lichen Sclerosus** - Chronic inflammatory skin condition of anogenital region. (?autoimmune) - Seen prepubesence + post-menopausal. Risk of progression to SCC. - Exam - white atrophic patches in figure of 8 pattern; adhesions/scarring (clitoral hood fusion, fusion of labia -> loss of vaginal opening) - Symp: asymp or itching, pain - Ix - gynae to diagnose (may need biopsy to rule out SCC) - Mx: 1st: topical steroids, avoid irritants (regular f/u)

Answer 10

**Pathophysiology** Causative organisms: - Chlamydia (1st) - N. Gonorrhoea - Mycoplasma genitalium - Mycoplasma hominis **Presentation** - Lower abdo pain, deep dyspareunia, fever, discharge - Dysuria, menstrual irregularities - Cervical excitation **Investigations** - Pregnancy test (exclude ectopic) - High vaginal swab (often +ve so treat regardless) **Management** - Low threshold for treating (clinical diagnosis) - PO ofloxacin + PO metronidazole - OR Im ceftriazone + PO doxy + PO metro **Complications** - Perihepatitis (Fitzh Hugh Curtis) - Infertility - Chronic Pelvic Pain - Ectopic Pregnancy

Answer 11

**Classification** - Overactive Bladder/Urge - Stress - Mixed (urge + stress) - Overflow - Functional (e.g. mobility issue, dementia) - True (e.g. fistula) Risk factors: age, previous pregnancy/childbirth, high BMI, hysterectomy, fam hx **Investigation** - Bladder diaries (3d minimum) - PV exam - ?prolapse - Urine dipstick and culture (?UTI, predisposing DM etc) - Urodynamic studies **Management** - Stress: - 1st: pelvic floor muscle training - 2nd: surgical (sling procedures) If surgery not suitable: duloxetine - Urge: - 1st: bladder retraining - 2nd: antimuscarinics e.g. oxybutynin, tolterodine, darifenacin - 3rd: mirabegron (b 3 agonist) - if worried about anticholinergic SEs (e.g. in elderly) Other types: treat cause

Answer 12

**Types + Presentation** - Rectocele - difficult defaecation, manual digitation, reducible mass - Urethrocele - stress incontinence, need to replace to voice - Uterine prolapse - Cystocele - double voiding, stress incontinence, recurrent UTI, need to replace to void All: sense of fullness in vagina w/ dragging discomfort. Visible protrusion. Sacral backache on lying down. **Investigation** - normally diagnosed clinically +/- USS **Management** minor --> pelvic floor physio + pessaries surgery if needed

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Gynaecology Flashcards

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