Gynaecology Flashcards
Gynae
- Benign
- Oncology
Gynae
- Benign
1. Fibroids
2. Pelvic pain
3. Menstrual problems - Oncology
1. Cervical screening
2. Colposcopy
3. Postmenopausal bleeding
4. Cancers
Obstetrics
- Care indications
Obstetrics
- Care indications
- Pre-conceptual/Antenatal
- High risk pregnancy
- Labour and delivery
- Puerperium
- Emergencies
Gynae History
- Structure
Gynae History
- Structure
- Reason for attendance
- Menstrual history
- First day of LMP
- Number of days and flow
- Cycle
- Bleeding (inter/post coit)
- Menarche age
- Pain - Contraception/HRT
- Previous gynae history
- Smear and result
- Problems and treatments/operations
- (PID, STI, cysts, smear, myomectomy/hysterectomy/prolapse) - Obstetric history
- Gravidity and parity
- Pregnancy outcomes/modes
- Birth weights - Medical and surgical
- Blood transfusion/complication
- Anaesthesia/complication - Medications/allergies
- Social history
- Support
- Social services, domestic violence, MH
- Smoking/drugs/alcohol - Sexual
- STI
- Partners - FH
- Cancers
- DM, HTN, CVD, VTE
Gynaecology
- Common complaints
Gynaecology
- Common complaints
- Periods
- painful/heavy/irregular - Pain
- Pelvic/on intercourse - Urinary incontinence
- Prolapse
- Infertility/Sterilisation
- Bleeding
- Pregnancy/postmenopausal - PID/discharge
Menstrual cycle
- HPA Hormones
Menstrual cycle
- Hormones
- GnRH
- Hypothalamus - LH/FST
- Pituitary - Oestrogen/progesterone
Menstrual cycle
- Start event
Menstrual cycle
- Start event
- First day of menses
Menstrual cycle
- Phases
Menstrual cycle
- Phases
- Follicular
- proliferative - Luteal
- Secretory
Follicular phase
- Development of….
Follicular phase
- Development of….
- Dominant follicle
Luteal phase
- Development of…
Luteal phase
- Development of
- Corpus luteum
Menstrual hormone peaks
- FSH
- LH
- E2
- P
Menstrual hormone peaks
- FSH
- First day of menses (day 0)
- Ovulation (14) - LH
- Ovulation (14) - E2
- Before ovulation (before 14)
- before menses - P
- Luteal phase
Normal cycles
- Length
- Regularity
- MBL
Normal cycles
- Length
1. 24-32 - Regularity
2. Best aged 20-40y
3. Shorter pre-menopause, longer post- - MBL
- 37-43ml
- 9-14% >80ml (likely anaemic)
Menstrual blood loss
- Factors
Menstrual blood loss
- Factors
- Age - increases
- Genetics (twin-studies)
- Parity (+ve correlation)
Menstrual acronyms
- HMB
- Metro
- IMB
- PCB
- Oligo
- Amen
Menstrual acronyms
- HMB
- menorrhagia - Metrorrhagia
- irregular - IMB
- Inter-menstrual - PCB
- Post-coital - Oligomenorrhea
- Infrequent - Amenorrhoea
- Absent
DUB
- 60% is…
- Definition
DUB
- Heavy menstrual bleeding
- no recognisable pelvic pathology
- no pregnancy/bleeding disorders
- Exclusion - 60% is Primary Menorrhagia
AUB/HMB
- Pathologies
- Medical/clotting
- Other
AUB/HMB
- Pathologies
1. Fibroids
2. Adenomyosis/endometriosis
3. IUCD
4. PID
5. Polyps - Medical/clotting
1. Hypothyroid
2. Liver
3. Von Willebrand’s
4. Thrombocytopenia/ leukaemia
5. Platelets/coags - Other
1. Cancer
2. Hyperplasia
AUB
- Clinical Assessment
AUB
- Clinical Assessment
Subjective
1. Only 50% have greater than normal loss
2. Only 60% with MBL<80ml consider them heavy
Best measure
1. QoL
- Work/social/clothing/bedding/sleep
- Anaemia
HMB
- Assessment
HMB
- Assessment
- Low risk
1. <45y, No IMB, No RFs for endometrial cancer
2. History +Exam + FBC
3. First line treatment - High risk
1. >45y, IMB, Suspicious, RFs
2. Hx + Ex + FBC + USS + Hysteroscopy & Biopsy
3. First line treatment
HMB
Medical Mx
HMB Medical Mx
- Symptomatic
1. Tranexamic acid
2. mefenamic acid - Fibroids
1. GnRH analogues
2. Esmya (ulipristal acetate) - Hormonal control
1. POP
2. LARC (long-acting reversible)
eg. Mirena (prog)
3. Implant
4. Depo-Provera - Hormonal control-combined
1. COCP
HMB
- Surgical Mx
HMB Surgical Mx
- Polyps
1. Hysteroscopic removal
(MYOSURE) - Fibroids
1. Myomectomy
2. Uterine artery embolization - Family complete
1. Endometrial ablation
(NOVAURE)
2. Hysterectomy
(Lap or open)
HMB
- Emergency management
HMB
- Emergency management
- Tranexamic acid
- Norethisterone
- 5mg po dts
- up to 7 days or 3 weeks on, 1 week off - GnRH analogues
- Monthly injection
- downregulate cycle (medical menopause)
Tranexamic acid
- effects
Tranexamic acid (anti-fibrinolytic)
- effects
- Plasminogen inhibition (tPA)
- Reduces MBL by 50%
- ADRs
- Nausea, abdo cramp
- Dizziness, tinnitus
- Rash
Mefenamic acid
- Effects
Mefenamic acid
- Effects
- NSAID
- Inhibit PG production - Reduces MBL by 20-44%
- ADRs
- GI
- Dizziness/headaches
- Liver
- Asthma & Renal
Infrequent/absent periods
- Definitions
Infrequent/absent periods
Oligomenorrhea
1. Cycle is slow
- 35 days - 6 months
Amenorrhoea
1º No menarche by 16
2º Absent for 3/12 if regular
- Absent for 6/12 if oligomenorrheic
Oligomenorrhea
- Causes
Oligomenorrhea
- Causes
- Constitutional
- Anovulation
1. PCOS
2. Thyroid
3. Prolactinoma
4. CAH
Amenorrhoea
- Causes
Amenorrhoea
- Causes
- Physiological
1. Pre-pubertal
2. Pregnancy
3. Menopause
Pathological
1. Cryptomenorrhea
- Hematocolpos
- Hematometra
- Uterine/endometrial cause
- Ovarian
- Pituitary/hypothalamic
Amenorrhoea
- Primary causes
Amenorrhoea
- Primary causes
- Delayed puberty
- Imperforate hymen
- Absent vagina
- Mullerian agenesis
- Turner
- PCOS (rare primary)
- CAH
Amenorrhoea causes
- Secondary
Secondary amenorrhoea
- Pregnancy
- PCOS
- Premature menopause
- Prolactinoma
- Thyroid disease
- Cushing’s
- EDs
- Syndromes
- Asherman (scarring)
- Sheehan (bleeding)
Amenorrhoea
- FSH investigation
Amenorrhoea
- FSH investigation
- Pituitary/hypothalamus
- Low FSH - Ovary
- High FSH
Primary Amenorrhoea
- Primary Ix pathway
Primary Amenorrhoea
- Ix
- Pregnancy test
- TSH
- Prolactin
- LH/FSH
a. Low FSH
- constitutional delay, ED, exercise, stress, illness
b. High FSH
- Uterus? (Mullerian agenesis XX, androgen insensitivity XY)
- Karyotyping? (Turner Xo, Premature menopause XX)
Secondary Amenorrhoea
- Ix
Secondary Amenorrhoea
- Ix
- Pregnancy
- TSH
- Prolactin
- High FSH
- Premature menopause
- Turner mosai - Normal FSH
- PCOS
- Uterine adhesions - Low FSH
- ED, exercise, stress, illness, sheehan
PCOS
- Features
PCOS
- Features
- Hyperandrogenism
- Acne
- Hirsutism
- Obesity - Anovulation
- Oligo/amenorrhoea
- Multiple follicles on US (12+ in one or both ovaries)
and/or
- Increased ovarian volume (>10cm3)
Rotterdam criteria
- PCOS
Rotterdam criteria
- PCOS
Two or more of:
- Clinical/biochemical signs of hyperandrogenism
- Oligo/amenorrhoea
- US features
PCOS
- DDx
PCOS
- DDx
- Obesity
- Premature ovarian failure
- Thyroid
- Prolactinoma
- CAH/ Androgen tumour/ Cushing’s
PCOS
- Ix
PCOS
- Ix
- SHBG
- Sex hormone binding globulin - Total testosterone
- FAI
- Free androgen index - FSH/LH
- TFT
- Prolactin
PCOS
- General Mx
PCOS
- General Mx
- Weight loss
- Healthy lifestyle
- Glucose tolerance screening
- MH screening
PCOS
- Specific Mx
- Periods
- Conception
- Androgenism
PCOS
- Specific Mx
- Periods
1. COCP
2. Cyclical progestogens - Conception
1. BMI
2. Folic acid
3. Fertility + semenalysis
4. Fertility referral
5. Ovulation induction - Androgenism
1. COCP
2. Acne standards
3. Hair removal
Gynae cancer
- Locations
Gynae cancer
- Locations
- Cervix
- Uterus
- Ovary
- Vagina and vulval
Cervical cancer
1. Deaths/Annual incidence
2. Preventability
Cervical cancer
- Deaths/annual incidence
850/3,100 - Preventability
99.8%
Uterine cancer
1. Deaths/Annual incidence
2. Preventability
Uterine cancer
1. Deaths/Annual incidence
- 2,400/9,000
- Preventability
- 34%
Ovarian cancer
1. Deaths/Annual incidence
2. Preventability
Ovarian cancer
- Deaths/Annual incidence
- 4,200/7,300 - Preventability
- 11%
Vagina
1. Deaths/Annual incidence
2. Preventability
Vagina
- Deaths/Annual incidence
- 100/230 - Preventability
- 75%
Uterine cancer
- Peak age
Uterine cancer
- Peak age
75-79yo
Endometrial ca
- Peak age
Endometrial ca
- Peak age
64-74
Endometrial ca
- Increased risk
- Lowered risk
Endometrial ca
- Increased risk
Unopposed oestrogen
1. Obesity
2. Early menarche/late menopause
3. Nulliparity
4. PCOS
5. Tamoxifen
6. Endometrial polyps
7. BRCA
8. DM, PD - Reduced risk
1. Continuous combined HRT
2. COCP
3. Physical activity
- Smoking
- Tea&coffee
- Lowered risk
Endometrial cancer
- Presentation
Endometrial cancer
- Presentation
- Present Early
- Pre-menopausal (1% risk)
1. Prolonged, frequent bleeding
2. IMB - Post menopausal
1. PMB (10% risk)
2. Discharge - Blood-stained, water, purulent
Endometrial pathologies
- Pre-malignant
- Malignant
Endometrial pathologies
- Pre-malignant
1. Endometrial hyperplasia - Malignant
1. Type I (80%) - Adenocarcinoma
- Type II (20%)
- Papillary Serous
- Clear Cell
- Carcinosarcoma - Sarcoma (rare)
Endometrial hyperplasia
- Subtypes
- Mx
Endometrial hyperplasia
- Subtypes
1. Complex or without atypia
2. Atypical (25-50% coexistent malignancy) - Mx
1. Progestagens
2. Surgery
FIGO
- Staging
- 5 year survival
FIGO Staging
- Limited to myometrium
- 80% - Cervical spread
- 60% - Uterine serosa
- 40% - Bladder/bowel/distant
- 20%
Endometrial cancers
- Dx
Endometrial cancers
- Dx
- Endometrial sampling
- Pipelle or D&C - Hysteroscopy
- Gold standard - Transvaginal US
- PMB
- >5mm endometrial thickness cutoff
Endometrial cancer
- Treatment
Endometrial cancer
- Treatment
- Surgical (80%)
- Hysterectomy + salpingo-oopherectomy
- Laparo/open - Non-surgical
- Progestagens
- Primary radiotherapy - Adjuvant radiotherapy (high risk)
- External beam
- Brachytherapy - Palliation
- Chemo, radio
- Hormonal, palliative
One-stop PMB clinic
- Ix
One-stop PMB clinic
- Ix
- Hx&Ex
- FBC
- TUS
- Hysteroscopy and Endo biopsy
Ovarian cancer
- Peak age
Ovarian cancer
- Peak age
70-74yo
Ovarian cancer
- Cell lines
Ovarian cancer
- Cell lines
- Surface epithelium (85-90%)
- Serous (50%) (B or M)
- Mucinous (10%) (B or M)
- Endometriod (10%)
- Clear cell (5%)
- Brenner tumours - Germ cells
- Teratoma (B)
- Dysgerminoma (HCG)
- Yolk sac (AFP)
- Choriocarcinoma - Stroma/sex cord
- Granulosa cell
- Theca cell (B)
- Sertoli-Leydic Cell
- Fibroma - Misc/meta
- Lymphoma
- Metastasis
- Krukenberg (Mucinous signet ring)
Ovarian cancer
- Risk factors
Ovarian cancer
- Risk factors
- Unopposed oestrogen
- Nulliparity
- Many menses
- Family Hx
- BRCA
- Endometriosis
Ovarian cancer
- Genetic risk
- BRCA 1
- BRCA 2
- Two relatives
- One relative
- HNPCC
Ovarian cancer
- Genetic risk
- BRCA 1 (50%)
- BRCA 2 (27%)
- Two relatives (23%)
- One relative (10%)
- HNPCC (12%)
Ovarian cancer
- Presentation
Ovarian cancer
- Presentation
- Abdo swelling (50%)
- Pain (50%)
- Anorexia (20%)
- N&V (20%)
- Weight loss (15%)
- Vaginal bleeding (15%)
Ovarian cancer
- Workup
Ovarian cancer
- Workup
- Pelvic Ex
- US
- FBC, UE, LFT
- CA125
- CT
- Ascitic tap cytology
- Surgical exploration
- Histopathology
Ovarian cancer
- Staging and survival
Ovarian cancer
- Staging and survival
- Ovary (90%)
- Pelvic organs (60%)
- Peritoneal cavity (30%)
- Distant metastasis (5%)
Ovarian cancer
- Treatment
Ovarian cancer
- Treatment
- Surgery + chemo
- TAH + BSO and debulking
- Platinum and Taxane
- Consider oophorectomy only - Non-epithelial tumours
- Conservative surgery
- Chemo - Recurrent disease
- Palliative chemo
Ovarian cancer
- Presentation
Ovarian cancer
- Presentation
- Older patient, high BMI
- Abdominal distension, anorexia, change in bowel habit
- Nulliparous
- unsuccessful infertility treatment - Family history of ovarian and endometrial
Ovarian cancer
- Dx
Ovarian cancer
- Dx
- Hx & Ex
- Ca125
- US abdo/pelvis
Cervical cancer
- Age distribution
- Histology
Cervical cancer
- Age distribution
1. Bimodal
2. 30s and 80s - Histology
1. 66% squamous
2. 15% adenocarcinoma
Cervical cancer
- RFs
Cervical cancer
- RFs
- Young age first intercourse
- Multiple sex partners
- No barrier
- Smoking
- COCP long-term
- Immunosuppression/HIV
- Not screened or vacinated
HPV
- Oncogenic types
- Low risk types
HPV
- Oncogenic types
- 16, 18
- 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 - Low risk types
- 6, 11
- 42, 43, 44
HPV
- Pathology
- Infection course
- Prevalence age 50
HPV
- Pathology
1. Proteins E6 & E7
2. Suppression of p53 tumour suppressor gene
3. Keratinocytes - Infection course
1. 8 months on average
2. Late teens and early twenties common - Prevalence age 50
1. Down to 5%
Cervical cancer natural history
- HPV
- CIN
Cervical cancer natural history
- HPV
1. Asymptomatic
2. Cleared or persists
- CIN
1. Asymptomatic
2. Regress, persists, or progress - 60% CIN1 spontaneous regression
- 30% of CIN3 invasion over 5-10 years
CIN
- Condition
- Location
- Symptoms
CIN
- Condition
1. Pre-malignant - Location
2. TZ junction (transitional zone) - Symptoms
0. Asymptomatic
- PCB/PMB
- IMB/blood stained discharge
- Advanced - Fistulae, renal failure, radiculopathy, lower limb oedema
CIN
- Classification
CIN
- Classification
- CIN1
- <33% of BM involvement - CIN2
- <66% of BM involvement - CIN3
- >66% of BM involvement
Cervical ca
- Staging
Cervical ca
- Staging
- Confined to cervix
A Microinvasive (<5mm d x 7mm w)
B Clinical lesion - Beyond cervix
A Upper 1/3 vagina
b Parametrium - Pelvic spread
A Lower 1/3 of vagina
B Pelvic side wall - Distant spread
A Adjacent organs
B Distant sites
Cervical cancer Mx
- Micro invasive
- Clinical lesions (1b-2a)
- Clinical lesions beyond stage 2a
- Lymph nodal involvement
- Recurrent disease
Cervical cancer mx
- Micro invasive
1. Conservative - Cone biopsy
3. Hysterectomy - Clinical lesions (1b-2a)
1. Wertheim’s (radical) hysterectomy
2. Or Chemo-radio - Clinical lesions beyond stage 2a
1. Chemo-radio - Lymph nodal involvement
1. Post-op radiotherapy - Recurrent disease
1. Radio
2. Chemo
3. Exenteration
4. Palliation
Cervical cancer
- Treatment complications
- Surgery
- Radiotherapy
Cervical cancer
- Treatment complications
- Surgery
- Infection/VTE/Haemorrhage
- Vesicovaginal fistula
- Bladder dysfunction
- Lymphocyst formation
- Short vagina - Radiotherapy
- Vaginal dryness/stenosis
- Cystitis/proctitis
- Loss of ovarian function
Cervical cancer
- Staging
- 5 year survival
Cervical cancer
IA - 86-99%
IB - 80-90%
II - 65-69%
III - 40-43%
IV - 15-20%
Cervical screening
- Invitation frequency
Cervical screening
- Invitation frequency
25-50
- 3 yearly
50-65
- 5 yearly
65+
- Selected patients
Cervical cytology
- Classifications
Cervical cytology
- Classifications
- Inadequate
- Normal
- Borderline
- Mild dyskaryosis
- Moderate dyskaryosis
- Severe dyskaryosis
- Possible invasion
Colposcopy
- Equipment
- Indication
Colposcopy
- Equipment
1. Low-power binocular microscopy - Indication
2. Look for features suggestive of CIN or invasion - Abnormal vascular pattern
eg. mosaicism or punctuation - Abnormal staining
eg. aceto-white, brown iodine
Cervical CIN
- Treatment
Cervical CIN
- Treatment
- See-and-treat
- Excisional
- LLETZ
- Large loop excision of transformation zone
- Cold knife cone - Destructive
- Cryocautery
- Diathermy
- Laser vaporisation - Follow-up colposcopy
CIN
- Diagnosis stages
CIN
- Diagnosis stages
- Smear
- Cytology
- Dyskaryosis - Colposcopy
- Opinion on visual assessment - Biopsy
- Histological diagnosis
- CIN 1/2/3
HSV vaccination
- Regimen
HSV vaccination
- Regimen
- Gardasil 6, 11, 16, 18
(Cervarix 16,18) - 3 injections
- over 6 months
- Prior to SI
- 5 years protection
.
VIN
- Condition
- Symptoms
- Treatment
VIN
- Condition
1. Vulvar intraepithelial neoplasia
2. Premalignant - can resolve or progress
- Symptoms
0. None
1. Itching/burning/pain - Treatment
1. Antihistamine
2. Imiquimod
3. Surgical excision
VIN
- RFs
VIN
- RFs
- HPV
- HSV 2
- Immunosuppression
- Chronic irritation
- Lichen sclerosus
Vulval cancer
- Epidemiology
- Types
- Treatment
Vulval cancer
- Epidemiology
1. Very rare
2. Elderly patients - Types
1. Usually SCC - 50% HPV
- 50% chronic skin disease
- Treatment
0. 75% 5 year survival
1. Surgery
2. Chemo-radio
Menarche
-Precocious
- Late
Menarche
-Precocious
1. Age 8
- Late
2. 14 with no 2°
3. 16 with 2°
Ovarian cancers
- Type by age
Ovarian cancers
- Type by age
- Young
- Germ cell - Middle
- Stromal - Older
- Epithelial
BRCA1 & BRCA 2
- Lifetime ovarian risk
BRCA1 & BRCA 2
- Lifetime ovarian risk
- BRCA 1
- 50% risk - BRCA 2
- 27% risk
CA125
- Tumor marker
CA125
- Tumor marker
- Epithelial tumors
Germ Cell Tumor
- markers
Germ Cell Tumor
- markers
- BetaHCG
- AFP
- LDH
Cervical
- Virology
- Cytology
- Histology
Cervical
- Virology
1. +Ve or -ve - Cytology
1. Low grade dyskariosis
2. High grade dyskariosis - Moderate or severe
- Histology
CIN 1 (will regress)
CIN 2 or 3 - treat before progression
Gynae cancer mainstays
- Uterus
- ovary
- cervix
Gynae cancer mainstays
- Uterus
1. Surgery - ovary
1. Surgery and chemo (radio) - cervix
1. Early surgery
2. Later chemo(radio)
