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3a > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Causes of abnormal uterine bleeding

A

Fibroids
Endometrial hyperplasia
Endometrial cancer
Adenomyosis
Perimenopause
Polyps
PCOS

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2
Q

Causes of post menopausal bleeding

A

Endometrial cancer
Endometrial atrophy
Endometrial hyperplasia
Polyps

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3
Q

First line medical management for abnormal uterine bleeding

A

Mirena coil

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4
Q

How long must pelvic pain last to be classed as chronic pelvic pain?

A

> 6 months

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5
Q

Causes of acute pelvic pain

A

Miscarriage
Ectopic pregnancy
Appendicitis
UTI
PID
Torsion/rupture of ovarian cyst
Acute pancreatitis
Cholangitis

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6
Q

Define endometriosis

A

Presence of endometrial-like tissue outside of the uterus

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7
Q

What age group does endometriosis typically effect?

A

25-35

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8
Q

What is the definitive way to diagnose endometriosis

A

Laparoscopic surgery

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9
Q

Medical management of endometriosis

A

Analgesia
Hormonal treatment - OCP, mirena coil

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10
Q

Surgical management of endometriosis

A
  • Laparoscopic surgery - to excise endometrial tissue and remove adhesions
  • Hysterectomy
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11
Q

What is adenomyosis and who does it typically effect?

A

The presence of endometrial tissue within the myometrium
Older women who have had children

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12
Q

What are fibroids?

A

Benign smooth muscle tumours of the myometrium

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13
Q

Fibroids effect…

A

… 30% of women over 30

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14
Q

Symptoms of fibroids

A

Asymptomatic
Menorrhagia
LUTS
Pelvic pain

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15
Q

Complications of fibroids

A
  • Torsion
  • Red degeneration
  • Malignant change to leiomyosarcoma
  • Pregnancy complications e.g. miscarriage, preterm labour
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16
Q

What criteria is used for making a diagnosis of PCOS?

A

The Rotterdam Criteria

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17
Q

What 3 key features are included in the Rotterdam Criteria? How many of these do you need for diagnosis?

A

2/3 features required for diagnosis:
1. Oligoovulation/anovulation
2. Hyperandrogenism
3. Polycystic ovaries on USS

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18
Q

Insulin resistance is a crucial part of PCOS. Give 3 ways increased insulin impacts PCOS

A
  1. Insulin promotes the release of androgens -> hyperandrogenism
  2. Insulin suppresses sex hormone-binding globulin (produced by the liver) which normally binds to androgens and suppresses their function
  3. High insulin halts the development of follicles in the ovaries -> anovulation
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19
Q

What would hormonal blood test show in PCOS?

A
  • Raised LH
  • Raised LH:FSH ratio
  • Raised testosterone
  • Raised insulin
  • Normal/raised oestrogen
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20
Q

What is gold standard for visualising the ovaries?

A

Transvaginal ultrasound

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21
Q

On TVS what findings indicate PCOS?

A
  • 12 or more developing follies in one ovary
  • Ovarian volume >10cm3
  • Follicles arranged around the periphery of the ovary giving a ‘string of pearls’ appearance
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22
Q

Why are women with PCOS at increased risk of endometrial cancer?

A

Normally after ovulation the corpus luteum releases progesterone. Women with PCOS ovulate infrequently/not at all -> insufficient progesterone. This means their endometrium proliferates in the presence of unopposed oestrogen -> endometrial hyperplasia -> rf for endometrial cancer

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23
Q

Give 3 options for restoring ovulation in women with PCOS?

A
  1. Weight loss
  2. Clomifene
  3. IVF
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24
Q

Give 2 broad causes of incontinence

A
  1. Detrusor overactivity
  2. Sphincter weakness
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25
Q

What features would indicate detrusor overactivity incontinence?

A
  • Urgency
  • Frequency
  • Nocturia
  • ‘Key in the door’
  • Incontinence during intercourse
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26
Q

What type of incontinence is seen with sphincter weakness?

A

Stress incontinence

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27
Q

What innervation, neurotransmitter and receptors are involved with detrusor overactivity?

A
  • Parasympathetic
  • ACh
  • Muscarinic
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28
Q

Give general management options for incontinence

A
  • Wt loss
  • Smoking cessation
  • Reduce caffeine
  • Leakage barriers
  • Vaginal support - pessaries
  • Vaginal oestrogen
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29
Q

What speculum should be used for investigating prolapsed?

A

Sims speculum

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30
Q

Give 2 surgical options for managing prolapse

A
  1. Hysterectomy for uterine prolapse
  2. Colpocleisis for women who do not wish to retain sexual function
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31
Q

Give 3 non-surgical options for managing prolapse

A
  1. Pelvic floor training (>16 weeks)
  2. Topical oestrogen (if prolapse + atrophy)
  3. Pessaries
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32
Q

Give 4 types of prolapse

A
  1. Uterine prolapse
  2. Vaginal vault prolapse
  3. Cystocele
  4. Rectocele
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33
Q

What 2 phases occur in the ovaries during the menstrual cycle?

A
  1. Follicular phase
  2. Luteal phase
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34
Q

What 3 phases occur in the endometrium during the menstrual cycle?

A
  1. Menstral phase
  2. Proliferative phase
  3. Secretory phase
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35
Q

What is the typical time period from ovulation to menstruation?

A

14 days

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36
Q

What happens during the follicular phase of the menstrual cycle?

A
  • Initially low progesterone + oestrogen and increasing FSH
  • The developing follicle releases oestrogen
  • Oestrogen inhibits FSH and increases LH
  • LH surge results in ovulation
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37
Q

What happens during the luteal phase of the menstrual cycle?

A
  • Follicle in ovary forms corpus luteum and secrete progesterone
  • If the ovum is not fertilised the corpus luteum regresses to form the corpus albicans
  • Progesterone decreases which results in mensuration
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38
Q

What endometrial phase does the luteal phase in the ovary trigger?

A

The menstrual phase

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39
Q

What happens during the menstrual phase of the menstrual cycle?

A

Falling progesterone results in shedding of the endometrium

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40
Q

What happens during the proliferative phase of the menstrual cycle? What ovarian phase does it coincide with?

A
  • Increasing oestrogen causes endometrial growth and early development of spiral arterioles and glands
  • Follicular phase in the ovaries
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41
Q

What happens during the secretory phase of the menstrual cycle? What ovarian phase does it coincide with?

A
  • Increasing progesterone (from the corpus luteum) prepares the endometrium for implantation (development of spiral arterioles and endometrial production of glycogen)
  • Early luteal phase in the ovaries
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42
Q

What is the 1st and 2nd line management of stress incontinence?

A
  1. Pelvic floor exercises/physio
  2. Duloxetine
43
Q

What is the 1st and 2nd line management of urge incontinence?

A
  1. Bladder training
  2. Oxybutinin
44
Q

What are side effects of oxybutinin?

A

Anticholinergic side effects - can’t see, can’t pee, can’t spit, can’t shit
- Dry eyes
- Dry mouth
- Urinary retention
- Constipation

45
Q

What is hypogonadism?

A

Lack of sex hormones - oestrogen and testosterone

46
Q

What are 2 reasons for hypogonadism?

A
  1. Hypogonadotropic hypogonadism
  2. Hypergonadotropic hypogonadism
47
Q

What is hypogonadotropic hypogonadism?

A

A deficiency of LH and FSH

48
Q

Give 5 causes of hypogonadotropic hypogonadism

A
  • Hypopituitarism
  • Damage to hypthal/pit. by radiotherapy or surgery for cancer
  • Excessive exercise/dieting
  • Kallman syndrome
  • Endocrine disorders - hyperprolactinaemia, Cushing’s, hypothyroidism
49
Q

What is Kallman Syndrome? What’s an additional feature of it?

A
  • Genetic condition causing hypogonadotropic hypogonadism
  • Anosmia (reduced/absent sense of smell)
50
Q

What is hypergonadotropic hypogonadism?

A

Where the gonads fail to respond to stimulation from the gonadotropins (LH/FSH)

51
Q

Why do you get high LH/FSH in hypergonadotropic hypogonadism?

A

Without negative feedback from the sex hormones the anterior pituitary produces increasing amounts of LH and FSH. This leads to high LH/FSH and low sex hormones

52
Q

What are 3 causes of hypergonadotropic hypogonadism?

A
  • Previous damage to gonads - torsion, cancer, infections (mumps)
  • Congenital absence of ovaries
  • Turners syndrome
53
Q

What type of amenorrhoea does congenital adrenal hyperplasia cause?

A

Primary amenorrhoea

54
Q

Why can androgen insensitivity syndrome present with primary amenorrhoea?

A

Although girls have female external genitalia, internally there are testes. They have absent uterus, upper vagina, fallopian tubes and ovaries.

55
Q

What is the most common structural cause of primary amenorrhoea? What are the symptoms?

A
  • Imperforate hymen
  • Cyclical pain as menses builds up but is unable to escape
56
Q

What are the levels of 1) LH/FSH and 2) sex hormones, in hypogonadotropic hypogonadism?

A

1) Low LH/FSH
2) Low sex hormones

57
Q

What are the levels of 1) LH/FSH and 2) sex hormones, in hypergonadotropic hypogonadism?

A

1) High LH/FSH
2) Low sex hormones

58
Q

Treatment of hypogonadotropic hypogonadism where pregnancy is wanted?

A

Pulsatile GnRH to induce ovulation and mensuration

59
Q

Treatment of hypogonadotropic hypogonadism where pregnancy is not wanted?

A

COCP to replace sex hormones

60
Q

What is secondary amenorrhoea?

A

No mensuration for more than 3 months

61
Q

What type of hypogonadism do you get in secondary amenorrhoea? Why?

A
  • Hypogonadotropic hypogonadism
  • The hypothalamus reduces production of GnRH in response to sig. physiological/psychological stress to prevent pregnancy in situations in which the body may not be fit
62
Q

Give 5 causes of secondary amenorrhoea. Which is the most common cause?

A
  • Pregnancy (most common)
  • Menopause/primary ovarian insufficiency
  • Hyperprolactinaemia
  • Ovarian causes - PCOS
  • Thyroid pathology
63
Q

What happens in hyperprolactinaemia?

A

High prolactin levels act on the hypothalamus to prevent release of GnRH –> no LH/FSH

64
Q

What’s the most common cause of hyperprolactinaemia?

A

Pituitary adenoma secreting prolactin

65
Q

What’s the treatment of hyperprolactinaemia?

A

Dopamine agonists (bromocriptine/cabergoline) to reduce prolactin production

66
Q

Why is it important to have a withdrawal bleed in PCOS? What can be used to stimulate this?

A
  • To prevent the risk of endometrial hyperplasia and endometrial cancer
  • Medroxyprogesterone for 14 days/regular use of the COCP
67
Q

When is first line for symptom control of menorrhagia if painless?

A

Tranexamic acid

68
Q

What type of drugs are tranexamic acid and mefenamic acid?

A
  • Tranexamic - antifibrinolytic
  • Mefenamic - NSAID
69
Q

What can be given when menorrhagia is associated with pain?

A

Mefenamic acid

70
Q

What can be given for hirsutism in PCOS? Which is contra-indicated in pregnancy?

A

Anti-androgen
- Cocyprindol
- Spirolactone
- Finasteride (c.i. in preg)

71
Q

What are functional cysts? Give 2 examples

A
  • Cysts related to fluctuating hormones of the menstrual cycle
  • Follicular cysts
  • Corpus luteum cysts
72
Q

What are corpus luteum cysts?

A
  • Occur when the corpus luteum fails to break down and instead fills with fluid
  • Can cause pelvic discomfort, pain, delayed menstration
  • Often seen in early pregnancy
73
Q

What are follicular cysts?

A
  • Represent the developing follicle
  • When they fail to rupture and release the egg the cyst can remain
  • Most common ovarian cyst
  • Harmless and tend to disappear after a few menstrual cycles
74
Q

What cysts are associated with endometriosis? Give both names for them

A
  • Endometrioma
  • Chocolate cysts
75
Q

What is the management of simple cysts in premenopausal women…
1. <5cm
2. 5-7cm
3. >7cm

A
  1. No further Rx, will resolve within 3 cycles
  2. Routine referral to gynae + yearly USS
  3. MRI/surgical evaluation as can be hard to characterise with ultrasound
76
Q

What is meigs syndrome?

A

A triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleural effusion
- Ascites

  • Typically occurs in older women
  • Removal of the tumour results in complete regulation of symptoms
77
Q

What are LH, FSH, oestrogen and progesterone levels in menopause?

A
  • Oestrogen and progesterone are low
  • LH and FSH are high as no negative feedback from oestrogen
78
Q

What is the medical management of fibroids <3cm? What is this the same management as?

A
  • Mirena coil (1st line)
  • Symptomatic management (NSAIDS/tranexamic acid)
  • COCP/POP
  • Same management as heavy menstrual bleeding
79
Q

What is the management of fibroids >3cm

A
  • Referral to gynae
  • May manage in the same way as smaller fibroids
  • Surgical options - uterine artery embolisation, myomectomy, hysterectomy
80
Q

What medications are used to reduce the size of fibroids before surgery? How do they work?

A
  • GnRH agonists e.g. goserelin or leuprorelin
  • Shrink the fibroid by inducing a menopause like state, this reduces the amount of oestrogen maintain the fibroid
81
Q

What aspect of the Rotterdam criteria for PCOS does hirsutism fall under?

A

Clinical and/or biochemical signs of hyperandrogenism

82
Q

When should you remove the coli in PID?

A

If no response to abx after 72 hours

83
Q

What features indicate ovarian torsion?

A
  • Vomiting
  • Peritonism
  • Fever
84
Q

What should you always look out for in patients presenting with secondary amenorrhoea?

A

Signs of menopause!!!! Night sweats, poor concentration, heat intolerance etc

85
Q

What indicates a pituitary/hypothalamic issue in secondary amenorrhoea?

A

Low oestrogen AND gonadotropins
- Low oestrogen should trigger pit/hypothalamus to increase gonadotrophin production

86
Q

What is haematocolpos?

A

Accumulation of blood in vagina, normally due to imperforate hymen

87
Q

What is the classical position of the uterus in endometriosis?

A

Fixed retroverted uterus

88
Q

What are the 4 types of fibroids?

A
  • Submucosal - below the endometrium
  • Intramural - within the myometrium
  • Subserosal - below the outer layer of the uterus
  • Pedunculated - on a stalk
89
Q

What is the management of cysts in post-menopausal women?

A
  • CA125 and refer to gynae
  • If raised Ca125 2WW
90
Q

What is lichen sclerosus?

A
  • A chronic inflammatory skin condition that presents with patched of shiny, white skin
  • Commonly affects the labia, perineum and perianal skin in women
91
Q

Typical presentation of lichen scelrosus

A
  • 45-60 year old female
  • Presenting with vulval itching and skin changes
  • Koebner phenomenon (signs and symptoms are worse with friction)
92
Q

How are patients with lichen sclerosus managed?

A
  • FU every 3-6 months with derm or gynae
  • Regular emollients
  • Flares are managed with potent topical steroids e.g. dermovate
  • Steriods are initially used once a day for 4 weeks then every other day for 4 weeks then twice a week
93
Q

What’s a critical complication of lichen sclerosus?

A

Development of squamous cell carcinoma of the vulva

94
Q

What are Bartholin’s glands? What happens when they become blocked?

A
  • A pair of glands either side of the vaginal introitus (the vaginal opening)
  • The produce mucus to help vaginal lubrication
  • When blocked they can swell and become tender causing Bartholin’s cyst
95
Q

What’s a complication of Bartholin’s cysts? What’s the management of this?

A
  • Bartholin’s abscess
  • Swab of pus/fluids for culture
  • Antibiotics
  • Surgery (may be required) to drain the abscess
96
Q

What is the management of Bartholin’s cysts?

A

Usually resolve with good hygiene, analgesia and warm compresses

97
Q

What are Nabothian cysts? Are they concerning? What causes them?

A
  • Fluid filled cyst on the surface of the cervix
  • They are harmless and unrelated to cervical cancer
  • Can occur after childbirth, minor trauma or cervicitis following infection
98
Q

How can Nabothian cysts present?

A
  • Often asymptomatic so may be found incidentally on speculum examination
  • If very large (rare) can cause a feeling of fullness
99
Q

What is the management of Nabothian cysts?

A

No treatment required, normally resolve spontaneously

100
Q

What happens in cervical ectropion?

A
  • When the columnar epithelium of the endocervix extend out to ectocervix (normally stratified squamous epithelium)
  • Columnar epithelium is more fragile and prone to trauma and bleeding
101
Q

How does cervical ectropion present?

A
  • Post coital bleeding
  • Increased vaginal discharge
  • Dyspareunia
102
Q

What’s the management of symptomatic cervical ectropium?

A

Cauterisation of the ectropium using silver nitrate or cold coagulation during colposcopy

103
Q

What are risk factors for cervical ectropion?

A

Cervical ectropium is associated with higher oestrogen levels meaning RF include younger age, COCP and pregnancy

3a (34 decks)

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