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Gynaecology Flashcards

1
Q

How is menorrhagia managed if no contraception is wanted ?

A

-> Tranexamic acid (if no associated pain)
-> Mefenamic acid (if associated pain)

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2
Q

How is menorrhagia managed if contraception is wanted ?

A
  • 1st : mirena coil
  • 2nd : combined oral contraceptivepill
  • 3rd : cyclical oral progestogens
  • 4th : progesterone only pill or implant
  • Final : endometrial ablation and hysterectomy
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3
Q

Give 6 possible causes of menorrhagia

A
  1. Dysfunctional uterine bleeding
  2. Fibroids
  3. PID
  4. Anticoagulation
  5. Bleeding disorders (e.g. VWD).
  6. Contraception (especially copper coil).
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4
Q

Define adenomyosis

A

Endometrial tissue within the myometrium

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5
Q

Who does adenomyosis usually effect?

A
  • Multiparous women in later reproductive years
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6
Q

What are the symptoms of adenomyosis ?

A

Menorrhagia
Dysmenorrhoea
Dyspareunia

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7
Q

What is felt on examination in adenomyosis ?

A

Enlarged, tender , boggy uterus

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8
Q

What is the first line investigation for adenomyosis

A

Transvaginal USS

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9
Q

How is adenomyosis managed

A
  • Hormonal / non hormonal management of menorrhagia
  • GnRH agonists
  • Uterine artery embolisation
  • Hysterectomy = definitive
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10
Q

what is adenomyosis associated with in pregnancy ?(8)

A

Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage

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11
Q

Explain puberty in girls

A
  • Occurs between 8-14
  • Breast buds, pubic hair and finally menstruation
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12
Q

Define primary ammenorrhoea

A

Not starting menstruation by :

  • 13 years when there is no other evidence of pubertal development
  • 15 years of age where there are other signs of puberty, such as breast bud development
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13
Q
  • How can causes of primary ammenorrhea be classified
A
  • Hypogonadotropic hypogonadism -> LH and FSH deficiency
  • Hypergonadotropic hypogonadism - > lack of response of the ovaries to LH and FSH
  • CAH
  • Androgen insensitivity syndrome
  • Structural pathology
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14
Q

Give 6 causes of hypogonadotropic hypogonadism

A
  • Hypopituitarism
  • Damage to hypothalamus / pituitary (radiotherapy, surgery etc)
  • Significant chronic conditions (CF/IBD)
  • Excessive exercise or anorexia
  • Endocrine disorders : GH deficiency, hypothyroid, cushing’s, hyperprolactinaemia
  • Kallman syndrome (+ reduced / absent sense of smell)
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15
Q

Give 3 causes of hypergonadotropic hypogonadism

A
  • Turner’s syndrome (XO)
  • Congenital absence of the ovaries
  • Previous damage to the gonads
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16
Q

Give 3 other causes of primary ammenorrhoea

A
  • Congenital adrenal hyperplasia
  • Androgen insensitivity syndrome
  • Structural pathology : imperforate hymen, transverse vaginal septae, vaginal agenesis, absent uterus, FGM
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17
Q

what investigations are done to assess primary ammenorrhoea

A

INITIAL Ix FOR UNDERLYING CONDITIONS
- FBC, U&E’s , coeliac screen
HORMONAL BLOOD TESTS
- FSH and LH
- Thyroid function tests
- IGF-1 for GH deficiency
- Prolactin
- Testosterone : raised in PCOS, CAH and androgen insensitivity syndrome
GENETIC TESTING
- Microarray for turner’s

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18
Q

Define secondary amenorrhoea

A

No menstruation for >3mnths after previous regular menstrual periods

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19
Q

Give 8 causes of secondary amenorrhoea

A
  • Pregnancy
  • Menopause and premature ovarian failure
  • Hormonal contraception
  • Hypothalamic or pituitary pathology
  • PCOS
  • Asherman’s syndrome
    -Thyroid pathology
  • Hyperprolactinaemia
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20
Q

Give 4 hypothalamic causes of secondary amenorrhoea

A

The hypothalamus reduces GnRH in response to stress = hypogonadotropic hypogonadism

  • Excessive exercise (e.g. athletes)
  • Low body weight and eating disorders
  • Chronic disease
  • Psychological stress
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21
Q

Give 2 pituitary causes of secondary amenorrhoea

A
  • Pituitary tumours, such as a prolactin-secreting prolactinoma
  • Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
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22
Q

Why does hyperprolactinaemia cause secondary amenorrhoea

A
  • Prolactin acts on the hypothalamus to reduce GnRH.
  • No GnRH -> reduced LH and FSH -> hypogonadotropic hypogonadism
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23
Q

What is the most common cause of hyperprolactinaemia

A

Pituitary adenoma secreting prolactin

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24
Q

What can be used for the treatment of hyperprolactinaemia if necessary

A
  • Dopamine agonists : bromocriptine, cabergoline
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25
Q

what investigations are done to assess secondary amenorrhoea (Five)

A
  • Rule out pregnancy with HCG urine
  • LH and FSH
  • Prolactin
  • Thyroid
  • Testosterone
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26
Q

What will LH and FSH levels suggest about the cause of secondary amenorrhoea ?

A
  • High FSH = primary ovarian failure
  • High LH or LH : FSH = PCOS
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27
Q

what treatment is given if amenorrhoea lasts >12 mnths and why ?

A

Increased risk of osteoporosis if there are also low oestrogen levels

  • Ensure adequate vitamin D and calcium intake
  • Hormone replacement therapy or the combined oral contraceptive pill
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28
Q

what kind of genetic condition is androgen insensitivity syndrome and what does it cause

A

X-linked recessive

  • End-organ resistence to testosterone causing genetically male children (46XY) to have a female phenotype
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29
Q

Give 4 features of androgen insensitivity syndrome

A
  • ‘primary amenorrhoea’
  • Little or no axillary and pubic hair
  • Undescended testes causing groin swellings
  • Breast development may occur as a result of the conversion of testosterone to oestradiol
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30
Q

How is androgen insensitivity syndrome diagnosed ?

A
  • Buccal smear or chromosomal analysis to reveal 46XY genotype
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31
Q

How is androgen insensitivity syndrome managed

A
  • Counselling - raise the child as female
  • Bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
  • Oestrogen therapy
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32
Q

What is atrophic vaginitis and how is it managed ?

A
  • Vaginal dryness, dyspareunia and occasional spotting in post menopausal women
  • Tx : vaginal lubricants and moisturisers. Topical oestrogen can help if needed.
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33
Q

what is Asherman’s syndrome and what is it most often caused by ?

A
  • Adhesions within the uterus
  • Dilatation and curettage procedure in the treatment of RPOC
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34
Q

How does Asherman’s present ?

A

Usually following dilatation and curettage, uterine surgery or endometritis with :

  • Secondary amenorrhoea
  • Significantly lighter periods
  • Dysmenorrhoea (painful periods)
  • Can also present with infertility
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35
Q

What is the gold standard for diagnosing intrauterine adhesions ?

A
  • Hysteroscopy
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36
Q

What is primary dysmenorrhoea and how is it managed ?

A
  • Painful period with no underlying pathology
  • NSAIDS like mefenamic acid/ ibuprofen
  • Second line : COCP
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37
Q

Give 5 causes of secondary dysmenorrhoea

A
  • Endometriosis
  • Adenomyosis
  • PID
  • Copper coil
  • Fibroids
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38
Q

Define endometriosis

A
  • Growth of ectopic endometrial tissue outside of the uterine cavity.
  • Lump of endometrial tissue outside the uterus = endometrioma
  • Endometriomas in the ovaries = ‘chocolate cysts’
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39
Q

How does endometriosis present ?

A
  • Cyclical abdo or pelvic pain
  • Deep dyspareunia
  • Dysmenorrhoea
    -Infertility
  • Cyclical bleeding from other sites, e.g. haematuria
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40
Q

what is seen on examination in endometriosis ?

A
  • Speculum : visible endometrial tissue in the vagina (esp posterior fornix).
  • Bimanual : fixed cervix
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41
Q

What is the gold standard Ix for diagnosing endometriosis ?

A
  • Laparoscopy
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42
Q

How does the american society of reproductive medicine stage endometriosis ?

A
  • 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
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42
Q

what is the 1st line management of endometriosis ?

A

Simple analgesia : paracetamol, NSAIDs

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43
Q
A
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44
Q

If analgesia is ineffective, how is endometriosis managed >

A

Hormonal management with the COCP, progesterone only pill, injection, implant, coil

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45
Q

If analgesia / hormonal contraception doesn’t help the Sx of endometriosis, what Tx options can be offered in secondary care ?

A
  • GnRH : idnuce ‘pseudomenopause’
  • Laparoscopic surgery to excise / ablate the endometrial tissue.
  • Hysterectomy
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46
Q

What are fibroids ?

A

Benign tumours of the smooth muscle of the uterus

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47
Q

Explain the different types of fibroid

A
  • Intramural : within the
  • Subserosal : just below the outer layer of the uterus.
  • Submucosal : just below the lining of the uterus
  • Pedunculated : on a stalk.
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48
Q

If not asymptomatic, how do uterine fibroids present ?

A
  • Menorrhagia : IDA
  • Prolonged menstruation
  • Abdo pain
  • Bloating or feeling full in the abdomen
  • Urinary or bowel symptoms due to pelvic pressure or fullness
  • Deep dyspareunia
  • Reduced fertility
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49
Q

Diagnosis of fibroids

A

Transvaginal USS

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50
Q

Management of menorrhagia secondary to fibroids

A
  • IUS : cannot be used if distortion of uterin cavity
  • NSAIDs e.g. mefenamic acid
  • Tranexamic acid
  • COCP
  • Oral progestogen
  • Injectable progestogen
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51
Q

Medical treatment options to shrink fibroids before surgery

A
  • GnRH agonists (Triptorelin)
52
Q

3 surgical options for shrinking / removing fibroids

A
  • Myomectomy
  • Hysteroscopic endometrial ablation
  • Hysterectomy
52
Q

What is red degeneration of fibroids ?

A
  • As they are sensitive to oestrogen, they grow in pregnancy
  • This can obstruct blood flow
  • Pregnant women, presenting with low grade fever, pain, vomiting.
53
Q

what are the symptoms of PMS ?

A
  • Emotional symptoms : anxiety, stress, fatigue and mood swings
  • Physical symptoms : bloating, breast pain
54
Q

What is the step-wise management of PMS ?

A
  • Mild : lifestyle advice
  • Moderate symptoms
    : COCP
    examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
  • Severe : SSRI (Fluoxetine)
55
Q

What is the criteria used for diagnosing PCOS. ?

A
  • Rotterdam criteria
56
Q

What is the rotterdam criteria

A
  • Requires 2! of 3 features :
  1. Oligoovulation/anovulation = irregular or absent periods
  2. Hyperandrogenism = hirsutism and acne
  3. Polycystic ovaries on USS
57
Q

what is defined as polycystic ovaries on USS ?

A

≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³

58
Q

what is crucial complication of PCOS ?

A

Insulin resistance and in turn DM

59
Q

what might be seen on examination in a woman with insulin resistance as a result of PCOS ?

A
  • Acanthosis nigricans
    : thickened, rough skin, typically found in the axilla and on the elbows.
60
Q

what baseline blood tests are done in PCOS to help diagnose and rule out other pathology

A
  • Testosterone
  • Sex hormone-binding globulin (low in PCOS)
  • LH
  • FSH
  • Prolactin (may be mildly elevated in PCOS)
  • TSH
61
Q

what do hormonal blood tests typically show in PCOS ?

A
  • Raised LH
  • Raised LH to FSH ratio
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
62
Q

what imagin is used in PCOS ?

A
  • Pelvic USS
  • Transvaginal USS is gold standard
63
Q

what is seen on the USS of someone with PCOS

A
  • 12 or more developing follicles in one ovary
  • Ovarian volume of more than 10cm3
  • ’ String of pearls’ appearance of the ovaries
64
Q

what is the general management of PCOS ?

A
  • Weight loss
  • Low glycaemic index, calorie-controlled diet
  • Exercise
  • Smoking cessation
65
Q

what is often given first line for managing hirsutism and acne in PCOS

A
  • Co-cyprindiol (COCP)
  • Ant-adrogenic effects
66
Q

what is a complication of co-cyprindiol

A

significantly increased risk of VTE

67
Q

If COCP doesnt work for hirsutism in PCOS what can be given ?

A

Topical elfornithine

68
Q

how is infertility managed in PCOS

A
  • Weight loss

SPECIALIST INPUT
- Clomifene
- Laparoscopic ovarian drilling
- IVF : increased risk of ovarian hyperstimulation syndrome

69
Q

what are women with PCOS at an increased risk of an why ?

A
  • Endometrial cancer
  • The are times of unopposed oestrogen due to the irregular or absent periods
70
Q

what can be given to women with PCOS to reduce the risk of endometrial cancer ?

A
  • Mirena coil
  • Inducing a withdrawal bleed at least every 3 – 4 months with either:
    • Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
    • Combined oral contraceptive pill
71
Q

How can different types of ovarian cysts be classified ?

A
  • Functional (follicular, corpus luteum)
  • Benign germ cell
  • Benign epithelial tumours : serous and mucinous cystadenoma
72
Q

what are follicular cysts

A
  • Commonest type of ovarian cyst in women of reproductive age
  • Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
  • Commonly regress after several menstraul cycles
73
Q

what is a corpus luteum cyst ?

A
  • Failure of the corpus luteum to break down and fills with fluid.
  • More likely to present with intraperitoneal bleeding than follicular cysts
74
Q

Explain the 2 types of epithelial cyst

A
  • Serous cystadenoma
    the most common benign epithelial tumour
  • Mucinous cystadenoma : can become huge and take up lots of space in the pelvis and abdomen
75
Q

What is a dermoid cyst / germ cell tumour

A
  • Most common benign overian tumour in women <25
  • Teratomas : they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone.
  • They are particularly associated with ovarian torsion.
76
Q

How can ovarian cysts present ?

A
  • Pelvic pain
  • Bloating
  • Fullness in the abdomen
  • Palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
77
Q

What is the RMI

A
  • Estimates risk of an ovarian mass being malignant
  • Takes into account : menopausal status, USS findings and CA125 level
78
Q

How are simple ovarian cysts in premenopausal women managed ?

A
  • <5cm : will almost always resolve within three cycles. They do not require a follow-up scan.
  • 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
  • > 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
79
Q

How are ovarian cysts in postmenopausal women managed ?

A
  • CA125 level check and referral to gynaecology
  • Raised CA125 = two week wait
  • Simple cysts <5cm with normal CA125 can be monitored with USS every 4-6mnths.
80
Q

What is Meig’s syndrome ?

A

Triad of :

  • Ovarian fibroma
  • Pleural effusion
  • Ascites
81
Q

Give 3 complications of an ovarian cyst

A
  • Torsion
  • Rupture, with bleeding into peritoneum
  • Haemorrhage into the cyst
82
Q

How does ovarian torsion present ?

A
  • Sudden onset severe unilateral pelvic pain
  • N&V
83
Q

What Ix are used in ovarian torsion

A
  • Initial : pelvic USS
  • Definitive : laparoscopic surgery
84
Q

What is seen on pelvic USS in ovarian torsion

A
  • ‘Whirlpool sign’
  • Free fluid in pelvis
  • Oedema of the ovary
85
Q

How is ovarian torsion managed ?

A
  • Detorsion
  • Oophorectomy
86
Q

What is defined as premature ovarian insufficiency

A
  • Onset of menopausal symptoms and elevated gonadotropin levels before the age of 40 years.
87
Q

Give 6 causes of premature ovarian insufficiency

A
  • Idiopathic (most common)
  • Bilateral oophorectomy
  • radiotherapy
  • Chemotherapy
  • Autoimmune disorders
  • Infection (e.g mumps)
88
Q

what will hormonal analysis show in premature ovarian insufficiency

A
  • Hypergonadotreopic hypogonadism
  • Raised LH and FSH (>30 IU/L)
  • Low oestradiol levels (<100pmol/l)
89
Q

What is required for a diagnosis of premature ovarian insufficiency

A
  • <40yrs, typical menopausal Sx and elevated FSH.
  • FSH levels need to be persistently raised (>25IU/l) on two consecutive samples separated by >4 wks.
90
Q

How is premature ovarian syndrome managed ?

A
  • HRT or COCP should be offered to women until the age of the average menopause (51 years)
91
Q

what is the average age of menopause

A
  • 51 yrs
92
Q

How long are menopausal women recommended to use effective contraception for ?

A
  • 12 months after the last period in women > 50 years
  • 24 months after the last period in women < 50 years
93
Q

Explain the definitions surrounding menopause

A
  • Menopause : when menstraution stops
  • Post menopause : period from 12mths after the final menstrual period
  • Permenopause : time around menopause, where a woman is experiencing vasomotor Sx & irregular periods
94
Q

what symptoms are seen in perimenopausal women ?

A
  • Change in periods : change in length and dysfunctional uterine bleeding
  • Vasomotor : hot flushes, night sweats
  • Urogenital : vaginal dryness & atrophy, urinary frequency
  • Psychological : anxiety and depression, STM impairment
95
Q

Give 2 long term complications of menopause

A

Osteoporosis
Increased risk of IHD

96
Q

How can the management of menopausal Sx be classified ?

A
  • Lifestyle
  • HRT
  • Non-HRT
97
Q

What is the lifestyle management of the menopause ?

A
  • Exercise, weight loss, reduce stress
  • Good sleep hygiene
98
Q

Give 4 contraindications to HRT as a management of the menopause

A
  • Current or past breast cancer
  • Any oestrogen-sensitive cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
99
Q

What are the non HRT management options of menopause-

A
  • Vasomotor : fluoxetine
  • Vaginal dryness : lubricant
  • Psychological : CBT / antidepressants
100
Q

Explain the normal epithelial lining of the cervix

A
  • Endocervix : columnar epithelium
  • Ectocervix : stratified squamous
  • Transformation zone : border between the two.
101
Q

What is cervical ectropion

A

When the columnar epithelium of the endocervix has extended to the ectocervix

102
Q

If not asymptomatic, how can cervical ectropion present ?

A
  • Postcoital bleeding
  • Increased vaginal discharge
  • Vaginal bleeding
  • Dyspareunia
103
Q

If problematic bleeding is present, how is cervical ectropion managed ?

A

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

104
Q

Who is more likely to suffer from cervical ectropion ?

A
  • Younger women, those on the COCP and pregnant women
  • This is because it is associated with higher oestrogen levels
105
Q

What is a nabothian cyst

A
  • Smooth, fluid filled cyst near the os of the cervix.
  • Between 2mm and 30 mm in size
  • Whitish/yellow appearance
  • Can occur after childbirth, minor trauma to the cervix or cervicitis
106
Q

How is a uterine prolapse graded

A
  • Grade 1: The lowest part is more than 1cm above the introitus
  • Grade 2: The lowest part is within 1cm of the introitus (above or below)
  • Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
  • Grade 4: Full descent with eversion of the vagina
107
Q

If not managed conservatively or with vaginal pessaries, how are different urogenital prolapses managed ?

A
  • Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • Uterine prolapse: hysterectomy, sacrohysteropexy
  • Rectocele: posterior colporrhaphy
108
Q

How is stress incontinence managed

A
  • Lifestyle
  • Pelvic floor for at least 3 mnths
  • Surgery
  • If surgery not wanted, duloxetine
109
Q

What is the management of urge incontinence ?

A
  • 1 : Bladder retraining for at least 6 wks.
  • 2 : Anticholinergic meds (oxybutin)
  • 3 : Mirabegron (beta-3-agonist in frail elderly pts preferred over oxybutin)
  • 4 : Invasive procedures
110
Q

What are the side effects of anticholinergic medications ?

A
  • Dry mouth, dry eyes, urinary retention, constipation and postural hypotension
  • Can cause cognitive decline, memory problems and worsening of dementia
111
Q

How does Mirabegron work and what is it contraindicated in ?

A
  • Beta-3 agonstist stimulating the sympathetic nervous system (can raised BP and increased risk of TIA and stroke)
  • CI in uncontrolled hypertension
112
Q

What are the symptoms of lichen sclerosis ?

A
  • Itching
  • Soreness and pain, worse at night
  • Skin tightness
  • Superficial dyspareunia

Usually affects the labia, perineum and parianal skin in women

113
Q

What is the appearance of the skin in lichen sclerosis ?

A
  • “Porcelain-white” in colour
  • Shiny
  • Tight
  • Thin
  • Slightly raised
  • There may be papules or plaques
114
Q

How is lichen sclerosis managed ?

A
  • Potent topical steroids (clobetasol propionate 0.05% - dermovate)
115
Q

what does lichen sclerosis increase the risk of ?

A

Squamous cell carcinoma of the vulva

116
Q

what are the 4 types of FGM ?

A
  • Type 1: Removal of part or all of the clitoris.
  • Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
  • Type 3: Narrowing or closing the vaginal orifice (infibulation).
  • Type 4: All other unnecessary procedures to the female genitalia.
117
Q

what do the upper vagina, uterus and fallopian tubes develop from

A

Mullerian ducts -> paramesonephric ducts

118
Q

what is defined as a complex cysts ?

A

Muli-loculated (septated)

119
Q

How are all complex cysts managed ?

A

Biopsy

120
Q

what investigations should all women with suspected PCOS receive

A
  • pelvic ultrasound
  • FSH and LH
  • Prolactin
  • TSH
  • Testosterone
  • Sex hormone-binding globulin (SHBG)
121
Q

urinary incontinence with a bladder that is still palpable after urination

A

Urinary overflow

122
Q

Action if suspected FGM

A

Report to the police

123
Q

Management of acutely unwell patient with suspected ruptured ectopic pregnancy

A

Resuscitate and arrange for emergency laparotomy

124
Q

What would urodynamics should in overflow incontinence

A

A high voiding pressure (>70cm H20) with §a low peak flow rate (<15ml/second)

125
Q

History of endometriosis + acute abdomen + free fluid in pelvis

A

Ruptured endometrioma

126
Q

Only surgical management of a fibroid, to retain fertility

A

Myomectomy

127
Q
A

Finals (92 decks)

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