Gynaecology Flashcards
Surgical treatment of uterine fibroids that preserves fertility?
Myomectomy
What is a rare feature of fibroids?
Polycythaemia secondary to autonomous production of EPO.
What is the most common treatment for cervical intraepithelial neoplasia (CIN)?
Large loop excision of transformation zone (LLETZ).
What is the most common cause of postmenopausal bleeding?
Vaginal atrophy
Name some causes of postmenopausal bleeding
- Vaginal atrophy
- HRT
- Endometrial hyperplasia
- Endometrial cancer
- Cervical cancer
- Ovarian cancer
- Vaginal cancer
How should women > 55 with postmenopausal bleeding be investigated?
2 week wait referral for endometrial cancer with transvaginal US.
How soon after a surgical abortion can an IUD be inserted?
Immediately after evacuation of uterine cavity.
What are the side effects from GnRH agonists?
Menopausal symptoms and loss of bone mineral density.
Name a drug used to shrink uterine fibroids
GnRH agonists e.g. Goserelin
Medical management of moderate and severe premenstrual syndrome?
- Moderate: COCP taken continuously.
- Severe: SSRI.
Name a secondary cause of amenorrhoea in very athletic women
Hypothalamic hypogonadism
Management for women with stage 1A cervical cancer who wish to maintain their fertility?
Cone biopsy.
Describe the first-line treatment for non-pregnant women with vaginal thrush
Oral fluconazole single-dose (150mg).
Why is tamoxifen a risk factor for developing endometrial cancer?
Due to its pro-oestrogen effect on the uterus and bone.
What are the recommended first line treatments for endometriosis?
NSAIDs &/or paracetamol
If analgesia doesn’t help endometriosis, what else should be tried?
Combined oral contraceptive pill or progestogens.
If NSAIDs or COCP/progestogens have not controlled symptoms of endometriosis, what else should be tried?
GnRH analogues
What is the gold standard investigation for endometriosis?
Laparoscopy
Name the classic symptoms of endometriosis
- Pelvic pain
- Dysmenorrhoea
- Dyspareunia
- Sub-fertility
What definition is used to classify menstrual bleeding as ‘abnormally heavy’?
An amount that the women considers to be excessive.
It was previously defined as a total amount of blood loss >80ml for the duration of the menstrual cycle.
What is the first line investigation for adenomyosis?
Transvaginal US
What is the definitive management for adenomyosis?
Hysterectomy
A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance. What is the most likely diagnosis?
Teratomas (dermoid cysts)
What is the first episode of menstruation called?
Menarche
What is the average age of menarche in UK?
12.8 years
Describe the role of FSH, LH, oestrogen, progesterone and inhibin with regards to the menstrual cycle
- FSH binds to granulosa cells to stimulate follicle growth, permit the conversion of androgens (from theca cells) to oestrogens and stimulate inhibin secretion.
- LH acts on theca cells to stimulate production and secretion of androgens.
- Moderate oestrogen levels exert negative feedback on the HPG axis. High oestrogen levels (in the absence of progesterone) positively feedback on the HPG axis. Oestrogen in the presence of progesterone exerts negative feedback on the HPG axis.
- Inhibin selectively inhibits FSH at the anterior pituitary.
Investigation for secondary dysmenorrhoea?
Referral to gynaecology.
Define primary vs. secondary dysmenorrhoea
- Primary: no underlying pelvic pathology and usually appears within 1-2 years of menarche. Due to excessive prostaglandin production. Pain starts just before or within a few hours of period onset.
- Secondary: develops many years after menarche and is due to underlying pathology e.g. endometriosis, adenomyosis, PID, copper coil, fibroids. Pain usually starts 3-4 days before onset of period.
Describe the management of primary dysmenorrhoea
- NSAIDS e.g. mefenamic acid or ibuprofen first line.
- Combined oral contraceptive pill second line.
What is the first line medication used for infertility in PCOS?
Clomifene
Subtotal (partial) vs total hysterectomy
- Subtotal (partial): removal of uterus, but not cervix.
- Total: removal of cervix with uterus.
Uterine fibroids are also known as…
Leiomyomas
What is the leading cause of hysterectomy?
Fibroids
Endometriomas in ovaries are often called what?
Chocolate cysts
Describe the American Society of Reproductive Medicine (ASRM) staging system for 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.
List the causes of a raised CA125
- Ovarian cancer
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
Why do multiple cysts develop in PCOS?
High levels of LH, increase androgen production which suppress LH surge and ovulation. Follicles develop within the ovary, but are arrested at an early stage, so they become cysts.
Differential diagnoses for PCOS?
- Hypothyroidism: obesity, hair loss and insulin resistance.
- Hyperprolactinaemia: oligomenorhoea/amenorrhoea, acne and hirsutism.
- Cushing’s disease: obesity, acne, hypertension, insulin resistance and depression.
- Androgen-secreting tumour.
- Congenital adrenal hyperplasia.
Why does PCOS increase the risk of endometrial cancer?
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
Why does HRT use in young women (< 50) with premature menopause NOT have an increased risk of breast cancer compared with the general population?
As women would ordinarily produce the same hormones at this age.
List some non-hormonal treatments for menopause
- Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress.
- CBT.
- Clonidine (agonist of alpha-adrenergic receptors) - vasomotor symptoms and hot flushes.
- SSRIs (e.g. fluoxetine)
- Venlafaxine (SNRI).
- Gabapentin.
Progestogens vs progesterone vs progestins
- Progestogens refer to any chemicals that target and stimulate progesterone receptors.
- Progesterone is the hormone produced naturally in the body.
- Progestins are synthetic progestogens.
How long does it take for HRT to have its full effect?
3-6 months.
When should you stop oestrogen-containing contraceptives or HRT before major surgery?
4 weeks before.
Does HRT act as contraception?
No!
How should HRT be stopped?
There is no specific regime for stopping HRT. It can be reduced gradually or stopped abruptly, depending on the preference of the woman. This choice does not affect long term symptoms. Gradually reducing the HRT may be preferable to reduce the risk of symptoms recurring suddenly.
Describe the grading system for uterine prolapse
- Grade 0: Normal
- 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
What is a uterine procidentia?
A prolapse extending beyond the introitus.
An 80 year-old woman presents to her GP with a 1.5cm ulcerated lesion on her left labium majus. Her history includes a two year history of vulval itching and soreness, which has failed to respond to topical steroid treatment. What is the most likely diagnosis?
Vulval carcinoma
List the causes of Asherman’s syndrome
- Dilatation and curettage procedure.
- Uterine surgery.
- Pelvic infection e.g. endometritis.
Describe the presentation of Asherman’s syndrome
It typically presents following recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea.
- Significantly lighter periods.
- Dysmenorrhoea.
- It may also present with infertility.
How would you diagnose Asherman’s syndrome?
- Hysteroscopy (gold standard) it can also involve dissection and treatment of the adhesions.
- Hysterosalpingography (contrast is injected into the uterus and imaged with xrays).
- Sonohysterography (uterus is filled with fluid and a pelvic US scan is performed).
- MRI.
Is cervical ectropion associated with cervical cancer?
No
Is cervical ectropion a contra indication to the COCP?
No
Is cervical ectropion a contra indication to the COCP?
No
What are Nabothian cysts?
Fluid-filled cysts often seen on the surface of the cervix. They’re harmless and unrelated to cervical cancer.
Describe the pathophysiology of Nabothian cysts
The columnar epithelium of the endocervix produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.
Treatment for Nabothian cysts
No treatment required when diagnosis is clear, as they don’t cause any harm and often resolve spontaneously.
When diagnosis uncertain you can refer to colposcopy.
Describe the pathophysiology of cervical polyps
Cervical polyps are benign growths protruding from inner surface of cervix caused by focal hyperplasia of the columnar epithelium of the endocervix.
What is the most common cause of Bartholin’s abscess?
E.coli
But can also be caused by chlamydia and gonorrhoea.
Name 2 risk factors for FGM
- Coming from a community that practise FGM.
- Having relatives affected by FGM.
Where do the upper vagina, cervix, uterus and fallopian tubes develop from?
The paramesonephric ducts (Mullerian ducts) - error in this can lead to congenital structural abnormalities.
What is a bicornuate uterus?
Where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance.
What is an imperforate hymen?
The hymen at the entrance of the vagina is fully formed, without an opening.
Treatment is with surgical incision to create an opening in the hymen.
What are transverse vaginal septae?
Where a septum forms transversely across the vagina.
This septum can either be perforate (with a hole) or imperforate (completely sealed).
What is vaginal hypoplasia and agenesis?
- Vaginal hypoplasia refers to an abnormally small vagina.
- Vaginal agenesis refers to an absent vagina.
- These occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix. Ovaries are usually unaffected, leading to normal female sex hormones (exception to this is with androgen insensitivity syndrome).
What is the cause of androgen insensitivity syndrome?
Mutation in androgen receptor gene on X chromosome causing lack of androgen receptors.
Why do patients with androgen insensitivity syndrome have female secondary sexual characteristics?
Extra androgens are converted into oestrogen.
Why do female internal organs not develop in androgen insensitivity syndrome?
Because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
Describe the presentation of androgen insensitivity syndrome
- In infancy with inguinal hernias containing testes.
- Or at puberty with primary amenorrhoea.
Describe the management plan for androgen insensitivity syndrome
- Bilateral orchidectomy to avoid testicular tumours.
- Oestrogen therapy.
- Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length.
Which strains of HPV are responsible for cervical cancer?
16 & 18
What is the key investigation in the diagnosis of cervical cancer?
Colposcopy +/- biopsy
Trachelectomy
Surgical removal of cervix
What is the most common cause of cervical cancer?
HPV
What risk factors do women with PCOS have for endometrial cancer?
- Amenorrhoea.
- Obesity.
- T2D.
- Insulin resistance.
Is smoking protective against endometrial cancer?
Yes
How long after childbirth can cervical screening commence?
3 months post-partum.
A 65-year-old woman presents to the GP with urinary incontinence. Her symptoms occur all day, and she has also noticed that when she does manage to go voluntarily her flow of urine is very poor. On examination, the GP can feel a distended bladder even though the patient has just urinated while waiting for the appointment.
What’s the most likely diagnosis?
Urinary overflow incontinence - as bladder is still palpable after urination.
A 46-year-old female presents with a 6 month history of abdominal pain and menorrhagia. On examination the abdomen is non-tender and the uterus feels bulky. What is the most likely diagnosis?
Fibroids
Why are COCPs containing drospirenone (e.g. Yasmin) used first line for PMS?
Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
In patients with urinary incontinence, what should be ruled out initially?
UTI and diabetes
What is the first line investigation for post-menopausal bleeding?
TVUS
What is the treatment for a vaginal vault prolapse?
Sacrocolpoplexy
Hx of endometriosis presenting with an acute abdomen and free fluid in pelvis
Endometrioma rupture
Whirlpool sign on ultrasound imaging
Ovarian torsion
