Gynaecology Flashcards
What should you be aware of in recurrent vaginal candidiasis?
If 4 or more episodes per year they should be tested for a predisposing condition such as Diabetes
What strains of HPV are associated with cervical cancer?
HPV Strains 16 and 18 are found in up to 95% of cervical cancer cases.
How does vaginal thrush present?
It typically presents as a thick, white, odourless discharge accompanied by vulvovaginal pruritus. Type two diabetes mellitus is a significant risk factor for developing vulvovaginal candidiasis.
What is the causative organism in BV?
Garnerella Vaginalis
Risk factors for uterine fibroids?
- Obesity
- Increasing age
- Early puberty
- Black ethnicity
- Family history
What is Meig’s Syndrome?
Triad of
- A benign ovarian tumour (fibroma)
- Ascites
- Pleural effusion
Risk factors for endometriosis?
- Early menarche
- Late menopause
- Delayed childbearing
- Family history
- Vaginal outflow obstruction
- White ethnicity
- Low BMI
- Autoimmune disease
- Late first sexual encounter
- Smoking
- Nulliparity
Risk factors for ectopic pregnancy?
- Previous ectopic pregnancy
- Assisted reproduction techniques
- IUD use
- Endometriosis
- Maternal age >35 years old
- Smoking
- Multiple sexual partners
What is the treatment for Trichomoniasis?
Treatment involves oral metronidazole for both the patient and their sexual partners.
What is a threatened miscarriage?
- Mild vaginal bleeding, usually without abdominal pain
- Cervical Os remains closed
- Patient may go on to have a miscarriage, or the bleeding may stop and a healthy pregnancy may continue
What is an inevitable miscarriage?
- Heavier bleeding associated with lower abdominal pain
- Cervical os is open
- No loss of products of conception
- Pregnancy will not continue
What is a complete miscarriage?
- Minimal bleeding
- Abdominal USS confirms complete loss of uterine contents
- Cervical os is closed
What is a missed miscarriage?
- Abdominal USS confirms the presence of a non-viable intrauterine pregnancy (i.e. the fetus has died but no spontaneously aborted)
- Often asymptomatic and picked up at scan, or the patient may notice a loss of the symptoms of pregnancy
- Cervical os is closed
What is an incomplete miscarriage?
- Abdominal USS showing partial loss of the products of conception
- Cervical os is open
What tumour marker is used in ovarian cancer?
CA125
What is the first line investigation for post-menopausal bleeding?
Transvaginal ultrasound
What is the Amsel criteria used for an what is it?
Used to diagnose bacterial vaginosis
- Clue cells visualised on wet-mount microscopy
- A thin, white, yellow, homogeneous discharge
- A vaginal pH of over 4.5
- The release of fishy odour when potassium hydroxide is added
What is a Nabothian cyst?
They are retention cysts formed due to the occlusion of glands in the mucosa of the uterine cervix causing them to be distended with retained secretions
How does the IUS work?
Causes thinning of the endometrium
Thickening of the cervical mucus
In some cases prevention of ovulation
How does the copper coil work?
The Copper within the IUD is spermicidal
The concentration of copper in the cervical mucus inhibits the motility of sperm into the womb
What antibiotics are required for pelvic inflammatory disease?
Single dose of IM Ceftriaxone 500mg
Oral doxycycline 100mg BD
Metronidazole 400mg BD for 14 days
What are the symptoms of PID?
Lower abdominal pain which is typically bilateral
Abnormal vaginal or cervical discharge which is often purulent
Deep dyspareunia
Abnormal vaginal bleeding
Secondary dysmenorrhoea
What are the signs of PID?
Lower abdominal tenderness
Adnexal tenderness of bimanual vaginal examination
Cervical motion tenderness of bimanual vaginal examination
Fever >38 in moderate to severe disease
What are some risk factors for Gestational Trophoblastic disease?
Multiple pregnancies
Being older than 45 years
Being less than 16 years old
History of a previous molar pregnancy
Menstrual factors
Asian ethnicity
What is the initial investigation to confirm ovulation?
Mid-luteal phase progesterone level
This should be taken seven days before the date she expects to start her period.
How does the depot injection work?
- Inhibiting ovulation
- Thickening cervical mucus
- Thinning the lining of the endometrium
What are the drugs and routes used for medical terminations of pregnancy?
Oral Mifepristone and Vaginal misoprostol
What is the most common cause of puritus vulvae?
Contact dermatitis
What is the investigation of choice for ectopic pregnancy?
Transvaginal ultrasound
What is the first line imagine of choice for suspected adenomyosis?
Transvaginal ultrasound
What are the features of adenomyosis?
- Dysmenorrhoea
- Menorrhagia
- Enlarged, boggy uterus
What is the management for adenomyosis?
Symptomatic treatment - tranexamic acid to manage menorrhagia
- GnRH agonists
- Uterine artery embolisation
- Hysterectomy - Considered the ‘definitive’ treatment
First-line treatment for urge incontinence
Bladder retraining
First-line treatment for stress incontinence
Pelvic floor muscle training
What are the risk factors for developing urinary incontinence?
- Advancing age
- Previous pregnancy and childbirth
- High body mass index
- Hysterectomy
- Family history
When should a pregnancy test be performed following medical management of a miscarriage?
3 weeks
Typical PCOS blood results?
- Raised LH:FSH ratio
- Testosterone may be normal or mildly elevated
- Sex hormone binding globulin is normal to low
What is the gold-standard investigation for endometriosis?
Laparoscopy
What is red degeneration?
Haemorrhage into a uterine fibroid- commonly occurs during pregnancy
What are the risk factors for Hyperemesis Gravidarum?
Increased levels of Beta HCG (Multiple pregnancies or trophoblastic disease)
Nulliparity
Obesity
Family or personal history of N&V of pregnancy
When can you diagnose hyperemesis gravidarum?
5% pre pregnancy weight loss
Dehydration
Electrolyte imbalance
What short-term treatments can help patients with uterine fibroids?
GnRH agonists may reduce the size of the fibroid
What is the most common treatment for cervical intraepithelial neoplasia?
Large loop excision of the transformation zone
When can expectant management of an ectopic pregnancy be performed?
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Risk factors for Ovarian Cancer?
- Family history: Mutations of the BRCA1 or the BRCA2 gene
- Many ovulations: early menarche, late menopause, nulliparity
What is the mechanism of action for the combined oral contraceptive pill?
Inhibits ovulation
What is the mechanism of action for the progestogen-only pill (excluding desogestrel)?
Thickens cervical mucus
When is HRT contraindicated?
- Undiagnosed vaginal bleeding
- Pregnancy
- Breastfeeding
- Oestrogen receptor positive breast cancer
- Acute liver disease
- Uncontrolled hypertension
- VTE
- Recent stroke, MI or Angina
What is a genital prolapse?
Genital or pelvic organ prolapse is the descent of pelvic structure(s) from their normal anatomical location toward or through the vaginal opening
What are fibroids?
Benign smooth muscle tumours of the myometrium of the uterus
Where is Ovarian cancer most likely to metastasize to first?
- The main lymphatic drainage of the ovary is to the para-aortic nodes.
What is the management for Atrophic Vaginitis?
- Hormonal treatments - systemic hormone-replacement therapy
- Topical oestrogen
- Lubricants
- Moisturisers
Over what endometrial thickness would you be suspicious of endometrial cancer?
- If the endometrial thickness is less than 5mm uniformly then the risk of endometrial cancer is less than 1 %
What can causes a Bartholin’s gland cyst?
Primary cause of Bartholin’s gland cysts and abscesses is the blockage of the gland’s duct.
Can be due to
- Thick mucus
- Inflammation
- Trauma
- Malignancy (Rare)
What is the management for Bartholin’s gland cyst?
- Incision and drainage
- Antibiotics
- Warm salt water baths
- Surgery
What is the predominant history type of Cervical cancer?
Squamous cell carcinoma
What are the risk factors for cervical cancer?
- HPV 16 and 18 infection (accounts for 70% of cases)
- Multiple sexual partners
- Smoking
- Immunosuppression (e.g. HIV or organ transplants)
What is the first-line investigation for Cervical Cancer?
Urgent Colposcopy
Who is included in Cervical Screening?
All women and people with a cervix between the ages of 25-64 years of age
24-49 recalled every three years
49+ every 5 years
How often is cervical screening for women who are HIV positive?
Every year
How long should you delay a cervical smear after birth, miscarriage or termination?
Should be delayed 3 months
What is the management of CIN 1
Mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
What is CIN 2?
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
What is CIN 3?
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
Why would you get shoulder tip pain in ectopic pregnancy?
If the ectopic pregnancy bleeds, the blood can irritate the diaphragm causing shoulder tip pain
What is the criteria for medical management of ectopic pregnancy and what is the management?
- Involves one off dose of Methotrexate
- Criteria are: Low bHCG, ability to attend follow up and adherence to avoiding pregnancy for a period following treatment
What staging system is used for Endometrial cancer?
FIGO staging system
In CIN1 where are the abnormal cells?
They are confined to the basal one-third of the epithelium
What is the first-line management of menorrhagia?
Levonorgestrel intrauterine system
Where can a fertilised ovum implant?
Fallopian tube, ovary, cervix, peritoneum, liver
What are the features of androgen insensitivity syndrome?
End-organ resistance to testosterone causing genotypically male children to have a female phenotype
‘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
How do you diagnose androgen insensitivity syndrome?
- Buccal smear or chromosomal analysis to reveal 46XY genotype
- After puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys
What is the management for androgen insensitivity syndrome?
- Counselling
- Bilateral orchidectomy
- Oestrogen therapy
What is a cervical ectropion?
Larger areas of columnar epithelium than normal are present on the ectocervix
What are the features of a complete hydatidiform mole?
- Vaginal Bleeding
- Uterus size greater than expected for gestational age
- Abnormally high serum hCG
- Ultrasound: ‘snow-storm’ appearance of mixed echogenicity
What are the causes of delayed puberty with short stature?
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome
What is the aim of cervical cancer screening?
Screen for HPV (1 mark)
Screen for abnormal cells indicative of pre-invasive (dyskaryosis) disease ‘cervical
intraepithelial neoplasia’ (1 mark)
What are the causes of delayed puberty with normal stature?
- PCOS
- Androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome
What are the worrying signs of cervical examination that would suggest malignancy?
- Irregular mass on the cervix
- Inflammation
- Bleeding
- Ulceration
What criteria system is widely used in the diagnosis of PCOS?
Rotterdam criteria
What medication is used first line for the management of acne in PCOS?
Combined oral contraceptive pill
Discuss the impact of PCOS on oestrogen and progesterone levels and how this relates to an increased risk of endometrial cancer
Women with PCOS ovulate infrequently so do not produce enough progesterone / produce less progesterone (progesterone is released after ovulation from the corpus luteum), but they continue to produce oestrogen.
Irregular menstruation means that the endometrial lining does not shed regularly.
This results in endometrial hyperplasia and increases the risk of endometrial cancer.
Why do you get urge incontinence?
Overactivity of the detrusor muscle
Why do you get stress incontinence?
Weakness of the pelvic floor and sphincter muscles
What are the theories for why endometriosis happens?
- Unknown
- Retrograde menstruation
- Sampsons theory
- Embolisation theory
- Metaplasia
What is androgen insensitivity syndrome?
An X-linked recessive syndrome dye to end organ resistance to testosterone causing genotypically male children to have a female phenotype
How do you diagnose AIS?
Buccal smear or chromosomal analysis to reveal 46XY
What is included in the Rotterdam criteria?
- Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
- Oligo/anovulation
- Clinical or biochemical features of hyperandrogenism
What is Ashermans syndrome?
Asherman’s syndrome is a rare, acquired, gynecological disorder of the uterus. It is characterized by the bonding of scar tissue that lines the walls of the uterus, which decreases the volume of the uterine cavity.
