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Obstetrics And Gynaecology > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is amennorhoea?

A

A lack of periods

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2
Q

What are three main groups of causes for primary amennorhoea?

A

Problems with hypothalamus or pituitary, problem with the gonads or structural (e.g imperforate hymen)

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3
Q

What the most common cause of amennorhoea?

A

Pregnancy

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4
Q

What are some other causes of secondary amennorhoea?

A

PCOS, Cushing’s, menopause, anorexia/stress, thyroid dysfunction, hormonal contraceptives, hyperprolactinaemia, premature ovarian failure

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5
Q

What are common causes of intermenstrual bleeding?

A

Cervical ectropion, hormonal contraception, STI, endometrial polyps or cancer, vaginal pathology, pregnancy, medications (e.g SSRIs and anticoagulants)

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6
Q

What is the word for painful periods?

A

Dysmenorrhoea

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7
Q

What can cause dysmenorrhea?

A

Endometriosis, fibroids, PID, copper coil, cervical/ovarian cancer, primary dysmennorhoea

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8
Q

What is the word for heavy periods?

A

Menorrhagia

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9
Q

What is it referred to when there is no identifiable cause for menorrhagia?

A

Dysfunctional uterine bleeding

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10
Q

What are some causes of menorrhagia?

A

Extremes of reproductive age, fibroids, endometriosis and adenomyosis, PID, copper coil, anticoag meds, bleeding disorders, connective tissue disorders, endometrial hyperplasia, PCOS

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11
Q

What are the key causes of postcoital bleeding?

A

Cervical cancer (+endometrial or vaginal), cervical ectropion, trauma, atrophic vaginitis

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12
Q

What is the term for cyclical pain felt during ovulation?

A

Mittelschmerz

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13
Q

How is primary amenorrhoea defined?

A

Not starting period by 13 when there’s no other signs of pubertal development
Not starting period by 15 where there are other signs of puberty

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14
Q

When do we typically seen girls starting periods in relation to starting puberty?

A

Puberty is normally between 8-14 for girls
Menarche usually starts 2 years after start of puberty

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15
Q

What cause of hypogonadotropic hypogonadism is associated with anosmia?

A

Kallman syndrome

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16
Q

What are some structural causes of amenorrhoea?

A

Imperforate hymen, female genital mutilation, transverse vaginal septae, vaginal agenesis, absent uterus

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17
Q

What will the levels of LH and FSH be like in hypogonadotropic hypogonadism and hypergonadotropic hypogonadism?

A

Hypogonadotropic= low LH and FSH
Hypergonadotropic= high LH and FSH

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18
Q

What hormonal blood tests can be used to investigate amenorrhoea?

A

FSH and LH
Thyroid
Testosterone (raised in PCOS, androgen insensitivity and CAH)
Prolactin
Insulin-like growth factor (used in screening of GH deficiency)

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19
Q

In patient with hypogonadotropic hypogonadism, how can we treat them if they want t be fertile and where pregnancy is not wanted?

A

Pulsatile GnRH can be used to induce ovulation and menstruation- can induce fertility
Pregnancy not wanted- combined contraceptive pill can induce regular menstruation

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20
Q

How is secondary amenorrhoea defined?

A

No menstruation for greater than 3 months after regular menstrual periods

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21
Q

Why does physiological or psychological stress lead to amennorhoea?

A

It reduces the production of GnRH. This is so the boys doesnt have a pregnancy when the body may not be fit for it

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22
Q

What medications can be used to reduce prolactin production?

A

Dopamine agonists like bromocriptine or cabergoline

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23
Q

In a patient with amenorrhoea, what would a high LH or a high FSH suggest as the cause?

A

High LH/ high LH:FSH ratio - indicates PCOS
High FSH - indicates primary ovarian failure

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24
Q

Why do women with PCOS require a withdrawal bleed every 3-4 months?

A

To reduce the risk of endometrial hyperplasia and endometrial cancer

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25
Q

What is the peak age group affected by endometrial cancer?

A

64-74

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26
Q

what increases the risk of endometrial cancer?

A

Early menarche/late menopause, nulliparity, PCOS, BRCA 1/2, endometrial polyps

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27
Q

hat lowers the risk of endometrial cancer?

A

COCP, HRT, physical activity

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28
Q

What is the pre-malignant condition associated with endometrial cancer?

A

Endometrial hyperplasia

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29
Q

What percentage of women with endometrial hyperplasia will develop cancer within 10 years?

A

20%

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30
Q

How is endometrial hyperplasia treated?

A

Progestagens and surgery

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31
Q

What are the types of endometrial carcinomas?

A

Type 1: endometrial adenocarcinoma
Type 2 clear cell, papillary serous, carcinosarcoma

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32
Q

what staging is used for endometrial carcinoma?

A

FIGO

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33
Q

What investigations are useful in diagnosing endometrial cancer?

A

Endometrial sampling, hysteroscopy (gold standard), transvaginal ultrasound

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34
Q

What factors will determine the primary treatment for endometrial cancer?

A

Stage, age, fitness for surgery and patient preference

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35
Q

What is the peak age for ovarian cancer?

A

70-74

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36
Q

What are the most common times of ovarian tumour?

A

Serous, mucinous and teratomas

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37
Q

What are risk factors for developing ovarian cancer?

A

Nulliparity, early menarche, late menopause, unopposed estrogen, FHx, BRCA 1/2, endometriosis

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38
Q

Ovarian cancer presents with non-specific symptoms, what symptoms is it likely to present with?

A

Abdominal bloating, pain, anorexia, N+V, weight loss, vaginal bleeding

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39
Q

What tumour marker is measured in ovarian cancer?

A

Ca125

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40
Q

Is CA125 specific to ovarian cancer?

A

No, can be raised in other gynae conditions like endometriosis, menstruation and any inflammatory condition in abdominal area

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41
Q

What ages are most affected by cervical cancer?

A

Bimodal distribution affecting women in 30s and 80s

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42
Q

what types of cervical cancer are most common?

A

Most are squamous cell carcinoma, adenocarcinomas also common

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43
Q

What are risk factors for cervical cancer?

A

Early age at first intercourse, multiple sexual partners, unprotected sex, smoking, long term COCP use, immunosupression/HIV

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44
Q

What lowers your risk of cervical cancer?

A

Regular cervical screening attendance and HPV vaccine

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45
Q

What are common presentations for cervical cancer?

A

Abnormal vaginal bleeding (Post coital bleeding, post menopausal bleeding, intermenstrual bleeding, blood stained vaginal discharge)
Vaginal discharge, pelvic pain and dyspareunia

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46
Q

What treatment options are available for CIN?

A

LLETZ (large loop excision of the transformation zone), cold knife cone, cryocautery, diathermy,

47
Q

What is the pre-malignant condition associated with vulval cancer?

A

Vulvar intraepithelial neoplasia

48
Q

What are the treatment options for vulvar intraepithelial neoplasia?

A

Conservative= antihistamines for itching
Medical= imiquimod
Surgical= excision

49
Q

What are risk factors of vulval cancer?

A

HPV, herpes simplex, smoking immunosupression, chronic vulvar irritation, lichen sclerosus

50
Q

What cancers is HPV associated with?

A

Cervical, anal, vulval, penile, throat, mouth

51
Q

What strains of HPV are most responsible for cervical cancers?

A

Type 16 and 18

52
Q

How does HPV promote the development of cancer?

A

By producing proteins (E6 and E7) which inhibit tumour suppressor genes

53
Q

What do the different levels of cervical intraepithelial neoplasia refer to regarding amount of dysplasia?

A

CIN 1= mild dysplasia
CIN 2= moderate dysplasia
CIN3= severe dysplasia

54
Q

What do the different levels of cervical intraepithelial neoplasia refer to regarding thickness of epithelial layer affected?

A

CIN1= 1/3
CIN2= 2/3
CIN3= all

55
Q

What do the different levels of cervical intraepithelial neoplasia refer to regarding what happens if not treated?

A

CIN 1= likely to return to normal without treatment
CIN2= likely to progress to cancer if not treated
CIN3= very likely to progress to cancer if not treated

56
Q

what are risk factors for genital prolapse?

A

pregnancy and vaginal delivery, menopause, increased intrabdominal pressure (obesity, chronic cough, constipation, heavy lifting), pelvic surgery e.g hysterectomy

57
Q

what are symptoms of genital prolapse?

A

heaviness or feeling of something coming down, dyspareunia, constipation, urinary problems

58
Q

what different structures are likely to prolapse into the anterior, posterior and apical vaginal wall?

A

anterior= bladder or urethra
posterior= rectum or small bowel
apical= uterus or vaginal vault collapse

59
Q

what conservative measures can be advised for patients with genital prolapse?

A

pelvic floor muscle exercises, weight loss, smoking cessation, avoiding heavy lifting

60
Q

what management can women with genital prolapse who are unfit for surgery be offered?

A

pessaries

61
Q

what surgical options are available for genital prolapse?

A

anterior colporrhaphy
posterior colporrhaphy
hysterectomy

62
Q

why are mesh repairs now used as a last resort?

A

associated with increased morbidity and complications

63
Q

does trandermal or oral HRT have a higher risk of VTE?

A

oral has 2-3 greater risk of VTE
transdermal patches are no associated with increased risk of VTE

64
Q

why is progesterone also given alongside oestrogen in HRT?

A

to reduce risk of endometrial cancer

65
Q

what is the most appropriate from of HRT in perimenopausal women?

A

monthly cyclical HRT

66
Q

what is the most appropriate form of HRT in post-menopausal women?

A

continuous combined HRT

67
Q

what are the oestrogen related side effects of HRT

A

breast tenderness, leg cramps, bloating, nausea, headaches

68
Q

what are progesterone related side effects of HRT?

A

pre-menstrual syndrome like symptoms: mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain

69
Q

what are general risks of HRT?

A

increased risk of breast Ca, endometrial Ca, VTE, stroke, ischaemic heart disease. PMS, leg cramps bloating

70
Q

what is lichen sclerosus?

A

a chronic inflammatory skin disease of anogenital region

71
Q

when can discomfort with lichen sclerosus be exacerbated?

A

urination and sex due to irritation of affected area

72
Q

how is lichen sclerosus managed?

A

topical corticosteroids, emollients, avoiding soaps in affected areas to prevent irritation

73
Q

how does lichen sclerosus classically present?

A

patches of thin, white, itchy, wrkinkled looking skin predominantly around the genitals and anus, more common in post-menopausal women

74
Q

what kind of steroids are used for vulval lichen sclerosus?

A

potent topical steroids like dermovate or clobetasol propionate

75
Q

what are clinical features of lichen sclerosus?

A

white atrophic patches, clitoral hood fusion, fusion of labia minora to majora, posterior fusion resulting in introitus narrowing

76
Q

what are uterine causes of heave menstrual bleeding?

A

fibroids, endometriosis, adenomyosis, endometrial hyperplasia or cancer, PID

77
Q

what are non uterine causes of heavy menstrual bleeding?

A

PCOS, extremes of reproductive age, copper coil, anticoagulant meds, bleeding disorders, hypothyroidism

78
Q

what investigations can be considered for heavy menstrual bleeding?

A

FBC, abominal/transvaginal USS, hysteroscopy +/- biopsy,

79
Q

if a woman has non-painful heavy periods and does not need contraception, what would help her symptoms?

A

tranexamic acid

80
Q

if a woman has painful heavy periods and does not need contraception, what one medication could help her symptoms?

A

mefenamic acid

81
Q

what contraception methods can help with heavy menstrual bleeding?

A

1st line = mirena coil
COCP
cyclical oral progestogens

82
Q

when would you refer heavy menstrual bleeding to secondary care?

A

treatment in primarycare unsuccessful, symptoms are severe, large fibroids >3cm

83
Q

what further management options are available for heavy menstrual bleeding when medical options have failed?

A

endometrial ablation (balloon thermal ablation) and hysterectomy

84
Q

which ethnic group are fibroids most common?

A

black women

85
Q

what are different types of fibroids?

A

intramural- in the myometrium
submucosal- just underneath the endometrium
subserosal- just underneath outer layer of uterus
pedunculated- on a stalk

86
Q

what are surgical options for management of large fibroids?

A

uterine artery embolisation, myomectomy, hysterectomy

87
Q

how can GnRH antagonists be used for fibroid treatmnt?

A

used short term to induce menopause state reducing oestrogen levels so fibroids shrink before myomectomy

88
Q

which fibroid surgical management option improves fertility?

A

myomectomy

89
Q

what are complications of fibroids?

A

heavy menstrual bleeding and anaemia
reduced fertility
constipation, urinary outflow obstruction and UTIs
red degeneration
torsion (usually pedunculated)
malignant change (rare <1%)

90
Q

what three features define hyperemesis gravidarum?

A

5% pre-pregnancy weight loss, dehydration and electrolyte imbalance

91
Q

what are typical blood results in PCOS?

A

raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG (sex hormone binding globulin) is normal to low

92
Q
A
93
Q

What are features seen on clinical examination with an adnexal torsion?

A

General- pyrexia, tachycardia
Abdominal- rebound tenderness localised guarding
Vaginal- cervical excitation, adnexal tenderness, adnexal mass

94
Q

Who is ovarian hyper stimulation syndrome likely to occur in? How can it present?

A

In women undergoing IVF who are having ovulation induction
Bloating, pelvic pain, nausea+vomiting

95
Q

What is premature ovarian insufficiency?

A

Menopause before the age of 40

96
Q

What conditions are women with premature ovarian insufficiency more at risk of?

A

CVD, stroke osteoporosis, cognitive impairment

97
Q

Do women with premature ovarian insufficiency still require contraception?

A

There is still a small of pregnancy so contraception still required

98
Q

Would HRT given before 50 to women with premature ovarian insufficiency increase the risk of breast cancer?

A

No as this would be replacing the oestrogen level to what they would’ve been

99
Q

How do we define chronic pelvic pain?

A

Intermittent or constant pain, over 6 months, not occuring exclusively with menstruation, intercourse or pregnancy

100
Q

What is the concept of visceral hyperalgesia?

A

Persistent pain leads to changes within CNS which magnify the original signal making the viscera more sensitive to pain than normal

101
Q

What are some differentials for chronic pelvic pain?

A

Endometriosis and adenomyosis, PID, IBS, interstitial cystitis, MSK pain, nerve entrapment, adhesions

102
Q

What are the three main theories for endometriosis aetiology?

A

Retrograde menstruation- endometrial tissue goes out into other structures through retrograde flow during menstruation
Coelomic metaplasia- tissue transforms into endometrial tissue
Mullerian remnants- embryological remenants find themselves outside of uterus

103
Q

How strong is the correlation between disease severity and symptom severity in endometriosis?

A

There is little correlation

104
Q

How can endometriosis appear on laparoscopy?

A

Chocolate cysts, adhesions and peritoneal deposits (powder burn deposits, red flame lesions)

105
Q

What examination findings are indicative of adenomyosis?

A

An enlarged, tender and boggy uterus

106
Q

What are typical examination findings with endometriosis?

A

A fixed, retroverted uterus, uterosacral ligament nodules, general tenderness, forniceal and uterine tenderness

107
Q

What medical management is available for endometriosis?

A

COCP, continuous progesterone therapy, GnRH analogues

108
Q

How do GnRH analogues work?

A

They increased stimulation of the receptors in anterior pituitary which eventually desensitises them so pituitary stops producing LH and FSH

109
Q

How do we define infertility?

A

An inability to conceive after 12 months of regular unprotected intercourse

110
Q

How do we define infertility?

A

An inability to conceive after 12 months of regular intercourse

111
Q

In fertility investigations when would we check folliculr phase LH, FSH and luteal phase progesterone levels?

A

Day 2- LH and FSH
Day 21- progesterone

112
Q

What advice can be given around natural management of menopause?

A

Exercise: running, swimming and yoga are recommended
Smoking cessation
Reducing alcohol and caffeine helps with hot flushes and night sweats
Mediterranean diet

113
Q

What medications are available to management menopausal symptoms?

A

HRT- combined, oestrogen only, sequential and cyclical
SSRIs for mood and hot flushes
Clonidine, gabapentin used for hot flushes
Vaginal oestrogen creams and lubricants for dryness

Obstetrics And Gynaecology (8 decks)

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