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3a Women's health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is endometriosis

A

the presence and growth of tissue similar to endometrium outside the uterus

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2
Q

Give 2 theories for the cause of endometriosis

A
  • retrograde menstruation
  • spread of endometrial cells through lymphatic system
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3
Q

Describe the presentation of endometriosis

A

can be asymptomatic or present with
* cyclical abdominal/ pelvic pain
* deep dyspareunia (pain on deep sex)
* dysmenorrhoea
* reduced fertility
* cyclical urinary/ bowel symptoms - painful stools

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4
Q

Give 3 vaginal examination findings of endometriosis

A
  • tender nodules in the posterior vaginal fornix
  • endometrial tissue visible on speculum exam
  • fixed cervix on bimanual exam
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5
Q

How is endometriosis diagnosed

A
  • GS: diagnostic laparoscopic surgery +/- biopsy
  • transvaginal ultrasound - useful to make/ exclude the diagnosis of an ovarian endometrioma
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6
Q

How is endometriosis managed medically

A
  • Analgesia - NSAIDs and paracetamol
  • combined oral contraceptive pill
  • progesterone only pill
  • gonadotrophin-releasing hormone analogues (eg goserelin)
  • Mirena coil
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7
Q

How is endometriosis managed surgically

A
  • laparoscopic surgery to excise or ablate endometrial tissue and remove adhesions
  • hysterectomy and bilateral salpingo-oophrectomy
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8
Q

What is the effect of hormonal therapies and laparoscopic treatment on fertility

A
  • laparoscopic treatment may improve fertility
  • hormonal therapies may improve symptoms but not fertility
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9
Q

What are fibroids

A

benign tumours of the smooth muscle of the uterus (myometrium)
aka uterine leiomyomas

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10
Q

Describe the epidemiology of fibroids

A
  • mc in black women
  • mc with increasing age during reproductive years
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11
Q

Describe the 3 types of fibroid

A
  • intramural - within the myometrium. As they grow, they change the shape and distort the uterus
  • Subserosal - just below the outer layer of the uterus. can be pedunculated (on a stalk)
  • submucosal - just below the lining of the uterus
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12
Q

How do fibroids present

A

typically asymptomatic but can present in several ways:
* heavy menstrual bleeding
* dysmenorrhoea
* urinary/ bowel Sx due to pelvic pressure or fullness
* reduced fertility

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13
Q

Describe positive findings of a fibroid on examination

A
  • abdo/ pelvic exam: palpable solid mass
  • bimanual: enlarged firm non-tender uterus
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14
Q

How are fibroids diagnosed

A
  • Ultrasound - determine number, size and position
  • MRI - considered for greater accuracy or if diagnosis unclear
  • hysteroscopy - assess distortion of uterine cavity
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15
Q

How are fibroids managed medically

A
  • Symptomatic: trial NSAIDs and tranexamic acid
  • Mirena (levonorgestrel IUS) - 1st line only if uterine cavity is NOT distorted
  • COCP
  • cyclical oral progestogens
  • pre-surgery Tx with GnRH agonist for 1-2m to shrink fibroid
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16
Q

What type of medication may increase the size of fibroids and possibly cause symptoms

A

hormone replacement therapy

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17
Q

How are fibroids managed radiologically

A

uterine artery embolization

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18
Q

How are fibroids managed surgically

A

Laparoscopic:
* Hysterectomy
* Myomectomy (just fibroid) - preservation of fertility

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19
Q

Give 4 complications of fibroids

A
  • torsion of pedunculated fibroids
  • red degeneration of fibroid
  • malignant change to a leiomyosarcoma
  • pregnancy Cx: PPH, prem labour, malpresentations
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20
Q

What is red degeneration of fibroids

A

refers to ischaemia, infarction, and necrosis of the fibroid due to disrupted blood supply.

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21
Q

During which stages of pregnancy is red degeneration more likely to occur?

A

more likely to occur during the second and third trimester of pregnancy

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22
Q

Give 2 reasons why red degeneration occurs during pregnancy?

A
  • the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
  • kinking in the blood vessels as the uterus changes shape and expands during pregnancy
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23
Q

What are the signs and symptoms of red degeneration?

A
  • severe abdominal pain
  • low-grade fever
  • tachycardia
  • uterine tenderness
  • vomiting
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24
Q

How do ovarian cysts present

A
  • most are asymptomatic
  • pelvic pain
  • bloating
  • fullness
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25
Q

What can cause acute pelvic pain in the presence of ovarian cysts?

A
  • ovarian torsion
  • haemorrhage
  • rupture of the cyst.
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26
Q

What are functional ovarian cysts associated with?

A

the fluctuating hormones of the menstrual cycle.

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27
Q

Describe 2 types of functional ovarian cysts

A

only found in premenopausal women
* follicular -persistent enlarged follicle
* corpus luteum - when the corpus luteum fails to break down and instead fills with fluid

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28
Q

Which functional ovarian cyst tends to cause more symptoms

A

lutein cysts
* pelvic discomfort, pain, delayed menstruation

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29
Q

What are serous cystadenomas

A

most common benign epithelial tumour

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30
Q

What are mucinous cystadenomas

A

Mucinous cystadenomas are benign tumours of epithelial cells that can become very large, occupying significant space in the pelvis and abdomen.

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31
Q

What are dermoid cysts, and what do they contain?

A

benign ovarian tumours that are teratomas. They originate from germ cells and may contain various tissue types such as skin, teeth, hair, and bone

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32
Q

What are sex cord-stromal tumours, and where do they originate?

A

rare tumours that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles).

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33
Q

Name two types of sex cord-stromal tumours

A
  • Sertoli–Leydig cell tumours
  • Fibromas
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34
Q

Which ovarian cyst is particularly associated with ovarian torsion

A

Dermoid cysts

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35
Q

What are endometriomas, and what causes them?

A

Endometriomas are ‘chocolate cysts’ that occur in the ovary due to endometriosis, which causes altered blood to accumulate. They can cause pain and disrupt ovulation

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36
Q

Name 3 ovarian masses more commonly seen in premenopausal women

A
  • follicular/ lutein cysts
  • dermoid cysts
  • endometriomas
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37
Q

How are ovarian cysts investigated

A
  • premenopausal women with a simple ovarian cyst <5cm on USS don’t need further investigations
  • Women <40 with a complex ovarian mass require tumour markers for a possible germ cell tumour: LDH, HCG, CA125, alpha-fetoprotein
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38
Q

How are ovarian cysts managed

A
  • <5cm: likely resolve within 3 cycles
  • 5-7cm: referral and yearly USS
  • > 7cm: consider MRI/ surgical evaluation
  • Persistent/ enlarging: laparoscopic ovarian cystectomy
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39
Q

What is the triad for Meig’s syndrome

A
  • ovarian fibroma
  • pleural effusion
  • ascites
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40
Q

What is adenomyosis

A

refers to the presence of endometrial tissue within the myometrium

41
Q

Which women are at a higher risk of adenomyosis?

A
  • multiparous
  • later reproductive years (>40)
42
Q

What are the features of adenomyosis?

A
  • Dysmenorrhoea (painful periods)
  • Menorrhagia (heavy menstrual bleeding)
  • Enlarged, boggy uterus
43
Q

What are the recommended investigations for adenomyosis?

A
  • 1st line: transvaginal ultrasound
  • MRI as an alternative.
44
Q

What are the management options for adenomyosis?

A
  • Tranexamic acid for menorrhagia
  • 1st line: Mirena, COCP
  • GnRH agonists
  • Uterine artery embolization
  • Hysterectomy - definitive treatment
45
Q

What are the key features of polycystic ovarian syndrome (PCOS)?

A
  • Subfertility and infertility
  • oligomenorrhoea (irregular) and amenorrhoea (absent)
  • Hirsutism (thick dark hair, male pattern) and acne - due to hyperandrogenism (high male sex hormones)
  • Obesity
  • Acanthosis nigricans (due to insulin resistance)
46
Q

What is Acanthosis nigricans

A

thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture

47
Q

What investigations are recommended to diagnose PCOS and exclude other pathology

A
  • Pelvic transvaginal ultrasound (GS): multiple cysts on the ovaries - string of pearls appearance
    Baseline investigations:
  • Testosterone
  • Sex hormone-binding globulin
  • Luteinizing hormone
  • Follicle-stimulating hormone
  • Prolactin
  • Thyroid-stimulating hormone
    Check for impaired glucose tolerance (OGTT)
48
Q

What hormonal blood test results are typical in polycystic ovarian syndrome (PCOS)?

A
  • Raised luteinising hormone (LH)
  • Raised LH to FSH ratio (high LH compared with FSH)
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
  • Sex hormone-binding globulin is normal/ low
49
Q

What criteria is used to diagnose polycystic ovarian syndrome (PCOS)?

A

Rotterdam criteria

50
Q

What are the diagnostic criteria for PCOS according to the Rotterdam criteria?

A

A diagnosis requires at least two of the three key features:
* Oligoovulation (irregular) or anovulation (absent) - manifested as infrequent or absent menstruation
* Signs of hyperandrogenism - e.g., hirsutism, acne, raised total/ free testosterone
* Polycystic ovaries on ultrasound, defined as:
- Presence of ≥ 20 follicles (measuring 2-9 mm in diameter) in at least one ovary
- and/or Increased ovarian volume > 10 cm³

51
Q

What are the management options for infertility in PCOS

A

aim to restore ovulation
* 1st: weight reduction
* Letrozole
* clomifene
* clomifene + metformin
* IVF
* laparoscopic ovarian drilling

52
Q

How is hirsutism and acne managed in PCOS ?

A
  • COCP - induce monthly bleed
    If there is no response to COC, consider topical eflornithine
  • Anti-androgen + COCP - e.g. Spironolactone or finasteride
  • discuss hair reduction and removal
  • retinoid for acne
53
Q

Give 4 complications of PCOS

A
  • T2DM
  • endometrial cancer/ hyperplasia
  • infertility
  • CVD
54
Q

How can risks of obesity, DM and CVD be reduced in PCOS

A
  • Weight loss
  • calorie-controlled diet
  • Regular exercise
  • Smoking cessation
  • Antihypertensive medications where required
  • Statins where indicated (QRISK >10%)
55
Q

What are the options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS

A
  • Mirena coil for continuous endometrial protection

Inducing a withdrawal bleed at least every 3-4 months with:
* Cyclical progestogens - e.g., medroxyprogesterone acetate 10 mg OD for 14 days
* COCP

56
Q

What is pelvic organ prolapse

A

descent of one of the pelvic organs resulting in protrusion on the vaginal walls

57
Q

What causes pelvic organ prolapse

A

result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

58
Q

What are the types of prolapse?

A
  • Cystocele and cystourethrocele
  • Rectocele
  • Uterine prolapse
  • Less common types: urethrocele and enterocele
59
Q

What causes rectoceles?

A

Rectoceles occur due to a defect in the posterior vaginal wall, allowing the rectum to protrude forward into the vagina

60
Q

What causes cystoceles?

A

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.

61
Q

What are the risk factors for prolapse?

A
  • Increasing age and postmenopausal status
  • multiple vaginal deliveries
  • Obesity
  • Ehlers danlos
  • chronic constipation/ cough
62
Q

What are the common presentations of prolapse?

A
  • dragging or heavy sensation
  • Urinary symptoms: incontinence, frequency, and urgency
  • constipation
  • sexual dysfunction
  • may have identified lump themselves - may reduce to enable urine/stool to pass
63
Q

What instrument allows separate inspection of the anterior and posterior vaginal walls during examination of a prolapse

A

Sims’ speculum

64
Q

How is urogenital prolapse managed

A
  • Conservative: pelvic floor exercises, weight loss, lifestyle changes
  • Vaginal ring pessaries
  • Surgery - hysterectomy, ant/ post colporrhaphy, sacrocolpoplexy
65
Q

What is hyperemesis gravidum

A

severe form of nausea and vomiting in pregnancy

66
Q

When is hyperemesis gravidarum most common during pregnancy?

A

between 8 and 12 weeks of pregnancy but may persist up to 20 weeks.

67
Q

What criteria does NICE suggest for admitting pregnant women with nausea and vomiting?

A
  • Continued N+V, unable to keep down liquids or oral antiemetics
  • Continued N+V with ketonuria and/or weight loss (greater than 5% of body weight) despite oral antiemetics
  • Confirmed or suspected comorbidity (e.g., inability to tolerate oral abx for a UTI)
    A lower threshold for admission is recommended if the woman has a co-existing condition (e.g., diabetes) that may be adversely affected by n+v
68
Q

What are the risk factors for nausea and vomiting in pregnancy ?

A
  • Increased levels of beta-hCG
  • multiple pregnancies
  • trophoblastic disease
  • nulliparity
  • obesity
  • family or personal history of NVP
69
Q

What are the RCOG guideline criteria for diagnosing hyperemesis gravidarum?

A

“prolonged” nausea and vomiting in pregnancy (NVP) plus:
* More than 5% weight loss compared to pre-pregnancy weight
* Dehydration
* Electrolyte imbalance

70
Q

What tool is used to assess the severity of nausea and vomiting in pregnancy (NVP)?

A

Pregnancy-Unique Quantification of Emesis (PUQE) score.

71
Q

What are the first line management options for hyperemesis gravidarum

A
  • Antihistamines : oral cyclizine or promethazine
  • phenothiazines: oral prochlorperazine or chlorpromazine
  • combination drug - doxylamine/pyridoxine
72
Q

What are the second line management options for hyperemesis gravidarum

A
  • D2 receptor antagonist : oral metoclopramide or domperidone
  • 5-HT3 receptor antagonist: ondansetron
73
Q

What are the precautions regarding the use of metoclopramide in treating nausea and vomiting in pregnancy?

A

Metoclopramide may cause extrapyramidal side effects and should not be used for more than 5 days.

74
Q

What is a potential concern when using ondansetron in pregnancy?

A

Ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate.

75
Q

What are some simple measures for managing nausea and vomiting in pregnancy?

A
  • Rest and avoid triggers (e.g., odours)
  • Bland, plain food, particularly in the morning
  • Ginger
  • P6 (wrist) acupressure
76
Q

What IV hydration treatment is commonly given to women admitted for nausea and vomiting in pregnancy

A

generally given normal IV saline with added potassium, as hypokalaemia is common

77
Q

Give 3 complications of hyperemesis gravidarum

A
  • AKI
  • Wernicke’s encephalopathy
  • oesophagitis
78
Q

What is the prevalence of infertility among couples, and what percentage of couples conceive within one year?

A
  • Infertility affects around 1 in 7 couples.
  • Approx 84% of couples who have regular sex will conceive within 1 year
79
Q

When should investigation and referral for infertility be initiated?

A
  • after 12 months of trying to conceive without success.
  • can be reduced to 6 months if the woman is older than 35
80
Q

What are the common causes of infertility and their approximate prevalence?

A
  • Male factor: 30%
  • Unexplained: 20%
  • Ovulation failure: 20%
  • Tubal damage: 15%
  • uterine problems: 15%
81
Q

What general lifestyle advice is recommended for couples trying to conceive?

A
  • woman should take 400 mcg of folic acid daily.
  • healthy BMI (20-25)
  • Avoid smoking and excessive alcohol.
  • Aim for intercourse every 2–3 days.
  • Avoid timing intercourse - stress and pressure
82
Q

What are the key investigations done in primary care for infertility?

A
  • Semen analysis
  • Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle)
  • Serum LH and FSH on day 2-5
  • anti-mullerian hormone
  • chlamydia screen
83
Q

What is the most accurate marker of ovarian reserve

A

anti-Mullerian hormone

84
Q

What are the key investigations done in secondary care for infertility?

A
  • transvaginal USS
  • hysterosalpingogram - patency of fallopian tubes
  • Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
85
Q

Medical Treatment for Restoring Fertility

A
  • Clomifene - stimulate ovulation
  • Gonadotropins - stimulate ovulation in women resistant to clomifene.
  • Pulsatile GnRH - Induces ovulation.
  • Dopamine Agonists - Used for ovulatory disorders secondary to hyperprolactinemia.
86
Q

Surgical Treatment for Restoring Fertility

A
  • Tubal Microsurgery: tubal catheterization or cannulation
  • Surgical Ablation: Resection of endometriosis plus laparoscopic adhesiolysis
  • Surgical Correction of Epididymal Blockage: For men with obstructive azoospermia;
87
Q

What are the key legal frameworks regarding abortion in the UK?

A

The law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for abortion from 28 weeks gestation to 24 weeks

88
Q

Under what conditions can an abortion be performed at any time during a pregnancy in the UK?

A
  • Continuing the pregnancy is likely to risk the life of the woman
  • Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
  • There is “substantial risk” that the child would suffer physical or mental abnormalities making them seriously handicapped
89
Q

What are the legal requirements for obtaining an abortion in the UK?

A
  • Two registered medical practitioners must agree that the abortion is indicated.
  • The procedure must be carried out by a registered medical practitioner in an NHS hospital or an approved premises.
90
Q

How are abortions managed medically

A
  • Mifepristone then misoprostol 1-2 days later
  • pregnancy test 2 weeks later to confirm end of pregnancy
91
Q

What is the role of mifepristone in the medical management of an abortion

A

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix

92
Q

What is the role of misoprostol in the medical management of an abortion

A
  • Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them
  • Prostaglandins soften the cervix and stimulate uterine contractions
  • From 10w gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion
93
Q

When should anti-D prophylaxis be given to women in the context of abortion?

A

Anti-D prophylaxis should be given to women who are Rhesus D negative and are having an abortion after 10+0 weeks’ gestation

94
Q

How are abortions managed surgically

A
  • cervical priming (softening and dilating) with misoprostol +/- mifepristone before procedures
  • manual vacuum aspiration
  • electric vacuum aspiration
  • dilatation and evacuation
  • Surgical abortion may be done with local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation, or general anaesthesia.
95
Q

What is Androgen Insensitivity Syndrome and how does it affect children?

A

an X-linked recessive condition caused by end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype externally.

96
Q

Why do the female internal organs not develop in androgen insensitivity syndrome

A

the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.

97
Q

Give 5 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
98
Q

How is androgen insensitivity syndrome managed

A
  • bilateral orchidectomy - reduce risk of testicular cancer
  • counselling - generally raised as females but discussed under specialist advice
  • oestrogen therapy

3a Women's health (12 decks)

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