Gynaecology 2 Flashcards
1
Q
One of the VIN types is associated with older women, lichen sclerosus and greater risk of malignant progression. Which is it?
A
Differentiated type VIN
2
Q
2 common symptoms of VIN?
A
Pain
Pruritis vulvae
3
Q
What histological type are most vulval cancers?
A
SCC
4
Q
What features of vulval cancer are more suggestive of malignancy than of VIN?
A
Pruritis
Bleeding (older women PMB), PCB
Discharge
5
Q
Is most vaginal malignancy primary or secondary?
A
Secondary from endometrium, cervix or vulva
6
Q
Vaginal cancer that is more common in teenagers and associated with maternal DES in pregnancy?
A
Clear cell adenocarcinoma
7
Q
3 broad types of prolapse?
A
Anterior wall
Apical
Posterior wall
8
Q
Subdivisions of anterior wall prolapse?
A
Cystocoele
Urethrocoele
Cystourethrocoele
9
Q
Subdivisions of apical prolapse?
A
Uterine
Cervical
Upper vaginal
10
Q
Subdivisions of posterior wall prolapse?
A
Rectocoele
Enterocoele (pouch of Douglas) - often has bowel in
11
Q
RFs for prolapse?
A
Parity - vaginal delivery, instrumental, long second stage, big babies
Age and menopause (low oestrogen so low collagen)
Connective tissue disorders e.g. Ehlers danlos
Spins bifida occulta
Raised IAP - obesity, chronic cough, heavy lifting
Iatrogenic mostly surgical - hysterectomy
12
Q
What is procidentia?
A
Complete prolapse and vaginal eversion
13
Q
What is the word for complete prolapse?
A
Procidentia
14
Q
Stage 0-4 of Pelvic Organ Prolapse Quantification grading? Based upon position of distal portion on straining.
A
Stage 0 = normal Stage 1 = >1cm above hymen Stage 2 = less than 1cm either side of hymen Stage 3 = >1cm below hymen Stage 4 = fully everted (procidentia)
15
Q
Management of prolapses?
A
Conservative - lose weight, quit smoking/stop cough etc
Medical - ring pessaries/shelf pessary
Surgical - sacrocolpopexy, uterine sling etc
16
Q
With which form of incontinence is prolapse often coexistent but not necessarily related?
A
Stress incontinence
17
Q
What is the pathophysiology behind stress incontinence?
A
Increased intra abdominal pressure with a weakened pelvic floor so bladder pressure > upper urethral pressure and sphincter leaks
18
Q
How is stress incontinence diagnosed?
A
UTI to rule out infection + urodynamics to rule out overactivity (urge) incontinence
19
Q
Management of stress incontinence?
A
Physiotherapy - pelvic floor training exercises for > 3m
Medical - SSRI (duloxetine) for mod-severe
Surgery if the above fail and significantly affecting QoL (TVT)
20
Q
How does urge/overactivity incontinence tend to present?
A
Urgency usually with frequency and nocturia
In the absence of proven infection
21
Q
How is urge/overactivity incontinence diagnosed?
A
Via cystometry Urodynamics - needs confirmed detrusor overactivity
22
Q
What are common causes of urge/overactivity incontinence?
A
Normally idiopathic - can be nervous system dysfunction
23
Q
Which type of incontinence can be associated with UTIs, medications and caffeine/alcohol?
A
Urge/overactivity
24
Q
What is mixed incontinence a combination of?
A
Stress and urge
25
Management of overactivity/urge incontinence?
Conservative - avoid triggers, caffeine etc and keep bladder diary
Bladder training + Anticholinergics e.g. Oxybutinin, tolterodine to suppress Detrusor activity
Topical oestrogens
Injected Botulinum toxin A (BTX) to paralyse Detrusor
26
What type of incontinence is associated with chronic retention or detrusor underactivity?
Overflow
27
What type of incontinence can have heavy and constant flow?
Chronic retention/overflow -> total
28
Causes of overflow incontinence?
Bladder cancer
Prostate increased size
Constipation
Detrusor underactivity - DM or neuropathies
29
What are the 2 types of VIN and which is most common? Which is associated with lichen sclerosus?
```
Usual type (most common)
Differentiated type (associated with lichen sclerosus)
```
30
In whom is endometriosis most common?
Nulliparous women closer to the menopause
31
What hormones does endometriosis growth depend on?
Oestrogen +/- progesterone
32
What are chocolate cysts?
Blood-filled endometriosis pockets
33
How does a frozen pelvis form from endometriosis?
Inflammation -> fibrosis and scarring -> adhesions
34
Key symptoms of endometriosis?
Cyclical chronic pelvic pain - just before menstruation (secondary dysmenorrhea)
Subfertility
Deep dyspareunia
Dyschezia and dysuria during menses
35
What Bimanual examination finding is suggestive of severe endometriosis with adhesions?
Retroverted immobile uterus + tenderness
36
What investigation differentiates between active lesions and chronic ones for endometriosis?
Laparascopy
Active lesions = red vesicles/petechial marks
-> white brown when less active
37
What investigation is best for adenomyosis?
MRI
38
What is an endometrioma?
Endometriotic ovarian lesion - risk of cancerous progression
39
Medical treatment for endometriosis if symptomatic?
Hormonal - COCP/cyclic Progestogens
GnRH analogues -> add back HRT
IUS will reduce menstrual symptoms
40
What is chronic pelvic pain?
Pain lasting over 6 months and not exclusively related to menstruation or sex
41
Differentials for chronic pelvic pain: cyclical vs non-cyclical?
Cyclical: endometriosis, adenomyosis
| Non-cyclical: IBS, interstitial cystitis, chronic PID, pelvic mass
42
Appropriate management of chronic pelvic pain?
Analgesia
COCP if cyclical and fertility not desired
Laparoscopy to investigate
43
Why are prepubescent and postmenopausal women more susceptible to UTI and genital tract infection?
Lower oestrogen so thinner atrophic vaginal epithelium and increased vaginal pH (so lactobacilli aren't as efficient vs infection)
44
Common causes of endometritis?
Instrumentation of uterus
| Complication of pregnancy e.g. PPROM, post CS, miscarriage, ToP
45
Presentation of endometritis?
Persistent, heavy, painful vaginal bleeding
Tender uterus, often open os
Fever, sepsis
46
What is acute PID/salpingitis?
Ascending pelvic infection, often sexual although occasionally descendant from appendix
47
What infection often precedes or coexists with salpingitis?
Endometritis
48
What is heavily protective against salpingitis to the extent that it almost never occurs during this?
A viable intrauterine pregnancy
| Less protective are COCP and IUS
49
Under what circumstances may acute PID go unnoticed?
Particularly gonococcal infection
| If no coexistent endometritis
50
Symptoms of acute PID/salpingitis (particularly gonococcal)?
Bilateral lower abdominal/pelvic pain
Deep dyspareunia
Discharge
O/E cervical excitation, lower abdo rebound tenderness and adnexal tenderness
51
What is the role of pelvic US in acute PID?
Looking for abscess formation or ovarian cysts
52
What infection is associated strongly with Fitz Hugh Curtis syndrome?
Chlamydia
53
In whom is chlamydia more commonly symptomatic?
Men - 50% symptomatic, only 20% of women
54
What complication of chronic PID can result in subfertility?
Hydro/pyosalpinx due to Fallopian tube adhesions
55
Definition of subfertility?
Failure to conceive after 1 year of regular unprotected sex
| Affects 15% of couples
56
Primary vs secondary failure to conceive?
```
Primary = never conceived
Secondary = previously conceived (even if not delivered)
```
57
4 broad areas of causes of subfertility?
Egg production
Male factor
Fertilisation incl tubal factor and sexual problems
Idiopathic
58
What are the most common causes of subfertility?
Ovarian dysfunction or idiopathic
59
Physiological subfertility in terms of egg production?
Egg genetic quality decreases with age so natural reduction in fertility as women get closer to the menopause (declines from roughly age 30)
60
What is mittelschmerz?
Pain +/- discharge and spotting around time of ovulation (day 13-14)
61
When is body temperature lowest in the ovarian cycle?
Just pre-ovulation, before rising in luteal phase
62
3 tests for ovulation (apart from proof I.e. Conception)?
Mid-luteal phase serum progesterone (elevated = ovulated)
USS (time consuming)
OTC wee sticks for LH to predict surge
63
5 broad areas of causes of anovulation?
Thyroid - Hypothalamic hypogonadism
Pituitary - hyperprolactinaemia
Ovarian - PCOS, Premature ovarian failure, gonadal dysgenesis
Other e.g. Thyroid or androgen secreting tumours
64
What is the mechanism behind hypothalamic hypogonadism?
Reduced GnRH production -> reduced LH, FSH and oestrogen
| -> anovulation
65
What is Kallmann's syndrome?
Non-development of GnRH secreting neurones
66
What medication can be given to induce ovulation in PCOS? Caveats?
Clomifene citrate
| Weight and lifestyle should be controlled first
67
What is ovarian hyperstimulation syndrome?
Side effect of IVF/GnRH agonists -> overstimulation of follicles which become large and painful and produce mega oestrogen
Can be fatal via hypovolaemia, electrolyte imbalance, ascites, VTE, pulmonary oedema
68
What condition is a major risk factor for OHSS particularly following clomifine use?
PCOS
69
What age of women are more susceptible to OHSS and why?
Younger women with higher follicular reserve
70
Typical presentations of OHSS?
4-5 days following egg harvest; abdo pain and distension due to fluid ascites, nausea and vomiting, pleural effusions (SOB), hypovolaemia -> VTE, reduced UO
71
What 2 things does spermatogenesis depend on?
LH -> testosterone production in Leydig cells
| FSH -> + testosterone make Sertoli cells produce and transport sperm
72
What is asthenospermia?
Poor sperm motility
73
5 common causes of abnormal semenalysis?
```
Idiopathic oligo/asthenozoospermia
Drugs, chemicals, smoking, alcohol
Varicocoele
Antisperm antibodies - common post-vasectomy reversal
Infection - mumps orchitis, epididymitis
```
74
What is another name for Kallmann's syndrome?
Hypogonadotrophic hypogonadism
75
Genetic causes of sperm abnormalities?
Klinefelters XXY
| CF
76
3 common causes of tubal dysfunction?
Infection - PID
Endometriosis
Surgery/adhesions
77
What are the 2 main methods for investigating tubal damage?
Lap and Dye
| Hysterosalpingogram - less invasive and safer but may not show endometriosis or adhesions
78
2 methods for intrauterine insemination?
In line with cycle (LH)
| GnRH ovulation induction (stimulated IUI)
79
What are the requirements for IUI?
Patent tubes and no ovarian problems
80
What does ICSI stand for and what assisted contraception method is it used in conjunction with?
Intracyctoplasmic Sperm Injection, oft used with IVF when indication is male factor infertility
81
What is the primary indication for IVF?
Tubal or idiopathic with confirmed ovulatory reserve via FSH/AMH
82
What are 3 methods of assessing ovarian reserve?
FSH (high = low reserve)
AMH (high = high reserve)
TVUS of ovaries to measure antral follicle count AFC
83
What technique associated with IVF may be useful for older women or those at higher risk of chromosomal abnormalities e.g. CF?
Preimplantation Genetic Diagnosis PGD
84
What are the best methods of contraception for use in adolescents?
Pill and condoms for STI protection
Depo-provera (risk of reduced bone density)
Emergency contraception
85
What long term risk does depo-provera carry, particularly in younger people?
Osteoporosis
86
What methods of contraception are recommended for those with IBD or other malabsorbative disorders?
Oral contraception use limited due to reduced absorption so alternatives e.g. Patch, injection, implants
Increased risk of osteoporosis anyway so avoid Depo-provera
87
Contraception suitable for those breastfeeding?
In theory breastfeeding is contraceptive in itself as it inhibits ovulation
However if using added contraception: avoid COCP but POP is fine
IUD fine from 4 weeks postpartum
88
Rules for contraception for women around the time of menopause?
Women under 50 should use contraception for > 2years post LMP
Women over 50 should use contraception for > 1 year post LMP
IUS can be particularly useful for those with excessive menstrual loss
89
How do combined oestrogen and progesterone contraceptives work?
Negative feedback loop - suppress LH and FSH via GnRH and thus inhibit ovulation
Also thin endometrium and thickens cervical mucus (progesterone)
90
What is the normal regime for COCP?
3 weeks on -> bleed due to prog withdrawal -> 1 week off
91
Major contraindications to COCP?
```
VTE, CV Hx
Migraine with aura
Active breast or endometrial cancer
Thrombophilias + liver disease
Pregnancy
Most smokers
Really high BMI
```
92
Apart from contraceptive use, what is the COCP useful for?
Cycle control - menorrhagia, dysmenorrhea, irregular periods
Acne and hirsutism
Simple ovarian cysts
93
What 3 conditions can the COCP be used to suppress?
Fibroids
Endometriosis
PID/ovarian cysts
94
What are some considerations to make when considering COCP usage?
Compliance/missed pill
Reduced absorption
Liver enzyme inducers e.g. Anticonvulsants
Major surgery (stop 4 weeks before)
STI risk (concurrent condom use in teens and young adults)
95
4 major side effects of the COCP?
Nausea
Headache
Breast pain
Weight gain
96
How does the POP work?
By inhibition of cervical mucus and preventing uterine proliferation - inhibit ovulation in 50%
97
4 progestogenic side effects?
Vaginal spotting (breakthrough bleeds)
Pre-menstrual syndrome
Weight gain
Breast pain
98
What can the POP cause if it doesn't result in anovulation (as in 50%)?
Functional ovarian cysts (follicular or luteal)
99
In whom is the POP>COCP?
In older women
| In those who the COCP is contraindicated
100
2 types of Long Acting Reversible Contraceptives LARCs?
Depo provera - progesterone injection
| Progestogen implant rod
101
How do the LARCs work and what do they therefore protect against?
Work by preventing ovulation and so protect against functional ovarian cysts and ectopics
102
Why is the progestogen rod implant a better choice than depo for teenagers and those with IBD?
Doesn't cause a reduction in bone density so no risk osteoporosis
103
2 options for emergency contraception?
Morning after pill or IUD
104
What 2 morning after pill options are there?
Levonelle - up to 3 days after sex
| Ulipristal (ellaOne) - up to 5 days after sex
105
When can an IUD be fitted after unprotected sex as emergency contraception?
Up to 5 days after sex or 5 days after expected date of ovulation
106
Potential complications of IUD/IUS insertion?
```
Pain/cervical shock due to increased vagal tone after insertion
Threads disappearing
IUD may worsen dysmenorrhea/menorrhagia
Infection and PID
Ectopic pregnancy
```
107
Which type of IUD can worsen menstrual symptoms?
Copper coil IUD
108
What are 2 causes of threads disappearing from IUD/IUS insertion?
Expulsion
| Perforation of uterine wall
109
Average age of menopause?
51
110
When is the menopause officially recognised?
12 months after LMP
111
Define the perimenopause?
From onset of symptoms to 1 year after LMP
112
What is premature menopause? What does it require?
Ovarian failure before age of 40
| Requires HRT until at least age of 50
113
What is PMB defined as?
Bleeding occurring >1 year after LMP
114
What are 3 important causes of PMB to rule out?
Endometrial cancer/hyperplasia with atypia
Intrauterine polyps
Cervical cancer
115
4 other potential causes of PMB?
Withdrawal bleeds with sequential HRT
Atrophic vaginitis
Cervicitis or cervical polyps
Ovarian carcinoma
116
What must purulent blood stained discharge be assumed to be until proven otherwise?
Endometrial carcinoma
117
Appropriate line of investigations for PMB?
Physical examination + smear test
| TVUS -> endometrial pipelle biopsy -> hysteroscopy
118
5 areas of symptoms of the menopause?
Cardiovascular - stroke and MI risk
Vasomotor - hot flushes, night sweats (-> sleep disturbance)
Urogenital - vaginal atrophy, dyspareunia, itching burning dysuria, urinary frequency, urgency, Nocturia, incontinence and infection
Sexual and psychological - loss of interest and arousal, dyspareunia, irritability, mood changes, depression, sleep disturbance
Osteoporosis
119
Lines of investigation for the menopause?
FSH
AMH
T4/TSH, LH, oestrogen, progesterone
120
When investigating anovulation, what low level of hormone indicates anovulation?
Low progesterone
121
General rules for types of HRT requirement?
Oestrogen only if no uterus
| Oestrogen and progesterone for uterus
122
Combined HRT regimes?
```
Quarterly or monthly bleeds (prog given sequentially)
No bleeds (prog given continuously e.g. IUS)
```
123
Which HRT method is the best for protecting vs endometrial cancer?
Continuous ie no bleed, as it induces endometrial atrophy
124
3 benefits of HRT?
Reducing troublesome symptoms
Reducing osteoporosis risk
Reducing colorectal cancer risk
125
4 potential risks of HRT?
Increased risk of endometrial cancer if oestrogen only and uterus present
Increased risk of breast cancer if combined
Increased risk of VTE particularly for oral (during 1st year)
Increased risk of gallbladder disease
126
What medications might be useful for perimenopausal symptoms for those wanting to avoid oestrogen (e.g. Breast ca risk)?
Progestogens
| SSRIs for vasomotor
127
What is a miscarriage and when do most occur?
Fetus dies or delivered dead before 24 weeks
| Most occur before 12 weeks
128
6 types of miscarriage?
```
Threatened
Inevitable
Complete
Incomplete
Septic
Missed
```
129
What indicates a threatened miscarriage?
Bleeding PV, closed cervical os. Fetus is still alive and correct size for dates
130
What fraction of people with threatened miscarriage go on to miscarry?
1/4
131
What indicates an inevitable miscarriage?
Heavier PV bleeding and open cervical os
132
What indicates an incompletely miscarriage?
Some but not all of fetal parts are passed; cervical os still open
133
What indicates a complete miscarriage?
All fetal parts have been passed and the cervical os is closed
134
What indicates septic miscarriage?
Uterine contents infected -> endometritis. Patient will have offensive vaginal loss with a tender uterus +/- systemic infection
135
What indicates a missed miscarriage?
Fetur not developed/died in utero but not recognised until bleeding or US
Small for dates fetus and closed os
136
What types of miscarriage present with an open os?
Incomplete
| Inevitable
137
What types of miscarriage present with a closed os?
Threatened
Complete
Missed
138
What are sporadic miscarriages usually caused by?
Isolated chromosomal or genetic abnormalities
139
What are 'recurrent miscarriages' and why do they most commonly occur?
3 or more miscarriages in succession
Antiphospholipid Abs (thrombosis in placental circulation)
Parental chromosomal defects
Anatomical factors
140
Appropriate investigations for possible miscarriage (bleeding PV)?
US to observe viable IUP or retained fetal products
HCG levels
FBC and rhesus
141
What hCG levels are indicative of viable IUP or miscarriage?
Increase of >66% in 48 hours is indicative of viable IUP
| Plateauing or decreasing suggests viable IUP
142
What investigations are combined to assess possibility of ectopic pregnancy?
HCG - if rise of >66% in 48 hours but no visible IUP suggests ectopic
Visualisation of IUP normally rules out ectopic
143
What is a heterotopic pregnancy?
IUP + ectopic pregnancy together
144
Under what circumstances does anti-D need to be given for miscarriage?
For bleeding > 12 weeks or surgically/medically managed in rhesus negative women
145
Management methods for non-viable IUP?
Expectant - for incomplete or inevitable miscarriage and no signs of infection
Medical - prostaglandins possibly with preceding mifepristone
Surgical - ERPC for infection, heavy bleeding or maternal choice
146
What is Asherman's syndrome?
A rare complication of ERPC and some uterine surgical procedures resulting in amenorrhea due to outflow blockage
147
When do rhesus negative women need to be given anti-D for ToP?
Within 72 hours of ToP
148
When is medical ToP most appropriate?
Less than 7-9 weeks
| From 13-24 weeks
149
When is surgical ToP most appropriate?
7-13 weeks
150
What is the most common area for ectopic pregnancy?
Fallopian tubes
| Occasionally Cornu, cervix, ovary, intra-abdo
151
RFs for ectopic pregnancy?
Previous ectopic
Tubal - PID, surgical adhesions
Increasing maternal age
Smoker
152
What should a patient who conceives despite IUD in situ be assumed to have until proven otherwise?
Ectopic pregnancy
153
Presentation for ectopic pregnancy?
```
Lower abdo pain - colicky then chronic
Scanty dark vaginal bleeding
Abdo/rebound tenderness
Adnexal tenderness, cervical excitation
Small uterus for dates, closed os
```
154
What should all women of reproductive age who present with bleeding, pain or collapse have done?
Pregnancy test
155
Medical management of ectopic pregnancy?
If unruptured, stable patient and hCG
156
Surgical management of ectopic pregnancy?
Laparoscopy and salpingectomy/salpingostomy if subacute
| Laparotomy and salpingectomy if acute
157
What is hyperemesis gravidarum?
Nausea and vomiting in early pregnancy so severe as to cause dehydration, weight loss or electrolyte disturbance
158
In whom is hyperemesis more common?
Older, multiparous women
UTI
Molar pregnancy
159
When does hyperemesis normally resolve by?
12-14 weeks
160
Management of hyperemesis?
IVT +/- antiemetics e.g. Cyclizine, metoclopramide, ondansetron
161
What vitamin needs to be given in hyperemesis?
B particularly thiamine to prevent wernicke-korsakoff
162
What is gestational trophoblastic disease GTD?
Trophoblastic tissue which normally invades the endometrium proliferates more aggressively than normal -> mega hCG levels
163
What is local, non-invasive trophoblastic overproliferation called?
Molar pregnancy - hyatidiform mole
164
2 types of hyatidiform mole?
Complete (no fetus, entirely paternal)
| Partial (+/- fetus, usually triploid)
165
What is a locally invasive GTD called and what does it have the potential to do?
Invasive mole
| Can metastasise and become a choriocarcinoma
166
What is persistently elevated hCG in the context of GTD called?
Gestational trophoblastic neoplasia GTN
167
In whom is GTD more common?
Asian women at extremes of reproductive age
168
How does GTD present?
Large uterus, possible heavy vaginal bleeding
Early pre-eclampsia and hyperthyroidism
Hyperemesis
169
What does a 'snowstorm' uterus on US indicate?
Complete moles
170
Management of GTD?
ERPC + histological diagnosis
| Serum or urine hCG follow up to rule out malignancy
