Gynaecology 2 Flashcards
One of the VIN types is associated with older women, lichen sclerosus and greater risk of malignant progression. Which is it?
Differentiated type VIN
2 common symptoms of VIN?
PainPruritis vulvae
What histological type are most vulval cancers?
SCC
What features of vulval cancer are more suggestive of malignancy than of VIN?
PruritisBleeding (older women PMB), PCBDischarge
Is most vaginal malignancy primary or secondary?
Secondary from endometrium, cervix or vulva
Vaginal cancer that is more common in teenagers and associated with maternal DES in pregnancy?
Clear cell adenocarcinoma
3 broad types of prolapse?
Anterior wallApicalPosterior wall
Subdivisions of anterior wall prolapse?
CystocoeleUrethrocoeleCystourethrocoele
Subdivisions of apical prolapse?
UterineCervicalUpper vaginal
Subdivisions of posterior wall prolapse?
RectocoeleEnterocoele (pouch of Douglas) - often has bowel in
RFs for prolapse?
Parity - vaginal delivery, instrumental, long second stage, big babiesAge and menopause (low oestrogen so low collagen)Connective tissue disorders e.g. Ehlers danlosSpins bifida occultaRaised IAP - obesity, chronic cough, heavy liftingIatrogenic mostly surgical - hysterectomy
What is procidentia?
Complete prolapse and vaginal eversion
What is the word for complete prolapse?
Procidentia
Stage 0-4 of Pelvic Organ Prolapse Quantification grading? Based upon position of distal portion on straining.
Stage 0 = normalStage 1 = >1cm above hymenStage 2 = less than 1cm either side of hymenStage 3 = >1cm below hymenStage 4 = fully everted (procidentia)
Management of prolapses?
Conservative - lose weight, quit smoking/stop cough etcMedical - ring pessaries/shelf pessarySurgical - sacrocolpopexy, uterine sling etc
With which form of incontinence is prolapse often coexistent but not necessarily related?
Stress incontinence
What is the pathophysiology behind stress incontinence?
Increased intra abdominal pressure with a weakened pelvic floor so bladder pressure > upper urethral pressure and sphincter leaks
How is stress incontinence diagnosed?
UTI to rule out infection + urodynamics to rule out overactivity (urge) incontinence
Management of stress incontinence?
Physiotherapy - pelvic floor training exercises for > 3mMedical - SSRI (duloxetine) for mod-severeSurgery if the above fail and significantly affecting QoL (TVT)
How does urge/overactivity incontinence tend to present?
Urgency usually with frequency and nocturia In the absence of proven infection
How is urge/overactivity incontinence diagnosed?
Via cystometry Urodynamics - needs confirmed detrusor overactivity
What are common causes of urge/overactivity incontinence?
Normally idiopathic - can be nervous system dysfunction
Which type of incontinence can be associated with UTIs, medications and caffeine/alcohol?
Urge/overactivity
What is mixed incontinence a combination of?
Stress and urge
Management of overactivity/urge incontinence?
Conservative - avoid triggers, caffeine etc and keep bladder diaryBladder training + Anticholinergics e.g. Oxybutinin, tolterodine to suppress Detrusor activityTopical oestrogensInjected Botulinum toxin A (BTX) to paralyse Detrusor
What type of incontinence is associated with chronic retention or detrusor underactivity?
Overflow
What type of incontinence can have heavy and constant flow?
Chronic retention/overflow -> total
Causes of overflow incontinence?
Bladder cancerProstate increased sizeConstipationDetrusor underactivity - DM or neuropathies
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)
In whom is endometriosis most common?
Nulliparous women closer to the menopause
What hormones does endometriosis growth depend on?
Oestrogen +/- progesterone
What are chocolate cysts?
Blood-filled endometriosis pockets
How does a frozen pelvis form from endometriosis?
Inflammation -> fibrosis and scarring -> adhesions
Key symptoms of endometriosis?
Cyclical chronic pelvic pain - just before menstruation (secondary dysmenorrhea)SubfertilityDeep dyspareunia Dyschezia and dysuria during menses
What Bimanual examination finding is suggestive of severe endometriosis with adhesions?
Retroverted immobile uterus + tenderness
What investigation differentiates between active lesions and chronic ones for endometriosis?
LaparascopyActive lesions = red vesicles/petechial marks-> white brown when less active
What investigation is best for adenomyosis?
MRI
What is an endometrioma?
Endometriotic ovarian lesion - risk of cancerous progression
Medical treatment for endometriosis if symptomatic?
Hormonal - COCP/cyclic Progestogens GnRH analogues -> add back HRTIUS will reduce menstrual symptoms
What is chronic pelvic pain?
Pain lasting over 6 months and not exclusively related to menstruation or sex
Differentials for chronic pelvic pain: cyclical vs non-cyclical?
Cyclical: endometriosis, adenomyosisNon-cyclical: IBS, interstitial cystitis, chronic PID, pelvic mass
Appropriate management of chronic pelvic pain?
AnalgesiaCOCP if cyclical and fertility not desiredLaparoscopy to investigate
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)
Common causes of endometritis?
Instrumentation of uterusComplication of pregnancy e.g. PPROM, post CS, miscarriage, ToP
Presentation of endometritis?
Persistent, heavy, painful vaginal bleedingTender uterus, often open osFever, sepsis
What is acute PID/salpingitis?
Ascending pelvic infection, often sexual although occasionally descendant from appendix
What infection often precedes or coexists with salpingitis?
Endometritis
What is heavily protective against salpingitis to the extent that it almost never occurs during this?
A viable intrauterine pregnancyLess protective are COCP and IUS
Under what circumstances may acute PID go unnoticed?
Particularly gonococcal infectionIf no coexistent endometritis
Symptoms of acute PID/salpingitis (particularly gonococcal)?
Bilateral lower abdominal/pelvic painDeep dyspareuniaDischargeO/E cervical excitation, lower abdo rebound tenderness and adnexal tenderness
What is the role of pelvic US in acute PID?
Looking for abscess formation or ovarian cysts
What infection is associated strongly with Fitz Hugh Curtis syndrome?
Chlamydia
In whom is chlamydia more commonly symptomatic?
Men - 50% symptomatic, only 20% of women
What complication of chronic PID can result in subfertility?
Hydro/pyosalpinx due to Fallopian tube adhesions
Definition of subfertility?
Failure to conceive after 1 year of regular unprotected sexAffects 15% of couples
Primary vs secondary failure to conceive?
Primary = never conceivedSecondary = previously conceived (even if not delivered)
4 broad areas of causes of subfertility?
Egg productionMale factorFertilisation incl tubal factor and sexual problemsIdiopathic
What are the most common causes of subfertility?
Ovarian dysfunction or idiopathic
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)
What is mittelschmerz?
Pain +/- discharge and spotting around time of ovulation (day 13-14)
When is body temperature lowest in the ovarian cycle?
Just pre-ovulation, before rising in luteal phase
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
5 broad areas of causes of anovulation?
Thyroid - Hypothalamic hypogonadismPituitary - hyperprolactinaemia Ovarian - PCOS, Premature ovarian failure, gonadal dysgenesisOther e.g. Thyroid or androgen secreting tumours
What is the mechanism behind hypothalamic hypogonadism?
Reduced GnRH production -> reduced LH, FSH and oestrogen-> anovulation
What is Kallmann’s syndrome?
Non-development of GnRH secreting neurones
What medication can be given to induce ovulation in PCOS? Caveats?
Clomifene citrateWeight and lifestyle should be controlled first
What is ovarian hyperstimulation syndrome?
Side effect of IVF/GnRH agonists -> overstimulation of follicles which become large and painful and produce mega oestrogenCan be fatal via hypovolaemia, electrolyte imbalance, ascites, VTE, pulmonary oedema
What condition is a major risk factor for OHSS particularly following clomifine use?
PCOS
What age of women are more susceptible to OHSS and why?
Younger women with higher follicular reserve
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
What 2 things does spermatogenesis depend on?
LH -> testosterone production in Leydig cellsFSH -> + testosterone make Sertoli cells produce and transport sperm
What is asthenospermia?
Poor sperm motility
5 common causes of abnormal semenalysis?
Idiopathic oligo/asthenozoospermiaDrugs, chemicals, smoking, alcoholVaricocoele Antisperm antibodies - common post-vasectomy reversalInfection - mumps orchitis, epididymitis
What is another name for Kallmann’s syndrome?
Hypogonadotrophic hypogonadism
Genetic causes of sperm abnormalities?
Klinefelters XXYCF
3 common causes of tubal dysfunction?
Infection - PIDEndometriosisSurgery/adhesions
What are the 2 main methods for investigating tubal damage?
Lap and DyeHysterosalpingogram - less invasive and safer but may not show endometriosis or adhesions
2 methods for intrauterine insemination?
In line with cycle (LH) GnRH ovulation induction (stimulated IUI)
What are the requirements for IUI?
Patent tubes and no ovarian problems
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
What is the primary indication for IVF?
Tubal or idiopathic with confirmed ovulatory reserve via FSH/AMH
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
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
What are the best methods of contraception for use in adolescents?
Pill and condoms for STI protectionDepo-provera (risk of reduced bone density)Emergency contraception
What long term risk does depo-provera carry, particularly in younger people?
Osteoporosis
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, implantsIncreased risk of osteoporosis anyway so avoid Depo-provera
Contraception suitable for those breastfeeding?
In theory breastfeeding is contraceptive in itself as it inhibits ovulationHowever if using added contraception: avoid COCP but POP is fineIUD fine from 4 weeks postpartum
Rules for contraception for women around the time of menopause?
Women under 50 should use contraception for > 2years post LMPWomen over 50 should use contraception for > 1 year post LMP IUS can be particularly useful for those with excessive menstrual loss
How do combined oestrogen and progesterone contraceptives work?
Negative feedback loop - suppress LH and FSH via GnRH and thus inhibit ovulationAlso thin endometrium and thickens cervical mucus (progesterone)
What is the normal regime for COCP?
3 weeks on -> bleed due to prog withdrawal -> 1 week off
Major contraindications to COCP?
VTE, CV HxMigraine with auraActive breast or endometrial cancerThrombophilias + liver disease PregnancyMost smokersReally high BMI
Apart from contraceptive use, what is the COCP useful for?
Cycle control - menorrhagia, dysmenorrhea, irregular periodsAcne and hirsutism Simple ovarian cysts
What 3 conditions can the COCP be used to suppress?
FibroidsEndometriosisPID/ovarian cysts
What are some considerations to make when considering COCP usage?
Compliance/missed pillReduced absorptionLiver enzyme inducers e.g. AnticonvulsantsMajor surgery (stop 4 weeks before)STI risk (concurrent condom use in teens and young adults)
4 major side effects of the COCP?
NauseaHeadacheBreast painWeight gain
How does the POP work?
By inhibition of cervical mucus and preventing uterine proliferation - inhibit ovulation in 50%
4 progestogenic side effects?
Vaginal spotting (breakthrough bleeds)Pre-menstrual syndromeWeight gainBreast pain
What can the POP cause if it doesn’t result in anovulation (as in 50%)?
Functional ovarian cysts (follicular or luteal)
In whom is the POP>COCP?
In older women In those who the COCP is contraindicated
2 types of Long Acting Reversible Contraceptives LARCs?
Depo provera - progesterone injectionProgestogen implant rod
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
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
2 options for emergency contraception?
Morning after pill or IUD
What 2 morning after pill options are there?
Levonelle - up to 3 days after sexUlipristal (ellaOne) - up to 5 days after sex
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
Potential complications of IUD/IUS insertion?
Pain/cervical shock due to increased vagal tone after insertionThreads disappearingIUD may worsen dysmenorrhea/menorrhagiaInfection and PID Ectopic pregnancy
Which type of IUD can worsen menstrual symptoms?
Copper coil IUD
What are 2 causes of threads disappearing from IUD/IUS insertion?
ExpulsionPerforation of uterine wall
Average age of menopause?
51
When is the menopause officially recognised?
12 months after LMP
Define the perimenopause?
From onset of symptoms to 1 year after LMP
What is premature menopause? What does it require?
Ovarian failure before age of 40Requires HRT until at least age of 50
What is PMB defined as?
Bleeding occurring >1 year after LMP
What are 3 important causes of PMB to rule out?
Endometrial cancer/hyperplasia with atypiaIntrauterine polypsCervical cancer
4 other potential causes of PMB?
Withdrawal bleeds with sequential HRTAtrophic vaginitisCervicitis or cervical polypsOvarian carcinoma
What must purulent blood stained discharge be assumed to be until proven otherwise?
Endometrial carcinoma
Appropriate line of investigations for PMB?
Physical examination + smear testTVUS -> endometrial pipelle biopsy -> hysteroscopy
5 areas of symptoms of the menopause?
Cardiovascular - stroke and MI riskVasomotor - hot flushes, night sweats (-> sleep disturbance)Urogenital - vaginal atrophy, dyspareunia, itching burning dysuria, urinary frequency, urgency, Nocturia, incontinence and infectionSexual and psychological - loss of interest and arousal, dyspareunia, irritability, mood changes, depression, sleep disturbanceOsteoporosis
Lines of investigation for the menopause?
FSH AMHT4/TSH, LH, oestrogen, progesterone
When investigating anovulation, what low level of hormone indicates anovulation?
Low progesterone
General rules for types of HRT requirement?
Oestrogen only if no uterusOestrogen and progesterone for uterus
Combined HRT regimes?
Quarterly or monthly bleeds (prog given sequentially)No bleeds (prog given continuously e.g. IUS)
Which HRT method is the best for protecting vs endometrial cancer?
Continuous ie no bleed, as it induces endometrial atrophy
3 benefits of HRT?
Reducing troublesome symptomsReducing osteoporosis riskReducing colorectal cancer risk
4 potential risks of HRT?
Increased risk of endometrial cancer if oestrogen only and uterus presentIncreased risk of breast cancer if combinedIncreased risk of VTE particularly for oral (during 1st year)Increased risk of gallbladder disease
What medications might be useful for perimenopausal symptoms for those wanting to avoid oestrogen (e.g. Breast ca risk)?
ProgestogensSSRIs for vasomotor
What is a miscarriage and when do most occur?
Fetus dies or delivered dead before 24 weeksMost occur before 12 weeks
6 types of miscarriage?
ThreatenedInevitableCompleteIncompleteSepticMissed
What indicates a threatened miscarriage?
Bleeding PV, closed cervical os. Fetus is still alive and correct size for dates
What fraction of people with threatened miscarriage go on to miscarry?
1/4
What indicates an inevitable miscarriage?
Heavier PV bleeding and open cervical os
What indicates an incompletely miscarriage?
Some but not all of fetal parts are passed; cervical os still open
What indicates a complete miscarriage?
All fetal parts have been passed and the cervical os is closed
What indicates septic miscarriage?
Uterine contents infected -> endometritis. Patient will have offensive vaginal loss with a tender uterus +/- systemic infection
What indicates a missed miscarriage?
Fetur not developed/died in utero but not recognised until bleeding or USSmall for dates fetus and closed os
What types of miscarriage present with an open os?
IncompleteInevitable
What types of miscarriage present with a closed os?
ThreatenedCompleteMissed
What are sporadic miscarriages usually caused by?
Isolated chromosomal or genetic abnormalities
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 defectsAnatomical factors
Appropriate investigations for possible miscarriage (bleeding PV)?
US to observe viable IUP or retained fetal productsHCG levelsFBC and rhesus
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
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
What is a heterotopic pregnancy?
IUP + ectopic pregnancy together
Under what circumstances does anti-D need to be given for miscarriage?
For bleeding > 12 weeks or surgically/medically managed in rhesus negative women
Management methods for non-viable IUP?
Expectant - for incomplete or inevitable miscarriage and no signs of infectionMedical - prostaglandins possibly with preceding mifepristone Surgical - ERPC for infection, heavy bleeding or maternal choice
What is Asherman’s syndrome?
A rare complication of ERPC and some uterine surgical procedures resulting in amenorrhea due to outflow blockage
When do rhesus negative women need to be given anti-D for ToP?
Within 72 hours of ToP
When is medical ToP most appropriate?
Less than 7-9 weeksFrom 13-24 weeks
When is surgical ToP most appropriate?
7-13 weeks
What is the most common area for ectopic pregnancy?
Fallopian tubesOccasionally Cornu, cervix, ovary, intra-abdo
RFs for ectopic pregnancy?
Previous ectopicTubal - PID, surgical adhesionsIncreasing maternal ageSmoker
What should a patient who conceives despite IUD in situ be assumed to have until proven otherwise?
Ectopic pregnancy
Presentation for ectopic pregnancy?
Lower abdo pain - colicky then chronicScanty dark vaginal bleedingAbdo/rebound tendernessAdnexal tenderness, cervical excitationSmall uterus for dates, closed os
What should all women of reproductive age who present with bleeding, pain or collapse have done?
Pregnancy test
Medical management of ectopic pregnancy?
If unruptured, stable patient and hCG
Surgical management of ectopic pregnancy?
Laparoscopy and salpingectomy/salpingostomy if subacuteLaparotomy and salpingectomy if acute
What is hyperemesis gravidarum?
Nausea and vomiting in early pregnancy so severe as to cause dehydration, weight loss or electrolyte disturbance
In whom is hyperemesis more common?
Older, multiparous womenUTIMolar pregnancy
When does hyperemesis normally resolve by?
12-14 weeks
Management of hyperemesis?
IVT +/- antiemetics e.g. Cyclizine, metoclopramide, ondansetron
What vitamin needs to be given in hyperemesis?
B particularly thiamine to prevent wernicke-korsakoff
What is gestational trophoblastic disease GTD?
Trophoblastic tissue which normally invades the endometrium proliferates more aggressively than normal -> mega hCG levels
What is local, non-invasive trophoblastic overproliferation called?
Molar pregnancy - hyatidiform mole
2 types of hyatidiform mole?
Complete (no fetus, entirely paternal)Partial (+/- fetus, usually triploid)
What is a locally invasive GTD called and what does it have the potential to do?
Invasive moleCan metastasise and become a choriocarcinoma
What is persistently elevated hCG in the context of GTD called?
Gestational trophoblastic neoplasia GTN
In whom is GTD more common?
Asian women at extremes of reproductive age
How does GTD present?
Large uterus, possible heavy vaginal bleedingEarly pre-eclampsia and hyperthyroidismHyperemesis
What does a ‘snowstorm’ uterus on US indicate?
Complete moles
Management of GTD?
ERPC + histological diagnosisSerum or urine hCG follow up to rule out malignancy
