Gynaecology 3 Flashcards
- What symptoms can be experienced with menopause?
2. How long do they typically last?
- changes to periods: erratic length and bleeding
- vasomotor symtoms: hot flushes + night sweats
- urogenital changes: vaginal dryness + atrophy, urinary frequency
- psychological: anxiety, depression, short-term memory loss
2. 2-5 years
When is menopause clinically diagnosed?
12 months without a period
Menopause management
- What lifestyle advice can be given?
- What non-HRT management can be given for the following symptoms:
a) vasomotor symptoms
b) vaginal dryness
c) psychological symptoms
1.
- exercise
- weight loss
- relaxation + reduce stress
- a) SSRI / SNRI
b) topical oestrogen / moisturiser / lubricant
c) CBT, antidepressants
Ovarian Cancer
90% are epithelial in origin with 70-80% being serous carcinomas
- What are the RFs?
(remember symptoms notoriously vague e.g. pain, bloating, diarrhoea)
- a) What investigation is done?
b) What else could cause this to be raised?
c) When should it not be carried out? - How is it managed?
- BRCA1+2
- lots of ovulations: early menarche, nulliparity, late menopause
- a) CA125
b)
- menstruation
- benign ovarian cysts
- endometriosis
c) if asymptomatic - usually surgery and platinum-based chemo
Ovarian cysts
- What should be done if a complex (multi-localated) cyst is seen on US?
- In women who have a simple cyst seen on US what should be done if:
a) premenopausal
b) postmenopausal
- biopsy to exclude cancer
- a) if <5cm + simple then rescan in 8-12 weeks and refer if persists
b) refer to gynaecology as physiological cysts are unlikely as these patients are not ovulating
Ovarian Torsion
- What are the RFs?
- What CFs are seen?
- What investigations are done?
1.
- ovarian mass (90% of cases)
- pregnancy
- OHSS
- deep, colicky lower abdominal pain
- N+V
- may precipitated by exercise
O/E may find adnexae tenderness
- laparoscopy diagnostic + therapeutic
US may show free-fluid or “whirlpool” sign
Ovarian tumours
- What are the surface derived tumours?
- Germ cell tumours
a) benign
b) malignant - What would you associate with the following sex cord tumours:
a) granulosa cell
b) sertoli-leydig cell
c) fibroma
- serous / mucinous cystadenoma / cystadenocarcinoma
carcinoma = malignant mucinous = mucous secreting
- Brenner tumour - “coffee-bean” nuclei
- a) mature teratoma (immature is malignant)
b)
- yolk sac: secretes AFP
- dysgerminoma: associated with Turner’s syndrome and secrete LDH and hCG
- a) early puberty / endometrial hyperplasia
b) produces androgens therefore masculinisation
c) meig’s syndrome: ascites + pleural effusion
Ovulation induction
Ovulation disorder is cause of infertility 25% of the time
- What is meant the following ovulation disorder:
a) Class 1
b) Class 2
c) Class 3 - How is ovulation induced in the following
a) Class 1
b) Class 2 - How long should a couple have tried for before being referred to fertility services?
- a) hypogonadotrophic anolvulation (e.g. hypothalamic amenorrhoea)
b) PCOS
c) hypergonadotrophic hypoestrogenic anovulation
- a) gonadotrophin therapy
b)
1st line: weight loss
2nd line: letrozole
3rd line: clomiphene
- 12 months
Pelvic Inflammatory Disease
- a) What is the most common cause?
b) What else can cause it?
vaginal swab can be done but is often negative
- What clinical features are seen?
- How is it managed?
- What should you suspect if a patiet with PID develops RUQ pain?
- a) chlamydia trachomatis
b)
- neisseria gonorrhoea
- mycoplasma - lower abdominal pain
- deep dyspareunia
- dysuria / menstruation irregularities
- discharge
- cervical excitation
- oral ofloxacin and metronidazole
OR
IM ceftriaxone + oral doxycycline + oral metronidazole - perihepatitis AKA Fitz-Hugh Curtis syndrome
Polycystic Ovarian Syndrome
- What clinical features are seen?
- What investigations are done?
- Treatment for infertility is as discussed in ovulation induction flashcard. How is acne / hirsutism treated?
- sub fertility
- oligomenorrhoea / amenorrhoea
- hirsutism / acne
- obesity
- acanthosis nigricans (darkening and thickening of skin folds due to insulin resistance)
- US: multiple cysts
- bloods: raised LH and insulin
(testosterone and PRL may also be raised)
- COCP
Topical eflornithine can also be considered
Postmenopausal bleeding
- What is on the differential?
- How should a patient with this be managed?
- vaginal atrophy (most common cause)
- endometrial hyperplasia
- HRT
- cancer: vaginal, cervical, endometrial, ovarian
- bleeding disorders
- abdo + vaginal exam
- urgent referral for US
- FBC to check for CA125, anaemia and bleeding disorder
- urine dipstick for haematuria or infection
Premature ovarian insufficiency
- What is it?
- What is seen on investigation?
- How is it managed?
- menopausal symptoms + elevated gonadotrophin levels before the game of 40
- raised LH and FSH
- > for diagnosis FSH should be raised in 2 blood tests 4-6 weeks apart
- low oestradiol
- HRT / COCP until average age of menopause (51)
Premenstrual Syndrome
- What is it?
- How are the following symptoms managed:
a) mild
b) moderate
c) severe
- physical (bloating, breast pain) and emotional (anxiety, mood swings) symptoms associated with luteal phase of cycle
- a) regular, frequent (2-3 hours) small meals rich in complex carbohydrates
b) COCP
c) SSRI
Urinary incontinence
- What investigations should be done?
- What is the management for
a) Stress incontinence
b) Urge incontinence
- bladder diary (at least 3 days)
- vaginal examination to assess ability to initiate voluntary contraction of pelvic floor muscles
- urine dipstick
- urodynamic studies
- a)
1st line: pelvic floor muscle retraining (8 contractions 3 times a day for 3 months)
2nd line: surgery
duloxetine (SNRI) can be offered if surgery denied
b)
1st line: bladder retraining (minimum 6 weeks)
2nd line: anti-muscarinics (e.g. oxybutynin, tolterodine, darifenacin)
3rd line: mirabegron (useful if worried about anti-cholinergic effect in elderly)
What should you suspect in a bladder still palpable after urination?
overflow incontinence (e.g. bladder outlet obstruction)
