Gynaecology Flashcards
Describe menopause, its symptoms, and management
Menopause is the cessation of a normal menstrual cycle in old age typically occurring at 50yrs of age, requires 1yr without periods. Problems are related to falling oestrogen levels.
Symptoms:
- Menstrual irregularity as cycles become anovulatory, before stopping
- Vasomotor disturbance e.g. Sweats, palpitations, and hot flushes (Brief, nasty, and may occur every few minutes, disrupting life and sleep)
- Atrophy of oestrogen-dependent tissues (genitalia, breasts) and skin. Vaginal dryness can lead to recurrent vaginal and urinary infection, dyspareunia, traumatic bleeding, stress incontinence and prolapse.
- Osteoporosis, the menopause accelerates bone loss which predisposes to fracture of femur neck, radius and vertebrae in later life
Management:
- Rule out other causes I.e. Thyroid and psychiatric problems. 2 FSH levels greater than 30IU/L is suggestive of menopause, test unreliable if patient on exogenous oestrogens.
- Hot flushes may respond to clonidine or HRT.
- HRT reduces symptoms of menopause but increases risk of breast and endometrial cancer and if long term increases risk of ovarian cancer. Also raises VTE risk, contraindicated if previous PE, unopposed oestrogen increases risk of endometrial cancer.
Describe Ovarian tumours, presentations, red flag symptoms, and management
94% are benign, they are usually cystic. 24% of all ovarian tumours are functional cysts e.g. Enlarged or persistent follicular or corpus luteum cysts. Most common type of tumour is epithelial, followed by germ cell (e.g. Teratomas in young women), and stormal.
6% are malignant and 5% of these are cystadenomas that have become malignant. Serous cystadenomas are papillary growths tat may be so prolific that the cyst appears solid. They are commonest in women aged 30-40 and about 30% are bilateral and 30% are malignant. Mucinous cystadenomas are the commonest large ovarian tumours, they are filled with mutinous material and may be multilocular. They are commonest in the 30-50 group and about 5% are malignant.
Presentation: asymptomatic, swollen abdomen +/- dull palpable mass, pressure effects on bladder causing urinary frequency, rupture +/- local Peritonism, Ascites, torsion, endocrine or metastatic effects.
Red flag symptoms:
- bloating, abdominal distension
- early satiety
- loss of appetite
- unexplained weight loss
- change of bowel habit
- fatigue
- onset of IBS like symptoms after 50years
- urinary frequency or urgency
- abdominal or pelvic pain
Management:
- consider ultrasound
- if pelvic mass or abdominal distension refer under 2 week wait.
- check ca-125, AFP, B-HCG (AFP + bHCG marker of Germ cell tumour)
- if less than 40yrs if CA-125 greater than 35IU/mL arrange urgent abdominal and pelvis ultrasound and if suggestive of ovarian cancer refer under 2-week wait rule
- Tumour debunking and Chemotherapy (Carboplatin + Paclitaxel)
Describe Ovarian Torsion, it’s causes, presentation, and management.
Rotation of the ovary at its peddle to such a degree as to occlude the ovarian artery/vein.
Causes: usually due to the development of an ovarian mass.
Presentation: Sudden onset of sharp and usually unilateral lower abdominal pain, accompanied by nausea and vomiting in 70%.
Management:
- Doppler ultrasound may help diagnosis.
- surgical treatment include laparoscopy to uncool the tossed ovary and oophoropexy to fixate the ovary which is likely to twist again.
What are some causes of vaginal discharge?
Non-offensive discharge may be physiological (pregnancy, sexual arousal, puberty, pill). Most discharges are smelly, itchy and due to infection:
Causes:
- Bacterial vaginosis
- Thrush (candida)
- trichomoniasis
- Gonorrhoea
Describe Pelvic Inflammatory Disease, its symptoms, and management.
Pelvic infection of the upper female reproductive system. Infections commonly affect the Fallopian tubes (salpingitis) and may involve the ovaries and parametria. 90% are sexually acquired mostly chlamydia. Untreated can lead to infertility (10-20%), ectopic pregnancy, chronic pelvic pain and cancer.
Symptoms: 60% asymptomatic. dyspareunia, irregular mentstruation. Patients with salpingitis may be most unwell, with pain, fever, and spasm of lower abdominal muscles. Cervicitis present with profuse, purulent or bloody vaginal discharge. Endometritis presents with heavy menstrual loss.
Management:
- swab and treat any infection
- trace sexual partners
- PO Ofloxacin + POl Metronidazole OR IM Ceftriaxone + PO Doxycycline + PO Metronidazole.
- In mild cases of PID intrauterine devices may be left in but otherwise consider removal.
Describe Miscarriages and the different types and symptoms.
Miscarriage is the loss if a pregnancy before 24weeks gestation. Most present with bleeding PV. Pregnancy tests remain +ve several days after foetal death.20% of all pregnancy.
Types + Symptoms:
- Threatened miscarriage, symptoms are mild and the cervical os is closed. Rest is advised but probably does not help, 75% will settle. It is associated with risk of subsequent preterm rupture of membranes (PROM) and preterm delivery so book mother at a hospital with good neonatal facilities.
- inevitable miscarriage, symptoms are severe and the os is open, if most of the products have already been passed, it is an incomplete miscarriage. If bleeding is profuse consider ergometrine 0.5mg IM. If there is unacceptable pain or bleeding arrange evacuation of retained products of conception (ERPC).
- Missed miscarriage, the foetus dies but is retained. There has usually been bleeding and the uterus is small for dates. Mifepristone and misoprostol may be used to induce uterine evacuation but 50% require surgical evacuation.
Describe Cervical Ectropion and its treatment.
A normal phenomenon, there is a red ring around the os because the endocervical epithelium has extended its territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under hormonal influence during puberty, with combined pill, and during pregnancy. As columnar epithelium is soft and glandular, Ectropion is prone to bleeding, to excess mucus production, and to infection.
Treatment: Cryocautery will treat these if they are a nuisance, otherwise no treatment is required.
Describe Cervical Screening, why we do it, how we do it, and details on screening process.
Why we do it:
Cervical cancer has a pre-invasive phase: Cervical Intra-epithelial Neoplasia (CIN). CIN I affects the lower basal third of the cervical epithelium and its associated with oncogene can HPV 6 + 11, and commonly regresses (57%). CIN II affects less than 2/3 of the epithelium and is more associated with more oncogenic types HPV 16 + 18 and is less likely to regress (43%). CIN III affects more than 2/3 or full thickness epithelium and is more associated with more oncogenic types HPV 16 + 18 and is less likely to regress (32%). A significant number of CIN II + III develop into invasive squamous carcinoma of the cervix.
How we do it:
Smear tests collect cervical cells for microscopy for dyskaryosis, abnormalities which reflect CIN. A smear identifies women who need cervical biopsy. The degree of dyskaryosis approximates to the severity of CIN. Moderate dyskaryosis and above require referral for colposcopy.
Screening Process:
1st smear at aged 25, then 3 yearly until 49, then 5 yearly from 50-64. HIV+ve women should have annual smears. Depending on results, depends on treatment and repeat.
Describe Bacterial Vaginosis, its symptoms and management.
There is increased risk of preterm labour, intra-amniotic infection in pregnancy.
Symptoms: Mostly asymptomatic, may present with vaginal discharge with fishy odour, vaginal pH is greater than 4.5. The vagina is not inflamed and priorities is uncommon.
Management:
-culture, treated with metronidazole 2g PO once or 400mg BD PO for 5 days if pregnant.
What are some causes of postcoital bleeding?
- unidentifiable in 50%
- cervical ectropion is most common identifiable cause. More common in women on COOP
- cervicitis secondary to chlamydia
- cervical cancer
- polyps
- trauma
Describe Polycystic Ovarian Syndrome (PCOS), its symptoms, tests, and management.
At least two of hyperandrogenism, oligo-ovulation, and polycystic ovaries on US. It is common, 5-20% of premenopausal women.
Symptoms: Subfertility (miscarriage) and infertility, Menstrual disturbances (oligomenorrhea and amenorhoea), hirsutism, acne, obesity, acanthosis nigricans
Tests: TVS shows multiple peripherally allocated follicles 3-5mm, string of pearls appearance, usually bilateral.
-FSH, LH, Prolactin (normal/mildly elevated consider alternative diagnosis if markedly raised), TSH (exclude thyroid dysfunction), and testosterone (normal/mildly elevated consider alternative diagnosis if markedly raised)are useful investigations. Check for impaired glucose tolerance.
Management:
- advise smoking avoidance
- encourage weight loss and excercise to increase insulin sensitivity
- Metformin improves insulin sensitivity, menstrual disturbance and ovulated function
- Co-cypindiol (Contains cyproterone an anti androgen) may be more effective in controlling acne and hirsutism than COCP. Spironolactone and fin astride may be used under specialist supervision to manage hirsutism.
- Clomifene is useful (in combination with Metformin) to stimulate ovulation.
- ovarian drilling Can help with fertility
Describe Amenorrhoea, it’s causes, and investigations.
May be divided into primary (failure to start menses by age of 16yrs) or secondary (cessation of established, regular menstruation for 6 months or longer.
Primary causes: Turners syndrome, testicular feminisation, congenital adrenal hyperplasia, congenital malformation of the genital tract e.g. Imperforate hymen, transverse septum, cervical stenosis.
Secondary causes:
- pregnancy/lactation
- hypothalamic Amenorrhoea (stress, excessive exercise)
- PCOS
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis/hypothyroidism
- sheehans syndrome
- ashermans syndrome
Investigations:
- exclude pregnancy with urinary or serum bHCG
- gonadotrophins, low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem
- prolactin if raised MRI pituitary
- androgen levels, may be raised in PCOS
- oestadiol
- TFT
Describe Menorrhagia, it’s causes, investigations, and management.
Increased menstrual blood loss typically more then 80ml/cycle but rarely measured. Occurs in 1in20 women. Ask about flooding, clots, and anaemia symptoms.
Causes: In girls pregnancy and dysfunctional uterine bleeding (diagnosis of exclusion occurs in anovulatory cycle at extremes of reproductive life) are likely. With increasing age think of ICUDs, fibroids, endometriosis, pelvic infection, polyps, hypothyroidism. In perimenopausal women think endometrial carcinoma. Ask about general bleeding issues due to von willebrands.
Investigations: Examination (enlarged uterus = fibroids, tender uterus = Adenomyosis) Speculum (?polyps), FBC, TFT, Coagulation, pelvic ultrasound.
Management:
- for those wanting contraception as well progesterone-containing IUS e.g. Mirena, should be 1st line treatment.
- 2nd line recommended drugs are anti-fibrinolytic E.g. Tranexamic acid and antiprostglandins. E.g. Mefenamic acid.
- 3rd line are progestogens or norethisterone.
- surgical options include endometrial resection suitable for women who have completed their families and who have less than 10wk size uterus and fibroids less than 3cm. For those wishing to retain fertility who have fibroids more than 3cm may need it from uterine artery embolisation or myomectomy.
What are some contraindications of COCP?
- Age over 35 and smoking more than 15/day
- consistently elevated systolic BP over 160, Diastolic over 95 or vascular disease
- less than 6 months postpartum if breastfeeding
- major surgery with prolonged immobilisation
- secondary Raynaud’s disease (with lupus anticoagulant)
- SLE with +ve or unknown anti-phospholipid
- Current VTE or history of VTE
- Migraine headaches with aura at any age
- current breast cancer
- Multiple risk factors for arterial cardiovascular disease
- cirrhosis.
Describe Ectopic Pregnancy, its symptoms, and management.
Implantation of a fertilised ovum outside the uterus 97% are tubal. Consider ectopic in a sexually active woman with abdominal pain, bleeding, fainting, or diarrhoea and vomiting.
Symptoms: Typical presentation is a woman with a history of 6-8wks amenorrhoea who presents with constant lower abdominal pain (may be unilateral) and later develops vaginal bleeding. If perforation peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination. On examination there is abdominal tenderness, cervical excitation, there may be an adnexal mass but NICE recommend not examine due to increased risk of rupturing pregnancy.
Management:
- ABCDE is the patient stable ?ruptured ectopic
- dipstick test bHCG for pregnancy, Blood bHCG
- ultrasound, if bHCG is greater than 6000 and an interuterine gestational sac is not seen probability of ectopic is high. Normally bHCG doubles over 48hrs, it may plateau in ectopic.
- laparotomy if ruptured and unstable, laparoscopy plus salpingectomy
- Methotrexate is sometimes used for small early ectopics (less than 3.5cm in greatest diameter, bHCG less than 3000, minimal symptoms) Visualisation of foetal heart is contraindication. 75% of women get some abdominal pain with treatment and admission and observation may be needed to ensure pain isn’t related to rupture.
- Some tubal pregnancies end themselves without any problem so conservative management may be an option in those without acute symptoms, and with falling bHCG levels that are less than 1000 initially. 88% successfully resolve if bHCG less than 1000. Twice weekly follow up.
Describe Endometrial Cancer, its risk factors, its symptoms, investigations, and management.
Post menopausal bleeding is endometrial cancer until proven otherwise.
Risk factors: Obesity, unopposed oestrogen, functioning ovarian tumour, FHx of breast, ovary or colon cancer, nulliparity, late menopause, early menarche, diabetes Mellitus, tamoxifen, pelvic irradiation, polycystic ovaries.
Symptoms: Postmenopausal bleeding, premenopausal women may have a change in bleeding e.g. Intermenstrual bleeding.
Investigations: Transvaginal ultrasound, normal endometrial thickness is less than 5mm. Hysteroscopy with endometrial biopsy. CT Staging
Management:
- Localised disease treated with abdominal hysterectomy with bilateral salpingectomy-oophorectomy. Patient with high-risk disease may have post operative radiotherapy.
- Progestogen therapy is sometimes used in frail elderly women not suitable for surgery
Describe Endometriosis, it’s features, investigations, and management.
A common condition characterised by growth of endometrial tissue outside of the uterine cavity. Classified as Adenomyosis if in the uterine wall (more often associated with pelvic surgery). It causes fibrosis and adhesions.
Feature: Chronic cyclical pelvic pain, dysmenorrhea (pain often starts days before bleeding), deep dyspareunia, Subfertility. Less commonly urinary symptoms e.g. Dysuria, urgent, and dyschezia(painful Bowel movements), GI-upset (differential in IBS). Examination may show immobile retroverte uterus.
Investigations: Laparoscopy + biopsy is the gold-standard (consider empirical treatment first 3-6 months unless infertility is main issue)
Management:
- NSAIDs and other analgesia for pain relief
- COCP 9wks back to back then 1wk off
- If insufficient or contraindicated progestogens may be used, oral or intrauterine (mirena)
- GnRH analogues can be used to induce a pseudo menopause state. HRT can be used to treat menopausal symptoms
- Surgical excision, or ablation can help reduce pain, relapse is common (shown to improve pregnancy rates)
Describe the normal menstrual cycle.
Pulsatile production of GnRH by the hypothalamus stimulates the pituitary to produce the gonadotrophins LH and FSH. These stimulate the ovary to produce oestrogen and progesterone.
In the first 4 days of the menstrual cycle FSH levels are high, stimulating the development of a primary follicle in the ovary. The follicle produces oestrogen, which stimulates the development of a glandular ‘proliferative’ endometrium and of cervical mucus which is receptive to sperm.
Around the 14th day oestrogen levels becomes high enough to stimulate a surge of LH. This stimulates ovulation. Having released the ovum, the primary follicle forms a corpus luteum and starts to produce progesterone. under this influence the endometrial lining is prepared for implantation and enters the secretory phase.
If the ovum is not fertilised the corpus luteum breaks down and hormone levels fall. This causes spiral arteries in the in the uterine endothelial lining to constict and the lining sloughs hence mensturation.
Normal menstruation lasts 2-7 days and normal blood loss is 20-80ml.
Describe Stress Incontinence and it’s management.
Involuntary voiding of small quantities of urine with rises in intra-abdominal pressure e.g. sneezing, laughing, coughing. It is commoner in women.
Management:
- exclude UTI and Diabetes.
- Optimise BMI
- Pelvic floor exercises with physiotherapy
- Duloxetine (SNRI) 40mg/12hr PO can reduce stress incontinence.
- surgery for severe stress symptoms resistant to drug or conservative treatment e.g. synthetic slings, mid urethral tension free tape.
Describe Vaginal Prolapse, the types, it’s causes, symptoms, and management.
A prolapse occurs when weakness of the supporting structure allows the pelvic organs to sag within the vagina.
Types: rectocele, cystocele, urethrocele, antrocele, vault
Causes: May be congenital but usually due to stretching at childbirth. Weakness is exacerbated by menopausal atrophy and coughing and straining.
Symptoms: Dragging sensation, worse by day. Cystitis, frequency, stress incontinence, difficulty in defecation may occur if rectocele.
Management:
- weight loss, stop smoking, stop straining (aim to reduce intrabdominal pressure)
- pelvic floor excercises
- if severe treat surgically e.g. Anterior or posterior wall repair.
Describe Lichen Sclerosus, its symptoms and management.
An inflammatory condition which usually affects the genitali and is more common in elderly females. It leads to atrophy of the epidermis with white plaques forming
Symptoms: White genital plagues, itch
Management:
-topical steroids and emollients
Describe Molar Pregancy, its symptoms, investigations, and management
A gestational trophoblastic disease which grows into a mass (hydatiform mole) in the uterus that has swollen proliferating chorionic villi. The villi grow in clusters that resemble grapes.
Symptoms: Heavy vaginal bleeding, large uterus, Hyperemesis, hypertension. Symptoms of hyperthyroidism
Investigations: Ultrasound shows snowstorm effect in uterus large for dates, bHCG is very high.
Management:
-evacuation of products by uterine suction or surgical curettage.
Describe Genital Warts, its symptoms, and management.
Caused by HPV especially types 6 and 11.
Symptoms: small 2-5mm fleshy protuberances which are slight pigmented, may bleed or itch
Management:
- topical podophyllum or cryotherapy depend on location. Solitary keratinised warts respond better to cryotherapy where as multiple non-keratinised warts are best treated topically
- imiquimod may be used second line
Describe Bartholin’s abscess and its management.
Bartholins gland and ducts lie under the labia minora. They secrete thin lubricating mucus during sexual excitation. If the duct blocks a painless cyst forms. This may become infected resulting in an extremely painful Fluctuant abscess, (unable to sit down), it is hugely swollen and hot red labium is seen.
Management:
-incision and drainage, marsupialisation.
