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Internal Medicine > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

External genitalia supply

A

Internal pudendal artery
Pudendal nerve
Inguinal lymph nodes drainage

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2
Q

Vagina blood supply

A

Vaginal branch (internal pudendal artery), uterine, inferior vesical and middle rectal arteries

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3
Q

Uterus blood supply

A

Uterine corpus - uterine artery (internal iliac artery)

Cervix - cervical branch (uterine artery)

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4
Q

Uterus ligaments

A 
Round ligaments (anteversion) - anterior surface of uterus, passes through broad ligaments, inguinal canals, terminate labia majorum, contains Sampson's artery
Uterosacral ligaments (support) - sacral fascia and insert into posterior interior uterus
Cardinal ligaments (support) - lateral pelvis walls, insert into lateral cervix and vagina
Broad ligaments (contains fallopian tube, round ligament, ovarian ligament, nerves, vessels and lymphatics) - lateral pelvic wall to sides of uterus
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5
Q

Ovarian ligaments

A

Suspensory ligament of ovary - connects ovary to pelvic wall, contains ovarian artery, ovarian vein, ovarian plexus, lymphatic
Ovarian ligament - connects ovary to uterus

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6
Q

Ovarian blood supply

A 
Ovarian arteries (aorta)
Left ovarian vein (left renal vein)
Right ovarian vein (inferior vena cava)
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7
Q

Mesosalpinx and mesovarium

A

Peritoneal fold that attaches the fallopian tubes and ovaries to broad ligament

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8
Q

Stages of puberty

A

Thelarche - breast development
Pubarche - pubic hair and axillary development
Growth spurt
Menarche - 10-15yo, 2 yrs following breast development

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9
Q

Follicular phase

A

Increase GnRH pulse stimulating release of FSH and LH
FSH - stimulate follicular growth, acts on granulosa cells (increase estrogen)
Dominant follicle persists and granulosa cells produce progesterogne.

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10
Q

Luteal phase

A 
LH surge (positive feedback from E + P) stimulates oocyte release after 36hrs.
Corpus luteum produces progesterone, degenerates after 14 days resulting in menses
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11
Q

Estrogen

A

Main hormone in follicular phase, stimulated by FSH.

- Reduces atreisa on the follicles
- Proliferation of endometrial tissue
- Decrease E receptors on all tissue
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12
Q

Progesterone

A

Main hormone in luteal phase, stimulated by LH.

- Stops endometrial proliferation and organises glands
- Prevents endometrial degradation
- Decreases E + P receptors
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13
Q

Premenstrual syndrome

A

Criteria:

- 1 affective (depression, angry, irritability, anxiety, confusion, social withdrawal) and 1 somatic (breast tenderness, abdominal bloating, headache, swelling)symptom during the 5 days before menses in 3 prior menstrual cycles
- Relieved within 4 days onset of menses
- Dysfunction in social or economic performance

Rx:

- Psychological support
- Avoid, sodium, sugars, caffine, alcohol. Dietary supplements
- Regular exercise, CBT, relaxation
- NSAIDs, spironolactone (fluid retention), SSRIs, OCP, danazol (inhibits pituitary-ovarian axis)
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14
Q

Dysmenorrhea differential (painful menstruation)

A 
Primary idiopathic
Secondary:
	- Endometriosis
	- Adenomyosis
	- Uterine polyps
	- Uterine anomalies
	- Leiomyoma
	- Intrauterine synechiae
	- Ovarian cysts
	- Cervical stenosis
	- Imperforate hymen, transverse vaginal septum
	- PID
	- IUD - copper
	- Foreign body
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15
Q

Acute pelvic pain - adenexal

A 
Mittelschmerz
Ruptured ovarian cysts
Ruptured ectopic pregnancy
Hemorrhage into cyst/neoplasm
Ovarian/tubal torsion
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16
Q

Acute pelvic pain - uterine

A

Fibroid degeneration
Torsion of pedunculated fibroid
Pyometra/hematometra (puss or blood in uterine cavity)

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17
Q

Acute pelvic pain - inflammation

A

Acute PID

Endometriosis

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18
Q

Chronic pelvic pain - gynae

A 
Chronic PID
Endometriosis
Adenomyosis
Adhesions
Dysmenorrhea
Ovarian cyst
Pelvic congestion syndrome
Ovarian remnant syndrome
(Sexual abuse)
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19
Q

Functional ovarian cysts

A

Corpus luteum cyst
Follicular cyst
Theca lutein cyst
Hemorrhagic cyst

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20
Q

Neoplasms of ovary

A

Dermoid cyst - benign and most common
Epithelial cell - malignant, most common in > 40 yrs
Germ cell - malignant, most common in

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21
Q

Dysparenunia - introital

A 
Inadequate lubrication
Vaginismus
Rigid/intact hymen
Bartholin's or Skene's gland infection
Lichen sclerosis
Vulvovaginitis - atrophic (hypoestrogen), chemical, infectious (chlamydia, trichomoniasis)
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22
Q

Dysparenunia - midvaginal

A

Urethritis
Short vagina
Trigonitis
Congenital anomality of vagina (vagina septum)

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23
Q

Dysparenunia - deep

A 
Endometriosis
Adenomyosis
Leiomyomata/fibroids
PID
Hydrosalpinx
Tubo-ovarian abscess
Uterine retroversion
Ovarian cyst
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24
Q

Primary amenorrhea - with secondary sexual development

A

Normal breast and pelvic development

- Hypothyroidism
- Hyperprolactinemia
- PCOS
- Hypothalamic dysfuntion

Normal breast, abnormal uterine development

- Androgen insensitivity
- Mullerian agenesis
- Uterovaginal septum
- Imperforate hymen
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25
Q

Primary amenorrhea - without secondary sexual development

A

High FSH (hypergonadotrophic hypogonadism)
- Gonadal dygenesis
○ Abnormal sex chromosome (Turner’s)
○ Normal sex chromosome (46XX, 46XY)

Low FSH (hypogonadotrophic hypogonadism)
	- Constitutional delay
	- Congenital abnormalities
		○ Isolated GnRH deficiency
		○ Pituitary failure (Kallman syndrome, head injury, pituitary adenoma)
	- Acquired
		○ Endocrine disorders (T1DM)
		○ Pituitary tumours
		○ Systemic disorders (IBD, JRA, chronic infections)
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26
Q

Secondary amenorrhea

A

With hyperandrogensim

- PCOS
- Autonomous hyperandrogenism: ovarian tumour, adrenal androgen-secreting tumour
- Late onset or mild CAH

Without hyperandrogenism

- Hypergonadotrophic hypogonadism (premature ovarian failure): idiopathic, autoimmune, iatrogenic with cyclophosphamide, radiation
- Hyperprolactinemia
- Endocrinopathies: hyper/hypothyroidism
- Hypogonadotrophic hypogonadism: pituitary destruction (ademoma, craniopharygioma, infiltration by sarcoid, head injury)
- Functional hypothalamic amenorrhea (stress related)
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27
Q

Progesterone challenge

A

Medroxyprogesterone acetate 10mg PO OD for 10-14 days, positive if uterine bleed within 2-7 days after completion of Provera. Positive test suggests adequate estrogen thickening of the endometrium.

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28
Q

Anovulatory bleeding

A

Due to estrogen dependent breakthrough bleeding.

- PCOS
- Thyroid dysfunction
- Elevated prolactin levels
- Rare estrogen producing tumours
- Stress, weight loss, exercise
- Liver and kidney disease
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29
Q

Ovulatory bleeding

A

Cyclic heavy or prolonged bleeding

- Anatomic lesion (polyp, fibroid, adenomyosis, neoplasm, foreign body
- Hemostatic defect
- Infection, trauma
- Local disturbances with prostaglandins (elevated endometrial vasodilatory prostaglandin, decreased vasoconstrictive prostaglandin)
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30
Q

Abnormal uterine bleeding treatment

A 
Removal of anatomic lesions
Medical
	- Mild DUB
		○ NSAIDs
		○ Anti-fibrinolytic
		○ COC
		○ Progestins on first 10-14 days if oligomenorrheic
		○ Mirena IUD
		○ Danazol
	- Severe DUB
		○ Replace fluid losses
		○ Estrogen or OCP
	- Clomiphene - anovulatory cycle but wishes to get pregnant
Surgery
	- Endometrial ablation (danazol, GnRH agonists)
	- Hysterectomy
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31
Q

Primary dysmenorrhea

A

Begins 6m - 2yrs after menarche. Colicky abdominal pain radiating to lower back, labia, and inner thighs. Begins hours before onset of bleeding and persisting for hours or days.
Rx: PG synthetase inhibitors, OCP

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32
Q

Endometriosis

A

Retrograde menstruation, metaplasia of coelomic epithelium.
Risk factors: family hx, nulliparity, age >25
Features: dysmenorrhea, dyspareunia, dyschezia, infertility
Physical: tender nodules on uterine ligaments, fixed retroversion of uterus, firm fixed adnexal mass
Labs: laparoscopy “chocolate cyst”, white lesions, biopsy
Rx:
Medical
- NSAIDs
- Pseudopregnancy: COC, depo-vera
- Pseudomenopause: danazol (weak androgen, SE: weight gain, fluid retention, acne, hirsutism), leuprolide (GnRH agonist)
Surgical
- Electrocautery + ablation
- Bilateral salpingo-oophorectomy + hysterectomy

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33
Q

Adenomyosis

A

Extension of endometrial glands and stroma into the endometrium. Mean age of presentation 40-50yo.
Features: asymptomatic, menorrhagia, secondary dysmenorrhea, dyspareunia, dyschezia.
Clinical: symmetrically bulky uterus, mobile, no adnexal tenderness, Halban sign (tender sofetened uterus on premenstrual bimanual exam)
Investigations: US, endometrial sampling
Rx: iron, analgesics, NSAIDs, OCP, low dose danazol OD, hysterectomy

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34
Q

Leiomyomata

A

Fibroids, diagnosed in premenopausal women >35, typically regress after menopause..
Features: asymptomatic, AUB, pressure/bulk symptoms (urinary frequency, acute urinary retention, constipation), acute pelvic pain (fibroid degeneration, fibroid torsion), infertility, pregnancy complications
Clinical: uterus asymmetrically enlarged, mobile
Tests: FBC, US, sonohysterogram, endometrial biopsy
Rx:
- Conservative:

35
Q

Estrogen side effects

A 
Nausea
Breast changes
Fluid retention
Weight gain
Migraines/headaches
Thromboembolic events
Liver adenoma
Breakthrough bleeding
36
Q

Progestrogen side effects

A 
Amenorrhea/breakthrough bleeding
Headaches
Breast tenderness
Increased appetite
Decreased libido
Mood changes
Hypertension
Acne/oily skin
Hirsutism
37
Q

IUD side effects

A 
For both copper and Mirena:
Breakthrough bleeding
Expulsion (5% in first year)
Uterine wall perforation
Ectopic pregnancy
PID (within first 10days)

Copper IUD:
Increased duration and volume of menses, dysmenorrhea

Progesterone IUD:
bloating, headache

38
Q

Female infertility - ovulatory dysfunction

A

Hypothalamic
Pituitary
Ovarian - PCOS, premature ovarian failure, luteal phase defect
Systemic disease - thyroid, Cushing’s renal/hepatic failure
Congenital - Turner’s, gonadal dysgenesis, gonaadotrophin deficiency
Stress, poor nutrition, excessive exercise

39
Q

Female infertility - outflow tract abnormality

A

Tubal factors - PID, adhesions, ligation/occlusion
Uterine factors - congenital anomalies (bicornate, septate uterus), intrauterine adhesions (Asherman’s syndrome), infection (endometreitis, pelvic TB), fibroids/polyps, endometrial ablation
Cervical factors - hostile/acidic cervical mucous, antisperm antibodies, structural defects (cone biopsy)

40
Q

Female infertility factors

A 
Ovulatory dysfunction 15-20%
Outflow tract abnormality 15-20%
Endometriosis 15-30%
Multiple factors 30%
Unknown factors 10-15%
41
Q

Ovulatory investigations

A

Day 3: FSH, LH, TSH, prolactin + DHEA, free testosterone (if hirsute)
Day 21-23: progesterone (confirm ovulation)

42
Q

Tubal investigations

A

HSG
SHG
Laparoscopy with dye

43
Q

Female infertility - treatment

A

Education - timing of intercourse (2 days around ovulation, or every other day)
Medical
- Ovulation induction
○ Clomiphene (estrogen antagonist, increases FSH, LH leading to ovulation)
○ HMG and FSH to stimulate ovulation
○ Beta-HCG for stimulation of ovum release
- Also
○ Bromocriptine (dopamine agonist)
○ Dexamethasone (for CAH)
○ Metformin (for PCOS)
○ Luteal phase progesterone supplementation (for luteal phase defect)
○ ASA for women with recurrent spontaneous abortions
Surgical
- Tubuloplasty
- Lysis of adhesions
- Artificial insemination
- IVF
- ICSI
Oocyte or sperm donors

44
Q

Male infertility

A 
Varicocele >40%
Idiopathic >20%
Obstruction 15%
Cryptorchidism 8%
Immunologic 3%

Test: semen analysis

45
Q

PCOS

A

Criteria: oligomenorrhea, hyperandrogenism, polycystic ovaries. Obesity increase peripheral conversion of estrogen, decreases FSH/increase LH secretion leading to anovulation/oligomenorrhea. Decreased FSH/increased LH secretion also increase ovarian secretion of androgens leading to hirutism. Insulin also decreases FSH/increase LH secretion.
Features: 15-35yrs, AUB, hirsutism, infertility, obesity, virilization, acanthosis nigricans (insulin resistance), FHx of diabetes.

Tests: DHEA, free testosterone, LH:FSH >2:1, transabdominal US for polycystic ovaries, fasting BG, OGTT

Rx:
Cycle control
- Decrease BMI, increase exercise
- OCP monthly or cyclic Provera (unopposed estrogen)
- Metformin if diabetic or trying to get pregnant
- Tranexamic acid (menorrhagia)
Infertility
- Medical induction: clomiphene, HMG, LHRH, recombinant FSH, metformin
- Ovarian drilling
- Bromocriptine
Hirsutism
- OCP: Diane (cyptoterone acetate - antiandrogenic), Yasmin (drospirenone and ethinyl estradiol - spironolactone analogue)
- Finasteride (5-a-reductase inhibitor)
- Spironolactone - androgen receptor analogue

46
Q

Physiologic discharge

A

Clear, white odourless with pH 3.8-4.2, contains Lactobacilli

47
Q

Prepubertal vulvovaginitis

A

Features: irritation, discharge, vulvar erythema, vaginal bleeding
Non-specific (25-75%)- lack of protective hair, lack of estrogen, susceptible to chemicals, medications, enuresis
Infectious - poor hygiene, recent infection, STI (sexual abuse)

48
Q

Postemenopausal vaginitis

A

Features: dyspareunia, post-coital spotting, mild pruritis
Clinical: atrophy with thinning of tissues, erythema, petechia, bleeding points, dryness
Rx: estrogen cream

49
Q

Candidiasis

A

Predisposing: immunosuppressed, recent abx, increased estrogen
Features: whitish cottage cheese, intense pruritus, swollen, erythema, vulvar burning, dysuria, dyspareunia
Test: pH

50
Q

Bacterial vaginosis

A

Organisms: Gardnerella vaginalis, Mycoplasma hominis
Features: grey thin diffuse discharge, fishy odour
Test: pH >4.5, clue cells, lack of WBC
Rx: metronidazole 500mg PO for 7 days

51
Q

Trichomoniasis

A

Organism: trichomonas vaginalis, sexually transmitted
Features: yello-green, malodourous, diffuse frothy, dysuria, tender vulva
Test: pH >4.5, motile flagellated organism, many WBC
Rx: metronidazole 2g single dose or 500mg BD 7 days, treat partner

52
Q

HPV

A

Warts: types 6 and 11
Cervical cancer: types 16 and 18

Cervical smear - koilocytosis
Prevention - vaccination

53
Q

Herpes simplex virus

A

HSV 2 genital, HSV 1 oral. Small painful lesions and ulcers, dysuria
Viral culture or DNA PCR
Rx: acyclovir 400mg PO TDS for 7 days, lignocaine cream

54
Q

Bartholin gland abscess

A

Blockage of duct, unilateral swelling and pain in inferior lateral opening of vagina.
Rx: warm compress, cephalexin for 7 days, incision and drainage

55
Q

PID

A

Features: fever, lower abdominal pain, abnormal discharge,
Risk factors
- Age

56
Q

Toxic shock syndrome

A

Presentation: sudden high fever, sore throat, headache, signs of multisystem organ failure, refractory hypotension
Risks: tampon use, diaphragm, wound infections, postpartum infections
Rx: remove source of infection, hydration, penicillinase-resistant abx

57
Q

Sexual response

A

Desire
Arousal
Orgasm
Resolution

58
Q

Sexual dysfunction

A

Lack of desire - assess organic vs relationship factors
Lack of arousal
Anorgasmia - self-exploration techniques
Dyspareunia - Kegel exercises, dilator treatment, psychotherapy, anesthetics for vulvodynia

59
Q

Menopause

A

Lack of menses for 1 yr
- Physiological: average 51yrs (follicular atresia)
- Premature ovarian failure: before 40yrs autoimmune, infection, Turner’s)
- Iatrogenic (surgical, radiation, chemotherapy)
Features:
- Vasomotor instability: hot flushes, night sweats, palpitations
- Urogenital atrophy: dyspareunia, pruritus, dryness, bleeding, incontinence, urgency
- Skeletal: osteoporosis, joint and muscle pain
- Psychological: mood disturbance, irritability
Investigations: high FSH on day 3 of cycle with FSH>LH
Rx
- Vasomotor: HRT, clonidine, SSRIs, venlafaxine, gabapentin, propranolol
- Vaginal atrophy: estrogen cream, lubricants
- Urogenital: lifestyle changes, local estrogen, surgery
- Osteoporosis: calcium and vit D supplements, weight bearing exercise, quit smoking, bisphosphonates, selective estrogen receptor modifiers, HRT
- Decreased libido: vaginal lubrication, counselling
- CVD: management of risk factos
- Mood: antidepressants, HRT

60
Q

HRT

A

Primary treatment for vasomotor instability, for

61
Q

Prolapse

A

Weakness of cardinal and uterosacral ligaments.
Factors: vaginal childbirth, aging, decreased estrogen, intra-abdominal pressure
Conservative Rx: Kegel exercises, local vaginal estrogen therapy, vaginal pessary

62
Q

Uterine prolapse

A

Groin/back pain, pressure in pelvis worse with standing, lifting, ulceration, bleeding, urinary incontinence.
Rx: surgery, sacralcolpopexy

63
Q

Vault prolapse

A

Protrusion of apex of vaginal vault into vagina, post hysterectomy

64
Q

Cystocele

A

Frequency, urgency, nocturia, stress incontinence, incomplete bladder emptying
Rx: surgical anterior repair

65
Q

Rectocele

A

Straining, digitation to evacuate stool, constipation.

Rx: laxatives, posterior repair

66
Q

Enterocele

A

Prolapse of small bowel in upper posterior vaginal wall

Rx: similar to hernia repair

67
Q

Stress incontinence

A

Risk factors: pelvic prolapse, pelvic surgery, vaginal delivery, hypoestrogenic state, age, smoking, neurological disease
Rx: conservative, vaginal tape, slings

68
Q

Urge incontinence

A 
Overactive bladder (idiopathic, detrusor instability), frequency, urgency, nocturia, leakage
Rx: lifestyle (reduce caffeine/liquid), smoking cessation, regular voiding), Kegel exercises, anticholinergics, TCA
69
Q

Endometrial carcinoma

A 
Risk factors:
Type 1: excess unopposed estrogen
	- Obesity
	- PCOS
	- Unbalanced HRT
	- Nulliparity
	- Late menopause
	- Estrogen producing ovarian tumour (granulosa cell)
	- HNPCC/Lynch syndrome
	- Tamoxifen
Type 2: not estrogen related

Type 1: post menopausal bleeding, AUB
Type 2: advanced stage disease at presentation with bloating, bowel dysfunction

Investigations: endometrial sampling, pelvic US (endometrial thickness >5mm in post menopausal)

Spread: direct extension, lymphatic (pelvic and para-aortic), transtubal dissemination to peritoneal cavity, hematogenous
Rx: surgical, radiotherapy, chemotherapy, hormonal therapy

70
Q

Uterine sarcoma

A

Presentation: vaginal bleeding, abdominal distention, discharge, pelvic pressure
Carcinosarcoma
Leiomyosarcoma - may arise from fibroid
Endometrial stromal sarcoma - perimenopausal or post menopausal with AUB

71
Q

Epithelial ovarian cancer

A

Mostly asymptomatic until advanced disease, symptoms: abdominal symptoms (nausea, bloating, dyspepsia, anorexia), and mass effect (constipation, urinary frequency), post menopausal bleeding
Risks:
- Excess estrogen: nulliparity, early menarche/late menopause
- Age
- Family hx of breast, colon, endometrial, ovarian cancer
- Caucasian
Protective:
- OCP (ovulation suppression)
- Pregnancy/breastfeeding
- Tubal ligataion
- Hysterectomy
- BSO for BRCA mutation carriers
Investigations:
- CA-125, FBC, LFTs,
- Transvaginal US, CT for staging
Rx:
- Early stage: BSO +/- hysterectomy +/- omentectomy +/- peritoneal washings +/- satging
- Advanced stage: debulking surgery, neoadjuvant chemo

72
Q

Functional ovarian tumours

A

Follicular cyst - follicle failure to rupture during ovulation, 4-8cm and may rupture, bleed, tort or infarct. Re-examine after 6 wks as usually regresses
Lutein cyst - corpus luteum fails to regress after 14 days, 10-15cm, may cause pain and delay onset of next period. Re-examine after 6 wks.
Theca-lutein cyst - atretic follicles stimulated by B-hCG, associated with molar pregnancy and clomphene. Cyst regresses with B-hCG fall

73
Q

Benign germ cell ovarian tumours

A

Benign cystic teratoma - most common, may rupture, twist, infarct. Laparoscopic cystectomy

74
Q

Malignant germ cell ovarian tumours

A

Rapidly growing, usually in children and women

75
Q

Nabothian cyst

A

Inclusion cyst on cervix

76
Q

Colposcopy

A

Apply acetic acid and identify white lesions to guide cervical biopsy

77
Q

Benign vulvar lesions

A

Hyperplastic dystrophy - squamous cell hyperplasoa, treated with steroid ointement for 6 wks
Lichen sclerosis - pruritus, dyspareunia, burning, treat with topical steroids for 2-4 wks

78
Q

Malignant vulvar lesions

A

90% squamous cell, melanomas, basal cell, Paget’s disease
Risks: HPV, VIN
Rx: colposcopy, biopsy, surgery, chemoradiation

79
Q

Benign vaginal lesions

A

Inclusion cysts
Endometriosis
Gartner’s duct cysts
Urethral diverticulum

80
Q

Malignant vaginal lesions

A

Risks: HPV infection, cervical and vulvar cancer.

VAIN (vaginal intraepithelial neoplasm), SCC, adenocarcinoma

81
Q

Complete mole

A

Most common, diffuse trophoblastic hyperplasia, no fetal tissues. Chromosomes completely of paternal origin (46XX, 46XY) as 2 sperm fertilise empty ovum. More common in South East Asians.
Features: snowstorm on US, raised B-hCG

82
Q

Partial mole

A

Focal trophoblastic hyperplasia with associated fetus or fetal parts. Chromosome often triploid from both parents.
Features: molar degeneration of placenta + fetal anomalies, raised B-hCG

83
Q

Hyatidiform mole treatment

A

Treatment:
- Suction D&C
- Rh prophylaxis
- Hysterectomy
- Chemotherapy if develops after evacuation
Follow-up
- Serial B-hCG every week until negative for >3, then monthly for 6-12 months
- Contraception for entire follow-up period

84
Q

Malignant GTD

A

Invasive mole - non-declining B-hCG following evacuation
Choriocarcinoma - often present with metastases
Placental-site trophoblastic tumour - low B-hCG, production of hPL

Metastases: lungs 80%, vagina 30%, pelvis, liver, brain

Internal Medicine (12 decks)

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