Gynaecology Flashcards
External genitalia supply
Internal pudendal artery
Pudendal nerve
Inguinal lymph nodes drainage
Vagina blood supply
Vaginal branch (internal pudendal artery), uterine, inferior vesical and middle rectal arteries
Uterus blood supply
Uterine corpus - uterine artery (internal iliac artery)
Cervix - cervical branch (uterine artery)
Uterus ligaments
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
Ovarian ligaments
Suspensory ligament of ovary - connects ovary to pelvic wall, contains ovarian artery, ovarian vein, ovarian plexus, lymphatic
Ovarian ligament - connects ovary to uterus
Ovarian blood supply
Ovarian arteries (aorta) Left ovarian vein (left renal vein) Right ovarian vein (inferior vena cava)
Mesosalpinx and mesovarium
Peritoneal fold that attaches the fallopian tubes and ovaries to broad ligament
Stages of puberty
Thelarche - breast development
Pubarche - pubic hair and axillary development
Growth spurt
Menarche - 10-15yo, 2 yrs following breast development
Follicular phase
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.
Luteal phase
LH surge (positive feedback from E + P) stimulates oocyte release after 36hrs. Corpus luteum produces progesterone, degenerates after 14 days resulting in menses
Estrogen
Main hormone in follicular phase, stimulated by FSH.
- Reduces atreisa on the follicles - Proliferation of endometrial tissue - Decrease E receptors on all tissue
Progesterone
Main hormone in luteal phase, stimulated by LH.
- Stops endometrial proliferation and organises glands - Prevents endometrial degradation - Decreases E + P receptors
Premenstrual syndrome
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)
Dysmenorrhea differential (painful menstruation)
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
Acute pelvic pain - adenexal
Mittelschmerz Ruptured ovarian cysts Ruptured ectopic pregnancy Hemorrhage into cyst/neoplasm Ovarian/tubal torsion
Acute pelvic pain - uterine
Fibroid degeneration
Torsion of pedunculated fibroid
Pyometra/hematometra (puss or blood in uterine cavity)
Acute pelvic pain - inflammation
Acute PID
Endometriosis
Chronic pelvic pain - gynae
Chronic PID Endometriosis Adenomyosis Adhesions Dysmenorrhea Ovarian cyst Pelvic congestion syndrome Ovarian remnant syndrome (Sexual abuse)
Functional ovarian cysts
Corpus luteum cyst
Follicular cyst
Theca lutein cyst
Hemorrhagic cyst
Neoplasms of ovary
Dermoid cyst - benign and most common
Epithelial cell - malignant, most common in > 40 yrs
Germ cell - malignant, most common in
Dysparenunia - introital
Inadequate lubrication Vaginismus Rigid/intact hymen Bartholin's or Skene's gland infection Lichen sclerosis Vulvovaginitis - atrophic (hypoestrogen), chemical, infectious (chlamydia, trichomoniasis)
Dysparenunia - midvaginal
Urethritis
Short vagina
Trigonitis
Congenital anomality of vagina (vagina septum)
Dysparenunia - deep
Endometriosis Adenomyosis Leiomyomata/fibroids PID Hydrosalpinx Tubo-ovarian abscess Uterine retroversion Ovarian cyst
Primary amenorrhea - with secondary sexual development
Normal breast and pelvic development
- Hypothyroidism - Hyperprolactinemia - PCOS - Hypothalamic dysfuntion
Normal breast, abnormal uterine development
- Androgen insensitivity - Mullerian agenesis - Uterovaginal septum - Imperforate hymen
Primary amenorrhea - without secondary sexual development
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)
Secondary amenorrhea
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)
Progesterone challenge
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.
Anovulatory bleeding
Due to estrogen dependent breakthrough bleeding.
- PCOS - Thyroid dysfunction - Elevated prolactin levels - Rare estrogen producing tumours - Stress, weight loss, exercise - Liver and kidney disease
Ovulatory bleeding
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)
Abnormal uterine bleeding treatment
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
Primary dysmenorrhea
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
Endometriosis
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
Adenomyosis
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
Leiomyomata
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:
Estrogen side effects
Nausea Breast changes Fluid retention Weight gain Migraines/headaches Thromboembolic events Liver adenoma Breakthrough bleeding
Progestrogen side effects
Amenorrhea/breakthrough bleeding Headaches Breast tenderness Increased appetite Decreased libido Mood changes Hypertension Acne/oily skin Hirsutism
IUD side effects
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
Female infertility - ovulatory dysfunction
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
Female infertility - outflow tract abnormality
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)
Female infertility factors
Ovulatory dysfunction 15-20% Outflow tract abnormality 15-20% Endometriosis 15-30% Multiple factors 30% Unknown factors 10-15%
Ovulatory investigations
Day 3: FSH, LH, TSH, prolactin + DHEA, free testosterone (if hirsute)
Day 21-23: progesterone (confirm ovulation)
Tubal investigations
HSG
SHG
Laparoscopy with dye
Female infertility - treatment
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
Male infertility
Varicocele >40% Idiopathic >20% Obstruction 15% Cryptorchidism 8% Immunologic 3%
Test: semen analysis
PCOS
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
Physiologic discharge
Clear, white odourless with pH 3.8-4.2, contains Lactobacilli
Prepubertal vulvovaginitis
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)
Postemenopausal vaginitis
Features: dyspareunia, post-coital spotting, mild pruritis
Clinical: atrophy with thinning of tissues, erythema, petechia, bleeding points, dryness
Rx: estrogen cream
Candidiasis
Predisposing: immunosuppressed, recent abx, increased estrogen
Features: whitish cottage cheese, intense pruritus, swollen, erythema, vulvar burning, dysuria, dyspareunia
Test: pH
Bacterial vaginosis
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
Trichomoniasis
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
HPV
Warts: types 6 and 11
Cervical cancer: types 16 and 18
Cervical smear - koilocytosis
Prevention - vaccination
Herpes simplex virus
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
Bartholin gland abscess
Blockage of duct, unilateral swelling and pain in inferior lateral opening of vagina.
Rx: warm compress, cephalexin for 7 days, incision and drainage
PID
Features: fever, lower abdominal pain, abnormal discharge,
Risk factors
- Age
Toxic shock syndrome
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
Sexual response
Desire
Arousal
Orgasm
Resolution
Sexual dysfunction
Lack of desire - assess organic vs relationship factors
Lack of arousal
Anorgasmia - self-exploration techniques
Dyspareunia - Kegel exercises, dilator treatment, psychotherapy, anesthetics for vulvodynia
Menopause
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
HRT
Primary treatment for vasomotor instability, for
Prolapse
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
Uterine prolapse
Groin/back pain, pressure in pelvis worse with standing, lifting, ulceration, bleeding, urinary incontinence.
Rx: surgery, sacralcolpopexy
Vault prolapse
Protrusion of apex of vaginal vault into vagina, post hysterectomy
Cystocele
Frequency, urgency, nocturia, stress incontinence, incomplete bladder emptying
Rx: surgical anterior repair
Rectocele
Straining, digitation to evacuate stool, constipation.
Rx: laxatives, posterior repair
Enterocele
Prolapse of small bowel in upper posterior vaginal wall
Rx: similar to hernia repair
Stress incontinence
Risk factors: pelvic prolapse, pelvic surgery, vaginal delivery, hypoestrogenic state, age, smoking, neurological disease
Rx: conservative, vaginal tape, slings
Urge incontinence
Overactive bladder (idiopathic, detrusor instability), frequency, urgency, nocturia, leakage Rx: lifestyle (reduce caffeine/liquid), smoking cessation, regular voiding), Kegel exercises, anticholinergics, TCA
Endometrial carcinoma
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
Uterine sarcoma
Presentation: vaginal bleeding, abdominal distention, discharge, pelvic pressure
Carcinosarcoma
Leiomyosarcoma - may arise from fibroid
Endometrial stromal sarcoma - perimenopausal or post menopausal with AUB
Epithelial ovarian cancer
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
Functional ovarian tumours
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
Benign germ cell ovarian tumours
Benign cystic teratoma - most common, may rupture, twist, infarct. Laparoscopic cystectomy
Malignant germ cell ovarian tumours
Rapidly growing, usually in children and women
Nabothian cyst
Inclusion cyst on cervix
Colposcopy
Apply acetic acid and identify white lesions to guide cervical biopsy
Benign vulvar lesions
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
Malignant vulvar lesions
90% squamous cell, melanomas, basal cell, Paget’s disease
Risks: HPV, VIN
Rx: colposcopy, biopsy, surgery, chemoradiation
Benign vaginal lesions
Inclusion cysts
Endometriosis
Gartner’s duct cysts
Urethral diverticulum
Malignant vaginal lesions
Risks: HPV infection, cervical and vulvar cancer.
VAIN (vaginal intraepithelial neoplasm), SCC, adenocarcinoma
Complete mole
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
Partial mole
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
Hyatidiform mole treatment
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
Malignant GTD
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
