Gynaecology Flashcards
External Genitalia Development
Identical before the 7th week, genital tubercle elongates, and two folds develop - urogenital folds becoming the labia minora, and the lateral folds becoming the labia majora.
Distinguishable by week 12
Pelvic Floor Anatomy (2 sections)
ABOVE THE UROGENITAL DIAPHRAGM
> Levator anii (Pubococcygeus, Iliococcygeus, Ischiococcygeus, Coccygeus)
> Piriformis
BELOW THE UROGENITAL DIAPHRAGM
> Ischiocavernosus
> Bulbocavernosus
> Transverse Perineal mm
> Anal sphincter
NERVES
> Pudendal N (from S2, S3, S4) - motor and sensation to external genitalia, anal sphincter, muscles of the pelvic floor
> Perineal N - branch of femoral cutaneous
Bartholin Cyst
Arises from occlusion of bartholin duct, leading to accumulation of mucinous secretions, and formation of a smooth cyst.
Important to rule out malignancy, managed by drainage and placement of Word catheter, or marsupialization (suturing open)
Uterine Fibroids - Pathology, Pathophysiology and Histology
Most common neoplasms of the uterus, they are monoclonal benign tumours of the myometrium, with 40% having chromosomal abnormalities.
Promoted by ovarian hormones - oestrogen promotes proliferation, while progesterone inhibits apoptosis. Thus, rarely develop before menarche or after menopause. Well circumscribed, white, firm lesion with pseudocapsule. Can hyalinize or become cystic, very rarely have malignant change.
Histologically, seen as smooth muscles in criss-cross pattern (compared to parallel pattern of normal tissue), high rate of mitosis. No capsule, pseudocapsule from compressed smooth muscle cells.
Uterine Fibroids - Classification (7)
> Subserosal
> Pedunculated subserosal
> Intramural
> Submucosal
> Pedunculated submucosal
> Cervical
> ParasiticUterine Fibroids - Clinical Presentation (4) and Differentials (4)
80% asymptomatic, however may present with
> Pressure/bloating
> Heavy menstrual bleeding (submucosal)
> Subfertility/Infertility (submucosal)
> Infarction = severe pain
Differentials include:
> Adenomyositis
> Ovarian neoplasm
> Pelvic Kidney
> Colon cancer
Uterine Fibroids - Investigation and Management (2 categories, 2 and 4)
Ix involves US assessment, gold standard imaging is MRI.
Mx not required if asymptomatic, indicated by symptoms or infertility.
MEDICAL MANAGEMENT
> OCP/Progestin-only therapy
> GnRH analog - not used regularly, reduced BMD
SURGICAL MANAGEMENT
> Myomectomy - most common, used in fertile women
> Endometrial Ablation - if fertility not a priority
> Uterine artery embolization - leads to fibroid necrosis
> Hysterectomy - definitive management
Nabothian Cyst
Incredibly common, occur on the cervix as a result of squamous metaplasia growing over crypts of mucous-secreting columnar cells, leading to mucous-filled cysts.
Cervical Polyps
The most common benign neoplastic growth of the cervix, growing from columnar epithelium. Most commonly cause coital bleeding and memorrhagia.
Congenital abnormalities of the Uterine Corpus and Cervix - 8 types
> Subseptate (little bump off top)
> Arcuate (top wall bent in slightly)
> Bicornuate (Uterus splits in two)
> Bicornuate + double cervix (uterus and cervix split in two)
> Unicornuate (just one side)
> Bicornuate with rudimentary horn (just one side with atrophied other side)
> Uterine didelphys (uterus and vaginal canal split in two)
> Cervical atresia - cervix does not meet vaginal canal)
Follicular and Corpus Luteal cysts
Follicular cysts develops if ovum not released, growing over 3cm large. Corpus Luteal cyst develops if grows over 3cm and does not regress after 14 days, tends to be solid (suspicious of malignancy)
Usually asymptomatic, may cause pelvic “heaviness” and rarely pain, may undergo torsion or rupture.
NEEDS TO BE DISTINGUISHED FROM MALIGNANCY via transvaginal US and CA-125, as well as RMI calculation. Follow up US to be performed after 6 weeks, to see if it grows or shrinks.
Risk of Malignancy Index
A scoring system used to combine different clinical information to help decide if an ovarian mass is malignant.
A. MENOPAUSAL STATUS
> Pre = 1
> Post = 3
B. US FEATURES
> Multiloculated = 1 point per locule
> Solid/Bilateral/Ascites - 2/3 = 3
C. Serum CA-125 titre
> Absolute Value = point value
RMI = ABC
If RMI > 200, suggests malignancy
Types of Benign Ovarian Neoplastic Tumors (3 categories, 3
EPITHELIAL TUMORS
> Serous
> Mucinoid
> Brenner
SEX CORD-STROMAL TUMORS
> Granulosa
> Theca
> Mixed Granulosa-Theca
> Sertoli-Leydig
> Fibroma
GERM CELL TUMORS
> Teratoma
> Dermoid Cyst
Serous Ovarian Tumors
Develops from mesothelial cells, lined with serous epithelium - flattened cuboidal cells. 70% benign, may form psammoma bodies (calcification)
Mucinoid Ovarian Tumors
Develops from mesothelial cells, lined with simple columnar mucinous epithelium (cervical origin), nuclei pushed to bottom. Often multicolular. 85% benign.
Brenner Tumor
Solid tumor with capsule, characterised by epithelial nests embedded in a fibrous stroma - cells similar to urothelial (transitional) cells.
Granulosa Ovarian Tumour
Most common in postmenopause, promote feminizing signs and symptoms - bleeding, menorrhagia, breast tenderness. Characterised by cells with little cytpolasm that lie close together, nuclei have furrows
Sertoli-Leydig Ovarian Tumor
Less common, cause virilizing symptoms - e.g. hirsutism, deep voice, cliteromegaly, muscularisation. Seen as a solid tumor with large nuclei (nucleolus visible), and abundant cytoplasm. May have cysts.
Ovarian Teratoma
Most common benign ovarian neoplasm, characterised by the different types of tissue types indispersed - skin, brain, intestine, stomach, retina, etc. Have cells from ecto, endo, and mesoderm.
Dermoid Cyst
A cyst lined with keratinized epithelium with adnexae (e.g. hair follicles, apocrine and eccrine glands, subcutaneous fat). Cyst usually filled with oil which, if ruptures, can cause chemical peritonitis and adhesions.
Complications of Ovarian Tumors (2)
> TORSION - presents with severe pain and tenderness, may be colic due to twisting and untwisting. Surgical Emergency
> RUPTURE - May spill blood or serous fluid, but worst is oily secretions of dermoid cyst, which may cause chemical peritonitis or adhesions
Amenorrhea
Lack of Menstration
Dysmenorrhea
Painful menstration
Menorrhagia
Heavy periods, increased duration of period
Metrorrhagia
Bleeding between periods
Term for painful intercourse
Dyspareunia
Differential for Acute Pelvic Pain (3 and 3)
GYNAECOLOGIC
> Rupture or Torsion
> Infection/Abscess rupture
> Pregnancy Complications - ectopic pregnancy, abortion
NON-GYNAECOLOGIC
> Gastrointestinal - appendicitis, gastroenteritis, obstruction
> Urinary Tract - cystitis, kidney stone
> Other - Porphyria, thrombophlebitis
Primary Dysmenorrhea - Pathophysiology, Presentation and Management
Occurs during ovulatory cycle, starting within 6-12 months of menarche.
Pain caused by uterine contractions, ischaemia, and prostaglandin production - high COX and progesterone activity, caused by ovulation.
Clinically presents as cramping that begins before bleeding, with lower back pain, altered bowel habits, headache, nausea, fatigue.
Managed by reassurance and NSAIDS (best started 2-3 days before period). OCP and other hormonal contraceptives are effective. Alternate therapies may be used (e.g. accupuncture, TENS, heat). Prostestogens are second line. IF NOT MANAGED BY ABOVE, CONSIDER ALTERNATE DIAGNOSIS
Secondary Dysmenorrhea - Differentials (6) and Investigations (4)
DIFFERENTIALS
> Endometriosis - the most common cause
> Ovarian/Uterine Neoplasm
> Pelvic Inflammatory Disease
> Adenomyosis - endometrial tissue in myometrium
> Pregnancy - not true dysmenorrhea, just presents so
> Ectopic Pregnancy - same as above
INVESTIGATIONS
> Pelvic examination with bimanual palpation (if has had intercourse before, targeting PID)
> Transvaginal US
> hCG - urine
> CBC/ESR/CRP - bloods
Chronic Pelvic Pain - Gynaecologic Differentials (6)
> Endometriosis - 1/3 of cases
> Unknown - 1/3/ of cases
> PID - just under 1/3 of cases
> Adhesions
> Adenomyosis
> FibroidsChronic Pelvic Pain - Non-Gynaecologic Differentials (4 main - 6, 2, 2, 0)
GASTROINTESTINAL
> IBS (most common)
> IBD
> Coeliac
> Diverticulitis
> Neoplasm
> Adhesions
GENITOURINARY
> Urethral Syndrome
> Painful Bladder Syndrome/Interstitial Cystitis
NEUROMUSCULAR
> Nerve entrapment
> Fibromyalgia
PSYCHOSOMATICChronic Pelvic Pain - Management (6)
> Identifying and managing underlying cause
> Multi-disciplinary team w/ psychologist (experience in chronic pain) and physical therapist
> CBT/Relaxation - to help manage pain
> Analgesia - NSAIDS
> Menstruation suppression - OCP
> Alternate Therapies - acupuncture, TENS, hypnosis
Normal Vaginal Flora, and vaginal factors
Mostly aerobic, with about 6 species, most dominant being the H2O2-producing, gram-negative rods lactobacillus.
Mix of flora determined by vaginal pH (3.8-4.5, from production of lactic acid) and glucose availability (from vaginal epithelium)
Wet prep of vaginal secretion - what it shows
> Normal Vaginal epithelium
> Few WBC
> Rarely, Clue cells - vaginal epithelium with bacteria adhered (usually gardnerella vaginalis), giving it an indistinct and speckled appearence.
Bacterial Vaginosis - Pathophysiology, Clinical Presentation, and Risks
Alteration of the normal flora, resulting in loss of H2O2 producing lactobacillus, and overgrowth of anaerobic bacteria - predominantly g.vaginalis and mycoplasma hominis.
Presents clinically as fishy odour and increased vaginal secretion.
Higher risk of PID, abnormal cervical cytology, and pregnancy risks, including premature labour, choramnionitis, and post-caesarian infection.
Bacterial Vaginosis - Diagnosis and Treatment
Diagnosis can be made in the room, with wet prep of vaginal secretions showing lots of clue cells. The whiff test can also be performed - addition of KOH produces a fishy odour. Alternative methods include gram staining, pH, and PCR.
Treatment involves metronidazole for 7 days - targets anaerobes while leaving the lactobacillus alone. Side effects include nausea, headache and metallic taste. Alternate antibiotic is clindamycin.
Trichomonas Vaginitis - Pathophysiology and Clinical Presentation
Caused by sexually transmitted flagellated parasite, trichomonas vaginalis. Highly contagious, able to make an anaerobic environment, promoting BV
Presents with profuse, malodorous, mucopurulent discharge, with vulvar pruritis and colpitis macularis (“strawberry” cervix)
Trichomonas Vaginalis - Diagnosis and Management
Diagnosis can be made by observing motile parasite on microscopy, however not seen in all cases - NAAT is gold standard. Testing for chlamydia and gonorrhoea should be done, and HIV/Syphilis serology considered.
Treated with metronidazole for patient and any partners - single dose of 2g effective in 95%.
