Gynaecology Flashcards
What is the most common cause of anaemia in the developed world? How much blood do you have to lose
menorrhagia
80ml
pneumonic for causes of menorrhagia
PID/polyps
Endometrial Carcinoma/endometriosis
Really bad
Hypothyroidism
Intra-uterine contraception (copper not mirena)
Ovarian Cancer
Dysfunctional Uterine Bleeding
Submucosal Fibroids (30%)
Investigations for menorrhagia
Bloods:
FBC, TFT, coagulation
Cervical smear:
STI test:
important if IMP, PCB or irregular bleed
Trans-vaginal USS: endometrial thickness, detects uterine fibroids/ovarian mass/polyps
Hysteroscopy: uterine cavity, detection of polyps/fibroids/pathological uterus
When would fast track referral + endometrial biopsy
Endometrial thickness > 10 mm (should be <5mm in post-menopausal) > 45 Reset onset of menorrhagia IMB unresponsive to TX
Management
Medical:
1st line: IUS
2nd:
Anti-fibrionolytic (tranexamic acid): take during pregnancy. ↓ menstruation 50%
NSAIDS (mefanemic acid)
↓ 30%, good for painful, CI: renal ↓, peptic ulcers
3rd line: Progesterone
oral or IV
Surgical
- Remove fibroids/polyps
- Endometrial ablation
- Hysterectomy
- Uterine Artery embolisation: uterine fibroids
Pneumonic for Gynae History
MOSSC Menstrual: LMP Obstetric Sexual Smears Contraception
3 bleeds questions
LMP, IMB, PCB
- any pain during sex
What questions can you not forget for any women
Is there any chance could you be pregnant
treatment for hyperprolactinaemia
bromocriptine/cabergoline
Names the following areas:
a) where the squamous and columnar epithelium meet at the entrance to the cervix
b) the area in which conversion between the two epitheliums occur and is liable to pre-malignancy development
a) Squamo-columnar junction
b) Transformational zone
What is the peak age of cervical intraepithelial neoplasia?
25-29 years
What infection is strongly linked to CIN & malignancy?
HPV 16, 18, 31, 33
Who is referred to colposcopy after a cervical smear? With what urgency
Low grade/high risk HPV -> normal referral
High grade -> urgent referral
Describe the management for CIN I/II/III
CIN I: follow up in 6 months for cytology
CIN II/III: TZ excised large loop excision of transformation zone (LLETZ) which is examined histologically
What is a complications of LLETZ
preterm delivery (shorted/opened cervix)- cerivcal suture is common
Causes of premature menopause
Primary:
Chromosomal - Turners, Fragile X
Autoimmune - Hypothyroid, Addison’s myasthenia gravis
Enzyme deficiencies - galactosaemia,
Secondary: Surgical menopause post oophorectomy Chemo/ radiotherapy Infections - tuberculosis, mumps, malaria, varicella
Effect of menopause on cardiovascular risk
CHD & stroke account for 1/3 of all deaths in women
Very uncommon before menopause ⇒ oestrogen is thought to be protective against CHD (early menopause also has 3x risk of CHD)
Describe other effects of menopause
Vasomotor:
Usually begin during the perimenopause and do not last > 5 years
Hot flushes & night sweats - affect ~70%
Sleep disturbance - tiredness, irritability & poor concentration
Reduced cognitive function
Mood changes
Bladder: ↑ frequency, urgency, dysuria, UTI
Vaginal: Dry, sore, dyspareunia
Osteoporosis: ↓ bone strength, ↑ risk of fracture
CHD & stroke
Benefits of HRT
Vasomotor: Treats hot flushes - most common reason for prescribing HRT
Osteoporosis: Reduces risk of osteoporotic fractures
Urogenital: Symptoms respond well to oestrogen - however may take months. Long term treatment as the symptoms can reoccur
Colorectal Ca ↓risk of colorectal cancer by 1/3
Risk of HRT
Increased risk of breast ca.
Increases risk by 2.3% every year ⇒ risk dependant on duration of use
Higher risk with combined than unopposed oestrogen (however that has higher risk of endometrial ca)
Effect is not sustained once HRT use is stopped → meaning 5 years after stopping HRT, risk is the same as for women who never had HRT
Increased risk of endometrial ca.
Higher risk with unopposed oestrogen, increases risk x4
⇒ should only be used in those who have had hysterectomy
Venous Thromboembolism Increased risk in 1st year of HRT: x4 in 1st 6 months x3 in 2nd 6 months No increased risk after 1st year
Describe HRT treatment
HRT oestrogen only in women who have had hysterectomy or oestrogen combined with progesterones in those who haven’t (prevents endometrial hyperplasia & carcinoma due to unopposed oestrogen)
Describe the delivery routes of oestrogen
Continuous or cyclical oral therapy. Patches. Creams or gels. Nasal sprays. Local devices such as the progestogen-releasing Mirena® IUS. The oestrogen-releasing vaginal ring.
Non-oral routes may be preferred as they avoid first metabolism and therefore have less effect on clotting and side effects.
How is progesterone given?
levonorgestrel, norethisterone tablets
Mirena IUS delivers 20µg levonorgestrel per day
What is tibolone?
Synthetic steroid with weak oestrogenic, progestogenic & androgenic effects
Treats vasomotor, psychological & libido symptoms
Also conserves bone mass & reduces risk of vertebral fracture
Less effective than the combined HRT at alleviating symptoms.
Causes of PMB?
Atrophic vaginitis Endometrial polyps Endometrial hyperplasia Endometrial carcinoma (10%) Cervical carcinoma
Hx/examination
LMP (confirm menopause)
Post-coital (think cervical polyp/malignancy)
Smear tests
Exam:
Abdominal and pelvic exam
Speculum
Smears (if due)
Investigations
USS:
Endometrial thickness if <3mm (or 5mm on HRT): liklihood of endometrial ca is very low
> 3mm = biopsy
THIS DOES NOT APPLY TO WOMEN ON TAMOXIFN: they have thickened endometrium -> hysterocsopy required
Epidemiology of endometriosis. When does it normally resolve and why?
1-2% or reproductive age (30-45). More common in nulliparous women.
Normally resolves after menopause (oestrogen dependant)
Clinical features of endometriosis
Cyclical non-colicky pain, restricted to time around menstruation
Pain normally begins a few days before menstruation and lasts until end.
May get pain on passing stools and deep dyspareunia
Sub-fertility
Chocolate cyst: endometrial cyst on ovary
Examination
Vaginal examination
tenderness +- thickening behind uterus/adnexa
speculum
Investigations
TVUSS: can detect gross endometriosis involving overies (cannot pick up peritoneal endometriosis)
Laproscopy: + allows excision of lesions
MRI andenomyosis
Management of endometriosis
50% disease regresses or does not progress.
Medical:
Hormonal treatment either mimics pregnancy or menopause
COCP: widely used for endometriosis, not suitable for older women or smokers. Advised back to back with 5 withdrawals a yr
progesterone only pill
GnRH: similar to menopause -> use limited to 6 months
Surgical:
Laproscopic: ablation & excision -> recurrence likely therefore use with medical Tx.
Definitive surgery: hysterectomy + salpingo-oophrectomy is curative. HRT needed to prevent post-menopausal side effects.
Complications of endometriosis
Subfertility 30-40%
Medical Tx does not improve fertility, surgical ablation does.
Differentials
Adenomyosis - MRI would be used to differentiate
Chronic PID - would also cause pelvic pain, however evidence of other infective symptoms would be present (foul discharge, cervical motion tenderness, sexual risk)
IBS - can also cause dyschezia however it would not be cyclical in relation to menstruation
Clinical features of adenomyosis
Dysmenorrhea (pain starts before period)
Menorrhagia
Bulky & tender ‘boggy’ uterus
Investigation for Adenomyosis
MRI is most definitive
What is the aetiology of adenomyosis
Multiparous women (most often diagnosed in 30s/early 40s)
Name 3 self limiting functional ovarian cysts. Also identify the most common.
Follicular cyst (most common)
Corpus luteal cysts: >3 cm
Theca luteal cyst: develops from excessive HcG
What management decreases the size of functional ovarian cysts
COCP
Which cyst is associated with PID. Describe the complications.
Tubo-ovarian cyst. An encapsulated pocket of pus between ovary & fallopian tube.
Abscess rupture -> sepsis
What is the medical name for a chocolate cyst. What is it associated with? Why is it called ‘chocolate’?
Endometrioma. Associated with endometriosis. Cysts with endometrial tissue form and if they burst = brown/chocolate fluid
60% of benign ovarian tumours are of which type?
Epithelial
Which epithelial ovarian tumour is most common in ages 40-50.
What percentage become malignant
Serous cystadenoma
20%
Which epithelial ovarian tumour is most common in ages 20-40?
What percentage become malignant?
Mucinous cystadenoma
5%
Which ovarian cyst often presents in post-menopausal women with symptoms of excessive oestrogen (e.g. PMB). Risk of what?
Thecoma: benign oestrogen secreting tumour.
Risk of ↑ oestrogen = endometrial carcinoma
What is a dermoid cyst?
A germ cell cyst (benign teratoma)
Combination of mesenchymal, epithelial, stromal tissue. Can contain teeth, hair, bone, cartilage.
Rarely malignant
Fibroid growth is dependant on what?
oestrogen (+ progesterone)
What happens to fibroids after then menopause?
↓ size, regress, calcify due to ↓ oestrogen
Hx of fibroids
Often asymptomatic (found incidently). Symptoms relate to site rather than size
30% menorrhagia. IMB if submucosal/polypoid
RARELY cause pain
If press on bladder may ↑ frequency (rarely hydronephrosis)
Fertility: can cause problems with implantation/miscarriage/preterm labour
Management
USS + MRI maybe required to distinguish from ovarian mass
If asymptomatic (50%): leave alone
Trans-cervical resection of fibroid (hysteroscopy) can shrink with GnRH first
Which ovarian cyst has a
Rokitansky’s protuberance?
Dermoid
Causes of IMB
- Pregnancy related: ectopic & trophoblastic disease
- physiological:
• spotting around ovulation
• perimenopause - Vaginal causes
• vaginitis
• tumuors - Cervical causes
• infection: chlamydia, gonorrhoea
• cancer
• polyps, ectropion - Uterine causes
• fibroids
• endometrial polyps
• cancer
• adenomyosis
• endometritis - Anovulaiton
• Hormone related: ↓ pituitary , Thyroid
• Functional problems: PCOS - Iatrogenic
• tamoxifen
• following smear
• missed OCP
• clotting problems
• breakthrough bleeding COCO, POP, IUS recent emergency
History for IMB
- Hx of bleeding: amount, looks, when in cycle, after sex
- Time, duration, getting worse
- Pain
- Infective: general health
- Menopause: hot flushes
- Thyroid: weight change, energy levels
- consider anaemia
- Hairyness, acne
Gynae Hx
- Could they be pregnant?
- IS bleed in pattern with period?
- Could they be menopausal?
- Recent smear results?
- Are they on contraception? How long? Do they take it regularly? Have they forgotten?
- STI: regular sexual partner, do they use protection, last STI check?
- Recent procedures, surgery
Obs Hx
PMHx:
- Cancer
- Thyroid?
- Bleeding disorders
- Seen an gynaecologist
Drug Hx
Examinations
- Abdo examination
- Bi-manual
- Speculum
• Swabs
• Smear
- masses: fibroids, malignancy
- Cervical tenderness: PID (chlamydia)
- Speculum: polyp or ectropion
Investigations
Smear TV ultrasound - > 35 years - < 35 if unresponsive to Tx - fibroids, ovarian mass, malignancy Endometrial biopsy - if endometrium is thickened, poly is suspected, > 40
Management if not anatomical cause is found?
Consider anovulatory
- IUS or COCP
- Surgical options (hysterectomy, uterine artery ablation)
Causes of secondary amenorrhoea?
- Physiological: pregnancy, lactation, menopause
- Pathological
Hypothalamic hypogonadism
GnRH ↓
Pituitary
Hyperprolactinaemiae
Adrenal/thyroid
- Thyroid
Overies:
Anovulation PCOS
Premature ovarian failure
Turners
Outflow
Asherman’s
Investigations
- Pregnancy test
- Gonadotrophins (↓ hypothalamic, ↑ ovarian)
- Prolactin
- Anndrogens
- Oestradoil
- TFT
Blood tests & investigations for PCOS
FSH:
↑ premature ovarian failure
↓ hypothalamic disease
- in PCOS
Prolactin
Testosterone
↑ PCOS or androgen secreting tumour, congenital adrenal hyperplasia
LH
↑ PCOS (not diagnostic)
TSH
TV USS:
> 8 sub-capsular follicular cycsts < 10mm in diameter
Other:
Diabetes screen
Complications of PCOS
- 50% develop type 2 diabetes
- 30% GDM
- ↑ CVD risk
- recurrent miscarriage 50-60%
- Sub fertility 75%
When does the menopause usually occur?
- Name some iatrogenic causes
- What age is considered premature menopause?
Around 52 years old.
- Surgical: hysterectomy, oophorectomy
- Chemo/radiotherapy
- < 45
chronic pelvic pain symptoms
- Severe, dull ache, intermittent, may feel like heaviness, sharp pains mixed in
- May have pain after sex, during bowels, when urinating
Causes
- Endometriosis
- Chronic PID
- IBS
- Fibroids
- Physiological
Typical Hx of ectopic pregnancy
Subacute lower abdo pain ++ bleeding in early pregnancy
- pain is often unilateral & initially colicky which turns into a constant pain that is well localised
- amenorrhoea 4-10weels
- shoulder tip pain & syncope: consider intraperitoneal bleed.
Examination
- may be some cervical motion tenderness or adnexal tenderness
- Tachycardia (blood loss)
- Hypotension & collapse
Investigation
- Urine HcG
- BHcG + US
> 1000IU/ml and empty uterus
Rises < 66% or plateaus
Tx for acute, haemodynamically unstable ectopic
Laparoscopy: salpingectomy or salpingotomy
Sub-acutre presentation & HcG is <1000IU/ml & declining
conservative
Sub-acutre presentation & HcG is <3000 & ectopic unruptured with no cardiac activity
Methotrexate
37 year old female present to GP. No period for last 7 weeks. Presents with pain & PV bleeding.
- Differentitals
- Examinatoin
Ectopic
Miscarriage
Polyps
Ectropion
Bi-manual:
- Locate tenderness
- CMT: ectopic
Speculum:
- OS open?
- Where is bleeding coming from
- Type of bleed
- Products of conception
- Confirm pregnancy
- TV-USS
- B-HCG
- FBC, Clotting, G&S, Rhesus status.
Clinical features of gestational trophoblastic disease
- Bleeding in first trimester
- exaggerated symptoms of pregnancy (e.g. hyperemesis)
- Uterus large for dates
- High serum hCG
- hypertension and hyperthyroidism (hCG can mimic TSH)
Management of trophoblastic disease
- Remove by suction & curettage
- Tissue sent for histology for confirmation of diagnosis
- Follow up HcG
- Pregnancy & COCP should be avoided until HcG levels drop
How common are fibroids
25% of women
