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Gynaecology Flashcards

1
Q

What is the most common cause of anaemia in the developed world? How much blood do you have to lose

A

menorrhagia

80ml

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2
Q

pneumonic for causes of menorrhagia

A

PID/polyps

Endometrial Carcinoma/endometriosis

Really bad
Hypothyroidism
Intra-uterine contraception (copper not mirena)

Ovarian Cancer
Dysfunctional Uterine Bleeding
Submucosal Fibroids (30%)

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3
Q

Investigations for menorrhagia

A

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

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4
Q

When would fast track referral + endometrial biopsy

A 
Endometrial thickness > 10 mm (should be <5mm in post-menopausal)
> 45 
Reset onset of menorrhagia 
IMB
unresponsive to TX
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5
Q

Management

A

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
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6
Q

Pneumonic for Gynae History

A 
MOSSC
Menstrual: LMP
Obstetric
Sexual 
Smears 
Contraception
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7
Q

3 bleeds questions

A

LMP, IMB, PCB

- any pain during sex

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8
Q

What questions can you not forget for any women

A

Is there any chance could you be pregnant

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9
Q

treatment for hyperprolactinaemia

A

bromocriptine/cabergoline

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10
Q

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

a) Squamo-columnar junction

b) Transformational zone

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11
Q

What is the peak age of cervical intraepithelial neoplasia?

A

25-29 years

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12
Q

What infection is strongly linked to CIN & malignancy?

A

HPV 16, 18, 31, 33

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13
Q

Who is referred to colposcopy after a cervical smear? With what urgency

A

Low grade/high risk HPV -> normal referral

High grade -> urgent referral

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14
Q

Describe the management for CIN I/II/III

A

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

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15
Q

What is a complications of LLETZ

A

preterm delivery (shorted/opened cervix)- cerivcal suture is common

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16
Q

Causes of premature menopause

A

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
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17
Q

Effect of menopause on cardiovascular risk

A

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)

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18
Q

Describe other effects of menopause

A

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

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19
Q

Benefits of HRT

A

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

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20
Q

Risk of HRT

A

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
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21
Q

Describe HRT treatment

A

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)

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22
Q

Describe the delivery routes of oestrogen

A 
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.

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23
Q

How is progesterone given?

A

levonorgestrel, norethisterone tablets

Mirena IUS delivers 20µg levonorgestrel per day

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24
Q

What is tibolone?

A

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.

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25
Causes of PMB?
``` Atrophic vaginitis Endometrial polyps Endometrial hyperplasia Endometrial carcinoma (10%) Cervical carcinoma ```
26
Hx/examination
LMP (confirm menopause) Post-coital (think cervical polyp/malignancy) Smear tests Exam: Abdominal and pelvic exam Speculum Smears (if due)
27
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
28
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)
29
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
30
Examination
Vaginal examination tenderness +- thickening behind uterus/adnexa speculum
31
Investigations
TVUSS: can detect gross endometriosis involving overies (cannot pick up peritoneal endometriosis) Laproscopy: + allows excision of lesions MRI andenomyosis
32
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.
33
Complications of endometriosis
Subfertility 30-40% Medical Tx does not improve fertility, surgical ablation does.
34
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
35
Clinical features of adenomyosis
Dysmenorrhea (pain starts before period) Menorrhagia Bulky & tender 'boggy' uterus
36
Investigation for Adenomyosis
MRI is most definitive
37
What is the aetiology of adenomyosis
Multiparous women (most often diagnosed in 30s/early 40s)
38
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
39
What management decreases the size of functional ovarian cysts
COCP
40
Which cyst is associated with PID. Describe the complications.
Tubo-ovarian cyst. An encapsulated pocket of pus between ovary & fallopian tube. Abscess rupture -> sepsis
41
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
42
60% of benign ovarian tumours are of which type?
Epithelial
43
Which epithelial ovarian tumour is most common in ages 40-50. What percentage become malignant
Serous cystadenoma | 20%
44
Which epithelial ovarian tumour is most common in ages 20-40? What percentage become malignant?
Mucinous cystadenoma 5%
45
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
46
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
47
Fibroid growth is dependant on what?
oestrogen (+ progesterone)
48
What happens to fibroids after then menopause?
↓ size, regress, calcify due to ↓ oestrogen
49
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
50
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
51
Which ovarian cyst has a | Rokitansky's protuberance?
Dermoid
52
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
53
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
54
Examinations
1. Abdo examination 2. Bi-manual 3. Speculum • Swabs • Smear - masses: fibroids, malignancy - Cervical tenderness: PID (chlamydia) - Speculum: polyp or ectropion
55
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 ```
56
Management if not anatomical cause is found?
Consider anovulatory 1. IUS or COCP 2. Surgical options (hysterectomy, uterine artery ablation)
57
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
58
Investigations
- Pregnancy test - Gonadotrophins (↓ hypothalamic, ↑ ovarian) - Prolactin - Anndrogens - Oestradoil - TFT
59
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
60
Complications of PCOS
- 50% develop type 2 diabetes - 30% GDM - ↑ CVD risk - recurrent miscarriage 50-60% - Sub fertility 75%
61
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
62
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
63
Causes
- Endometriosis - Chronic PID - IBS - Fibroids - Physiological
64
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.
65
Examination
- may be some cervical motion tenderness or adnexal tenderness - Tachycardia (blood loss) - Hypotension & collapse
66
Investigation
- Urine HcG - BHcG + US > 1000IU/ml and empty uterus Rises < 66% or plateaus
67
Tx for acute, haemodynamically unstable ectopic
Laparoscopy: salpingectomy or salpingotomy
68
Sub-acutre presentation & HcG is <1000IU/ml & declining
conservative
69
Sub-acutre presentation & HcG is <3000 & ectopic unruptured with no cardiac activity
Methotrexate
70
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 1. Confirm pregnancy 2. TV-USS 3. B-HCG 4. FBC, Clotting, G&S, Rhesus status.
71
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)
72
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
73
How common are fibroids
25% of women

GOSH (13 decks)

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