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GOSH > Gynaecology > Flashcards

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
Q

Causes of PMB?

A 
Atrophic vaginitis 
Endometrial polyps
Endometrial hyperplasia 
Endometrial carcinoma (10%)
Cervical carcinoma
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26
Q

Hx/examination

A

LMP (confirm menopause)
Post-coital (think cervical polyp/malignancy)
Smear tests

Exam:
Abdominal and pelvic exam
Speculum
Smears (if due)

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27
Q

Investigations

A

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

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28
Q

Epidemiology of endometriosis. When does it normally resolve and why?

A

1-2% or reproductive age (30-45). More common in nulliparous women.

Normally resolves after menopause (oestrogen dependant)

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29
Q

Clinical features of endometriosis

A

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

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30
Q

Examination

A

Vaginal examination
tenderness +- thickening behind uterus/adnexa

speculum

31
Q

Investigations

A

TVUSS: can detect gross endometriosis involving overies (cannot pick up peritoneal endometriosis)

Laproscopy: + allows excision of lesions

MRI andenomyosis

32
Q

Management of endometriosis

A

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
Q

Complications of endometriosis

A

Subfertility 30-40%

Medical Tx does not improve fertility, surgical ablation does.

34
Q

Differentials

A

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
Q

Clinical features of adenomyosis

A

Dysmenorrhea (pain starts before period)
Menorrhagia
Bulky & tender ‘boggy’ uterus

36
Q

Investigation for Adenomyosis

A

MRI is most definitive

37
Q

What is the aetiology of adenomyosis

A

Multiparous women (most often diagnosed in 30s/early 40s)

38
Q

Name 3 self limiting functional ovarian cysts. Also identify the most common.

A

Follicular cyst (most common)

Corpus luteal cysts: >3 cm

Theca luteal cyst: develops from excessive HcG

39
Q

What management decreases the size of functional ovarian cysts

A

COCP

40
Q

Which cyst is associated with PID. Describe the complications.

A

Tubo-ovarian cyst. An encapsulated pocket of pus between ovary & fallopian tube.

Abscess rupture -> sepsis

41
Q

What is the medical name for a chocolate cyst. What is it associated with? Why is it called ‘chocolate’?

A

Endometrioma. Associated with endometriosis. Cysts with endometrial tissue form and if they burst = brown/chocolate fluid

42
Q

60% of benign ovarian tumours are of which type?

A

Epithelial

43
Q

Which epithelial ovarian tumour is most common in ages 40-50.

What percentage become malignant

A

Serous cystadenoma

20%

44
Q

Which epithelial ovarian tumour is most common in ages 20-40?

What percentage become malignant?

A

Mucinous cystadenoma

5%

45
Q

Which ovarian cyst often presents in post-menopausal women with symptoms of excessive oestrogen (e.g. PMB). Risk of what?

A

Thecoma: benign oestrogen secreting tumour.

Risk of ↑ oestrogen = endometrial carcinoma

46
Q

What is a dermoid cyst?

A

A germ cell cyst (benign teratoma)
Combination of mesenchymal, epithelial, stromal tissue. Can contain teeth, hair, bone, cartilage.

Rarely malignant

47
Q

Fibroid growth is dependant on what?

A

oestrogen (+ progesterone)

48
Q

What happens to fibroids after then menopause?

A

↓ size, regress, calcify due to ↓ oestrogen

49
Q

Hx of fibroids

A

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
Q

Management

A

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
Q

Which ovarian cyst has a

Rokitansky’s protuberance?

A

Dermoid

52
Q

Causes of IMB

A
  • 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
Q

History for IMB

A
  • 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
Q

Examinations

A
  1. Abdo examination
  2. Bi-manual
  3. Speculum
    • Swabs
    • Smear
  • masses: fibroids, malignancy
  • Cervical tenderness: PID (chlamydia)
  • Speculum: polyp or ectropion
55
Q

Investigations

A 
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
Q

Management if not anatomical cause is found?

A

Consider anovulatory

  1. IUS or COCP
  2. Surgical options (hysterectomy, uterine artery ablation)
57
Q

Causes of secondary amenorrhoea?

A
  • Physiological: pregnancy, lactation, menopause
  • Pathological

Hypothalamic hypogonadism
GnRH ↓

Pituitary
Hyperprolactinaemiae

Adrenal/thyroid
- Thyroid

Overies:
Anovulation PCOS
Premature ovarian failure
Turners

Outflow
Asherman’s

58
Q

Investigations

A
  • Pregnancy test
  • Gonadotrophins (↓ hypothalamic, ↑ ovarian)
  • Prolactin
  • Anndrogens
  • Oestradoil
  • TFT
59
Q

Blood tests & investigations for PCOS

A

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
Q

Complications of PCOS

A
  • 50% develop type 2 diabetes
  • 30% GDM
  • ↑ CVD risk
  • recurrent miscarriage 50-60%
  • Sub fertility 75%
61
Q

When does the menopause usually occur?

  • Name some iatrogenic causes
  • What age is considered premature menopause?
A

Around 52 years old.

  • Surgical: hysterectomy, oophorectomy
  • Chemo/radiotherapy
  • < 45
62
Q

chronic pelvic pain symptoms

A
  • Severe, dull ache, intermittent, may feel like heaviness, sharp pains mixed in
  • May have pain after sex, during bowels, when urinating
63
Q

Causes

A
  • Endometriosis
  • Chronic PID
  • IBS
  • Fibroids
  • Physiological
64
Q

Typical Hx of ectopic pregnancy

A

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
Q

Examination

A
  • may be some cervical motion tenderness or adnexal tenderness
  • Tachycardia (blood loss)
  • Hypotension & collapse
66
Q

Investigation

A
  • Urine HcG
  • BHcG + US
    > 1000IU/ml and empty uterus
    Rises < 66% or plateaus
67
Q

Tx for acute, haemodynamically unstable ectopic

A

Laparoscopy: salpingectomy or salpingotomy

68
Q

Sub-acutre presentation & HcG is <1000IU/ml & declining

A

conservative

69
Q

Sub-acutre presentation & HcG is <3000 & ectopic unruptured with no cardiac activity

A

Methotrexate

70
Q

37 year old female present to GP. No period for last 7 weeks. Presents with pain & PV bleeding.

  • Differentitals
  • Examinatoin
A

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
Q

Clinical features of gestational trophoblastic disease

A
  • 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
Q

Management of trophoblastic disease

A
  • 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
Q

How common are fibroids

A

25% of women

GOSH (13 decks)

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