Gynaecology Flashcards
what is a threatened miscarriage?
Symptoms of bleeding/pain but pregnancy continues.
Cervical os closed & uterine size normal for dates
what is an inevitable miscarriage?
Presents in the process of miscarriage although fetes may still be alive. Cervical os is open
in a complete miscarriage what can be seen on examination?
cervical os is Closed
Uterus no longer enlarged
at how many weeks by transvaginal ultrasound will the fetal heartbeat be detected?
6+ weeks
when is the yolk sac visible by TV ultrasound?
5.5 weeks
what drugs are used in the medical management of miscarriage?
Prostaglandins (misoprostol) +/- Antiprogesterones (mifepristone)
how to prostaglandins and antiprogesterones work to assist in medical management of miscarriage?
Induce uterine contractions to expel remaining POC.
what is a recurrent miscarriage?
> 3 miscarriages in succession
how are antiphospholipid antibodies managed as a cause of recurrent miscarriage?
Aspirin and LMWH
*likely thrombosis in uteroplacental circulation
what is the most common site of ectopic pregnancy?
Fallopian tube (95%)
cannot be viewed on USS
on examination what is the size of the uterus and status of the cervical os in ectopic pregnancy?
Uterus - smaller than expected
Cervical os - closed
what is the difference in timings between a transvaginal and abdominal ultrasound?
On abdominal ultrasound landmarks will not be seen until a week later
what is the surgical management of ectopic pregnancy?
Salpingectomy = removal of affected tube.
what is a salpingostomy?
Removal of ectopic from the tube
what drug is used in the medical management of ectopic pregnancy?
Methotrexate
what is a molar pregnancy?
Trophoplastic tissue (which is part of the blastocyst that normally invades the endometrium) proliferates in a more aggressive way than normal.
what is the classic appearance on ultrasound in molar pregnancy?
‘SNOWSTORM’ appearance of swollen villi with complete moles
what is hyperemesis gravidarum?
Excessive nausea and vomiting of pregnancy such that the individual is unable to maintain adequate hydration & endangers fluid, electrolyte and ; nutritional status.
what is the definition of post-menopausal bleeding?
Vaginal bleeding occurring atleast 12 months after the last menstrual period
In PMB when is endometrial biopsy +/- hysteroscopy indicated?
If the endometrium is >4mm or multiple bleeds
what are fibroids?
Benign tumours of the myometrium
why do fibroids regress after the menopause?
Due to a reduction in circulating oestrogen
what are the pressure effects of fibroids?
Bladder - frequency, retention, hydronephrosis
On examination what is the classic finding in a patient with fibroids?
Solid mass may be palpable - arise from the pelvis and be continuous with the uterus
Multiple small fibroids - knobbly enlargement.
how do GnRH agonists work in treatment of fibroids?
Cause temporary amenorrhoea and fibroid shrinkage by inducing a temporary menopausal state
which phase of the menstrual cycle is constant?
Luteal phase (last 14 days)
when is the proliferative phase of the menstrual cycle and which hormone is responsible?
Proliferative phase = days 5-14
Oestrogen produced by Follicles
when is the secretory phase of the menstrual cycle and which hormone is responsible?
Secretory phase: day 14-28
corpus luteum produces PROGESTERONE -
from where are FSH and LH secreted?
Anterior Pituitary
From where is Gonadotrophin-Releasing hormone (GnRH) produced?
Hypothalamus
from where is oestrogen released?
Ovary
which hormone is responsible for ovulation?
LH (causes ovulation 36 hours after surge)
what is a Graffian follicle?
An almost mature follicle
*corpus haemorrhagicum = ruptured follicle
what hormones are secreted by the corpus luteum?
PROGESTERONE
*also oestradiol
when do progesterone levels peak?
Day 21
what effect does progesterone have on the endometrium?
Causes secretory changes in the endometrium, increased lipids and glycogen, glands swell and there is an increased blood supply
how thick is the endometrium at ovulation?
2-3mm
how thick is the endometrium in the secretory phase?
4-6mm
on what day is the optimal condition for implantation?
day 20-22: stable, vascular, nutrient rich
what are the characteristics of the cervix mid cycle?
Strongly and runny (spinnbarkeit)
Facilitates sperm access at ovulation to promote the chances of fertilisation taking place
what are the characteristics of the cervix in the luteal phase?
Tenacious and inelastic (due to progesterone). Prevents microbial ingress, protects developing embryo. Critical to maintenance of pregnancy (mucus plug)
what is menorrhagia defined as?
Blood loss >80mL in an otherwise normal menstrual cycle
what investigation can be used to assess endometrial thickness?
TV ultrasound
in which women would you perform an endometrial biopsy if they present with menorrhagia?
Endometrial thickness >10mm
suspected polyp
>40 years recent onset
what are the common anatomical causes of menorrhagia?
Fibroids
Polyps
Adenomyosis
Tumours
in which situation would you to uterine artery embolisation instead of a myomectomy for the treatment of fibroids?
For woman who want to retain the uterus and avoid surgery
what is the definition of oligomenorrhoea?
menstruation that occurs every 35 days to 6 months
what is primary amenorrhoea?
Where menstruation has not begun by age 16
what is secondary amenorrhoea?
Where previous normal menstruation ceases for >6months
what is asherman’s syndrome?
Asherman syndrome (AS) or Fritsch syndrome, is a condition characterized by adhesions and/or fibrosis of the endometrium particularly but can also affect the myometrium
which of hypo or hyperthyroidism can lead to amenorrhoea?
Both
Does turner’s syndrome result in primary or secondary amenorrhoea?
Primary
what are the commonest causes of secondary amenorrhoea?
Premature menopause/ovarian failure
Polycystic ovary syndrome (PCOS)
Hyperprolactinaemia
what hormone levels would you expect in hypothalamic hypogonadism?
Decreased GnRH, LH, FSH and estradiol
what is Sheehan’s syndrome?
are condition where severe postpartum haemorrhage causes pituitary necrosis and varying degrees of hypopituitarism
in hypothyroidism are the prolactin levels reduced or raised?
Raised
what genotype is present in Turner’s syndrome?
45 XO
What stature do you expect in Turner’s syndrome?
Short stature and poor secondary sexual characteristics
what is haematocolpos?
Menstrual flow accumulates in the vagina
*Haematometra = accumulates in uterus
What is rokitansky’s syndrome?
Absence of vagina with or without a functioning uterus
how are cervical ectropions commonly managed?
Cryotherapy
in secondary dysmenorrhoea is pain relieved or aggravated by the onset of menstruation?
Relieved (pain precedes menstruation)
Is PMS caused by fluctuation of hormones in the 1st or 2nd half of the cycle?
2nd half
what are the treatment options for severe PMS?
SSRIs (continuous or in 2nd half of cycle)
100ug oestrgoen HRT patch
Combined oral contraceptive
GnRh agonists + add back oestrogen therapy –> pseudo menopause
Bilateral oophorectomy (require combined HRT or COC for bone and endometrial protection)
how many women are affected by PCOS?
5%
and causes 80% of anovulatory infertility
*20% of women have PCO but majority have regular ovulatory cycles. May develop PCOS if put on weight.
what are the criteria for diagnosing PCOS?
Diagnosis of PCOS requires 2/3 of:
1) PCO on ultrasound
2) Irregular periods (>35 days apart)
3) Hirsutism: clinical (acne or excess body hair) &/or biochemical (raised serum testosterone)
raised insulin levels in PCOS have what effect on the adrenal glands and the liver?
Increased LH and insulin on PCO –> increased ovarian androgen production
Increased adrenal androgen production and reduce hepatic production of steroid hormone binding globulin (SHBG) –> increased free androgen levels
what is the effect of increased intraovarian androgens?
Disruption of folliculogenesis
why do changes in weight modify the phenotype and alter the severity of PCOS?
Increased body weight –> increased insulin –> increased androgen
what is a normal LH:FSH ratio?
LH:FSH = 1:1
If 2:1 or 3:1 supporting evidence for diagnosing PCOS
What is another name for fibroids?
Leiomyomata - benign tumour of the myometrium
What is Meig’s syndrome?
Meig’s syndrome:
Benign ovarian cyst (usually a fibroma)
Ascites
Pleural effusion
What is the most common ovarian cyst in women of a reproductive age?
Follicular cyst
what is elforinithine?
Topical anti androgen used for facial hirsutism
what must be avoided in patients taking anti androgens cyproperone acetate spironolactone?
Conception
how many women with PCOS develop type 2 DM?
50%
how many women with PCOS develop GDM?
30%
Transversely what is the appearance of a fibroid?
whorled appearance. Smooth muscle and fibrous elements
are fibroids more common in parous or non-parous women?
Non-Porous
which type of fibroid can form intracavity polyps?
Submucosal fibroids
why do fibroids regress after the menopause?
Reduction in circulating oestrogen
what type of fibroid degeneration is common in pregnancy?
Red degeneration - pain & uterine tenderness, haemorrhage and necrosis risk
what type of fibroid degeneration is common postmenopausally?
Calcification
what complications can fibroids cause in pregnancy?
Premature labour Malpresentation Transverse lie Obstructed labour Postpartum haemorrhage
what is adenomyosis?
Presence of endometrial tissue within the myometrium
why might an Hb level be high in someone with fibroids?
Fibroids secrete erythropoietin
*Hb can be low - vaginal bleeding or high (EPO)
why might GnRH treatment be used before transcervical resection of fibroids?
GnRH agonists shrink fibroid, reduce vascularity, thin endometrium making resection easier and safer
what is a chocolate cyst?
Ovarian endometrioma.
Develop in women with endometriosis and can enlarge up to 6-8cm.
is a mature solid teratoma or immature solid teratoma malignant?
Immature solid teratoma
what score is used to determine risk in ovarian cyst presentation?
Risk of malignancy index = U (Ultrasound score) x M (menopausal score) x CA125 (IU/ml)
what is sheehan’s syndrome?
Sheehan’s syndrome/postpartum hypopituitarism= hypopituitarism (decreased functioning of the pituitary gland), caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth
why do some menopausal women experience dyspareunia?
Atrophic vaginitis
what does CIN II signify?
Atypical cells in lower 2/3 of the epithelium
which strains of HPV are most commonly associated with cervical cancer?
16,18 (also 31,33)
for which types of cancer is the combined pill protective?
Ovarian, Uterine
for which types of cancer is the combined pill a risk factor?
Breast, Cervical
what two stains are used at colposcopy to determine abnormality of cells in the transformation zone?
- Schillers Iodine
2. Acetic acid
in cancerous/CIN cells what happens to the schillers iodine used at colposcopy?
It is not taken up by cancerous cells as they contain low amounts of glycogen and high amount of protein.
Normal cells - appear brown
in cancerous/CIN cells what happens to the acetic acid used at colposcopy?
Cancerous/CIN cells appear white
if a cervical tumour presses on the ureters what stage is it?
Stage 3
if a cervical tumour invades the bladder what stage is it ?
Stage 4
what is the imaging modality of choice for assessing spread of cervical cancer?
MRI
what is the difference between stage 1a and stage 1b cervical cancer?
Stage 1a - microscopic
Stabe 1b - clinically visible
what is the difference between stage 2a and stage 2b cervical cancer?
Stage 2a - involvement of 2/3 of the vagina without the parametrium
Stage 2b - invasion of parametrium
above what stage cervical cancer is chemo-radiotherapy performed alone and surgery not an option?
Stage >2b
2b - involvement of parametric and 2/3 of vagina
what is a trachelectomy?
Removal of the cervix
*radical trachelectomy includes removal of the parametrium
above what stage cervical cancer is chemo-radiotherapy performed alone and surgery not an option?
Stage >2b
2b - involvement of parametric and 2/3 of vagina
what type of cancer is cervical cancer?
Squamous cell carcinoma (80%)
what type of cancer is endometrial cancer?
adenocarcinoma (90%)
- of columnar endometrial gland cells
what are some of the causes of endogenous oestrogen excess?
PCOS
Oestrogen secreting tumours
Nullipairty
Late menopause
what are some of the causes of exogenous oestrogen excess?
Unopposed oestrogen therapy
Tamoxifen therapy
why is bilateral salpingoopherectomy performed in endometrial cancer but not cervical cancer?
Endometrial ca = hormone dependent
Cervical cancer - not hormone dependent
is chemotherapy a routinely used treatment in endometrial cancer?
No
what is the most common type of ovarian cancer?
serous cystadenocarcinoma
if there are bilateral masses is it more or less likely to be malignant ovarian cancer?
More likely
Other features of malignancy: rapid growth, ascites, solid/septate on USS, increased vascularity
what is the staging of ovarian cancer if the disease is beyond the pelvis but confined to the abdomen?
Stage 3
what is the staging of ovarian cancer if the disease is beyond the abdomen? eg. in the lungs
Stage 4
what is the staging of ovarian cancer if the disease is beyond the ovaries but confined to the pelvis?
Stage 2
what CA125 result would warrant a pelvic and abdominal ultrasound?
> 35IU/ml
at what risk of malignancy index score would you refer to a specialist MDT?
RMI >250
what should be done for investigations of ascites in ovarian cancer?
Paracentesis of ascites
which condition is associated with carcinoma of the vulva?
Lichen sclerosis
what treatment is offered to women with >Stage 1b vulval cancer?
Triple incision radical vulvectomy
what symptom is indicative of tubal cancer?
Florid discharge
which speculum should be used in the examination of urinary incontinence?
Sim’s speculum
Look for cystocele or uretherocele
which drug is licensed for the treatment of urinary stress incontinence?
Duloxetine (SNRI)
what is the difference between overactive bladder and detrusor overactivity?
OAB: urgency with or without incontinence, usually with frequency or nocturne
Detrusor overactivity: urodynamic diagnosis - involuntary detrusor contraction during the filling phase which may be spontaneous or provoked
*can have symptoms of OAB without detrusor overactivity and vice versa
