gynaecology Flashcards
how can vulcal cancer present
as lichen sclerosis and atrophius with fusion of the labia
Bartholins cyst explain
A subcutaeous pea sized deep in the lower third of labia produces mucus to lubricate the vulva and vagina and drains into the vestibule within the hymen and labia minora cyst forms when the duct gets blocked - at 5oclock and 7 o clock region
bartholins abscess
women in 20’s tender swelling of labia with erythema opportunist infections by vulval flora mixed anaerobic and aerobic growth commonly e coli stre and staph and prteus not STI!!!!!
Bartholins abscesss treatment
incision and drainage broad spec abx - amox and cefalexin can have marsupoalisation to keep the opening of cyst open
What it nabothian cyst
small mucus filled cyst in the surface of the cervix it is squamous and grows over the columnar epithelium of the endocervis blocking the cervical crypts and is absolutely normal
What is ectropian?
everted columar epithelium when the cells inside of the womb protrude out to the neck of the womb. It is oestrogen dependent and the pill COCP causes it
endometriosis pathophysiology
retrograde menstruation which thickens cyclically causing pain worse pre menstrually at the onset of the period frozen pelvis - scaring and adhesions which look grey/ white
depsotis occur in the ovaries caused chocolate cycts
symptoms of endometriosis
pre menstrual dysmenhorrea deep dysparenuria chronic pelvic pain
hwo is the uterus in endometriosis
retroverted
Diagnosis of endometriosis
confirmed by biopsy ca125 levels may be raised due to periotneal involvement but not a useful diagnostic tool
managment of endometriosis
- expectant - asymptomatic women with mild disease
- symptoms relif - analegesia
- Prevent hormonal stimulation of ectopic endometrium so inhibit ovarian hormone prodection - progestrogents , COCP, IUS, GnRh create temporary menopause and
Surgical treatment of endometriosis
diathermy or laser and excision
34y/o cyclical pelvic pain and deep dysparenuria parter and her trying to concieve for the last two years diagnositc laparoscopy reveals endometrial depostis and tubo ovarian adhesions
surgical mangement- she wishes to concieve and nothing will help her as much as surgery to insure adhesiosn are not blocking her. surgery may remove symptomatic relif anf improve chances of conception
17 y/O cyclic pelvic pain and deep dysparenuria has a boyfriend but no wish to concieve at present takes paracetamol and diclofenac with minimal effect diagnostic laposcopy demonstrates small amounts of endometriosis on the uterosacral ligaments
medical simple analgesics have helped so as ther endo is mild med option should be tried with COCP which can provide contraception too and surgical optiosn should be reserved for cases where med managment has failed or fertility is desired and she be carefully ocnsidered in someone so young
37 y/o undergone laparoscopic tubal sterilisation at the time of the sterilisation spots of endometroisi were found on the uterosacral ligaments in the pouch of douglas and on the obaries - denies any pelvis pain
no treatment needed mild eno which is aymptomatic - if symptomatic it would present with pain and subfertility in servere cases inflammation and fibrosis can lead to a frozen pelvis
why do you not want to start COC on patient from day 21 if are BREASTFEEDING
oestrogen may inhibit lactation
LH:FSH ratio in PCOS AND OESTORGEN
LH inc but only to a basal there is no surgery therefore the egg is never relevease and remains in ovaries to form cysts. with dec FSH oestrogen will be dec
symptoms of PCOS
- Acne and hirtism - Inc androgens
- Subfertility - anovulation
- heavy irrgeular bleeding - Lack of adequate luteal phase proliferaltive endometrium
USS of a PCOS
STRONGS OF PEARLS
Rotterdam criteria in PCOS
Summarises the many features of PCOS
S - Strings of pearls
H - hyperandrogenism(too much teststosterone) acne hirtis
O - oligomenhorrea - period at intervals > 35 days
P - prolactin normal
prolactin t4 and cortisol need to be normal and the first two are deffo needed for a diagnosis but this method is flawed as it does not tkaae into consideration the insulin resistance present in many people
blood tests for pcos
day 21 progestrogen, total or free testosterone , fasting glucose adnd lits to seei nsulin resistance
Procating T4 and TSH to see prolactinoma and hypothyroidism
How do you exclude congenital adrenal hyperplasia
17-hydroxyprogesterone measure
secondary amehorrea causes (4p’s)
PCOS Premature ovarian insufficentcy, prolactinoma, Pregnancy
management in pcos
is dependent on the clinical presentation
- weight loss
- acne - benzoyl peroxide and or Abx
- oligomenhorrea - check endo thickness and induce withdrawal bleed with progrestrogen or COC
- Infertility- weight loss, metformin, ovulation with clomifen IVF with gonadotrophins
What does clomifen do ?
blocks oestrogen recpetors at hypothalmus and pitutary to prevent negative feedback and lead to inc FSH stimulation folicular development
SE of clomifen
ovarian hyperstimulation where the ovary increases in sizze and multiple follicles release vegf causing ascities and if severe systemic reaction with shock
primary amenhorrea and secondary amenhorrea definition
primary is failure of menstruation by 16 years with otherwise normal sextual characteristics
Secondary is absent periods for 6 motnhs in a women who had previously regular periods or 12 months in women with irregular periods
Causes of amenhorrea
PREGNANCYYYYY!!!!!!!!!!!!!!
Hypothalamic - GnRH defisincey
Pituitary tumour- hyperprolactinoma inhibiting ovulation c pituitary necrosis in (sheehan syndrome)
Ovarian- PCOS premature ovarian insufficentcy
Outflow probs - imperforate hymen , cervical stenosis absent uterus (rokitansky !!!)
Investigations for amenhorrea
- pregnancy test
- thyroid function - hyper hypo inhibits ovulation
- LH/FSH 0 raised =ovarian insifficentcy
reduced = hypothalamic/pit problem
increased = FSH/LH
Testosterone - exclude androgen secreting tumour USS if abnormal gential tract suspected
treament of gonadotrophin insufficientcy
replace them if fertility desired if not COCP
pcos treatmenet
wl ,metformin /ovulation induction if fertility desired
wl cocp if fertility not desired
ovarian insifficentcy treatment
no treatment but COCP and HRT may improve symptoms eff donantion if fertiltiy desired
Gential treat abnormality treatment
outflow obstruction then its urgical
Tokitansky -no treatment surrogagcy
Chylamidia signs
dysuria and discharge intementsrual and post coital bleeding ascending infection acute salpingitis or PID
On hisotoly there will be elementsry bodies which become reticulocyte bodies which produces discharge
THE SWABS to use for this in female
the bacteria enters the endocervix in women therefore that needs to be endocervical swab
treatment of chylamidia
antibiotics oral doxycycline 100mg BD for 7 days erythromycin in pregnancy gonoccocu co infection then azihtromycin and ceftriazone SEX in trichomonas ?
Signs and symptoms of PID
typically bilateral deep dysparenuria vaginal discharge and abnormal vaginal bleeding
Cuae of PID
mixture of organism as the travel up the genital tract
Acute PID/SALPINGITIS symptoms
low abdo tenderness, fever, cervisitits cervical motion tenderness and adenexal tenderness
investigation in acute PID / salpingitis
FBC CRP triple swabs pelvic USS or laparoscopy if uncertain
Treatment of PId/ SALPINGITIS
ceftriaxone then oral doxycycline metronidazole for 14 days if fever unwell pertonism admit for IV therapy
Subfertility
How long do you need to try for at least
a failure to concieve after 12 months regular unprotected intercourse primary female partner never conceived sexondary female partner has conceived
2 years
commonest cause of subferitlity
annovulation can be due to hypothalamopituitary acis
hypthalamic causes of annovulation
stress anorexia
anti pit causes of annovulation
prolactinoma
ovarian causes of annovulation
PCOS or premature ovarian insifficentcy (D21 confirms ovulation)
How do you address tubal patency
with a hysterosapingogram where you fill and spill or a lapaoscopy and dye
male factor subfertiltiy and investigation
Azospermia- absent spermatozoa
few spemaozoa - oligospermia
excess or abnormal sperm - teratozoospermia
a significant proportion of immotile sperm asthenozoospermia
semen analysis count>15million motility >40% and forms of sperm >4
Treatment for subferitlity
conservative - weightloss smoking cessation refuce caffeine and alcohol intake and intercorurse 2-3 times a week timing cycyle not recommended as it creates stress
medical treatment - annovulation - comifene gonadoptrophines GNRH with or without asisted reporduction
treamtent presmature ovarian insufficiency subferiltiy
egg donation and iVF
Tubal damage IVF
tubal surgery or IVF
MALE FACTOR TREATMENT
asisted reporduction
The three asisted repro techniques
- intrauterine insemination - good for azospermia can select the fast sperm
- in vitrofertilidation
- intracytoplasmic sperm injections - single sperm into a single egg good for oligospermia
Difference betwen miscarrigae early preganacy loss and premature preterm labour
miscarrigae - >24 weeks
early preganancy loss <12 weeeks
early premetm labour is give steorids and its after 24 weeks
the imporance of uss in a miscarrigae
confirms location of the pregnancy femosntratess fetal heart rate on uss an is associated with a sucessful pregnancy and visualise the adenexa - for ectopics too
investigations in miscarrigae
FBC blood group and antibosy and rhesus status
three types of managment for a miscarriage
FIRST CONFIRM DIAGNOSIS WITH USS
1. expectant wait and see - first line and resolution takes wks
Explore other options if at increased risk of bleeding adverse exp of pregnancy or women prefers :
2. medical - vaginal prostaglafin misoprostolol
3. surgical - evaculation of retained products of conception
4. give anti d if rhesus negative
how to investigate a pregnancy of unknown origin on transvaginal uss
- will have done a TVUSS first
- HCG measure it
1500> = increased = intrauterine preganancy likely but its probs so early cant be seen on USS repeat in 7-14 dys
Suboptimal increase = ectopic pregnancy - clincial review within 24 hrs - look for this it should double every 2 days in early prehgnancy !!!
decreased = falling preganancy do a pregnancy test in two weeks
RF FOR ECTOPIC
and the three symptoms
P = Previous ectopic I = intrauterine contraceptive device P = prelvic inflammatory disease P = pelvic or tubal surgery A = assisted repro
bleeding amenhorrea and pain
pelvic exam of a ectopic
cervical motion tenderness
uterine size does it match gestation
how does molar prgegnancy present
vaginal bleeding in fisrt trimester with all symptoms of prhganncy exaggerated high HCG and hyperemesis gravidum
