GYNAECOLOGY Flashcards
(228 cards)
1
Q
What are fibroids?
A
BENIGN tumours of the myometrium
2
Q
When are fibroids more common?
A
Around the menopause (regress after) and HRT can feed growth
3
Q
When are fibroids less common?
A
If parous, if been on the combined pill
4
Q
What are the 3 types of fibroids?
A
Intramural, subserosal, submucosal
5
Q
What is fibroid growth dependent on?
A
Oestrogen and progesterone which is why they regress after menopause due to less circulating oestrogen (unless on HRT)
6
Q
5 symptoms of fibroids?
A
50% asymptomatic. MENORRHAGIA DYSMENORRHOEA INTERMENSTRUAL loss URINARY symptoms if large SUBFERTILITY if tubes blocked or implantation failed
7
Q
On examination of fibroids…
A
Solid palpable mass, either one mass continuous with uterus or several small masses
8
Q
4 gynaecological risks/complications of fibroids
A
CALCIFY
TORT
DEGENERATE and cause pain/haemorrhage
0.1% malignant
9
Q
4 obstetric risks/complications of fibroids
A
Premature labour
Malpresentation
Obstruction
Post partum haemorrhage
10
Q
Investigations for fibroids (3/4)
A
Ultrasound, MRI
Laparoscopy
Possible hysteroscopy
11
Q
4 medical treatments of fibroids (if large/symptomatic)
A
Tranexamic acis
NSAIDs
Progestens i.e. Mirena coil
GnRH agonists in short courses if not conceiving
12
Q
4 surgical treatments of fibroids (if large/symptomatic)
A
Hysteroscopic surgery with presurgical GnRH agonists
Open/laparoscopic myomectomy
Hysterectomy
Artery embolisation/uterine ablation
13
Q
When is endometrial cancer most common?
A
Age 60, 15% are premenopausal
14
Q
What is the most common type of endometrial cancer
A
Adenocarcinoma of columnar endometrial gland cells
15
Q
6 risk factors for endometrial cancer
A
High OESTROGEN production Oestrogens used unopposed by progestogens Obesity PCOS Nulliparity Late menopause Tamoxifen
16
Q
2 protective factors for endometrial cancer
A
Combined oral contraceptive pill
Pregnancy
17
Q
What premalignant disease occurs before endometrial cancer
A
Endometrial hyperplasia with atypia
18
Q
4 symptoms of endometrial cancer
A
Postmenopausal bleeding
If premenopausal - irregular bleeding
Abdominal pain
Dyspareunia
19
Q
Where does endometrial cancer spread (3) including lymph (2)
A
Cervix, upper vagina, ovaries
Pelvic and para aortic lymph nodes
20
Q
Investigations for endometrial cancer (3)
A
Ultrasound
Pipelle endometrial biopsy
Hysteroscopy
21
Q
Treatment for endometrial cancer (3)
A
Hysterectomy and bilateral sapingoopherectomy
Staged after hysterectomy, if high risk radiotherapy for lymph nodes
Chemo if advanced
22
Q
5 types of ovarian malignancy
A
Epithelial tumours (50% Adenocarcinoma, 25% Endometrioid carcinoma, 10% Clear cell carcinoma)
Germ cell tumours i.e. teratoma
Sex cord stromal tumours
23
Q
Define X cancer
A
A malignant neoplasm arising from the tissues of the X
24
Q
When are epithelial ovarian tumours more common?
A
Postmenopausal women
May be borderline malignant first - surgical removal
25
When are germ cell tumours more common and what is the main type?
In younger women, progress more quickly and severely
| Dysgerminoma most common type
26
What is a teratoma?
Type of germ cell tumour
Contains differentiated teeth and hair
If small, asymptomatic but if large rupture painful
27
What are the 4 most common primary cancers for ovarian metastases?
Breast
Stomach (Krukenberg tumour)
Bowel
Endometrial
28
Why does ovarian cancer present late?
Often silent and detected when they are very large and cause abdominal distension
Vague symptoms
29
Risk factors for ovarian cancer (4)
```
ANYTHING THAT INCREASES NO. OF OVULATIONS
Early menarche
Late menopause
Nulliparity
BRCA1/2, HNPCC genes
```
30
Protective factors for ovarian cancer (3)
Pregnancy
Lactation
COCP
31
Symptoms of ovarian cancer (6)
```
Abdominal distension
Early satiety
Increased urinary urgency/frequency
Vaginal bleeding
Altered bowel habit i.e. constipation
Abdominal/pelvic pain
```
32
3 signs of ovarian cancer O/E
Abdominal/pelvic mass
Ascites
Cachexia
33
Investigations for ovarian cancer (4)
Ca125 if over 50 and symptomatic
If raised, USS
Alpha fetoprotein and beta hCG for germ tumours
CT for metastases
34
How is risk of ovarian cancer calculated
USS score, if menopausal and Ca125 levels
35
Treatment of ovarian cancer (4)
Laparotomy and total hysterectomy, bilateral salpingoopherectomy and partial omentectomy (if young preserve uterus and other ovary if possible)
Peritoneal and lymph node biopsies
Chemotherapy if advanced
Radiotherapy for germ cell tumours
36
Complications of ovarian cysts (3)
Rupture
Haemorrhage
Torsion
37
How are ovarian cysts detected?
If silent, on USS
If large, cause distension
Pain from complications
38
What is an endometriotic cyst? (endometrioma)
Caused by endometriosis leading to accumulation of blood in 'chocolate' cysts
39
What is a functional cyst?
Follicular cyst - persistently enlarged follicles
Lutein cyst - persistently enlarged corpus luteum
Only found before menopause
COCP protective as inhibits ovulation
Small chance of malignant change
40
What is endometriosis and where does it commonly occur?
The presence and growth of tissue similar to endometrium outside the uterus
Uterosacral ligaments and on the ovaries
41
When is endometriosis more common?
Age 30-45
| If nulliparous
42
What is endometriosis dependent on?
Oestrogen - regresses in pregnancy and after menopause
43
Complications of endometriosis (4)
Inflammation
Progressive fibrosis
Adhesions
Rupture
44
What is a theory of endometriosis aetiology
Retrograde menstruation - when menstruating some tissue goes up and escapes through fallopian tubes then spreads
Individual factors determine if it grows
45
Symptoms of endometriosis (5)
```
Often absent
Chronic, cyclical pelvic pain
Dysmenorrhoea
Deep dyspareunia
Subfertility
Dyschezia during menses
Cyclical haematuria/rectal bleeding if severe
```
46
Signs on examination of endometriosis (3)
Tenderness/thickening behind uterus or in adnexa
Advanced - retroverted uterus
Advanced - Immobile rectovaginal nodule
47
Investigations for endometriosis (4)
Bloods for anaemia, hormones
Laparoscopy with biopsy
TV USS if ?ovarian endometrioma
MRI if ?extensive spread
48
Treatment of symptomatic endometriosis
Pain relief - NSAIDs, opiates
Medical - GnRH analogues, COCP, progestogens
Surgical - diathermy resection, remove adhesions, remove endometriomas
Last resort hysterectomy and bilateral salpingoopherectomy
49
What is an ectopic pregnancy?
When the embryo implants outside the uterus, most commonly in the fallopian tube in the ampulla
These sites are not able to sustain trophoblast invasion so bleeding or rupture can occur
50
Risk factors for ectopic pregnancy (8)
```
Older age
Low socioeconomic class
Factors damaging the tubes -
Pelvic inflammatory disease
Assisted conception
Pelvic surgery especially tubal
Previous ectopic
Smoking
Copper IUD (as only prevents uterine pregnancy)
```
51
Symptoms of ectopic pregnancy (5)
```
Abnormal PV bleeding
Pain in lower abdomen
Collapse
Shoulder tip pain
Amenorrhoea 4-10 weeks
```
52
On examination signs of ectopic pregnancy (6)
```
Hypotension
Tachycardia
Rebound tenderness of abdomen
Cervical excitation causes pain
Adnexal tenderness
Closed cervical os and smaller uterus than expected for gestation
```
53
Investigation of ectopic pregnancy (4)
Urine hCG pregnancy test
TV USS detects uterine pregnancies over 5 weeks
Serum hCG - declining or slower rising (<50% in 48hr) suggests not intrauterine
Laparoscopy gold standard
54
3 types of management of ectopic pregnancy and when indicated
Conservative observation if small, unlikely to rupture
Medical if clinically stable, unruptured with no fetal cardiac activity and <3000 hCG
Surgical if haemodynamically unstable or severe symptoms
55
What is medical management of ectopic pregnancy
Single dose methotrexate
Monitor hCG
Second dose or surgery may be needed
56
What is surgical management of ectopic pregnancy
Laparoscopy/laparotomy gold standard
Salpingectomy to remove tube
Salpingostomy just to remove ectopic (increased risk for RPC and future ectopic but preserves fertility if other tube damaged)
57
Define miscarriage
When the foetus dies or delivers dead before 24 completed weeks of gestation (majority before 12), occurring in around 20% of pregnancies
58
What causes miscarriage
Increased maternal age
Isolated chromosomal abnormalities (>60%)
If recurrent, may be from genetic abnormality, anatomical problem, antiphospholipid antibodies, infection, smoking, PCOS
59
Name 6 types of miscarriage
```
Threatened miscarriage (25% miscarry)
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Missed miscarriage
```
60
Describe threatened miscarriage
Bleeding
Foetus alive
Uterus expected size
Cervical os closed
61
Describe inevitable miscarriage
Miscarriage that is about to occur.
Heavy bleeding
Foetus may be alive, but will die
Cervical os open
62
Describe incomplete miscarriage
Heavy bleeding
Some foetal tissue passed, some retained
Cervical os open
63
Describe complete miscarriage
All foetal tissue passed
Bleeding diminished or stopped
Uterus small
Os closed
64
Describe septic miscarriage
Uterus infected causing endometritis
Offensive vaginal loss
Tender uterus
Possible abdominal pain, peritonism, fever
65
Describe missed miscarriage
Foetus did not develop or died in utero
Not recognised until bleeding, or USS
Uterus smaller than expected
Os closed
66
2 general symptoms of miscarriage
Bleeding
| Pain from contractions
67
Investigations of miscarriage (3)
USS
Blood hCG levels (increasing <66%/48hr if viable intrauterine)
Rhesus group bloods
68
General management of miscarriage (5)
Admit if suspected ectopic, sepsis, heavy bleeding
Removal of products in the os
IM ergometrine to contract uterus and stop bleeding if non viable
IV ABx if infected
Anti-D if rhesus -ve
69
Expectant management of miscarriage is...
successful in 80% within 2-6 weeks if incomplete, lower if missed
70
Medical management of miscarriage
Prostaglandin misoprostol (possibly with progesterone mifepristone before) successful in >80% if incomplete, lower if missed
71
Surgical management of miscarriage
Evacuation of retained products of conception under GA with vacuum aspiration
>95% successful
72
What is CIN?
Cervical intraepithelial neoplasia (cervical dysplasia)
Premalignant condition of the cervix where atypical cells are found in the squamous epithelium
Can be mild I moderate II or severe III
73
Significance of CIN to cervical cancer
Dyskaryotic, frequently mitosing cells
Malignancy ensues if severe dysplasia
1/3 of CIN II/III will develop cancer in 10 years if untreated
74
Cause of CIN?
| Risk factors
```
Cause - Human papilloma virus
RFs - Number of sexual encounters
COCP
Smoking
Immunocompromise
```
75
What is the cervical screening programme
Vaccine for teenage girls
Cervical smears from 25-49 every 3 years then every 5 years from 49-64
If CIN II/III present, excise transformation zone with diathermy (LLETZ) and take biopsy for cancer
76
What are the two types of cervical cancer
90% squamous cell carcinomas
| 10% columnar cell adenocarcinomas
77
What are the two peaks of incidence of cervical cancer
30s and 80s
| Most present between 25-49
78
What is the cause of cervical cancer
Same as CIN - HPV found in all cases
79
Symptoms of cervical cancer (3)
Postcoital bleeding
Offensive vaginal discharge
Postmenopausal or intermenstrual bleeding
80
Give 3 late stage symptoms of cervical cancer
Uraemia
Haematuria
Rectal pain and bleeding
81
Sign on examination of cervical cancer
Palpable mass or ulcer on cervix
82
Investigations of cervical cancer (4)
Biopsy
Examination under anaesthetic
Cystoscopy if ?bladder involvement
MRI for staging and spread
83
Management of cervical cancer
Stage 1a - cone biopsy/LLETZ, hysteroscopy if older
Stage 1/2a - if negative nodes, hysterectomy and node clearance
If positive nodes chemoradiotherapy
If negative nodes and want to reserve fertility, trachelectomy - removes most of cervix and upper vagina and reinforces internal os with stitches
Severe or if older, unfit for surgery - radio and chemotherapy even if nodes negative
84
Types of vaginal carcinoma
Primary squamous cell carcinoma - quite rare
| Secondary common from cervix, uterus, vulva
85
Symptoms of vaginal carcinoma (3)
Bleeding
Discharge
Mass/ulcer
86
Treatment of vaginal carcinoma
Radiotherapy
| Possible surgery
87
What is the premalignant disease to vulval carcinoma?
Vulval intraepithelial neoplasia
88
What is the most common type of vulval carcinoma
Squamous cell carcinoma
89
Risk factors of vulval carcinoma (5)
```
Lichen sclerosis
Smoking
Age
Immunosuppression
Paget's disease of vulva
```
90
Symptoms of vulval carcinoma (4)
Itching
Bleeding
Discharge
Possible mass
91
Investigations of vulval carcinoma
Biopsy
| Assess fit for surgery
92
Treatment of vulval carcinoma
Stage 1a - wide local excision
Other - wide local excision and groin lymphadenectomy
Possible adjuvant radiotherapy before surgery
93
What is the age range for vaginal and vulval carcinomas
Older women over 60
94
What are polycystic ovaries?
Polycystic describes the appearance of multiple small follicles in an enlarged ovary on TVUSS
20% of woman have polycystic ovaries but normal cycles
95
Prevalence of PCOS and relation to infertility
5% have PCOS
| Makes up 80% anovulatory infertility
96
Diagnostic criteria for PCOS (2 of 3)
Polycystic ovaries on USS
Irregular periods >35 days apart
Hirsutism
97
What is hirsutism
Raised testosterone, acne, excess hair
98
What causes PCOS?
```
Genetic susceptibility
Disordered LH and raised insulin
Increased androgen production
Disrupted folliculogenesis and ovulation
Obesity (also increases insulin and androgens)
```
99
Symptoms of PCOS (5)
```
Obesity
Acne
Excess hair
Oligo/amenorrhoea
Subfertility
```
100
Investigations for PCOS(4)
Test FSH, prolactin, TSH for anovulation
Serum testosterone
LH levels may be raised
USS
101
Treatment for PCOS (5)
```
Lose weight
COCP
Anti androgens - spironolactone
Metformin reduces insulin, hirsutism, promotes ovulation
Eflornithine for hirsutism
```
102
Treatment for PCOS if conceiving (4)
Clomifene to induce ovulation - limit 6 months
Ovarian diathermy
Gonadotrophins
IVF
103
Define dysmenorrhoea
Painful menstruation
104
Causes of dysmenorrhoea (3)
High prostaglandin levels in endometrium
Uterine contractine
Uterine ischaemia
105
Define primary dysmenorrhoea
When no organic cause is found, usually coincides with the start of menstruation, affects 50% of women
106
Treatment for primary dysmenorrhoea
NSAIDs
| COCP - ovulation suppression
107
Define secondary dysmenorrhoea
Pain due to pelvic pathology, often precedes menstruation and relieved by onset
108
Other symptoms of secondary dysmenorrhoea
Deep dyspareunia
Menorrrhagia
Irregular menstruation
109
Investigations for dysmenorrhoea
Pelvic USS
| Laparoscopy
110
Causes of secondary dysmenorrhoea
```
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumours
```
111
What is premenstrual syndrome?
Psychological and physical symptoms that get worse in the luteal phase
112
Define menorrhagia
Excessive menstrual bleeding in an otherwise normal cycle, interfering with physical/emotional/social quality of life, possibly occurring with other symptoms
80mL blood loss
Affects 1/3 of women, most subclinical
113
Causes of menorrhagia (6)
```
Fibroids/polyps
Chronic pelvic infection
Ovarian/endometrial/cervical malignancies
Prostaglandin changes
Anticoagulants, Von Willebrands
Thyroid disease
```
114
Symptoms of menorrhagia (4)
Flooding and clots is excessive loss
Anaemia
Irregular enlarged uterus if fibroids
Tender uterus if adenomyosis
115
Investigations of menorrhagia (6)
```
Check Hb
Check coagulation
TFTs
Pelvic TVUSS
Endometrial pipelle biopsy
Hysteroscopy
```
116
Treatment of menorrhagia (7)
1 - progestogen IUS (mirena)
2 - tranexamic acid for 4 days during menstruation
2 - NSAIDs (inhibit prostaglandin synthesis)
2 - COCP
3 - oral/IM progestogens
3 - GnRH agonists for 6 months
4 - Surgical ablation/hysterectomy
117
Define amenorrhoea
Absence of menstruation
118
Define primary amenorrhoea
Menstruation has not started by age 16 - may be manifestation of delayed puberty (no secondary sex characteristics by 14) or problem with menstrual outflow
119
Define secondary amenorrhoea
Previously normal menstruation ceases for 6 months or more
120
Causes of primary amenorrhoea - non pathological (2)
Constitutional delay, medications (progestogens, GnRH analogues, antipsychotics)
121
Causes of primary amenorrhoea - pathological (11)
```
Anorexia
Athleticism
Psychological
Hyperprolactinaemia
Hypo/hyperthyroid
Adrenal tumours/hyperplasia
PCOS
Premature ovarian failure
Turner's/gonadal dysgenesis
Androgen insensitivity
Imperforate hymen, vaginal septum
```
122
Causes of secondary amenorrhoea - non pathological (4)
Pregnancy, lactation, menopause, medications
123
Causes of secondary amenorrhoea - pathological (10)
```
Anorexia
Athleticism
Psychological
Hyperprolactinaemia
Hyper/hypothyroid
Adrenal tumour
PCOS
Premature ovarian failure
Asherman's syndrome
Cervical stenosis
```
124
Mechanism by which anorexia/athleticism causes amenorrhoea and treatment
Hypothalamic hypogonadism - GnRH and so LH/FSH reduce and so does oestrogen. Treat with COCP
125
Causes of hyperprolactinaemia and treatment
Pituitary hyperplasia, benign adenomas, hypo/erthyroidism. Prolactin inhibits GnRH. Treat with bromocriptine, surgery, thyroid hormones
126
Define chronic pelvic pain
Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse
127
Causes of chronic pelvic pain (7)
```
Endometriosis/adenomyosis
Adhesions
IBS
Interstitial cystitis
Depression, sleep disorders
PID
Pelvic venous congestion
```
128
Treatment of chronic pelvic pain
Treat cause i.e. diet and antispasmodics for IBS, analgesia, COCP, GnRH agonist, HRT, IUS, laparoscopy if unresolved, possible gabapentin or amitriptyline
129
What is pelvic inflammatory disease
Sexually transmitted pelvic infection, usually coexisting with endometritis
130
Risk factors for PID (4)
Young age
Low socioeconomic class
Sexually active (multiple partners, no condoms)
Nulliparous
131
Cause of PID
Ascending bacteria in the vagina/cervix, sexual factors account for 80%
Can be from descending infection from pelvis
132
What can cause STI spread to pelvic
Spontaneous
Uterine instrumentation
Childbirth or miscarriage complications
133
Most common STI causes of PID
Chlamydia and gonorrhoea
| Frequently polymicrobial
134
Symptoms of PID (5)
```
Many asymptomatic
Subfertility
Menstrual disturbance
Bilateral lower abdominal pain
Deep dyspareunia
Abnormal PV bleeding/discharge
```
135
Signs of PID (4)
```
Tachycardia and fever if severe
Signs of peritonism if severe
Bilateral adnexal tenderness
Cervical excitation
PV bleeding or discharge
```
136
Investigations for PID (5)
```
Endocervical swabs
Blood cutures if fever
WBC, CRP
Pelvic USS
Laparoscopy (+biopsy and culture)
```
137
Treatment of PID
Analgesia
| Antibiotics - ceftriaxone IM single dose, doxycycline, metronidazole BD 14 days orally
138
Complications of PID (5)
```
Abscess
Tubal damage
Subfertility
Ectopic pregnancy
Chronic infection and pain
```
139
What is chronic PID
A persisting infection due to no treatment or inadequate treatment. Treat with analgesia and different antibiotics
140
Symptoms of chronic PID (7)
```
Dense adhesions, obstructed and fluid filled tubes
Chronic pain
Dysmenorrhoea
Deep dyspareunia
Heavy/irregular bleeding
Chronic PV discharge
Subfertility
```
141
Signs of chronic PID (3)
Abdominal tenderness
Adnexal tenderness
Retroverted uterus
142
Investigations of chronic PID (2)
Transvaginal USS
| Laparoscopy
143
What is utero-vaginal prolapse
Descent of the uterus and/or vaginal walls beyond anatomical confines, occurring as a result of weakness in supporting structures
144
Types of prolapse (5)
```
Urethrocoele
Cystocoele
Apical prolapse
Enterocoele
Rectocoele
```
145
What is a urethrocoele
Prolapse of the lower anterior vaginal wall, including the urethra
146
What is a cystocoele
Prolapse of the upper anterior vaginal wall, including bladder (+urethra=cystourethrocoele)
147
What is an apical prolapse
Prolapse of uterus, cervix and upper vagina
148
What is an enterocoele
Prolapse of upper posterior vaginal wall, including small bowel
149
What is a rectocoele
Prolapse of lower posterior vaginal wall, including anterior rectum
150
Causes of prolapse (8)
```
Pregnancy and vaginal delivery - 50% of all parous women have some prolapse
Large baby
Prolonged labour
Instrumental delivery
Obesity
Chronic cough or constipation
Pelvic mass
Surgery
Abnormal collagen disorder - Ehler Danos
```
151
Symptoms of prolapse (4)
Dragging or lump sensation - worse at end of day or when standing
Bleeding, discharge
Problems during intercourse
Urinary symptoms
152
Investigations of prolapse (4)
Abdominal and bimanual examination
Speculum
Pelvic USS
Urodynamic tests
153
Treatment of prolapse (4)
Weight reduction and physio
Pessaries - ring, shelf, with topical oestrogen
Vaginal hysterectomy
Hysteropexy - mesh to fix structures
154
Describe physiological vaginal discharge
Non offensive, no itch, clear discharge
Increases around ovulation, pregnancy, if on pill
MAY be due to cervical ectropion (give cryotherapy)
155
Symptoms, treatment of atrophic vaginitis
Redness
Raised pH
Increased discharge
Treat with oestrogen
156
Discharge symptoms of malignancy
Bloody offensive discharge
157
What is stress incontinence?
Involuntary leakage of urine on effort or exertion, or sneezing/coughing, main cause of incontinence in women
158
Main cause of stress incontinence?
Urethral sphincter weakness
159
Risk factors for stress incontinence? (5)
```
Pregnancy and vaginal delivery
Prolonged labour/instrumental
Age
Obesity
Previous hysterectomy
```
160
Mechanism of incontinence?
Increase in intra-abdominal pressure, bladder is compressed and pressure rises
If bladder neck has slipped below the pelvic floor because its support is weak, bladder pressure will be greater than bladder neck pressure
Unless pelvic floor muscles can compensate
161
Symptoms of stress incontinence? (4)
Leakage of urine on exertion
May coexist with faecal incontinence
May have prolapse
May have urge incontinence
162
Investigations of stress incontinence?
Urine dipstick
| Cystometry to exclude overactive bladder
163
Management of stress incontinence? (6)
```
Lose weight
Treat cough e.g. stop smoking
Pelvic floor muscle training for 3 months
Vaginal cones/sponges
2nd line duloxetine (SNRI)
Surgery - mid urethral sling
```
164
What is overactive bladder?
Urgency, with or without urge incontinence, usually with frequency or nocturia in the absence of proven infection
165
Causes of overactive bladder? (3)
Detrusor overactivity - involuntary contractions in filling
Can follow operations for USI
Possible neuropathy - MS, spinal cord injury causing bladder contractions
166
Mechanism of overactive bladder?
Urgency, bladder pressure may overcome urethral pressure and patient leaks
Can be spontaneous or with provocation - running tap, coughing
167
Symptoms of overactive bladder? (4)
Urgency
Frequency
Nocturia
May coexist with faecal urgency or prolapse
168
Investigations of overactive bladder? (2)
Diary - frequent passage of small volumes of urine esp. at night
Cystometry shows contraction on filling
169
Management of overactive bladder? (7)
Reduce fluid intake, avoid caffeine
Bladder training - resist urgency, void to a timetable
Anticholinergics (antimuscarinics) relax detrusor
Oestrogen
Botulinum toxin A weakens muscle
Neuromodulation and sacral nerve stimulation
Surgery for very severe or resistant
170
What is a vaginal fistula?
Abnormal opening to bladder, bowel or rectum allowing urine or stool to leak through vagina
171
Types of vaginal fistula (6)
```
Vesicovaginal (to bladder)
Uterovaginal
Urethrovaginal
Rectovaginal
Colovaginal
Enterovaginal (to small intestine)
```
172
Causes of vaginal fistula? (5)
```
Abdominal surgery - C section, hysterectomy
Malignancy
IBD, diverticulitis
Infection
Trauma
```
173
Treatment of vaginal fistula? (3)
If small, catheter to drain and allow to heal
Antibiotics if infected
Most need surgery - mesh repair
174
What is ovarian torsion?
Twisting of the ovary around its ligamentous supports, blocking adequate blood supply
175
Symptoms of ovarian torsion? (4)
Abdo pain
Abdo mass
Nausea
Vomiting
176
Management of ovarian torsion? (2)
Possible TVUSS with Doppler to identify
| Laparoscopic diagnosis and treatment - surgical emergency to detort and fix in place
177
What is lichen sclerosis?
Vulval epithelium thinning with loss collagen
178
Cause of lichen sclerosis?
Autoimmune basis, thyroid disease may coexsit
| Postmenopause
179
Symptoms of lichen sclerosis? (5)
Severe pruritis
Trauma from scratching - bleeding, skin splitting
Dyspareunia
Pink-white papular fissured skin
Possible adhesions narrowing vaginal opening
180
Treatment of lichen sclerosis? (2)
Topical steroids
| Biopsy to exclude vulval cancer
181
What is adenomyosis? (3)
Presence of the endometrium and its underlying stroma in the myometrium
Associated with endometriosis, fibroids
Oestrogen dependent
182
Symptoms of adenomyosis?
Menorrhagia
Dysmenorrhoea
Enlarged uterus - may have pockets of menstrual blood within myometrium
183
Management of adenomyosis? (5)
```
MRI to diagnose
Progesterone IUS
COCP
NSAIDs
Hysterectomy often needed
```
184
What is abnormal uterine bleeding?
Irregular uterine bleeding (outside normal period) in the absence of recognisable pelvic pathology, systemic disease, or pregnancy
185
Cause of abnormal uterine bleeding?
Imbalance in sex hormones
186
Disease causes of abnormal uterine bleeding?(4)
PCOS
Endometriosis
Polyps/fibroids
STIs
187
Symptoms commonly coexisting with abnormal uterine bleeding? (4)
Mennorhagia
Intermenstrual bleeding
Pelvic pain
Breast pain
188
Management of abnormal uterine bleeding? (4)
```
Diagnosis of exclusion
COCP
IUS, implant
Clomifene - resets menstruation
Surgery - D and C, ablation
```
189
What is androgen insensitivity syndrome?
A person who is genetically male (who has one X and one Y chromosome) is resistant to male hormones (androgens).
The person has some or all of the physical traits of a woman, but the genetic makeup of a man
190
What are endometrial polyps?
Small, usually benign tumours that grow into the uterine cavity from the endometrium
191
Causes of endometrial polyps?
High oestrogen levels
| Tamoxifen
192
Symptoms of endometrial polyps? (3)
Menorrhagia
Intermenstrual bleeding
Occasional prolapse
193
Management of endometrial polyps? (3)
Diagnosed at USS or at hysteroscopy often
Biopsy for carcinoma
Resect polyp with diathermy
194
What are congenital uterine malformations?
Abnormalities resulting from differing degrees of failure of fusion of the two Mullerian ducts at around 9 weeks gestation
A spectrum, mainly asymptomatic
195
Symptoms of congenital uterine malformations? (3)
May be diagnosed at pregnancy - cause malpresentations, recurrent miscarriage, retained placenta
Sexual problems if vaginal septum (didelphys)
Amenorrhoea if imperforate hymen
196
Types of congenital uterine malformations? (6)
Didelphys - total failure to fuse, 2 uterine cavities and 2 vaginas
Bicornuate - partially divided
Unicornuate - one side only developed
Hypoplastic
Septate - thin dividing tissue in uterus
Arcuate - concave shape towards the fundus
197
Treatment of congenital uterine malformations? (3)
Hysteroscopic resection if small septa
Possible surgery for other types
Assisted reproduction
198
What is Asherman's syndrome?
Uncommon consequence of excessive curettage at ERPC after miscarriage/delivery causing adhesions in the uterus
199
Symptoms of Asherman's syndrome (3)
Reduction in menstrual flow
Infrequent periods
Infertility
200
Management of Ashermans syndrome (2)
Hysteroscopy to diagnose
| Dissection of adhesions - common recurrence
201
What is a prolactinoma?
Benign noncancerous tumor of the pituitary gland that produces a hormone called prolactin
202
Symptoms of prolactinoma? (5)
```
Infertility
Amenorrhoea
Irregular periods
Vaginal dryness
Lactation (galactorrhoea)
```
203
Diagnosis of prolactinoma? (2)
Bloods - prolactin level, TFTS
| MRI to diagnose
204
Treatment of prolactinoma? (2)
Dopamine agonists - bromocriptine (inhibits prolactin)
| Surgery, possible radiation
205
What is premenstrual syndrome?
Encompasses psychological, behavioural and physical symptoms that are experienced regularly during the luteal phase of the menstrual cycle, resolve by end of menstruation
206
How common is PMS?
95% experience, only 5% severe
207
Cause of PMS?
Differing neurochemical responses to ovarian function and sex hormones e.g. progesterone
208
Symptoms of PMS? (6)
```
ALL CYCLICAL
Tension/irritability
Depression
Loss of control
Bloating
GI upset
Breast pain
```
209
Management of PMS? (5)
SSRIs either continuously or in second half of cycle
COCP
Oestrogen patches
GnRH and oestrogen - pseudomenopause
Bilateral oopherectomy if severe - with HRT/COCP after
210
Medical methods of TOP?
Mifepristone - antiprogesterone
with Misoprostol - prostaglandin 2 days later
Labour is initiated
211
When is medical TOP done?
Up to 24 weeks.
| If after 22 weeks potassium chloride injected into the fetal heart to prevent live birth
212
Surgical methods of TOP?
Suction curretage
| Dilatation and evacuation
213
When is surgical TOP done?
Up to 24 weeks
Suction curretage between 7-13
D+C above 13 weeks
214
Complications of TOP? (4)
Haemorrhage
Infection
Uterine perforation
Abortion failure
215
What is menarche?
Onset of menstruation, normally the last manifestation of puberty in the female, average 13 years
216
Hormone axis controlling menstruation?
Hypothalamic-pituitary-gonadal axis
GnRH pulses, releasing FSH and LH
Stimulates ovarian oestrogen release
217
Purpose of menstruation?
Hormones cause ovulation and induce changes in the endometrium preparing it for implantation if fertilisation occurs
218
Days 1-4 of the menstrual cycle? (2)
First day of the cycle is the first day of menstruation
| Endometrium shed as hormonal support withdrawn - possible painful contraction
219
Days 5-13 of the menstrual cycle? (4)
Pulses of GnRH from the hypothalamus stimulate LH and FSH release which induce follicular growth
Follicles produce oestradiol and inhibin which suppress FSH so only 1 oocyte matures
When oestradiol levels are very high, LH surge occurs and ovulation follows after 36 hours
Oestradiol encourages proliferative myometrium
220
Days 14-28 of the menstrual cycle? (4)
The follicle from the released egg becomes the corpus luteum which produces oestrogen progesterone
Secretory changes in the endometrium
Corpus luteum regresses if egg is not fertilised
As hormonal support fails, endometrium breaks down and cycle restarts
221
What are the phases of the menstrual cycle?
Menstruation
Proliferative (follicular) phase
Secretory (luteal) phase
222
What is menopause?
Permanent cessation of menstruation following from loss of ovarian follicular activity, normally around 51 years
After 12 months of amenorrhoea
223
What is premature menopause?
Permanent amenorrhoea <40 years
224
What is perimenopause?
Time preceding menopause where periods become erratic
225
Symptoms of menopause?
```
Hot flushes
Insomnia
Skin and breast atrophy
Hair loss
Atrophic vaginitis
Prolapse
Urinary symptoms
Osteoporosis
CV disease
```
226
Investigations for menopause?
Low anti-Mullerian hormone
| Raised FSH
227
Treatment for menopause?
HRT to alleviate symptoms - risk of breast cancer
| Bisphosphonates for osteoporosis
228
What is HRT?
Use of exogenous oestrogens when endogenous secretion absent
