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3A REVISION > GYNAECOLOGY > Flashcards

GYNAECOLOGY Flashcards

1
Q

What are fibroids?

A

BENIGN tumours of the myometrium

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2
Q

When are fibroids more common?

A

Around the menopause (regress after) and HRT can feed growth

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3
Q

When are fibroids less common?

A

If parous, if been on the combined pill

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4
Q

What are the 3 types of fibroids?

A

Intramural, subserosal, submucosal

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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)

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6
Q

5 symptoms of fibroids?

A 
50% asymptomatic.
MENORRHAGIA
DYSMENORRHOEA
INTERMENSTRUAL loss
URINARY symptoms if large
SUBFERTILITY if tubes blocked or implantation failed
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7
Q

On examination of fibroids…

A

Solid palpable mass, either one mass continuous with uterus or several small masses

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8
Q

4 gynaecological risks/complications of fibroids

A

CALCIFY
TORT
DEGENERATE and cause pain/haemorrhage
0.1% malignant

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9
Q

4 obstetric risks/complications of fibroids

A

Premature labour
Malpresentation
Obstruction
Post partum haemorrhage

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10
Q

Investigations for fibroids (3/4)

A

Ultrasound, MRI
Laparoscopy
Possible hysteroscopy

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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

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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

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13
Q

When is endometrial cancer most common?

A

Age 60, 15% are premenopausal

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14
Q

What is the most common type of endometrial cancer

A

Adenocarcinoma of columnar endometrial gland cells

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15
Q

6 risk factors for endometrial cancer

A 
High OESTROGEN production
Oestrogens used unopposed by progestogens
Obesity
PCOS
Nulliparity
Late menopause
Tamoxifen
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16
Q

2 protective factors for endometrial cancer

A

Combined oral contraceptive pill

Pregnancy

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17
Q

What premalignant disease occurs before endometrial cancer

A

Endometrial hyperplasia with atypia

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18
Q

4 symptoms of endometrial cancer

A

Postmenopausal bleeding
If premenopausal - irregular bleeding
Abdominal pain
Dyspareunia

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19
Q

Where does endometrial cancer spread (3) including lymph (2)

A

Cervix, upper vagina, ovaries

Pelvic and para aortic lymph nodes

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20
Q

Investigations for endometrial cancer (3)

A

Ultrasound
Pipelle endometrial biopsy
Hysteroscopy

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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

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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

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23
Q

Define X cancer

A

A malignant neoplasm arising from the tissues of the X

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24
Q

When are epithelial ovarian tumours more common?

A

Postmenopausal women

May be borderline malignant first - surgical removal

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25
Q

When are germ cell tumours more common and what is the main type?

A

In younger women, progress more quickly and severely

Dysgerminoma most common type

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26
Q

What is a teratoma?

A

Type of germ cell tumour
Contains differentiated teeth and hair
If small, asymptomatic but if large rupture painful

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27
Q

What are the 4 most common primary cancers for ovarian metastases?

A

Breast
Stomach (Krukenberg tumour)
Bowel
Endometrial

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28
Q

Why does ovarian cancer present late?

A

Often silent and detected when they are very large and cause abdominal distension
Vague symptoms

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29
Q

Risk factors for ovarian cancer (4)

A 
ANYTHING THAT INCREASES NO. OF OVULATIONS
Early menarche
Late menopause
Nulliparity
BRCA1/2, HNPCC genes
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30
Q

Protective factors for ovarian cancer (3)

A

Pregnancy
Lactation
COCP

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31
Q

Symptoms of ovarian cancer (6)

A 
Abdominal distension
Early satiety
Increased urinary urgency/frequency
Vaginal bleeding
Altered bowel habit i.e. constipation
Abdominal/pelvic pain
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32
Q

3 signs of ovarian cancer O/E

A

Abdominal/pelvic mass
Ascites
Cachexia

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33
Q

Investigations for ovarian cancer (4)

A

Ca125 if over 50 and symptomatic
If raised, USS
Alpha fetoprotein and beta hCG for germ tumours
CT for metastases

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34
Q

How is risk of ovarian cancer calculated

A

USS score, if menopausal and Ca125 levels

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35
Q

Treatment of ovarian cancer (4)

A

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

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36
Q

Complications of ovarian cysts (3)

A

Rupture
Haemorrhage
Torsion

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37
Q

How are ovarian cysts detected?

A

If silent, on USS
If large, cause distension
Pain from complications

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38
Q

What is an endometriotic cyst? (endometrioma)

A

Caused by endometriosis leading to accumulation of blood in ‘chocolate’ cysts

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39
Q

What is a functional cyst?

A

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

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40
Q

What is endometriosis and where does it commonly occur?

A

The presence and growth of tissue similar to endometrium outside the uterus
Uterosacral ligaments and on the ovaries

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41
Q

When is endometriosis more common?

A

Age 30-45

If nulliparous

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42
Q

What is endometriosis dependent on?

A

Oestrogen - regresses in pregnancy and after menopause

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43
Q

Complications of endometriosis (4)

A

Inflammation
Progressive fibrosis
Adhesions
Rupture

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44
Q

What is a theory of endometriosis aetiology

A

Retrograde menstruation - when menstruating some tissue goes up and escapes through fallopian tubes then spreads
Individual factors determine if it grows

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45
Q

Symptoms of endometriosis (5)

A 
Often absent 
Chronic, cyclical pelvic pain
Dysmenorrhoea
Deep dyspareunia
Subfertility
Dyschezia during menses
Cyclical haematuria/rectal bleeding if severe
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46
Q

Signs on examination of endometriosis (3)

A

Tenderness/thickening behind uterus or in adnexa
Advanced - retroverted uterus
Advanced - Immobile rectovaginal nodule

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47
Q

Investigations for endometriosis (4)

A

Bloods for anaemia, hormones
Laparoscopy with biopsy
TV USS if ?ovarian endometrioma
MRI if ?extensive spread

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48
Q

Treatment of symptomatic endometriosis

A

Pain relief - NSAIDs, opiates
Medical - GnRH analogues, COCP, progestogens
Surgical - diathermy resection, remove adhesions, remove endometriomas
Last resort hysterectomy and bilateral salpingoopherectomy

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49
Q

What is an ectopic pregnancy?

A

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

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50
Q

Risk factors for ectopic pregnancy (8)

A 
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)
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51
Q

Symptoms of ectopic pregnancy (5)

A 
Abnormal PV bleeding
Pain in lower abdomen
Collapse
Shoulder tip pain
Amenorrhoea 4-10 weeks
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52
Q

On examination signs of ectopic pregnancy (6)

A 
Hypotension
Tachycardia
Rebound tenderness of abdomen
Cervical excitation causes pain
Adnexal tenderness
Closed cervical os and smaller uterus than expected for gestation
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53
Q

Investigation of ectopic pregnancy (4)

A

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

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54
Q

3 types of management of ectopic pregnancy and when indicated

A

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

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55
Q

What is medical management of ectopic pregnancy

A

Single dose methotrexate
Monitor hCG
Second dose or surgery may be needed

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56
Q

What is surgical management of ectopic pregnancy

A

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)

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57
Q

Define miscarriage

A

When the foetus dies or delivers dead before 24 completed weeks of gestation (majority before 12), occurring in around 20% of pregnancies

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58
Q

What causes miscarriage

A

Increased maternal age
Isolated chromosomal abnormalities (>60%)
If recurrent, may be from genetic abnormality, anatomical problem, antiphospholipid antibodies, infection, smoking, PCOS

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59
Q

Name 6 types of miscarriage

A 
Threatened miscarriage (25% miscarry)
Inevitable miscarriage 
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Missed miscarriage
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60
Q

Describe threatened miscarriage

A

Bleeding
Foetus alive
Uterus expected size
Cervical os closed

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61
Q

Describe inevitable miscarriage

A

Miscarriage that is about to occur.
Heavy bleeding
Foetus may be alive, but will die
Cervical os open

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62
Q

Describe incomplete miscarriage

A

Heavy bleeding
Some foetal tissue passed, some retained
Cervical os open

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63
Q

Describe complete miscarriage

A

All foetal tissue passed
Bleeding diminished or stopped
Uterus small
Os closed

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64
Q

Describe septic miscarriage

A

Uterus infected causing endometritis
Offensive vaginal loss
Tender uterus
Possible abdominal pain, peritonism, fever

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65
Q

Describe missed miscarriage

A

Foetus did not develop or died in utero
Not recognised until bleeding, or USS
Uterus smaller than expected
Os closed

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66
Q

2 general symptoms of miscarriage

A

Bleeding

Pain from contractions

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67
Q

Investigations of miscarriage (3)

A

USS
Blood hCG levels (increasing <66%/48hr if viable intrauterine)
Rhesus group bloods

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68
Q

General management of miscarriage (5)

A

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

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69
Q

Expectant management of miscarriage is…

A

successful in 80% within 2-6 weeks if incomplete, lower if missed

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70
Q

Medical management of miscarriage

A

Prostaglandin misoprostol (possibly with progesterone mifepristone before) successful in >80% if incomplete, lower if missed

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71
Q

Surgical management of miscarriage

A

Evacuation of retained products of conception under GA with vacuum aspiration
>95% successful

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72
Q

What is CIN?

A

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

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73
Q

Significance of CIN to cervical cancer

A

Dyskaryotic, frequently mitosing cells
Malignancy ensues if severe dysplasia
1/3 of CIN II/III will develop cancer in 10 years if untreated

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74
Q

Cause of CIN?

Risk factors

A 
Cause - Human papilloma virus
RFs - Number of sexual encounters
COCP
Smoking
Immunocompromise
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75
Q

What is the cervical screening programme

A

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

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76
Q

What are the two types of cervical cancer

A

90% squamous cell carcinomas

10% columnar cell adenocarcinomas

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77
Q

What are the two peaks of incidence of cervical cancer

A

30s and 80s

Most present between 25-49

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78
Q

What is the cause of cervical cancer

A

Same as CIN - HPV found in all cases

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79
Q

Symptoms of cervical cancer (3)

A

Postcoital bleeding
Offensive vaginal discharge
Postmenopausal or intermenstrual bleeding

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80
Q

Give 3 late stage symptoms of cervical cancer

A

Uraemia
Haematuria
Rectal pain and bleeding

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81
Q

Sign on examination of cervical cancer

A

Palpable mass or ulcer on cervix

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82
Q

Investigations of cervical cancer (4)

A

Biopsy
Examination under anaesthetic
Cystoscopy if ?bladder involvement
MRI for staging and spread

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83
Q

Management of cervical cancer

A

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

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84
Q

Types of vaginal carcinoma

A

Primary squamous cell carcinoma - quite rare

Secondary common from cervix, uterus, vulva

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85
Q

Symptoms of vaginal carcinoma (3)

A

Bleeding
Discharge
Mass/ulcer

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86
Q

Treatment of vaginal carcinoma

A

Radiotherapy

Possible surgery

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87
Q

What is the premalignant disease to vulval carcinoma?

A

Vulval intraepithelial neoplasia

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88
Q

What is the most common type of vulval carcinoma

A

Squamous cell carcinoma

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89
Q

Risk factors of vulval carcinoma (5)

A 
Lichen sclerosis
Smoking
Age
Immunosuppression
Paget's disease of vulva
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90
Q

Symptoms of vulval carcinoma (4)

A

Itching
Bleeding
Discharge
Possible mass

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91
Q

Investigations of vulval carcinoma

A

Biopsy

Assess fit for surgery

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92
Q

Treatment of vulval carcinoma

A

Stage 1a - wide local excision
Other - wide local excision and groin lymphadenectomy
Possible adjuvant radiotherapy before surgery

93
Q

What is the age range for vaginal and vulval carcinomas

A

Older women over 60

94
Q

What are polycystic ovaries?

A

Polycystic describes the appearance of multiple small follicles in an enlarged ovary on TVUSS
20% of woman have polycystic ovaries but normal cycles

95
Q

Prevalence of PCOS and relation to infertility

A

5% have PCOS

Makes up 80% anovulatory infertility

96
Q

Diagnostic criteria for PCOS (2 of 3)

A

Polycystic ovaries on USS
Irregular periods >35 days apart
Hirsutism

97
Q

What is hirsutism

A

Raised testosterone, acne, excess hair

98
Q

What causes PCOS?

A 
Genetic susceptibility
Disordered LH and raised insulin
Increased androgen production
Disrupted folliculogenesis and ovulation
Obesity (also increases insulin and androgens)
99
Q

Symptoms of PCOS (5)

A 
Obesity
Acne
Excess hair
Oligo/amenorrhoea 
Subfertility
100
Q

Investigations for PCOS(4)

A

Test FSH, prolactin, TSH for anovulation
Serum testosterone
LH levels may be raised
USS

101
Q

Treatment for PCOS (5)

A 
Lose weight
COCP
Anti androgens - spironolactone
Metformin reduces insulin, hirsutism, promotes ovulation
Eflornithine for hirsutism
102
Q

Treatment for PCOS if conceiving (4)

A

Clomifene to induce ovulation - limit 6 months
Ovarian diathermy
Gonadotrophins
IVF

103
Q

Define dysmenorrhoea

A

Painful menstruation

104
Q

Causes of dysmenorrhoea (3)

A

High prostaglandin levels in endometrium
Uterine contractine
Uterine ischaemia

105
Q

Define primary dysmenorrhoea

A

When no organic cause is found, usually coincides with the start of menstruation, affects 50% of women

106
Q

Treatment for primary dysmenorrhoea

A

NSAIDs

COCP - ovulation suppression

107
Q

Define secondary dysmenorrhoea

A

Pain due to pelvic pathology, often precedes menstruation and relieved by onset

108
Q

Other symptoms of secondary dysmenorrhoea

A

Deep dyspareunia
Menorrrhagia
Irregular menstruation

109
Q

Investigations for dysmenorrhoea

A

Pelvic USS

Laparoscopy

110
Q

Causes of secondary dysmenorrhoea

A 
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumours
111
Q

What is premenstrual syndrome?

A

Psychological and physical symptoms that get worse in the luteal phase

112
Q

Define menorrhagia

A

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
Q

Causes of menorrhagia (6)

A 
Fibroids/polyps
Chronic pelvic infection
Ovarian/endometrial/cervical malignancies
Prostaglandin changes
Anticoagulants, Von Willebrands
Thyroid disease
114
Q

Symptoms of menorrhagia (4)

A

Flooding and clots is excessive loss
Anaemia
Irregular enlarged uterus if fibroids
Tender uterus if adenomyosis

115
Q

Investigations of menorrhagia (6)

A 
Check Hb
Check coagulation
TFTs
Pelvic TVUSS 
Endometrial pipelle biopsy 
Hysteroscopy
116
Q

Treatment of menorrhagia (7)

A

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
Q

Define amenorrhoea

A

Absence of menstruation

118
Q

Define primary amenorrhoea

A

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
Q

Define secondary amenorrhoea

A

Previously normal menstruation ceases for 6 months or more

120
Q

Causes of primary amenorrhoea - non pathological (2)

A

Constitutional delay, medications (progestogens, GnRH analogues, antipsychotics)

121
Q

Causes of primary amenorrhoea - pathological (11)

A 
Anorexia
Athleticism
Psychological
Hyperprolactinaemia
Hypo/hyperthyroid
Adrenal tumours/hyperplasia
PCOS
Premature ovarian failure
Turner's/gonadal dysgenesis
Androgen insensitivity
Imperforate hymen, vaginal septum
122
Q

Causes of secondary amenorrhoea - non pathological (4)

A

Pregnancy, lactation, menopause, medications

123
Q

Causes of secondary amenorrhoea - pathological (10)

A 
Anorexia
Athleticism
Psychological
Hyperprolactinaemia
Hyper/hypothyroid
Adrenal tumour
PCOS
Premature ovarian failure
Asherman's syndrome
Cervical stenosis
124
Q

Mechanism by which anorexia/athleticism causes amenorrhoea and treatment

A

Hypothalamic hypogonadism - GnRH and so LH/FSH reduce and so does oestrogen. Treat with COCP

125
Q

Causes of hyperprolactinaemia and treatment

A

Pituitary hyperplasia, benign adenomas, hypo/erthyroidism. Prolactin inhibits GnRH. Treat with bromocriptine, surgery, thyroid hormones

126
Q

Define chronic pelvic pain

A

Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse

127
Q

Causes of chronic pelvic pain (7)

A 
Endometriosis/adenomyosis
Adhesions
IBS
Interstitial cystitis
Depression, sleep disorders
PID
Pelvic venous congestion
128
Q

Treatment of chronic pelvic pain

A

Treat cause i.e. diet and antispasmodics for IBS, analgesia, COCP, GnRH agonist, HRT, IUS, laparoscopy if unresolved, possible gabapentin or amitriptyline

129
Q

What is pelvic inflammatory disease

A

Sexually transmitted pelvic infection, usually coexisting with endometritis

130
Q

Risk factors for PID (4)

A

Young age
Low socioeconomic class
Sexually active (multiple partners, no condoms)
Nulliparous

131
Q

Cause of PID

A

Ascending bacteria in the vagina/cervix, sexual factors account for 80%
Can be from descending infection from pelvis

132
Q

What can cause STI spread to pelvic

A

Spontaneous
Uterine instrumentation
Childbirth or miscarriage complications

133
Q

Most common STI causes of PID

A

Chlamydia and gonorrhoea

Frequently polymicrobial

134
Q

Symptoms of PID (5)

A 
Many asymptomatic
Subfertility
Menstrual disturbance
Bilateral lower abdominal pain 
Deep dyspareunia
Abnormal PV bleeding/discharge
135
Q

Signs of PID (4)

A 
Tachycardia and fever if severe
Signs of peritonism if severe
Bilateral adnexal tenderness
Cervical excitation
PV bleeding or discharge
136
Q

Investigations for PID (5)

A 
Endocervical swabs
Blood cutures if fever
WBC, CRP
Pelvic USS
Laparoscopy (+biopsy and culture)
137
Q

Treatment of PID

A

Analgesia

Antibiotics - ceftriaxone IM single dose, doxycycline, metronidazole BD 14 days orally

138
Q

Complications of PID (5)

A 
Abscess
Tubal damage
Subfertility
Ectopic pregnancy
Chronic infection and pain
139
Q

What is chronic PID

A

A persisting infection due to no treatment or inadequate treatment. Treat with analgesia and different antibiotics

140
Q

Symptoms of chronic PID (7)

A 
Dense adhesions, obstructed and fluid filled tubes
Chronic pain
Dysmenorrhoea
Deep dyspareunia
Heavy/irregular bleeding
Chronic PV discharge
Subfertility
141
Q

Signs of chronic PID (3)

A

Abdominal tenderness
Adnexal tenderness
Retroverted uterus

142
Q

Investigations of chronic PID (2)

A

Transvaginal USS

Laparoscopy

143
Q

What is utero-vaginal prolapse

A

Descent of the uterus and/or vaginal walls beyond anatomical confines, occurring as a result of weakness in supporting structures

144
Q

Types of prolapse (5)

A 
Urethrocoele
Cystocoele
Apical prolapse
Enterocoele
Rectocoele
145
Q

What is a urethrocoele

A

Prolapse of the lower anterior vaginal wall, including the urethra

146
Q

What is a cystocoele

A

Prolapse of the upper anterior vaginal wall, including bladder (+urethra=cystourethrocoele)

147
Q

What is an apical prolapse

A

Prolapse of uterus, cervix and upper vagina

148
Q

What is an enterocoele

A

Prolapse of upper posterior vaginal wall, including small bowel

149
Q

What is a rectocoele

A

Prolapse of lower posterior vaginal wall, including anterior rectum

150
Q

Causes of prolapse (8)

A 
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
Q

Symptoms of prolapse (4)

A

Dragging or lump sensation - worse at end of day or when standing
Bleeding, discharge
Problems during intercourse
Urinary symptoms

152
Q

Investigations of prolapse (4)

A

Abdominal and bimanual examination
Speculum
Pelvic USS
Urodynamic tests

153
Q

Treatment of prolapse (4)

A

Weight reduction and physio
Pessaries - ring, shelf, with topical oestrogen
Vaginal hysterectomy
Hysteropexy - mesh to fix structures

154
Q

Describe physiological vaginal discharge

A

Non offensive, no itch, clear discharge
Increases around ovulation, pregnancy, if on pill
MAY be due to cervical ectropion (give cryotherapy)

155
Q

Symptoms, treatment of atrophic vaginitis

A

Redness
Raised pH
Increased discharge
Treat with oestrogen

156
Q

Discharge symptoms of malignancy

A

Bloody offensive discharge

157
Q

What is stress incontinence?

A

Involuntary leakage of urine on effort or exertion, or sneezing/coughing, main cause of incontinence in women

158
Q

Main cause of stress incontinence?

A

Urethral sphincter weakness

159
Q

Risk factors for stress incontinence? (5)

A 
Pregnancy and vaginal delivery
Prolonged labour/instrumental
Age
Obesity
Previous hysterectomy
160
Q

Mechanism of incontinence?

A

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
Q

Symptoms of stress incontinence? (4)

A

Leakage of urine on exertion
May coexist with faecal incontinence
May have prolapse
May have urge incontinence

162
Q

Investigations of stress incontinence?

A

Urine dipstick

Cystometry to exclude overactive bladder

163
Q

Management of stress incontinence? (6)

A 
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
Q

What is overactive bladder?

A

Urgency, with or without urge incontinence, usually with frequency or nocturia in the absence of proven infection

165
Q

Causes of overactive bladder? (3)

A

Detrusor overactivity - involuntary contractions in filling
Can follow operations for USI
Possible neuropathy - MS, spinal cord injury causing bladder contractions

166
Q

Mechanism of overactive bladder?

A

Urgency, bladder pressure may overcome urethral pressure and patient leaks
Can be spontaneous or with provocation - running tap, coughing

167
Q

Symptoms of overactive bladder? (4)

A

Urgency
Frequency
Nocturia
May coexist with faecal urgency or prolapse

168
Q

Investigations of overactive bladder? (2)

A

Diary - frequent passage of small volumes of urine esp. at night
Cystometry shows contraction on filling

169
Q

Management of overactive bladder? (7)

A

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
Q

What is a vaginal fistula?

A

Abnormal opening to bladder, bowel or rectum allowing urine or stool to leak through vagina

171
Q

Types of vaginal fistula (6)

A 
Vesicovaginal (to bladder)
Uterovaginal 
Urethrovaginal
Rectovaginal
Colovaginal
Enterovaginal (to small intestine)
172
Q

Causes of vaginal fistula? (5)

A 
Abdominal surgery - C section, hysterectomy
Malignancy
IBD, diverticulitis
Infection
Trauma
173
Q

Treatment of vaginal fistula? (3)

A

If small, catheter to drain and allow to heal
Antibiotics if infected
Most need surgery - mesh repair

174
Q

What is ovarian torsion?

A

Twisting of the ovary around its ligamentous supports, blocking adequate blood supply

175
Q

Symptoms of ovarian torsion? (4)

A

Abdo pain
Abdo mass
Nausea
Vomiting

176
Q

Management of ovarian torsion? (2)

A

Possible TVUSS with Doppler to identify

Laparoscopic diagnosis and treatment - surgical emergency to detort and fix in place

177
Q

What is lichen sclerosis?

A

Vulval epithelium thinning with loss collagen

178
Q

Cause of lichen sclerosis?

A

Autoimmune basis, thyroid disease may coexsit

Postmenopause

179
Q

Symptoms of lichen sclerosis? (5)

A

Severe pruritis
Trauma from scratching - bleeding, skin splitting
Dyspareunia
Pink-white papular fissured skin
Possible adhesions narrowing vaginal opening

180
Q

Treatment of lichen sclerosis? (2)

A

Topical steroids

Biopsy to exclude vulval cancer

181
Q

What is adenomyosis? (3)

A

Presence of the endometrium and its underlying stroma in the myometrium
Associated with endometriosis, fibroids
Oestrogen dependent

182
Q

Symptoms of adenomyosis?

A

Menorrhagia
Dysmenorrhoea
Enlarged uterus - may have pockets of menstrual blood within myometrium

183
Q

Management of adenomyosis? (5)

A 
MRI to diagnose
Progesterone IUS
COCP
NSAIDs
Hysterectomy often needed
184
Q

What is abnormal uterine bleeding?

A

Irregular uterine bleeding (outside normal period) in the absence of recognisable pelvic pathology, systemic disease, or pregnancy

185
Q

Cause of abnormal uterine bleeding?

A

Imbalance in sex hormones

186
Q

Disease causes of abnormal uterine bleeding?(4)

A

PCOS
Endometriosis
Polyps/fibroids
STIs

187
Q

Symptoms commonly coexisting with abnormal uterine bleeding? (4)

A

Mennorhagia
Intermenstrual bleeding
Pelvic pain
Breast pain

188
Q

Management of abnormal uterine bleeding? (4)

A 
Diagnosis of exclusion
COCP
IUS, implant
Clomifene - resets menstruation
Surgery - D and C, ablation
189
Q

What is androgen insensitivity syndrome?

A

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
Q

What are endometrial polyps?

A

Small, usually benign tumours that grow into the uterine cavity from the endometrium

191
Q

Causes of endometrial polyps?

A

High oestrogen levels

Tamoxifen

192
Q

Symptoms of endometrial polyps? (3)

A

Menorrhagia
Intermenstrual bleeding
Occasional prolapse

193
Q

Management of endometrial polyps? (3)

A

Diagnosed at USS or at hysteroscopy often
Biopsy for carcinoma
Resect polyp with diathermy

194
Q

What are congenital uterine malformations?

A

Abnormalities resulting from differing degrees of failure of fusion of the two Mullerian ducts at around 9 weeks gestation
A spectrum, mainly asymptomatic

195
Q

Symptoms of congenital uterine malformations? (3)

A

May be diagnosed at pregnancy - cause malpresentations, recurrent miscarriage, retained placenta
Sexual problems if vaginal septum (didelphys)
Amenorrhoea if imperforate hymen

196
Q

Types of congenital uterine malformations? (6)

A

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
Q

Treatment of congenital uterine malformations? (3)

A

Hysteroscopic resection if small septa
Possible surgery for other types
Assisted reproduction

198
Q

What is Asherman’s syndrome?

A

Uncommon consequence of excessive curettage at ERPC after miscarriage/delivery causing adhesions in the uterus

199
Q

Symptoms of Asherman’s syndrome (3)

A

Reduction in menstrual flow
Infrequent periods
Infertility

200
Q

Management of Ashermans syndrome (2)

A

Hysteroscopy to diagnose

Dissection of adhesions - common recurrence

201
Q

What is a prolactinoma?

A

Benign noncancerous tumor of the pituitary gland that produces a hormone called prolactin

202
Q

Symptoms of prolactinoma? (5)

A 
Infertility
Amenorrhoea
Irregular periods
Vaginal dryness
Lactation (galactorrhoea)
203
Q

Diagnosis of prolactinoma? (2)

A

Bloods - prolactin level, TFTS

MRI to diagnose

204
Q

Treatment of prolactinoma? (2)

A

Dopamine agonists - bromocriptine (inhibits prolactin)

Surgery, possible radiation

205
Q

What is premenstrual syndrome?

A

Encompasses psychological, behavioural and physical symptoms that are experienced regularly during the luteal phase of the menstrual cycle, resolve by end of menstruation

206
Q

How common is PMS?

A

95% experience, only 5% severe

207
Q

Cause of PMS?

A

Differing neurochemical responses to ovarian function and sex hormones e.g. progesterone

208
Q

Symptoms of PMS? (6)

A 
ALL CYCLICAL
Tension/irritability
Depression
Loss of control
Bloating
GI upset
Breast pain
209
Q

Management of PMS? (5)

A

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
Q

Medical methods of TOP?

A

Mifepristone - antiprogesterone
with Misoprostol - prostaglandin 2 days later
Labour is initiated

211
Q

When is medical TOP done?

A

Up to 24 weeks.

If after 22 weeks potassium chloride injected into the fetal heart to prevent live birth

212
Q

Surgical methods of TOP?

A

Suction curretage

Dilatation and evacuation

213
Q

When is surgical TOP done?

A

Up to 24 weeks
Suction curretage between 7-13
D+C above 13 weeks

214
Q

Complications of TOP? (4)

A

Haemorrhage
Infection
Uterine perforation
Abortion failure

215
Q

What is menarche?

A

Onset of menstruation, normally the last manifestation of puberty in the female, average 13 years

216
Q

Hormone axis controlling menstruation?

A

Hypothalamic-pituitary-gonadal axis
GnRH pulses, releasing FSH and LH
Stimulates ovarian oestrogen release

217
Q

Purpose of menstruation?

A

Hormones cause ovulation and induce changes in the endometrium preparing it for implantation if fertilisation occurs

218
Q

Days 1-4 of the menstrual cycle? (2)

A

First day of the cycle is the first day of menstruation

Endometrium shed as hormonal support withdrawn - possible painful contraction

219
Q

Days 5-13 of the menstrual cycle? (4)

A

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
Q

Days 14-28 of the menstrual cycle? (4)

A

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
Q

What are the phases of the menstrual cycle?

A

Menstruation
Proliferative (follicular) phase
Secretory (luteal) phase

222
Q

What is menopause?

A

Permanent cessation of menstruation following from loss of ovarian follicular activity, normally around 51 years
After 12 months of amenorrhoea

223
Q

What is premature menopause?

A

Permanent amenorrhoea <40 years

224
Q

What is perimenopause?

A

Time preceding menopause where periods become erratic

225
Q

Symptoms of menopause?

A 
Hot flushes
Insomnia
Skin and breast atrophy
Hair loss
Atrophic vaginitis
Prolapse
Urinary symptoms
Osteoporosis
CV disease
226
Q

Investigations for menopause?

A

Low anti-Mullerian hormone

Raised FSH

227
Q

Treatment for menopause?

A

HRT to alleviate symptoms - risk of breast cancer

Bisphosphonates for osteoporosis

228
Q

What is HRT?

A

Use of exogenous oestrogens when endogenous secretion absent

3A REVISION (17 decks)

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