Gynaecology Flashcards
Who does vaginal cancer affect
What are the 3 ways it presents?
What is the 1st and 2nd stage of management?
Where does secondary cancer arise from?
Give 5 RF of vaginal cancer
Vaginal cancer generally only affects older post menopausal ladies
Pain, Vaginal Discharge or Bleeding or a mass
1st stage: surgery
2nd stage: radiotherapy
The secondary cancer arises from cervix, endometrium, vulva
Risk Factors:
- Lichen sclerosis
- HPV
- pelvic radiation
- CIN
What is a definition of a hydatiform mole?
What causes one?
Explain the differences between a complete, partial and invasive mole
Give 5 RF:
Give 3 symptoms:
Give 3 investigations:
What is the treatment: and what is the management post evacuation?
What is a definition of a hydatiform mole? Is a growing mass of tissue in the womb that can not develop into a foetus. It is a result of abnormal conception
What causes one? It is caused when all the genetic information comes from the mother. The trophoblast which is part of the blastocyst proliferates more aggressively and secretes hCG in excess
Explain the differences between a complete, partial and invasive mole
- Complete: all genetic information is from the mother
- Partial: the cells have 3 sets of chromosomes (caused by 2 sperm and one egg)
- Invasive mole: when the mole invades the myometrium. Has metastatic potential to form choriocarcinomas
Give 5 RF:
- Extreme age (bellow 16 or over 45)
- Previous molar pregnancy
- multiple pregnancy
- Asian
- Use of COCP
Give 3 symptoms:
- Feeling larger than date
- Bad morning sickness
- Vaginal bleeding
Give 3 investigations:
- Beta HCG. this will be very very high as more trophoblast is secreting it
- Pelvic ultrasound
- Histology
Treatment:
- Need a pelvic evacuation
- Need to monitor the beta HCG post evacuation and pregnancy test to see if all was removed
- Need to monitor for a while to confirm the cause is not gestational trophoblastic disease (if it is chemo is needed)
What is the treatment: and what is the management post evacuation?
What is an uterine rupture? Is it serious When does it happen normally? What is a protective factor? What are the two types? What are 5 RF? What are 5 symptoms? What investigations would you do? What is your management?
What is an uterine rupture? This is when the uterus ruptures normally due to a traumatic event or previous C Section Scar
Is it serious? It is dangerous it is an emergency!
When does it happen normally? It happens after trauma, or if there has been a previous C Section not LSCS. Another cause is just de nova
What is a protective factor? Having a LSCS
What are the two types? Incomplete (normally surgical scar asymptomatic) or complete (emergency surgery required normally a RTA)
What are 5 RF?
What are 5 symptoms?
What investigations would you do?
What is your management?
What is mastitis?
What are 4 symptoms you get?
What are the two types you can get?
What is the causative organism?
Mastitis is the inflammation of the duct systems in the breast. Normally caused by a blockage.
Symptoms: red, hot, painful breast. Lady will have a fever and flu like symptoms
Lactional: caused by breast feeding. You need to aspirate and treat with Abx
Non-Lactional: blocked duct secondary to smoking
Causative organism: Staph Aureus
What is chronic periodical mastitis associated with?
It is associated with nipple numbness, nipple necrosis and and recurrent sepsis.
Treatment total duct excision
What are 3 signs of an inflammatory breast cancer?
Red
Oedematous
Lymphadenopathy
Thickening of Skin
How do you treat cyclical breast pain ?
Make sure you have a well supported bra
If not tell them to use NSAIDs and a low fat diet
How is life limited in a normal cell?
What is altered in malignant cells?
What controls cell death?
Life is limited by the number of divisions by telomeres
Malignant cells lengthen their telomeres
Apoptosis controls cell death
What are the stages of the Cell Cycle?
G1: growth S1: synthesis to double the chromosomes G2: double check everything Mitosis Cytokinesis
Where in the cell cycle does Tumor Supressor Genes work?
They work at G1 to slow down the process before S1
What is P53?
It is a transcription factor that controls the rate of cell division and cell death.
When it is activated it leads to reduction in cells
What are oncogenes. Give an example?
they are genes that speed up the growth and division of cells so promote cancer forming
Cancer can not be caused by a single mutated oncogene. As there is a conflicting tumour supressor gene to stop that. Thus there needs to be multiple modified genes
How common in Breast Cancer? Name two genes that cause it? What are 5 RF for breast cancer? Does pre or post menopausal cause an increased risk? Give 5 signs of breast cancer?
- 1 in 8
- BRCA 1 BRCA2
- RF include: smoking, no parity, no breast feeding, age, obesity, FH and COCP or HRT
- Post menopausal as increased fat
- 5 Signs: nipple inversion, bloody discharge from nipple, dimpling of skin, breast lump, redness or irritation of breast skin.
What is the treatment for breast cancer?
Normally you do a breast conservation with radiotherapy
Alongside this you need to do Axilla surgery
Depending on receptors you need to give medication for those too
Is lobular or ductal breast cancer a worst prognosis?
Lobular
What prognostic index is used for breast cancer?
The Nottingham prognostic index
What are the different types of breast cancer receptor types?
What is the treatment for them
HER2:give trastuzumab and chemotherapy
Triple Negative: chemo
ER receptor +ve: give the patient tamoxifen and chemotherapy. You also need to give bisphonates!
What breast cancer has the best prognosis and the which has the worst?
Worst: triple negative
Best: Oestrogen receptor positive
WHAT is primary breast reconstruction used for:
How do you treat locally advanced breast cancer (when you can see it on the skin?)
Increased option for skin preservation and better cons metic appearance. Lowers psychological trauma
You need to use radio to shrink it then give chemo and/or hormonal therapy
DCIS : What are 5 RF? Why is it becoming more prevalent? How does it occur? How do you diagnose? What are the two treatments?
- RF: age, early menarche, late menopause, no parity, no breast feeding, HRT and COCP use, smoking and FH
Routine mammogram
It occurs due to the lining cells of the epithelium proliferate allowing for central necrosis. But they can’t metastasise.
Mammogram or US then biopsy
Treatment: Wide local excision and radiotherapy
Prolactinoma:
- What is one?
- Who are they common in?
- What is the pathophysiology?
- What are 5 signs and symptoms?
- How do you diagnose it?
- How do you treat it?
What are 3 causes of hyperprolactinaemia?
A benign growth in the posterior pituitary gland
More common in females
The pathophysiology: is that there is a prolactin excess due to a tumor of the lactroph cells of the posterior pituitary. Prolactin is normally released due to prolactin agonists like Epidermal Growth Factor or VIP. Or by infant suckling.
Symptoms include: - Galactorrhoea - Amennorhoea - Loss of libido - Erectile dysfunction - Visual field issues - Hirsutism. Diagnosis: serum prolactin, visual fields and MRI of head Treatment: dopamine agonists like cabergoline then surgery
Other causes include: pregnancy, head injury and breast stimulation
When does premature menopause occur?
What are 3 possible causes?
What are two possible complications
What would you treat it with?
Happens before the age of 40 (2 SD below average)
Radiotherapy, Chemotherapy, Hysterectomy + oophectomy and Tamoxifen
Osteoporosis and Heart Disease
Treatment: HRT until the age of 52
What is Menopause?
What is the average age that this happens?
What is climacteric?
The seizing of menstrual period. CLassed as a year
Happens around mid 40s to 50s
Climacteric: this is the difference between reproductive to non reproductive state
The pathophysiology is that when you are young oestrogen stimulates a lot of follicles to be released and from there you get a chief follicle. When you get older there is resistance to FSH and LH and less follicles. Causing menstruation to seize
What is the hormone profile of a menopausal women?
What are some symptoms (5 of menopause?)
What is the treatment?
Increased LH and FSH
Decreased progesterone and oestrogen
Hot flush, mood disturbance, poor concentration, urinary symptoms, vaginal atrophy and sexual difficulties
You need to give the patient: HRT and alongside a protective progesterone. They will also need bisphosphonates
Vasa Previa:
- What is this?
- What are 3 RF of this?
- How does it present?
- What is the management?
This is when there are vessels running below the presenting part of the foetus
Low lying placenta, IVF and multiple pregnancies are all risk factors
It presents with ROM then vaginal bleeding and foetal distress
Emergency C Section. Often still not fast enough
What is a placenta increta?
What are 3 RF?
How do you investigate?
What is the treatment?
When the placenta is morbidly fixed to the myometrium
The 3 RFs include: previous C Section, previous placenta praevia and advanced maternal age.
Investigations: Doppler US and MRI
Management: you need to give uterine artery embolization and methotrexate
What is a placenta praevia What are 5 RF? What two types can you get? What is the presentation? How do you make a diagnosis? What investigations would you like to do? What is the management plan?
This is when the placenta is low lying and covering the cervical os
There are 5 RF: these include previous C Section, increasing age, smoking and multiple pregnancy
You can get PP major (urgent surgery) or minor
The presentation is painless vaginal bleeding in the 3rd trimester
You diagnose the condition from 20w scan but then checked at 3rd trimester
Investigations: anti-d, group and save, clotting profile and don’t forget to do foetal CTG.
Management: at 3rd trimester sent into hospital. Give steroids and C SEction
What is the pathophysiology of PCOS?
What are the tests for PCOS? Name 3
- That the theca cells are producing too many androgens.
- This causes there to be increased LH and insulin resistance
- You then get this leading to reduced SHBG by the liver and causes free testosterone
- Increased LH from pituitary
- Basal days 2-5 of LFT, FSH, prolactin and testosterone
- Abdo US
- SHBG levels
What is the Rotterdam Criteria?
Criteria in diagnosing PCOS It involves 3 steps: - Anovulatory - Clinical signs of hyperandrogenism (acne, male balding and hirsutism) - Polycystic ovaries >12 in both ovaries
How do you help PCOS get pregnant
Need to give lifestyle advice
You need to give metformin
You need to give clomifene
You can do ovarian drilling
PCOS
What are 5 symptoms and 3 signs
What is the diagnostic criteria called?
What is the management?
Amenorrhoea (<9 in a year) Low/irritable mood Acne Subfertility Hirsuitism
Male balding
Central obesity
Rotterdam
Management:
- conservative: weight loss, more exercise
- Use of COCP
- Metformin
What is a partogram?
What is is dependent on?
What does it plot
A diagram showing the progress of labour
The 3 Ps the power, passage and passenger
The progression of cervical dilatation and descent of the head
What cm is classed as late phase on a partogram?
What is the minimal rate per hour after the late phase?
What is classed as slow progress?
What else is recorded on the partogram except for dilation and head descent?
- 4 cm
- 1cm per hour
- Less than 2 cm dilation in 4 hours
- You get maternal vital, foetal heart rates contraction frequency and liquor colour
What does a CTG do?
Measures the foetal heart rate electronically and on paper.
One tranducer is for the abdomen (foetal HR) or on the scalp
The second transducer is for uterine contractions
What can a CTG be used for?
To measure foetal distress
What is the vulva?
The area of skin that stretches from the labia majora laterally and the mons pubis anteriorly
It is lined by squamous cell epithelium
Possible metastatic spread by the inguinal lymph nodes
What would be some of the symptoms of vulval cancer?
- Itchiness
- A mass
- Bleeding
- Superficial dyspareunia
- Soreness and burning
What are the causes of vulval cancer?
Infection
Dermatological
Neoplasm
What is the pre-malignant condition to vulval cancer?
Vulval Intraepithelial neoplasia (VIN)
Atypical cells in the vulval epithelial
What are the different types of VIN?
- Usual type VIN: warty appearance, most common condition and seen in 35-55 yr olds. Cause is HPV, CIN and smoking
- Differentiated type VIN: not as common as usual type. Associated with lichen sclerosis. Unifocal and has ulcers
More likely to become cancer than usual VIN
What is the management of VIN?
- You need local wide excision
- Symptom relief: steroids and emollients
What is Asherman’s Syndrome?
What are 3 causes of Asherman’s Syndrome?
What type of amennorhoea is it?
What are 4 symptoms?
What is the Gold Standard Diagnosis?
What is 1st line treatment?
- Uncommon acquired gynaecological issue. That presents as amenorrhoea, increased cramps and infertility
- Dilatation and Curettage, Endometriosis and infection with schistomiasis or tuberculosis
- Secondary amennorhoea
- Amenorrhoea
- Increased menstrual cramps
- Infertility
- Repeated miscarriages
Gold Standard: Hysteroscopy
Treatment: surgery to remove scar tissue and adhesions
What is Lichen Sclerosis
Where does it affect in women and in men?
Who does it affect?
What is the cause?
Lichen Sclerosis is a chronic inflammatory dermatitis that affects the skin of the anogenital region.
It affects anogenital in women and glans penis in men.
It commonly affects young boys or older men (AI so common in diabetes)
The cause is autoimmune
What can make Lichen Sclerosis worse? What is Koebner's response? What are 4 symptoms? What does it look like? What are two ways to diagnose it? How do you treat it?
Sex, irritating clothing and urine
The above problems lead to Koebner’s response making it better.
Symptoms: itchiness, dyspareunia, discomfort and bleeding
Signs: it has thick white shiny plaques. If it is a chronic condition the labia can get so inflamed that adhesions form and they fuse together.
Diagnosis: clinical examination and biospy
Management: steroids and emollients
Increased risk of differentiated VIN
What is Adenomyosis? Who is it common in? What is driving it's pathophysiology? What are 4 possible causes? What are 3 RF? What are 4 symptoms? What is the diagnostic test? How do you manage the condition?
This is when you get endometrial tissue that grows in the muscular wall of the uterus. Normally resolves after menopause.
It common in women in their 40s/50s and those who have given birth/ endometriosis and fibroids.
Driven by oestrogen!!!
Causes include: invasive tissue growth, embryological origin, stem cell origin and uterine inflammation.
RF: uterine surgery, childbirth and middle age
Symptoms: Heavy or prolonged periods, severe cramping period pain, pelvic pain and bloated and tender lower abdomen.
Diagnosis: by US
Mangement: NSAIDs, Mirena coil and hysterectomy.
Is cord prolapse dangerous?
What happens in a cord prolapse?
What are 3 RF?
What is the management?
It is an obstetric emergency
What happens is that the umbilical cord descends below the presenting part of the baby. If left there there cord will undergo compression and spasm. This will lead to hypoxia
3 RF:
- Pre term
- Multiple pregnancy
- Flexed breach
- Poly hydramnios
Management:
- Push the foetus back into the vagina and give terbutaline (anti-tocolytic agent)
- No presenting part: do C Section. Presenting part go to surgery and do Instrumental delivery.
What is Paget’s Disease of the Breast
How may people with Paget’s have invasive breast cancer?
What is the pathophysiology of paget’s disease?
Where on the breast does it begin?
Give 4 symptoms?
How do you diagnose?
What is the treatment?
- Eczema like skin changes to the nipple skin and areola
- Very high percentage of people with Paget’s disease have invasive breast cancer
- Invades the epidermis via the mammary duct epithelium, This then proliferates and leads to thickening of the affected skin.
- Always starts at the nipple and spreads
- Symptoms: skin changes, unilateral, sore and inflamed, itchy and burning sensation with a bloody nipple discharge
- Diagnosis: via Biopsy and mammogram
- Treatment: surgical central excision. Depending on cause give appropriate chemotherapy and radiotherapy.
What breast cancer is paget’s disease associated with?
High grade: oestrogen and progesterone receptor breast cancer
