gynaecology Flashcards
1
Q
what are the risk factors for urinary incontinence?
A
advancing age previous pregnancy and childbirth high BMI hysterectomy family history
2
Q
what are the different types of urinary incontinence?
A
overactive bladder (urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence - both urge and stress
overflow incontinence - due to bladder outlet obstruction e.g. prostate enlargement
3
Q
what investigations would you perform for urinary incontinence?
A
bladder diaries should be completed for a minimum of three days
empty supine stress test urinalysis post-void residual measurement cough stress test urodynamic testing vaginal exam to exclude organ prolapse
4
Q
how is urge incontinence managed?
A
1st line is behavioural approach plus lifestyle changes (bladder training and pelvic floor exercises, plus weigh loss, caffeine reduction, fluid management, smoking cessation)
2nd line -antimuscarinincs oxybutynin (immediate release), tolterodine (immediate release). oxybutynin should be avoided in frail old women.
mirabegron may be useful in frail older patients
5
Q
how is stress incontinence managed?
A
1st line - pelvic floor exercises, vaginal device, lifestyle changes - weight loss, caffine reduction, fluid management
if there is urethral sphincter insufficiency - pseudoephdrine or duloxetine
surgical procedures may be required
retropubic suspension
retropubic colposuspension (burch colposuspension)
mid-urethral sling
6
Q
What are the types of urogenital prolapse?
A
cystocele, cystourethrocele
rectocele
uterine prolapse
7
Q
what are the risk factors for urogenital prolapse?
A
increasing age multiparity vaginal deliveries obesity spina bifida
8
Q
how do prolapses present?
A
sensation of pressure, heaviness, bearing down
urinary sypmtoms - incontinence, frequency, urgency
consipation
sexual dysfunction
lower back pain
9
Q
how are prolapses managed?
A
if asymptomatic
observation and pelvic floor exercises and weight loss
the use of a pessary
vaginal wall repair
10
Q
what are the different types of pessaries used for prolapse?
A
Ring - usually first line, but requires intact perineal body for retention
shelf - used when ring pessary not retained
11
Q
What are uterine fibroids?
A
they are also known as leiomyomata
Fibroids are benign smooth muscle tumours of the uterus,
smooth muscle and fibrous elements are present
*the growth is oestrogen and progesterone dependant
12
Q
what are the different types of uterine fibroids?
A
intramural (confined to the myometrium)
subserosal (located just under the uterine serosal (outer surface) and can distort the outer surface of the uterus)
pedunculated (on a stalk)
submucosal (develops immediately underneath the endometrium and protrudes into the uterine cavity
13
Q
what are the risk factors for fibroids?
A
obestiy early menarche increasing age fam history ethnicity
14
Q
what are the symptoms of fibroids?
A
many patients will be asymptomatic
symptoms are more related to the site rather than the size
submucosal will cause abnormal menstrual bleeding whereas subserosal is more likely to be asymptomatic
The main presentation is menorrhagia Pain - dysmenorrhoea there may be pressure symptoms - urinary frequency and retention Fertility can be impaired a solid pelvic mass may be palpable
15
Q
what are the problems of fibroids with pregnancy?
A
premature labour malpresentation transverse lie obstructed labour postpartum haemorrhage
16
Q
what investigations would you perform for fibroids?
A
USS - transvaginal
endometrial biopsy
you could also consider:
MRI
hysteroscopy
laparoscopy
17
Q
how would you manage fibroids?
A
levonorgestrel-releasing intrauterine system
other options:
OCP
tranexamic acid
GnRH agonist - may reduce the size of fibroid - good for short term management
OR
myomectomy
If fertility preservation is not required…
uterine artery embolisation
hysterectomy
18
Q
What are the different types of functional ovarian cysts?
A
Follicular cysts (most common, due to non-rupture of the dominant follicle, they commonly regress after several menstrual cycles). Usually not bigger than 3cm
Corpus luteum cyst - occurs when the corpus luteum does not break down in the absence of pregnancy. Usually less than 5cm
Theca-lutein cysts - in response to hCG - only occur during pregnancy.
19
Q
what are benign germ cell tumours?
A
dermoid cysts
also called mature cystic teratomas
they are usually line with epithelial tissue and hence may contain skin appendages, hair and teeth
torsion is more common than with other types of tumour?
20
Q
what are the classifications of cysts?
A
Physiological: occur as an exaggerated response to normal physiological processed; follicular, endometriotic, corpus luteum and theca lutein cysts
Infectious: and abscess or cystic collection of cellular debris
Benign neoplastic: excessive growth of normal ovarian tissue types without dysplasia - serous cystadenoma, mucinous cystadenoma, adenofibroma, fibroma, dermoid cyst and brenner’s tumour.
Malignant neoplastic: serous cystadenocarcinoma, endometrioid carcinoma and immature teratoma
Metastatic: invasion and growth of neoplastic tissue from another malignant source, most commonly ovarian, endometrial, colonic or gastric cancers.
21
Q
what is an endometrioma?
A
a pathological cyst - also called chocolate cysts and are present in the ovaries of people with endometriosis.
There is bleeding into the cyst which gives the appearance
22
Q
what is the presentation of ovarian cysts?
A
chronic pain
pressure symptoms (bowel/bladder frequency and constipation)
acute pain - rupture or bleeding into a cyst
bloating and early satiety
Ovarian cancer presentation is vague and delayed
23
Q
what are the complications of ovarian cysts?
A
rupture into the peritoneal cavity causes intense pain particularly with and endometrioma or a dermoid
Haemorrhage into a cyst or peritoneal cavity causes pain
peritoneal cavity haemorrhage is occasionally severe enough to cause hypovolaemic shock
torsion of the pedicle causes infarction of the ovary and tube and causes severe pain
24
Q
what investigations would you perform for ovarian cysts ?
A
transvaginal USS
CA125
25
how are ovarian cysts managed?
if the patient is acutely ill - laparoscopy or laparotomy
26
what is an enterocele?
prolapse of the upper posterior wall of the vagina. The resulting puch usually contains a loop of small bowel
27
what are the different degrees of prolapse?
first degree - the lowest part of the prolapse descends half way down the vaginal axis to the introitus
second degree - the lowest part of the prolapse extends to the level of the hyman and through the hyman on straining
third degree - the lowest part of the prolapse extends through the hymen and lie outside the vagina
fourth degree - complete prolapse - no support visible
28
what are the surgical options for prolapse?
uterine prolapse - vaginal hysterectomy, hysteropexy
vaginal vault prolapse - sacrocolpopexy, sacrospinous fixation
vaginal wall prolapse - anterior and posterior repairs
29
what is ovarian torsion?
A twisting of the ovary and/or fallopian tube on its vascular and ligamentous supports, blocking adequate blood flow to the ovary
30
what can cause ovarian torsion?
underlying anatomical abnormalities
cysts and neoplasms account for 90% of all cases and . the rest occur in normal appearing ovaries
the larger the ovary the more chance there is of torsion
also long fallopian tubes
sudden increase in abdominal pressure
31
what are the signs of ovarian torsion
usually sudden onset of deep colicky abdominal pain associated with vomiting and distress
abdominal and pelvic tenderness
palpable adnexal mass
32
what investigations would you perform for ovarian torsion?
FBC - leukocytosis may increase the suspicion of torsion however it is not always seen
pregnancy test
transvaginal USS - enlarged ovary; soli, cystic or complex adnexal mass; diminished or absent blood flow to the ovary
abdominal USS
urinalysis
surgical visualization - confirms diagnosis
33
what are the differentials for ovarian torsion?
```
ectopic pregnancy
PID
appendicitis
endometriosis
UTI
ovarian cyst
```
34
how is ovarian torsion managed?
1st line - surgical detorsion
| 2nd line - salpingo-oophorectomy
35
what are the different types of germ cell tumours?
teratoma
dysgerminoma
yolk sac tumour
choriocarcinoma
36
what are the different types of sex cord-stomal tumours?
granulose cell tumour (malignant - produces oestrogen leading to precocious puberty in children or endometrial hyperplasia in adults)
Sertoli-leydig cell tumour (benign, produces androgens - masculinising effects
Fibroma (benign) tyically occurs around the menopause - classically causing a pulling sensation
37
what is a kurkenberg tumour?
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
38
what is Lichen sclerosus?
an chronic inflammatory skin disease of the anogenital area in women - usually in the elderly
the vulval epithelium is thin with a loss of collagen
39
what are the clinical features of lichen sclerosus?
white atrophic patches on the skin, usually within the anogenital region
most common symptom is itching and the skin may undergo fissuring or erosions which causes pain
sexually active women often experience dyspareunia
some patients are asymptomatic
inflammatory adhesions can form and potentially cause fusion of the labia
vulval carcinoma can develop in 5% of cases. 1
40
how is lichen sclerosus managed?
first line - topical steroids e.g. clobetasol
| if severe - immunosuppression
41
when may patients with lichen sclerosus need a biopsy?
if there is a suspicion of neoplastic change
if disease fails to respond to adequate treatment
if there is extragenital LS, with features suggesting an overlap with morphoea
if there are pigmented areas, in order to exclude an abnormal melanocytic proliferation
42
what is the most common type of ovarian cancer?
epithelial carcinoma - 95%
43
if a women under the age of 30 is affected by ovarian cancer what is the likely type of cancer?
germ cell tumour
44
what are some risk factors for ovarian cancer?
family history of the BRCA1 or BRCA 2 gene
many ovulations: early menarche, late menopause, null parity
**pregnancy, lactation and the use of OCP are protective
45
what are the clinical features of ovarian cancer?
** silent nature means it presents v late on
70% of patients present with stage 3-4
persistent abdominal distension and bloating, feeling full, LOA, pelvic/abdo pain, urinary symptoms (urgency and frequency)
symptoms similar to IBS
there may be a palpable abdominal mass
46
is there screening for ovarian cancer?
no screening for the general population only for high risk patients (fam history of ovarian and/or breast cancer)
47
what is the staging of ovarian cancer?
stage 1 - disease macroscopically confined to ovaries
1a - one ovary affected - capsule intact
1b - both ovaries affected- capsule intact
1c - 1a or 1b with tumour on the surface, ruptured capsule, cytologically positive ascites, or positive peritoneal washings
stage 2 - disease extends to the pelvis - e.g. uterus, fallopian tubes or other pelvic tissue
stage 3 - abdominal disease and/or effected lymph nodes
stage 4 - disease beyond the abdomen
the degree of differentiation or grade is also reported
48
what investigations would you perform for ovarian cancer?
CA125 should be measured in woman over 50 with any abdominal symptoms
If CA125 is raised above 35 IU/mL then urgent USS of abdo and pelvis should be ordered.
USS
in women under 40 AFP and hCG should be measured as these are indicative of germ cell tumours
49
how is ovarian cancer managed?
usually surgery and platinum based chemo (carboplatin)
50
what are the different types of cervical cancer?
70-80% are squamous cell carcinomas
15% adenocarcinoma (worse prognosis)
15% mixed in type
51
what happens before cervical cancer develops?
cervical cancer usually develops as a progression from cervical intraepithelial neoplasia which occurs over the course of 10-20 years - sometimes this does regress and does not form cancer
52
what are some risk factors for cervical cancer?
```
HPV infection
smoking
STIs
>8 years of OCP use
immunodeficiency e.g. HIV
early onset of sexual activity
multiple sexual partners
```
53
what are the features of cervical cancer?
```
may be asymptomatic
abnormal vaginal bleeding (post coital, intermenstrual or post-menopausal)
vaginal discharge (blood stained or foul smelling)
many cases detected through routine screening
```
54
what is the most important causative factor for the development of cervical cancer?
Human papillomavirus HPV
55
what stereotypes of the HPV are the most important in the development of cervical cancer?
16
18
33
56
what forms of HPV are responsible for genital warts?
6
| 11
57
what can endocervical cells infected with HPV develop into?
Koilocytes
58
what are the characteristics of koilocytes?
enlarged nucleus
irregular nuclear membrane contour
the nucleus stains darker than normal (hyperchromasia)
a perinuclear halo may be seen
59
who is screened for cervical cancer and how often?
25-49 - 3 yearly screening
| 50-64 - 5 yearly screening
60
how is the cervical cancer screened?
Papanicolaou (Pap) smears
or liquid based cytology
61
what investigations would you perform for cervical cancer?
vaginal or speculum examination
colposcopy
biopsy
HPV testing
62
what are the different abnormal cervical smear results?
Borderline or Mild dyskaryosis - The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis - consistent with cervical intraepithelial neoplasia (CIN) 2, Severe dyskaryosis - consistent with CIN 3, suspected invasive cancer: refer for urgent colposcopy
63
what is the management of cervical cancer?
stage 1a - micro invasive disease - cone biopsy
if greater than 2cm - radical hysterectomy and lymphadenectomy
if fertility is desired then a radical trachelectomy can be performed.
Radiotherapy and chemo can be added.
chemo - often cisplatin based before or after surgery
64
who is the HPV vaccine being offered to? and what forms of HPV does it protect against?
all 12- and 13-year-olds (girls AND boys) in school Year 8 will be offered the human papillomavirus (HPV) vaccine.
it protects against 6, 11, 16 and 18.
65
what are the three types of cervical intraepithelial neoplasia?
Pre invasive disease
CIN1: low grade lesion with mildly atypical cellular change in the lower third of the epithelium
CIN 2: high grade lesion with moderately atypical cellular changes confined to basal two thirds of the epithelium
CIN 3: severely atypical cellular changes encompassing greater than two thirds of epithelial thickness and includes full thickness lessons
66
who is the HPV vaccine being offered to? and what forms of HPV does it protect against?
all 12- and 13-year-olds (girls AND boys) in school Year 8 will be offered the human papillomavirus (HPV) vaccine.
it protects against 6,11, 16 and 18.
67
what are the risk factors for endometrial cancer?
```
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen
DM
tamoxifen
PCOS
hereditary nonpolyposis colorectal carcinoma (lynch syndrome)
```
68
what factors reduce the risk of endometrial cancer?
hormonal contraceptives
being older at the time you give birth
breastfeeding
69
what are the clinical features of endometrial cancer?
post menopausal bleeding
premenopausal women may have change in intermenstrual bleeding
pain and discharge are unusual features
associated with obesity - obesity is also associated with a worse outcome
70
what are the two types of endometrial cancer?
type 1 - majority - low grade endometrial cancers which are oestrogen sensitive
type 2 - high grade more aggressive and are not sensitive to oestrogen and tend not to be related to obesity
71
what investigations would you perform for endometrial cancer?
pelvic transvaginal USS - endometrial thickness greater than 3mm and a stripe appearance
endometrial biopsy - will show adenocarcinoma
hysteroscopy
pap smear
FBC
72
what is the basic staging of endometrial cancer?
stage 1 - lesions confined to the uterus (1a/b to do with the degree of myometrial invasion)
stage 2 - carcinoma may extend to cervical stroma but not beyond the uterus
Stage 3 - tumour invades through uterus but stays within pelvis
stage 4 - further spead (a-bowel/bladder, b- distant metastasis)
73
how is endometrial hyperplasia managed?
non-malignant simple or complex hyperplasia can be treated with progesterone
atypical hyperplasia should be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy.
74
how is endometrial cancer treated?
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
75
what is vulval intraepithelial neoplasia?
premalignant disease of the vulva
| it is the presence of atypical cells in the vulval epithelium
76
what are the risk factors for vulval carcinoma?
```
age over 65
HPV infection
vulval intraepithelial neoplasia
immunosuppression
Lichen sclerosus
```
77
what is vulval intraepithelial neoplasia?
premalignant disease of the vulva
78
what are the two types of vulval intraepithelial neoplasia?
usual type - most common, can be warty, basaloid or mixed and is more common in women aged 35-55. It is associated with HPV
differential type - rarer, can be associated with lichen sclerosis and is seen in older women. the lesions are uni-focal in the form of an ulcer or plaque and is linked to keratinizing squamous cell carcinoma of the vulva. The risk of progression to cancer is higher than with other types
79
what are the symptoms and treatment for vulval intraepithelial neoplasia?
pruritus and pain are common with VIN
emollients and topical steroids may help but the gold standard is local surgical excision to relieve symptoms, confirm histology and exclude invasive disease.
80
what are the clinical features of carcinoma of the vulva?
pruritus, bleeding or discharge and may find a mass.
examination will reveal an ulcer or mass most commonly on the labia majora or clitoris.
The inguinal lymph nodes may be enlarged, hard and immobile.
81
what is the most common type of vaginal cancer?
squamous cell carcinoma
82
how does vaginal cancer present?
bleeding or discharge
| mass or ulcer is evident
83
what is clear cell carcinoma of the vagina?
most of them are a rare complication affecting daughters of women prescribed DES during pregnancy to try and prevent miscarriage.
84
what is endometriosis?
the growth of ectopic endometrial tissue outside the uterine cavity
85
what are the most common sites of endometriosis?
pelvic peritoneum and the ovaries.
86
what are the clinical features of endometriosis?
```
sometimes asymptomatic
dysmenorrhea
chronic or cyclical pelvic pain
dyspareunia
subfertility
pain on passing stools during menses
```
87
what investigations would you perform for endometriosis?
transvaginal USS
diagnostic laparoscopy
maybe consider MRI
88
how is endometriosis managed?
analgesia - NSAIDs or paracetamol
combined OCP
progestogen (IM, intrauterine device or tablet)
2nd line GnRH analogues +/- HRT - acts by inducing a pre-menopausal state
Surgical if symptoms seriously - laser ablation, laparoscopic excision
if very serious - hysterectomy and bilateral salpingo-oophorectomy
89
what is adenomyosis?
the presence of functional endometrial tissue within the myometrium of the uterus
90
what are the clinical features of adenomyosis?
```
my be asymptomatic
menorrhagia
dysmenorrhoea
deep dyspareunia
uterus may be enlarged and tender
```
91
what investigations would you perform for adenomyosis?
Transvaginal USS
| MRI - it can be seen clearly on MRI
92
how is adenomyosis managed?
```
main aim is symptom control
only cure is hysterectomy
NSAIDs
GnRH agonists
uterine artery embolisation
```
93
what is dysfunctional uterine bleeding?
abnormal uterine bleed in the absence of structural or organic disease
94
what are some causes of dysfunctional menstrual bleeding?
```
low oestrogen levels
stress
obesity
anorexia
exercise
hormone imbalance
drugs
```
95
what investigations would you do for dysfunctional uterine bleeding?
routine investigations (history and exam, pregnancy test, pap smear and culture, blood)
biopsy
hysteroscopy
transvaginal USS
96
what is the treatment for dysfunctional uterine bleeding?
tranexamic acid
NSAID
IUS
OCP
endometiral ablation
hysterectomy
97
what is menorrhagia?
excessive menstrual blood loss that interferes with the woman's physical, emotional, social and material quality of life
98
what are some causes of menorrhagia?
in many women there is not pathology it can be attributed to
it may be a result from subtle abnormalities of endometrial homeostasis or uterine prostaglandin levels
uterine fibroids and polyps are the most common pathology found
chronic pelvic infection, ovarian tumours
endometrial and cervical malignancies
thyroid disease
99
what investigations would you perform for menorrhagia?
```
check the patients Hb
coagulation screen and test for VWD
TFT
transvaginal USS
endometrial biopsy
```
100
how would you manage menorrhagia?
if they dont need contraception use tranexamic acid ir NSAIDs
if they need contraception
1st line - IUS
2nd line - COCP
3rd line - long-acting progestogens (depo)
surgical - polyp removal, endometrial ablation, resection of fibroid , hysterectomy, uterine artery embolization
101
what is dysmenorrhoea?
painful menstruation due to contraction and uterine ischaemia
102
what is primary and secondary dysmenorrhoea?
primary - menstrual pain occurring with no underlying pelvic pathology
secondary - menstrual pain that occurs with an associated pelvic pathology
103
what causes primary dysmenorrhoea?
excessive release of prostaglandins by endometrial cells
104
what are the clinical features of dysmenorrhoea?
lower abdominal pain or pelvic pain which can radiate to lower back or anterior thigh
pain usually crampy in nature and lasts 48-72 hours
pain can be associated with nausea, vomiting, diarrhoea and dizziness
uterine tenderness may be present
105
what investigations would you perform for dysmenorrhoea?
rule out any underlying pathology
if risk of STI - high vaginal swab and endocervical swab
if there is a pelvic mass palpated a transvaginal USS should be performed.
106
how do you manage primary dysmenorrhoea?
the aim is symptomatic improvement
lifestyle changes - stop smoking
NSAIDs (ibuprofen, naproxen, mefenamic acid - they work by inhibiting the production of prostaglandins)
hormonal contraception - OCP or IUS
107
what are some causes of secondary dysmenorrhoea?
```
endometriosis
fibroids
PID
adenomyosis
IUD
cervical stenosis
```
108
what is the normal age of puberty in females?
8-14 years
109
what is the first sign of puberty in girls?
the beginning of breast development (thelarche), the formation of the breast buds signifies the onset of thelarche
110
what is the second stage of puberty in girls?
pubarche - typically growth of hair in the pubic area, approx 2 years after pubarche, hair begins to grown in the axillary area as well.
111
what is the menopause?
a physiological process which begins at around the age of 40 and progress until the final merach =e and the end of fertility - mean age is 51.
the definition of menopause is the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea.
112
what are the hormonal changes during the menopause?
reduction in circulating oestrogen due to reduced sensitivity of the ovary to circulating gonadotropins FSH and LH due to the reduction in follicle numbers
levels of FSH and LH significantly rise due to low oestrogen
113
what are the symptoms experienced in menopause?
Hot flushes
atrophy of the vagina and thinning of the myometrium
vaginal thinning and dryness which can cause dyspareunia
oestrogen protects bone mass and density by reducing activity of osteoclasts - increased risk of fractures
IHD - oestrogen protects against heart disease
night sweats
mood changes
mild memory impairment
114
what investigations can be used to confirm menopause?
pregnancy test
| FSH for women under 40 (will be elevated)
115
how is symptomatic menopause managed?
1st line - lifestyle changes
- regular exercise, weight loss and reduce stress, good sleep hygiene
2nd line - for those who can not manage their symptoms -
HRT for up to 5 years- oestrogen should be combined with progesterone in women who have not had a hysterectomy
3rd line - for night sweats and hot flushes - SSRI (venlafaxine) or clonidine
for urogenital symptoms - vaginal oestrogens and vaginal moisturiser
116
what is premature ovarian failure?
Cessation of menses for more than 1 year before 40 years of age secondary to loss of ovarian function.
117
what are some causes of premature ovarian failure?
```
genetic disorders
autoimmune disorders
infections
toxic causes (including chemotherapy or radiation)
galactosaemia
idiopathic.
```
118
what investigations would you perform for premature ovarian failure?
```
pregnancy test
FSH levels - raised
LH levels - raised
oestradiol level will be low
AMH will be low
TFT
prolactin level
transvaginal USS
```
119
how would you manage premature ovarian failure?
HRT therapy - oestrogen and progesterone
| vaginal oestrogen
120
what is androgen insensitivity syndrome?
an X-recessive condition due to end-organ resistance to testosterone causing genotypically male children to have a female phenotype
121
what are the features of androgen insensitivity syndrome?
```
female external genitalia
a short blind-ending vagina
absent uterus and fallopian tubes
normal breast development
sparse pubic and axillary hair
```
primary amenorrhoea
undescended testes causing groin swelling
breast development may occur as a result of conversion of testosterone to oestradiol
122
how is androgen insensitivity syndrome managed?
if CAIS is diagnosed before puberty the testes may be left in to allow natural puberty
after puberty - gonadectomy should be offered because of the difficulty monitoring intra abdominal testes
HRT with oestrogen should be started following gonadectomy
some may require testosterone replacement
BMD should be checked for osteopenia once sexual activity is anticipated the vaginal lengthening with the use of dilators should be offered - if this fails then offer vaginoplasty
123
what is a hydatidiform mole?
Gestational trophoblastic disorder
it is growth of an abnormal fertilised egg or an overgrowth of tissue from the placenta - women appear to be pregnant, but the uterus enlarges much more rapidly than in normal pregnancy
124
what are the three types hydatidiform moles?
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma
125
what is a complete hydatidiform mole?
entirely paternal in origin, usually when one sperm fertilises an empty oocyte and undergoes mitosis.
126
what are the features of a complete hydatidiform mole?
- bleeding in the first or early second trimester
exaggerated symptoms of pregnancy
- exaggerated symptoms of pregnancy e.g. hyperemesis
- uterus large for date
- very high serum levels of hCG
-hypertensions and hyperthyroidism may be seen
127
what are the risk factors for hydatidiform moles?
age - extremes in reproductive life (<15 or >40)
ethnicity - 2 times higher in east asia
previous molar pregnancy
128
what is a partial hydatiform mole?
usually triploid, derived from two sperms entering one oocyte
there is variable evidence of a fetus
one maternal and two paternal haploid sets
129
how are hydatidiform moles managed?
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
130
what is pelvic inflammatory disease?
infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum.
It is usually the result of ascending infection from the endocervix
however scan be descending infection from local organs such as the appendix
131
what are the common causes of pelvic inflammatory disease?
Chalmydia trachomatis
Neisseria gonorrhoeae
mycoplasma genitalium
mycoplasma hominis
132
what are the clinical features of PID?
```
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities
vaginal or cervical discharge
cervical excitation
high fever in severe cases
peri-hepatitis (fitz-hugh-curtis syndrome) - characterised by right upper quadrant pain due to adhesions
```
133
what investigations would you perform for PID?
```
endo-cervical swab
blood cultures if there is a fever
WBC and CRP and ESR
pelvic USS
laparoscopy
```
134
how is PID managed?
ceftriaxone (IM) and doxycycline (oral)
metronidazole can be added
2nd line
oflaxacin plus metronidazole
135
what are the complications of PID?
abscess
infertility
chronic pelvic pain
ectopic pregnancy
136
what are endometrial polyps?
they are adenomas
| focal overgrowth of the endometrium
137
what are the symptoms of endometrial polyps?
often asymptomatic
can cause menorrhagia and intermenstrual bleeding
sometimes can cause prolapse of the cervix
138
investigations for polyps?
USS or hysteroscopy
139
treatment for polyps?
resections during hysteroscopy - they should be sent for biopsy
140
what is chronic pelvic pain?
intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6-month duration
141
what investigations would your perform for chronic pelvic pain?
```
urinalysis
urine culture
cervical swab
MRI
transvaginal USS
laparoscopy
psychological evaluation may be helpful in some patients
```
142
what are some possible causes of chronic pelvic pain?
```
endometriosis
adenomyosis
gynaecological or pelvic adhesions
psychological factors
pelvic congestion syndrome
intesitial cystitis
haemorrhagic ovarian cysts
fibromyalgia
IBS
```
143
what is the pathophysiology of PCOS?
insulin resistance - means the body has to produce extra insulin to compensate - high levels of insulin cause the ovaries to produce too much testosteroen which interferes with the development of follicles and prevents normal ovualtion
insulin also increases the free testosterone circulating in the body by supressing the hepatic synthesis of sex hormone binding globulin
also hypersecretion of LH which stimulates production of androgens secretion form theca cells
144
what are the clinical features of PCOS?
subfertility and infertility
menstrual disturbances - oligomenorrhea and amenorrhoea
hirtutism and acne due to hyperandrogenism
obesity
acanthosis nigricans - due to insulin resistance
145
what investigations would you perform for PCOS?
- serum total and free testosterone - elevated
-DHEAS - serum dehydroepiandrosterone sulfate - elevate
- serum SHBG
- serum prolactin
- TSH
-oral glucose tolerance test
basal (day 2-5) LH, FSH, TFT, prolactin, testosterone
146
how is PCOS managed?
weight loss
improve menstrual regularity with weight loss, metformin COCP
eflornithine topical may help with acne and hair growth
If fertility is desired - clomifene
147
what is turner's syndrome ?
chromosomal disorder, involving a complete or partial absence of the second sex chromosome
148
what are the features of turners syndrome?
```
short stature
shield chest, widely spaced nipples
webbed neck
bicuspid aortic valve, coarctation of the arota
primary amenorrhoea
cystic hygroma
high arched palate
short fourth metacarple
delayed or absent puberty
horseshoe kidney
hypothroidism
```
149
how do you diagnose tuners syndrome?
karyotype
150
how do you manage tuners syndrome?
if there is poor growth - growth hormone (somatropin) and oxandrolone
those with pubertal delay or arrest - low dose oestrogen and cyclic progesterone
after establishment of cyclical bleeding - ovarian HRT and breast implants
151
what is asherman's syndrome ?
an acquired uterine condition charcterised by the formation if adhesions (scar tissue) inside the uterus
152
what are the risks in pregnancy in people with ashemans?
placenta previa
placenta increta
exessive bleeding
153
what is a prolactinoma?
a type of pituitary adenoma
benign
they produce prolactin
154
how can pituitary adeomas be classified?
size
- microadenoma <1cm
- macroadenoma >1cm
hormonal status - secretory/functioning
155
what are the clinical features of prolactinomain women?
```
amenorhoea and oligomenorrhoea
infertility
galactorrhoea
loss of libido
visual deterioration - temoral hemianopia
osteoporosis
```
156
what investigations would you perform for a prolactinoma/.
serum prolactin
pituitary MRI
computerised visual field exam
157
how do you treat a prolactinoma?
if asymtomatic - observation
if it is symtomatic - give a dopamine agonist (cabergoline)
surgery is performedfor patients who cannot tolerate or fail to respond to medical therapy
