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Obs & Gynae > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Define primary amenorrhoea

(2 definitions)

A

Not starting menstruation

a) by the age of 14, with no other evidence of sexual development
b) by the age of 16, with other signs of sexual development (e.g. breast bud development)

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2
Q

What age ranges does ‘normal’ puberty take place in

a) girls
b) boys

A

8-14 years

9-15 years

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3
Q

How does puberty normally progress in girls? Which changes occur and in which order?

(3)

A

Breast bud development (thelarche)

Pubic hair development (pubarche)

Periods starting (menarche)

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4
Q

How long does puberty normally take from start to finish?

A

4 years

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5
Q

How often does menarche typically occur after onset of puberty?

A

2 years from start of puberty

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6
Q

What is hypogonadotropic hypogonadism (secondary hypogonadism)?

A

Gonadal failure (underactive gonads) caused by lack of LH/FSH release from anterior pituitary

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7
Q

Where in the HPG axis is the problem in hypogonadotropic hypogonadism (secondary hypogonadism)?

What will you see on a hormonal profile (LH and FSH levels)?

A

In the hypothalamus or pituitary gland

Low LH and FSH levels

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8
Q

What is hypergonadotropic hypogonadism (primary hypogonadism)?

A

Gonadal failure (underactive gonads) due to impaired response of the gonads to FSH and LH stimulation

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9
Q

Where in the HPG axis is the problem in hypergonadotropic hypogonadism (primary hypogonadism)?

What will you see on a hormonal profile (FSH and LH levels)? Why?

A

In the ovaries (gonads)

High FSH and LH levels
No negative feedback from sex hormone production

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10
Q

Name some endocrine causes of primary amenorrhoea (excluding primary/secondary hypogonadism)

A 
Hypothyroidism
Hyperprolactinaemia
Congenital adrenal hyperplasia
Turners Syndrome
Androgen insensitivity Syndrome
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11
Q

What investigations should be ordered for suspected primary amenorrhoea? (2)

A

Pelvic USS

Hormone tests - FSH, LH, TSH, Prolactin

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12
Q

What are some hypothalamic causes of primary amenorrhoea? (3)

A

Excessive exercise
Stress
Eating disorder

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13
Q

What is the management of primary amenorrhoea?

A

Treat underlying cause

Primary ovarian failure or PCOS —> COCP

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14
Q

What is a patient with primary amenorrhoea at risk of, due to low oestrogen levels?

What is the treatment for this, if the primary amenorrhoea has a permanent cause? (2)

A

Osteoporosis

Ensure adequate vitamin D and calcium
Hormone replacement therapy - e.g. COCP

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15
Q

Define secondary amenorrhoea

A

No menstruation for more than 3 (or 6) months after having previously started periods

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16
Q

What are the two most common causes of secondary amenorrhoea?

A

Pregnancy (most common)

Menopause

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17
Q

What are some hypothalamic causes of secondary amenorrhoea?

A

Excessive exercise
Low BMI
Eating disorder
Stress

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18
Q

State two pituitary causes of secondary amenorrhoea

A

Prolactinoma (pituitary tumour)

Pituitary failure (Sheehan syndrome)

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19
Q

What are some ovarian causes of secondary amenorrhoea? (3)

A

PCOS
Premature ovarian failure
Menopause

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20
Q

State a uterine cause of secondary amenorrhoea

A

Asherman’s Syndrome

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21
Q

What thyroid disorder is associated with secondary amenorrhoea?

A

Hypothyroidism

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22
Q

Why do high prolactin (hyperprolactinaemia) levels cause secondary amenorrhoea?

A

Prolactin prevents the release of GnRH from the hypothalamus

Increased prolactin —> Low GnRH —> Low FSH/LH —> hypogonadotropic hypogonadism (primary hypogonadism)

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23
Q

What is the most common cause of hyperprolactinaemia?

A

Pituitary adenoma secreting prolactin

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24
Q

If high prolactin levels are found on investigation of hyperprolactinaemia, what investigation is indicated?

A

CT/MRI head

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25
Q

What is the medical treatment for hyperprolactinaemia?

A

Dopamine agonists - e.g. bromocryptine

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26
Q

What LH/FSH levels are seen in…

a) primary ovarian failure
b) PCOS

A

High FSH

High LH (LH/FSH ratio)

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27
Q

What does a progesterone stimulation test, test for?

A

Whether there is sufficient oestrogen

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28
Q

What is the normal and abnormal result of a progesterone stimulation test?

A

Normal = withdrawal bleed within 7 days of stopping progesterone

Abnormal = no withdrawal bleed, low oestrogen is preventing build up of endometrium

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29
Q

What is androgen insensitivity syndrome?

A

Condition where there is insensitivity of the body to androgens (testosterone) so male characteristics do not develop normally

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30
Q

What is the external and internal sexual anatomy of someone with androgen insensitivity syndrome?

A

External - normal female genitalia, female breasts

Internal - testes, NO uterus/upper vagina/Fallopian tubes/ovaries

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31
Q

What is the management of androgen insensitivity syndrome? (3)

A

Generally raised as female - up to individual

Oestrogen therapy

Bilateral orchidectomy

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32
Q

In what pattern is androgen insensitivity syndrome inherited?

What karyotype will he possess?

A

X-linked condition

46 XY - male karyotype

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33
Q

What is premenstrual syndrome caused by?

A

Fluctuations in hormones during the premenstrual period (especially fall in oestrogen and progesterone)

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34
Q

What are common symptoms of premenstrual syndrome? (6)

A 
Bloating
Headaches
Backache
Anxiety
Low mood
Irritability
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35
Q

When in the cycle do symptoms of premenstrual improve?

A

With onset of menstruation

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36
Q

When symptoms of premenstrual syndrome are severe and have significant effect on quality of life, it is called…

A

Premenstrual dysphoric disorder

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37
Q

What is the management of premenstrual syndrome?

A

Lifestyle changes
COCP
SSRIs

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38
Q

What are some common causes of menorrhagia?

A

FIbroids
PCOS
Hyperthyroidism
Contraceptives
Connective tissue disease - e.g. Ehlers-Danlos syndromes
Bleeding disorders - e.g. Von Willebrand disease
Endometrial cancer

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39
Q

What examination should be performed in cases of menorrhagia?

A

Pelvic examination

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40
Q

State some indications for pelvic/transvaginal USS

A

Abnormal pelvic examination
Post-coital bleeding
IMB
Other pelvic symptoms - e.g. pelvic pain

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41
Q

What is the non-contraceptive medical management for menorrhagia? (2)

A

Tranexamic acid

Mefanamic acid

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42
Q

What is the difference between tranexamic and mefanamic acid?

(Type of medication and symptoms it improves)

A

Tranexamic = anti-fibrinolytic, reduces bleeding

Mefanamic = NSAID, reduces bleeding AND associated pain

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43
Q

What is the contraceptive management of menorrhagia?

A

Mirena coil
COCP
POP
Depo injection

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44
Q

What is the final (last resort) management for menorrhagia? (2)

A

Endometrial ablation

Hysterectomy

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45
Q

What is a fibroid? What is another name for them?

A

Tumour of the smooth muscle of the uterus

Uterine leiomyoma

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46
Q

What is the most common age for development of fibroids?

A

Late reproductive age (pre-menopause)

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47
Q

What ethnicity are fibroids most common in?

A

Afro-Caribbean

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48
Q

What hormone affects the growth of fibroids?

A

Oestrogen causes fibroids to grow

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49
Q

Name 4 types of fibroids based on its location in the uterus

A

Intramural
Subserosal
Submucosal
Pedunculated

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50
Q

Where is an intramural uterine fibroid located?

A

Within the myometrium

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51
Q

Where is a subserosal uterine fibroid located?

How do they typically grow?

A

Just below outer layer of myometrium

Outwards, becoming very large and filling abdominal cavity

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52
Q

Where is a submucosal uterine fibroid located?

A

Below the endometrium

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53
Q

What is a pedunculated uterine fibroid?

A

A fibroid on a stalk

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54
Q

What are the symptoms associated with uterine fibroids? Which symptom is the most common?

A

Menorrhagia (most common)

Longer menstruation > 7 days
Abdominal pain, worse on menstruation
Bloating
Urinary or bowel symptoms
Deep dyspareunia
Reduced fertility
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55
Q

Through which investigation are uterine fibroids diagnosed?

A

Pelvic/transvaginal USS

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56
Q

What is included in the conservative management of uterine fibroids?

A

Analgesia
Tranexamic acid

Mirena coil

COCP

GnRH agonists - e.g. goserelin

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57
Q

How does goserelin work in the treatment of uterine fibroids? What is its mechanism of action?

A

Reduces size of fibroids by inducing menopause and reducing oestrogen supply to fibroid

GnRH agonist

58
Q

Name some invasive procedures for the management of uterine fibroids

A

Uterine artery embolisation
Myomectomy
Hysteroscopic endometrial ablation
Hysterectomy

59
Q

How does uterine artery embolisation work in the treatment of uterine fibroids?

A

Blocks blood supply to fibroid, causing it to shrink

60
Q

What are some complications of uterine fibroids?

A

Menorrhagia —> anaemia

Infertility

Pregnancy complications - e.g. Premature labour, miscarriages

Constipation

Urinary outflow obstruction/UTIs

Red degeneration

61
Q

What is red degeneration?

A

Complication of uterine fibroids
Haemorrhage infarct of the fibroid
Typically occurs in pregnancy

62
Q

What are the symptoms of red degeneration of a uterine fibroid?

What is the management?

A

Abdominal pain
Low grade fever
Vomiting

Conservative

63
Q

What are some differential diagnoses for post-coital bleeding? (6)

A 
Idiopathic
Cervical ectropion
Infection
Cervical cancer
Polyp/fibroids 
Other cancers - endometrial, vaginal
64
Q

What are some differential diagnoses for IMB? (6)

A 
Cervical ectropion
Polyp/fibroids
Endometrial cancer
Cervical cancer
STI
Contraception
65
Q

What is cervical ectropion?

A

When the columnar epithelium of the endocervix is displayed on the ectocervix and is visible on speculum examination

66
Q

What causes cervical ectropion?

A

Increased oestrogen levels

67
Q

What are some symptoms of cervical ectropion?

A

Often asymptomatic

Discharge
Post-coital bleeding

68
Q

What is the treatment in symptomatic cases of cervical ectropion?

A

Silver nitrate therapy

Diathermy

69
Q

What is the transformation zone of the cervix?

A

The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix

70
Q

What is endometriosis?

A

The presence of ectopic endometrial tissue outside the uterus

71
Q

What is the theory for the cause of endometriosis?

A

During menstruation, there is backflow of the endometrial lining through Fallopian tubes and into the pelvis (retrograde menstruation)

It then seeds itself at locations around the pelvis

72
Q

When in the menstrual cycle are endometriosis symptoms the worst?

A

During menstruation

73
Q

What are the symptoms of endometriosis? (5)

A

Cyclical abdominal/pelvic pain
Deep dyspareunia
Cyclical bleeding from other sites - e.g. haematuria
Fertility problems

74
Q

What is the gold standard investigation for endometriosis?

A

Diagnostic laparoscopy for abdominal endometrial tissue

75
Q

What are some management options for endometriosis? (5)

How do they work?

A

Analgesia - symptom treatment

COCP - regulate cycle

Depo injection (long term progesterone) - can stop menstruation

GnRH agonist (goserelin/Zoladex) - induces ‘menopause’

Laparoscopic surgery to dissect/cauterise ectopic tissue

76
Q

What is the last resort treatment of endometriosis?

A

Hysterectomy and bilateral salpingo-opherectomy

Not guaranteed to resolve symptoms

77
Q

What is the triad associated with a diagnosis of PCOS?

A

Polycystic ovaries on scan
Anovulation
Hyperandrogenism

78
Q

What is a tumour marker for the detection of ovarian cancer?

A

CA125

79
Q

Ovarian cysts are typically asymptomatic, what symptoms can they present with?

A

Pelvic pain
Bloating
Pelvic mass on examination if large

80
Q

How are ovarian cysts typically diagnosed?

A

Incidentally on pelvic USS

81
Q

Name 5 types of ovarian cyst

What is the most common?

A

Functional cysts - follicular (most common) or corpus luteum

Serous cystadenoma

Mucinous cystadenoma

Dermoid cyst

82
Q

What causes a follicular ovarian cyst?

What is the prognosis?

A

When a developing follicle fails to rupture

Harmless and usually disappear after a few cycles

83
Q

What causes a corpus luteum ovarian cyst?

A

Follicle releases the egg, but the corpus luteum persists and fills with fluid

84
Q

What is a serous cystadenoma?

A

Benign tumour of the epithelial cells

85
Q

What is a mucinous cystadenoma?

A

Another type of benign tumour of epithelial cells, can become very large

86
Q

What is a dermoid cyst?

A

Benign ovarian tumours (teratomas)

Originate from germ cells and can fill with various tissue types (hair and bone)

87
Q

What is the main complication of dermoid cysts?

A

Torsion

88
Q

What are the complications of ovarian cysts? (3)

A

Torsion

Haemorrhage

Rupture

89
Q

What is ovarian torsion?

A

Where the ovary twists on itself and the blood supply is disturbed

90
Q

What can cause ovarian torsion? (2)

A

Usually secondary to other ovarian pathology

Cyst
Tumour

91
Q

In what aged women, does ovarian torsion typically occur?

A

Women of reproductive age

92
Q

What are some symptoms of ovarian torsion?

What is sometimes seen on examination?

A

Acute unilateral iliac fossa pain
Nausea
Vomiting
Tenderness

Palpable mass and tenderness on examination

93
Q

How is ovarian torsion diagnosed?

A

USS

- Ideally transvaginal

94
Q

What are some complications of ovarian torsion? (4)

A

Pain
Infection
Rupture
Loss of function of ovary (other ovary can usually compensate)

95
Q

What are some symptoms of PCOS? (5)

A 
Weight gain
Hirsutism - male pattern hair growth
Oligomenorrhoea /amenorrhoea
Acanthosis nigricans
Impaired glucose tolerance
96
Q

What LH, FSH, insulin and testosterone levels are seen?

A

LH - raised
LH:FSH - raised
Insulin - raised
Testosterone - raised

97
Q

What criteria is used for diagnosis of PCOS?

A

Any two of the following three

Infrequent or absent ovulation
Hyperandrogenism
Polycystic ovaries on USS

98
Q

How can insulin resistance as a result of PCOS be treated?

How does it work?

A

Metformin

Improves insulin resistance and reduces circulating insulin levels

99
Q

What effect do high levels of insulin have on androgen levels?

A

Promotes the release of androgens from ovaries and adrenal glands

Increases them

100
Q

What is the general management for PCOS? (2)

A

Weight loss

COCP

101
Q

What is the stepwise approach to the management of infertility as a result of PCOS?

A

Weight loss

Metformin

Clomifene

102
Q

What are some medications that can be used to treat hirsutism as a result of PCOS?

A

Dianette (anti-androgen contraceptive)
Spironolactone
Finasteride

103
Q

How is the menopause diagnosed?

A

Cessation of periods for 12 months after last menstrual period

104
Q

How long is contraception recommended for women after their last menstrual period?

A

2 years for women under 50

1 year for women over 50

105
Q

How are oestrogen, progesterone, LH and FSH levels affected by the menopause?

A

LH/FSH = HIGH, in response to drop in gonadal hormones

Oestrogen/Progesterone = LOW

106
Q

What hormonal changes cause the menopause?

A

Drop in oestrogen and progesterone

107
Q

What are some peri-menopausal symptoms?

A 
Hot flushes
Mood swings
Premenstrual syndrome
Irregular periods
Heavier or lighter periods
Reduced libido
Vaginal dryness
108
Q

What are some of the management options for peri-menopausal symptoms? (3)

A

HRT
SSRIs - e.g. fluoxetine, citalopram
CBT

109
Q

What are some non-hormonal treatments for peri-menopausal symptoms?

A

Lifestyle advice
SSRIs
SSNRI - Venlafaxine
Clionidine

110
Q

How should medical management differ when treating a peri-menopausal woman compared to post-menopausal?

A

Peri = cyclical treatment

Post = continuous

111
Q

Oestrogen is combined with progesterone in women with a uterus to reduce the risk of…

A

Endometrial cancer

112
Q

Oestrogen combined with progesterone increases the risk of…

A

Breast cancer

113
Q

When can oestrogen be given unopposed to menopausal women?

A

If they have had a hysterectomy

114
Q

As well as reducing the symptoms of the menopause what is another benefit of HRT?

A

Reduced osteoporosis

115
Q

What are some risks associated with HRT? (4)

A 
Breast cancer
Endometrial cancer
Stroke
Coronary artery disease
Thrombosis
116
Q

What are some side effects of HRT? (4)

A 
Bloating
Breast swelling
Breast tenderness
Weight gain
Headaches
117
Q

What is FGM?

A

Surgically changing the female genitals for non-medical reasons

118
Q

Is FGM illegal?

A

YES

Legal requirement to report any discovered cases to the police

119
Q

Which country has the highest levels of FGM?

A

Somalia

120
Q

What are the 4 types of FGM?

A

1 = removal of the clitoris

2 = removal of clitoris and labia minora

3 = narrowing or closing vagina orifice

4 = any other unnecessary procedures to the female genitalia

121
Q

What is pelvic organ prolapse? What causes it?

A

Descent of pelvic organs into the vagina

Weakness and laxity of ligaments and muscles surrounding the uterus

122
Q

What is a uterine prolapse?

A

Where the uterus itself prolapses into the vagina?

123
Q

What is a rectocoele?

A

Defect in the posterior vaginal wall causing the rectum to prolapse into the vagina

124
Q

What symptom is a rectocoele particularly associated with?

A

Constipation

+ Urinary retention

125
Q

What is a cystocoele?

A

A defect in the anterior vaginal wall causing the bladder to prolapse in to the vagina

126
Q

What are the grades of uterine prolapse?

Grades 0 - 5

A

Grade 0 = normal

Grade 1 = remains above introitus by more than 1cm

Grade 2 = less than 1cm above or below introitus

Grade 3 = between 1cm below the introitus and at least 2cm of vagina left above introitus

Grade 4 = full eversion of the vagina

127
Q

What are some risk factors for pelvic organ prolapse?

A 
Multiple vaginal deliveries
Traumatic vaginal deliveries
Increasing age
Obesity
Chronic constipation
Connective tissue disorder
128
Q

What symptoms do patients with pelvic organ prolapse present with?

A

Urinary symptoms
Bowel symptoms
Sexual dysfunction
Feeling of something coming down

129
Q

On what movements do pelvic organ prolapses typically get worse?

A

Straining

Bending down

130
Q

What are the 3 management options for pelvic organ prolapse?

A

Conservative management

Vaginal pessary

Surgery

131
Q

Outline the conservative management of pelvic organ prolapse (4)

A

Physiotherapy - pelvic floor exercises
Lifestyle changes based on symptoms
Medications for symptoms - e.g. stress incontinence
Vaginal oestrogen cream

132
Q

How do vaginal pessaries work? How often should they be changed/cleaned?

A

Inserted inside the vagina to provide support for the uterus

Cleaned regularly and changed every 4 months

133
Q

What are some side effects of vaginal pessaries?

A

Vaginal irritation/erosion

134
Q

What complication has been associated with the use of mesh repairs in the surgical management of pelvic organ prolapse?

A

Chronic pelvic pain

135
Q

What is urge incontinence?

A

Leakage of urine due to detrusor overactivity

136
Q

What is stress incontinence?

A

Leakage of urine on increased intra-abdominal pressure (laughing/coughing), due to weakness of pelvic floor muscles and sphincters

137
Q

What are some risk factors for developing incontinence?

A 
Increase age
Increased alcohol
Increased caffeine
Increased carbonated drinks
Increased BMI
Previous pregnancies
Previous vaginal deliveries
138
Q

What are some investigations that can be undertaken for urinary incontinence? ($)

A

Urinalysis
Bladder diary
Post void bladder scan
Urodynamic studies

139
Q

What is the management of stress incontinence? (5)

A 
Weight loss
Pelvic floor exercises
Reduced fluids, caffeine, alcohol, carbonated drinks
Medical management - duloxetine
Surgery - tension free vaginal tape
140
Q

What is the management of urge incontinence? (2)

A

Bladder retraining

Anti-muscarinic medications - e.g. oxybutynin, tolterodine

Obs & Gynae (6 decks)

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