Gynaecology Flashcards
Fibroids aetiology
Benign proliferation of smooth muscle
Oestrogen responsive
Enlarge during pregnancy
Calcify during menopause
RFs
- Afro-Caribbean
- Early menarche
- Younger women
- Family Hx
- Genetic - Fumarate hydratase
Protective…
- COCP
- Late menarche
- Parity
Fibroids presentation
Dysfunctional BLEEDING!
- Menorrhagia
- Dysmenorrhoea
- Intermenstrual
Bloating
Urinary urgency
Suprapubic pain
SUBFERTILITY!
Fibroids investigations
O/E - BULKY UTERUS
TVUS
MRI - Adenomyosis?
FBC - Anaemia
Fibroids management
- MIRENA COIL
< 3cm + HMB
- Tranexamic acid
- NSAIDS
- Progesterones
- COCP
> 3cm + HMB
- Ullipristal acetate
- Surgery
Myomectomy - If looking to conceive
Ablation
Hysterectomy
Uterine artery embolisation
Fibroids complications
Subfertility
Degeneration
- Hyaline
- Cystic
- Calcification
Red degeneration - Blood in fibroid
- Occurs in pregnancy
- N/V + Abdo pain + fever
- NSAIDS + Rest
Torsion of pedunculated
Fibroids pregnancy complications
Premature labour
Obstructed labour
Malpresentation
PPH
Red degeneration
Adenomyosis aetiology / presentation / investigations / management
Endometrial tissue in the myometrium
RFs
- Multiparous
- Age ^^^
Boggy uterus
Dysmenorrhoea
Menorrhagia
Investigations - MRI
Management
- GnRH analogue
- Hysterectomy
Endometrial hyperplasia
Abnormal proliferation of endometrium outside normal menstrual cycle
Cancer risk!
Presentation - Dysfunctional bleeding
Management
- Typical - High dose progesterones - MIRENA COIL
- Atypical - Hysterectomy
Endometriosis aetiology + location
Endometrial tissue outside the uterine cavity
- Uterosacral ligament
- Ovaries
Cause - UNKNOWN
- Retrograde menstruation
- Impaired immunity
- Genetic
Endometriosis presentation
Pain!
- Deep dyspareunia
- Cyclical dysmenorrhoea - Before period
Subfertility
Urinary symptoms
- Dysuria
- Urgency
Dyschezia
Endometriosis investigations + examination
O/E
- Reduced organ motility
- Tender modularity in posterior fornix
- Fixed retroverted uterus
Laparoscopy and biopsy
- Endometrium outside the uterine cavity
TVUS - Look for ovarian cysts
Ca125
MRI - Adenomyosis
Endometriosis management
Analgesia
Stop cycle
- COCP
- Mirena coil
- Progesterones
Secondary care
- GnRH analogue
- Surgery - Ablation
Endometriosis complications
Fibroids
Adhesions
Subfertility
Ectopic pregnancy
Endometrial cancer risk factors
75% post-menopausal
Unopposed oestrogen
Obesity
Diabetes
Early menarche
Late menopause
Nulliparity
Hereditary non-polyposis colorectal cancer - HNPCC
PCOS
Tamoxifen
Endometrial cancer types / presentation
Adenocarcinoma
Adenosquamous - Poor prognosis
PMB
PMB
PMB
Intermenstrual bleeding
Pain
Pyometra - Uterine infection
B-symptoms - Fatigue and weight loss
Endometrial cancer investigations
2WW REFERRAL!!!!
TVUS
Hysteroscopy and biopsy > 4mm thickness
CT/MRI staging
Endometrial cancer staging and management
- Confined to uterus - Hysterectomy and BSO
- Uterus and cervix - Radical hysterectomy*
- Uterus, cervix, serosa - Chemo and radiotherapy
- Distant mets - Chemo and radiotherapy
- Radical hysterectomy
- Uterus
- Ligaments
- 1” of vagina
Prognosis - Early detection - GOOD!
PMB DDx
- Endometrial cancer
- Vaginal atrophy
Endometrial hyperplasia
HRT spotting
Ovarian cancer
Ovarian cyst
Cervicitis
Cervical cancer
Vaginal cancer
Intrauterine cysts / polyps
Risk factors - OESTROGEN
- Late menopause
- Early menarche
- Obesity
- Nulliparity
- Diabetes
- PCOS
PC - Dysfunctional bleeding
Ix - TVUS
Rx - Curettage / Diathermy
Complications - Cancer and subfertility
Cervical histology
Uterus - Simple columnar
Endocervix - Glandular ciliated columnar - Adenocarcinoma
Transformational zone - Squamocolumnar junction - Malignancy risk
Ectocervix - Stratified squamous epithelium
Cervical screening age groups / method
< 25 - Not offered - Screening not shown to reduce number of cancers
25-49 - Every 3 years
50-64 - Every 5 years
Immunocompromised - Annually
Liquid based cytology - Examination of cervical cells
Cervical screening results and management
Normal - Repeat in 3/5 years
Inadequate
- Repeat smear
- If 2 inadequate - Refer for colposcopy
Borderline - Mild dyskaryosis
- HPV test
- Positive - Refer for colposcopy
- Negative - Return to routine
Moderate or severe dyskaryosis
- 2ww colposcopy referral
CIN aetiology
Pre-malignant state
Atypical cells present in squamous epithelium
70% SCC
15% Adenocardinoma
15% mixed
HPV - 16, 18, 33
Sexual partners ^^^
Smoking
Immunosuppression
CIN presentation
Post-coital bleeding
Intermenstrual bleeding
Post-menopausal bleeding
Vaginal discharge
Asymptomatic?
CIN investigations / grading / management
Colposcopy
Punch biopsy
CT-PET
- Dyskaryosis in 1/3 epithelium
- Dyskaryosis in 2/3 epithelium
- Dyskaryosis in > 2/3 - Carcinoma in situ
Malignant - Invasion of basement membrane
LLETZ - Large loop excision of transformational zone
REPEAT SMEAR IN 6 MONTHS!
Cervical ectropion
RFs
Presentation
Management
Endocervix spreads to ectocervix - EVERSION
RFs - OCP and pregnancy
Presentation
- PCB
- Discharge
Management
- Stop OCP
- Cryotherapy
Cervicitis
Presentation
Management
Infection of the cervix
Presentation - Discharge
Management
- Antibiotics
- Antivirals
- Antifungals
- Cryotherapy
Cervical polyps
Presentation
Management
Aetiology
Benign tumour of the cervix
Presentation
- IMB
- PCB
Management - Avulsion
Cervical cancer staging
- Confined to cervix
2a. Cervix and upper vagina
2b. Cervix, upper vagina and parametrium - Cervix, upper vagina, parametrium, lower vagina and pelvic wall
- Cervix, upper vagina, parametrium, lower vagina, pelvic wall, bowel, bladder and other structures
Cervical cancer management
- Cone biopsy
Pelvic nodes -ve - Hysterectomy
Pelvic nodes +ve - Radical hysterectomy
2a. Hysterectomy, radiotherapy, chemotherapy
Ovarian cyst types
Physiological
- Follicular
- Corpus luteum
Benign cell tumour - Dermoid cyst
Benign epithelial tumour
- Serous cystadenoma
- Mucinous
Benign sex cord tumour
Fibroma
Ovarian cyst - Physiological
Follicular
- Non-rupture of dominant follicle
- Regress after a few menstrual cycles
Corpus luteum
- Corpus luteum does not break down
- Fills with blood or fluid
Benign germ cell tumour
Dermoid cyst
Skin
Hair
Teeth
Seen in < 30
Benign epithelial tumour
Serous cystadenoma
- Seen in 40-50s
- Can be malignant
Mucinous
- Very large
- May rupture to become pseudomyxoma peritonei
Ovarian cyst presentation / investigations
Bloating
Lower back pain
Deep dyspareunia
Early satiety
Dyschezia
Urinary symptoms
TVUS
Ca125 - Rule out cancer
Laparoscopy - Aspiration
MSU
hCG
Ovarian cyst management
Pre-menopausal < 5cm - Watch and wait
Pre-menopausal > 5cm - Laparoscopic ovarian cystectomy
Post-menopausal < 5cm - Watch and wait
Post-menopausal > 5cm - Bilateral oophorectomy
Ovarian cyst complications
Torsion
- Fever
- Abdo pain
- Vomiting
Rupture
- Abdo pain
- Shock
Haemorrhage
Peritonitis
Ovarian torsion aetiology
Ovary twists on supporting ligaments
Blood supply is compromised
Fallopian tube involvement = Adnexal torsion
Ovarian cyst
Ovarian cancer
Pregnancy
Fertility treatments
Ovarian torsion presentation / investigations / management
Fever
Colicky abdo pain
Vomiting
Adnexial mass
Examination - Adnexal tenderness
USS
- Free fluid
- Whirlpool sign
Management - Laparoscopy
Ovarian cancer - Aetiology
Risk factors vs Protective factors
Oestrogen responsive
80% serous carcinoma
RFs - BRCA!!!
- HNPCC
- Nulliparity
- Early menarche
- Late menopause
Protective…
- COCP
- Pregnancy
Ovarian cancer presentation / investigations
IBS symptoms
- Early satiety
- Abdo pain
- Change in bowel habit
Urinary symptoms
- Ca125
- If > 35 - Urgent USS - Abdo and pelvis
- Laparotomy and biopsy to confirm
Ovarian cancer risk of malignancy index
U x M x Ca125
U - USS findings - BAMMS
M - Menopausal status
Score > 125 - Requires MDT and staging
Ovarian cancer - USS findings
BAMMS
Bilateral lesions Ascites Mets Multilocular cysts Solid areas
Ovarian cancer staging and management
- Ovary
- Pelvic
- Abdo invasion
- Mets outside the abdomen
Surgery
Radiotherapy
Platinum based chemo
Hyatidiform mole aetiology
Gestational trophoblastic disease
Implantation of non-viable foetus
Asian
Extremes of age
Previous HM
HM presentation
hCG ^^^
Hyperemesis gravidarum
Painless menstrual bleeding - Obvs weird when they’re preggo
Hyperthyroid picture - hCG mimics T4
Proteinuria
HTN
Abdo pain
HM investigations
hCG ^^^
Urine dip - Proteinuria
BP - HTN
USS
- Snowstorm appearance
- Bunch of grapes
- Honeycomb
Menorrhagia aetiology
Bleeding that patient deems to be excessive or abnormal
Idiopathic - 50%
Fibroids - 30%
Uterine
- Fibroids
- Polyps
- Adenomyosis
Systemic
- Thyroid
- Bleeding disorders
- Diabetes
- Obesity
Iatrogenic
- Anticoags
- IUD - Copper coil
Menorrhagia investigations
FBC
Other bloods if indicated…
- TFT
- Clotting
- LFTs
TVUS - Fibroids?
Menorrhagia management
Treat anaemia
Contraceptives…
- Mirena coil
- COCP
Non-contraceptives
- Tranexamic acid
- Mefenamic acid - Pain relief
Dysmenorrhoea aetiology and management
Idiopathic - Normal?
Endometriosis
Adenomyosis
Fibroids
PID
Ovarian tumour
Management - Treat cause
- Mefenamic acid
- COCP
- TENS
PCB causes
Cervical ectropion
Cervical cancer
Cervicitis
Cervical polyps
Trauma
IMB causes
Non-malignant
- Fibroids
- Uterine polyps
- Adenomyosis
- Ovarian cyst
- PID
Malignant
- Endometrial cancer
- Ovarian cancer
- Cervical cancer
IMB investigations and management
FBC
TFT
Clotting
Cervical smear if due?
TVUS
Management
- IUD
- COCP
Acute pelvic pain DDx
Woman of childbearing age - Ectopic until proven otherwise!
Mittleschmerz - Pain midway through menstrual cycle - Normal
Miscarriage
Ovarian cyst rupture
Ovarian torsion
PID
UTI
Appendicitis
Chronic pelvic pain DDx
Go to answer - Endometriosis!
IBS/IBD
PID
Ovarian cyst
Adenomyosis
Uterine prolapse
Adhesions
Psychological - Previous abuse
PID aetiology and presentation
STI
- Chlamydia
- Gonorrhoea
Pelvic pain
Deep dyspareunia
Cervical excitation
Fever
STI symptoms
RUQ pain
Dysfunctional menstrual bleeding
PID investigations / management / complications
Triple swab
- Endocervical chlamydia swab
- Endocervical sample
- High vaginal swab
TVUS - Rule out differentials
Management - Treat infection
- PO ofloxacin + Met
- IM Cef + PO doxy + PO met
Complications
- Subfertility
- Ectopic
- Chronic pelvic pain
Vaginal intraepithelial neoplasia
Usual
- Common in 35-50
- May develop into squamous cell carcinoma
Differentiated
- More common in older women
- Associated with lichen sclerosis
- Higher risk of squamous cell carcinoma
Vaginal intraepithelial neoplasia
Presentation
Investigations
Management
Presentation
- Pruritus
- Pain
Management
- Local surgical excision
- Imiquimod
Vulval cancer aetiology and histology
Most common in > 65
Squamous cell carcinoma
Causes
- HPV
- VIN
- Lichen sclerosis
- Immunosuppression
Vulval cancer presentation / investigations / management
Ulcer/mass in labia majora!
Bleeding
Pruritus
Discharge
Superficial dyspareunia
Investigations - Biopsy lesions
Management
- Wide local excision
- Groin lymphadenectomy
Lichen simplex
Presentation
- Itching
- Thick labia majora
Risk factors
- Sensitive skin - Dermatitis and eczema
Management
- Avoid irritant
- Antihistamines
- Steroid cream
Lichen planus
Associated with AI disease
Presentation
- Flat purple lesions
- PO and PV
- Painful
- Erosive
Management - Steroid cream
Lichen sclerous
Associated with AI disease
Presentation
- Thin vulval epithelium
- Pink and white papule - Parchment like skin
- Itching
- Dyspareunia
Associated with SCC
Management - Steroid cream and emollients
Atrophic vaginitis
Post-menopausal women
Presentation
- PMB
- Vaginal dryness
- Itching
- Dyspareunia
TVUS - Rule out endometrial cancer
Management
- Topical oestrogen
- Lubricants
- Creams
Vaginal cancer
Squamous cell carcinoma
Clear cell carcinoma
Presentation
- Dysfunctional menstrual bleeding
- PMB
- Discharge
- Mass
Management - Radiotherapy
Female genital mutilation
Partial or complete removal of external genitalia
Any injury to female organs
For non-medical reasons
- Removal of clitoris
- Excision - Removal of clitoris and labia
- Infibulation - Narrowing of the vagina
- Any other harmful procedure
- Piercing
- Incising
- Scraping
Prolactinoma
Pituitary adenoma - Benign tumour of the pituitary gland
Micro < 1cm
Macro > 1cm
Secretory/functioning - Excess of a particular hormone
OR
Non-secretory/functioning
Excess prolactin symptoms
Women
- Amenorrhoea
- Infertility
- Galactorrhea
- Osteoporosis
Men
- Impotence
- Loss of libido
- Galactorrhea
Prolactinoma diagnosis and management
Diagnosis - MRI
Management…
Dopamine agonists - Inhibit release of prolactin
- Cabergoline
- Bromocriptine
Surgery?
Prolapse aetiology
Age ^^^
Childbirth
Radiotherapy
Chronic pressure
- Tumour
- Constipation
- Cough
- Obestity
Prolapse types
Anterior
- Cystocele
- Urethrocele
- Cystourethrocele
Posterior
- Enterocoele
- Rectocele
Vault - Upper vagina drops down
Uterine - Uterus drops into vagina
Prolapse presentation and grading
Dragging sensation
Heaviness
“Bearing down”
Urinary symptoms
Sexual difficulties
0 - No descent with strain 1 - 1cm above hymen 2 - Within 1cm of hymen 3 - 1cm below hymen 4 - Vaginal eversion
Prolapse management
Conservative
- Pelvic floor exercises
- Weight loss
Ring pessary
Oestrogen cream - If menopausal
Surgery
- Anterior colporrhaphy
- Posterior colporrhaphy
- Hysterectomy
