Gynaecology Flashcards
RFs of endometrial cancer?
excess endogenous oestrogen:
- nulliparity
- obesity
- PCOS
- early menarche/ late menopause
- oestrogen-secreting tumour
- tamoxifen
- Lynch II syndrome
- diabetes mellitus
protective factors for endometrial cancer?
smoking
COCP
grand-parity
breast feeding
RFs of cervical cancer?
smoking HPV 16,18,31,33 immunocompromised increased number of sexual partners COCP no vaccinated/screened
protective factors for cervical cancer?
vaccination
screening
barrier contraception
RFs for ovarian cancer?
continuous ovulations:
- nulliparity
- early menarche/ late menopause
- BRCA 1 and 2
- lynch II syndrome
protective factors for ovarian cancer?
interrupting ovulation:
- pregnancy
- breast feeding/ lactation
- COCP
what to think if post-menopausal bleeding?
endometrial cancer
causes of endometrial cancer?
most are adenocarcinomas, related to unopposed oestrogen
features of endometrial cancer?
PMB
pre-menopausal women who have heavy or irregular periods
PV discharge and pyometra
diagnosis of endometrial cancer?
TV USS shows endometrial thickness >4mm
hysteroscopy with biopsy
CT/MRI
staging of endometrial cancer?
FIGO staging I- uterus only II- uterus and cervix III- beyond uterus but within pelvis IV- extending outside the pelvis e.g. bowel and bladder
tx of endometrial cancer?
hysterectomy +/- pelvic lymph nodes with bilateral salpingo-oophrectomy
radiotherapy
progesterone therapy if not fit for surgery
what to suspect of post-coital bleeding?
cervical cancer
where is cervical cancer most common?
squamo-columnar junction (transformation zone) is predisposed to malignant change
types of cervical cancer?
SCC (most common)
adenocarcinoma
peaks of incidence of cervical cancer?
2 peaks-
30-39 years
>70 years
screening of cervical cancer?
smear test
25-49 -> 3-yearly screening
50-64 -> 5-yearly screening
sexually active women
what are the different types of CIN (cervical intra-epithelial neoplasia)?
CIN 1- bottom 1/3 of squamous epithelium
CIN 2- bottom 2/3 of squamous epithelium
CIN 3- full thickness dysplasia
what are the different results of a smear test?
normal - repeat in 3 years
inflammatory- repeat in 6 months, colposcopy after 3 abnormal results
borderline (20-30% CIN II-III)- HPV +ve refer for colposcopy, HPV -ve repeat in 3 years
moderate (50-75% CIN II-III)- refer for urgent colposcopy
severe (80-90% CIN II-III)- refer for urgent colposcopy
inadequate 3x smear tests- colposcopy
features of cervical cancer?
abnormality in bleeding- PCB, IMB, PMB
watery vaginal discharge
incidental finding
later changes- weight loss, heavy vaginal bleeding, ureteric obstruction, bowel disturbance, vesico-vaginal fistula, pain
Ix of cervical cancer
colposcopy and biopsy
bloods
CT abdo and pelvis
MRI pelvis
mx of cervical cancer?
LLETZ- large loop excision of the transformation zone if CIN II-III
hysterectomy
lymphadenectomy
chemo-radiotherapy
types of ovarian cancer?
surface derived tumours (epithelial)
germ cell tumours
sex cord- stromal tumours
mets
when does genetic testing need to be done with ovarian cancer?
two 1st degree relatives with OC
features of ovarian cancer?
subtle and non-specific bloating and distension, pain, ascites, abdo mass bowel obstruction dyspareunia early satiety diarrhoea/constipation B symptoms
when to refer for ovarian cancer?
Risk of Malignancy Index= CA125 x USS score x post-menopausal status
>250= 2 week-wait
post-menopausal status-> 1 if pre-, 3 if post-
CA125 -> number
USS score-> 1 if 0-1 features, 3 if 2+ features
features on USS score for ovarian cancer?
bilateral disease solid septations on the tumour fluid (ascites) abdo pathology
ix of ovarian cancer?
FBC, U&E, LFTs CA125 If <40 -> AFP, LDH, hCG (could be germ cell tumour) TVS CXR CT abdo/pelvis MRI sample ascites
FIGO staging for ovarian cancer?
1= confined to ovary
2= outside ovary but in pelvis
3= outside pelvis but in abdomen
4- distant mets
tx for ovarian cancer?
surgery- full staging laparotomy
chemotherapy
what is vulval cancer?
most are squamous cell carcinomas and occur in women >65 years
RFs for vulval cancer?
HPV vulval intraepithelial neoplasia HIV lichen sclerosis smoking Paget's disease of the vulva
features of vulval cancer?
lump on ulcer on labia majora
itching, irritation, bleeding, discharge
tx of vulval cancer?
wide local excision
groin lymphadenopathy if tumour <1mm deep
what is hydatidiform mole?
a tumour producing lots of hCG giving rise to exaggerated pregnancy symptoms and strongly positive pregnancy tests
USS feature of hydatidiform mole?
snow-storm appearance
features of hydatidiform mole?
early pregnancy failure- failed miscarriage (painless vaginal bleeding) or signs on USS
severe morning sickness or 1st trimester pre-eclampsia are rarer presentation
can cause hyperthyroidism so present with symptoms similar to thyrotoxicosis
tx of hydatidiform mole?
molar tissue is removed from uterus by suction
give anti-D if Rh -ve
pregnancy should be avoided until hCG is normal for 6 months
can metastasise to lung, vagina, brain, skin or liver
acute causes of pelvic pain in women?
ectopic pregnancy UTI appendicitis PID ovarian torsion miscarriage
chronic causes of pelvic pain?
endometriosis
IBS
ovarian cyst
urogenital prolapse
what is an ectopic pregnancy?
implantation of a fertilised ovum outside of the uterus
most are in the ampulla of the Fallopian tube
when to consider ectopic pregnancy?
positive pregnancy test with empty uterus
high b-hCG
RFs for ectopic pregnancy?
slowing ovum’s passage to the uterus
- damage to the tubes (salpingitis, PID, tubal surgery)
- prev ectopic
- IVF
- IUCD in situ
- Failed sterilisation
features of ectopic pregnancy?
- 6-8 weeks amenorrhoea
- lower abdo pain usually constant and unilateral
- vaginal bleeding: may be dark brown in colour
- peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
- cervical excitation
- adnexal mass
Ix of ectopic pregnancy?
positive pregnancy test TVUS- empty uterus, free fluid in adnexae/pouch of Douglas slow falling bHCG serum progesterone bloods- cross match
mx of ectopic pregnancy?
Rh -ve women should receive anti-D immunoglobulin
- Expectant- small and ruptured, hBG <200, clinically stable
- Medical- size <35mm, unruptured, no pain, no foetal HR, serum hCG <1500
- methotrexate- IM by USS or laparoscopic visualisation - Surgical- size >35mm, severe pain, potentially ruptured, hCG >1500
- salpingectomy- remove affected tube
- salpingotomy- remove the pregnancy and reconstruct the tube
how many weeks gestation is a miscarriage classed as?
less than 24 weeks gestation
how to diagnose a complete miscarriage?
TV USS demonstrating a crown-rump length greater than 7mm with no cardiac activity
types of miscarriage?
threatened missed inevitable inomplete complete miscarriage with infection
what is a ‘blighted ovum’ showing?
missed miscarriage
causes of miscarriage?
- genetic abnormalities
- endocrine factors- poorly controlled DM, thyroid, PCOS
- maternal illness and infection
- maternal drugs- NSAIDs and antidepressants
- smoking, alcohol, drugs
- abnormalities of the ueris e.g. bicornuate uterus
- cervical incompetence
- antiphospholipid syndrome
- thrombophilia- anti-thrombin III, protein C, protein S
how is antiphospholipid syndrome diagnosed?
vascular thrombosis and 3+ consecutive miscarriages <10 weeks or 1 foetal death >10 weeks
mx of antiphospholipid syndrome?
aspirin and heparin
Ix of suspected recurrent miscarriage?
parental blood for karyotyping cytogenic analysis of products of conception pelvic USS thrombophilia screening LA or aCL antibodies
what does a thrombophilia screen include?
FBC and clotting screen - Activated Protein C resistance
protein C - Factor V Leiden (if APCR positive)
protein S - prothrombin gene mutation
antithrombin
lupus anticoagulant - anticardiolipin antibodies
mx of miscarriage?
Rh -ve women to receive anti-D Ig for >12 weeks pregnancy
1. conservative- used for incomplete miscarriages where uterus is small
- medical- <12 weeks- misoprostol (prostaglandin analogue)
>12 weeks- mifepristone (antiprogesterone) followed by misoprostol - surgical- ERPC- evacuation of retained POC
what are fibroids?
benign smooth muscle tumours of the uterus
oestrogen dependent- enlarge in pregnancy and COCP and atrophy after menopause
RFs for fibroids?
menopause
afro-caribean ethnicity
FH
nulliparous
features of fibroids?
asymptomatic menorrhagia fertility problems lower abdo pain- may be due to torsion or red degeneration mass frequency of urine
what is red degeneration?
when thrombosis of capsular vessels is followed by venous engorgement and inflammation, causing abdo pain and localised peritoneal tenderness- usually in the last half of pregnancy
mx of red degeneration
bed rest and analgesia
resolves within 4-7 days
diagnosis of fibroids?
pelvic exam- bulky, non-tenderous uterus USS- TVS or abdo US hysteroscopy laparoscopy biopsy
complications of fibroids?
enlargement torsion degeneration leiomyosarcoma transformation (malignant)
mx of fibroids?
medical tx for fibroids <3cm
1st line= IUS, tranexamic acid or COCP for meorrhagia
- GnRH analogues e.g. goserelin
-Ullipristal acetate- Esmya (can be taken for 3-6 months to shrink fibroids prior to surgery)
-Surgery- myomectomy, hysterectomy, emdometrial ablation
-Uterine artery embolisation- recommended for women with large fibroids (not of child-bearing age)
how does a GnRH analogue work?
injection that stops the pituitary gland producing oestrogen
can only be used for 6 months due to demineralisation of bone risk
can induce menopause-like side effects
causes of menorrhagia?
- dysfunctional uterine bleeding
- fibroids
- endometriosis and adenomyosis
- PID
- IUCD
- hypothyroidism
- bleeding disorders
- in women >45 years with failed medical management- consider endometrial carcinoma
Ix of menorrhagia?
exclude pregnancy bloods- FBC, haematinics, TSH cervical smear if due STI screen speculum examination if high risk- TVUS
mx of menorrhagia if requires contraception?
- mirena IUS
- COCP
- Depo-provera
mx of menorrhagia if doesn’t require contraception?
- tranexamic acid (anti-fibrinolytics)
- NSAIDs e.g. mefenamic acid taken during days of bleeding. CI= peptic ulceration
short-term management- norethisterone (IM progestogens)
surgical mx of menorrhagia?
endometrial ablation
hysterectomy
mx of primary dysmenorrhoea (pain w/o organic pathology)?
NSAIDs inhibit prostaglandins e.g. mefenamic acid during menstruation
Paracetamol
Hycoscine butylbromide is a smooth muscle anti-spasmodic
COCP for ovulatory pain
what is endometriosis?
the presence of endometrial tissue outside the uterine cavity
hormonally drive by oestrogen so affects women of child-bearing age
what is adenomyosis?
the presence of endometrial tissue within the myometrium
happens in older women who have had children
causes a BULKY UTERUS
3 theories of endometriosis?
1) retrograde menstruation
2) metaplasia of mesothelial cells
3) impaired immunity
features of endometriosis?
- classic triad- dysmenorrhoea, cyclical pelvic pain, deep dyspareunia (from involvement of uterosacral ligaments)
- subfertility
- LUTS
- ruptured endometriomas- cause sudden intesnse pain
examination of endometriosis?
may be normal if there is minimal disease
fixed retroverted uterus on bimanual examination
adnexal masses or tenderness
common sites for endometriosis?
uterosacral ligaments ovaries (chocolate cyst) rectum vagina bladder lungs
ix of endometriosis?
gold standard= laparoscopy with biopsy
TVS is useful for diagnosing ovarian endonmetriotic cysts
MRI if bowel involvement
tx of endometriosis?
- NSAIDs/paracetamol for pain
- Suppression of menstruation- COCP, mirena IUS, implant, depot, progestogens
- GnRH analogues e.g. goserelin can be used <6 months to suppress oestrogen
- Surgery- laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
complications of endometriosis?
infertility
adhesions
tubal/ovarian dysfunction
what is lichen sclerosus?
an inflammatory condition which affects the genitalia and more common in elderly females
leads to atrophy of the epidermis with white plaques forming
main symptom of lichen sclerosus?
itch
diagnosis of lichen sclerosus?
skin biopsy done if clinical diagnosis can not be made
mx of lichen sclerosus?
topical steroids and emolliants
complication of lichen sclerosus?
increased risk of vulval cancer
pathophysiology of PCOS?
- disordered LH production
- peripheral insulin resistance
- causes increase ovarian androgen production
- excess small ovarian follicles and irregular/absent ovulation
- raised peripheral androgens -> hirsutism
rotterdan criteria for PCOS?
2/3 of:
- multiple small follicles in an enlarged ovary- on TVUS
- irregular periods
- hirsutism
- clinical- acne/excess body hair
- biochemical- raised serum testosterone
other features of PCOS?
Subfertility and infertility
menstrual disturbances- oligomenorrhoea and amenorrhoea
hirsutism, acne
obesity
acanthesis nigricans (due to insulin resistance)
ix of PCOS?
TVUS
Bloods- FSH, prolactin, TSH, total and free testosterone, sex hormone binding globulin, LH
Impaired glucose tolerance
mx of PCOS?
General- weight reduction, COCP to regulate periods
Hirsutism- COCP, topical eflornithine, cyproterone
Infertility- weight loss, metformin (improves insulin sensitivity), clomifene citrate, ovarian drilling
how does comifene citrate work?
induces ovulation, it should only be used for women with BMI <35 and for no more than 6 cycles due to risk of ovarian cancer
long term consequences of PCOS?
Gestational diabetes
T2DM
CV disease
endometrial cancer
what’s the HPO cycle for the menstrual cycle?
hypothalamic-pituitary-ovarian axis
hypothalamus-> (GnRH)-> anterior pituitary-> (FSH/LH) -> ovary-> oestrogen and progesterone (oestrogen positive feedback and progesterone is negative feedback)
what causes release of an egg?
LH
what does FSH do?
causes the maturation of an egg in the ovary
follicle produces oestrogen
what does oestrogen and progesterone do?
oestrogen causes proliferation of the endometrium and causes a surge in LH for ovulation at 14 days
progesterone maintains it, formed by the corpus luteum
when is primary amenorrhoea classified?
failure to start menstruating in a 16 year old, or a 14 year old without breast development
causes of primary amenorrhoea?
constitutional delay
congenital malformation of the genital tract
hypothalamic failure-> anorexia, kallman’s syndrome (GnRH deficiency)
gonadal failure-> turner’s syndrome
features of turner’s syndrome?
45XO (should be considered in any girls with short stature or primary amenorrhoea) neck webbing obesity CV problems poor breast developement congenital heart defects renal malformations hearing loss
what is congenital adrenal hyperplasia?
females born with ambiguous genitalia from exposure to excess androgens in foetal life
babies -> salt losers and very unwell
teenagers-> severe hirsutism and acne
causes of secondary amenorrhoea?
normal menstruation ceases of >6 months
- HPO-> stress, exercise, weight loss
- Pituitary-> hyperprolactinaemia, sheehan’s syndrome
- Adrenal-> hyper/hypothyroidism
- Ovary-> PCOS, premature ovarian failure
- Acquired-> asherman’s syndrome
causes of ovarian failure?
secondary to chemo, radiotherapy, surgery
menopause symptoms, infertile
FSH/LH raised, O+P low
rx= HRT, IVF
what is sheehan’s syndrome?
post partum hypopituitarism
PPH results in ischaemic necrosis of pituitary gland
decreased FSH/LH -> anovulation
Rx= hormone replacement, corticosteroids, levothyroxine
what is asherman’s syndrome?
intrauterine adhesions
most commonly after dilatation and curettage after miscarriage
Ix of secondary amenorrhoea?
exclude pregnancy gonadotrophins- low levels show hypothalamic cause prolactin androgen levels (PCOS) Oestradiol TFTs
mx of secondary amenorrohea?
treat cause
can do progesterone cause to see if endometrium sheds
what causes PID?
Ascending infection from the endocervix
- chlamydia
- gonorrhoea
- mycoplasma genitalium
- mycoplasma hominis
features of PID?
Lower abdo pain fever deep dyspareunia dysuria and menstrual irregularities vaginal or cervical discharge cervical excitation perihepatitis (Fitz-hugh curtis syndrome)
ix of PID?
Screen for chlamydia and gonorrhoea
mx of PID?
Oral ofloxacin and oral metronidazole OR
IM ceftriaxone and oral doxycycline and oral metronidazole
features of menopause?
change in periods
vasomotor symptoms- hot flushes, night sweats
urogenital changes- vaginal dryness and atrophy, urinary frequency
psychological- anxiety and depression, short-term memory loss
long-term complications- OP, increased risk of IHD
mx of menopause?
- lifestyle modifications- good sleep hygiene, regular exercise, weight loss, reduce stress
- HRT- unopposed oestrogens or O+P
- Non-hormone replacement therapy- fluoxetine, citalopram, vaginal lubricant, vaginal oestrogen, CBT etc
CI to HRT?
Current or past breast cancer
any oestrogen-sensitive cancer
undiagnosed vaginal bleeding
untreated endometrial hyperplasia
what is ovarian torsion?
occurs unilaterally in combination with a pathologically enlarged ovary
RFs for ovarian torsion?
pregnancy
malformations
tumours
previous surgery
features of ovarian torsion?
severe lower abdo pain
N&V
fever
management of ovarian torsion?
rule out ectopic- hCG urine dip FBC USS- may show free fluid laparoscopy-diagnostic and therapeutic analgesia
name a benign germ cell tumour?
dermoid cyst (mature cystic teratoma)
name a physiological cyst?
follicular cyst- due to non-rupture of a dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
causes of male infertility?
30% of causes of infertility surgery STI varicocele systemic illness abnormal genitalia examination
female causes of infertility?
unexplained
ovulation failure
tubal damage
other causes
basic investigations for infertility (male and female)
semen analysis
serum progesterone 7 days prior to expected next period- usually day 21 (>30 indicates ovulation)
chlamydia screening
day 2-5 FSH and LH
TSH, prolactin, testosterone, rubella status
secondary care investigations for infertility?
TVUS
HSG- hysterosalpingogram
HyCoSy
laparoscopy and dye test is gold standard
mx of infertility?
- lifestyle modification- weight loss, folic acid, regular sexual intercourse, smoking/drinking advice
- ovulation induction- clomifene citrate (6-8 cycles), laparoscopic ovarian drilling (used in patients with PCOS), gonadotrophins, metformin (PCOS)
- SURGERY- tubal catheterisation, treat endometriosis, adhesolysis
- IVF-screen for HIV, Hep B and C
what is the NHS assisted contraception criteria?
no children non-smokers BMI <30 under 42 years of age don't require gamete donation
contraindications to COCP?
>35 and smoke >15 a day migraine with aura history of VTE, stoke, IHD breast feeding <6 weeks post-partum uncontrolled hypertension breast cancer major surgery
name some types of emergency contraception?
levonorgestrel (stops ovulation and inhibits implantation- must be taken within 72 hours)
Ulipristal (inhibits ovulation- no later than 120 hours after unprotected sex)
IUCD- must be inserted within 5 days
what is the fraser guidelines?
used to assess if patient who has not reached 16 years of age is competent to consent to treatment
criteria:
-the person understands the advice
-can’t be persuaded to tell their parents
-likely to begin or continue having sex
-without it, their physical or mental health is likely to suffer
-their best interests require them to receive contraceptive advice or treatment with or without parental consent
what nerves are involved in controlling continence?
parasympathetic (cholinergic)- S3-5 -> drive detrusor activity in voiding
sympathetic (noradrenergic)-> urethral contraction, inhibition of detrusor contraction
RFs for incontinence?
advancing age prev pregnancy and childbirth high BMI hysterectomy FH
types of urinary incontinence?
overactive bladder (urge incontinence)- detrusor overactivity
stress incontinence- leaking when laughing/coughing etc
mixed incontinence
overflow incontinence- due to bladder outlet obstruction e.g. BPH
Ix of urinary incontinence?
bladder diaries should be completed for a minimum of 3 days
vaginal exam to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles e.g. kegal exercises
urine dipstick and culture- rule out UTI and DM
Urodynamic studies
mx of stress incontinence?
pelvic floor muscle training
surgery- retropubic mid-urethral tape procedures
mx of urge incontinence?
bladder retraining
antimuscarinics- oxybutynin, tolterodine
mirabegron
name some types of prolapse?
cystocele- anterior wall of vagina and bladder
rectocele- lower posterior wall with the rectum
enterocele- vaginal wall with loops of intestine from Pouch of Douglas
uterine prolapse- protrusion of uterus downwards into the vagina
grading of prolapse?
1st grade- down to introitus
2nd grade- down to introitus, and through the introitus on training
3rd grade- outside vagina
4th grade- the uterus lies outside the vagina
mx for prolapse?
weight loss, pelvic floor muscle exercises
ring pessary
surgery- colporrhaphy, colposuspension, hysterectomy, sacrocolpoplexy
what is thrush?
vaginal candidiasis
predisposing factors for thrush?
DM, abx, steroids, pregnancy, immunosuppression
features of throush?
‘cottage cheese’, non-offensive discharge
itch
vulval erythema, fissuring, satellite lesions
mx of thrush?
clotrimazole pessary
itraconazole or fluconazole orally
what is trichomonas vaginalis?
flagellated protozoan parasite
features of trichomonas vaginalis?
green,frothy, smelly discharge
vulvovaginitis
strawberry cervix
pH >4.5
ix of trichomonas?
microscopy shows motile trophozoites (high vaginal swab)
mx of trichomonas?
oral metronidazole
AVOID ALCOHOL
what is bacterial vaginosis?
overgrowth of anaerobic organisms such as Gardnerella vaginalis
features of bacterial vaginosis?
grey, white discharge withy fishy smell
positive whiff test
CLUE cells on microscopy
mx of BV?
oral metronidazole for 5-7 days
features of chlamydia trachomatis?
asymptomatic in 70% of women and 50% of men
women- cervicitis (discharge, bleeding), dysuria
men- urethral discharge, dysuria
Ix of chlamydia and gonorrhoea?
NAAT- urine (first void urine sample), vulvovaginal swab or cervical swab
should be carried out 2 weeks after exposure
mx of chlamydia?
doxycycline (7 days) or azithromycin (single dose)
contact tracing
what is gonorrhoea?
gram negative diplococcus
Neisseria gonorrhoea
features of gonorrhoea?
males- urethral discharge, dysuria
females- cervicitis e.g. leading to vaginal doscharge
mx of gonorrhoea?
a single dose of IM ceftriaxone 1g
ciprofloxacin if CI’d
what is cervical ectropion?
the columnar epithelium of the endocervix is displaced on the ectocervix and is visible on speculum
caused by increased oestrogen levels
can cause discharge or post-coital bleeding
mx of cervical ectropion
silver nitrate or diathermy
what is meig’s syndrome?
Occurs in older women. The ovarian tumour is a fibroma that generates the associated pleural effusion and ascites.
triad of meig’s syndrome?
Pleural Effusion
Ascites
Benign ovarian tumour
general advice to women trying to get pregnant?
The woman should be taking 400mcg folic acid daily
Aim for a health BMI
Avoid smoking and drinking excessive alcohol
Have intercourse 2-3 times a week.
“Timed intercourse” to coincide with ovulation is not necessary or recommended
Ix of infertility?
BMI Semen analysis Serum LH and FSH on day 2-5. High FSH suggests poor ovarian reserve, high LH suggests PCOS / ovarian failure. Serum progesterone on Day 21 of the cycle. A rise indicates that ovulation has occurred and the corpus luteum has formed and started secreting progesterone. Anti-Mullarian hormone USS pelvis Hysterosalpingogram Laparoscopy and dye test
what is Anti-Mullarian hormone?
Anti-Mullarian hormone can be measured at any time during the cycle and is the most accurate maker of ovarian reserve (the number of follicles that the woman has left in her ovaries). It is released by the granulosa cells in the follicles and falls as the eggs are used up. A high level indicates a good ovarian reserve.
