Gynaecology Flashcards
1
Q
Menstruation
Hormones (5)
A
Cycle controlled by hypothalamic-pituitary-ovarian axis
Gonadotrophin-releasing hormones are produced by the hypothalamus
Stimulates pituitary to produce gonadotrophins: FSH + LH
They stimulate the ovary to produce oestrogen and progesterone
They modulate production of gonadotrophins by negative feedback on the hypothalamus and pituitary
2
Q
Menstruation
Cycle (8)
A
At start, FSH levels high, stimulating development of a primary follicle
The follicle produces oestrogen, which stimulates the development of a glandular ‘proliferative’ endometrium and of cervical mucus receptive to sperm
14 days before menstruation the oestrogen level becomes high enough to stimulate surge of LH, stimulating ovulation
Primary follicle forms corpus + produces progesterone
Endometrial lining prepared for implantation, ‘secretory phase’
Cervical mucus becomes hostile to sperm
If ovum not fertilised, corpus luteum breaks down and hormone levels fall
Reduced hormones causes arteries in uterine endothelium to constrict and slough
3
Q
Hypothalamo-Pituitary Ovarian Axis Feedback
A
+ve feedback: oestrogen on hypothalamus and anterior pituitary days 12-14
-ve feedback: oestrogen and progesterone on hypothalamus and anterior pituitary for most of cycle, this prevent more than one egg being released
4
Q
Hormones in the Ovarian Cycle
A
Oestrogen is present in the follicular phase
Progesterone is released in the luteal phase to prepare the uterus for pregnancy, if no implantation the corpus luteum degenerates
Corpus luteum secretes progesterone
5
Q
Roles of Main Female Reproductive Hormones
A
GnRH (from hypothalamus): stimulates LH and FSH secretion from anterior pituitary
LH (from anterior pituitary): maintains dominant follicle and stimulates corpus luteum function
FSH (from anterior pituitary): stimulates follicular recruitment and development
Oestradiol (from granulosa cells): supports secondary sex characteristics, -ve feedback of LH + GnRH
Progesterone (from corpus luteum): maintains secondary endometrium
6
Q
Primary Amenorrhoea
Definition (1)
A
Failure to start menstruating before age 16, or 14 if no secondary sexual characteristics
7
Q
Primary Amenorrhoea
Aetiology (6)
A
Familial late puberty Heavy exercise/stress/weight loss Pituitary and hypothalamus disease Gonadal dysgenesis (ovaries prematurely depleted of follicles and oocytes) Turner syndrome PCOS
8
Q
Primary Amenorrhoea
Treatment (4)
A
Weight gain/less exercise/less stress
If amenorrhoea persists for >12 months, consider osteoporosis prophylaxis
Treat hypothalamic/hypoprolactinaemic causes
HRT or COCP if amenorrhoea >12 months
9
Q
Secondary Amenorrhoea
Definition (1)
A
Periods stop for >6 months in the absence of pregnancy
10
Q
Secondary Amenorrhoea
Aetiology (7)
A
Hypothalamic-pituitary-ovarian causes are common: stress, weight loss, exercise
Hyperprolactinaemia: may have galactorrhoea
Hypo- and hyper-thyroidism
PCOS
Ovarian insufficiency/failure (premature menopause, secondary to chemo/radio, genetic- Turner’s)
Post-pill amenorrhoea
Asherman’s syndrome (adhesions after D+C)
11
Q
Secondary Amenorrhoea
Investigations (6)
A
BhCG to exclude pregnancy
Serum free androgen index (increased in PCOS)
FSH/LH (low if hypothalamic-pituitary cause but may be normal if weight loss/exercise)
Prolactin (increased by stress, hypothyroidism, prolactinomas)
TFTs
Testosterone level (may indicate androgen secreting tumour)
12
Q
Secondary Amenorrhoea
Treatment (2)
A
Premature ovarian failure can’t be reversed but hormone replacement is necessary to control symptoms of oestrogen deficiency and protect against osteoporosis
For hypothalamic-pituitary-ovarian malfunction: weight loss + lifestyle measures, clomifene/gonadotrophin releasing hormone for fertility
13
Q
Polycystic Ovarian Syndrome
Signs + symptoms (5)
A
Oligomenorrhoea/amenorrhoea Hirsutism (excess hair) Acne Subfertility Acanthosis nigrans (reflects hyperinsulinaemia)
14
Q
Polycystic Ovarian Syndrome Rotterdam Criteria (4)
A
2 out of 3 must be present
Polycystic ovaries (12 or more follicles or ovarian volume >10cm3 on ultrasound)
Oligo-ovulation or anovulation
Hyperandrogenism (clinical or biochemical signs)
15
Q
Polycystic Ovarian Syndrome
Investigations (6)
A
TFTs (rule out dysfunction) Prolactin (rule out hyperprolactinaemia) Rule out androgen secreting tumours Rule out Cushing's Testosterone high LH high
16
Q
Polycystic Ovarian Syndrome
Treatment (6)
A
Weight loss (high insulin sensitivity)
Metformin (improve insulin sensitivity and improve menstrual disturbance)
Clomifene (induces ovulation)
Ovarian drilling when don’t respond to clomifene (intent is to reduce steroid production)
COCP (control bleeding and reduce risk of unopposed oestrogen)
Anti-androgen (reduce hirsutism)
17
Q
Polycystic Ovarian Syndrome
Complications (4)
A
Gestational diabetes
Type 2 diabetes
CV disease
Endometrial cancer
18
Q
Menorrhagia
Definition (1)
A
Heavy periods, blood loss >80ml/cycle
19
Q
Menorrhagia
Aetiology (8)
A
Dysfunctional uterine bleeding (most common)- heavy and/or irregular bleeding in absence of pelvic pathology Fibroids Endometriosis Adenomyosis Early pregnancy loss Hypothyroidism Coagulation disorders (vWB, platelet abnormalities, warfarin) Endometrial cancer
20
Q
Menorrhagia
Signs + symptoms (7)
A
Heavy, prolonged vaginal bleeding, often worse at extremities of reproductive life
Dysmenorrhoea
Symptoms of anaemia
Pallor
If intermenstrual or post coital bleeding check smear history
Enlarged uterus suggests fibroids or adenomyosis
Speculum examination may reveal a cervical polyp
21
Q
Menorrhagia
Investigations (6)
A
Exclude pregnancy FBC TSH Cervical smear if due STI screen If <45 no further investigation and start treatment, if >45 with risk factors/failed medical therapy then do transvaginal US and biopsy to look for fibroids, polyps, endometrial thickness
22
Q
Menorrhagia
Treatment (7)
A
Mirena IUS 1st line
Antifibrinolytics eg.tranexamic acid during bleeding
NSAIDs eg. mefanamic acid during bleeding, especially if also dysmenorrhoea
COCP
3rd line progestogens IM eg. norethisterone stops heavy bleeding short term
Endometrial ablation
If have fibroids but wish to retain fertility: uterine artery embolisation or myomectomy, otherwise hysterectomy
23
Q
Menopause Average age (1)
A
52
24
Q
Menopause
Pathology (2)
A
Perimenopause: high number of anovulatory cycles leads to less progesterone and less endometrial secretory changes and irregular menses
Menopause: oestradiol falls due to lack of developing follicles and their granulosa cells, lack of -ve feedback to pituitary causes and increased FSH and LH
25
Menopause
| Signs + symptoms (4)
Menstrual irregularity as cycles become anovulatory, before stopping
Vasomotor disturbance- sweats, palpitations and flushes
Atrophy of oestrogen-dependent tissues (vagina, breasts)- vaginal dryness which my lead to vaginal and urinary infections, stress incontinence and prolapse
Osteoporosis: menopause accelerates bone loss
26
Menopause
| Treatment (3)
Contraception until >1 year amenorrhoea
Oestrogen cream for vaginal dryness
HRT: systemic- tablets/patches (bypasses 1st pass metabolism so reduces VTE risk) or local-creams, no uterus = oestrogen only, uterus = oestrogen + progesterone (oestrogen and cyclical progesterone whilst still having periods, continuous combined HRT in post-menopausal)
27
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Menopause
HRT contraindications (6)
```
```
Oestrogen-dependent cancer
Past PE
Undiagnosed PV bleeding
High LFTs
Pregnancy
Breastfeeding
```
28
Menopause
| Effects of HRT (6)
```
Fluid retention
Bloating
Breast tenderness
Nausea
Headaches
Mood swings, depression , acne due to progesterone
```
29
Menopause
| Alternatives to HRT (3)
SSRIs for vasomotor symptoms
Calcium, vitamin D, bisphosphonates for osteoporosis
Lubricants/vaginal oestrogens if vaginal dryness main symptom
30
Menopause
| Benefits of HRT (4)
Reduction of vasomotor symptoms (usually evident by 4 weeks and maximum effect by 3 months)
Improved genital symptoms and sexual function
Reduced osteoporotic fractures
Reduced risk of colorectal cancer
31
Menopause
| Risks of HRT (3)
```
Breast cancer (increases risk by 2.3% per year, back to never user after 5 years)
Endometrial cancer (unopposed oestrogen only)
VTE (doubled risk)
```
32
Post Menopausal Bleeding
| Differentials (6)
```
Endometrial cancer
Vaginal atrophy
Cervical cancer
Bleeding related to HRT use
Endometrial hyperplasia or polyp
Vaginal cancer
```
33
Post Menopausal Bleeding
| Investigations (3)
TVUSS: endometrial thickness >4mm requires further investigation
Endometrial biopsy
Hysteroscopy
34
Post-Coital and Intermenstrual Bleeding
| Differentials (3)
Upper: pelvic inflammatory disease
Cervical: cervicitis (chlamydia/gonorrhoea), cervical ectropion/erosion, cervical/endometrial polyps, cervical cancer
Vaginal: vaginal atrophy, trauma/sexual abuse, vaginal cancer
35
Intermenstrual Bleeding Only
| Differentials (6)
Pregnancy related
Physiological: ovulation spotting, perimenopausal
Vaginal: vaginitis
Uterine: endometrial cancer, fibroids, adenomyosis, endometritis
Ovary: oestrogen secreting tumours
Iatrogenic: post smear/colposcopy, missed OCPs
36
```
Endometriosis
Definition (1)
```
Endometrial tissue outside uterus (oestrogen dependent)
37
```
Endometriosis
Risk factors (3)
```
Reproductive age (oestrogen driven)
Family history
Nulliparity
38
Endometriosis
| Signs + symptoms (7)
Pin- may be cyclical due to endometrial tissue responding to menstruation or it amy be constant due to formation of adhesions from chronic inflammation
Severe dysmenorrhoea
Deep dyspareunia
Subfertility
Tender nodules in rectovaginal septum or uterosacral ligaments
Fixed retroverted uterus
Adnexal masses
39
```
Endometriosis
Investigations (3)
```
Laparoscopy + biopsy gold standard: chocolate cysts filled with old blood
TVUSS: identifies ovarian endometriotic cysts but poor for other disease parameters
MRI: maps extent of endometriosis, especially good for bowel involvement
40
```
Endometriosis
Treatment (2)
```
Medical: COCP, progesterone (POP, Depo, Mirena), GnRH analogues with addback HRT
Surgical: if medical fails, laparoscopy using ablation/excision/coagulation, hysterectomy last resort
41
Adenomyosis
| Definition (1)
Endometrial tissue in or deep to the myometrium
42
Adenomyosis
| Signs + symptoms (2)
Dysmenorrhoea
| Menorrhagia
43
Adenomyosis
| Investigations (2)
MRI indicates diagnosis
| Laparoscopy/hysteroscopy may be normal but do uterine muscle biopsy
44
Adenomyosis
| Treatment (2)
Mirena
| Hysterectomy
45
Leiomymoma (Fibroids)
| Defintion (2)
Benign smooth muscle tumours of the uterus
| Submucosal (under endometrium), intramural, subserosal (under the visceral peritoneum)
46
```
Leiomymoma (Fibroids)
Risk factors (5)
```
```
Age
Family history
Increased weight
Afro-Caribbean
Enlarge in pregnancy and on combined pill because they are oestrogen dependent (atrophy after menopause)
```
47
Leiomymoma (Fibroids)
| Signs + symptoms (6)
```
May be asymptomatic
Menorrhagia
Fertility problems if submucosal
Pain
Mass abdominally
If large, may cause urinary frequency or obstructed labour
```
48
Leiomymoma (Fibroids)
| Investigations (3)
TVUSS
Hysteroscopy
Endometrial biopsy
49
Leiomymoma (Fibroids)
| Treatment (5)
GnRH analogues: shrunk fibroids
Selective progesterone receptor modulator (ullipristal acetate) to shrink fibroids and induce amenorrhoea
Myomectomy to retain fertility
Uterine artery embolisation (doesn't retain fertility)
Hysterectomy only cure
50
Leiomymoma (Fibroids)
| Complications (1)
Red degeneration in pregnancy: capsular vessel thrombosis then venous engorgement causes abdo pain, vomiting and fever
51
```
Endometrial Cancer
Risk factors (8)
```
```
Post-menopausal
Unopposed oestrogen
Nulliparity (pregnancy = progesterone)
Obesity, type 2 diabetes (increased peripheral oestrogen)
Anovulatory cycles as PCOS (absence of corpus luteum = absence of progesterone)
Early/late menopause
Genetic: HNPCC
Oestrogen-only HRT
```
52
Endometrial Cancer
| Pathology (2)
Adenocarcinoma most common
| Serous and clear cell carcinoma more aggressive, older women affected
53
Endometrial Cancer
| Sings + symptoms (3)
Post-menopausal bleeding
PV discharge
If pre-menopausal, irregular + heavy periods
54
Endometrial Cancer
| Investigations (4)
TVUSS (endometrial thickness >4mm)
Endometrial biopsy
Hysteroscopy
CT/MRI for staging
55
Endometrial Cancer
| Staging (FIGO) (4)
I- body of uterus only
II- body + cervix
III- advancing beyond uterus but not beyond pelvis
IV- outside pelvis eg. bladder/bowel
56
Endometrial Cancer
| Treatment (3)
Total hysterectomy + bilateral salpingooophorectomy
Also do radiotherapy if advanced
High dose progesterone for palliation
57
Endometrial Cancer
| Survival (2)
Stage I: 85% 5 year survival
| Stage IV: 25% 5 year survival
58
HPV Infection
| Epidemiology (2)
Peak prevalence 15-25
| Lifetime exposure risk 75%
59
HPV Infection
| Aetiology (2)
6+11 cause genital warts
| 16+18 cause cervical cancer
60
HPV Infection
| Pathology (2)
Virus enters cell nuclei disrupting the normal cell cycle to cause abnormal cell growth
Most low grade: intraepithelial lesions (LSILs) cleared within 6-12 months but some persist + progress to HSIL
61
HPV Infection
| Vaccination (1)
Girls + boys aged 12
62
```
HPV Infection
Cervical screening (3)
```
Women aged 25-64 (3 yearly 25-50, 5 yearly until 64 if normal)
Cells removed from transformation zone (columnar endocervical canal meeting squamous ectocervix- vaginal cervix)
Looking for dyskaryosis, if present then do colposcopy
63
Cervical Intra-Epithelial Neoplasia
| Aetiology (2)
HPV 16+18 cause high grade changes
| HPV 6+11 can cause transient low grade changes
64
```
Cervical Intra-Epithelial Neoplasia
Risk factors (4)
```
Persistent high-risk HPV infection
Exposure risk increased by having multiple partners
Smoking
Immunocompromised
65
Cervical Intra-Epithelial Neoplasia
| Pathology (4)
Non-invasive squamous cell changes that don't invade beyond basement membrane
CIN1 (mild): lowest 1/3 epithelium
CIN2 (moderate): 2/3 epithelial thickness, 3-5% progress to cancer
CIN3 (severe): full epithelial thickness, 20-30% progress to cancer
66
Cervical Intra-Epithelial Neoplasia
| Treatment (2)
CIN1: 6-monthly colposcopy if HPV +ve and LLETZ (large loop excision of transformation zone) if persistent
CIN 2/3: LLETZ
67
```
Cervical Cancer
Risk factors (5)
```
```
HPV 16/18
Multiple partners
Early first intercourse age
Smoking
45-55 years old
```
68
Cervical Cancer
| Pathology (1)
Squamous carcinoma
69
Cervical Cancer
| Signs + symptoms (5)
Post coital bleeding
Watery, offensive discharge
On speculum: visible tumour that bleeds on contact
On bimanual: roughened + hard cervix, becomes fixed when advances
Advanced disease: heavy vaginal bleeding, ureteric obstruction, weight loss
70
Cervical Cancer
| Investigations (4)
FBC, U&E, LFT
Punch biopsy for histology
Colposcopy
CT/MRI abdo pelvis for staging
71
Cervical Cancer
| Staging (FIGO) (4)
I: confined to cervix (1a microscopic, 1b macroscopic)
II: spread to upper 2/3 vagina
III: spread to lower 1/3 vagina
IV: spread to bladder/rectum
72
Cervical Cancer
| Treatment (4)
Stage 1a <3mm in depth: local excision (fertility sparing) or hysterectomy
Stage 1a-IIa: radical hysterectomy
Stage IIB/IVA/unfit: radical chemoradiation, 24h caesium insertion
Stage IVB: palliative radiotherapy to control bleeding
73
Pelvic Mass
| Differentials (5)
```
Ovarian: benign cyst, ovarian cancer
Fallopian: ectopic, PID
Uterine: fibroid, endometrial cancer
Colorectal cancer
Pelvic lymphadenopathy
```
74
```
Ovarian Cancer
Risk factors (5)
```
```
Nulliparity
Early menarche and/or late menopause
BRCA 1+2
HNPCC
Age (rare <30)
```
75
```
Ovarian Cancer
Protective factors (4)
```
Pregnancy
Breastfeeding
COCP
Tubal ligation
76
Ovarian Cancer
| Signs + symptoms (10)
```
Often vague symptoms misinterpreted as IBS/diverticular disease, 75% only present to gynae at stage III
Indigestion
Bloating
Weight loss/gain
Early satiety
Fatigue
Altered bowel habit
Pelvic mass
Ascites
Supraclavicular node enlargement
```
77
Ovarian Cancer
| Investigations (6)
```
FBC, U&E, LFT
CA125 (although also raised in endometriosis, menstruation, benign ovarian cysts)
TVUSS + TAUSS
CXR (pleural effusion/lung mets)
CT abdo/pelvis
Ascitic fluid pathology
```
78
Ovarian Cancer
| Risk of malignancy index (5)
```
RMI = U x M x CA125
U= ultrasound features, 1 point each for; multilocular/solid areas/bilateral/ascites/intra-abdominal mets
M= menopausal status (1= pre, 3= post)
C= CA125
RMI >200 suggestive of malignancy
```
79
Ovarian Cancer
| Staging (4)
Stage 1- limited to ovary within capsule
Stage 2- one/two ovaries with pelvic extension
Stage 3- one/two ovaries with peritoneal implants outside pelvis/nodes
Stage 4- distant mets
80
Ovarian Cancer
| Treatment (2)
Full staging laparotomy + removal of as much tumour as possible
Chemotherapy
81
Ovarian Cancer
| Screening (3)
Population screening not proven
Screen high risk women (gene mutations/2+ relatives) with pelvic exam, ultrasound CA125 yearly
For high risk women may recommend bilateral salpingoophorectomy
82
Ovarian Cancer
| 5 year survival (4)
Stage 1: 75-90%
Stage 2: 45-60%
Stage 3: 30-40%
Stage 4: <20%
83
Benign Ovarian Tumours
| Classification (6)
Functional cysts: enlarged/persistent follicular or corpus luteum cysts, extremely common and physiological if of reproductive age
Endometriomas: ovarian cysts filled with old blood
Fibromas
Teratomas: from primitive germ cells, may contain hair/teeth
Serous cystadenomas: cyst appears solid
Mucinous cystadenomas: commonest large ovarian tumours, filled with mucinous material
84
Benign Ovarian Tumours
| Investigations (4)
FBC
Tumour markers
TVUSS
MRI for large cysts, distinguishing benign from malignant disease
85
Benign Ovarian Tumours
| Treatment (2)
Pre-menopausal: if no features of malignancy and cyst <5cm discharge, if >5cm or symptomatic then laparoscopic ovarian cystectomy
Post-menopausal: do RMI, cysts <5cm managed conservatively, moderate cysts bilateral oophorectomy
86
Acute Pelvic Pain
| Differentials (8)
```
Pregnancy: miscarriage, ectopic
Ovarian: cyst rupture or torsion
PID
Pelvic tumour
Dysmenorrhoea
Appendicitis
IBS
Strangulated hernia
```
87
Pelvic Inflammatory Disease
| Definition (1)
Infection of the upper genital tract
88
Pelvic Inflammatory Disease
| Aetiology (2)
Usually from ascending infection from endocervix (STIs, uterine instrumentation, post-partum)
Descending infections from other organs eg. appendicitis
89
```
Pelvic Inflammatory Disease
Risk factors (3)
```
Age <25
Previous STI history
New/multiple sexual partners
90
Pelvic Inflammatory Disease
| Signs + symptoms (7)
```
Lower abdo pain
Deep dyspareunia
Vaginal discharge
Intermenstrual/post-coital bleeding
Dysmenorrhoea
Fever
Cervical excitation on examination
```
91
Pelvic Inflammatory Disease
| Investigations (3)
Vulvovaginal/endocervical swabs for chlamydia and gonorrhoea
If acutely unwell: FBC (high WCC), CRP (high), blood cultures if septic
TVUSS if suspect tubo-ovarian abscess
92
Pelvic Inflammatory Disease
| Treatment (3)
Contact tracing
Ceftriaxone IM as outpatient
Ceftriaxone IV and doxycycline IV then oral as inpatient
93
Pelvic Inflammatory Disease
| Complications (4)
Tubo-ovarian abscess
Ectopic pregnancy
Subfertility
Tubal blockage
94
Ovarian Torsion
| Pathology (4)
Ovarian cyst disrupts the weight of the ovary causing the ovary to tort
Venous return to ovary occluded
Becomes oedematous, occluding arterial supply
Pain improves after 24h after ovary starts to die
95
Ovarian Torsion
| Signs + symptoms (4)
Sudden severe lower unilateral abdo pain
Nausea + vomiting
Lower abdo tenderness
Adnexal tenderness/mass
96
Ovarian Torsion
| Investigations (1)
Pelvic USS: oedematous ovary with reduced blood flow
97
Ovarian Torsion
| Treatment (1)
Urgent laparoscopy to untwist ovary and remove cyst
98
Ruptured Ovarian Cysts
| Aetiology (1)
Ovarian cyst ruptures due to physical activity
99
Ruptured Ovarian Cysts
| Signs + symptoms (2)
Sudden onset unilateral lower abdo pain
| Shock if fluid and blood loss in very large cysts
100
Ruptured Ovarian Cysts
| Investigations (1)
Pelvic USS: free fluid (commonly in pouch of Douglas)
101
Ruptured Ovarian Cysts
| Treatment (2)
Haemodynamically stable: observation and analgesics
| Haemodynamically unstable: urgent laparoscopy to control haemorrhage
102
Vulval Lumps and Ulcers
| Differentials (7)
```
Vulval cancer
Local varicose veins
Viral warts
Herpes simplex
Molluscum contagiosum
Inguinal hernia
Varicocele
```
103
Vulval Itching and Plaques
| Differentials (6)
```
VIN
Vulval cancer
Lichen sclerosis
Lichen planus
Lichen simplex
Vulvovaginitis
```
104
Vulval Pain
| Differentials (2)
Vulvovaginitis
| Vulvodynia (chronic vulval pain with no identifiable cause)
105
```
Vulva Intraepithelial Neoplasia
Risk factors (5)
```
```
Smoking
HPV 16+18
Other genital tract intraepithelial neoplasia
Immunosuppression
Lichen sclerosis
```
106
Vulva Intraepithelial Neoplasia
| Signs + symptoms (4)
Ulcer/plaque with red, white or brown discolouration
Raised papules/plaques
Roughened appearance
Sharp border
107
Vulva Intraepithelial Neoplasia
| Investigations (1)
Punch biopsy
108
Vulva Intraepithelial Neoplasia
| Treatment (3)
Painful irritation lesions excised
Topical treatments- imiquimod
Recurrence is common so follow up regularly
109
Vulva Cancer
| Pathology (2)
Squamous cell carcinoma preceded by VIN or lichen sclerosis
| Basal cell carcinoma/melanoma less common
110
```
Vulva Cancer
Risk factors (6)
```
```
Age 70-80
HPV 16+18
Smoking
Other genital tract intraepithelial neoplasia/malignancy
Immunosuppression
Lichen sclerosis
```
111
Vulva Cancer
| Signs + symptoms (6)
```
Pain
Itch
Bleeding
Lump
Ulcer
Enlarged groin nodes
```
112
Vulva Cancer
| Investigations (1)
Punch biopsy
113
Vulva Cancer
| Staging (4)
I: microinvasion <2cm
II: >2cm
III: local spread + local node involvement
IV: distant/local advanced spread and pelvic node involvement
114
Vulva Cancer
| Treatment (5)
If <2cm: local excision
If >1mm deep: radical local excision with unilateral/bilateral node dissection
Advanced disease: radical vulvectomy
Radiotherapy pre-op to shrink tumours if sphincters may be affected
Chemoradiation if unfit for surgery
115
Vulva Cancer
| Survival (1)
5-year survival >80% if <2cm and no nodes, otherwise <50%
116
Incontinence
| Control of bladder function (2)
In women, continence is maintained in the urethra by the external sphincter and pelvic floor muscles maintaning a urethral pressure
Micturition occurs when these muscles relax and the bladder detrusor muscle contracts
117
Incontinence
| Signs + symptoms (8)
Involuntary leakage of urine
Continuous leakage is most commonly due to vesicovaginal fistula or an ectopic ureter
Increased daytime voids (normal is 4-7)
Nocturia (up to 70 >1 night time void = abnormal)
Nocturnal enuresis
Urgency (most frequently due to detrusor overactivity)
Voiding difficulties (hesitancy, straining and slow/intermittent stream)
May have feeling of incomplete emptying, bladder pain (interstitial cystitis) or signs of a UTI
118
Incontinence
| Classification (4)
Stress incontinence: leakage on effort/exertion, or on sneezing/coughing commonly due to urethral sphincter weakness
Urge incontinence: leakage with a strong desire to pass urine, commonly coexists with frequency and nocturia and forms overactive bladder syndrome
Mixed incontinence: combo of urge and stress
Overflow incontinence: usually due to injury/insult eg. post-partum- treat with catheter
119
Incontinence
| Investigations (5)
Urinalysis + MSU for MC+S to exclude UTI
Frequency/volume chart (normal in stress incontinence, high diurnal frequency and nocturia in overactive bladder)
Imaging for incomplete bladder emptying and check for pelvic mass
Cystoscopy for anatomical visualisation
Urodynamics (looks at ability of bladder to store and void urine)- shows involuntary detrusor contractions in overactive bladder
120
Stress Urinary Incontinence
| Epidemiology (1)
1 in 10
121
Stress Urinary Incontinence
| Pathology (1)
Detrusor pressure exceeds closing pressure of the urethra
122
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Stress Urinary Incontinence
Risk factors (5)
```
```
Pregnancy
Oestrogen deficiency after menopause leads to weakening of pelvic support and thinning of the urothelium
Radiotherapy
Congenital weakness
Trauma or radical pelvic surgery
```
123
Stress Urinary Incontinence
| Treatment (7)
Weight loss
Smoking cessation
Pelvic floor exercises for at least 3 months
Duloxetine
Peri-urethral injections of bulking agents often successful and have lower morbidity than other procedures
Tension free vaginal tape most common
Colposuspension (now rare)
124
Overactive Bladder Syndrome
| Epidemiology (1)
1 in 6 women
125
Overactive Bladder Syndrome
| Pathology (3)
Implies underlying detrusor overactivity
Unpredictable and may be confused with stress incontinence
Diagnosis made on urodynamics- involuntary detrusor contractions during filling
126
Overactive Bladder Syndrome
| Treatment (4)
Conservative: avoid excessive fluid intake, caffeinated and carbonated drinks + alcohol, bladder retraining- to suppress urinary urge and extend intervals between voiding
Anticholinergics main pharmacological treatment, blocks parasympathetic nerves and relaxing detrusor
Intravaginal oestrogen cream in vaginal atrophy
Botulinum toxin injections into detrusor very effective
127
Pelvic Organ Prolapse
| Classification (5)
Urethrocele: prolapse of lower anterior vaginal wall involving urethra only
Cystocele: prolapse of upper anterior vaginal wall involving bladder
Uterovaginal prolapse: uterus + cervix + upper vagina
Enterocele: prolapse of upper post. wall of vagina usually containing small bowel loops
Rectocele: prolapse of lower post. wall of vagina involving rectum bulging
128
```
Pelvic Organ Prolapse
Risk factors (7)
```
Pregnancy (parity, macrosomia)
Vaginal birth (prolonged second stage, forceps)
Previous pelvic surgeries
Age
Obesity
Sport (long distance running, weight lifting)
Chronic cough
129
Pelvic Organ Prolapse
| Grading (3)
1st degree: lowest part of the prolapse descends halfway down the vaginal axis to the introitus
2nd degree: lowest part of prolapse extends to the level of the introitus and through the introitus on straining
3rd degree: lowest part of prolapse extends through the introitus and outside the vagina
130
Pelvic Organ Prolapse
| Signs + symptoms (5)
Dragging sensation
Feeling of something 'coming down'
Dyspareunia
With cystocele, urinary urgency + frequency, incomplete bladder emptying
With rectocele, constipation and difficulty defecating
131
Pelvic Organ Prolapse
| Treatment (4)
Pelvic floor muscle training
Silicone ring pessaries
Colposuspension surgery
Hysterectomy
132
Female Infertility
| Aetiology (3)
Anovulation: PCOS
Tubal: endometriosis, tubal surgery
Unknown
133
Female Infertility
| History (6)
```
Duration of infertility
Contraception
Fertility in previous relationships
Sexual history
Smoking + alcohol
Menstrual history
```
134
Female Infertility
| Examination (3)
BMI
Hair and body fat distribution
Abdo + pelvic exam: pelvic mass, fixed retroversion, tenderness
135
```
Female Infertility
Referral criteria (3)
```
Immediate: regular periods, abnormal tests, HIV or Hep B
After 1 year of trying <35
After 6 months of trying 35-45
136
Female Infertility
| Investigations (9)
```
TSH
Rubella status
Chlamydia screen
If periods are regular, mid-luteal progesterone 7 days before expected period
If periods are irregular, day 1-5 FSH, LH, testosterone
TVUSS
Histo-salpingo contrast sonography
Laparoscopy
Dye test of tubal patency
```
137
Female Infertility
| Management (5)
Lifestyle modification
Anovulation: weight loss/gain, clomifene, gonadotrophins, laparoscopic ovarian drilling
Tubal disease: tubal catheterisation
Intrauterine adhesions: hysteroscopic adenolysis
IVF: tubal disease, endometriosis, anovulation not responding to clomifene, maternal age, unexplained subfertility >2 years
138
Male Infertility
| Aetiology (5)
Semen abnormality: testicular cancer, alcohol, smoking
Azoospermia: anabolic steroids, hypogonadotrophic hypogonadism, cryptochordism, orchitis, Klinefelter's syndrome, congenital absence of vas deferens, chlamydia + gonorrhoea
Immunological: anti-sperm antibodies, infective (rubella)
Coital: erectile dysfunction, phimosis, retrograde ejaculation, failure of ejaculation (MS, spinal cord injury)
139
Male Infertility
| History (6)
```
Duration of infertility
Fertility in previous relationships
Sexual history
Smoking and alcohol
History of undescended testes
History of mumps
```
140
Male Infertility
| Examination (4)
Testicular size
Testicular maldescent
Epididymitis (STI)
Vas deferens (CF/vasectomy)
141
```
Male Infertility
Referral criteria (3)
```
Immediate: testicular problems, abnormal tests, HIV or Hep B
After 1 year <35
After 6 months 35-45
142
Male Infertility
| Investigations (3)
```
Semen sample (low vol, low conc, low motility)
Hormone profile (FSH, LH, testosterone, oestradiol, sex hormone binding globulin)
Urine analysis for retrograde ejaculation
```
143
Male Infertility
| Management (4)
Lifestyle modification
Abnormal serum analysis: prescribe multivitamin (selenium, zinc, vit C) and re-test in 3 months
Intracytoplasmic sperm injection
IVF: male subfertility unexplained subfertility >2 years
144
Regular Contraception: COCP
Mode of action (3)
Effectiveness (1)
Mode of action:
- prevent ovulation by altering FSH + LH due to -ve feedback of progesterone and oestrogen on hypothalamus and pituitary to stop surge
- prevents implantation (inadequate endometrium)
- alters cervical mucus to prevent sperm penetration
Effectiveness:
- 99% if taken perfectly
145
Regular Contraception: COCP
Contraindications (5)
Risks (3)
Side effects (4)
```
Contraindications:
- smoker
- migraine with aura
- breastfeeding up to 6 months
- FH of breast cancer
- CV/VTE risk
Risks:
- VTE
- breast cancer
- cervical cancer
Side Effects:
- headaches
- nausea
- mood swings
- breast tenderness
```
146
Regular Contraception: COCP
Advantages (4)
Disadvantages (3)
```
Advantages:
- controlled timing of periods
- reduced PMS
- reduced risk of ovarian, endometrial and colon cancer
- improves acne
Disadvantages:
- requires remembering to take at same time each day
- breakthrough bleeding
- user dependent
```
147
Regular Contraception: Combined Contraceptive Patch
Mode of action (1)
Use (1)
Mode of action:
- inhibits ovulation
Use:
- wear patch 3 weeks then 1 week patch free
148
Regular Contraception: Combined Vaginal Ring
| Mode of action (1)
Inhibits ovulation
149
Regular Contraception: Progesterone Only Pill
Mode of action (2)
Effectiveness (1)
```
Mode of Action:
- thickens cervical mucus
- hormones either norethisterone, levonorgestrel, desogestrel
Effectiveness:
- 99% if taken perfectly
```
150
Regular Contraception: Progesterone Only Pill
Contraindications (3)
Risks (2)
Side effects (3)
```
Contraindications:
- breast cancer
- severe cirrhosis
- liver tumours
Risks:
- ovarian cysts
- breast cancer
Side Effects:
- acne
- breast tenderness
- mood changes
```
151
Regular Contraception: Progesterone Only Pill
Advantages (4)
Disadvantages (1)
```
Advantages:
- suitable for breastfeeding
- ok for migraine with aura
- ok for high BMI
- improved period timing
Disadvantages:
- remembering to take (but no breaks)
```
152
Regular Contraception: Depo-Provera Injection
Mode of action (3)
Side effects (3)
```
Mode of Action:
- inhibits ovulation
- thickens cervical mucus
- given every 12 weeks
Side Effects:
- irregular bleeding
- weight gain
- fertility can take up to 1 year to return
```
153
Regular Contraception: Implant
Mode of action (3)
Side effects (4)
```
Mode of Action:
- inhibits ovulation
- thickens cervical mucus
- lasts 3 years
Side Effects:
- heavy/irregular bleeding
- headache
- nausea
- breast pain
```
154
Regular Contraception: Intrauterine System
Mode of action (3)
Advantages (2)
Risks (3)
```
Mode of Action:
- levonorgestrel
- prevents endometrial proliferation
- thickens cervical mucus
Advantages:
- initially frequent bleeding but later light menses with less dysmenorrhoea and some get amenorrhoea
- lasts 3 years (Jaydess) or 5 years (Mirena)
Risks:
- perforation
- PID
- expulsion
```
155
```
Regular Contraception: Intrauterine Contraceptive Device
Mode of action (2)
Advantages (1)
Disadvantages (1)
Risks (3)
```
```
Mode of Action:
- decreases sperm motility and survival
- lasts 10 years
Advantages:
- effective immediately
Disadvantages:
- makes periods heavier, longer and more painful
Risks:
- perforation
- PID
- expulsion
```
156
Emergency Contraception
| Levonorgestrel (4)
Dose 1.5mg
Mode of action: stops ovulation and inhibits implantation
72h after unprotected sex
Side effects: disturbance of current menstrual cycle, vomiting, diarrhoea
157
Emergency Contraception
| Ulipristal (4)
Dose 30mg
Mode: progesterone receptor modulator which inhibits ovulation
120h after unprotected sex
Side effects: disturbance of current menstrual cycle, vomiting, diarrhoea
158
```
Emergency Contraception
Intrauterine device (3)
```
Mode: inhibits fertilisation or implantation
5 days after unprotected sex or if after 5d then up to 5d after likely ovulation date
Advantages: very effective, can be left in for long term contraception
159
Termination of Pregnancy
| Incidence (3)
Worldwide >20% of pregnancies are terminated
In the UK 1/3 of women have had a termination by age 45
>200,000 per year in UK
160
Termination of Pregnancy
| Abortion Act Criteria (5)
2 doctors sign + fetus <24 weeks
Risk to mother's life if pregnancy continues
Termination necessary to prevent grace injury to physical/mental health of mother
Continuance risks physical/mental health of existing children of mother
Substantial risk that if child were born he/she would suffer such physical or mental abnormalities as to be seriously handicapped
161
```
Termination of Pregnancy
Before termination (5)
```
Offer counselling and information
Ultrasound to confirm gestation and identify non-viable/ectopic pregnancies
Screen for STIs
Antibiotics prophylaxis to reduce post-op infections
Plan contraception
162
Termination of Pregnancy
Medical (1)
Surgical (2)
```
Medical:
- mifepristone to prime cervix followed by misoprostol (prostaglandin)
Surgical:
- vacuum aspiration: from 7-14wks
- dilation and evacuation: 13-24wks
```
163
Termination of Pregnancy
| Complications (4)
Failure 1:100
Infection
Haemorrhage
Uterine perforation/rupture
164
Vaginal Discharge Differentials (4)
Physiological: pregnancy, puberty, COCP
Non-STI infection: thrush, bacterial vaginosis
STI: chlamydia, gonorrhoea
Paediatric: fecal flora, pre-pubertal atrophic vaginitis (lack of vaginal oestrogen), staph/strep infection, foreign body, sexual abuse
165
STI Symptoms in Females (9)
Vaginal discharge: gonorrhoea, chlamydia, trichomoniasis, BV
Postcoital bleeding: gonorrhoea, chlamydia
Intermenstrual bleeding: gonorrhoea, chlamydia
Dyspareuria: genital herpes, gonorrhoea, chlamydia
Dysuria: gonorrhoea, chlamydia, trichomoniasis, herpes
Vulvitis: thrush, BV, herpes, gonorrhoea, chlamydia
Skin changes: herpes, warts
Abdo/pelvic pain: PID
Systemic: PID (fever), HIV (weight loss)
166
STI Symptoms in Males (6)
Testicular pain/swelling: epidydmo-orchitis (secondary to gonorrhoea/chlamydia)
Itching/sore skin: candida, herpes, HSV, genital warts
Skin lesions: herpes, genital warts
Urethral discharge: gonorrhoea, chlamydia
Dysuria: gonorrhoea, chlamydia, herpes
Systemic: PID (fever), HIV (weight loss), chlamydia (Reiter's syndrome)
167
```
Chlamydia
Incubation period (1)
```
7-14 days (chlamydia trichomatis)
168
Chlamydia
| Signs + symptoms (4)
M: asymptomatic in 20%, slight penile dischage, dysuria
F: asymptomatic in 80%, vaginal discharge, dysuria, intermenstrual bleeding, postcoital bleeding
Conjunctivitis
Cervical bleeding on contact
169
Chlamydia
| Investigations (1)
Nucleic acid amplification test (NAAT) via 1st void urine M and self-taken vaginal swab in F
170
Chlamydia
| Treatment (1)
Azithromycin 1g, follow up test for reinfection at 3-12 months
171
Chlamydia
| Complications (3)
F: PID, Fitz Hugh Curtis Syndrome (complication of PID involving liver capsule inflammation leading to adhesions), infertility
M: epididymitis (can cause infertility), prostatitis
B: reactive arthritis (Reiter's syndrome)
172
```
Gonorrhoea
Incubation period (1)
```
5-6 days on average 2 day- 2 week range (Neisseria gonorrhoea)
173
Gonorrhoea
| Signs + symptoms (2)
M: asymptomatic, dysuria
F: asymptomatic (50%), dysuria, vaginal discharge (thick and yellow), IMB, PCB
174
Gonorrhoea
| Investigations (2)
NAAT 1st void urine in M
| Culture for antibiotic sensitivities (smear from urethra, vagina, rectum)
175
Gonorrhoea
| Treatment (2)
IM 500g ceftriaxone + 1g azithromycin
| Test cure at 2 weeks and test for reinfection at 3 months
176
Gonorrhoea
| Complications (2)
M: epididymitis, prostatitis
F: PID, Bartholin's abscess
177
```
Trichomoniasis
Incubation period (1)
```
5-28 days (trichomoniasis vaginalis- flagellated parasite)
178
Trichomoniasis
| Signs + symptoms (2)
M: asymptomatic
F: asymptomatic (10-30%), vaginal discharge (thin, green, frothy and foul), vulvitis
179
Trichomoniasis
| Investigations (1)
Microscopy of wet preparation of high vaginal swab
180
Trichomoniasis
| Treatment (1)
Metronidazole 400mg oral twice daily for 5 days OR 2g single dose
181
```
Syphilis
Incubation period (1)
```
9-90 days until chancre appears (treponema pallidum- spirochete)
182
Syphilis
| Signs + symptoms (5)
Primary: chancre (painless ulcer)
Secondary: 6w-6m following primary infection, non-pruritic rash on palms and soles, generalised lymphadenopathy, systemic symptoms (pyrexia, fatigue, malaise)
Early latent: asymptomatic infection and positive diagnosis within 2y of infection
Late latent: asymptomatic infection and positive diagnosis after 2y of infection
Tertiary: untreated over many years (neurosyphilis- general paresis, stroke, cardiovascular syphilis- aortitis, aortic aneurysm)
183
Syphilis
| Investigations (3)
Serology of treponema pallidum: IgG/IgM, enzyme immunoassay, particle agglutination test (serology always remains +ve)
PCR: ulcer swab
Disease activity: cardiolipin serology tests
184
Syphilis
| Treatment (2)
Early (<2w): benzylpenicillin once IM or doxycycline 100mg oral 2x/day for 2 weeks
Late (>2y): benzylpenicillin IM weekly for 3w or doxycycline 100mg 2x/day for 28 days
185
Herpes
| Aetiology (2)
HSV type 1 (spread through oral sex)
| HSV type 2 (main cause)
186
```
Herpes
Incubation period (1)
```
5 days- months
187
Herpes
| Signs + symptoms (2)
Asymptomatic (80%)
Recurring symptoms monthly or annually (burning/itching followed by tender ulceration, tender inguinal lymphadenopathy, flu-like symptoms)
188
Herpes
| Investigations (1)
PCR swab from lesion
189
Herpes
| Treatment (3)
Primary outbreak: aciclovir 200mg 5x/day or 400mg 3/day for 5 days
Infrequent recurrences: lidocaine ointment, aciclovir 1x/day until symptoms gone
Frequent recurrences: aciclovir 400mg 2x/day as suppression
190
Anogenital Warts
| Aetiology (1)
HPV 6+11
191
```
Anogenital Warts
Incubation period (1)
```
2w-8m
192
Anogenital Warts
| Signs + symptoms (2)
Lumps
| Occasional itching/bleeding
193
Anogenital Warts
| Treatment (1)
Popphyllotoxin as home treatment, cryotherapy, imiquimod, diathermy removal if bulky
194
Thrush
| Aetiology (1)
Candida albicans
195
```
Thrush
Risk factors (6)
```
```
Pregnancy
Contraceptives
Steroids
Immunodeficiencies
DM
Antibiotics
```
196
Thrush
| Signs + symptoms (3)
Curd-like non-offensive discharge
Sore + itchy vulva and vagina
Redness
197
Thrush
| Investigations (1)
Microscopy and culture shows mycelia and spores
198
Thrush
| Treatment (1)
Clotrimazole 500mg pessary and cream for vulva or oral fluconazole 150mg single dose
199
Bacterial Vaginosis
| Aetiology (1)
Altered bacterial flora eg. Gardnerella vaginalis
200
Bacterial Vaginosis
| Signs + symptoms (1)
Fishy discharge
201
Bacterial Vaginosis
| Investigations (1)
Microscopy and culture
202
Bacterial Vaginosis
| Treatment (1)
Metronidazole 2g oral once
203
Bacterial Vaginosis
| Complications (3)
Pre-term labour
Intra-amniotic infection in pregnancy
HIV susceptibility
