Gynaecology Flashcards
1
Q
Definition of menorrhagia?
A
excessive menstrual blood loss that interferes with the womans physical, emotional, social and material QoL. (usually considered to be > 80ml)
2
Q
Causes of painless menorrhagia?
A
coagulation defect (vWFD, haemophilia) fibroids polyps endometrial CA withdrawal from contraception
3
Q
Causes of painful menorrhagia?
A
PID endometriosis adenomyosis miscarriage ectopic pregnnacy (acute)
4
Q
Management of menorhagia?
A
1) Mirena coil
2) Tranexamic acid - taken during menstruation only
Mefanamic acid
3) COCP
4) Gonadotopin releasing hormone agonists
Surgical if found cause: polyp removal endometrial ablation uterine artery embolizatoin hysteroscopic myomectomy (fibroids)
5
Q
Investigations for menorrhagia?
A
Fb/Hb to check for anaemia
Coagulation + TFT
Transvaginal USS
Hysteroscopy + biopsy
6
Q
what is the likely diagnosis in a woman with cyclical abdominal pain associated with menstrual cycle and dyspaerunia ?
A
endometriosis
7
Q
Pathophysiology of endometriosis?
A
Chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity. The tissue acts just like normal endometrial tissue and responds to cyclical hormone levels, gowing and bleeding at certain times.
8
Q
where is tissue most commonly found in endometriosis?
A
ovaries uterosacral ligaments pouch of douglas rectosigmoid colon ureters and bladder can also occur in scar sites e.g. cesarean scar
9
Q
Differential diagnosis for endometriosis?
A
adenomyosis
ectopic pregnancy
fibroids
PID
10
Q
symptoms of endometriosis?
A
dyspareunia
cyclical abdominal pain associated with menstruation
chronic pelvic pain
infertility
11
Q
investigations of suspected endometriosis?
A
transvaginal USS- thickened ovary + chocolate cyst (endometrioma)
laprascopy with biopsy (gold standard)
12
Q
management of endometriosis?
A
NSAID's for pain relief COC GnRH agonist Mirena surgical ablation or laparoscopy
13
Q
MOA of tranexamic acid?
A
competitively binds to receptor site on plaminogen, reducing the conversion of plasminogen to plasmin, preventing fibrin degradation and preserving the framework of fibrin’s matrix structure.
reduces fibrinolytic activity, reducing blood loss by up to 50%
14
Q
MOA of mefanemic acid?
A
inhibit prostaglandin synthesis causing reduced blood loss (NSAID)
15
Q
MOA of GnRH agonist?
A
causes hypersecretion of GnRH, which initially causes increase in LH and FSH (24hrs), however after a period there is pituitary sensitisation and negative feedback, causing down regulation of LH+FSH, and thus reduced production of oestrogen (which drives bleeding and pain).
16
Q
Risks of using GnRH agonist?
A
increased risk of osteoporosis due to depleted oestrogen.
HRT must be prescribed alongside GnRH agonist.
17
Q
complications of endometriosis?
A
frozen pelvis infertility risk of ectopic adhesions-> urine retention and constipation anaemia
18
Q
what is adenomyosis?
A
presence of ectopic endometrial glandular tissue within the myometrium (thick muscular layer of uterus) - often occurs after pregnancy
19
Q
presentation of adenomyosis?
A
cyclical pelvic pain
menorrhagia
dysmenorrhea
20
Q
investigations of adenomyosis?
A
transvaginal USS - enlarged uterus
MRI
21
Q
management of adenomyosis/
A
progesterone IUS -> mirena
COCP
+/- NSAIDs for pain
hysterectomy if severe and required
22
Q
likely diagnosis in patient with pelvic pain, fever, deep dyspareunia and vaginal discharge?
A
PID
23
Q
what is PID and what organisms commonly cause infection?
A
Infection of the upper genital tract usually with: chlamydia gonorrhoea mycoplasma hominis mycoplasma genitalium
24
Q
what are the RF of PID?
A
STD
IUD insertion
previous PID
bacterial vaginosis
25
symptoms of PID?
```
bilateral lower abdominal pain + deep dyspareunia -> classical presentatoin
dysmenorrhea
menorrhagia
fever
n+v
vaginal discharge
cervicitis
tachycardia
```
26
findings on examination of PID?
```
tachycardia
high fever
bilateral adnexal tenderness
cervical excitation
mass (pelvic abscess) on palpation if present
```
27
investigations of PID?
endocervical swabs with nucleic acid amplification testing
cervical swabs
pregnancy test
urinalysis
bimanual examination - cervical motion tenderness
FBC+ WCC
pelvic USS- to exclude abscess or ovarian cyst
laparoscopy with direct visualisation of the fallopian tubes - most effective test but not feasible in primary care usually
28
complications of PID?
ovarian abscess
infertility
chronic pelvic pain
ectopic pregnancy
29
management of PID?
analgesia + IM ceftriaxone
| then - doxycycline + metronidazole
30
definition of menopause?
permanent cessation of menstruation - LMP> 12 months
31
at what age does premature ovarian failure occur?
<40 years old
32
symptoms of menopause/premature ovarian failure?
Vasomotor- hot flushes, night sweats, sleep disturbance, tiredness, irritability
Urogenital- vaginal atrophy, urinary problems, dryness, frequent infection, frequency, urgency
Sexual dysfunction
Osteoporosis- joint pain
33
Investigations of menopause?
FSH - high
LH, ostradiol + progesterone- low
Anti-mullerian hormone - low
DEXA bone density scan
34
Management of menopausal symptoms?
HRT- oestrogen in women without a uterus, oestrogen + progesterone in women with uterus
Tibolone - treats vasomotor, psychological and libido problems + conserves bone mass
clonidine - alpha adrenoreceptor stimulation causing vasodilation for hot flushes
SSRI/SNRI's
Lubricants and moisturizers
Prevention of osteoporosis - bisphosphonates etc.
35
What are the benefits of HRT?
osteoporosis prevention
| colorectal cancer prevention
36
what are the risks of HRT?
breast + ovarian CA risk is increased
endometrial CA risk increased if unopposed oestrogen
VTE
37
Causes of post-menopausal bleeding?
```
endometrial ca - biggest risk
polyps + fibroids
atrophic vaginitis
hormone therapy
ovarian carcinoma
```
38
investigations of post-menopausal bleeding?
```
bimanual and speculum exam
smear
transvaginal USS
endometrial biopsy - pipette
hysteroscopy _ polypectomy
```
39
what are the different types of prolapse?
1) cytocele- prolapse of upper anterior vaginal wall
2) uterine
3) enterocele - upper posterior vaginal wall
4) urethrocele- lower anterior vaignal wall
5) rectocele- lower posterior wall
40
what are the ligaments that support the vagina and uterus
cardinal (transverse cervical)
| uterosacral
41
RF for prolapse?
```
pregnancy and vaginal delivery
menopause
obesity
constipatoin
chronic cough
heavy lifting
pelvic mass
```
42
symptoms of prolapse?
draggin sensation
heaviness in pelvis
cysto-urethrocele: urgency, incontinence, incomplete bladder empyting, retention
rectocele: constipation, difficulty with defecation
43
investigations of prolapse?
USS to exclude pelvic/abd masses
| urodynamics to exclude incontinence
44
what grading system is used to assess severity of prolapse?
POP- pelvic organ prolapse grading
45
management of prolapse?
```
weight reduction
post menopausal- oestrogen
physio- pelvic floor exercises (kegel exercises)
biofeedback and vaginal cones
intravaginal pessaries - ring or shelf
surgical - hysterectomy or repair
```
46
pathophysiology of fibroids?
benign tumour of smooth muscle (leiomyoma) - well circumscribed smooth nodules that grow in the myometrium in response to oestrogens and progesterones. During menopause, they stop growing due to low oestrogen and often calcify
47
symptoms of fibroids?
menorrhagia
erratic bleeding
abdominal pain
dysmenorrhea
urgency + incomplete emptying- if pressing on the bladder
fertility may be impaired if tubal ostia are blocked
48
examination of fibroids?
solid mass palpable on pelvic/abdo exam
| Enlarged, often irregular, firm, non-tender uterus palpable on bimanual pelvic examination
49
investigations of fibroids?
```
transvaginal USS
MRI if not visualised by USS
endometrial sampling if abnormal bleeding
hysteroscopy with biopsy
pregnancy test if child baring age
```
50
complication of fibroid during pregnancy?
1) Torsion of a pedunculated fibroid
2) Red degeneration- inadequate blood supply to the fibroid during pregnancy results in haemorrhage and necrosis - presents with fever, pain and vomiting
51
complication of pregnancy due to fibroids?
preterm labour
malpresentation
PPH
obstruction of labour
52
management of fibroids?
medical:
1) tranexamic acid, NSAID's, progesterone in menorrhagia
2) GnRH agonist - temporary shrinkage of fibroid but only used for 6 months
surgery:
1) myomectomy- laparoscopic or open
2) hysterectomy- radical
53
what are the different types of incontinence?
overflow- urethral blockage, incomplete emptying, ineffective detrusor
urge- bladder oversensitivity
stress- increased abdominal pressure, relaxed pelvic floor
54
symptoms of urinary incontinence?
```
daytime frequency
incomplete emptying
nocturia
bladder pain
involuntary leakage
bladder pain
dysuria
```
55
causes of overflow incontinence?
dis-inhibited detrusor muscle action - causes urgency
| OR if bladder pressure exceeds the urethral pressure
56
investigations of urge incontinence?
urinary diary
urine dipstick
urodynamic studies- detrusor over activity by cystometry
57
management of urge incontinence?
relaxation - kegel
antimuscarinic medications- oxybutynin (Oxybutynin suppresses involuntary contractions of the bladder's smooth muscle (spasms) by blocking the release of acetylcholine)
58
what is stress incontinence?
incontinence on effort/exertion/coughing and sneezing
59
causes of stress incontinence/
```
pregnancy
vaginal delivery
prolonged labour/forceps
prolapse
obesity
age
```
60
management of stress incontinence?
kegel exercises- pelvic floor training
| sugrery: trans-obturator tape, tension free vaginal tape
61
what is overflow bladder incontinence?
incontinence due to impaired detrusor contractibility resulting in leakage
62
management of overflow bladder?
intermittent catheterization
| alpha blockers- tamsulosin
63
what type of carcinoma is endometrial carcinoma?
adenocarcinoma of columnar endometrial gland cells
64
what are the risk factors of endometrial carcinoma?
1) unopposed oestrogen (increasing thickening and growth of the endometrium which increases likelihood of mutations)
2) obesity - through peripheral conversion of androgens to oestrogens
late menopause (prolonged exposure to oestrogen)
3) PCOS
4) Tamoxifen (given in breast cancer)
5) genetic
6) DM
7) HTN
8) nulliparity
65
signs and symptoms of endometrial cancer?
```
non-specific
irregular periods
post-menopausal bleed ***
dyspareunia
difficulty urinating
```
66
what are the stages of endometrial cancer?
stage 1- lesion confined to uterus
stage 2- confined to uterus + cervix
stage 3- tumour invades through the uterus to ovaries, pevlic node or para-aortic pelvic node involvement
stage 4- further spread i.e bowel/bladder or distant mets
67
investigations of suspected endometrial cancer?
transvaginal USS- thickness (biopsy if >11mm without bleeding or >5mm plus bleeding)
hysteroscopy and pipelle biopsy
MRI
CA125 measurement (may be raised even tho not ovarian cancer)
68
management of endometrial cancer?
total hysterectomy + bilateral salpingoophrectomy
| radiotherapy in addition
69
definition of subfertility?
failure to conceive after 12 months of regular sex 2-3 times a week
70
what are some female factors that may cause infertility?
annovulation- PCOS, hypothalamic hypogonadism, hyperprolactinaemia, TFT, premature ovarian failure, anatomical- fibroids, endometriosis, tubal dysfunction (PID, surgery)
71
what are some male factors that may cause infertility?
```
variocele
poor sperm quality/count
drug/chemical exposure
Kleinfelters syndrome
retrograde ejaculation
```
72
investigations for inferility?
1) detect ovulation - mid luteal phase serum progesterone day 21 (produced from corpus luteum)
2) FSH, LH, testosterone, prolactin, PCOS, TSH - to detect causes of anovulation (PCOS- LH:FSH ratio high, premature ovarian failure - FSH:LH high)
3) semen analysis
4) laparoscopy and dye - look for tubal abnormalities
73
management of infertility?
clomifene - improve fertility ( Clomid works by making the body think that your estrogen levels are lower than they are, which causes the pituitary gland to increase secretion of follicle stimulating hormone, or FSH, and luteinizing hormone, or LH)
lifestyle- smoking, weight loss, alcohol, folic acid
treat specific disorder if cause found
counselling + support for couple
74
pathophysiology of PCOS?
Production of excessive cysts on the ovaries due to a combination of:
- increased LH production by the pituitary (loss of LH surge so no ovulation)
- hyperinsulinemia - which increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding.
Testosterone causes hirstuism + is converted to estrone in adipose tissue.
75
what are the features of PCOS?
amenorrhoea (increased androgen)
hirstuism, acne, alopecia (increased androgen)
infertility (cystic ovaries)
obesity
increased risk of endometrial carcinoma due to high estrone
76
complications of PCOS?
endometrial and breast cancer
high BMI- HTN, DM, MI
infertility
anxiety and depression
77
investigations of PCOS?
USS- visualise the cysts
LH:FSH ratio high
increased testosterone
78
management of PCOS?
weight loss
COCP
clomiphene
metformin
spironolactone-> treats the hirstuism
Ketoconazole (inhibits androgen synthesis by inhibiting desmolase in Theca cells) -> treats Hirsutism
atni-androgens for the acne and hirstuism
79
MOA of clomiphene?
appears to reduce oestrogen thus stimulating the hypothalamus to cause the release of more FSH+LH, to increase the oestrogen-> improves fertility and hirstuism
80
causes of post coital bleeding?
```
Cervical carcinoma
Cervical ectropion
Cervical polyps
Cervicitis
Vaginitis
```
81
what is primary and secondary amenorrhoea?
Primary: has never had a period
- 14yo girls and no secondary sexual features (pubes start at 12yo, periods at 13 normally, boobs 9-11)
- 16yo girls
Secondary: Previously normal, stopped for >6mo
82
causes of primary amenorrhoea?
```
Turners syndrome
late puberty
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of genital tract (imperforate hymen)
```
83
causes of secondary amenorrhoea?
```
hypothalamic-pituitary-ovarian inbalance
emotional distress/stress
low body weight
excessive excersise
systemic disease
hyper/hypo thyroid
drug induced
Sheehans syndrome
Ashermans syndrome
PCOS
cerivcal stenosis
```
84
investigations of amenorrhoea?
```
physcal exam
FSH
LH
testosterone
TFT
prolactin
USS adrenals
CT pituitary
gonadotrophins
```
85
what type of cancer is cervical cancer?
80% SCC
| 20% adenocarcinoma
86
RF of cervical cancer?
HPV 16, 18 + 33 all associated
increased sexual partners
early age of first intercourse
frequency of intercourse
87
what is the screening currently for cervical cancer?
liquid based cytology smear of the transformation zone offered to all women 25-65years
every 3 years 25-50yrs
every 5 years 50-65yrs
if results show borderline/low grade dyskaryosis then lab will test for HPV. IF positive- refer for colposcopy.
88
symptoms of cervical cancer?
```
abnormal discharge
bleeding after intercourse
abnormal heavy bleeding during periods/irregular bleeding
dyspareunia
unexplained pelvic pain or back pain
```
involvement of ureters, bladder and rectum nerves- haematuria, rectal bleeding, pain
backache
leg pain
bowel changes
89
what is the staging of cervical cancer?
1- lesion confined to cervix
2- invasion into vagina, but not the pelvic side wall
3- invasion of vaginal wall causing ureter obstruction
3- invasion of bladder/rectal mucosa or beyond true pelvis
90
investigations of cervical cancer?
smear test - liquid based cytology
colposcopy
biopsy tumour for histology
91
where does cervical cancer usually spread?
parametrium and vagina
pelvic side wall
pelvic nodes
92
management of cervical cancer?
cone biopsy or simple hysterectomy if early
laparoscopic lymphadenectomy and radical trachelectomy or radical hysterectomy if advanced
if very severe-> chemo/radiotherapy to improve symptoms
LLETZ if low CN-> large loop excision of the transitional zone or cryotherapy
93
what type of cancer is ovarian carcinoma?
serous adenocarcinoma
94
pathophysiology of ovarian cancer?
irritation of the ovarian surface by damage during ovulation leads to DNA damage and unregulated cancerous growth.
BRCA 1+2 are involved in repair of damaged DNA -> mutations lead to increased risk of ovarian and breast cancer.
95
RF of ovarian cancer?
early menarche
late menopause
nulliparity
FHx-> breast or ovarian cancer or colorectal cancer
96
what are some protective factors of ovarian cancer
pregnancy
lactation
COCP
97
presentation of ovarian cancer?
IBS like symptoms - bloating, urinary symptoms, loss of appetitie
98
investigations of ovarian cancer?
```
USS+ CT
CA125
calculate RMI
MRI
very rarely laparoscopy + biopsy- this is much more commonly done during removal of the tumour
```
99
How is RMI calculated?
U (USS score) x M (menopausal status) x CA125
IF > 250- refer to MDT
100
management of ovarian cancer?
total hysterectomy and bilateral sapingoophrectomy + retroperitoneal lymph node assessment + chemotherapy
101
what are the different stages of ovarian cancers?
1- confined to ovaries
2- confined to pelvis
3- confined to abdomen
4- beyond abdomen to lungs or liver
102
what are some functional cysts of the ovary?
follicular
| corpus luteum
103
which is the most common type of ovarian cyst?
follicular
104
what is a follicular cyst?
due to non-rupture of dominant follicle or failure of atresia in the non-dominant follicle
105
what is corpus luteum cyst?
failure of the corpus luteum to break down causes it to fill with blood and form a cyst
106
what is the most common type of benign ovarian tumour?
dermoid cyst (teratoma)
107
what is found inside a teratoma?
epithelial tissue - skin appendages, hair and teeth
108
what are the two types of benign epitherlial tumours?
serous cystadenomas- most common
| mucinous cystadenoma- can become enormous
109
what is a molar pregnancy?
hydatitiform mole- where a non-viable pregnancy implants in the uterus and fails t ocome to term
110
presentation of molar pregnancy?
vaginal bleeding
excessive hyperemesis
pelvic pain
111
investigations of molar pregnancy?
USS- snowstorm
elevated hCG
low TSH
112
management of molar pregnancy?
evacuation of pregnancy- suction curettage
| methotrexate
113
RF for ectopic pregnancy?
```
damage to tubes
previous ectopic
endometriosis
IUCD
POP
IVF
```
114
presentation of ectopic?
```
amenorrhoea
pain
vaginal bleeding
D+V
shoulder tip pain (diaphragm irritation)
cervical excitation
adnexal tenderness
```
115
investigation of ectopic?
Transvaginal USS
serum hCG
laparoscopy
116
management of ectopic pregnancy?
expectant- falling hCG and clinically stable - monitor hCG levels and repeat TVS
medical- methotrexate IM, measure hCG levels and give another dose if not falling
surgical- laparoscopic linear salpingostomy (rather than salpingectomy- as want to preserve the tube)
117
definition of miscarriage?
loss of clinically recognised pregnancy before 24 weeks
118
causes of miscarriage?
```
chromosomal
abnormal development
uterine defects - fibroids
infections
trauma
antiphospholipid syndrome
```
119
what are the different stages of miscarriage?
threatened- bleed
inevitable/incomplete- open cervix, products in os, no heartbeat
complete- passed tissue, closed os
120
management of miscarriage?
misoprostol - help the uterus contract and expel tissue
| vacuum aspiration if needed
121
what are the options for emergency contraception?
Levonorgestrel = take within 120hrs of UPS for effectiveness – acts both to stop ovulation and inhibit implantation. If vomit <2hrs then repeat dose
IUD:
Inserted within 5d of UPS, or 5d after likely ovulation date
Inhibits fertilization or implantation
Prophylactic antibiotics if high risk of STI. Kept minimum till next period
122
what is the MOA of COCP?
inhibits LH surge mid-cycle, inhibiting ovulation
123
SE of COCP?
```
irregular bleeding
nausea
headache
increased BP
weight gain
breast pain
```
124
CI of COCP?
thromboembolic event, migraines with aura, chronic liver disease
125
MOA of POP?
thickens cervical mucous
126
what long-acting contraceptions are there?
depo- IM injection every 12 weeks works to prevent mid-cycle LH surge
implant- prevents ovulation and impairs oocyte maturation and cervical mucosa thickening
127
how does the IUD work?
local irritation that is hostile to oocyte and sperm
128
what is a dermoid cyst derived from?
derived from primitive germ cells that can differentiate into any other cell type
129
what are the cancer markers for ovarian cancer?
Ca-125
| alpha fetoprotein
130
what could be felt in vaginal examination of endometriosis?
fixed retroverted uterus
tender nodules on uretosacral ligaments
tender uterus
enlarged ovaries
