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Danny's Phase 3A Medicine > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

OVARIAN CANCER

Causes?

A
  • Epithelial ovarian tumours
  • Germ cell tumours
  • sex cord-stromal tumours
  • metastatic tumours
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2
Q

OVARIAN CANCER

What is the most common cause?

A

Epithelial ovarian tumors (85-90%)

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3
Q

OVARIAN CANCER

how will germ cell tumours present and who are they common in?

A

common in women <35 and they present as a rapidly enlarging abdominal mass (often rupture/torsion)

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4
Q

OVARIAN CANCER

Risk factors?

A
  • Increasing age
  • Lifestyle (smoking, obesity, lack of exercise)
  • Nulliparous
  • early menarche/ late menopause

BRCA1&2

History of:
family
infertility
endometriosis

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5
Q

OVARIAN CANCER

Epidemiology

A

1/5th most common cancer in women

incidence rises with age

PEAK 70/80s

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6
Q

OVARIAN CANCER

Clinical Presentation

A
  • 75% present with advanced disease (3rd/4th stage)
  • IBS symptoms in older women

LATER

  • abdominal discomfort/bloat/distention
  • urinary frequency
  • dyspepsia
  • fatigue
  • weight loss

MASS WITH PAIN

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7
Q

OVARIAN CANCER

Ddx?

A
  • benign tumour/cyst
  • endometriosis
  • bowel mass
  • peritoneal carcinoma
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8
Q

OVARIAN CANCER

Diagnostic tests and results?

A
  • Symptoms and age
  • Ca125 tumour marker
  • USS + CT abdomen
  • CXR pleural effusion +lung mets?
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9
Q

OVARIAN CANCER

Staging?

A

1- ovaries

2- one or both ovaries with pelvic extension/ implants

3- one or both ovaries with microscopically confirmed peritoneal implants outside pelvis

4- one or both ovaries with distant mets

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10
Q

OVARIAN CANCER

Treatment?

A

Abdominal hysterectomy and bilateral salpingo-oopherectomy

Chemo for stage 2-4

Radio for early disease

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11
Q

ENDOMETRIAL CANCER

basic scientific definition

A

Cancer of the endometrium arises from the lining of the uterus and is an OESTROGEN DEPENDANT TUMOUR

this can include myometrial sarcoma

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12
Q

ENDOMETRIAL CANCER

Risk Factors?

A
  • prolonged exposure of unopposed oestrogen
  • Nulliparous
  • Late menopause
  • Obesity
  • Diabetes
  • Tamoxifen (breast cancer prevention/treatment)
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13
Q

ENDOMETRIAL CANCER

What is the most common type of tumour and what are the two different types?

A

80% are adenocarcinomas

Type 1= Oestrogen dependent endometrioid

Type 2= Oestrogen-independent non-endometrioid carcinomas

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14
Q

ENDOMETRIAL CANCER

Epidemiology?

A

90% of women with endometrial cancer are over 50

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15
Q

ENDOMETRIAL CANCER

Clinical Presentation

A

Post-menopausal bleeding/abnormal uterine bleeding- EARLY SIGN

  • heavy/irregular periods in pre-menopausal
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16
Q

ENDOMETRIAL CANCER

Diagnostic tests and results?

A
  • Transvaginal US scan (TVS- Transvaginal sonography)- endometrial thickness >4mm
  • Endometrial pipelle biopsy if over 4mm
  • Hysteroscopy
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17
Q

ENDOMETRIAL CANCER

Treatment?

A
  • Total abdominal/ laparoscopic hysterectomy with bilateral salpingo-oopherectomy with/without lymphadectomy
  • post-operative chemotherapy
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18
Q

CERVICAL CANCER

Cause?

A

persistent infection with human papillomavirus (HPV)

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19
Q

CERVICAL CANCER

What is CIN?

A

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer.

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20
Q

CERVICAL CANCER

Describe the 3 grades of CIN

A

CIN I= lower basal 1/3 of cervical epithelium

CIN II= affects <2/3 of cervical epithelium

CIN III= affects >2/3 of full thickness of epithelium

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21
Q

CERVICAL CANCER

who is screened?

A

25-49 every 3 years

50-65 every 5 years

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22
Q

CERVICAL CANCER

What is dyskaryosis?

A

Dyskaryosis means abnormal nucleus and refers to the abnormal epithelial cell which may be found in cervical sample. It is graded from low to high grade based on degree of abnormality.

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23
Q

CERVICAL CANCER

name the tests/ plan from a :

Borderline/ mild dyskaryosis?

A

Test for HPV

-ve = back to routine

+ve= colposcopy

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24
Q

CERVICAL CANCER

name the tests/ plan from a :

moderate dyskaryosis?

A

Urgent colposcopy within 2 weeks. Consistent with CIN II.

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25
Q

CERVICAL CANCER

name the tests/ plan from a :
severe dyskaryosis or suspected invasive cancer?

A

Urgent colposcopy within 2 weeks.

consistent with CIN III

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26
Q

CERVICAL CANCER

name the tests/ plan from a :
inadequate smear?

what if they keep being inadequate?

A

inadequate = repeat smear

consistently inadequate = colposcopy

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27
Q

CERVICAL CANCER

Risk factors?

A
  • persistent HPV (high risk is HPV 16&18)
  • early intercourse <16yrs
  • women with multiple sexual partners
  • smoking limits ability to clear HPV
  • lower social class
  • immunosuppression
  • COCP
  • non attendance of cervical screening programme
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28
Q

CERVICAL CANCER

what are the 3 most common tumours seen?

A
  • bulky ectocervical tumour which fills uppeer vagina
  • invasive, bulky tumour that can enlarge to a size that fills lower pelvis
  • destructive, invasive tumour that erodes tissues, causing ulceraton and excavation with infected, necrotic cavities
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29
Q

CERVICAL CANCER

What % of cancers are found through screening and what is the most common age to get it?

Most common type of tumour?

A

30% found through screening
most common age is 25-34

70% of tumours are squamous cell

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30
Q

CERVICAL CANCER

Clinical presentation?

A
  • Abnormal vaginal bleeding
  • Vaginal discharge
  • post micturition bleeding
  • vaginal discomfort/ urinary symptoms
  • Haematuria
  • polyuria
  • red or white patches on cervix
  • pelvic mass
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31
Q

CERVICAL CANCER

Ddx?

A
  • cervicitis
  • dysfunctional uterine bleeding
  • PID
  • endometrial cancer
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32
Q

CERVICAL CANCER

Diagnostic tests and results?

A
  • Colposcopy with cystoscopy
  • Punch biopsy
  • bimanual examination (rough and hard cervix)

CT scan for mets +- lymph nodes

PET for staging (FIGO staging)

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33
Q

CERVICAL CANCER

treatment?

A
  • Local excision/ hysterectomy

Potential Radio

  • Chemo (most common cisplatin)
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34
Q

VULVAL CANCER

Cause?
Most common type of tumour?
symptoms?
Tx?

A

Cause- Vulval intraepithelial neoplasia

Tumour? Squamous (90%)

Symptoms?
vulval itch/sore
persistent lump
post-menopausal bleeding
painful urination

tx? Surgery/radio

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35
Q

VAGINAL CANCER

Cause and epidemiology?

Symptoms and tx?

A

commonly HPV or due to metastatic spread from cervical/uterine

bleeding & radio.

poor prognosis- 58% 5 yr survival

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36
Q

BREAST CANCER

Risk factors?

modifiable and non modifiable lifestyle factors?

A

Modifiable = weight, exercise, smoking, alcohol

Non-modifiable= age, breast density, menopause age, BRCA 1&2

HRT

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37
Q

BREAST CANCER

Clinical features?

A

Commonly- normal looking breast with small lump 90%

inflammatory- peau d’orange in drawn nipple and lymphatic oedema

Metastatic-bones (pain in hip/fracture presentation)

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38
Q

BREAST CANCER

Presenting symptoms?

A
  • Painless lup
  • nipple discharge/ in-drawing
  • skin tethering

Pain and tenderness uncommon

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39
Q

BREAST CANCER

Diagnosis?

A

TRIPLE ASSESSMENT

Clinical score 1-5
Imaging score 1-5
Biopsy score 1-5

  • Mammography
  • High resolution US
  • Core biopsy
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40
Q

BREAST CANCER

What are the tumour markers?

A

CA 15-3

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41
Q

BREAST CANCER

when would you use breast conservation treatment?

A

small tumour relative to breast size <25%

not allowed if under nipple
pre op chemo and additional radio if this tx is chosen

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42
Q

BREAST CANCER

When would you do a mastectomy?

A
  • large tumour relative to breast size
  • tumour underneath nipple/ in drawing nipple
  • more than one cancer in same breast
  • delayed reconstuction
  • patient choice
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43
Q

BREAST CANCER

40% of breast cancers have axillary disease.

when would you use full-axillary clearance?

what are the complications?

A

if glands are clinically involved
no need for further surgery

  • 10% lymphedema

high complication rate- seromas, arm stiffness, drain, axillary numbness

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44
Q

BREAST CANCER

when would you do limited axillary surgery?

what are the benefits of limited surgery.

A

if glands are clinically normal

  • day surgery, no significant complications, no drains, day surgery
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45
Q

BREAST CANCER

What are the histological morphology subtypes?

What staging is used?

A
  • Ductal carcinoma 70%
  • Lobular 10%

TNM staging

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46
Q

BREAST CANCER

if a woman is HER-2 positive what post op treatment must she take?

A

Trastuzumab

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47
Q

BREAST CANCER

All women are ER+ve.

what drugs must be taken post op if they are:

Pre-menopause
post-menopause

A

Pre= Tamoxifen (inhibits oestrogen receptors on breast cancer cells

Post= Aromatase inhibitors (inhibits aromatase enzyme responsible for conversion of androgens to oestrogen post menopausal)
Anastrozole

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48
Q

BREAST CANCER

When would someone have

Radiotherapy?
Chemotherapy?

A

Radio = when a women has had lumpectomy and aggressive disease after mastectomy

Chemo = aggressive disease and high risk (e.g young age, HER-2 +ve or ER -ve, grade 3, node positve and tumour size)

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49
Q

ATROPHIC VAGINITIS

What is it common in and why?

how is it diagnosed?

A

Common in post-menopausal women due to falling levels of oestrogen.

Diagnosis of exclusion. Rule out pathology first through TVS

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50
Q

ATROPHIC VAGINITIS

Causes?

A
  • Natural menopause or oophorectomy
  • Anti- oestrogen treatments e.g- Tamoxifen, aromatase inhibitors
  • Radio/chemo
  • can occur post-partum due to reduced oestrogen levels
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51
Q

ATROPHIC VAGINITIS

When oestrogen levels fall what changes are seen to the vaginal mucosa?

A
  • Thinner
  • Drier
  • Less elastic
  • more fragile
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52
Q

ATROPHIC VAGINITIS

When oestrogen levels fall what changes are seen to the vaginal epithelium

A

becomes inflamed contributing to urinary symptoms

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53
Q

ATROPHIC VAGINITIS

When oestrogen levels fall this changes vaginal pH,flora and potentially periurethral tissues. Why is this bad?

A
  • changes in vaginal pH/flora may predispose to UTI’s or vaginal infections
  • if periurethral tissues are affected this may contribute to pelvic laxity and stress incontinence
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54
Q

ATROPHIC VAGINITIS

Clinical Symptoms?

A
  • Vaginal dryness
  • Burning/itching of vagina
  • Dyspareuria
  • Vaginal discharge
  • Post-meno bleeding
  • Urinary symptoms
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55
Q

ATROPHIC VAGINITIS

Name some urinary symptoms?

A
  • polyuria
  • nocturia
  • dysuria
  • UTIs
  • Stress/urgency incontinence
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56
Q

ATROPHIC VAGINITIS

Clinical signs?

A
  • Reduced pubic hair
  • Painful vaginal examination
  • Lack of vaginal folds
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57
Q

ATROPHIC VAGINITIS

Ddx?

A
  • Genital infections
  • Uncontrolled diabetes
  • Local irritation due to soap/underwear
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58
Q

ATROPHIC VAGINITIS

Diagnostic tests and results?

A

TVS- rule out pathology

- Investigate if post menopausal bleeding is occuring

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59
Q

ATROPHIC VAGINITIS

Treatment?

A
  • Vaginal lubricants and mositurisers
  • Vaginal oestrogen
  • HRT
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60
Q

FIBROIDS

What are they?

What are they stimulated by?

Why may they go through benign degeneration and calcification?

A

Common benign tumours of the smooth muscle cells of the uterine myometrium

stimulated by O&P

benign calcification may occur due to the centre of larger fibroids not receiving adequate blood supply

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61
Q

FIBROIDS

How are they classified?

What are the most common type?

A
  • Intramural
  • Submucosal
  • Subserosal

Most common is intramural

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62
Q

FIBROIDS

What do they following terms mean:

Intramural?
Submucosal?
Subserosal?

A

Intramural- growing within the endometrium

Submucosal- growing into the uterine cavity (can be pedunculated and may protrude through cervical os)

Subserosal- growing outwards from the uterus. Uterine, cervical, intraligamentous, pedunculated subserous (abdominal)

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63
Q

FIBROIDS

Cause?

A

Acquired genetic change plus effects of hormones and growth factors

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64
Q

FIBROIDS

Risk factors?

A
  • Obesity
  • Early menarche
  • Afro-caribbean
  • Aged 30-40
  • Family history
  • COCP
  • Pregnancy
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65
Q

FIBROIDS

Epidemiology?

A

single most common indication for hysterectomy. (clinically apparent in up to 25% of women)

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66
Q

FIBROIDS

Clinical presentation?

A
  • Half may be asymptomatic
  • Present between 30-50
  • Excessive/prolonged heavy periods
    Pelvic pain
  • Recurrent miscarriage
  • Subfertility
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67
Q

FIBROIDS

What may be found on examination?

what may menorrhagia cause?

A

Palpable abdominal mass arising from pelvis

potential iron-deficiency anaemia which may lead to lethargy and pallor

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68
Q

FIBROIDS

Ddx?

A
  • Dysfunctional uterine bleeding
  • Endometrial polyps, cancer, endometriosis
  • PID
  • Ovarian tumour
  • Pregnancy
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69
Q

FIBROIDS

Diagnostic tests an results?

A
  • Pregnancy test
  • FBC (anaemia)
  • TVUS

MRI if US not definitive

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70
Q

FIBROIDS

Medical treatment?

A
  • Tranexamic acid-antifibrinolytic agent
  • GnRH agonists
  • Ulipristal acetate
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71
Q

FIBROIDS

Surgical treatment?

A
  • Myomectomy

- Hysterectomy (only cure for fibroids) for women who have completed their family

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72
Q

FIBROIDS

When would you do a myomectomy?

A
  • excessive enlarged uterine size
  • Pressure symptoms present
  • Medical management not sufficient to control symptoms
  • Fibroids are causing subfertility
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73
Q

FIBROIDS

NAme a GnRH agonist and its cons?

A
  • Goserelin

they used to shrink fibroids but then fibroids regrow when discontinued.

Not a long term option as it will start to demineralise bone

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74
Q

FIBROIDS

What is ulipristal acetate, what does it do and when is it used?

A
  • Selective progesterone receptor modulator

they shrink fibroids and induce amenorrhoea

used before surgery and for emergency contraception

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75
Q

OVARIAN CYSTS

What are the three main types?

A
  • Functional (24%)
  • Benign (70%)
  • Malignant (6%)`
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76
Q

OVARIAN CYSTS

Name some benign neoplastic causes

A

Benign epithelial neoplastic cysts

Benign neoplastic cystic tumours of germ cell origin

Benign neoplastic solid tumours
(Fibroma <1% malignant)

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77
Q

OVARIAN CYSTS

Name some benign fibrous causes

A
  • Adenofibroma
  • Teratoma
  • brenner tumour
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78
Q

OVARIAN CYSTS

What is a brenner tumour

A

Brenner tumours are a rare subtype of the surface epithelial-stromal tumour group of ovarian neoplasms. majority are benign but some are malignant

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79
Q

OVARIAN CYSTS

Risk factors?

A
  • Obesity
  • Tamoxifen therapy
  • Early menarche
  • Infertility
  • Dermoid cysts can run in families TERATOMAS
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80
Q

OVARIAN CYSTS

Epidemiology?

A
  • Predominantly pre-menopausal

- benign neoplastic cystic tumours of germ cell origin are most common in young women

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81
Q

OVARIAN CYSTS

Clinical presentation?

A

PAIN

  • dull ache in lower abdomen
  • lower back pain
  • rupture can lead to severe abdo pain + fever
  • Dyspareuria
  • Irregular vaginal bleeding
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82
Q

OVARIAN CYSTS

Examination findings?

What would ascites suggest?

A
  • Swollen abdomen with palpable mass, dull to percussion

Ascites suggests malignancy

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83
Q

OVARIAN CYSTS

What may cysts cause?

A
  • Torsion, infarction or haemorrhage which would cause severe pain
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84
Q

OVARIAN CYSTS

Complications of rupture?

A

rupture can cause peritonitis and shock

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85
Q

OVARIAN CYSTS

What can hormone secreting tumours cause?

A
  • virilisation
  • menstrual irregularities
  • post-menopausal bleeding
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86
Q

OVARIAN CYSTS

Ddx?

A
  • PCOS
  • Endometrioma
  • Malignant ovarian tumour
  • bowel problems
  • PID
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87
Q

OVARIAN CYSTS

Diagnostic tests and results?

A
  • Pregnancy test
  • FBC for infection/haemorrhage
  • TVS/USS

CT/MRI if USS not definitive

Diagnostic laparoscopy

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88
Q

OVARIAN CYSTS

What is the tumour marker for Ovarian cancer

A

CA125

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89
Q

OVARIAN CYSTS

For suspected ovarian cancer we do a RISK OF MALIGNANCY INDEX (RMI)

What is this a product of?

A

Product of USS score, menopausal status and serum CA125 levels

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90
Q

OVARIAN CYSTS

in the RMI we do a USS score. What findings add a point to the USS score?

(out of 5)

A

USS scores 1 point for each of the following:

  • Multi ocular cysts
  • Solid areas
  • Metastases
  • Ascites
  • Bilateral lesions
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91
Q

If you were to find Rokitansky’s Protuberance on histopathology what would this mean?

A

A solid protuberance from a mature dermoid cyst (teratoma)

It often contains calcific, dental, adipose, hair, and/or sebaceous components. This region has the highest propensity to undergo malignant transformation.

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92
Q

OVARIAN CYSTS

Treatment?

Small?
Moderate?
Large?

A

small <50mm = do not require follow up

Moderate 50-70mm = yearly US follow up

Large = consider further MRI imaging

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93
Q

OVARIAN CYSTS

Surgical treatment?

A

Cystectomy
Oopherectomy

Acute onset of symptoms require hospital admission

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94
Q

OVARIAN TORSION

Clinical presentation?

A

Sudden onset deep seated colicky pain

  • Iliac fossa pain radiating to loin,groin or back
  • potential fever
  • Pain may improve after 24hrs and the ovary is dead
95
Q

OVARIAN TORSION

What may US show?

A

free fluid (oedema) due to venous supply cut off

whirlpool sign (twisting/volvulus)- wrapping of vessels around a central axis which makes it look a bit like a target.

96
Q

OVARIAN TORSION

Diagnostic test?

A

Laparoscopy

97
Q

What is Mittelschmerz?

A

Ovulation pain that can last up to 48 hours

usually on one side of the abdomen

98
Q

ENDOMETRIOSIS

What is it?

A
  • Chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity
99
Q

ENDOMETRIOSIS

Where is it most common?

A
  • Pelvic cavity (including ovaries
  • Uterosacral ligaments
  • Pouch of Douglas
  • Recto-sigmoid colon
  • Bladder
  • Distal ureter
100
Q

ENDOMETRIOSIS

What is Adenomyosis?

A

The invasion of endometrial tissue into the myometrium

101
Q

ENDOMETRIOSIS

Cause?

A
  • Retrograde menstruation

- Impaired immunity (retrograde tissue isn’t destroyed)

102
Q

ENDOMETRIOSIS

Risk Factors?

A
  • Early menarche
  • Late menopause
  • Delayed childbearing
  • Short menstrual cycles
  • Obstruction to vaginal outflow
  • Fallopian or uterus defects
  • Genetic predisposition
  • Alcohol use
  • low body weight
103
Q

ENDOMETRIOSIS

What is seen to be protective of endometriosis?

A
  • multiparity

- COCP

104
Q

ENDOMETRIOSIS

Epidemiology?

A

Higher prevalence in infertile women 25-40%

exclusive to women of reproductive age

105
Q

ENDOMETRIOSIS

Classic triad of symptoms?

A
  • Dysmenorrhoea
  • Deep dyspareuria
  • Cyclical or chronic pelvic pain

(chronic/constant inflammation brings pain)

106
Q

ENDOMETRIOSIS

Other symptoms?(other than triad)

A
  • Sub fertility
  • Dysuria
  • Bloating
  • lethargy
  • Constipation
  • Lower back pain
107
Q

ENDOMETRIOSIS

Ddx?

A
  • PID
  • Ectopic pregnancy
  • Torsion of ovarian cyst
  • Appendicitis
  • Primary dysmenorrhoea
  • IBS
  • uterine fibroids
108
Q

ENDOMETRIOSIS

Diagnostic tests and results?

Gold standard?

A

gold= Laparoscopy with biopsy

  • Bimanual examination
  • Transvaginal US
  • MRI good for if bowel involved
109
Q

ENDOMETRIOSIS

Whats the classic sign on a bimanual examination?

A

Fixed, retroverted uterus

110
Q

ENDOMETRIOSIS

Treatment for pain?

A

NSAIDs/Paracetamol

111
Q

ENDOMETRIOSIS

Medical treatment?

A

Suppression of ovarian function for at least 6 months:

  • COCP
  • Medroxyprogesterone acetate (injectable contraception)
  • GnRH agonist (Goserelin) for a max of 6 months
112
Q

ENDOMETRIOSIS

Surgical treatment?

A

Laparoscopic excision or ablation

Hysterectomy with salpingo-oophorectomy (last resort)

113
Q

POLYCYSTIC OVARIAN SYNDROME (PCOS)

What is it?

A

A syndrome of polycystic ovaries in association with systemic symptoms causing reproductive, metabolic and psychological disturbances

114
Q

PCOS

What is the basic pathophysiology?

A

Excess androgens produced by theca cells of the ovaries due to either:

1) hyperinsulinaemia
2) Increase of luteinising hormone (LH) levels

115
Q

PCOS

How are excess androgens caused by hyperinsulinaemia?

A

1) Insulin resistance, weight gain leads to further insulin resistance
2) This leads to increased androgen production and reduced production of sex hormone-binding globulin (SHBG) in the liver
3) Free testosterone subsequently raised

116
Q

PCOS

Why does hyperinsulinaemia cause increased androgen production?

A

Insulin mimics the action of insulin growth factor 1 (IGF-1), which augments androgen production by the theca cell in response to LH. Since insulin decreases levels of SHBG, the circulating levels of free testosterone are also increased.

117
Q

PCOS

Why may you have raised LH?

A
  • Increase production in the anterior pituitary

- genetic conditions, like Turner syndrome or Klinefelter syndrome

118
Q

PCOS

Clinical presentation?

(common triad)

A
  • Oligomenorrhoea (less than 9 periods a year)/ Amenorrhoea
  • Infertility/ subfertility
  • Signs of androgen production (excess testosterone)
119
Q

PCOS

Name some signs of excess androgen production?

A
  • Acne
  • Hirsutism (XS hair)
  • Deep voice
  • Alopecia
  • Male pattern balding
  • reduced breast size
120
Q

PCOS

Name some signs of insulin resistance

A
  • Acanthosis nigricans
  • psychological symptoms (depression, mood swings, anxiety, poor self-esteem)
  • Obesity
  • Sleep apnoea
121
Q

What is the commonest cause of secondary infertility?

A

PCOS

122
Q

PCOS ddx?

A
  • thyroid disorder
  • cushings
  • acromegaly
  • medication side effects
  • Hyperprolactinaemia
123
Q

PCOS

Diagnostic tests? Triad?

A
  • signs of excess androgen production (acne, hirsutism, decreased breast size)
  • oligo/amenorrhoea
  • cystic ovaries on US (12 or more on one ovary) - strings of pearls
124
Q

PCOS

Biochemical results?

A
  • Raised testosterone
  • Sex hormone binding globulin (SHBG) low

LH levels elevated (1:1 ratio to FSH)

Impaired glucose tolerance (insulin resistance)

125
Q

PCOS

Which hormone is always normal on test?

A

Prolactin

126
Q

PCOS

What is the Rotterdam Criteria?

A

Strings of pearls
Hyperandrogenism
Oligomenorrhoea
Prolactin normal

SHOP

127
Q

PCOS

Treatment?

A

TREAT THE SYMPTOMS

128
Q

PCOS

Treatment of Hirsutism and acne?

A

Co-cyprindol /Eflornithine

SEVERE Acne= Isotretinoin

129
Q

PCOS

Tx for insulin resitance?

A

Metformin

130
Q

PCOS

Tx for weight loss?

A

Lifestyle

Medication =Orlistat

131
Q

PCOS

tx for fertility?

A
  • Letrozole
  • Metformin
  • Laparoscopic ovarian drilling or gonodotrophins
  • Need 4 periods a year to develop lining of the womb
132
Q

What is Menopause?

A

Permanent cessation of menstruation from loss of follicular activity

133
Q

MENOPAUSE

Symptoms and Consequences of menopause?

A
  • CV disease (cause of death of 1/3 of women)
  • Vasomotor symptoms
  • Urogenital problems due to oestrogen deficiency
  • Osteoporosis
134
Q

MENOPAUSE

Early signs of menopause?

A
  • irregular periods
  • vasomotor
  • vaginal dryness
  • reduced libido
  • poor conc and fatigue
  • headaches
  • joint pain
135
Q

MENOPAUSE

signs of ongoing menopause?

A

GU symptoms (frequency, urgency, UTIs)

Atrophic vaginitis

PMB

136
Q

MENOPAUSE

Late signs of menopause?

A
  • Osteoporosis
  • CVD
  • Dementia
137
Q

MENOPAUSE

Name some vasomotor symptoms?

A
  • Hot flushes
  • Night sweats
  • Palpitations
138
Q

MENOPAUSE

Name some urogenital problems due to oestrogen deficiency

A
  • Dyspareuria
  • Dryness
  • Frequency, urgency, incontinence
139
Q

MENOPAUSE

Investigations?

A
  • increased FSH suggests fewer oocytes

DEXA scan for bone density estimation and biochemistry for monitoring

140
Q

MENOPAUSE

What is the direct measurement of ovarian reserve?

A

Anti-mullerian hormone

141
Q

MENOPAUSE

treatment?

A

HRT

may consist of oestrogen progesterone and tibolone (mixed) to treat symptoms and conserve bone density

142
Q

What are the pros and cons of HRT?

A

Pros:

  • Symptom management
  • Osteoporosis prevention
  • Colo-rectal cancer prevention

Cons

  • Risk breast Ca if combined
  • Risk of endometrial Ca if oestrogen only
  • Risk of gallbladder disease
143
Q

MENOPAUSE

Treatment for hot flushes and night sweats?

A
  • Progesterone, Clonidine, SSRIs
144
Q

MENOPAUSE

Medical Treatment for Osteoporosis?

A

1st- Bisphosphonates
2nd - strontium ranelate
3) Teriparatide
4th- denosumab

145
Q

Ddx for Intermenstrual bleeding?

A

Pregnancy related (ectopic, hydatiform molar, miscarriage)

Fibroids

Endometriosis

Infection (STI)

Cancers (endometrial, cervical)

Iatrogenic (tamoxifen, missed pill, drugs altering clotting e.g. SSRIs, anti-coags, corticosteroids)

146
Q

Post-coital bleeding Ddx?

A
  • Infection
  • Cervical/ endometrial polyps

Cervical/endometrial/vagina cancer

  • Trauma
147
Q

Pelvic pain Ddx?

A

Pregnancy related

Appendicitis

PID

ovarian cysts, torsion, fibroids, endometriosis

UTI/ pyelonephritis

Kidney stones

148
Q

What are common symptoms of a:

Ectopic Pregnancy?

A

USUALLY ACUTE

6-8 weeks of:
- Amneorrhoea

Lower abdominal pain
Later develops vaginal bleeding

Shoulder tip pain

& cervical excitation may be seen

149
Q

What are common symptoms of a:

UTI?

A

USUALLY ACUTE

Dysuria and frequency
suprapubic burning

150
Q

What are common symptoms of a:

Appendicitis?

A

USUALLY ACUTE

Pain in abdomen then moves to right iliac fossa

  • Tachycardia
  • Pyrexia
  • Rovsings Sign (press LIF and get more pain in RIF)
151
Q

What are common symptoms of a:

Pelvic Inflammatory Disease?

A

USUALLY ACUTE

  • Pelvic pain
  • Fever
  • Deep dyspareuria
  • Discharge
  • Dysuria and menstrual irregularities
  • cervical excitation on examination
152
Q

What are common symptoms of a:

Ovarian Torsion?

A

USUALLY ACUTE

sudden onset unilateral lower abdominal pain (brought on by exercise)

Nausea and vomiting

Unilateral tender adnexal mass on examination

153
Q

What are common symptoms of a:

Miscarriage?

A

USUALLY ACUTE

Vaginal bleeding

crampy lower abdominal pain

following a period of amenorrhoea

154
Q

What are common symptoms of a:

Endometriosis?

A

USUALLY CHRONIC

Chronic pelvic pain

Dysmenorrhoea - pain often starts days before bleeding

Deep dyspareunia

Subfertility

155
Q

What are common symptoms of a:

IBS?

A

USUALLY CHRONIC

  • bloating, abdo pain, change in bowel habit
  • Nausea
156
Q

What are common symptoms of a:

Ovarian cyst?

A

USUALLY CHRONIC

Unilateral dull ache (could be intermittent or only coital pain)

torsion or rupture = severe abdo pain

large cysts = abdominal swelling or pressure effects on bladder

157
Q

What are common symptoms of a:

Urogenital prolapse?

A

USUALLY CHRONIC

Older women

Pressure, heaviness ‘bearing down’

urinary symptoms : incontinence, frequency, urgency

158
Q

Define Menarche?

A

Last manifestation of puberty following development of secondary sex characteristics by oestrogen

The hypothalamic- pituitary axis is involved as:

GnRH > FSH, LH > ostrogen release from ovaries

159
Q

What causes a menstrual cycle?

A

Hormonal changes causes ovulation and induce endometrial change to prepare for implantation

160
Q

MENSTRUAL CYCLE

What happens in day:

1-4?

A
  • hormonal support withdrawn
  • endometrial shed
  • sometimes painful myometrial contraction

Oestradiol increase causes endometrium to reform and thicken

Positive feedback on LH causes ovulation 36 hours later

161
Q

MENSTRUAL CYCLE

What happens in day:

5-13?

A

GnRH stimulates FSH & LH

LH induces follicular growth which produces oestradiol and
inhibin > suppresses FSH with negative feedback so only one oocyte matures

162
Q

MENSTRUAL CYCLE

What happens in day:

14-28?

A

Follicle that becomes Corpus Luteum, which produces more progesterone than oestradiol causing increased blood supply and cells to enlarge in the endometrium

163
Q

What happens if the corpus luteum is not fertilised?

A

The corpus luteum will collapse if the egg is not fertilised causing oestrogen and progesterone levels to fall.

164
Q

PREMENSTRUAL SYNDROME

What is it?

A

Premenstrual syndrome describes the emotional and physical symptoms women experience prior to menstruation > ie. in luteal phase

165
Q

PREMENSTRUAL SYNDROME

Common symptoms?

A
  • Anxiety
  • stress
  • fatigue
  • mood swings
166
Q

PREMENSTRUAL SYNDROME

Management?

Treatment for severe?

A
  • Lifestyle advice, healthy diet, exercise, stress reduction methods, regular sleep

Paracetamol
COCP
SSRIs
for mederate to severe

167
Q

MENORRHAGIA

Definition?

A

Excessive menstrual blood loss (>80mL) within a normal menstrual cycle, interfering with the woman’s physical, emotional and social quality of life.

168
Q

MENORRHAGIA

Causes?

A

Most = no histological problem

30% fibroids
10% polyps

OTHERS

  • PID
  • Malignancy
  • Hypothyroidism
  • Von willebrand disease
169
Q

MENORRHAGIA

Assessment?

A
  • FBC, TSH/T4, coagulation function
  • TVS to assess endometrial thickness and masses

(If >10mm and >40 then endometrial biopsy with hysteroscopy to exclude cancer)

170
Q

MENORRHAGIA

Medical management?

A

1st- IUS e.g Mirena

2nd - Tranexamic acid (antifibrinolytic), NSAIDs or COCP

3rd- Progestogen e.g. depo or GnRH agonist causing amneorrhoea

171
Q

MENORRHAGIA

Surgical treatment?

A
  • Endometrial ablation
  • resection of fibroids
  • Uterine artery embolization
172
Q

Post coital bleeding

What is it and what are the likely causes?

What is the assessment?

A
  • Non-menstrual bleeding that occurs immediately after sexual intercourse

Causes :
infection
cervical ectropion, polyps, carcinoma

Assessment - examination and smear

173
Q

What is primary amenorrhoea?

A

if menstruation has not started by the age of 16.

Absence of secondary sexual characteristics by 14 with no menarche.

174
Q

what is secondary amneorrhoea

A

When previously normal menstruation seizes for over 6 months

175
Q

AMENORRHOEA

Causes of primary amenorrhoea?

A
  • Turner’s Syndrome
  • Androgen Insensitivity Syndrome
  • Congenital malformations of genital tract
  • Congenital adrenal hyperplasia
  • IMPERFORATE HYMEN
176
Q

What is Oligomenorrhoea?

A

menstruation occurring every 35days to 6 months

177
Q

AMENORRHOEA

Why may a low birth weight cause secondary amenorrhoea?

A

Low birth weight is linked to increased Ghrelin.

  • Ghrelin inhibits hypothalamic - pituitary ovarian axis so therefore GnRH amplitude is altered.
  • This decreases the pituitary release of FSH and LH
178
Q

AMENORRHOEA

Causes of secondary amenorrhoea?

A
  • Drug induced
  • pregnancy (breast-feed)
  • Hyperprolactinaemia (inhibits GnRH secretion)
  • Hypothyroidism
  • Ovarian causes (PCOS)
  • Pituitary tumour
  • Hypothalamic hypogonadism
179
Q

AMENORRHOEA

investigations?

A
  • BhCG (check for pregnancy)
  • FSH/LH
  • Prolactin
  • TFTs
  • Testosterone levels
180
Q

AMENORRHOEA

What would a low FSH/LH mean?

A

Hypothalamic pituitary ovarian axis problem

181
Q

AMENORRHOEA

What would a high FSH/LH mean?

A

Premature ovarian failure

182
Q

AMENORRHOEA

Treatment of premature ovarian failure?

A

this cannot be reversed with HRT

However;

Enough given to control symptoms of oestrogen deficiency + prevent osteoporosis

183
Q

AMENORRHOEA

Treatment of HPO axis malformation?

A

If mild (stress/exercise) = sufficient activity to stimulate enough oestrogen to produce an endometrium

Severe = GnRH analogues

184
Q

AMENORRHOEA

What would you give to a woman who is wanting fertility now?

A

Clomifene for mild symptoms

185
Q

Why may someone get Dysmenorrhoea?

A

high prostaglandin levels in the endometrium

Contraction

Uterine Ischaemia

186
Q

Causes of secondary Dysmenorrhoea?

A 
Fibroids
Adenomyosis
Endometriosis
PID
Tumours
187
Q

GENITOURINARY PROLAPSE

What is it?

A

descent of one or more of the pelvic organs including:

uterus/ vaginal walls
bladder
rectum
small/large bowel
Vaginal vault
188
Q

GENITOURINARY PROLAPSE

Associated symptoms?

A

Urinary
Bowel
Sexual
Local pelvic symptoms

189
Q

GENITOURINARY PROLAPSE

Risk factors?

A
  • Increasing age
  • Vaginal delivery
  • Increasing parity
  • High BMI
  • Spina bifida and spina bifida occulta (occulta is latin for hidden- closed spina bifida)
  • Pelvic mass
  • Menopause
  • Iatrogenic (pelvic surgery
190
Q

How may a prolapse occur?

A

pelvic organs losing their structure through muscle trauma, neuropathic injury or stretching

  • orientation and shape of pelvic bones have also been implicated
191
Q

What muscles support the pelvic organs?

A

Levator ani muscles and endopelvic fascia

192
Q

Name the three anterior compartment prolapses

A

Urethrocele- urethra into vagina

Cystocele- bladder into vagina

Cystourethrocele- both

193
Q

Name the three middle compartment prolapses

A

Uterine prolapse- into vagina

vaginal vault prolapse - descent of vaginal vault post hysterectomy

Enterocele

194
Q

What is an enterocele?

A

Herniation of the pouch of Douglas into the vagina

195
Q

What is a posterior compartment prolapse

A

Rectocele- prolapse of the rectum into the vagina

196
Q

What are the 4 stages of vaginal prolapse

A

Stage 1 - more than 1cm above the hymen

Stage 2 - within 1cm proximal/distal of the hymen

Stage 3 - more than 1cm below the plane of the hymen but protudes no further than 2cm less than the total length of the vagina

stage 4 - complete eversion of the vagina

197
Q

GENITOURINARY PROLAPSE

Symptoms?

A
  • Can be asymptomatic
  • Sensation of dragging down, pressure, heaviness

Discomfort

Dyspareuria

198
Q

GENITOURINARY PROLAPSE

anterior Symptoms?

A
  • waterworks related
  • incontinence
  • frequency
  • urgency
199
Q

GENITOURINARY PROLAPSE

Posterior Symptoms?

A
  • Constipation/straining
200
Q

GENITOURINARY PROLAPSE

Diagnostic tests and results?

A

Sims speculum

Bimanual = exclude pelvic masses

potentially US/MRI

201
Q

GENITOURINARY PROLAPSE

Treatment?

A

CONSERVATIVE - Reduction of intrabdominal pressure

  • weight loss
  • stop smoking
  • constipation tx
  • pelvic floor muscle exercises
202
Q

GENITOURINARY PROLAPSE

Surgical tx?

A
  • Hysterectomy
  • Colporrhapy (vaginal wall repair)
  • Colposuspension (stress incontinence tx)
  • Sacrohysteropexy (holds the uterus in place)
  • Sacrospinous fixation
203
Q

What is a sacrospinous fixation?

A

A sacrospinous fixation is an operation to attach the top of the vagina or the cervix (neck of the womb) to a pelvic ligament (sacrospinous ligament) with a stitch. … The operation is primarily intended to treat prolapse of the uterus (womb) or the vault (top) of the vagina (if you have had a hysterectomy).

204
Q

What is a sacrohysteropexy

A

Laparoscopic sacrohysteropexy is a surgical procedure to correct uterine prolapse by re-suspending the prolapsed uterus to the anterior longitudinal presacral ligament using a thin strip of polypropylene mesh

205
Q

What is colposuspension?

A

Colposuspension is an operation to treat stress incontinence (leakage of urine when you exercise, sneeze or strain). We put stitches inside the pelvis through an incision (cut) across your lower abdomen (tummy). The stitches pull up your vagina around the area of the bladder opening.

206
Q

What is a Colporrhaphy

A

Colporrhaphy is the surgical repair of a defect in the vaginal wall, including a cystocele (when the bladder protrudes into the vagina) and a rectocele (when the rectum protrudes into the vagina)

207
Q

INCONTINENCE

What are the two types?

A

Urgency - overactive bladder (involuntary detrusor muscle bladder contractions)

Stress- Sphincter weakness (detrusor pressure > closing pressure of urethra)

208
Q

INCONTINENCE

Symptoms of overactive bladder?

A
  • URGENCY
  • Frequency
  • Nocturia
  • ‘Key in door’
  • Enuresis
209
Q

INCONTINENCE

Symptoms of stress?`

A
  • coughing
  • laughing
  • lifting
  • exercise
  • movement
210
Q

INCONTINENCE

Causes of stress?

A
  • Menopause = low oestrogen = weakening pelvic support

- radiotherapy, congenital weakness, pelvic surgery

211
Q

INCONTINENCE

Simple assessments?

A

dipstick/ urinaylsis

  • MSU
  • urine diary
  • residual urine measurement
  • ePAQ questionnaire
212
Q

INCONTINENCE

what would you check on Urinalysis?

A

Nitrates & leukocytes = infection

Haematuria= Glomerulonephritis

Proteinuria = Renal Disease

Glycouria = diabetes

213
Q

INCONTINENCE

What would you check on a frequency volume chart? (urine diary)

A
  • Frequency and quantity of urination
  • Frequency and quantity of leakage
  • Fluid intake
  • Diurnal viariation
214
Q

INCONTINENCE

How do you measure residual urine?

A

Urine in and out of the catheter

215
Q

INCONTINENCE

What is the ePAQ questionnaire?

A

Questionnaire to determine the impact on life to determine management plan

216
Q

INCONTINENCE

What questions are involved in the ePAQ questionnaire

A

Urinary - pain, voiding, stress, overactive bladder

Vaginal- pain, capacity, prolapse

Bowel- IBS, constipation, continence

Sexual- dyspareuria, overall sex life

217
Q

INCONTINENCE

Lifestyle treatment?

A
  • weight loss
  • reduce caffiene
  • smoking cessation
  • avoiding straining
218
Q

INCONTINENCE

Containment treatment?

A
  • Pads and pants

- catheters

219
Q

INCONTINENCE

Treatment of Stress incontinence?

A
  • pelvic floor muscle training

Duloxetine (SNRI- antidepressant)

220
Q

INCONTINENCE

Surgical treatment of stress incontinence?

A
  • Support urethra

1) Colposuspension
2) Sling
3) TVT (tension free vaginal tape)

restore pressure transmission to urethra

221
Q

INCONTINENCE

Surgical treatment for overactive bladder?

A
  • Bladder Drill
  • bypass
  • botox
222
Q

INCONTINENCE

Drug treatment for overactive bladder

A

Anticholinergics

Antimuscarinics

Adrenergic agonist

223
Q

INCONTINENCE

Give examples of some Antimuscarinics

A
  • Oxybutynin

- Tolterodine

224
Q

INCONTINENCE

What is the nerval innervation of the detrusor

A

Parasympathetic S2-S4

225
Q

INCONTINENCE

Name an adrenergic agonist and what it does

A

Mirabegron

relaxes detrusor and increases bladder capacity

226
Q

INCONTINENCE

Name some side effects of Antimuscarinics

A
  • Dry mouth
  • Blurred vision
  • Drowsiness
  • Constipation
  • Tachycardia
227
Q

What do FSH and LH bind to on the ovarian follicle?

A

LH = theca cells

FSH = granulosa cells

228
Q

Where is GnRH produced?

Where are FSH and LH produced?

A

Hypothalamus

Anterior pituitary

229
Q

When LH and FSH have binding to the various cells, what is produced?

A

1) Theca cells produce Androstenedione
2) Granulosa cells produce aromatase
3) Aromatase converts Androstenedione into oestrogen
4) oestrogen creates negative feedback to stop producing FSH
5) once oestrogen becomes really high = becomes positive feedback to produce loads of FSH and LH
6) Influx of FSH and LH = release of oocyte

230
Q

What effect does high oestrogen levels have on the endometrium?

A

1) Thickening of endometrium
2) growth of endometrial glands
3) emergence of spiral arteries to supply the released oocyte
4) make cervical mucus more hospitable for incoming sperm

231
Q

What is the dominant hormone in the luteal phase?

A

Progesterone - luteinised granulosa and theca cells produce progesterone and inhibin so a negative feedback on FSH/LH and oestrogen

232
Q

What does the corpus luteum become?

A

Corpus albicans - doesn’t produce hormones

low progesterone means spiral arteries collapse and functional layer sloughs off

233
Q

What are the two phases of the uterus in the menstrual cycle?

A

days 1-14 = Menstrual/ follicular/ proliferative phase

days 15-28 = luteal/ secretory phase

Danny's Phase 3A Medicine (10 decks)

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