Gynaecology Flashcards
1
Q
What phase of the menstrual cycle does PMS affect?
A
Luteal phase
2
Q
Premenstrual dysphoric disorder affects what 2 areas?
A
Physical (breast tenderness) and emotional (irritability)
3
Q
3 recommendations to manage PMS
A
- Adopt a healthy balance lifestyle
- Continuous use of COCP
- Antidepressants
4
Q
Menorrhagia refers to
A
> 80 ml of blood loss per month - this may be due to excessive volume or excessive duration > 1 week
5
Q
3 different questions to ask to categorise ‘very heavy periods’
A
- How long does it take you to fill a sanitary towel? - 1-2 hours
- Bleeding lasting > 7 days
- Passing large clots
6
Q
5 causes of menorrhagia
A
- Lack of ovulation: PCOS, hypothyroidism
- Structural: Endometriosis, leiomyomas, polyps.
- Pregnancy complication: Miscarriage
- Coagulopathies
- Iatrogenic: Anticoagulant, copper IUD
7
Q
3 disorders to rule out on bloods when a patient has menorrhagia
A
- Anaemia (iron studies)
- Hypothyroidism (TFT)
- Coagulation screening (thrombophilia)
8
Q
Management of heavy periods (4 points)
A
- No pain: Tranexamic acid to reduce blood loss
- Pain: Mefenamic acid (NSAID)
- Contraceptives: Particularly levonorgestrel IUD (Mirena) or POP
- Surgery: Endometrial ablation if finished having children, hysterectomy
9
Q
What type of drug is tranexamic acid and what is its MOA?
A
Antifibrinolytic that blocks conversion of plasminogen to plasmin, thus prevents fibrin degradation
10
Q
Investigations for menorrhagia
A
- Bloods: Rule out anaemia, thyroid disorders, coagulopathies
- Swabs: Rule out infection
- Pelvic/transvaginal ultrasound: Rule out polyps, cancer
- Hysteroscopy
11
Q
Dysmenorrhoea refers to
A
Painful menstruation with or without pelvic pathology
12
Q
Primary dysmenorrhoea refers to
A
Painful periods in absence of pelvic pathology
13
Q
Primary dysmenorrhoea is most common in
A
First year after menarche as ovulation becomes established
14
Q
Secondary dysmenorrhoea refers to
A
Pain many years after the menarche, during menstruation or in the luteal phase, due to pelvic pathology
15
Q
5 causes of secondary dysmenorrhoea
A
- PID
- Endometriosis
- Leiomyoma
- Polyps
- Adenomyosis
16
Q
Difference between primary and secondary dysmenorrhoea
A
Primary dysmenorrhoea is in the absence of pelvic pathology, often in 1st year post menarche.
17
Q
Investigations for dysmenorrhoea
A
- Bloods
- STI test
- Urinalysis
- Pelvic/transvaginal ultrasound
- Laparoscopy/hysteroscopy
18
Q
Amenorrhoea refers to
A
Transient/permanent absence of menstrual flow
19
Q
Primary menorrhoea refers to
A
Absence of menarche by 13 years with no pubertal maturation or by 15 years with appropriate secondary sexual characteristics
20
Q
Secondary amenorrhoea refers to
A
Lack of menses in a non-pregnant female for < 3 cycles of previous interval or < 6 months if previously having irregular periods
21
Q
4 causes of primary dysmenorrhoea
A
- Family history of delayed periods
- Structural pathology: FGM, imperforate hymen
- Turner’s Syndrome (XO)
- Hypogonadotropic hypogonadism (Kallman Syndrome - reduced/absent smell), damage to gonads (mumps, cancer)
22
Q
5 causes of secondary dysmenorrhoea
A
- Pregnancy
- Menopause/premature ovarian failure
- Hormonal contraception
- Hypogonadotropic hypogondadism (reduced GnRH) secondary to weight loss/excess exercise/chronic disease/stress
- PCOS
23
Q
Investigations for secondary dysmenorrhoea
A
- HCG urine test
- Measure LH/FSH or FSH:LH ratio - high LH or high LH:FSH = PCOS
- Measure TFT
- Measure androgens
- MRI for pituitary tumours (hyperprolactinaemia)
24
Q
Menopause is defined as
A
Cessation of menses for < 12 months without a reason such as pregnancy/hormone therapy/premature menopause
25
5 signs/symptoms of menopause
1. Amenorrhoea > 60 years (menopause likely in 2 years)
2. Irregular menstrual cycle
3. Vasomotor symptoms - Hot flushes, night sweat
4. Vaginal symptoms - Dryness, itching, dyspareunia due to reduced oestrogen causing urogenital atrophy
5. Mood swings
26
Management for menopause (4 points)
1. Contraception: If < 50 y/o for 2 years; if > 50 y/o for 1 years - does not affect menopause
2. Hormone therapy (oestrogen/transdermal oestradiol and progestin patches) to prevent against endometrial hyperplasia and cancer
3. Topical oestrogen and vaginal moisturisers
4. Testosterone for reduced libido
27
PCOS triad (2 out of 3 are diagnostic)
Rotterdam Criteria
1. Irregular/absent ovulation
2. Hyperandrogensim
3. Polycystic ovaries on ultrasound (volume > 10 cm3)
28
5 signs/symptoms of PCOS
1. Irregular menstruation
2. Infertility
3. Hirsutism: Male facial hair pattern, darkened hair
4. Acne
5. Obesity/hypertension/diabetes
29
What is a risk factor of having PCOS
Endometrial cancer
30
Why are women with PCOS most at risk of endometrial cancer?
Obesity/diabetes/amenorrhoea reduces progesterone. Endometrial lining continues to proliferate under influence of oestrogen but is not shed - increasing risk of cancer.
31
Blood tests for PCOS
1. Testosterone
2. Serum 17-hydroxyprogesterone: Excludes adult adrenal hyperplasia
3. *** High LH or high LH:FSH ***
4. TFT
5. Prolactin
6. Oestrogen
32
Gold-standard for diagnosing PCOS
Transvaginal ultrasound - best view of ovaries
33
What is not reliable in teenagers with possible PCOS?
Pelvic ultrasound
34
Transvaginal US PCOS findings
String of pearls - > 12 follicles/ovary and/or ovarian volume > 10cm3
35
Initial management of absent periods/infertility in someone with PCOS
Weight loss
36
Management of risk of endometrial cancer in PCOS
Contraception - Mirena coil provides continuous protection, regular withdrawal bleeds if using COCP/POP
37
Cervicitis is most commonly caused by
STI
38
What should be performed before any internal vaginal examination?
Pregnancy test
39
What procedure will diagnose dyskaryosis?
Smear test/cervical screening cytology results
40
A woman receives a diagnosis of cervical dyskaryosis. What does this mean?
Dyskaryosis describes abnormal changes in the squamous cells lining the cervix with varying degrees of severity.
41
What procedure diagnoses CIN?
Colposcopy
42
Biggest risk factor for non-HPV cervical cancer
Non-compliance with cervical screening
43
2 HPV strains that cause cervical cancer
HPV 16 and 18
44
2 HPV strains that cause genital warts
HPV 6 and 11
45
3 signs/symptoms of CIN/cervical cancer
1. Abnormal bleeding
2. Mucoid/purulent/blood vaginal discharge
3. Pelvic pain and dyspareunia
46
Ways to prevent cervical cancer
1. HPV vaccine (Gardasil)
2. Regular smear testing
3. Smoking cessation
4. Safe sex
47
How often must women aged 25-49 have cervical screening?
Every 3 years
48
How often must women aged 50-64 have cervical screening?
Every 5 years
49
How often must women with HIV/previous CIN etc have cervical screening?
Every year
50
How long must a post-partum woman wait for a smear test?
12 weeks
51
Management of CIN I
Repeat smear every 3-6 months, may resolve by itself
52
Management of CIN II or III
Biopsy - Punch or large loop excision of transformation zone under local
Treat - Cone biopsy under GA
53
Most common type of cervical cancer
Squamous cell
54
Gold-standard management for cervical cancer
Chemoradiation
55
Prognosis for a woman with stage 1A cervical cancer
98%
56
Cervical polyps may be a sign of
Cervical cancer
57
3 causes of cervical polyps
1. Cancer
2. Increased oestrogen (tamoxifen treatment, HRT)
3. Infection - HPV, herpes
58
When are women commonly diagnosed with cervical insufficiency?
During pregnancy or cervical screening
59
RF of having cervical insufficiency in a pregnant woman
Spontaneous loss in 2nd trimester - management includes progesterone supplements in 2nd/3rd trimester or cervical cerclage (stitch cervix close and re-open in 3rd trimester)
60
3 causes of an incompetent cervix
1. Trauma
2. Congenital conditions
3. Pregnancy
61
Cervical ectropion is defined as
Benign eversion of the endocervix (columnar epithelium) into the ectocervix (stratified squamous cells).
62
What cells are found at the ectocervix in cervical ectropion?
Columnar epithelial cells
63
2 main symptoms of cervical ectropion (typically asymptomatic)?
1. Excessive discharge - Columnar epithelial cells at endocervix and now the ectocervix secrete discharge
2. Post-coital bleeding - Columnar epithelial cells are fragile and therefore easily damaged during sexual intercourse
64
Main finding on a speculum examination in a woman with cervical ectropion
Well-demarcated red ring around cervical os, surrounded by pale pink squamous epithelium
65
Main cause of cervical ectropion
Increased oestrogen - Pregnancy, COCP, younger women
66
If you're unsure on a diagnosis of cervical ectropion what management is recommended?
1. Cervical screening to screen for pre-malignant changes
| 2. Colposcopy to screen for malignancy
67
Most common type of vaginal/vulval cancer
Squamous cell, rarely malignant melanomas.
68
What skin condition can cause vaginal cancer?
Lichen sclerosis
69
RF for lichen sclerosis
Women, pre-existing autoimmune conditions, skin conditions, thyroid conditions
70
What is a rectocele?
Posterior vaginal prolapse caused by the rectum prolapsing forwards into the vagina
71
3 symptoms of rectocele
1. Palpable lump in vagina that can be moved
2. Constipation
3. Urinary symptoms
72
3 stages of management for rectocele
1. Conservative: Kegel exercise, weight loss, reduce caffeine, pads, increase fluid/fibre to resolve constipation
2. Pessary to support vagina with oestrogen cream
3. Surgery
73
General RF for rectocele
Increased intra-abdominal pressure (i.e. chronic constipation, obesity, coughing)
74
What is a cystocele?
Anterior vaginal wall defect whereby the bladder prolapses into the vagina
75
What is a Bartholin's cyst?
Fluid-filled, non-infected sac in one of the Bartholin's glands located on the labia majora caused by duct blockage.
76
What can a Bartholin's cyst develop into?
Bartholin's abscess which is infected and requires treatment
77
A pea-sized, non-tender lump in the labia majora could be
Bartholin's cyst
78
When should a biopsy be performed in someone with a suspected Bartholin's cyst?
Woman > 40 y/o as ?vulval malignancy
79
2 types of surgery for a Bartholin's abscess
1. Word catheter/gland balloon under LA
| 2. Marsupialisation under GA
80
Most common bacteria that causes a Bartholin's abscess
E. coli then STIs
81
What is a small benign cyst near the cervical os called?
Nabothian's cyst
82
Candidiasis is also known as
Thrush
83
Creamy white plaques adherent to the mucosa alongside vulva discomfort could be a sign of
Candidiasis
84
What pH is candidiasis on a swab?
Acidotic < 4.5
85
What can anti fungals damage?
Latex condoms
86
Canesten Duo contains what 2 medications
Antifungal Fluconazole tablet with anti fungal clotrimazole cream
87
Vulva itchiness in a young girl is termed
Vulvovaginitis
88
Vulva itchiness in a post-menopausal woman is termed
Atrophic vaginitis
89
Atrophic vaginitis is caused by
Reduced oestrogen levels that lead to vaginal dryness and vaginal atrophy
90
Vulvovaginitis is caused by
Faecal bacteria spreading and irritating the vulva and vagina
91
What typically protects the vagina and vulva from infection in a fertile woman?
Oestrogen
92
2 types of infection causing infective vaginitis
STIs and candidiasis
93
2 types of management for atrophic vaginitis/dryness
1. Vaginal lubricants
2. Topical oestrogen - contraindicated with systemic HRT and may increase risk of endometrial hyperplasia so yearly reviews.
94
A longitudinal vaginal septum gives
A double vagina
95
A young girl presents to the GP with uncontrolled period flow even when using a tampon. What may be the cause?
Longitudinal vaginal septum - gives the appearance of 2 vaginas
96
A young girl has yet to start her period. She presents to A&E with severe abdominal pain that has been gradually getting worse. What could this be?
Transverse vaginal septum - blood will collect behind vagina
97
Purple patches with white lines (Wickham's Striae) on the vulva is a sign of
Lichen planus
98
Shiny white patches affecting the vulva could be a sign of
Lichen sclerosus
99
A woman complains of vulva itchiness and skin changes that worsen when wearing tight underwear. What is this phenomenon termed?
Koebner's
100
Management for vulval lichen conditions
Clobetasol propionate topical steroid and emollients
101
Loss of lactobacillus in the vagina causes an acidotic or alkaline pH?
Alkaline as less lactic acid produced
102
What type of cells might be shown on a BV swab?
Clue cells - Gardnerella vaginalsis
103
Offensive fishy-smelling, grey-white, thin discharge is a sign of
BV
104
What should be avoided when taking metronidazole and why?
Alcohol as can cause flushing, nausea, vomiting, shock, angioedema.
105
BV increases the risk of what 2 things
1. Catching STIs
| 2. Pregnancy complications
106
Endometriosis is defined as
Presence of ectopic endometrial tissue outside of the uterus
107
Endometriomas in the ovaries are termed
Chocolate cysts
108
Endometriomas found in the myometrium are termed
Adenomyosis
109
Retrograde menstruation is defined as
Endometrial lining flowing backwards in menstruation into the fallopian tubes, pelvis and peritoneum
110
3 RF for endometrios
1. Early menarche
2. FH
3. White ethnicity
111
Gold-standard for endometriosis diagnosis
Laparoscopy - biopsy confirms lesions and these can be removed to improve symptoms
112
3 primary care steps of management for endometriosis
1. Pain and symptom diary
2. Analgesia: NSAID and paracetamol
3. Hormonal treatment either with COCP/POP/Mirena etc to stop ovulation/reduce endometrial lining or HRT
113
When to refer a woman with endometriosis (3 points)
1. Symptoms are severe/persistent/recurrent
2. Pelvic symptoms
3. GI/GU symptoms
114
What is a leiomyoma?
Oestrogen-sensitive benign fibroid tumour of the uterine myometrium
115
What 2 fibroids can be pedunculate?
Subserosal and submucosal
116
What type of fibroid may press on the bladder?
Subserosal
117
What type of fibroid may extend into the uterine cavity and cause reduced fertility?
Submucosal
118
5 referral criteria for referring a lady with leiomyoma
1. Compressive symptoms
2. Dyspareunia
3. Pelvic pain
4. Fertility issues
5. Fibroid > 3 cm
119
What must be avoided in women with uterine distortion?
IUD/IUS
120
What are pregnant women with a history of large > 5 cm fibroids at risk of?
Red degeneration of fibroids - fibroid outgrows blood supply leading to ischaemia, infarction and necrosis
121
What shape is a bicornuate uterus?
Heart-shaped
122
What is a uterus didelphys?
A double uterus
123
What type of cancer is endometrial cancer?
Oestrogen-dependent adenocarcinoma
124
What is the biggest cause of endometrial cancer?
Exposure to unopposed oestrogen
125
6 RF for exposure to unopposed oestrogen
1. Age
2. Early menarche
3. Late menopause
4. PCOS/obesity/T2DM
5. No/few pregnancies
6. Oestrogen-only HRT or tamoxifen
126
3 symptoms of endometrial cancer
1. Post-menopausal bleeding (> 12 months since last period)
2. Abnormally heavy menstruation
3. Haematuria/anaemia/raised platelets
127
Normal endometrial thickness in a post-menopausal woman
< 4 mm
128
Type of biopsy that diagnoses endometrial cancer
Pipelle biopsy
129
Referral criteria for a transvaginal ultrasound in suspected endometrial cancer
Women > 55 years with
1. Unexplained discharge
2. Visible haematuria and raised platelets, anaemia, glucose
130
Cloudy discharge with abnormal vaginal bleeding could be a sign of
Chlamydia
131
STI investigation test for chlamydia/gonorrhoea in women
NAAT
132
STI test for chlamydia/gonorrhoea in men
Gram stain urine
133
Skin lesions, poly arthritis and conjunctivitis can be a sign of
Disseminated gonorrhoea
134
Primary syphilis is marked by the formation of a
Chancre
135
Secondary syphilis affects what 3 areas
Skin - Maculopapular rash
Lymph nodes - Lymphadenopathy
Mucous membranes - Fever/malaise
136
Genital herpes is caused by what 2 HSV strains?
1 and 2
137
3 treatments for candidiasis
Clotrimazole cream
Clotrimazole pressary
Flucanazole tablet
138
What can antifungals for thrush damage?
Condoms
139
Thick, frothy, green fish-smelling discharge can be a sign of
Trichomoniasis parasitic inception
140
Abx for trichomoniasis
Metronidazole
141
Complication of 2 year + use of contraceptive injection?
Osteoporosis
142
What layer of the skin is the contraceptive implant placed into?
Subdermal
143
What affects the efficacy of the contraceptive pills?
Nausea and vomiting
144
Female tubal occlusion has a failure rate of
1/200
145
What emergency contraception is used if unprotected sex has been within 72 hours?
Levonelle
146
What emergency contraceptive dose has to be doubled when a woman is > 70 kg?
Levonelle
147
If someone takes Levonelle and within 2 hours vomits, what is recommended?
IUD or another dose
148
What's the time frame to take Ella-One or ulipristal acetate?
120 hours
