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RHCN > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Definition of dyspareunia

A

Persistent or recurrent pain with attempted or complete vaginal entry or penile-vaginal intercourse

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2
Q

9 causes of dyspareunia

A
  1. dermatological disease e.g. lichen planus, psoriasis
  2. inadequate lubrication
  3. paravaginal infection e.g. urethritis, vaginitis
  4. vaginal atrophy
  5. vaginismus (sexual pain-penetration disorder)
  6. vulvodynia
  7. endometriosis
  8. pelvic inflammatory disease
  9. interstitial cystitis
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3
Q

What is vaginismus/sexual pain-penetration disorder

A

Involuntary contraction of the pelvic floor muscles that inhibits entry into the vagina

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4
Q

Types of postpartum sexual dysfunction

A

Sexual desire dysfunction
Sexual pain disorders - dyspareunia, SPPD, vulvodynia
Sexual arousal disorder

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5
Q

How is polycystic ovarian syndrome diagnosed

A

Rotterdam criteria - 2 out of 3 of the following:

  1. clinical or biochemical hyperandrogenism
  2. menstrual irregularities (<9 cycles per years or >35 days between cycles)
  3. polycystic ovaries on ultrasound
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6
Q

Symptoms of PCOS

A 
Sub/infertility
Mood changes
Acne
Fatigue
Insulin resistance
High testosterone levels
Excessive body hair growth
Weight changes (gain)
Ovarian cysts
Low sex drive
Irregular or missed periods
Male pattern baldness/thinning hair
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7
Q

Pathophysiology of PCOS

A

Excess androgens produced by theca cells of the ovaries (due to either hyperinsulinaemia or increased LH)

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8
Q

Biochemical results in PCOS

A

Normal or slightly raised testosterone

Increased LH and increased LH:FSH

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9
Q

Biochemical results in premature ovarian insufficiency

A

Raised LH and FSH

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10
Q

Biochemical results in hypogonadotropic hypogonadism

A

Reduced LH and FSH

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11
Q

Complications of PCOS

A

Insulin resistance leading to diabetes, obesity, dyslipidaemia, increased cardiovascular risk

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12
Q

Pharmacological management of PCOS

A

Co-cyprindrol - hirsutism and acne
COCP, progestogen-only pill, IUS - control menstrual irregularity
Metformin
Eflornithine - hirsutism
Orlistat - weight loss, improving insulin sensitivity
Clomifene - induction of ovulation

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13
Q

Mechanism of clomifene

A

Anti-oestrogen which induces gonadotrophin release by occupying oestrogen receptors in the hypothalamus therefore interfering with feedback. Aims to stimulate ovulation.

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14
Q

Regime for clomifene

A

50mg OD for 5 days. If no ovulation by 30 days later, 100mg OD for 5 days. If no ovulation a further 30 days later, 150mg OD for 5 days.

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15
Q

Describe HPV triage system for cervical screening

A

If HPV is positive, sample is examined cytologically. If no abnormal change, repeat HPV test in 12 months. If repeat HPV is negative, return to normal recall. If repeat is still HPV positive, send for cytology again. If still no abnormal change, HPV test repeated again in 12 months. If HPV now negative, return to normal recall. If 2nd repeat HPV (3rd result) is still positive, regardless of cytology, send for colposcopy. If any cytology is abnormal at any point, refer for colposcopy.

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16
Q

What to do with inadequate HPV samples

A

Repeat within 3 months. If second sample is also inadequate, send for colposcopy

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17
Q

What is the most common cause of cervical cancer

A

HPV strains 16, 18, 33

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18
Q

Risk factors for cervical cancer

A 
HPV - frequent UPSI, multiple sexual partners
Smoking
High parity
FHx
Long term use of COCP
HIV
Immunocompromise
STIs
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19
Q

Common presentation of cervical cancer

A 
Abnormal vaginal bleeding
Vaginal discharge
Dyspareunia 
Pelvic pain
Weight loss
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20
Q

Differentials for abnormal vaginal bleeding

A 
Cervical ectropion
Polyp
Fibroids
Pregnancy-related
Cervical cancer
Endometrial cancer
Hormonal contraception
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21
Q

Management approach for early stage cervical cancer

A

Large loop excision of the transformation zone (LLETZ)
Cone biopsy
Simple hysterectomy if fertility not needed

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22
Q

Management approach for middle stage cervical cancer

A

Radical hysterectomy with lymphadenectomy

Chemoradiation

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23
Q

Management approach for end stage cervical cancer

A

Chemotherapy and palliative radiotherapy

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24
Q

Downsides of cone biopsy

A

Weakens the cervix therefore patient is at higher risk of miscarriage or preterm labour

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25
Q

What is a trachelectomy

A

Removal of cervix, surrounding tissue and upper part of vagina (uterus left in place)

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26
Q

Cervical screening programme

A

Women (and transgender men with retained cervix) aged 25-64
25-49 = every 3 years
50-64 = every 5 years

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27
Q

3 types of ovarian tumour

A

Epithelial ovarian tumour
Germ cell tumour
Sex cord-stromal tumour

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28
Q

Examples of germ cell tumour and demographic

A

Dysgerminoma
Teratoma
Women under 35 most commonly

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29
Q

Risk factors for ovarian cancer

A 
Smoking
Obesity
Asbestos 
High number of ovulations: use of clomifene, nulliparous, early menarche and late menopause
BRCA1 and 2
FHx
Endometriosis
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30
Q

Protective factors for ovarian cancer

A

Childbearing
Breastfeeding
Early menopause
OCP

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31
Q

Common presentation of ovarian cancer

A

Vague symptoms: weight loss, fatigue, anorexia, IBS-like symptoms (abdo pain, distension, bloating), urinary frequency
Late stage associated with ascites and pleural effusion

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32
Q

What is the risk malignancy index

A

Calculated by ultrasound findings, menopausal status and CA 125 level (cancer antigen) to determine the risk that an adnexal mass is malignant
Refer to specialist MDT if >250

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33
Q

What is the surgical approach for treatment of ovarian cancer

A

Optimal debulking + chemotherapy

34
Q

What stage is ovarian cancer commonly found

A

Late stage - 60% of cases

35
Q

What is CIN

A

Cervical intraepithelial neoplasia - pre-cancerous state when abnormal tissue is found on the cervix, commonly caused by HPV

36
Q

What is endometrial hyperplasia

A

Abnormal proliferation of the endometrium - risk factor for developing endometrial cancer (greater number of cells)

37
Q

Classification of endometrial hyperplasia

A

Hyperplasia without atypia - risk of developing into cancer <5%, cells appear normal
Atypical hyperplasia - risk of developing into cancer ~28%, cells appear abnormal/irregular

38
Q

What causes endometrial hyperplasia

A

Unopposed oestrogen (oestrogen without progesterone)

39
Q

Risk factors for endometrial hyperplasia

A 
Obesity
Exogenous oestrogen use
Oestrogen-secreting ovarian tumour
Tamoxifen
PCOS
Nulliparity
Hereditary non-polyposis colorectal carcinoma
Diabetes
40
Q

Presentation of endometrial hyperplasia

A

Abnormal vaginal bleeding - IMB, PMB, PCB, menorrhagia, oligomenorrhoea

41
Q

How to investigate for endometrial hyperplasia

A 
Pipelle biopsy (+/- hysteroscopy)
Transvaginal ultrasound in post-menopausal women to determine whether biopsy is needed
42
Q

Management of typical endometrial hyperplasia

A

Address risk factors e.g. obesity
Progestogen treatment e.g. Mirena, oral progestogen
Endometrial biopsy every 6 months
Consider hysterectomy

43
Q

Management of atypical endometrial hyperplasia

A

Total hysterectomy and bilateral salpingo-oophorectomy is gold standard
Progestogen treatment and 3-monthly biopsy if fertility needing to be preserved

44
Q

Most common type of endometrial cancer

A

Endometrioid adenocarcinoma (oestrogen-dependent)

45
Q

Risk factors for endometrial cancer

A 
Unopposed oestrogen:
Nulliparous
Late menopause
Obesity
Endometrial hyperplasia
Hereditary non-polyposis colorectal carcinoma
PCOS
T2DM
Tamoxifen
46
Q

Common presentation of endometrial cancer

A

Post-menopausal bleeding

47
Q

Investigations for endometrial cancer

A

Transvaginal ultrasound (if post-menopausal) to determine thickness of endometrium and assess need for hysteroscopy and biopsy

48
Q

Staging system for gynaecological cancers

A

FIGO (international federation for gynaecology and obstetrics)

49
Q

Management of early stage endometrial cancer

A

Total abdominal/radical hysterectomy and bilateral salpingo-oophorectomy +/- lymphadenectomy

50
Q

Management of late stage endometrial cancer

A

Maximal/optimal debulking surgery with adjuvant chemotherapy/radiotherapy

51
Q

What is the medical name for uterine fibroids

A

Leiomyomas

52
Q

Definition of fibroids

A

Benign smooth muscle tumours of the uterus arising from the myometrium

53
Q

Risk factors for fibroids

A 
Early menarche
Increasing age
Obesity
Ethnicity (black females)
FHx in first degree relative
54
Q

Differentials for fibroids

A

Endometrial polyps
Ovarian tumour
Leiomyosarcoma (myometrial malignancy)
Adenomyosis

55
Q

What is adenomyosis

A

Presence of functional endometrial tissue within the myometrium

56
Q

Protective factors for fibroids

A

Pregnancy

57
Q

Pathophysiology of fibroids

A

Benign growth beginning in a single myometrial cell and causes upregulation of hormone receptors. High levels of oestrogen and progesterone maintain growth of fibroids.

58
Q

In what time of life do fibroids tend to develop

A

Child-bearing age
Don’t occur before puberty due to low levels of oestrogen/progesterone
Tend to shrink after menopause due to decreasing hormone levels

59
Q

3 types of fibroid related to location

A

Intramural - confined to myometrium
Submucosal - protrudes into uterine cavity
Subserosal - protrudes and distorts perimetrium, may be pedunculated

60
Q

Most common presentation of fibroids

A

Asymptomatic, picked up incidentally on pelvic imaging or abdominal examination

61
Q

Possible symptoms of fibroids

A 
Menorrhagia
Dysmenorrhoea
Abdominal swelling
Pelvic pain
Dyspareunia 
Urinary/bowel symptoms
Subfertility
62
Q

Signs on examination for fibroids

A

Solid mass or enlarged uterus palpated on bimanual or abdo exam

63
Q

Pregnancy-related complications of fibroids

A 
Infertility
Malpresentation 
Placental abruption
IUGR
Preterm labour
Red degeneration
64
Q

Non-pregnancy related complications of fibroids

A

Prolapsed fibroid
Hyaline degeneration, cystic degeneration
Anaemia
Endocrine effects - polycythaemia, hypercalcaemia, hyperprolactinaemia

65
Q

Investigations for fibroids

A

Transvaginal USS (1st line)
FBC
Pelvic MRI +/- hysteroscopy

66
Q

Medical management of fibroids

A

Tranexamic acid, mefenamic acid
COCP, POP, IUS
GnRH analogues (used pre-operatively to reduce size, can only be used for 6 months)

67
Q

Surgical management of fibroids

A

Hysteroscopy and transcervical resection of fibroid (TCRF)
Myomectomy - preserves fertility (uterus)
Hysterectomy
Uterine artery embolization (UAE)

68
Q

Adenomyosis after menopause

A

Symptoms subside as ectopic endometrial tissue is hormone responsive

69
Q

Difference between endometriosis and adenomyosis

A 
Endometriosis = when endometrial tissue is found outside of the uterus
Adenomyosis = when endometrial tissue invades into myometrium
70
Q

Risk factors for adenomyosis

A

High parity
Uterine surgery e.g. curettage or ablation
Previous c-section
Genetic predisposition

71
Q

Causes of menorrhagia and dysmenorrhoea

A 
Endometriosis
Adenomyosis
Fibroids
Endometrial hyperplasia/ carcinoma
PID (not cyclical)
Hypothyroidism 
Coagulation disorders
72
Q

Pathophysiology of adenomyosis

A

Endometrial tissue (stroma) is allowed to communicate with underlying myometrium after uterine damage (e.g. pregnancy, childbirth, c-section, uterine surgery, surgical MOM or TOP)

73
Q

Most common location of adenomyosis

A

Posterior uterine wall

74
Q

What hormone receptors are found in endometrial tissue in adenomyosis

A

Oestrogen, progesterone, androgen

75
Q

What is an adenomyoma

A

Collection of endometrial glands in the myometrium forms a visible nodule

76
Q

Symptoms of adenomyosis

A

Menorrhagia
Dysmenorrhoea - starts as cyclical pain but may worsen to daily pain
Deep dyspareunia
Irregular bleeding

77
Q

Investigations for adenomyosis

A

Transvaginal USS
MRI
Definitive dx made from histology after hysterectomy

78
Q

MRI findings in adenomyosis

A

Endo-myometrial junctional zone shows irregular thickening

79
Q

Management principles for adenomyosis

A

Control of dysmenorrhoea and menorrhagia

Only curative therapy is hysterectomy

80
Q

Medical management of adenomyosis

A 
Conservative - analgesia (NSAIDs)
Reduce menorrhagia:
- COCP
- POP
- IUS
- GnRH
- aromatase inhibitors
81
Q

Surgical management of adenomyosis

A

Uterine artery embolization
Endometrial ablation and resection
Hysterectomy (curative)

RHCN (5 decks)

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