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Phase 3a > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is classed as menorrhagia and what investigations should be done?

A

> 80ml blood lost

Investigations

  • FBC, TSH/T4, coagulation
  • TVUSS - if >10mm thickness and >40 years then do biopsy + hysteroscopy to exclude cancer
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2
Q

What are the management options for menorrhagia?

A
  1. IUS - mirena
  2. Tranexamic acid (anti-fibrinolytic), NSAIDS, COCP
  3. Progesterone

Surgery:

  • endometrial ablation
  • fibroids/ polyp resectiono
  • uterine artery embolisation

If intermenstrual bleeding - do a smear test too

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3
Q

What are the main causes of post-coital bleeding?

A

Infection

Cervical ectropion, polyps or carcinoma

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4
Q

What are the causes and management of dysmenorroea?

A

Increased prostaglandins in endometrium, causing contractions and uterine ischaemia.

Primary - NSAIDS, COCP
Secondary - pelvic pathology, pain is 3-4 days before onset

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5
Q

What are the causes of primary amenorrhoea? (periods not started by 16)

A
  • Turner’s syndrome
  • Androgen insensitivity syndrome
  • Congenital malformations of genital tract
  • Congenital adrenal hyperplasia
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6
Q

What are the causes of secondary amenorrhoea? (previously normal but stopped for more than 6 months)

A
  • physiological (pregnancy, menopause, lactation)
  • Medications (GnRH analogues, antipsycotics, progestogens)
  • Hypothalamic hypogonadism (exercise, weight loss – tx- HRT, COCP)
  • Hyperprolactinaemia
  • Ovarian - PCOS, tumours, ovarian failure
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7
Q

When investigating amenorrhoea, what would high or low FSH/LH levels tell you?

A

High = premature ovarian failure

Low = Hypopituitary ovarian axis problem

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8
Q

How can you manage amenorrhoea due to an HPO axis problem?

A 
Mild = lifestyle (stress/ execise)
Severe = GnRH analogues

If fertility is wanted immediately give CLOMIFENE

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9
Q

What are the investigations and managements of menopause?

A

Investigations

  • high FSH = suggests low oocytes
  • Anti-Mullerian hormone
  • DEXA scan

Tx = HRT

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10
Q

What are the benefits and risks of HRT?

A

Benefits
- symptom management, osteoporosis prevention, colorectal cancer prevention

Risks
- increased risks of breast, endometrial cancer and gallbladder disease

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11
Q

What is the classic presentation of endometriosis?

A
  1. Dysmenorrhoea
  2. Deep dyspareunia
  3. Chronic, cyclical pelvic pain

Other - subfertility, dysuria, bloating, lethargy, constipation, lower back pain

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12
Q

What is the gold standard for diagnosis of endometriosis?

What would be the sign on bimanual examination?

A

Laparoscopy + biopsy

Fixed retroverted uterus

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13
Q

What is the treatment for endometriosis?

A

Pain - NSAIDS, paracetamol
Ovarian suppression - COCP, Depo-provera injections, GnRH agonists (only for <6 months), mirena
Surgery - ablation, hysterectomy as last resort

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14
Q

What is the pathology of PCOS?

A

Excessive androgens produced by thecal cells in ovaries, due to either insulin resistance or raised LH

Causes cysts

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15
Q

What is the presentation of PCOS?

A 
Oligo/a-menorrhoea
Infertility or subfertility
Obesity
Acne
Hirsutism
Alopecia / male pattern balding
Deep voice
Psychological Sx
Sleep apnoea
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16
Q

What is the rotterdam criteria for diagnosing PCOS?

A

SHOP

String of pearls >12 cysts on 1 ovary on uss
Hyperandrogenism
Oligomenorrhoea
Prolactin = normal

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17
Q

What would you expect to see on the following blood tests in PCOS?

  • Total testosterone
  • LH
  • GTT
A

Total testosterone = normal or slightly raised
LH = raised
GTT = impaired

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18
Q

What is the treatment for PCOS?

A

Treat symptoms

Treat menstrual irregularity (COCP, mirena)
Insulin resistance - metformin
Hirsutism + acne - Co-cyprindol
Fertility - clomifene

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19
Q

What is the main histopathology of ovarian cancer?

A

Epithelial cell

Other = germ cell (younger women, aggressive), sex-cord stromal tumours, metastatic

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20
Q

What are the presenting symptoms of ovarian cancer?

What are the risk factors for ovarian cancer?

A

Insidious onset IBS-like symptoms
Pelvic/ abdo mass + pain
Fatigue and weight loss
Uterine bleeding

RFs
Age, infertility, early or late menopause, BRCA genes

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21
Q

What are the diagnostic tests for ovarian cancer?

A

Ca125 Tumour marker
USS, CT abdo and pelvis
CXR to check for lung mets

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22
Q

What is the staging of ovarian cancer?

A
  1. Ovaries only
  2. 1 or both ovaries and implants outside ovaries
  3. 1 or both ovaries and peritoneal implants outside ovaries
  4. 1 or both ovaries and distant mets
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23
Q

What is the histology for endometrial cancer and what are the 2 types?

A

80% are adenocarcinomas

Type 1 = oestrogen dependent endometrioid
Type 2 = oestrogen independent non-endometrioid

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24
Q

What are the symptoms of endometrial cancer?

What are the risk factors for endometrial cancer?

A

Post menopausal/ abnormal bleeding
Heavy or irregular periods

RFs
Obesity
Prolonged exposure to unopposed oestrogen (late menopause)
Age
Tamoxifen
Endometrial hyperplasia, PCOS
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25
Q

How is endometrial cancer diagnosed?

A

TVUSS - if endometrial thickness is >4mm then do a biopsy

Hysteroscopy

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26
Q

What is the screening programme for cervical cancer?

A

Smear testing:
Every 3 years if 25-49
Every 5 years if 50-69

2 week wait for colposcopy if moderate (or worse) dyskaryosis

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27
Q

What are the symptoms of cervical cancer?

A

Persistent HPV infection

Post-coital bleeding
Vaginal discharge
Vaginal discomfort
Urinary symptoms

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28
Q

How is cervical cancer diagnosed?

A

Colposcopy and biopsy
Maybe cystoscopy aswell
CT
PET for staging

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29
Q

What are the symptoms vulval cancer?

what is the histoollogy of vulval cancer?

A

itching, soreness, pain on micturition, ‘lump’, bleeding

90% are squamous cell

30
Q

What is the presentation and histology of vaginal cancer?

A

Often late presentation, bleeding
Usually mets from other gynae cancers

Mostly squamous cell

31
Q

What are the symptoms of breast cancer?

A 
Painless, hard, fixed, lump
Nipple discharge
Indrawn nipple, peau d'orange, oedema
Skin tethering
METS - bone pain
32
Q

What is the diagnosis of breast cancer?

A

TRIPLE ASSESSMENT

  • Clinical score 1-5
  • Imaging score 1-5 (2 views mammography, high res USS)
  • Biopsy score 1-5
  • tumour markers
33
Q

What should be given in ER +ve breast cancer?

A

Premenopausal = tamoxifen

Postmenopausal = aromatase inhibitors (Anastrazole)

34
Q

What should be given in HER2 +ve breast cancer?

A

Trastazumab / Herceptin

Impairs heart function so may be contraindicated in heart failure

35
Q

What are the DDx for a breast lump?

A 
Cancer
Fibroadenoma
Firboadenosis (fibrocystic)
Breast cysts
Breast abscess
Fat necrosis
Lipoma
36
Q

What is the most common cause of ovarian cysts in young women?

A

Benign neoplastic cystic tumours of germ cell origin

37
Q

What are the different types of ovarian benign neoplastic solid tumours? (solid ovarian cysts)

A 
Fibroma
Thecoma
Adenofibroma
Teratoma
Brenner's tumour (rare, mostly benign)
38
Q

What is the characteristic histology for a teratoma?

A

Rokitarsky’s proturberance

39
Q

What is the clinical presentation for ovarian cysts?

A

Asymptomatic
Pain - dull ache, lower back pain, dyspareunia
Irregular bleeding
Swollen abdomen with palpable mass
dull to percussion = suggestive of malignancy

Rupture - peritoonitis and shock

40
Q

What are the main investigations for diagnosing an ovarian cyst?

A

Pregnancy test first

TVUSS + diagnostic laparoscopy
CT or MRI
Ca125 Tumour marker for ovarian cancer

RMI = risk of malignancy index
- USS score + menopause? + Ca125 levels

41
Q

How are ovarian cysts managed?

What are the risks?

A

<50mm - no follow up needed
50-70mm - annual USS
May need surgery

Risks:

  • torsion
  • infection
  • haemorrhage
  • rupture
42
Q

What are the symptoms of ovarian torsion?

A

Sudden, deep colicky pain in iliac fossa - radiates to loin/groin/back
Low grade fever
Vomiting and distress
Pain may improve after 24 hours = ovary is dead

43
Q

How is ovarian torsion diagnosed and treated?

A

Adnexal tenderness OE
USS - free fluid due to oedema, whirlpool sign
Laparoscopy + surgery

44
Q

What are the 3 types of fibroids?

A
  1. Intramural
  2. Submucosal - growing into uterine cavity, may protrude through os
  3. Subserosal - growing outwards from uterus (uterine / cervical…)
45
Q

What are the risk factors for fibroids?

A 
Obesity
Age 30-40
Black
First degree relative with fibroids
COCP
Pregnancy
46
Q

What is the clinical presentation of fibroids?

What would be seen on examination?

A 
May be asymptomatic
Heavy/ long periods (may cause anaemia)
Pelvic pain and acute pain during pregnancy
Recurrent miscarriage
Subfertility

OE = palpable mass, signs of anaemia

47
Q

How are fibroids diagnosed?

A

TVUSS

Also FBC and pregnancy test

48
Q

How are fibroids treated?

A

Conservative Tx if mild
Tranexamic acid
GnRH - shrinks fibroids but not suitable long term
Ulipristal acetate - before surgery (selective progesterone receptor modulator)

Surgery

  • surgical removal
  • uterine artery embolisation
  • hysterectomy
49
Q

What is lichen sclerosis?

A

Chronic inflammatory skin condition in anogenital region.
Pre-pubescent and post-menopausal
Potential to develop into squamous cell carcinoma
Possible autoimmune connection

Sx = white atrophic patches, itching and dyspareunia, adhesions + scarring

Tx = topical steroids, follow up for cancer risk

50
Q

What is adenomyosis?

What are the symptoms

A

Endometrial tissue within the myometrium. This is hormone dependent so resolves with menopause - it may occur alongside fibroids or endometriosis.

Sx:
1. Dysmenorrhoea
2. Menorrhagia
3. Dyspareunia
Infertility + pregnancy complications
51
Q

How is adenomyosis diagnosed and managed?

A

TVUSS, histological examination of uterus after hysterectomy (not practical)

Tx
Tranexamic acid, NSAIDS
Mirena
COCP
Cyclical oral progestogens
GnRH analogues
52
Q

What is asherman’s syndrome?

How does it present?

A

Adhesions within uterus - after endometrial curettage (scraping), surgery, or pelvic infection

Sx:
Secondary amenorrhoea
lighter periods
dysmenorrhoea
infertility
53
Q

What is the gold standard method of diagnosing Ashermans syndrome?

A

Hysteroscopy

Mx = dissect adhesions during hysteroscopy

54
Q

What is a cervical ectropion?

What are the symptoms?

A

When the columnar epithelium of the endocervix extends to the ectocervix.

Sx
May be asymptomatic
Post-coital bleeding
Increased discharge
Dyspareunia
55
Q

What are the common causes of PID?

A

STI - chlamydia, gonorrhoeea, mycoplasma genitalium

Non-STI - gardnerella vaginalis (BV), haemophilus influenzae, E. coli

56
Q

What are the symptoms of PID?

A 
Pelvic pain
Dyspareunia
Abnormal bleeding and discharge
FEVER --> look for Sx of sepsis
Dysuria

OE = infective signs, tenderness, cervical excitation

Fitz-Hugh-Curtis syndrome = inflammation/ infection of liver capsule

57
Q

What is stress incontinence?

A

Weakness of pelvic floor and sphincter muscles

Leaking when laughing or coughing

58
Q

What is urge incontinence?

A

Overactivity of the detrusor muscle.

59
Q

What is overflow incontinence?

A

Chronic urinary retention due to obstruction.

Rare in women.
Refer for urodynamic testing

60
Q

What modifiable lifestyle factors can contribute to urinary incontinence?

A

Caffeine consumption
Alcohol consumption
Medication
BMI

61
Q

What investigations would you do for bladder incontinence?

A

Bladder diary
Urine dipstick testing
Post-void residual bladder volume
Urodynamic testing - urge incontinence not responding to first line tx

62
Q

What are the outcome measures in urodynamic testing?

A

Patients should stop taking anticholinergic / bladder medications 5 days before tests.

Cystometry = measures detrusor contraction
Uroflowmetry = flow rate
Leak point pressure
Post-void residual
Video urodynamic testing = not routine
63
Q

How is stress incontinence managed?

A

Lifestyle
Pelvic floor exercises for at least 3 months
Surgery
Duloxetine = SNRI (2nd line as alternative too surgery)

64
Q

How is urge incontinence managed?

A

Bladder retraining = gradually increasing time between voiding foor at least 6 weeks
Anticholinergic medication = oxybutynin
Mirabegron = less of an anticholinergic burden
Invasive procedures

Other = botulinum toxin type A, percutaneous sacral nerve stimulation, augmentation cystoplasty, Urinary diversion

65
Q

What are the main causes of premature ovarian failure?

A

Idiopathic
Iatrogenic - chemotherapy, radiotherapy, surgery
Autoimmune - coeliac, adrenal insufficiency, thryoid disease
Genetic - FHx, Turner’s
Infection - mumps, TB, CMV

66
Q

What is the definition of premature ovarian failure?

A

<40 years, typical menopausal Sx, elevated FSH (persistently raised)

67
Q

How is premature ovarian failure managed?

A

HRT until normal menopause age
traditional HRT = lower BP
COCP = less stigma

68
Q

Explain the basics of HRT

A

Exogenous oestrogen given to perimenopausal + postmenopausal women

Progesterone also given to women that have a uterus (prevent endometrial hyperplasia/ cancer)

69
Q

What are some non-hormonal treatments for menopause?

A

Clonidine = agonist of alpha-2 adrenergic receptor/ imidazoline receptors in brain – helpful for vasomotor symptoms + hot flushes

70
Q

What are the indications for HRT?

A

Replacing hormones in premature ovarian insufficiency (even if no Sx)
Menopause:
- reducing hot flushes and night sweats
- Improve low mood, libido, poor sleep, joint pain
- reducing risk of osteoporosis <60 yrs

71
Q

What are the main forms of pelvic organ prolapse?

A

Uterine
Vault prolapse - in women who have no uterus
Rectocele - rectum into vagina, associated with constipation + urinary retention - may use fingers to allow defaecation
Cystocele

72
Q

What is the management for prolapse?

A
  1. Conservative management - pelvic floor, weight loss, lifestyle, oestrogen cream
  2. Vaginal pessary
  3. Surgery

Phase 3a (13 decks)

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