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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
How is endometrial cancer diagnosed?
TVUSS - if endometrial thickness is >4mm then do a biopsy | Hysteroscopy
26
What is the screening programme for cervical cancer?
Smear testing: Every 3 years if 25-49 Every 5 years if 50-69 2 week wait for colposcopy if moderate (or worse) dyskaryosis
27
What are the symptoms of cervical cancer?
Persistent HPV infection Post-coital bleeding Vaginal discharge Vaginal discomfort Urinary symptoms
28
How is cervical cancer diagnosed?
Colposcopy and biopsy Maybe cystoscopy aswell CT PET for staging
29
What are the symptoms vulval cancer? what is the histoollogy of vulval cancer?
itching, soreness, pain on micturition, 'lump', bleeding 90% are squamous cell
30
What is the presentation and histology of vaginal cancer?
Often late presentation, bleeding Usually mets from other gynae cancers Mostly squamous cell
31
What are the symptoms of breast cancer?
``` Painless, hard, fixed, lump Nipple discharge Indrawn nipple, peau d'orange, oedema Skin tethering METS - bone pain ```
32
What is the diagnosis of breast cancer?
TRIPLE ASSESSMENT - Clinical score 1-5 - Imaging score 1-5 (2 views mammography, high res USS) - Biopsy score 1-5 - tumour markers
33
What should be given in ER +ve breast cancer?
Premenopausal = tamoxifen Postmenopausal = aromatase inhibitors (Anastrazole)
34
What should be given in HER2 +ve breast cancer?
Trastazumab / Herceptin *Impairs heart function so may be contraindicated in heart failure*
35
What are the DDx for a breast lump?
``` Cancer Fibroadenoma Firboadenosis (fibrocystic) Breast cysts Breast abscess Fat necrosis Lipoma ```
36
What is the most common cause of ovarian cysts in young women?
Benign neoplastic cystic tumours of germ cell origin
37
What are the different types of ovarian benign neoplastic solid tumours? (solid ovarian cysts)
``` Fibroma Thecoma Adenofibroma Teratoma Brenner's tumour (rare, mostly benign) ```
38
What is the characteristic histology for a teratoma?
Rokitarsky's proturberance
39
What is the clinical presentation for ovarian cysts?
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
What are the main investigations for diagnosing an ovarian cyst?
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
How are ovarian cysts managed? What are the risks?
<50mm - no follow up needed 50-70mm - annual USS May need surgery Risks: - torsion - infection - haemorrhage - rupture
42
What are the symptoms of ovarian torsion?
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
How is ovarian torsion diagnosed and treated?
Adnexal tenderness OE USS - free fluid due to oedema, whirlpool sign Laparoscopy + surgery
44
What are the 3 types of fibroids?
1. Intramural 2. Submucosal - growing into uterine cavity, may protrude through os 3. Subserosal - growing outwards from uterus (uterine / cervical...)
45
What are the risk factors for fibroids?
``` Obesity Age 30-40 Black First degree relative with fibroids COCP Pregnancy ```
46
What is the clinical presentation of fibroids? What would be seen on examination?
``` 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
How are fibroids diagnosed?
TVUSS Also FBC and pregnancy test
48
How are fibroids treated?
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
What is lichen sclerosis?
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
What is adenomyosis? What are the symptoms
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
How is adenomyosis diagnosed and managed?
TVUSS, histological examination of uterus after hysterectomy (not practical) ``` Tx Tranexamic acid, NSAIDS Mirena COCP Cyclical oral progestogens GnRH analogues ```
52
What is asherman's syndrome? How does it present?
Adhesions within uterus - after endometrial curettage (scraping), surgery, or pelvic infection ``` Sx: Secondary amenorrhoea lighter periods dysmenorrhoea infertility ```
53
What is the gold standard method of diagnosing Ashermans syndrome?
Hysteroscopy Mx = dissect adhesions during hysteroscopy
54
What is a cervical ectropion? What are the symptoms?
When the columnar epithelium of the endocervix extends to the ectocervix. ``` Sx May be asymptomatic Post-coital bleeding Increased discharge Dyspareunia ```
55
What are the common causes of PID?
STI - chlamydia, gonorrhoeea, mycoplasma genitalium Non-STI - gardnerella vaginalis (BV), haemophilus influenzae, E. coli
56
What are the symptoms of PID?
``` 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
What is stress incontinence?
Weakness of pelvic floor and sphincter muscles Leaking when laughing or coughing
58
What is urge incontinence?
Overactivity of the detrusor muscle.
59
What is overflow incontinence?
Chronic urinary retention due to obstruction. Rare in women. Refer for urodynamic testing
60
What modifiable lifestyle factors can contribute to urinary incontinence?
Caffeine consumption Alcohol consumption Medication BMI
61
What investigations would you do for bladder incontinence?
Bladder diary Urine dipstick testing Post-void residual bladder volume Urodynamic testing - urge incontinence not responding to first line tx
62
What are the outcome measures in urodynamic testing?
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
How is stress incontinence managed?
Lifestyle Pelvic floor exercises for at least 3 months Surgery Duloxetine = SNRI (2nd line as alternative too surgery)
64
How is urge incontinence managed?
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
What are the main causes of premature ovarian failure?
Idiopathic Iatrogenic - chemotherapy, radiotherapy, surgery Autoimmune - coeliac, adrenal insufficiency, thryoid disease Genetic - FHx, Turner's Infection - mumps, TB, CMV
66
What is the definition of premature ovarian failure?
<40 years, typical menopausal Sx, elevated FSH (persistently raised)
67
How is premature ovarian failure managed?
HRT until normal menopause age traditional HRT = lower BP COCP = less stigma
68
Explain the basics of HRT
Exogenous oestrogen given to perimenopausal + postmenopausal women Progesterone also given to women that have a uterus (prevent endometrial hyperplasia/ cancer)
69
What are some non-hormonal treatments for menopause?
Clonidine = agonist of alpha-2 adrenergic receptor/ imidazoline receptors in brain -- helpful for vasomotor symptoms + hot flushes
70
What are the indications for HRT?
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
What are the main forms of pelvic organ prolapse?
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
What is the management for prolapse?
1. Conservative management - pelvic floor, weight loss, lifestyle, oestrogen cream 2. Vaginal pessary 3. Surgery

Phase 3a (13 decks)

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