Gynaecology Flashcards
1
Q
What speculum is used when examining pelvic organ prolapse
A
Sim’s
2
Q
What is the uterus divided into
A
Corpus and cervix uteri
3
Q
What shape is the uterus in most women
A
Anteverted
4
Q
How long are fallopian tubes
A
10 cm
5
Q
How is the fallopian tubes divided
A
Isthmus
Infundibulum
Ampulla
6
Q
What does the uterine artery branch off from
A
Internal iliac
7
Q
How is the uterus drained venous
A
internal iliac vein
8
Q
Right vs left ovary venous drainage
A
Right - IVC
Left: Left renal vein
9
Q
Where do ovarian arteries branch from
A
Abdominal aorta under renal artery
10
Q
Blood supply of vagina
A
Vaginal artery
Inferior vesical artery
Clitoral branch of pudendal artery
11
Q
Peritoneal coverage of ureters
A
Retro
12
Q
Blood supply of bladder
A
Superior and inferior vesicle arteries (internal iliac artery)
13
Q
Blood supply of rectum
A
Superior, middle and inferior rectal arteries (inferior mesenteric, internal iliac and peudendal arteries)
14
Q
Lymphatic drainage of ovaries, cervix and endometrium
A
Para-aortic nodes
15
Q
Types of FGM
A
1: Sunna - removal of prepuce with or without part or entire clit
2. Clitoridectomy with partial or total excision of labia minor
3. Removal of part or all external genitalisa with narrowing of vaginal canal.
16
Q
Immediate complications of FGM
A
- Shock and pain
- Haemorrhage
- Organ damage
- Acute urinary retention
17
Q
Long-term complications of FGM
A
- Recurrent UTI
- Urethral obstruction
- Pelvic infection
- Sexual dysfunction
- HIV.AIDS
- Pregnancy
- Depression
18
Q
How is FGM sexual dysfunction treated
A
- De-infibulation under GA
19
Q
How is FGM obstructed labour or tears/urethral injury treated
A
De-infibulation during second stage of labour under LA
20
Q
What is de-infibulation
A
- Surgical technique to open the vagina
21
Q
What causes malformation of the genital tract
A
Failure of paramesonephric ducts to form:
Complete - Rokitansky syndrome
Partial - unicornuate uterus
22
Q
Signs and symptoms of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome
A
Painless primary amenorrhoea, normal secondary sexual characteristics, blond ending or absentt vagina
Rokitansky: Vaginal dilation
23
Q
Signs of imperforate hyman
A
Clinical pain
Primary amenorrhoea
Blush bulging
Memorane visible at introitus
Treatment: Cruciate incision in obstructive membrane
24
Q
Signs of transverse vaginal septum
A
Clinical pain
primary ammoenorhea
Abdo mass + urinary retention
25
Signs of longitudinal vaginal septa and rudimentary uterine horns
Dyspareunia
Abdo mass
Treatment: Surgical vaginoplasty
26
What week does gender become apparent during development
12th week
27
What structures form in 6th week of life
1. Genital ridges (induced by primordial germ cells of yolk sack)
2. Medonephic ducts
3. Paramesonpephci ducts
28
What do the paramesonephric ducts develop into
1. Fallopian tubes
2. Uterus
3. Cervix
4. Upper 4.5 of vagina
29
What structure forms the lower 1/5 of the vagina
sinovaginal bulbs of the urogenital sinus, which fuses with the paramesonephric ducts
30
What do the muscles of the vagina and uterus develop from
Mesoderm
31
What gene causes development of male genitalia
SRY gene - produces anti-mullerian hormone
32
Investigations of genital tract malformation
1. MRI - GOLD
2. Karyotyping to exclude androgen insensitivity syndrome e
3. Vaginoscopy
33
Pathophysiology of 46XX Karyotypee
1. Congenital adrenal hyperplasia
| 2. Causes hermaphroditism
34
Pathophysiology of 46XY Karyotype
1. AIS
| 2. Defects in testosterone biosynthesis (5 alpha reductase, 17 betahydroxysteroid dehydrogenase deficiency)
35
What is congenital adrenal hyperplasia
1. recessive
Cortisol deficiency causes increased ACTH secretion and androgen production
36
What causes congenital adrenal hyperplasia
21-hydroxylase deficiency
37
Signs of CAH
1. Neonatal salt wasting crisis
2. Hypoglycaemia
3. Childhood virilization and accelerated growth with restricted final height due to early epiphyseal closure
4. Hirstiusm and oligomenorrhoea
38
Management of CAH
1. Glucocorticoid (dexamtheasone) to suppress ACTH
Remember - risk for iatrogenic cushion's syndrome
2. Salt-losing - fludrocortison to replace aldosterone
39
What causes androgen insensitivity syndrome
1. Mutation in androgen receptor gene causing resistance to androgens in target tissues
40
Clinical features of AIS
1. External female genitalisa
2. Absent uterus and fallopian tubes
3. Breast development
4. Sparse pubic hair
5. Short blind-ending vagina
Can also be very mild (e.g. not present oil puberty when they have a high-pitched voice and gynaecomastia)
41
Management of AIS
1. Gonadectomy
2. HRT with oestrogen
3. Check bone mineral density
4. Psychological intervention
42
Management of AIS
1. Gonadectomy
2. HRT with oestrogen
3. Check bone mineral density
4. Psychological intervention
43
Where is CRH produced
Hypothalamus
44
Where is ACTH produced
Pituitary glands
45
Where does ACTH act
Adrenal cortex - fasciulata
46
Three layers of adrenal cortex
1. Zona glomerulosa
Fasciulata
Reticularis
47
What is produced in the fasciulata
Glucocorticoids - lipid soluble has to be bound to a protein in the blood to be transported
48
Role of cortisol
1. Iridium rhythm
2. Maintain BP by increasing sensitivity to catecholamines
2. Supress immune system by reducing inflammatory mediators
49
Exogenous vs endogenous cushings
1. EXO - by drugs
2. ENDO - by body
Causes atrophy of the adrenal glands by stopping producing f ACTH
50
What drugs can cause cushings
1. Prednisolone
51
What is endogenous cushing caused buy
Pituitary adenoma - causes excess ACTh production
Causes yperpalasia of adrenal glands
Tumours of adrenal glands - causes cells of fascilulata to rapidly divide
suppresses CRH and ACTH but cells continue to secrete cortisol production
52
Ectopic sources of ACTH
Small cell lung cancer
Bronchial carcinoids
53
Symptoms of cushion's
1. destroys superficial layers of body
Muscle wasting, thin extremities and skin thinning, easy bruising and abdo striae
Osteoporosis
Increased blood glucose due to increased gluconeogenesis - insulin resistance
Moon shaped face
Buffalo hump
Fat redistribution
Arterial hypertension: catecholamine effect
Increased BP by working as aldosterone
Inhibits secretion of GnRH - amenorrhoea
Increased ACTh causes increased androgen - Hirsutism
Immunosuppression
Impair brain function
54
Diagnosis of cushings
24 hr urine free cortisol
Blood or saliva tests at midnight
Dexamthetsone suppression tests - surpasses ACTh production -> serumcortisol unchanged should go down
if pos: ACTH plasma levels:
low - adrenal tumours
high - cushing disease
55
Diagnosis of cushings
24 hr urine free cortisol
Blood or saliva tests at midnight
Dexamthetsone suppression tests - surpasses ACTh production -> serumcortisol unchanged should go down
if pos: ACTH plasma levels:
low - adrenal tumours
high - cushing disease
56
What is precocious puberty
1. Signs of puberty before 8 or menarche before 10
57
Problem of precocious puberty
Accelerate linear growth with premature epiphyseal closere
58
Causes of precocious puberty
1. Idiopathic
2. hypothyroidism
3. Ovarian cyst
59
Investigation for precocious puberty
1. Bone age
2. Cranial MRI
3. Pelvic USS
4. FSH/LH/17hydroxyprogesterone
5. TFTs
6. GNrH stimulation test
60
Treatment of precocious puberty
1. GnRH analogue
61
What are the tanner stages
Female:
```
B1 - Prepubertal
B2 - Breast Bud
B3 - Juvenile with smooth counter
B4 - Areola and papilla project above breast
B5 - Adult
```
Male:
G1 - Prepubertal, testicular volume <1.5 ml
G2 - Penis grows in length, volume (1.5-1.6)
G3 - Penis grows further in length and circumference, testicular volume (6-12 ml)
G4 - Development of glans penis, darkening of scrotal skin + testicular volume (12-20ml)
G5 - Adult genitalia, testicular volume > 20ml
```
Pubic Hair:
PH1 - None
PH2 - Sparse at the base
PH3 - Dark, coarser
PH4 - Filling out towards adult distribution
```
62
What defines delayed puberty
1. Absence of menstruation and secondary sexual characteristics by 14
63
Causes of delayed puberty
1. Weight loss
2. Hypothalamic disorders
3. varian failure
64
Investigations for delayed puberty
1. LH/FSH/testosterone/TFTs/Prolactin
2. Karyotype
3. Pelvic ultrasound/MRI if mullein anomaly suspected
4. Cranial MRi if prolactin is high
65
What is vulvovaginitis + treatment
1. Starts when girl becomes responsible for going toilet
T: Wiping front to back
Loose cotton underwear
Emollient
66
Differential for vulvovaginitis
Sexual abuse
67
What causes labial adhesions
1. Hypo-oestrogenic state
68
What is lichen sclerosus + treatment
Sticky, white plaques in butterfly patter around anogenital area - sparing of vagina
Signs:
Dysuria, surface bleeding and purport from itching
T: Topical corticosteroids
69
Target BP in clinic and ABPM/HBPM
clinic; 140/90
ABPM: 135/85
70
HbA1c target with lifestyle and metformin
48 mol/mol (6.5%)
target is 53 on sulfonylurea
71
Drug treatment of T2DM
Metformin
Metformin + Glisten/sulfonylurea/pioglitazone/sglt-2 inhibitor
then triple therapy of above
Re-visit diabetes on osmosis
72
When should double therapy start
if hba1c is over 58 mol/mol
73
Signs of hypercalcaemia
```
Stones (renal)
Bones (pain)
Groans (also pain, nausea and vomiting)
Thrones (polyuria)
Psychiatric overtones
```
74
Characteristic x ray finding in hyperparathyroidism
Pepperpot skull
75
Most important complication of fluid rests in DKA
Cerebral oedema (Raised glucose and ketones)
76
Treatment of MODY diabetes (HNF1A)
Gliclazide - sulfonylureas
77
What can ovarian cysts be divided into
Simple or COmplex
78
What types of simple cysts are there
Follicular cyst: Dominant follicule fails to rupture / Normal surge of LH doesn't happen
This is the MOST common ovarian mass in young individuals
Corpus Luteum cyst
Theca Lutein Cyst
79
What is polycystic ovary syndrome
multiple follicular cysts
80
What causes PCOS
1. Chronic anovulation
Dysfunction in hypothalamic-pituitary-ovarian axis.
This causes amenorrhoea and excess androgen production (hirsutism)
81
What causes a corpus luteum cyst (haemorrhgaic cyst)
Instead of regressing, it continues to grow
The ruptured follicle begins producing large quantities of estrogen and progesterone in preparation for conception. If a pregnancy doesn't occur, the corpus luteum usually breaks down and disappears. It may, however, fill with fluid or blood, causing the corpus luteum to expand into a cyst, and stay in the ovary.
82
How can we distinguish between a corpus luteum cyst and other cysts
Appears as an enlargement of the ovary itself instead of a mass
83
What causes a theca lutein cyst
Overstimulation of hCG (ONLY SEEN IN PREGNANCY)
Stimulates growth of follicular theca cells on both OVARIES
Thus, bilateral cysts (REMEMBER THIS) during pregnancy
84
When is theca lutein cyst more likely to develop
1. Multiple foetuses
| 2. Gestational trophoblastic disease
85
What is gestational trophoblastic disease
pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.
86
Diagnosis of gestational trophoblastic disease
Check for serum beta hCG.
87
4 Characteristcics of a complex cyst
1. Large
2. Irregular borders
2. Internal septations (multilocular)
3. Fluid is heterogenous (something other than just fluid inside it)
88
Name the three types of ovarian tumours
1. Epithelial ovarian tumours (from surface epithelium of ovaries)
2. Germ cell (from primordial germ cells)
3. Sex Cord-stromal (from connective tissue of ovaries)
89
Most common ovarian tumour
Epithelial ovarian
90
4 Types of epithelial ovarian tumours
1. Serous (cystic)
2. Mucinous
3. Endometrioid
4. Transitional
They can either be benign, malignant or borderline
91
Histology of serous/mucinous cyst adenoma
Single cost with simple cuboidal and columnar cells.
92
What group of women are most likely to have serous/mucinous cystasenoma
Premenopausal women (30-40)
93
Characteristics of serous vs mutinous cyst adenoma
Serous: bilateral and fallopian tube-like epithelium
CONTAIN PSAMMOMA BODIES (calcium deposits around dead cells)
Mucinus: Unilateral
Mucus secreting epithelium (columnar)
Pseudomyxoma Peritonei
Ends up leaking into the appendix or GI - metastases
94
What characterises borderline tumours
Mix of characteristics from benign and malignant types but have bette outcomes than malignant (less likely to metastasise)
95
What cells do epithelial ovarian tumours arise from
Usually called ENDOMETRIOMAS (so from endometrial cells)
96
What causes endometriomas
Benign cysts that occur in endometriosis (endometrial tissue from uterus grown on ovary).
Endometrial tissue responds to hormones -> bleeds within cavity during menstruation (CHOCOLATE CYSTS as blood turns dark)
Once these rupture, the contents spill inside peritoneal cavity
97
What are entometrioids tumours made of
Type of malignant endometriadenomas ovarian tumour that is composed of endometrial-like glands
98
What type of ovarian tour are brenner tumours
Benign Epithelial Ovarian tumour made form transitional cells
99
Histology of Brenner tumours
Coffee bean shaped
100
What can brenner tumours transition to
Squamous cell carcinoma
101
4 Types of germ cell tumours
Fetal
Oocyte
Yolk Sac
Placenta
102
What are teratomas
Tumours that arise from fetal tissue
103
What are the two types of teratomas
1. Mature Cystic Teratoma (dermoid cyst)
| 2. Immature Teratoma
104
What is composed of a mature cysts teratoma
1. Skin, Hair, Nails etc (fully developed tissue)
| 2. Stroma Ovarii
105
What is the most common ovarian tumour in females (10-30)
Mature cystic teratoma
106
Characteristics of mature cystic teratoma
1. Benign (sometimes can progress to squamous cell carcinoma)
2. Usually unilateral
Important to look at age
107
What is stroma Ovari
ONLY CONTAINS THYROID TISSUE
These secrete T2 and T4 - hyperthyroidism
108
Important signs for stroma ovarii
Normal thyroid exam
Low TSH
Ovarian Mass
109
What is an immature teratoma
Undifferentiated fetal tissue (neuroectoderm)
MALIGNANT AND VERY AGGRESSIVE
110
What age onset is immature teratoma
Less than 20
111
What are oocyte germ cell tumours called
Dysgerminomas (most common malignant germ cell tumours) - adolescent
These are ovarian analogues of testicular seminomas
112
Histology of dysgerminomas
Fried-Egg Appearance
113
What are markers for Dysgerminomas
LDH
hCG
These tend to be abundant in the tumour cells
114
What is the tumour of the yolk sac called
Endodermal sinus tumour - MALIGNANT
115
In what patients are endodermal sinus tumours (yolk sac) most common
Children
116
Sign of endodermal sinus tumour on physical exam
Yellow Haemorrhagic mass
117
Histology of endodermal sinus tumours
Schiller-Duval Bodies (malignant cells surround central blood vessels)
118
Lab results for endodermal sinus tumour
Increased alpha fetoprotein (AFP)
119
What are placental germ cell tumours called
Choriocarcinoma (Can sometimes happen in ovaries)
120
Histology of Choriocarcinoma
1. Cytotrophobblasts
2. Syncytiotrophoblast
BUT NO VILLI unlike placental tissue
High chance of bleeding and spreading via circulation
121
Cytotropholoblasts vs syncytiotrophoblast
Cato - light cytoplasm and uninuclei
Syncytio - dark cytoplasm and multiple nuclei
122
Lab results for choriocarcinoma
1. High hCG levels
123
What is the alpha subunit of hCG levels similar to
TSH and thus stimulates TSH levels - causing hyperthyroidism
124
Symptoms of choriocarcinoma
1. Heat Intolerance
2. Sweating
3. Palpitations
125
Signs for choriocarcinoma
1. Hyperthyroidism
2. Normal thyroid
3. Ovarian Mass
4. High hCG levels
126
Four subtypes of Sex cord-stomal tumours
Granulose Cell Tumours
Thecomas
Fibromas
Sertoli-Leydig tumours
127
Where do sex cord-stomal tumours arise from
Connective tissue of ovaries
128
What is the most malignant type of sec cord-stomal tumour
Granulose cell tumour
129
Histological appearance of granulose cell tumour
1. Call-Exner Bodies
Granulose-like cells surrounding eosinophilic fluid
130
Marker for granulose cell tumours
Raised Inhibin B - produced by granulosa cells.
131
What are thecfmas mad elf
BENGIN
Made of Theca Cells
132
In what women are granulose and theca cell tumours common
POSTMENOPAUSAL WOMEN
133
Lab results of granulose and theca cell tumours
Excessive oestrogen secretion:
Weight Gain
Breast Tenderness
Irregular Menses
Menorrhagia
134
What are fibromas made of
Bundles of fibroblasts - BENIGN
135
What is Meigs Syndrome
1. Ascites
2. Hydrothorax
Fibromas
136
What are contained in Leydig Cells
Reinke crystals
137
Lab results for Sertoli-Leydig tumours
1. Secrete androgens (testosterone)
Thus, symptoms include acne, hirsutism, deeper voice, hair loss.
138
What tumours are bilateral
theca lutein cyst
Krukenberg tumour
139
Where do krukenberg tumours come from
GI system: Diffuse gastric carcinoma
140
Histology of krukenberg cells
Signet ring cells (vacuole with mucin and nucleus)
141
Risk factors for ovarian cancer
1. Less ovulation cycles = lower risk (less cell division):
Having kids
Breast feeding
Contraceptives
```
2. More cycles:
No pregnancy
Infertility
Early Menarche
Late menopause
Endometriosis
PCOS
```
3. BRCA-1 or 2 mutation
4. Endometrial/colon/GI cancer in family
142
Symptoms of Ovarian cancer
1. Change in bowel habits
2. Pelvic discomfort (pulling sensation in groin)
3. Bloating
4. Dull/aching lower abdominal pain
143
What are ovarian torsions
Ovary twists around suspensory ligament.
Causes sudden, sharp and acute pelvic pain (cuts of blood supply)
144
Symptoms of PCOS and sertoli-leydig cell tumours
1. Amenorrhoea
2. Acne
3. Hirsutism
145
Symptoms of endometriomas
1. Dysmenorrhoea (pain)
| 2. Fertility issues
146
Symptoms of strums ovary and choriocarcinoma
1. Hyperthyoridism
147
Symptoms of granulose and theca cell tumours
1. Oestrogen excess
Precocious puberty (before 8)
Mennorhagia and menorrhagia
Menopausal - Uterine bleeding
148
Signs of metastasise
1. Ascites
2. Abdo mass
3. Abdo distention
4. Bowel obstruction
5. Pleural effusion
6. Sister Mary Joseph nodules (nodes around umbilicus) - usually indicative of gastric cancer
149
Diagnosis of Ovarian cancer
1. Pelvic exam
2. Blood test (LDH, beta-HCG, AFP and Inhibin B)
3. Imaging: Transvaginal/Abdo ultrasound
4. CT/MRI of pelvis
GOLD STANDARD - Biopsy
150
Tumour marker to gage efficacy of chemotherapy
Carbohydrate antigen 125.
Not specific enough for diagnosis or screening
151
Adverse effect of cancer therapy on Ovaries, Uterus and hypothalamus
1. Ovarian failure
2. Reduced uterine function
3. Hypogonadotrophic hypogonadism
152
What is the follicular phase of the menstrual cycle
1. Pulsatile release of hypothalamic GnRH -> FSH from anterior pituitary gland
2. FSH promotes ovarian follicular development -> recruitment of a dominant follicle containing oocyte
3. Follicular garnulosa cells produce oestrogen (endometrial proliferation)
4. Increased Oestrogen levels to stop further FSH production
153
What does oestrogen inhibit
FSH
154
What happens to cause ovulation
1. Increasing follicle oestrogen from positive feedback vita activin
2. LH surge 36 hours before ovulation
155
Stages of the luteal phase
1. The follicle collapses down to become corpus luteum
2. Progesterone and oestrogen act on oestrogen primed endometrium to induce secretory changes (thickens and increased vascularity)
3. Corpus luteum turns into corpus albicans after 14 days.
4. if implantation occurs, hCG keeps CL maintained (progesterone continues secretion to support endometrium)
5. Pregnancy absence causes CL degeneration (rapid fall in progesterone and oestrogen -> menstruation)
156
What does the corpus luteum produce
Oestrogen and progesterone
157
What days do ovulation occur
14-18 days
158
What days does the corpus luteum develop
20-26
159
What protein causes GnRH to be secreted
Kisspeptin
160
What stimulates the production of Estradiol
LH and FSH acting on eggs to produce it
161
Role of estradiol
Proliferation of endometrium
162
How does the fertilised oocyte maintain the endometriumm
Develops in fetus:
Fetal hCG maintains ovarian production of progesterone and placental progesterone
163
Where is progerstone produced
Adrenal Cortex
Ovarian corpus luteum
Placenta later on
164
Where is oestrogen produced
Ovaries (theca interna)
Placenta when pregnant
165
How long is the menstrual cycle
28 Days
166
When does LH production start and end
12-14
167
What causes variation in ovulatory cycles
The follicular phase (luteal phase is fixed)
168
Average menstruation (bleeding days)
3-5 days
169
What is Oligomenorrhoea
1. When cycles last longer than 32 DAYS
170
Causes of oligomenorrhoea
1. PCOS
2. Low BMI
3. Hyperprolactinaemia and mild thyroid disease
171
Management for dysmenorrhoea
1. STI screen
2. USS
3. Laparoscopy
172
Management of dysmenorrhoea
Symptom control:
1. Mefenamic Acid (500mg)
2. Paracetamol, hot water bottles, B1 and mg
Treat underlying causes
173
How is dysfunctional uterine bleeding diagnosed
1. Exclusion, any abnormal uterine bleeding in absence of pathology or pregnancy
(> 80mL)
Usually menorrhagia
174
Treatment of DUB
1. Tranexamic (controls bleeding) and mefenamic acid (NSAID)
Endometrial ablation
2. IUS (delivers measured doses of levonorgestrel)
3. NSAID: Medenamic acid
4. COCP to regulate cycle
175
5 reasons for pregnancy termination under law (ABCDE
A: Continuance would be a greater risk to pregnant woman's life than termination
B: Termination will prevent permanent injury physical or mental health
C: Has not exceeded 24 weeks and continuance would cause physical and mental health injuries
D: Pregnancy has not exceeded 24th week and continuance would have physical and mental health risks
E: Substantial risk if child was born
176
Surgical termination 7-13wks
Conventional suction termination
177
Surgical termination greater than 13 eeks
Dilatation and evacuation following cervical prep
178
Risk with dilatation and evacuation
Greater gestation = higher risk of bleeding
179
What cervical prep should be given
1. Misoprostol
2. Gemeprost
3. Mifepristone
180
Medical intervention for abortion
Mifepristone
181
What is the mifepristone
Anti progesterone -? causes uterine contractions, blessing from placental bed and sensitises uterus to prostaglandins
182
What is misoprostol
Prostaglandin E1 analogue -> uterine contractions
183
What is gemeprost
Prostaglandin E1 analogue - softens and dilates cervix
184
Prophylaxis for TOP
Metronidazole + Doxy/azithromycin
185
Complications of TOP
1 .Significant bleeding
2. UTI
3. Cervical trauma
186
4 pathologies to consider in early pregnancy bleeds
1. Miscarriage
2. Ectopic pregnancy
3. Gestational trophoblastic disease
4. Chlamidyia
187
Define miscarriage
Defined as the expulsion of a pregnancy, embryo, or fetus at a stage of
pregnancy when it is incapable of independent survival BEFORE 20 weeks of pregnancy
188
When do miscarriages usually occur
12 weeks
189
Symptoms of a threatened, complete or incomplete miscarriage
1. Bleeding
2. Abdo pain
3. Closed cervic (incomplete right be open)
190
USS findings for threatened miscarriage
1. Inauterine gestation sac
2. Fetal pole
3. Fetal Heart activity
191
Management for threatened miscarriage
1. Anti-D if >12 weeks or heavy bleeding/pain
192
USS findings for complete miscarriage
1. Empty Uterus
| 2. Endometrial thickness (<15 mm)
193
Management of complete miscarriage
1. Anti - D (> 12 weeks)
| 2. Serum hCG
194
USS findings in incomplete miscarriage
1. Uterine contents pass through open cervix
195
Management of incomplete miscarriage
1. Anti - D and surgery
196
Symptoms of missed miscarriage
1. Bleeding
2. Pain
3. Closed cervix
197
USS finding of missed miscarriage
1. Fetal pole > 7mm
2. No fetal heart activity
3. Mean gestation sac diameter >25 mm with no fetal pole or yolk sac
198
Symptoms of inevitable miscarriage
1. Bleeding + pain
2. Open cervix
3. Uterine contents visible during pelvic exam
199
USS finding of inevitable miscarriage
1. Inauterine gestation sac
2. Fetal Pole
3. Fetal Heart Activity
200
USS finding of pregnancy of unknown location
1. Positive pregnancy test
2. Empty uterus
3. No sign of extrauterine pregnancy
201
Management of PUL
1. Serum hCG assay and initial serum progesterone to exclude ectopic
202
How can chromosomal abnormality cause miscarriage
ANEUPLOIDY (Extra or missing chromosomes)
Polyploidy (where a zygote receives more than 1 set of 23 chromosomes) 69 or 92 chromosomes
Translocation (Unbalanced exchange of DNA so one might have too much or too little dna)
203
What condition is caused by Monosomy
Turner's
204
If the zygote is genetically viable, what is the next cause of a miscarriage (think about the cycle)
1. Blastocyst is unable to implant on the endometrium - no blood supply
205
What causes an ectopic pregnancy
1. When blastocyst ends up implanting onto other tissues before reaching the uterus (e.g. the fallopian tube)
206
Why are ectopic pregnancies likely to end in miscarriage
1. No space
| 2. No blood supply
207
What is the next cause of miscarried blastocyst implantation is successful
1. Coprus luteum may not secrete enough progesterone to continue development of oocyte
208
What is the next cause of a miscarriage if the corpus luteum successfully secretes progesterone
1. Placenta unable to exchange gases, o2 and glucose
209
In what stage of pregnancy is the embryonic period
3-8 weeks
210
What can cause a miscarriage during the embryonic period
1. Teratogen damage (birth defects) - medications
Isotretinoin, mercury, alcohol, smoking
Brain and heart develop in this period
211
How can growing fetes be assessed 10-14 weeks of pregnancy
1. Chorionic villus sampling
212
What is chorionic villus sampling
Needle or catheter used to take a sample of the placenta for genetic analysis
213
How can growing fetes be assessed 15 weeks of pregnancy
Amniocentesis
214
What is amniocentesis
1. Aspiration of amniotic fluid
215
Complications of growing fetes assessment
Trauma and infection -> miscarriage
216
What two uterine abnormalities can cause miscarriages
1. Septate uterus
| 2. Submucosal leiomyoma (fibroid tissue in submucosa that limits space)
217
What infections can cause miscarriage s
1. Listeria monocytogenes
2. Cytomegalovirus (+HSV)
3. Toxoplasma gondii
218
Risk factors for miscarriages
1. Obesity
2. Endocrine (Thyroid, DM, PCOS)
2. APl, SLE (blood clot)
3. High BP
4. AGe
219
What is a septic abortion
1. Happens during incomplete miscarriage - caused by infection
220
What is a complete miscarriage
1. Uterine cavity is empty + cervix closed
221
What is a missed miscarriage
1. Fetus is not viable but cervix has not opened - may be asymptomatic
222
Symptoms of miscarriage
'blood clots' - placental or fetal tissues
Lower abdo pain
Increased vaginal bleeding
223
Diagnosis of miscarriage
1. Transvaginal USS
2. Pelvic exam
3. HCG levels
224
Medical intervention for ectopic pregnancy
1. IM Methotrexate
Monitor hCG levels
Surgery: laparotomy (salpingectomy)
225
Side effects of methotrexate
1. Conjunctivitis
2. Stomatitis
3. GI upset
226
What is a pregnancy of unknown location
1. No sign of intrauterine pregnancy, ectopic or related products of conception but positive pregnancy test (hCG>5UL)
227
What does <20nmol/l of progesterone mean for the pregnancy
1. Likely to fail
228
If rise in hCG<66%, what does this mean for the pregnancy or >1500 IU/L
Possibly ectopic
229
What is beta-hCG secreted by
1. Trophoblasts
230
What compound is beta-hcg similar to
LH
231
Risk factors for recurrent miscarriage
. Ageing
2. APS
Fibroids
Protein C and S deficiency
232
Management of recurrent miscarriage
1. Pelvic USS
2. Thrombophilia screening
3. Lupus anticoagulant
4. Anticardiolipin antibodies
233
Life style advice for people with miscarriages
1. Bed Rest
2. Smoking cessation
3. Reduce alcohol intake
4. Losing Weight
234
What is hyperemesis gravid
1. Excessive vominiting dur to elevated hCG
235
When does hyperemesis gravid occur
1. 1st trimester
236
Symptoms of HG
1. VOmiting
2. Weight loss
3. Muscle wasting
4. Dehydration
237
How to read HG
1 .IV fluids
2. Replace K+
3. Keep nail by mouth
4. Promethazine (antiemetics)
238
Investigations for HG
1. Urinalysis to detect ketonesin urines
2. MSU to exclude UTI
3. FBC
4. U and E
239
Investigations for HG
1. Urinalysis to detect ketonesin urines
2. MSU to exclude UTI
3. FBC
4. U and E
240
What does LH act on
Theca cells -> produce androstenedione
Granulose cells respond to FSH -> aromatase
This then breaks androstenedione to oestrogen
Oestrogen acts as a negative feedback loop on FSH so only one follicle is stimulated
241
What happens to the granulose cell once the dominant follicle forms
Develops LH receptors so more oestrogen is screwed
-> POSITIVE FEEDBACK so pituitary is more responsive to gnRH - MORE FSH AND LH
These then band to the theca cells to rupture follicle and release oocyte
END OF FOLLICULAR PHASE
242
What part of the menstrual cycle does cos occur in
1. Follicular
243
What causes polycystic ovary syndrome
Exes LH production causes excess production of androstenedione by theca cells
Excess flows into blood -> estrange by aromatase in fat
Negative feedback prevents LH surge so no follicular destruction. forms a cyst.
Prevents ovulation
244
Risk factor for PCOS
1. Insulin reisstance - disrupts menstrual cycle
Theca cells have insulin receptors causing them to grow and divide - too many LH receptors
245
Symptoms of PCOS
1. Excess androstenedione cause hirsutism, male-pattern baldness, acne
2. lack of ovulation causes amenorhheoa and oligomenorhea
3. Insulin resistance - Acanthuses nigricans/overweight
246
PCOS diagnosis
1. LH:FSH ratio
2. Raised androstenedione
3. Pelvic USS to look for follicles but not necessary for diagnosis
247
Treatment of PCOS
1. Wieght loss
2. Metformin
3. Spironolactone and contraception as teratogenic
4. Oral contraceptive to regulate cycle
5. Clomiphene citrate to induce ovulation
6. Ovarian drilling to poke the cysts
248
Symptoms of hirsutism and virilization
1. Weight Gain
2. Acne
3. Male Pattern Balding
Virilization: Deepened voice and clitoromegaly
249
Where can excess androgen production (testosterone) be produced
1. Ovaries
| 2. Adrenal gland
250
How can excess hair growth in hirsutism be quantified
Ferriman-Gallwey score
251
What is the Ferriman-Gallway score
measures hair in 9 areas:
1. Upper lip
2. Chest
3. Upper bids
4. Lower abdo
5. Upper arms
6. Chin
7. Upper back
8. Lower back
9. Thigh
Graded 0-4
Take into account ethnicity
252
Score of FGS
1. 8-15 (mild)
2. 16-25 (moderate)
3. >25 (severe)
Asian: > 2
Meditteranaena, middle eastern and latina (only over 10)
Change of hair growth pattern and rate
253
Ovarian diseases that can cause hirsutism
1. PCOS MAIN
2. Androgen tumours
3. Luteoma
254
Adrenal gland causes of hirsutism
1. CAH
2. Cushings
3. Tumours
4. Acromegaly
255
What women are more likely to have pcos
Premenopausal
256
Symptoms of PCOS
1. Menstrual irregularities (oligoenorrhoea or amenorhheoa)
2.
257
What is non-classic congenital adrenal hyperplasia
1. 21-Hydroxylase deficiency
So 17-hydroxyprogesterone ends up as androgens (excess)
258
Role of 21-hydroxylase
Converts 17-hydroxyprogesterone -> 11 deoxycrotisol -> cortisol
259
What shows on USS TV for PCOS
1. 12 follicles (2-9 mm)
| 2. Ovarian Volume >10cm^3
260
Test for PCOS
1. TV USS and serum total testosterone
*>60 ng/Dl
<150ng/dL
261
PCOS vs CAH
17-hydroxyprogesteorne elevated (>200ng/mL)
262
Test for CAH
ACTH stimulation stimulates adrenal hormon production (1500 ng/ml)
263
Treatment for CAH
COCP to reduce hirsutism and cycle regulation
| Spironolactone
264
What drug induces ovulation
Clomiphene citrate
265
Red flags for hirsutism/ virilization
1. Rapidly worsening hirsutism and vilirilzation may be an adrenal and ovarian tumour
266
Tests for tumours causing virilization and hirsutism
Serum Testosterone >150ng/dL
Serum DHEA: <700 is ovarian
>700 adrenal
267
Chemo for ovarian tumours
Bleomycin, Etoposide and cisplatin
268
Test for malignant adrenal carcinomas
1. Urinary Metanephrine test
High metanephrine = alpha blockers to prevent hypotensive crisis
269
Therapy for stage 4 adrenal tumours
Mitotane and radiation therapy
Debunking surgery
270
In what women is ovarian hyperthecosis seen
Post-menopausal
271
Signs of Ovarian hyperthecosis
1. Testosterone > 150ng/dL
2. Insulin reisstance
3. Hyperinsulinemia
4. No cysts on USS TV and physical exam
5. Increased bilateral ovarian stroma
272
Treatment for ovarian hyperthecosis
Insulin reisstance + want pregancy: Metformin + Clomiphene
Insulin resistance + no pregnancy: COCP + Spironolactone
273
What is the sole symptom of hirsutism called (nothing else wrong with them, lab results normal)
IP hirsutism
Shaving
274
Treatment for hirstusim
1. Laser and electrolysis
2. Spironolactone
2. Cyproterone acetate
3. Finasteride
4. Flutamide
5. Eflornithine hydrochloride
6. GnRH agonist
275
Pharmacology of spironolactone
1. Aldosterone antagonist
Stops ovarian and adrenal androgen production
Also inhibits 5-alpha reductase in skin - acne
Can cause hyperkalaemia
276
Pharmacology of cyproteone acetate
1. Inhibits LH secretion
Can cause oedema, fatigue, weight loss
277
Pharmacology of finasteride
1. Inhibits 5-alpha reducatese
278
What is endometriosis
Where the endometrial cells grow outwards (outside the womb)
279
Three layers of threproductive system
1. Perimetric
2. Myometrium
3. Endometrium
280
What happens in endometriosis
1. Cells making up the endometrium migrate to other parts of the reproductive system and start growing to form a mass (ovaries, tubes and uterine ligaments)
281
What are the 5 main theories that can cause endometriosis
1. Retrograde menstruation theory
2. Immune system dysfunction (allows cells to grow)
3. Metaplastic theory (cells of peritoneum transform into endometrial tissue)
4. Benign metastases theory
5. Extrauterine stem cell theory
Last two may explain how they show up in lungs and hearts
282
RF for endometriosis
1. FH
2. Never been pregnant
3. Early menarche
4. Late menopause
283
Normal endometrial cells vs implanted
1. Implanted: high levels of aromatase to produce oestrogen
2. Pro-inflammatory factors causing inflammation and scarring (adhesion)
Chronic inflammation and hormone level changes will cause bleeding or endometriomas (choice cysts) on ovaries
284
What genes mutate in endometriomas
PTEN
ARID1A
Increases risk of ovarian carcinoma
285
Symptoms of endometriomas
Reproductive organs:
- pelvic pain
- Bleeding
- dysmenorrhea
- dysparaenuia
Pouch of douglas:
- dyschezia (pain in defecation)
Bladder: Painful urination
Intestines: Abdo pain
pain gets worse during periods
tend to be sub fertile due to scarring causing implantation difficulties
286
Diagnosis of endometriosis
Laparoscopy
287
Treatment of endometriosis
1. Oetsorgen-progesterone OCP (ovarian suppression
2. Progesterone analogs (medroxyprogesteroene + levonorgesterol)
3. Danazol (steroid that inhibits mid cycle surges of FSH and LH
4. Gonadotropin-releasing hormone modulators tor educe oestrogen levels
288
Surgical treatment of endometriosis
1. Excision of implants
| 2. Pain is delimitation: oophorectomy or hysterectomy
289
Common sites for endometriosis
1. pouch of douglas
2. Uterosacral ligaments
3. Ovarian fosse
4. Bladder
5. Peritoneum
290
Appearance of endometriosis
choco cyst
291
Examination of endometriosis
1. Pelvic exam and speculum
2. TV USS
3. Laparoscopy and biopsy
292
What grading system is used for endometriosis
1. rASRM 1996
Location, size, depth of infiltration, adhesions
Stage I: Minimal endometriosis (1–5 points).
• Stage II: Mild endometriosis (6–15 points).
• Stage III: Moderate endometriosis (16–40 points). • Stage IV: Severe endometriosis (>40 points).
293
How are GnRH analogues admitted
SC injection
294
What is Amenorrhoea
No menstruation
295
What is primary amenorrhoea
1. Menstruation never starts
296
Three cases in where amenorrheoa is normal
1. Before Puberty
2. During pregnancy and lactation
3. After menopause
297
What is the follicular phase
1. Where follicles 'race' to become the more dominant mollicule to be released at ovulation
2. All release oestrogen which suprsses GnRH to rduce FSH and LH production.
298
How long does the menstrual phase last
5 Days
299
What is the profilerative phase
Follows the menstrual phase where increased in ovarian oestrogen to thicken endometrium layer.
Increased blood supply from spiral artieries to endometrium.
300
What occurs in the luteal phase
Occurs after ovulation: where coprus luteum produces progesterone to thicken endometrium:
Spiral arteries continue to grow
If not fertilised: Progesterone and oestrogen levels decrease
301
When are people diagnsoed with Amenorrheoa
After age 16 (suspected after 13 with no menarche)
302
Most common cause of primary amenorrheoa
Turner Syndrome (45, X) - where one chromosome is completely absent They have 45 instead of 46 chromosomes
secondary cause: Müllerian Agenesis (MRKH syndrome)
Rare: ANdrogen Insensitivity Syndrome and Kallman syndrome
303
What are ovaries replaced by in Turner's and how is this seen on histology
1. Streak Gonads (functional, fibrous tissues)
Turner's causes accelerated degeneration of ovarian follicles - menopause before menarche
No Ovarian oestrogen means less inhibition on GnRH = raised LH and FSH
304
What is MRKH syndrome
Mullerian ducts responsible for Uterus, cervix, upper 2/3rds vagina do not develop. and are thus, absent or obstructed: absence of menses.
Ovaries develop normally and produces oestrogen so FSH and LH are normal.
305
What is androgen insensitivity syndrome
Biologically male (46, XY) but tissues do not respond to testosterone.
No uterus, fallopian tubes or ovaries - menses absent
Have testicales stuck in the ignuinal canal or abdomen which produce testosterone (keeping LH and FSH normal)
306
Consequence of testosterone production by testicles that isn't binding to tissues in AIS
1. Excess -> converted to oestrogen causing development of female secondary sex characteristics.
307
What is Kallman syndrome
Neurons failt o migrate from nose to hypothalamus during fetal development: low levels of GnRH, FSH and LH -> low oestrogen
So puberty never starts or is incomplete.
308
What is secondary amenorrhoea
At least 3 menstrual cycles for women who had regular cycles, 6 months for females who had irregular cycles.
309
Most common causes of secondary amenorrheoa
1. Pregnancy
2. Functional Hypothalamic amenorrheoa - where decreased GnRH secretion causes LH, FSH and oestrogen to decrease
Seen in Anorexia, nutritional deficiencies and strenuous excercise or emotional stress
3. PCOS
4. Hyperprolactinemia which inhibits GnRH production.
5. Hypothyroidism: low thyroid hormone levels causes more TRH to be secreted ->stimulates prolactin release
6. Premature ovarian failure
7. Intrauterine Adhesions (Asherman syndrome)
310
What is premature ovarian failure
Ovarian Follicles -> undergo accelerated atresia -> depletes before 40 -> Early menopause -> decreased oestrogen and raised FSH and LH
311
What is Asherman Syndrome
1. Intrauterine Adhesions: Scar tissue in uterine cavity in females undergone uterine instrumentation. Causes no functional endometrium left
So endometrium becomes refractory to hormones
312
Symptoms of Turner's
1. Short stature
2. Absent Secondary Sex Characteristics
3. Wide or Webbed Neck
4. PRIMARY Ammenorheoa
5. Broad chest with widely spaced nipples
6. Cubitus Valgus
This is because the X chromsome carries genes for growth and developement: Single copy of SHOX gene (short stature homeobox) causes short stature.
CV defects (coarctation and biscupid aortic valve):
Symptoms of syanosis of lower extrmeities
Horshoe kidneys (they become fused during development)
Symptoms: UTI
Risk for T2DM and hypothyroidism.
These risks get greater depending on how severe genetic is missing
Babies born with lymphedema and lymph related swelling at back of neck (CYSTIC HYGROMA - neck webbing)
313
Symptoms of Mullerian Agenesis
1. Dyspareeunia and infertility
| 2. Primary amenorrheoa
314
Symptoms of Kallman
1. Absence of smell
315
Symptoms of Functional Hypothalamic Amenorrhoea
Decreased wight, bone density and fractures
316
Diagnosis for:
1. Turner's
2. Androgen insensitivity
3. Mullerian Agenesis
4. Inauterine adhesions
1+2: Karyotyping
2+3: Ultrasound
4: Hysteroscopy
317
Treatment of turner's, pcos, premature ovarian failure
1. Hormone Replacement Therapy (OCOP)
318
Treatment of prolactinoma
Cabergoline which inhibits prolactin
319
How does the X Karyotype in Turner's arise (from meiosis)
Non Disjunction of chromsoomes (the split is uneven)
Mosaicism
Deleting short-arm but the rest of the chromosome stays in tact - again mosaicism and happens at random.
320
What is mosaicism
1. Follows conception
Individual has some cells with 45X and 46XX
Non disjunction occurs in subsequent mitosis of the zygote
321
What is cubitus valgus
Arms overturned outwards
322
What is Amenorrhoea
No menstruation
323
What is primary amenorrhoea
1. Menstruation never starts
324
Three cases in where amenorrheoa is normal
1. Before Puberty
2. During pregnancy and lactation
3. After menopause
325
What is the follicular phase
1. Where follicles 'race' to become the more dominant mollicule to be released at ovulation
2. All release oestrogen which suprsses GnRH to rduce FSH and LH production.
326
How long does the menstrual phase last
5 Days
327
What is the profilerative phase
Follows the menstrual phase where increased in ovarian oestrogen to thicken endometrium layer.
Increased blood supply from spiral artieries to endometrium.
328
What occurs in the luteal phase
Occurs after ovulation: where coprus luteum produces progesterone to thicken endometrium:
Spiral arteries continue to grow
If not fertilised: Progesterone and oestrogen levels decrease
329
When are people diagnsoed with Amenorrheoa
After age 16 (suspected after 13 with no menarche)
330
Most common cause of primary amenorrheoa
Turner Syndrome (45, X) - where one chromosome is completely absent They have 45 instead of 46 chromosomes
secondary cause: Müllerian Agenesis (MRKH syndrome)
Rare: ANdrogen Insensitivity Syndrome and Kallman syndrome
331
What are ovaries replaced by in Turner's and how is this seen on histology
1. Streak Gonads (functional, fibrous tissues)
Turner's causes accelerated degeneration of ovarian follicles - menopause before menarche
No Ovarian oestrogen means less inhibition on GnRH = raised LH and FSH
332
What is MRKH syndrome
Mullerian ducts responsible for Uterus, cervix, upper 2/3rds vagina do not develop. and are thus, absent or obstructed: absence of menses.
Ovaries develop normally and produces oestrogen so FSH and LH are normal.
333
What is androgen insensitivity syndrome
Biologically male (46, XY) but tissues do not respond to testosterone.
No uterus, fallopian tubes or ovaries - menses absent
Have testicales stuck in the ignuinal canal or abdomen which produce testosterone (keeping LH and FSH normal)
334
Consequence of testosterone production by testicles that isn't binding to tissues in AIS
1. Excess -> converted to oestrogen causing development of female secondary sex characteristics.
335
What is Kallman syndrome
Neurons failt o migrate from nose to hypothalamus during fetal development: low levels of GnRH, FSH and LH -> low oestrogen
So puberty never starts or is incomplete.
336
What is secondary amenorrhoea
At least 3 menstrual cycles for women who had regular cycles, 6 months for females who had irregular cycles.
337
Most common causes of secondary amenorrheoa
1. Pregnancy
2. Functional Hypothalamic amenorrheoa - where decreased GnRH secretion causes LH, FSH and oestrogen to decrease
Seen in Anorexia, nutritional deficiencies and strenuous excercise or emotional stress
3. PCOS
4. Hyperprolactinemia which inhibits GnRH production.
5. Hypothyroidism: low thyroid hormone levels causes more TRH to be secreted ->stimulates prolactin release
6. Premature ovarian failure
7. Intrauterine Adhesions (Asherman syndrome)
338
What is premature ovarian failure
Ovarian Follicles -> undergo accelerated atresia -> depletes before 40 -> Early menopause -> decreased oestrogen and raised FSH and LH
339
What is Asherman Syndrome
1. Intrauterine Adhesions: Scar tissue in uterine cavity in females undergone uterine instrumentation. Causes no functional endometrium left. Collagen -> adhesions
So endometrium becomes refractory to hormones
Olfactor placode contains olfactor neurons which migrate to cribriform plate and have neurones secreting GnRH which pass thorugh cribriform plate and settle in the pituitary glands
340
Symptoms of Turner's
1. Short stature
2. Absent Secondary Sex Characteristics
3. Wide or Webbed Neck
4. PRIMARY Ammenorheoa
5. Broad chest with widely spaced nipples
6. Cubitus Valgus
This is because the X chromsome carries genes for growth and developement: Single copy of SHOX gene (short stature homeobox) causes short stature.
CV defects (coarctation and biscupid aortic valve):
Symptoms of syanosis of lower extrmeities
Horshoe kidneys (they become fused during development)
Symptoms: UTI
Risk for T2DM and hypothyroidism.
These risks get greater depending on how severe genetic is missing
Babies born with lymphedema and lymph related swelling at back of neck (CYSTIC HYGROMA - neck webbing)
341
Symptoms of Mullerian Agenesis
1. Dyspareeunia and infertility
| 2. Primary amenorrheoa
342
Symptoms of Kallman
1. Absence of smell (hyposmia or anosmia)
Low GnRH means
REDUCED Testosterone in men
REDUCED progesterone and oestrogen in women
Stops puberty from happening
It's a HYPOgonadotropic HYPOgonadism disorder
343
Symptoms of Functional Hypothalamic Amenorrhoea
Decreased wight, bone density and fractures
344
Diagnosis for:
1. Turner's
2. Androgen insensitivity
3. Mullerian Agenesis
4. Inauterine adhesions
1+2: Karyotyping
2+3: Ultrasound
4: Hysteroscopy
345
Treatment of turner's, pcos, premature ovarian failure
1. Hormone Replacement Therapy (OCOP)
346
Treatment of prolactinoma
Cabergoline which inhibits prolactin
347
How does the X Karyotype in Turner's arise (from meiosis)
Non Disjunction of chromsoomes (the split is uneven)
Mosaicism
Deleting short-arm but the rest of the chromosome stays in tact - again mosaicism and happens at random.
348
What is mosaicism
1. Follows conception
Individual has some cells with 45X and 46XX
Non disjunction occurs in subsequent mitosis of the zygote
349
What is cubitus valgus
Arms overturned outwards
350
Where is GnRH released
Hypophyseal portal system
351
WHat cells are responsible for the production of sperm
Sertoli Cells - FSH
352
What cell does LH bind to in women
Theca cells - produce andostendione and progestrone
353
What cells covert androstendione to oestrogen
Granulosa cells
354
Male-specific symptoms in Kallman syndrome
1. Small penis and testes
2. Improper testicular decent
3. Low SPERM count
Low muscle mass, deep voice or facial hair
355
Women-specific symptoms in Kallman syndrome
1. Amenorrheoa
2. Oligomenorrhoea
3. Lack of breast and pubic hair development
INFERTILITY
Osteoporosis in both genders
356
What causes endometritis
1. Normal Bacterial Flora of lower genital tract
USUALLY caused by retention of products of conception (placental or fetal tissue after delivery or abortion)
IAU, contraception
Bactera: C. trachomatis, n.gonnorhoea, M tuberculosis which can travel down
357
Symptoms of acute endometritis
1. Fever
2. Abnormal uterine bleeding
3. Lower abdo pain
4. Dysuria
4. Dyspareunia
358
Symptoms of chornic endometritis
Normal, maybe some pain
359
Diagonosis of endometritis
1. Microsopcic: Neutrophils in endometrium - ACUTE
2. Lymphocytes in endometrium - CHRONIC
3. Chronic granulomatous endomtritis (granulomas) - TB
360
What causes endometrial hyperplasia
1. Long standing exposure to high oestrogen levels with no counteracting progesterone
361
RF for endometrial hyperplasia
1. Obesity (extra adipose converts androgen to oestrogen)
2. Tumours secreting oestrogen (granulosa cell tumours of ovaries)
3. PCOS (follicles all secrete oestrogen so no luteal body to secrete progesterone)
4. NUMBER OF YEARS EXPOSED TO OESTROGEN so early menarche, late menopause, nulliparous (no pregnant women)
362
Why are pregannt women less likely to hav eendometrial hyperplasia
1. Because more oestorgen and progestrone is produced, then more progesterone is produced which is protective
363
What drugs can cause endometrial hyperplasia
1. Oestrogen HRT
| 2. Tamoxifen (breast cancer medication that blocks oestrogen receptors but stimulates endometrium)
364
Risk factor for endometrial cancer
Hyperplasia - dpeends on the histological features of hyperplasia
2. Age; 55-65
3. FH of Hereditary nonpolyposis colorectal cancer (lynch syndrome)
365
Types of histoological appearances for endometrial hyperplasia
1. Simple: Ratio of dilated glands to stroma is similar to normal tissues
2. Complex: More glands and less stroma (high ratio) - more at risk of cancer
366
Main type of endometrial carcinoma
1. Endometriod carcinoma (TYPE 1)
Where the cancer cell looks like normal endometrial cells
Linked to hyperplasia (prolongued expsure)
2. Less common is Type 2
367
What genetic mutation is involved in endometrioid carcinoma
1. Loss of PTEN tumour supressor gene
368
Sub-types of type 2 (not linked to oestrogen) endometrial cancer
1. Serous carcnioma
369
Histology of serous carcinoma
1. Psammoma bodies (finger like calcium deposits around necrotic cells)
370
RF for type 2 endometrial cancer
1. Endometrial atrophy (more aggressive) and happen in older women
371
gene foundin type 2 denometrial cancer
TP53
372
Symptoms of Endomterial hyperplasia and carcinoma
1. Menorrhagia (heavy)
2. Metorrhagia (between cycles)
3. Menometrorrhagia (combination of both)
ANY painless vaginal bleeding in postmenopausal women (suspect hypeprlasia or cancer)
4. Enlargement of WHOLE uterus is bound to cause abdo pain and cramping.
373
Diagnosis of hyperplasia and carcinoma
Transvaginal ultrasound and biopsy to confirm
374
Treatment of hyperplasia
1. Stopping drugs
2. Weight loss
3. Correcting anovulation
4. Progesterone medications
Cancer is treated by hysterectomy with bilateral salpingo-oophorectomy
Removal of pelvic and para-aortic lymph notes
Raido and chemotherapy
375
What are endometrial polups
1. Benign growth of the endometrium layers
376
RF for endometrial polyps
1. Frequent Tamoxifen therapy
HISTORY of breast cancer treatment
377
Symptoms of endometrial polyps
1. Asymptomatic
2. Abnormal uterine bleeding
Diagnosed with TVUSS
378
What is Adenomyosis
1. Endometrial tissue develops ectopically in myometrium
This then repsonds to hormonal changes
379
Symptoms of adenomyosis
1. Dysmenorrhoea
2. Heavy menstrual bleeding
3. chronic pain
380
Physical exam founding of adenomyosis
1. Enlarged, globular and boggy soft on palpation
381
Diagnosis of adenomyosis
1. Histopathological analysis of uterus after hysterectomy
If they wish to have children, just symptom relief using OCOP GnRH modulators.
382
What are leiomyomas
Uterine fibroids - bengin tumours of smooth muscle.
383
How are leiomyomas classified
1. Based on location:
Intramural (develop in uterine wall)
Submucosal fibroids (smooth muscle cells from endometrium)
Subserosal fibroids (smooh cells at perimetrium)
Pedunculated (if they grow into uterus cavity)
Usually develop in groups
384
RF of uterine fibroids
1. African decent
2. More oestrogen = more fibroids so age: 2040 and pregnancy
3. Nulliparous
4. Early menarche
5. Late menopause
385
Symptoms of leiomyomas
1. Abnormal uterine bleeding
2. Abdo pain
3. Fullness feeling
5. Iron deficiency anaemia in premenopausal women
Submucousal and intramural: Infertility and miscarriage
Pregnancy:
Preterm labour
Postpartum haemorrhage
Fetal malpresentation
386
Diagnosis of uterine fibroids
1. Pelvic exam followed by USS
| 3. Biopsy
387
Gross examination of fibroids
1. Round, firm and grayish-white
| 2. Necrosis or haemorrhage
388
Microsocpic exam of fibroids
1. Whorled-pattern of smooth muscle (wave-like)
389
Treatment of symptomatic fibroids
1. Myomectomy/hysterectomy/uterine artery embolization using a catheter
390
What is leiomyoscaroma
Rare smooth muscle from myometrium
DE NOVO (they do not progress, they start as a sarcoma)
391
RF of leiomyosarcoma
Postmenopausal individuals
392
Symptoms of leiomyosarcoma
1. Abnormal uterine bleeding
| 2. Abdominal pelvic pain or pressure.
393
Diagnosis of leiomyosarcoma
1. Ultra sound
2. Biopsy
Leiomyomas have no necrosis or haemorrhage while leiomyosarcoma have a single lesion and necrosis/haemorrhage
394
Name the two layers of the cervix
1. Endocervix (columnar epithelial cells)
2. Ectocervix (mature squamousepithelial cells)
Meet at the squamocolumnar junction. This has the transofmration zone where immature cells multiply and differentiate.
395
What is metaplasia
Where stem cells differentiate to a cell type that replaces the normal specialised cells in a tissue (replacable)
396
What is dysplasia
Fully diffrentiated cells regress into immature cells (varying)
397
Where does cervical intraepithelial neoplasia take place
In the basal layer of the transformation zone - dysplasia
398
What causes cervical intraepithelial neoplasia
HPV infection (16,18,31,33)
These invade stratified epithelial cells (immature where high cell turnover because of rubbing together of surfaces - anus)
6 and 11 are low risk and cause warts
399
High risk HPV strains vs low risk
High risk makes huge amounts of E6 and E7 proteins using host DNA which push mature squamous cells through cell replication by blocking tumour suppression genes.
Leads to uncontrolled replication.
400
RF for HPV
1. Multiple sexual partners
2. Not using condoms
3. Smoking
4. Immunosuppression
5. Early age at first sexual intercourse
401
What are koilocytes
Dysplastic, HPV infected epithelial cells
These cells accumulate in cervical epithelium from basal layer onwards.
402
Histological characteristics of koilocytes
1. Immature squamous
2. Dense, irregular staining
3. Perinuclear clearing (halo)
403
Grading of cervical intraepithelial neoplasia
1. CIN 1 (1/3rd basal layer)
2. CIN 2 (affects 2/3rds)
3. CIN 3 (Almost All epithelium)
4. CIS (in situ) entire thickness affected.
After CIS, cancerous cells break through epithelial basement membrane and cervical stroma.
Squamous cell carcnioma
The higher the grade, the more likely progression to carcnioma.
Progression fro infection to CIN to cancer is slow (can take between 10-30 years typically presents between 40-50)
404
What is the second most common type of cervical cancer
Adenocarcnioma arising from epithelial gland cells of cervix.
Associated with HPV.
405
Symptoms of cervical cancer
1. Spreads to nearing tissues like uterus and vagina- thus metastatic from cervix and can even invade through periteal cavity to abdomen and anus.
2. If it invades and blocks ureters, can cause hydronephrosis -> renal failure. As kidneys produce urine but cannot drain so causes distention of renal pelvis and kidneys.
Causes flank pain
3. Spread through lymphatic systems to lungs and liver.
Causes pelvic pain
4. Spread to bladder:
- Urinary frequency
- Dysuria
- Haematuria
5. Rectum:
Constipation
Asymptomatic for a long time:
1. Postcoital bleeding
2. Vaginal discomfort
3. Foul smelling vaginal discharge
406
How is screening for CIN and cervical cancer done
1. PAP smear to test for dysplasia (pos or neg). If pos, then colposcopy is done to obtain biopsy.
2. HPV DNA testing to see if its high risk
3. WORLDWIDE cervical cancer most common gyne cancer
407
How is CIN and cervical cancer diagnosed
1. Pelvic exam for lesionss (looks like an ulceration) + barrel shaped cervix where mass is enlarged, indurated.
2. Confirmed by biopsy and MRI for metastasis.
408
How is CIN treated
1. Local excision by cryosurgery or Conization
409
What is conization
Removal of transformation zone.
410
How is cervical cancer treated
1. Tumour removal or uterus and lymph nodes.
411
What strains does the HPV vaccine protect against
```
1. 16
18
31
33
45
52
58
```
6,11
412
What is Rokitansky protuberance
When hair, dermal appendages, bone and teeth are present, projecting from the white shiny Masses from the wall of a cystic teratoma towards the centre of the cyst.
413
What is the management steps for a negative hrHPV
1. Return to normal recall
414
4 Exceptions to a negative hrHPV test
1. test of cure pathway: individuals treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure
2. Untreated CIN1 pathway
3. Follow up for incompletely excised CIN
4. Follow up borderline changes in endocervical cells
415
What are the management steps for a positive hrHPV
1. Cytological examination of samples
| 2. Colposcopy to check for dyskaryosib , invasive cell carcinoma or glandular neoplasia
416
If cytology is normal following a positive hrHPV test, what is done
Repeat test in 12 months . I fnevative again, return to normal recall, if positive = repeat again in 12 months
417
If hrHPV remains +ve at 24 months, what should be done
Colposcopy
418
If a hrHPV sample is deemed inadequate, what should be done
Repeat sample within 3 months
419
What is premenstrual syndrome
Emotional and physical symptoms women may experience during the luteal phase of the normal mestrual cycle (e.g., anxiety, stress, fatigue and mood swings) or breast pain and bloating
420
Management of PNS
1. regular, frequent (2-3 hourly) small balanced meals rich in complex carbs
2. COCP
3. SSRIs for severe symptoms for mood.
421
Classic symptom of endometrial cancer
Postmenopausal bleeding
| 2. Premenopausal women may have changes in intermenstrual bleeding
422
Classic sign of endometriosis
1. Long history of pelvic pain, that increases in severity during menstruation. Pain reduces in the absence of mesntruation
423
What is PID
Infection and inflammation of the female pelvic organs such as the uterus, Fallopian tubes and surrounding peritoneum. Acending infections from c trachmatis, gonorrhoea and mycoplasma
424
Treatment of PID
1. Oral oflaxacin + metronidazole
425
Complications of PID
1. Fitz-Hugh Curtis Syndrome (RUQ pain) - peri hepatitis
2. Ectopic pregnancy
3. Infetility
426
How long can a urine pregnancy test stay positive for after termination
4 weeks
427
What is the trend in hCG levels following termination
Initial steep decline in first two weeks followed by gradual decline over a further two weeks
428
Who is needed to approve a pregnancy
Two medical practitioners in a listened NHS hospital
429
What is the upper limit for an abortion
24 weeks
430
What is the method used to terminate a pregnancy at 9 week gestation
Mifepristone followed by vaginal misoprostol to stimulate uterine contractions
431
When should individuals treated for CINI, 2 or 3 be invited for a follow up
6 months
432
What treatment should be given to pregnant women who have thrush
Clotrimazole pessary as fluconazole is contraindicated.
433
What is the only effective treatment for large fibroids causing fertility problems
Myomectomy
434
What is stress incontinence
The weakening or damage to the muscles preventing urination
435
What is urge incontinence
Overactivity of the detrusor muscles
436
How is urge incontinence treated
Bladder retraining
437
How is stress incontinence treated
Pelvic floor muscle training or Duloxetine
438
What is the GOLD STANDARD for endometriosis
Laparoscopy
439
Investigations for ovarian cancer
CA125
| 2. TVUSS
440
On examination, what is characteristic of endometriosis
A fixed, retroverted uterus.
441
What is the main form of vulval cancer
Squamous cell carcinoma
442
RF for vulval squamous cell carcnioma
```
over 65
HPV
VIN
Immunosuppression
Lichen Sclerosus
```
443
Features of vulval carcnioma
1. Lump or ulcer on labia majora
2. Inguinal lymphadenopathy
3. Itching and irritation
444
What is Meigs's syndrome
1. Triad of ascites, pleural effusion and banging. ovarian tumours. effusion Classically on the right
445
What is Meigs's syndrome typically associated with
1. Fibromas
446
Most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
447
Most common benign ovarian tumour in women under the age of 25
Teratoma
448
What causes a corpus lute cyst
If the pregnancy doesn't occur, the corpus lute should break down, if this doesn't happen it forms a cyst
449
Serous vs mutinous cystasenomas
Arise from the ovarian surface epithelium
Bears resemblance to serous carcinoma vs can cause pseudomyxoma peritonea.
450
Examination findings in a complete miscarriage vs a missed miscarriage
1. Empty uterus of TVUSS with heavy blood loss vs a feotus with no cardiac activity.
451
What system is used to score the severity of nausea and vomiting in pregnancies
1. Pregnancy-Unique Qualification of Emesis.
452
RF for cervical ectropion
COCP, due to higher oestrogen level.s
453
When is a laparoscopic salpingectomy indicated for an ectopic pregnancy
>35mm in size.
454
Long term complications of a vaginal hysterectomy with anteroom-posterior repair
Enterocele
| Vaginal vault prolapse
455
In what condition is a strawberry cervix (erythematous cervix with pinpoint areas of exudation) found
Trichomonas vaginalis.
456
How is stage 1 of endometrial cancer treated
Hysterectomy with bilateral salpingo-oophorectomy
457
Fibroids vs adenomyoisis
Uterus feels bulky on examination vs boggy uterus with subendometrial linear striations.
458
What is an ovulation test
Day 21 progesterone levels
459
When is a day 21 progesterone test indicated
If a woman of a reproductive age has not conceived after 1 year of unprotected vaginal sexual intercourse with no known cause for infertility.
460
Symptoms of urogenital prolapse
Seen in ODLER WOMEN:
Sensation of pressure, heaviness or 'bearing down'.
461
What ca reduce the risk of endometrial hyperplasia and carcnioma in people with PCOS
Levonorgestrel-releasing intrauterine system.
462
What is Mittelschmerz
1. Occurs due to the small amount of fluid released during ovulation. Pain settles between 24-48 hours.
463
Most common complication of pregnancy termination (including when given misoprostal and mifepristone)
Infection.
464
What is ovarian hyper stimulation syndrome
Seen in infertility treatments
1. Often result in multiple luteinized cysts causing VEGF and other vasoactive substances to surge. Causes increased membrane permeability and loss of fluid.
465
Symptoms of ovarian hyper stimulation syndrome
Mild: Abdo Pain
Abdo bleeding
Modderate: Nausea and vomiting
Ascites
Severe: Ascites
Oliguria
Haematocrit > 45%
Hypoproteinaemia
Critical: ARDS
Anuria
Tense Ascites
466
When should Semen Analysis be performed (how long should they abstain)
Between 3 to 5 days
467
When should a semen test be repeated
If there is mild oligozoospermia, repeat test in 3 months.
468
What would be seen in PID during a hysterosaplingography
Bilateral blocked Fallopian tubes
469
What is the classic triad for IBS
Abdominal Pain
Bloating
Change in Bowel Habit
470
What is fibroid degeneration
1. Uterine fibroids are sensitive to oestrogen and grow during pregnancy. If they outstrip their blood supply, they go degeneration, where they present with pain, fever and committing.
471
Management of fibroid degeneration
Rest and analgesia.
472
Role of tranexamic acid
Used to treat or prevent excessive blood loss, and often used in emergencies.
473
When do fibroids begin to regress
Following menopause
474
What is the criteria of expectant management for an ectopic pregnancy (watchful waiting)
1. An enraptured embryo
2. <35mm in size
3. No Heartbeat
4. Be asymptomatic
5. Have a B-hCG level of <1,0000 IU/L and declining.
475
When is surgical management of an ectopic pregnancy needed
1. Sizer >35mm
2. Rupturable/signs of infection
3. Pain
4. Visible foetal heartbeat
5. Serum B-hCG > 1,5000 IU/L
476
What is medical management of an ectopic pregnancy
Methotrexate
477
What level of serum progesterone indicates ovulation
>30 nmol/L
478
Three components of the Risk Malignancy Index for Ovarian Cancer
1. USS findings
2. Menopausal status
3. CA125
479
What is a vesicovaginal fistula
An opening between the bladder and the vagina
480
Symptoms of vesicovaginal fistulas
Continous dribbling incontinence after prolonged labour
481
What causes overflow incontinence
Bladder Outlet Obstruction (e.g., protostar enlargement)
482
Examination for Incontninecen
1. Bladder diaries for 3 days
| 2. Urodynamic studies
483
What is the routine cervical smear call for:
- 25-49
- 50-65
25-49: Every 3 years
50-65: Every 5 years
484
What defines menopause
Amenorrhoea for > 1 year
485
When should a cyclical HRT regime be used over continuous
When a patient has not yet achieved her menopause (perimenopausal)
486
What is cyclical combined HRT
Oestrogen is given daily, but progesterone is only used for a few weeks in the cycle.
487
What is a contraindication for HRT
Undiagnosed vaginal bleeding
Current or past breast cancer
Untreated endometrial hyperplasia
488
How long do menopausal symptoms last for
7 years
489
How are vasomotor symptoms of menopause treated
Fluoxetine
490
How long should HRT be used before stopping
2-5 years.
491
Treatment for Primary dysmenorrhoea (period pains)
NSAIDs (mefanemic acid)
492
Pharmacology of mefanemic acid
inhibits both COX-1 and COX-2 , stopping the formation of prostaglandins.
493
Investigations for an ectopic pregnancy
TVUSS
494
What investigation is needed to diagnose premature ovarian failure
FSH levels (RAISED in menopausal women)
495
What part of the reproductive system, is an ectopic pregnancy most prone to rupture
Isthmus
496
Management of women with secondary dysmenorrheoa
Refer to gynaecology
497
What condition are dysgermbnomas's associated with
Turner's
498
What do dysgerminoma's secrete
hCG and LDH
499
What do yolk sac tumours (endodermal sinus tumours) secrete
AFP
500
Where do choriocarcinoma's typically spread
To the lungs.
501
What do sertoli-leydig tumours secrete
Androgens
502
When do fibromas's occur
Menopause
503
Symptoms of fibroma's
Pulling sensation in the pelvis
504
How is a cervical IA tumour treated
Either hysterectomy with node clearance or for maintaining fertility, a c one biopsy with negative margins
505
Management of cervical stage IB tumours
Radiotherapy (brachytherapy or external beam radiotherapy) with chemotherapy (cisplatin)
506
How are stage II, III and IV tumours treated
Radiation with concurrent chemotherapy
507
Complications of radiotherapy
Ovarian failure
Bowel fiborsis
Lymphodemoa
508
Complications of a hysterectomy
Urethral fistula
509
In what condition is a whirl pool sign seen
Ovarian torsion (bowel twists around itself)
510
First line treatment for menorrhagia (heavy vaginal bleeding)
Mirena inauteirine system,
511
When does endometriosis begin to disspitate
After menopause as oestrogen levels decline.
512
Management of endometriosis
COCP
If wanting to conceive, referral to fertility services.
513
What surgery would improve fertility in women with endometriosis
Laporoscopic adhesiolysis.
514
Surgical first line intervention for ectopic pregnancy
Salpingectomy.
515
Stages of ovarian cancer metastases
1. Stage 1: confined to ovaries
Stage 2: Outside ovaries but within the pelvis
Stage 3: Outside pelvis but within abdomen
Stage 4: Distant Metastasis
516
Symptoms of a ruptured cyst vs ruptured ectopic pregnancy
Rupture is caused by intercourse or strenuous activity and has free fluid in pelvic cavity vs rupture for ectopic is unprecedented
517
What drug is given to reduce the size of the fibroid and uterus
GnRH agonist (Leuprolide)
518
Why is GnRH given before fibroid surgery
To reduce operative blood loss
519
Symptoms of APS
1. Low platelet count
2. Livedo reticulais
3. Dementia/headaches
520
Genetic markers for APS
HLA-DR4, HLA-DR7
521
Autoimmune proteins in APS
1. Anti-cardiolipin antibodies (inhibits protein C)
2. Lupus anticoagulant antibodies (bind to prothrombin, increasing cleavage to thrombin)
3. Anti-ApoH.
522
Consequences of APS
Recurrent miscarriage
2. Inauterine growth restriction
Preterm birth
523
How long do post-menopausal women have to wear contraception for (over 50)
2 years after last menstrual period (1 for people over 50)
524
What is vaginal vault prolapse
1. When the top of the vagina slips from its normal position and sags down
525
What usually causes a vaginal vault prolapse
Hysterectomy
526
Surgical treatment of vaginal vault prolapse
Sacrocolpopexy
527
What is the secrocolpopexy
Suspends the vaginal apex to sacral promontory
528
What is a cystocele
When the wall between the bladder and th evagina weekends, causing the bladder to drop or sag into the vagina
529
RF for cystocele
Age
Overweight
Child birth
Heavy lifting
530
Symptoms of a cystocele
Pelvic heaviness or fullness
Lower back pain
UTIs
Urinary urgency, frequency, hesitancy, poor flow, post micturition dribbling and feeling of an incomplete bladder.
531
Surgical treatment of a cystocele
Anterior colporrhaphy
532
Management of a cystocele
Keagel's
533
Surgical intervention of a uterine prolapse
Hysterectomy
534
Surgical intervention of a rectocele
Posterior colporrhaphy
535
What gynaecological condition can cause Wernicke's encephalopathy
Hyperemesis Gravidarum
536
When should progesterone levels be checked when checking for subferitlity
Day 21 OR 7 days before the end of the cycle.
537
Most common type of epithelial cell tumour
Serous cyst adenoma
538
Most common form of secondary amenorrhoea in a very athletic woman and why
Hypothalamic hypogonadism:
Because in women with low fat levels, the hypothalamus releases less GnRH = hypogonadism
Less successful pregnancies!
539
What criteria is used to diagnose PCOS
Rotterdamn criteria
540
What is the Rotterdam criteria
Anovulation and Hyperandrogenism
541
How should a HIV patient be screening for CIN
Annual cervical cytology.
542
Describe the RAAS system
The juxtaglomurelar cells contain Baroreceptors to detect low BP
1. High BP: Inhibit Renin release
2. Low BP: Stimulate Renin release
2. Information travels to mechanoreceptors via the sympathetic nerve fibres at the carotid sinus and aortic arch.
3. Macula Densa Cells detect GFR: When BP rises, GFR rises. More fluid and Na+ and Cl- reach macula densa. which is sent back to the baroreceptors of the juxtaglomerular cells
4. Renin -> plasma -> angiotensinogen -> cleaves -> angiotensin I -> flots to the livers -> endothelial cell ACE cleaves 2 amino acids -> angiotensin II
Angiotensin II binds to receptors, causing smooth muscle contraction. and aldosterone secretion
Causes efferent arterioles to constrict or dilate.
543
What is produced in the zone resticularis
DHEA and Androstenedione
544
What is produced in the zone fascilculata
Glucocorticoids (cortisol)
545
What is produced in the zone glomerulosa
Mineralocorticoids (aldosterone)
546
Role of aldosterone
Binds to DCT cells, Na+/K+ move K+ from blood into the urine and Na+ from tubules into blood. Water moves in with Na+ to increase BP
Binds to alpha-intercalated cells ATPase pumps, excreting H+ and moving HCO3- ions into extracellular space = metabolic alkalosis
547
Common source of a krukenberg tumour
Gastric adenocarcinomas
548
Management of gender identity crisis
1. Referral to gender identity clinic
| 2. Referral to local psychiatric services if low mood or deliberate self harm involved
549
How many assessments do a gender identity clinic require
Typically 2
550
Cosmetic surgery for a trans male
Bilateral mastectomy with male chest reconstruction
551
What two surgeries are conducted for trans male
Hysterectomy
Oopherectomy
552
What does the NHS not fund for trans patients
ENT, mammoplasty or facial surgery
553
When can cross sex hormones be prescribed
16 years old
554
What medications are given to trans women
```
SC Goserelin (1 or 3 months)
Leuprorelin
```
Estradiol Valerate
Finasteride
Cyproperone Acetate
Sprinolcatone
555
When are gel and transdermal patches of estradiol particularly indicated
Over 40, smokers or chronic disease due to DVT
556
What is Goserelin
A GnRH agonist, : increases LH production before sensitising receptors and inhibiting LLH and FSH production: prevents development of secondary sex characteristics.
557
Four effects of feminising hormones
1. Body fat redistribution
2. Decreased muscle mass
3. Skin Softening
4. Decreased libido
5. Decreased erections
6. Breast growth
6. Reduced sperm countr
558
How long does it take for feminising hormones to take effect
3-6 months
559
Risks of feminising hormones
1. DVT
2. Gallstones
3. Elevated LFTs
4. Weight Gain
560
How do feminising hormones affect prostate cancer
Reduces it
561
When iso estradiol stopped during surgery (trans)
1. 4-6 weeks before. GnRH analogues do not need to be stopped.
562
When can GnRH analogues be stopped
After gonadectomy
563
What treatment is lifelong in trans women
Oestradiol
564
How often do trans women need to be monitored for
6 monthly
565
How long do trans men need testosterone for
Life long
566
Why does haematocrit levels need to be monitored in trans men
Because adult male RBC mass is greater than in women.
567
How is testosterone given to trans men
Testosterone undecanoate (1gm in 4mls every 10-20 weeks)
568
How do topical testosterones need to be taken
Serum levels of testoesterone need to be taken 4-6 hours after application
569
If Hb are elevated in trans men, what should be done to the testosterone dose
Needs to be reduced
570
How is ovarian suppression done
Goserelin implant every 4 weeks and then moved to 12 weeks 10.8mg dose.
571
Side effects of goserelin
Hot flushes
Depression
Loss of libido
572
When is goserelin contraindicated in trans men
Pregnancy
573
Why is ovarian suppression done
To achieve estradiol levels similar to men
574
When in management is ovarian suppression introduced
After the introduction of testosterone.
575
4 effects of masculinising hormone therapy
```
Clitralmegaly
Body fat redistribution
Vaginal atrophy
Cessation of menses
Deep voice
```
576
Risks of masculinising hormones
1. Polycythaemia (can cause strokes)
2. Weight Gain
3. Acne
4. Androgenic alopecia
577
What is the implication of Oligospermia/ Azoospermia with:
Raised serum FSH and LH
Low Testosterone levels
Primary defect in spermatogenesis (hypergonadroptopic hypogonadism)
578
Threshold for oligohydramnios
AFI <5
579
Theshold for polyhydramnnios
AFI >8
580
Why does hyperemesis gravid arum cause metabolic alkalosis
LOSS OF H+,
581
How is metabolic alkalosis corrected
Pancrease produces HCO3- but this ends up in the blood not the intestines
582
First line treatment to treat infertility in PCOS
Letrozole (not clomiphene citrate)
583
Pharmacology of letrozole
1. Aromatase inhibitor, reduces negative feedback caused by oestrogen, increasing FSH proudction and allowing follicular rupture
584
Treatment of a prolactinoma
Bromocriptine
585
Pharmacology of bromocriptine
Dopamine receptor agonist
586
What is the first line treatment for obese women with PCOS struggling to conceive
Metformin
587
How should hirsutism be managed
COCP
588
Treatment of recurrent vaginal candidasis
Oral fluconazole (think Tom)
589
What is the action of metformin
Increases peripheral insulin sensitivity
590
What family history is a strong precursor for endometrial cancer
HNPCCC/ Lynch Syndrome.
591
What other structures may ovarian cysts press against
The Bladder (signs of urinary frequency etc)
592
When is referral for facial hair depilation or mastectomy
12 months
593
When are hormone therapy started
6 months
594
How long does transition tend to take
3-5 years
595
Name three anti-androgens
Finasteride
Cypropterone
Spironolactone (androgen receptor antagonist)
596
What medication is given to trans men to control mensturtaion
GnRH agonist
597
Two forms of testosterone
IM injection
Transdermal gel
598
How often are injections monitored for (trans mens hormones)
3 months (6-8 weeks for transdermal patches)
599
Continual monitoring for transmen
Every 6 months for 3 years
600
Main risk of feminising hormones
VTE
601
When are feminising hormones reduced in dose
After the age of 50.
602
What is the initial management of a miscarriage
Vaginal misoprostol
603
What is th gold standard for diagnosing adenomyosis
MRI
604
What is the initial management of a medical abortion
Mifepristone and prostaglandins (misoprostol)
605
Is a migraine with aura, a contraindication for HRT
No
606
How is HRT given
Topical
607
If a patient has a mirena coil, what HRT is given
Oestrogen patch as the patient's mirena coil supplies progesterone.
608
What is the primary treatment for stage2-4 ovarian tumours
Surgical excision of tumour
609
Why is a transdermal/topical HRT preferred over Oral
Does not increase risk of VTEs
610
How is a pregnant woman under 6 weeks managed if they have vaginal bleeding or cramps
Send the patient home and manage expectantly
611
What factor is most associated with a miscarriage
Obesity
612
What test is done to check for vesicovaginal fistulae
Urinary dye studies
613
In what two conditions is cervical excitation found in
PID, Ectopic Pregnancy
614
What is the most common cause of recurrent first trimester miscarriages
APL
615
What is the most common cause of postcoital bleeding
Cervical ectropion
616
How to treat glandular atrophy of endometriosis
Oral Progestagens
| Depot Provera or Mirena
617
Adenomyosis vs Endometriosis
Endo metriosis is in young and nulliparous women
Adenomyosis happen in older women with multiparty
618
A patient presents with an ovarian mass. Investigations reveal a tumour with cells secreting mucin and peripheral nuclei. What tumour is this
This is a Kurkenburg tumour, remember signet ring cells appearance under microscopy.
619
What ratio is found in lab tests, that suggest PCOS
Elevated LH:FSH ratio (remember, elevated serum oestrogen will inhibit FSH production)
620
What virus can cause hydros fetalis in the womb
Parvovirus 19
(remember: slapped cheek appearance).
621
What is the fried egg appearance of a dysgerminoma
Germ cells with clear cytoplasm surrounding a central nucleus.
622
What would be seen on a bimanual examination for chlamidyia
Cervical motion tenderness (cervicitis)
More likely to be chlamidyia than gonnorheoa as it's more prevalent.
623
What genetic mutation causes turner's syndrome
Only one chromosome is functional
624
What is the consequence of prolonged tampons or alien objects in the vagina
Toxic Shock Syndrome: Staph Aureus infection that causes diffuse erythema that desquaminates as the patient recovers. Also fever, confusion and abdominal pain.
625
Risk Factors for VTE
```
T - Trauma or Travel
H - Hospitalisation
R - Relatives (e.g., V Leiden)
O - Old Age
M - Malignancy
B - Bone Fractures
O - Obesity and Obstetrics
S - Surgery
I - Immobility
S - Sickness (e.g., APL, Paroxysmal Nocturnal Haemoglobinuria, Nephrotic Syndrome)
```
626
What medications can cause folic acid deficiency
Phenytoin
methotrexate
Pregnancy
Alcohol Excess
627
First Line Treatment of Candidasis
Itraconazole
628
What chronic gynecological problem is associated with Ovarian Hyperstimulation Syndrome
PCOS
629
What medication is used to treat endometrial cancers
Provera (Medroxyprogesterone) - Slows the growth of malignant cells
630
In what Endometrial cancer stages is a total abdominal hysterectomy with bilateral salpingoopherectomy done
Stage I and II
631
How is stage IIB endometrial carcinoma treated
Wertheim's radical hysterectomy (removal of the lymph nodes as well)
632
What is the most common complication of a myomectomy
Adhesions
633
Indications for referral to colposcopy in two weeks (emergency)
Remember - standard is 6 weeks
Usually 2 weeks if there is high-grade dyskaryosib (moderate or severe) on cytology
634
Indications for 6 week colposcopy reviews
Inadequate results
Borderline
Low grade (mild) dyskaryosib
635
Ovarian Cysts vs Fibroids presentation
Fibroids develop on the uterus (suprapubic tenderness) while Ovarian cysts are unilateral, flank pain
636
When are medical treatments for menorrhagia contraindicated
If the fibroid is over 3cm in size (IUS, tranexamic acid and COCP are all contraindicated)
637
What chronic gynaecological condition is a risk factor for ectopic pregnancy
Endometriosis
638
Name the two types of abnormalities that can be found on a Pap smear
Atypical Swuamous Cells
| Cervical Squamous Intrsepithelial Lesions (CSIL)
639
What is a barrel-shaped cervix
In cervical cancer: When the tumour develops under the endocervical canal, looks like a mass on speculum examination
640
What is the difference between stage Ia and stage IB cervical cancer
Ia - Can only be seen under a microscope + <5mm
Ib - Seen with the naked eye/ >5mm
641
What is stage 2 cervical cancer (2a and 2b)
IIA - Upper 2/3rds of the vagina
| IIB - Spread to parametric
642
What is stage 3 cervical cancer (IIIa, IIIb, IIIc)
IIIa - Lower 3rd of vagina
IIIb - Pelvic wall and ureters
IIIc - Lymph nodes
643
What is stage four cervical cancer
Adjacent organs or Distant organ spread
644
What is diagnostic for chlamidyia and gonorrhoea
NAAT using a urine sample
Then a urethral swab for gonorrhoea if NAAT is positive
645
What results indicate a successfully treated SYphilis
VDRL negative, TPHA positive
646
What factor determines if someone with PID must come into the hospital
a fever > 38 degrees
647
How long must the pain last to diagnose endometriosis
Over 6 months
648
What is the second line management if COCP is contraindicated
Mirena Coil/progesterones
649
What ethnicity is associated with increased risk of ectopic pregnancies
Black Race
650
What are the wolffish ducts
Embryonic structures that form the male genitalia (stabilised by testosterone)
651
What is the most common type of ovarian tumour in pre-menopausal women
Germ cell ovarian tumour
Epithelial Ovarian Tumour is the most common overall but most commonly arise in postmenopausal women
652
When is a salpingostomy indicated over a salpingectomy
Incision into the Fallopian tube to remove the pregnancy
Usually preferred/ first line if there has been damage/surgery/infection to the other tube - to preserve fertility
653
When should PID always be suspected
Leucocytosis + Fever
654
What is the first line investigation done for suspected ovarian cancers/cysts
Usually a TransABDOMINAL USS in girls who aren't sexually active
Then a TVUSS in sexually active girls.
655
How does Hereditary haemochromatosis lead to amenorrhoea
Iron overload - deposits in the hypothalamus and ovaries.
Accompanied by Joint Pain and LIVER FIBROSIS
656
Name two fertility saving treatments used in Grade IA CIA
Cone Biopsy
Radical Trachlectomy (removal of cervix, upper vagina and pelvic lymph nodes)
Followed by cervical cerclage
657
What USS finding points to atrophic vaginitis over endometrial cancer
ENDOMETRIAL THINNING - Less than 5/4mm in thickness
658
What is the most likely diagnosis for PV bleeding in post menopausal women
Atrophic Vaginitis - most likely diagnosi s
But should be sent for Gynecological assessment to check for endometrial cancer
659
First line management of complex cysts (multiloculated)
No matter what the size is, these need a biopsy to exclude malignancy
660
What are the M rules for an ovarian cyst
```
irregular, solid
Ascites
At least 4 papillary sturctures
Irregular multilocular solid tumour
Very strong blood flow
```
Any of these, and the cyst would need a biopsy
661
What factor reduces the risk of hyperemesis gravidarum
Smoking
662
Why is a beta-HCG test repeated in 48 hours
Viable Intrauterine Pregnancy: HcG levels will double
Ectopic: hCG stays the same
Miscarriage: hCG will drop
663
When is surgery indicated for fibroids
Over 3 cm
664
When is the mirena coil contraindicated in fibroids
If there is too much distortion of the cavity
Otherwise, it's still first line
665
What is anenterocele
Prolapse of the small bowel
666
What is the first line investigation for endometriosis
TVUSS
Then lapporoscopy as it can cause bowel perforation for no reason if they do not have endometriosis
667
What feature of an ovarian mass means urgent referral to hospital services
Over 50:
Abdo distention
Pelvic Pain
Urinary symptoms
668
Management of Bartholin's gland
Incision and drainage
669
When is oestrogen HRT indicated
Hysterectomy (no uterus)
| On a progesterone pill
670
What is the first line treatment of vasomotor symptoms of menopause
HRT
Then Sertraline (actually second line)
671
How to treat low sex drive n Hot
Testosterone alongside HRT
672
Treatment of urogenital atrophy in menopause
Vaginal oestrogen with HRT
673
Side effect of HRT
Initial irregular bleeding, must take note of this
674
First line investigation in adenomyosis
TVUSS
675
Immediate management of a uterine fibroid if a woman is trying to conceieve
Transexamic Acid
Mirena coil is not an immediate management
676
Why is Metformin given for PCOS
1. Regulates LH secretion
2. Reduces gluconeogenesis in the liver (less androgens produced)
3. Apetite Reduction
4. Decreases sex-hormone binding globulin in the liver
677
First line treatment of stage IA1
Conservative management or cone biopsy
678
Management of Stage IA2-IIA cervical cancer
<4cm = radical hysterectomy with lymphadenectomy
>4cm = Chemoradiation
<2cm and wanting to conceive: Radical Trachlectomy and lymphadenectomy
679
First line management of Stage IIB-IVA:
Chemotherapy
680
IF TVUSS for suspected endometriosis is normal, what should be done
Laporoscopy
681
What surgical intervention Is used for endometriosis if fertility is not a priority
Laporoscopic excision
682
Before laparoscopic excision, what should be given to patients
GnRH 3 months before surgery
683
A woman presents with high BMI, hyperpigmentation and thickening of the skin across the back of her neck and in both axilla, what is the most likely diagnosis
PCOS! Acanthas Nigrans from insulin resistance
684
What is secondary dysmenorrhoea
Defined as painful mensturation secondary to pathology
685
Define primary dysmenorrhoea
Painful mensturtaion in the absence of underlying pathology
686
When should 3-monthly cyclical HRT be used compared to 1-monthly
3 monthly - irregular periods
1 monthly - regular periods
Perimenopausal women
687
When should we conduct a blood hcg test vs immediate transfer to early pregnancy assessment unit
Blood HCg - pregnancy of unknown location
Immediate referral - symptomatic abdominal pain, requiring USS
688
When is an USS contraindicated for extopics
Before 5 weeks, an ectopic is known as a PUL and requires b-hcg. A ectopic can’t be seen on the scan before 5 weeks so no point admitting to early pregnancy assessment unit.
Over 5 weeks = assessment in hospital and USS
689
When is expectant management indicated for ectopic pregnancies
Clinically stable and pin free
hCG levels < 1,000
690
What is expectant management of an ectopic
Repeat hCG on days 2, 4 and 7
To continue expectant management, should only drop by 15%
691
When is methotrexate given for ectopic
hCG: 1,000-1,500
Have pain but not significant
692
When should surgery be used as first line treatment for ectopic
Unable to return for follow-up
Significant pain
hCG > 5,000
Adnexal mass > 35mm
Visible foetal heartbeat
Anyone with hCG 1,500-5,000 can be offered either depending on their pain and the other factors we’ve discussed
693
When should you offer OGTT to PCOS women
Impaired fasting glucose (6.1 to 6.9)
694
Should metformin be offered in primary care for PCOS
No
695
What does low sex hormone-binding globulin levels indicate
Marker for insulin reisstance
696
What medication can be given to induce a bleed in prolonged amenorrhoea
Medroxyprogesterone for 14 days
Then TVUSS
697
First line treatment of acne and hirsutism
COCP
698
First line management for cyclical breast pain
As the woman to keep a pain diary
Re-assurance, tell to wear bra's
699
When in PCOS should women be offered OGTT
700
First line management of Grade 1, low grade dyskariosis in CIN
DO NOT TREAT - Just watchful management and refer for another screen in 12 months time
701
What size endometrium would indicate endometrial hyperplasia and a need for a biopsy
>4mm
702
Expectant management vs Medical Management of an ectopic pregnancy
Asymptomatic vs little pain
B-HCG < 1,000 vs B-hCG < 1,500
703
Why is a withdrawal bleed done for women with PCOS
Because, intervals >3 months between periods causes endometrial hyperplasia in women with PCOS. Giving medroxyprogesterone or an IUS provides opposing oestrogen to keep the endometrium at its current size
704
Under what size, is a cyst considered simple/non concerning
<5cm
705
Indications for an endometrial biopsy at hysteroscopy
Persistent intermenstrual bleeding in women aged 45 or older
706
If Clomiphene/Letrozole fail in fertility management for someone with PCOS, what is the second line management
Second Line: Ovarian Drilling
Third Line: IVF
707
When should a pelvic ultrasound be used in suspected ovarian cancer
Serum CA-125 -> Pelvic USS
Only do a pelvic USS if >35 IU/ml
