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Obs and Gynae > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What are fibroids?

A

Benign tumours of the smooth muscle of the uterus

Also called uterine leiomyomas

Affecting 40-60% of women in later reproductive years

Grow in response to oestrogen

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2
Q

Types of fibroids (4)

A

Intramural - within the myometrium

Subserosal - just below the outer layer of the uterus

Submucosal - just below the lining of the uterus

Pedunculated means on a stalk

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3
Q

How do fibroids present?

A

Often asymptomatic

Heavy menstrual bleeding (most common)

Prolonged menstruation, lasting more than 7 days

Abdominal pain, worse during menstruation

Bloating or feeling full in the abdomen

Urinary or bowel symptoms due to pelvic pressure or fullness

Deep dyspareunia (pain duringintercourse)

Reduced fertility

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4
Q

Investigating fibroids

A

Abdominal and bimanual examination may reveal a palpable pelvic mass

Hysteroscopy is the initial investigation

Pelvic ultrasound for larger fibroids

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5
Q

What is the management of fibroids <3cm?

A

Same as heavy menstrual bleeding

Mirena coil

Symptomatic management with NSAIDs and tranexamic acid

Combined oral contraceptive

Cyclical oral progestogens

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6
Q

What is the management of fibroids >3cm?

A

Referral to gynaecology

Medical management as <3cm

Surgery:
Uterine artery embolisation
Myomectomy
Hysterectomy

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7
Q

What are the potential complication of fibroids? (8)

A

Heavy menstrual bleeding, often with iron deficiency anaemia

Reduced fertility

Pregnancy complications, such as miscarriages, premature labour and obstructive delivery

Constipation

Urinary outflow obstruction and urinary tract infections

Red degeneration of the fibroid

Torsion of the fibroid, usually affecting pedunculated fibroids

Malignant change to a leiomyosarcoma is very rare (<1%)

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8
Q

What is red degeneration of fibroids?

A

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply

More likely in fibroids >5cm during 2nd/3rd trimester

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9
Q

How does red degeneration of fibroids occur?

A

Pregnant, hx of fibroids

Severe abdominal pain

Low-grade fever

Tachycardia

Often vomiting

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10
Q

What is endometriosis?

A

Where there is ectopic endometrial tissue outside the uterus

Endometrial tissue outside the uterus is described as an endometrioma

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11
Q

What are the symptoms of endometriosis?

A

Pelvic pain
Cyclical, dull, heavy or burning pain during menstruation

Deep dyspareunia

Dysmenorrhoea

Infertility

Cyclical bleeding from other sites, such as haematuria`

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12
Q

What is found in examination of endometriosis?

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix

A fixed cervix on bimanual examination

Tenderness in the vagina, cervix and adnexa

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13
Q

How is endometriosis diagnosed?

A

Ultrasound may reveal large endometriomas and chocolate cysts
Often unremarkable

Need referral to a gynaecologist for laparoscopy (GOLD STANDARD)

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14
Q

Staging of endometriosis

A

Stage 1: Small superficial lesions

Stage 2: Mild, but deeper lesions than stage 1

Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions

Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

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15
Q

What does the management of endometriosis invole?

A

Initial management

Hormonal management

Surgical management

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16
Q

What is the initial management of endometriosis?

A

Establishing a diagnosis

Providing a clear explanation

Listening to the patient, establishing their ideas, concerns and expectations and building a partnership

Analgesia as required for pain (NSAIDs and paracetamol first line

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17
Q

What is the hormonal management of endometriosis?

A

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful

Progesterone only pill

Medroxyprogesterone acetate injection (e.g. Depo-Provera)

Nexplanon implant

Mirena coil

GnRH agonists

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18
Q

What is the surgical management of endometriosis?

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)

Hysterectomy

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19
Q

What is menopause defined as?

A

Permanent end to menstruation

No periods for 12 months - then postmenopause

Around age of 51

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20
Q

What is premature menopause?

A

Period from 12 months after the final menstrual period onwards

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21
Q

What is perimenopause?

A

Time leading up to menopause and 12 months after

May experience vasomotor symptoms and irregular periods

Typically >45

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22
Q

What are perimenopausal symptoms?

A

Hot flushes

Emotional lability or low mood

Premenstrual syndrome

Irregular periods

Joint pains

Heavier or lighter periods

Vaginal dryness and atrophy

Reduced libido

23
Q

Risks associated to menopause

A

Cardiovascular disease and stroke

Osteoporosis

Pelvic organ prolapse

Urinary incontinence

24
Q

Management of perimenopausal symptoms

A

No treatment

Hormone replacement therapy (HRT)

Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)

Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors

Cognitive behavioural therapy (CBT)

SSRI antidepressants, such as fluoxetine or citalopram
(SNRI - Venlafaxine)

Testosterone can be used to treat reduced libido (usually as a gel or cream)

Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)

Vaginal moisturisers, such as Sylk, Replens and YES

25
When is progesterone used in HRT?
In women that have a uterus Prevent endometrial hyperplasia and endometrial cancer
26
What are the indications for HRT?
Replacing hormones in premature ovarian insufficiency, even without symptoms Reducing vasomotor symptoms Improving symptoms such as low mood, decreased libido, poor sleep and joint pain Reducing the risk of osteoporosis
27
Risks of HRT (5)
Increased risk of breast cancer Increased risk of endometrial cancer Increased risk of venous thromboembolism (2 – 3 times the background risk) Increased risk of stroke and coronary artery disease with long term use in older women The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
28
Contraindications for HRT (8)
Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy
29
What is premature ovarian insufficiency?
Menopause before the age of 40 years Presents with early onset of the typical symptoms of the menopause
30
What are the causes of POI? (5)
Idiopathic (the cause is unknown in more than 50% of cases) Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease Genetic, with a positive family history or conditions such as Turner’s syndrome Infections such as mumps, tuberculosis or cytomegalovirus
31
What iare the features of PCOS?
Multiple ovarian cysts Infertility Oligomenorrhea Hyperandrogenism Insulin resistance
32
What is the rotterdam criteria?
Used for making a diagnosis of polycystic ovarian syndrome Requires at least two of the three key features: Oligoovulation or anovulation, presenting with irregular or absent menstrual periods Hyperandrogenism, characterised by hirsutism and acne Polycystic ovaries on ultrasound
33
How does PCOS present? (6)
Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern
34
What can cause hirsuitism?
PCOS Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids Ovarian or adrenal tumours that secrete androgens Cushing’s syndrome Congenital adrenal hyperplasia
35
What do PCOS bloods show?
Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH) Raised testosterone Raised insulin Normal or raised oestrogen levels
36
How is PCOS diagnosed?
Transvaginal ultrasound - GOLD STANDARD Follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance
37
Risk associated with PCOS
Several risk factors for endometrial cancer: Obesity Diabetes Insulin resistance Amenorrhoea
38
In what population are ovrian cysts more worrying?
Postmenopausal women
39
Presentation of ovarian torsion
Sudden onset severe unilateral pelvic pain Pain is constant, gets progressively worse Associated with nausea and vomiting Usually due to ovarian cyst More common in pregnancy
40
How is ovarian torsion diagnosed?
Pelvic USS
41
What is cervical ectropion?
Columnar epithelium of the endocervix as extended out to the ectocervix More fragile and prone to trauma - more likely to bleed with trauma
42
How does cervical ectropiom present?
Often asymptomatic May present with: Increased vaginal discharge Vaginal bleeding Dyspareunia Postcoital bleeding
43
What is pelvic organ prolapse?
Descent of pelvic organs into the vagina Result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
44
What is uterine prolapse?
The uterus itself descends into the vagina
45
What is vault prolapse?
Vault prolapse occurs in women that have had a hysterectomy Top of the vagina (the vault) descends into the vagina
46
What is a rectocele?
Defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina Associated with constipation
47
What is a cystocele?
Defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
48
Risk factors for prolapse?
Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and postmenopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining
49
How is prolapse managed?
Conservative management Vaginal pessary Surgery
50
What is atrophic vaginitis?
Refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen AKA genitourinary syndrome of menopause
51
How does atrophic vaginitis present?
Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation Consider in women with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse
52
What is seen on examination of atrophic vaginitis?
Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair
53
How is atrophic vaginitis managed?
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES Topical oestrogen - Estriol cream, applied using an applicator (syringe) at bedtime Estriol pessaries, inserted at bedtime Estradiol tablets (Vagifem), once daily Estradiol ring (Estring), replaced every three months

Obs and Gynae (19 decks)

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