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Gynaecology Flashcards

1
Q

DIFFERENT DIAGNOSES

  1. What are the two types of Amenorrhoea?
  2. What are causes of primary Amenorrhoea?
  3. What are causes of secondary Amenorrhoea?
  4. What are some investigations to determine the cause of Amenorrhoea?
  5. What are some causes of irregular bleeding?
  6. What are some causes of dysmenorrhoea (painful periods)?
  7. What are some causes of Intermenstrual bleeding?
  8. What are some causes of Menorrhagia?
  9. What are some causes of post-coital bleeding?
  10. What are some causes of Pelvic pain?
  11. What are some causes of Vaginal discharge?
A
  1. Primary and secondary (had periods before)
  2. Hypogonadotrophic Hypogonadism, Hypergonadotrophic hypogonadism, Imperforate hymen
  3. Pregnancy (most common), menopause, physiological stress, medications i.e. contraception, PCOS, premature ovarian failure, thyroid issues (hyper / hypo), prolactinoma, Cushing’s
  4. Pregnancy test (Beta-hCG), TFTs (hypothyroidism), Prolactin levels (Increased in prolactinoma), Serum Oestriol (premature ovarian failure), Androgen levels (low in PCOS), Gonadotropins (low if hypothalamic dysfunction)
  5. Extremes of age (menarche, menopause), Physiological stress, hormonal issues (thyroid, prolactin, cushing’s), medications i.e. POP, antidepressants, antipsychotics
  6. Primary (no cause), endometriosis, adenomyosis, PID, copper coil, fibroids, ovarian and cervical cancer
  7. Cervical, Endometrial, Vaginal cancer. Hormonal contraception, Pregnancy, medications i.e. SSRIs, anticoagulants
  8. Dysfunctional Menorrhagia (no cause), Copper Coil, PID, Endometriosis, Fibroids, Anticoagulant drugs, Bleeding disorders, Endocrine, PCOS, Endometrial hyperplasia / cancer
  9. Cervical cancer, cervical ectropion, trauma, cervical polyps, endometrial cancer, vaginal cancer
  10. UTIs, dysmorrhoea, IBS, ovarian cysts, ovarian torsion, ovarian rupture, endometriosis, PID, appendcitis, mittelschmerz, ectopic
  11. Can be physiological, Bacterial vaginosis, Chlamydia, Candidiasis, Gonorrhoea, Trichomonas, Foreign body, Ovulation (cyclical)
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2
Q

BACTERIAL VAGINOSIS

  1. What is it?
  2. What are the risk factors?
  3. What should be asked when history taking?
  4. What is the presentation?
  5. What do you tend not to get with BV? If you do, what may this mean?
  6. What are the investigations and findings?
  7. What is the management?
  8. What should you advise patients to do regarding management and why?
A
  1. An overgrowth of anaerobic organisms i.e. Gardnerella Vaginalis due to loss of lactobacilli which usually keeps pH low in vagina
  2. Multiple sexual partners, excessive vaginal cleaning, recent ABX, copper coil
  3. Sensitively ask about using soaps to clean vagina
  4. Fishy, grey watery discharge. Otherwise asymptomatic
  5. Tend not to get itching, irritation or pain. Otherwise consider another diagnosis or co-occurring infection
  6. Positive whiff test. Vaginal pH via swab and pH paper, >4.5, and high / low vaginal swab shows “clue cells”
  7. If asymptomatic, no treatment. Otherwise 5-7 day course of Metronidazole
  8. Avoid alcohol, due to Disulfiram reaction
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3
Q

CANDIDIASIS

  1. What is it?
  2. What are risk factors?
  3. What is the presentation?
  4. What are the investigations?
  5. What is the management?
  6. What should you advise patients to do regarding management and why?
A
  1. A fungal infection caused by candida albicans
  2. Diabetes mellitus, immunosuppression i.e. steroid use, using antibiotics for another infection
  3. Thick, white discharge with NO SMELL. May have itching and irritation. In severe cases erythema, oedema, dyspareunia
  4. Usually clinical diagnosis. Vaginal pH test will be < 4.5, and vaginal swab can confirm diagnosis
  5. Antifungal cream. pessary or oral antifungal i.e. Clotrimazole. OTC Canesten Duo
  6. To use other forms of contraception for five days after, as it can damage latex condoms
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4
Q

In general, when a patient attends a GUM clinic for STI screening, as a minimum, they are tested for what?

A

Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)

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5
Q

CHLAMYDIA

  1. What is the pathogen which causes Chlamydia?
  2. What is the incubation period?
  3. What are the features in women?
  4. What are the features in men?
  5. What are the risk factors?
  6. Outline the National Chlamydia Screening Programme
  7. What is the first-line investigation?
  8. What is the medical management for Chlamydia?
  9. What is the medical management for Chlamydia if pregnant?
  10. What are other points to consider when managing a patient for Chlamydia?
A
  1. Chlamydia trachomatis
  2. 1-3 weeks
  3. Discharge, bleeding, dysuria (can be asymptomatic)
  4. Discharge and dysuria (can be asymptomatic)
  5. Young, sexually active, multiple partners
  6. Screening every sexually active person under 25 annually or when they change partners
  7. Vulvovaginal swab for women or urine test for men, for the NAAT (Nucleic acid Amplification Test)
  8. Doxycycline for 7 days
  9. Azithromycin, Clarithromycin or Erythromycin
  10. No sex for the 7 days of treatment, refer patients to GUM clinic for contact tracing and offer patients treatment before results come back, Test and trace for other STIs, advice + education
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6
Q

What is the most common STI in the UK?

A

Chlamydia

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7
Q

PELVIC INFLAMMATORY DISEASE

  1. What is it?
  2. What are the causes of Pelvic Inflammatory Disease?
  3. What are the features of PID?
  4. What are risk factors of PID?
  5. What are the investigations?
  6. What is the management?
  7. What are some complications of PID?
  8. Outline the liver complication of PID?
A
  1. Inflammation and infection of the organs of the pelvic, caused by an ascending infection from cervix
  2. Neisseria gonorrhoea, chlamydia trachomatis, mycoplasma genitalium
  3. Suprapubic abdominal pain, fever, deep dyspareunia, dysuria, menstrual irregularities, vaginal discharge
  4. Multiple sexual partners, not using barrier contraception, younger age, copper coil, existing STI, previous PID
  5. Pregnancy test to rule out ectopic pregnancy, NAAT for gonorrhoea, chlamydia, mycoplasma. High vaginal swab for BV and candidiasis, CRP and ESR may be elevated, microscopy showing PUS CELLS
  6. Refer to GUM clinic for management and contact tracing. One off dose of IM Ceftriaxone, oral doxycycline and oral metronidazole. Remove IUD if severe PID
  7. Ectopic pregnancy, infertility / subfertility, chronic pelvic pain, sepsis, FITZ-HUGH CURTIS SYNDROME
  8. Inflammation of the liver capsule (Glisson’s capsule), causing RUQ and referred shoulder tip pain
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8
Q

GONORRHOEA

  1. What type of bacteria is Neisseria Gonorrhoeae?
  2. Where can Gonorrhoea affect?
  3. What are the risk factors?
  4. What are the clinical features?
  5. What are the investigations?
  6. How may you manage Gonorrhoea?
A
  1. Gram negative diplococci
  2. Mucous membranes of columnar epithelium, i.e. endocervix, urethra, rectum, pharynx, conjunctiva
  3. Young, sexually active, multiple partners, other STIs i.e. HIV / Chlamydia
  4. Green, yellow purulent and odourless discharge, dysuria, pelvic pain, testicular pain / swelling in men, pharyngeal infection i.e. sore throat, conjunctivitis
  5. NAAT via swab or urine test, rectal / pharyngeal swab for MSM, standard charcoal swab for microscopy, culture, sensitivities
  6. One-off dose of IM Ceftriaxione (if unknown sensitivities) or oral ciprofloxacin (if known sensitivites). If patient refuses IM injection, consider Cefixime and Azithromycin.

Abstain from sex for 7 days, test and treat for other STIs, patient education and advice

NAAT Test of Cure if asymptomatic, blood cultures if symptomatic

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9
Q

TRICHOMONAS

  1. What are the features of Trichomonas?
  2. What are the investigations and findings?
  3. What is the management?
A
  1. Offensive, yellow / green vaginal discharge, strawberry cervix
  2. Vaginal pH >4.5 (similar to BV), microscopy will show motile trophozoites
  3. Metronidazole (similar to BV)
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10
Q

GENITAL HERPES

  1. What is HSV-1 associated with?
  2. What is HSV-2 associated with?
  3. What are the features of genital Herpes?
  4. How is it genital herpes diagnosed?
  5. How is it managed?
A
  1. Cold sores
  2. Genital herpes
  3. Ulcers and blistering of genitalia, neuropathic pain, flu-like symptoms, dysuria, inguinal lymphadenopathy
  4. Refer to GUM, oral acyclovir. Conservative measures i.e. paracetamol, topical lidocaine 2%, topical vaseline, loose clothing, avoiding intercourse
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11
Q

MENORRHAGIA

  1. What is it defined as?
  2. What are some LOCAL causes of Menorrhagia?
  3. What are some SYSTEMIC causes of Menorrhagia?
  4. What are the investigations for Menorrhagia?
  5. What are general principles of managing Menorrhagia?
A
  1. Normal is 40ml, menorrhagia is >80ml however is very dependent on woman / subjective
  2. Dysfunctional Menorrhagia (no cause), uterine fibroids, endometriosis, polyps, adenomyosis, PID, endometrial hyperplasia / cancer
  3. Hypothyroidism, bleeding disorder (vWD), iatrogenic (anticoagulant medication, copper IUD)

4.

  • Pelvic exam with speculum and bimanual palpation
  • FBC: Iron deficiency anaemia
  • Hysteroscopy if ?fibroids, endometrial hyperplasia
  • TV US if ?larger fibroids, adenomyosis, hysteroscopy declined
  • Swabs if ?infection, i.e. PID
  • Coagulation screen if ?clotting disorder
  • Ferritin, will be low
  • Thyroid function tests
  1. Consider treating the underlying cause.

If the woman does not want contraception; Tranexamic acid (if no pain), Mefenamic acid (if pain)

If the woman wants contraception; Mirena Coil IUS is first-line, COCP is second-line, Norethisterone is third-line

Refer to secondary care

Surgical management: Endometrial ablation, uterine artery embolisation, hysterectomy

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12
Q

DYSFUNCTIONAL UTERINE BLEEDING

  1. What are the features?
  2. When does it occur?
  3. How common is it?
A
  1. Mainly the isolated symptom of heavy bleeding with no pain, regular cycles, no intermenstrual bleeding or postcoital bleeding. Is a diagnosis of exclusion however
  2. Occurs from menarche
  3. Occurs in 50% of women with menorrhagia

IT IS A DIAGNOSIS OF EXCLUSION HENCE MUST INVESTIGATE PRIOR

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13
Q

UTERINE FIBROIDS

  1. What are they?
  2. In what patients are they common in?
  3. Why are fibroids rare before puberty?
  4. What is the presentation?
  5. How are asymptomatic individuals managed?
  6. How are symptomatic individuals managed?
  7. What is red degeneration of fibroids?
  8. What are the features of fibroid degeneration?
  9. What is the management of it?
A
  1. Fibroids are benign smooth muscle tumours of the uterus
  2. More common in afro-carribean women
  3. Rare before puberty because they are oestrogen sensitive
  4. May be asymptomatic, menorrhagia, abdominal pain worsened by menstruation, longer menstruation >7 days, bloating, fullness, urinary / bowel symptoms due to pressure. deep dyspareunia, subfertility, polycythemia (RARE)
  5. No treatment, just monitor
  6. If menorrhagic, Mirena Coil, Tranexamic acid / Mefanamic acid, COCP. If to shrink them, use GnRH agonists i.e. Goserelin prior to myomectomy, endometrial ablation, hysterectomy or uterine artery embolisation
  7. When fibroids enlarge rapidly during pregnancy, outgrowing the blood supply and becoming ischaemic
  8. Abdominal pain, mild fever, nausea, vomiting
  9. Rest, analgesia
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14
Q

ENDOMETRIOSIS

  1. What is it?
  2. What are the features?
  3. What are examination findings?
  4. What are the investigations?
  5. What is the management in a women with no intention to conceive?
  6. What is the management in a women with intention to conceive?
  7. What are endometriomas in ovaries called?
  8. What is adenomyosis?
A
  1. Growth of ectopic endometrial tissue outside the uterus, called an endometrioma
  2. Chronic pelvic pain, cyclical. Deep dyspareunia, dysmenorrhoea, infertility / sub-fertility, cyclical bleeding elsewhere i.e. haematuria, bowel / urinary symptoms
  3. May visualise endometrial tissue in vagina on speculum, may feel a fixed cervix on bimanual palpation, may feel tenderness in vagina, cervix and adnexae
  4. Laparoscopy is GOLD STANDARD. Pelvic US may show large endometriomas and chocolate cysts
  5. Paracetamol + NSAIDs. COCP, POP, Depo Injection, Nexplanon, Mirena Coil. Hysterectomy
  6. Paracetamol + NSAIDs. GnRH agonists, laparoscopic surgery.
  7. Chocolate cysts
  8. Endometrial tissue in myometrium
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15
Q

ADENOMYOSIS

  1. What is it?
  2. In what patients is it common in?
  3. What are the features?
  4. What are the investigations?
  5. What is the management?
A
  1. Endometrial issue within the myometrium
  2. More common in older, multiparous women
  3. Pelvic pain, dysmenorrhoea, menorrhagia
  4. Transvaginal US, MRI, Transabdo US
  5. Same as menorrhagia management: Mirena Coil, Tranexamic acid / Mefanamic acid, COCP. If to shrink them, use GnRH agonists i.e. Goserelin prior to myomectomy, endometrial ablation, hysterectomy or uterine artery embolisation
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16
Q

POLYCYSTIC OVARIAN SYNDROME

  1. What is it?
  2. What are the clinical features?
  3. Outline the Rotterdam criteria?
  4. What imaging investigations can be ordered? What may be seen?
  5. What blood tests can be ordered? What may be seen?
  6. What is the principles of managing PCOS?
  7. Outline points for each principle?
  8. What is Acanthosis Nigricans?
  9. Why is there an increased risk of Endometrial cancer?
A
  1. A condition causing metabolic / reproductive issues in women
  2. Amenorrhoea / oligomenorrhoea, infertility, obesity, hirsutism, acne, male pattern baldness, acanthosis nigricans
  3. 1) Oligomenorrhoea / Amenorrhoea, 2) Hyperandrogenism i.e. Hirsutism / acne, 3) Polycystic ovaries on US, i.e. “beads on string appearance” or volume >10cm3. Need 2 of 3
  4. Pelvic Ultrasound, “beads on string appearance” or volume >10cm3
  5. LH and FSH. Both will be elevated, with raised LH:FSH ratio. Testosterone will be elevated, Insulin elevated, Prolactin mildly elevated, Normal to raised oestrogen, OGTT showing impaired fasting glucose / glucose tolerance, or diabetes
  6. General management, managing infertility, hirsutism, acne and reducing risk of endometrial cancer
  7. General management: Weight loss, can use Orlistat. Exercise, smoking cessation, eating calorie controlled diet with low glycaemic index, using antihypertensives and statins if QRISK >20

Managing infertility: Weight loss, Clomifene / Metformin, IVF. If they become pregnant then screen for gestational diabetes

Hirsutism: Weight loss, COCP, laser hair removal, spironolactone

Acne: COCP, retinoids, ABX

Endometrial cancer risk: IUS, with COCP / progestrogens for withdrawal bleeds every 3-4 months

  1. Dark, velvety skin in axilla, neck, associated with insulin resistance
  2. PCOS patients have oligmenorrhoea / amenorrhoea, hence do not ovulate or release progesterone, leading to unopposed oestrogen. This increases risk of endometrial cancer
17
Q

SECONDARY AMENORRHOEA

  1. What is it defined as?
  2. When do you consider assessment?
  3. What are local causes of secondary amenorrhoea?
  4. What are systemic causes of secondary amenorrhoea?
  5. In hyperprolactinemia, what are the blood test results? And features?
  6. What are some investigations you may want to do to determine the cause of Secondary Amenorrhoea?
A
  1. Defined as no periods for over 3 months after having had periods
  2. Consider assessment after 3-6 months in women who had previously regular periods, or 6-12 months in women who had previously irregular periods
  3. Pregnancy (most common), PCOS, menopause, premature ovarian failure, contraception, Asherman’s syndrome
  4. Hypothalamic amenorrhoea (stress, anorexia, athletes), Prolactinoma / hyperprolactinaemia, Cushing’s syndrome, Thyroid issues, Sheehan’s syndrome
  5. High prolactin, low LH and FSH. Secondary amenorrhoea, plus galactorrhoea
    • Pelvic US, ?cysts in PCOS
    • MRI of head, ?prolactinoma
    • bHCG, ?pregnancy
    • LH and FSH, will be elevated with high LH:FSH ratio in PCOS, or low in hyperprolactinemia
    • Prolactin, ?PCOS, will be elevated and Prolactinoma
    • Testosterone, ?PCOS, will be elevated
    • TFTs, may have high TSH and low T3/T4, ?hypothyroid or low TSH and high T3/T4, ?hyperthyroid
18
Q

PREMATURE OVARIAN FAILURE

  1. What is Premature Ovarian Failure clinically defined as?
  2. What are causes of Premature Ovarian Failure?
  3. What are the FSH, LH and serum Oestriol levels in Premature Ovarian Failure?
  4. What are the features of Premature Ovarian Failure?
  5. What is the management of Premature Ovarian Failure?
A
  1. The cessation of periods with elevated gonadotropins before the age of 40
  2. Idiopathic (50% of cases), Iatrogenic
  3. High FSH and LH, low Serum Oestriol
  4. Oligomenorrhoea, amenorrhoea with signs of low oestrogen levels i.e. hot flushes, vaginal dryness, night sweats
  5. HRT or COCP (may be more acceptable, less stigma)
19
Q

GYNAECOLOGY HISTORY TAKING

  1. What things should you ask about?
A

Presenting Complaint of each symptom
PV Bleeding: menorrhagia, intermenstrual, post-coital, post-menopausal
PV Discharge: colour, smell, texture, blood, how often, how much
Pain: Pelvic pain, dysmenorrhoea, dyspareunia
Pregnancy

Bowel + Urinary symptoms

MOSCC (Menstrual, Obstetric, Sexual, Cervical Smear, Contraceptive History)

Menstrual: 1st day of LMP, menarche, menopause, cycle length, period length, flow, clots, pain

Obstetric: Children - ages, birth weight, delivery, complications. Miscarriages - how many, at what stage, complications. Terminations - how many

Sexual: Regular partner, M/F, how long, how many in last 6 months. Pain / discomfort during intercourse, what type of intercourse. Any issues with infertility

Cervical: Last date of smear test, normal / abnormal

Contraception

Then PMHx, DHx, allergies, FHx, SHx

20
Q

MENOPAUSE

  1. What is it defined as?
  2. What is premature menopause defined as?
  3. What are the features of menopause?
  4. What do blood tests show?
  5. What are complications of menopause?
  6. How is menopause diagnosed?
  7. How long do women need to be contraception for?
  8. What are some management options?
A
  1. Defined as cessation of periods for 1 year if above 50 years old, or two years if below 50
  2. Before 40
  3. Vasomotor symptoms: hot flushes, night sweats. Gynaecological symptoms: Vaginal dryness, polyuria, change in menstruation, reduced libido. Psychological symptoms: Anxiety, depression, memory loss
  4. Low serum oestriol. High FSH / LH
  5. IHD, Osteoporosis
  6. If above 45, clinically. If below 45, via FSH blood test
  7. 2 years if below 50, 1 year if above 50
  8. For vasomotor symptoms: exercise, weight loss, reduce stress, fluoxetine, citalopram, venlafaxine

For psychological symptoms: good sleep hygiene, exercise, relaxation, self help, CBT, antidepressants

For gynaecological symptoms: Vaginal lubrication, moisturisers,, vaginal oestrogens

HRT

21
Q

What is the most common cause of Post-coital bleeding?

A

Cervical ectropion

22
Q

CERVICAL ECTROPION

  1. What is it?
  2. What are the features?
  3. What are the risk factors?
  4. What is the management?
A
  1. Transformation of stratified squamous epithelium to columnar epithelium on the ectocervix, due to high levels of oestrogen
  2. Vaginal discharge, post-coital bleeding
  3. COCP, pregnancy
  4. Ablation
23
Q

OVARIAN TORSION

  1. What is it?
  2. What are the features?
  3. What are the risk factors?
  4. What are some investigations and findings?
  5. What is the management?
  6. What are complications?
A
  1. When an ovary twists on its supporting ligaments, compromising blood supply
  2. Sudden onset, severe, LIF / RIF pain, progressively getting worse. Nausea and vomiting, localised tenderness, palpable mass, mild fever
  3. Young female of reproductive age, pregnancy, Ovarian hyperstimulation syndrome
  4. Pelvic US: Whirlpool sign, may see free fluid in peritoneal cavity, oedematous ovary. Laparoscopic surgery is definitive diagnosis however
  5. Laparoscopic surgery “de-torsion” or oophorectomy
  6. Abscess, sepsis, peritonitis, adhesions
24
Q

NABOTHIAN CYST

  1. What is it?
  2. What is the presentation?
  3. What is the management?
A
  1. A cyst of the cervix. The columnar epithelium secretes mucus and when the squamous epithelium slightly covers the columnar epithelium, the mucus can get trapped
  2. Asymptomatic. Usually incidentally found on speculum exam
  3. Reassurance
25
Q

ASHERMAN’S SYNDROME

  1. What is it?
  2. What procedures may cause it?
  3. What are the features?
  4. What is the gold-standard investigation?
  5. What is the management?
A
  1. Adhesions within the uterus following uterine damage
  2. D&C, uterine surgery, endometritis
  3. Secondary amenorrhoea, LIGHTER periods, dysmenorrhoea, infertility
  4. Hysteroscopy
  5. Cutting the adhesions (high risk of recurrence)
26
Q

PRIMARY AMENORRHOEA

  1. How can the causes be categorised?
  2. What are the LH, FSH and Oestrogen levels in Hypogonadotrophic Hypogonadism?
  3. What are the LH, FSH and Oestrogen levels in Hypergonadotrophic Hypogonadism?
  4. What are causes of Hypogonadotrophic Hypogonadism?
  5. What are causes of Hypergonadotrophic Hypogonadism?
  6. What are structural causes of primary amenorrhoea
  7. What are some basic blood tests you can do investigate Primary Amenorrhoea
  8. What are some special hormone tests you can do investigate Primary Amenorrhoea
  9. What are some genetic tests you can do investigate Primary Amenorrhoea
  10. What are some special imaging tests you can do investigate Primary Amenorrhoea
A
  1. Hypogonadotrophic Hypogonadism, Hypergonadotrophic Hypogonadism, Structural, Other: Congenital Adrenal Hyperplasia and Androgen Insensitivity Syndrome
  2. LH, FSH LOW, Oestrogen LOW
  3. LH, FSH HIGH, Oestrogen LOW
  4. Hypopituitarism (low pituitary gland activity), damage to the hypothalamus or pituitary gland (radiation, chemo, surgery), chronic conditions i.e. CF / Coeliacs / IBD, excessive exercise & dieting, constitional delay in growth, endocrine i.e. GH deficiency, hypothyroidism, Cushing’s, hyperprolactinaemia, Kallman’s
  5. Gonadal damage i.e. torsion, cancer, mumps, congenital absence, Turner’s syndrome
  6. Imperforate hymen, absent testes, FGM
7. 
FBC; anaemia
Ferritin; anaemia
TFTs; thyroid dysfunction
IgA-TTG; anti-EMA; Coeliacs

8.
FSH and LH; hyper/hypogonadotrophic
IGF-1; GH deficiency
Prolactin; elevated in hyperprolactinaemia
Testosterone; elevated in PCOS, androgen insensivity, congenital adrenal hyperplasia

  1. Chromosomal analysis for Turner’s and Androgen Insensitivity Syndrome
  2. X-Ray of wrist; CDGD
    MRI of brain; hypothalamus / pituitary / Kallman’s
    Pelvic US; PCOS, Undescended testes in Androgen insensitivity
27
Q

OVARIAN CYSTS

  1. What is the presentation of ovarian cysts?
  2. What are the two main types of Functional Cysts?
  3. What is the most common type of cyst?
  4. What is the prognosis of a Follicular Cyst?
  5. Why do Follicular cysts occur? What do they look like?
  6. Why do Corpus Luteum cysts occur? What do they look like?
  7. Give an example of a Benign Germ Cell Tumour, what do they look like?
  8. What are the two types of Benign Epithelial Tumours? Which are more common
  9. What factors will reduce the risk of Ovarian malignancy?
  10. What is the tumour marker associated with Ovarian cancer?
  11. How are pre-menopausal women managed with Ovarian cysts?
  12. How are post-menopausal women managed with Ovarian cysts?
  13. What is Meig’s syndrome?
  14. What is the most common benign ovarian tumour in women under 30?
  15. Rokitansky’s protuberance is associated with which ovarian cyst?
  16. Which ovarian cyst is most associated with Ovarian torsion?
A
  1. Pelvic pain, bloating, abdominal fullness, palpable mass
  2. Follicular and Corpus Luteum Cysts
  3. Follicular
  4. Disappears after a few cycles
  5. Non rupture of dominant follicle, fluid filled
  6. When the corpus luteum fails to break down, fluid / blood filled
  7. Dermoid cysts, are lined with epithelial tissue and contain hair, teeth, nails
  8. Serous cystadenoma (more common) and Mucinous cystadenoma
  9. Late menarche, early menopause, being pregnant and taking the COCP
  10. CA125
  11. If below 5cm, will likley resolve by 3 cycles. If between 5-7cm, routine referral to gynaecology and yearly US monitoring. If >7cm, ?MRI or surgical input
  12. Correlate cyst with CA125. If positive, refer to gynaecology under 2ww. If negative and below 5cm, monitor
  13. Fibroma + Ascites + Pleural Effusion
  14. Benign Germ Cell (Dermoid / Teratoma)
  15. Dermoid / Teratoma
  16. Dermoid / Teratoma
28
Q

CERVICAL CANCER

  1. What is the most common type of Cervical cancer? What is second most common?
  2. What HPV strains are associated with Cervical cancer?
  3. Which HPV strains are associated with genital warts?
  4. Does cervical cancer affect younger women or older women?
  5. What are risk factors of cervical cancer?
  6. What may be the presentation of cervical cancer?
  7. On speculum, what may be visualised in a woman with cervical cancer?
  8. How often does cervical screening occur for women?
  9. Outline the principles of a cervical screening test?
  10. When should HIV positive patients and pregnant women get their smears done?
  11. If a woman has an inadequate sample for their smear test, what happens? What happens if this repeats?
  12. If a woman has a HPV- sample, what happens?
  13. If a woman has a HPV+ sample with normal cytology, what happens? What happens if this continues a second time? A third time?
  14. If a woman has a HPV sample+ with abnormal cytology, what happens?
  15. During colposcopy, CIN may be diagnosed. What is CIN? What are the different grades and their meanings?
  16. If any woman has been diagnosed with and treated for CIN on Colposcopy, how does this change management?
  17. What is the staging system for Cervical cancer?
  18. Outline the FIGO staging system and what each means
  19. How do you manage CIN to Stage 1a cervical cancer?
  20. How do you manage Stage 1b to 2a cervical cancer?
  21. How do you manage Stage 2b to 4a cervical cancer?
  22. How do you manage Stage 4b cervical cancer?
A
  1. Adenocarcinoma, then squamous cell carcinoma
  2. HPV Strains 16, 18 and 33
  3. HPV Strains 6 and 11
  4. Younger women
  5. Early sexual activity, multiple sexual partners, not using barrier contraception, smoking, non-attendance to cervical screening, COCP >5 years, many pregnancies, FHx
  6. Abnormal vaginal bleeding (post-coital, intermenstrual, post-menopausal), vaginal discharge, dyspareunia, pelvic pain
  7. Inflammation, bleeding, an ulcer, a tumour
  8. Every 3 years between 25-49, and 5 years between 50 and 64
  9. Cervical smear is initially checked for HPV. If positive, then check cytology. If HPV negative, cytology is not checked
  10. If HIV positive, every year. If pregnant, then 12 weeks postpartum
  11. Repeat after 3 months. If this continues 2x more, then refer to colposcopy
  12. Continue routine monitoring, back to normal 3 or 5 year recall depending on sage
  13. Repeat HPV test in 12 months. Repeat HPV test then. Then refer to colposcopy
  14. Refer to colposcopy
  15. CIN = Cervical Intraepithelial Neoplasia
    CIN1: Mild dysplasia, affecting 1/3 thickness, likely normal without treatment

CIN2: Moderate dysplasia, affecting 2/3 thickness, likely to progress to cancer without treatment

CIN3: Severe dysplasia, very likely to progress to cancer without treatment

  1. Offered a test of cure 6 months later
  2. FIGO Staging System
  3. Stage 1 - Confined to cervix
    Stage 2 - Extends to top 2/3 of vagina
    Stage 3 - Extends to bottom 1/3 of vagina
    Stage 4 - Invades bladder, rectum, beyond pelvis
  4. LLETZ or Cone Biopsy
  5. Radical hysterectomy, removal of lymph nodes with chemo / radiotherapy
  6. Chemo / radiotherapy
  7. Surgery, radiotherapy, chemotherapy, palliative care
29
Q

ENDOMETRIAL CANCER

  1. In what patients is commonly seen in?
  2. What is Endometrial cancer dependent on?
  3. What are risk factors to Endometrial cancer?
  4. Why is obesity a risk factor?
  5. Why is Tamoxifen a risk factor?
  6. Why is PCOS a risk factor?
  7. Why is early menarche, late menopause and few pregnancies a risk factor?
  8. What are protective factors of Endometrial cancer?
  9. What is the main presentation of Endometrial cancer?
  10. How might you investigate suspected Endometrial cancer?
  11. What is normal thickness of endometrial lining?
  12. What is the main management of Endometrial cancer?
  13. What is the prognosis?
A
  1. Post-menopausal women
  2. OESTROGEN
  3. Think unopposed Oestrogen: early menarche, late menopause, few pregnancies, oestrogen-only HRT, increased age, obesity, PCOS, tamoxifen, HNPCC, T2D
  4. Fat tissue has sources of Oestrogen
  5. Tamoxifen has an anti-oestrogenic effect on breast cancer, but a pro-oestrogenic effect on endometrial tissue
  6. PCOS causes amenorrhoea / oligomenorrhoea, leading to unopposed oestrogen due to lack of ovulation
  7. More periods, more oestrogen
  8. COCP, mirena coil, many pregnancies, SMOKING
  9. Post-menopausal bleeding, post-coital bleeding, intermenstrual bleeding, menorrhagia
  10. If above 55 and post-menopausal bleeding, then refer to 2ww pathway. Perform a TVUS, and hysteroscopy w/ endometrial biopsy
  11. Normal is less than 4mm
  12. TAH and SBO (Total abdominal hysterectomy, and bilateral salpino-oophrectomy) + may have chemoradiation
  13. Good prognosis
30
Q

ENDOMETRIAL HYPERPLASIA

  1. What is it?
  2. What are the features?
  3. What are the two main types?
  4. How are they managed?
A
  1. Abnormal proliferation of endometrial lining, greater than normal for menstruation. Some may develop into endometrial cancer
  2. Post-menopausal bleeding
  3. Hyperplasia without atypia, and Atypical hyperplasia
  4. If hyperplasia without atypia, can give Mirena Coil (IUS) or COCP. If atypical hyperplasia, due to risk of malignant potential - hysterectomy
31
Q

OVARIAN CANCER

  1. In what patients is it more common?
  2. What is the most common type?
  3. What are the risk factors?
  4. What are the clinical features?
  5. Why do you get referred hip / groin pain?
  6. What is the investigations?
  7. What is the management?
  8. What is RMI?
A
  1. Older women, peak age around 60
  2. Epithelial cancers, typically SEROUS carcinoma
  3. BRCA1, BRCA2, early menarche, late menopause, nulliparity, old age, smoking, recurrent Clomiphene use
  4. VAGUE presentation, abdominal bloating, early satiety, anorexia, urinary / bowel symptoms, weight loss, abdominal / pelvic mass
  5. Ovarian mass pressing on obturator nerve
  6. 2ww if pelvic / abdominal mass / ascites, CA125, abdo / pelvic US, CT scan + biopsy, paracentesis (ascitic tap), diagnostic laparotomy
  7. Surgery + chemotherapy
  8. Risk Malignancy Index:
    CA125, US findings, Menopausal status
32
Q

ATROPHIC VAGINITIS

  1. In what patients is it more common? Why?
  2. What is the presentation?
  3. How may the vagina appear on examination?
  4. What is the management?
A
  1. Postmenopausal women
  2. Itching, dryness, dyspareunia, occasional spotting
  3. Pale, dry, thin skin, sparse pubic hair
  4. Vaginal lubricants, moisturisers, oestrogen creams / pessaries / tablets / ring
33
Q

ECTOPIC PREGNANCY

  1. What is it?
  2. Where is an ectopic most commonly found?
  3. An ectopic found where is most dangerous?
  4. What may be the features in history?
  5. What are the risk factors of an ectopic pregnancy?
  6. What may be the features on examination?
  7. What are the TWO investigations you’d want to do?
  8. What may be visualised on one of them?
  9. How much does bhCG change in 48 hours in a normal pregnancy?
  10. How much does bhCG change in 48 hours in an ectopic pregnancy?
  11. How much does bhCG change in 48 hours in a miscarriage?
  12. What is the broad principles of management?
  13. When may you consider surgical management?
  14. What is surgical management?
  15. What is medical management?
  16. What is expectant management?
  17. What information would you need to know to determine the management?
  18. What advice would you give a women who requires medical management?
A
  1. Refers to the implantation of an embryo outside the uterus
  2. Commonly at the ampulla of the fallopian tube
  3. Commonly at the isthmus of the fallopian tube
  4. Amenorrhoea for 6-8 weeks, constant RIF / LIF pain, dark brown vaginal bleeding, lower abdominal / pelvic pain, dizziness, syncope, shoulder tip pain
  5. PID, older age, smoking, previous ectopic, IUS / IUD, IVF, POP, previous fallopian tube surgery
  6. Abdominal tenderness, cervical excitation, adnexal mass
  7. bhCG, transvaginal US
  8. On TVUS: may see gestational sac with yolk sac or foetal pole, “blob sign”, “bagel sign”, “tubal ring sign”, empty uterus, fluid in uterus
  9. Doubles every 48 hours in normal pregnancy
  10. Rises no more than 63% every 48 hours in ectopic pregnancy
  11. Falls more than 50% every 48 hours in miscarriage
  12. Refer to EPAU (Early Pregnancy Assessment Unit), followed by Expectant, Medical or Surgical Management
  13. If bhCG >1,500, if foetal heartbeat is present, if in severe pain, if greater than >35mm, if ruptured
  14. Salpingectomy (first-line) or Salpingotomy (if other tube is damaged)
  15. MTX
  16. Measure bhCG every 48 hours
  17. Size of embryo, whether it’s ruptured or not, whether foetal heartbeat is present, where patient is in pain or not, the bhCG levels
  18. Should withhold trying to conceive for 3 months after due to teratogenicity of MTX
34
Q

MISCARRIAGES

  1. What is a miscarriage?
  2. What is defined as an early miscarriage?
  3. What is defined as a late miscarriage?
  4. What is “missed” miscarriage?
  5. What is a “threatened” miscarriage?
  6. What is an “inevitable” miscarriage?
  7. What is an “incomplete” miscarriage?
  8. What is a “complete” miscarriage?
  9. What is an “anembryonic” miscarriage?
  10. What is the first-line investigation for suspected miscarriage?
  11. How do you manage a miscarriage <6 weeks?
  12. How do you manage a miscarriage >6 weeks?
  13. How do you specifically manage an incomplete miscarriage?
  14. When may medical / surgical management trump expectant management?
A
  1. A spontaneous termination of pregnancy
  2. < 12 weeks
  3. 12 - 24 weeks
  4. Foetus not alive, no symptoms
  5. Vaginal bleeding, cervical os closed, foetus alive
  6. Vaginal bleeding, open cervical os
  7. Retained products of conception
  8. No retained products of conception, full miscarriage
  9. Gestational sac, no embryo
  10. TV US
  11. Expectant management
  12. Expectant management is first-line for first 7-14 days, followed by medical (Misoprostol) or surgical management if unsuccessful (Manual / Electric vaccum aspiration)
  13. Medical or surgical management
  14. If haemorrhage, has coagulation disorder, infection
35
Q

PRE-ECLAMPSIA

  1. What is it? What is it caused by?
  2. What is the classic triad of Pre-Eclampsia?
  3. What is gestational hypertension defined as?
  4. What is Eclampsia?
  5. What are risk factors of Pre-Eclampsia?
  6. What are the symptoms of Pre-Eclampsia?
  7. How is it diagnosed?
  8. How is it prevented in women with high / moderate risk?
  9. What anti-hypertensive is first, second, third line?
  10. What anti-hypertensive is suitable for asthmatics?
  11. What medication is administered to prevent seizures? When is it given?
  12. What medication is administered to treat seizures?
  13. What is HELLP syndrome? What does it stand for?
A
  1. NEW hypertension in pregnancy with end-organ dysfunction, notably proteinuria. Occurs after 20 weeks, due to spiral arteries forming abnormally and leading to high vascular resistance
  2. Oedema, proteinuria, hypertension
  3. HTN after 20 weeks, with no proteinuria
  4. When seizures occur due to Eclampsia
  5. HTN in previous pregnancy, CKD, T1D, T2D, autoimmune diseases i.e. SLE, antiphospholipid syndrome, first pregnancy, being >40 years old, BMI >35, pregnancy interval >10 years, family history of pre-eclampsia, multiple pregnancy
  6. Headache, visual disturbances, nausea and vomiting, RUQ / epigastric pain, oedema, brisk reflexes, papillo-oedema
  7. BP systolic >140, diastolic >90, PLUS 1) Proteinuria or 2) Organ dysfunction or 3) Placental dysfunction
  8. Aspirin 75mg from 12 weeks to birth
  9. Labetalol, then Nifedipine then Methyldopa
  10. Nifedipine
  11. Magnesium sulphate, given for 24 hours after delivery
  12. Magnesium Sulphate
  13. A complication of Pre-Eclampsia & Eclampsia, characterised by Haemolysis, Elevated LFTs, Low Platelets
36
Q

GESTATIONAL DIABETES

  1. What are the complications of Gestational Diabetes for the neonate? And for mum?
  2. What are the risk factors for developing Gestational Diabetes?
  3. How are mothers screened for Gestational diabetes? What is the result?
  4. How much Folic acid should a diabetic woman take before trying to conceive?
  5. How do you treat Gestational Diabetes?
  6. If a diabetic woman became pregnant, how is her diabetic medication changed?
  7. How do you treat neonatal hypoglycaemia?
A
  1. For baby: Macrosomia, neonatal hypoglycaemia, shoulder dystocia, large for dates foetus. For mum: Increased risk of T2D
  2. Previous gestational diabetes, previous macrosomic baby BMI >30, ethnic origin, family history of T2D
  3. OGTT at 24-28 weeks. Positive for gestational diabetes if fasting glucose >5.6 and 2 hours glucose >7.8
  4. 5mg Folic acid
  5. If Fasting glucose < 7 = 1-2 weeks of diet and exercise followed by Metformin and Insulin. If however Macrosomic, Insulin and Metformin straight away. If Fasting glucose > 7 = Metformin and Insulin
  6. Stop all oral hypoglycemic agents, apart from Metformin
  7. IV dextrose and NG feeding

Gynaecology (1 decks)

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