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Women's Health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is adenomyosis?

A

endometrial tissue in myometrium

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2
Q

In whom is adenomyosis more common?

A

multiparous women towards end of reproductive years

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3
Q

Features of adenomyosis:

A
  • dysmenorrhoea
  • menorrhagia
  • enlarged, boggy uterus
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4
Q

Management of adenomyosis:

A
  • GnRH agonists

- hysterectomy

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5
Q

What is primary amenorrhoea?

A

failure to start menses by age of 16 years

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6
Q

Causes of primary amenorrhoea:

A
  • Turner’s syndrome
  • testicular feminisation
  • congenital adrenal hyperplasia
  • congenital malformations of genital tract
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7
Q

What is secondary amenorrhoea?

A

cessation of established regular menstruation for at least 6 months

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8
Q

Causes of secondary amenorrhoea (after excluding pregnancy):

A
  • hypothalamic amenorrhoea (stress, exercise)
  • PCOS
  • hyperprolactinaemia
  • premature ovarian failure
  • thyrotoxicosis
  • Sheehan’s syndrome
  • Asherman’s syndrome (intrauterine adhesions)
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9
Q

Initial investigations amenorrhoea:

A
  • exclude pregnancy with urinary or serum bHCG
  • gonadotrophins (low - hypothalamic, raised - ovarian)
  • prolactin
  • androgens (PCOS)
  • oestradiol
  • thyroid function tests
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10
Q

What is androgen insensitivity syndrome?

A
  • X-linked recessive condition due to end organ resistance to testosterone
  • genotypically male children with female phenotype
  • complete androgen insensitivity syndrome - new term for testicular feminisation syndrome
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11
Q

Features of androgen insensitivity syndrome:

A
  • primary amenorrhoea
  • undescended testes causing groin swellings
  • breast development (conversion of testosterone to estradiol)
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12
Q

Diagnosis of androgen insensitivity syndrome:

A

buccal smear or chromosomal analysis to reveal genotype

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13
Q

Management androgen insensitivity syndrome:

A
  • bilateral orchidectomy (increased risk testicular cancer due to undescended testes)
  • oestrogen therapy
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14
Q

What is atrophic vaginitis?

A
  • in post menopausal women
  • vaginal dryness, dyspareunia and spotting
  • treatment with vaginal lubricants and moisturisers
  • or topical oestrogen cream if no help
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15
Q

Main differential diagnoses for bleeding in the first trimester:

A
  • miscarriage
  • ectopic pregnancy
  • implantation bleeding
  • misc: cervical ectropion, vaginitis, trauma, polyps
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16
Q

Symptoms suggestive of ectopic pregnancy:

A
  • positive pregnancy test with following symptoms (refer immediately):
  • pain and abdominal tenderness
  • pelvic tenderness
  • cervical motion tenderness
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17
Q

Management of >= 6 weeks gestation and bleeding:

A

early pregnancy assessment service

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18
Q

< 6 weeks gestation and bleeding but not pain or risk factors for ectopic pregnancy:

A
  • manage expectantly
  • return if bleeding continues or pain
  • repeat urine pregnancy test after 7-10 days
  • negative pregnancy test - miscarried
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19
Q

Most common types of cervical cancer:

A
  • squamous cell (80%)

- adenocarcinoma (20%)

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20
Q

Features cervical cancer:

A
  • abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
  • vaginal discharge
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21
Q

Risk factors for cervical cancer:

A
  • HPV (16,18 and 33)
  • smoking
  • HIV
  • early first intercourse, many sexual partners
  • high parity
  • lower socioeconomic status
  • COCP
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22
Q

Mechanism of HPV causing cervical cancer:

A
  • HPV 16 and 18 produce oncogenes E6 and E7 genes respectively
  • E6 inhibits p53 tumour suppressor
  • E7 inhibits RB suppressor gene
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23
Q

Who is offered a smear test?

A
  • 25-49 years: 3 yearly
  • 50-64 years: 5 yearly
  • not over 64 (even self referring)
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24
Q

Cervical screening in pregnancy:

A

delayed until 3 months post partum unless missed screening or previous abnormal

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25
Q

Cervical screening in women who have never been sexually active:

A
  • very low risk

- can opt-out of screening

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26
Q

Types of cervical screening:

A
  • now LBC over Pap
  • sample rinsed into preservative fluid rather than smearing onto slide
  • LBC reduces rate of inadequate smears and increased sensitivity and specificity
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27
Q

Best time to take cervical smear:

A

mid cycle

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28
Q

When is cytological examination performed on a cervical screening sample?

A

if test for hrHPV is positive (if negative, return to normal recall)

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29
Q

Procedure if cervical sample is hrHPV positive:

A
  • examined cystologically
  • if cytology abnormal - colposcopy
  • if cytology normal repeat test at 12 months
30
Q

Possible results of colposcopy

A
  • low grade dyskaryosis
  • high grade dyskaryosis (moderate)
  • high grade dyskaryosis (severe)
  • invasive squamous cell carcinoma
  • glandular neoplasia
31
Q

What to do if hrHPV positive but cytology normal and test repeated at 12 months:

A
  • if now hrHPV negative - normal recall
  • if positive and cytology still normal - further repeat test 12 months later
  • if negative at 24 months - normal recall
  • if hrHPV positive at 24 months - colposcopy
32
Q

What to do if the cervical sample is inadequate:

A
  • repeat within 3 months

- if 2 consecutive inadequate - colposcopy

33
Q

Negative hrHPV should return to normal recall UNLESS:

A
  • been treated for CIN 1, 2 or 3 invited 6 months after treatment for TOC repeat cervical sample
  • untreated CIN1 pathway
  • follow up incompletely excised cervical glandular intraepithelial neoplasia/stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
  • follow up for borderline changes endocervical cells
34
Q

FIGO stages of cervical cancer:

A 
IA
IB
II
III
IV
35
Q

Cervical cancer stage IA:

A
  • confined to cervix, only visible by microscopy
  • less than 7 mm wide
  • A1 = <3mm deep
  • A2 = 3-5mm deep
36
Q

Cervical cancer stage IB:

A
  • confined to cervix, clinically visible or larger than 7mm wide
  • B1 = <4cm diameter
  • B2 = >4cm diameter
37
Q

Cervical cancer stage II:

A
  • extension of tumour beyond cervix but not to pelvic wall
  • A = upper two thirds of vagina
  • B = parametrical involvement
38
Q

Cervical cancer stage III:

A

-extension of tumour beyond cervix and to pelvic wall
-A = lower third of vagina
-B = pelvic side wall
NB - any tumour causing hydronephrosis or non functioning kidney - stage III

39
Q

Cervical cancer stage IV:

A
  • extension of tumour beyond pelvis or involvement of bladder or rectum
  • A = bladder or rectum
  • B = distant sites outside pelvis
40
Q

Management of cervical cancer stage IA tumours:

A
  • hysterectomy with/without lymph node clearance
  • nodal clearance for A2 tumours
  • to maintain fertility, cone biopsy with negative margins can be performed
  • radical trachelectomy option for A2
41
Q

Management of cervical cancer stage IB tumours:

A
  • B1: radiotherapy with concurrent chemotherapy
  • radiotherapy: brachytherapy or external beam radiotherapy
  • cisplatin chemotherapeutic agent
  • B2 tumours: radical hysterectomy with pelvic lymph node dissection
42
Q

Management of cervical cancer stage II and III tumours:

A
  • radiation with concurrent chemotherapy

- hydronephrosis: nephrostomy

43
Q

Management of cervical cancer stage IV tumours:

A
  • radiation/chemotherapy

- palliative chemotherapy may be best for stage IVB

44
Q

Complications of cervical cancer surgery:

A
  • bleeding, damage, infection etc.
  • cone biopsies and radical trachelectomy may increases risk of preterm birth in future pregnancies
  • radical hysterectomy may cause ureteral fistula
45
Q

Complications of radiotherapy in cervical cancer:

A
  • short term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
  • long term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
46
Q

How does cervical ectropion come about?

A
  • ectocervix has transformation zone where stratified squamous epithelium meets columnar epithelium of cervical canal
  • elevated oestrogen levels causes larger area of columnar epithelium on ectocervix
  • also known as cervical erosion
  • can use ablative treatment if troublesome
47
Q

Features of cervical ectropion:

A
  • vaginal discharge

- post coital bleeding

48
Q

Features of complete hydatidiform mole:

A
  • vaginal bleeding
  • uterus size greater than expected for gestational age
  • abnormally high serum hCG
  • US: snow storm appearance of mixed echogenicity
49
Q

Causes of delayed puberty with short stature:

A
  • Turner’s syndrome
  • Prader-Willi syndrome
  • Noonan’s syndrome
50
Q

Causes of delayed puberty with normal stature:

A
  • PCOS
  • androgen insensitivity
  • Kallman’s syndrome
  • Klinefelter’s syndrome
51
Q

What is primary dysmenorrhoea?

A
  • no underlying pelvic pathology

- may be caused by excessive endometrial prostaglandin production

52
Q

Management of primary dysmenorrhoea:

A
  • NSAIDs such as mefenamic acid and ibuprofen in up to 80% of women (inhibit prostaglandin production)
  • COCP second line
53
Q

What is secondary dysmenorrhoea?

A
  • typically develops many years after menarche
  • underlying pathology
  • 3-4 days before onset of period
  • refer all to gynaecology
54
Q

Causes of secondary dysmenorrhoea:

A
  • endometriosis
  • adenomyosis
  • PID
  • intrauterine devices
  • fibroids
55
Q

Features of ectopic pregnancy:

A
  • lower abdominal pain (due to tubal spasm, first symptoms, unilateral)
  • vaginal bleeding (may be dark brown, less than period)
  • history of recent amenorrhoea
  • peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
  • dizziness, fainting, syncope
  • breast tenderness
56
Q

What are some typical examination findings in ectopic pregnancy?

A
  • tenderness
  • cervical excitation
  • adnexal mass (do not examine due to risk of rupture)
  • serum bHCG >1500
57
Q

Risk factors for ectopic pregnancy:

A
  • damage to tubes (PID, surgery)
  • previous ectopic
  • endometriosis
  • IUCD
  • POP
  • IVF
58
Q

Investigation ectopic pregnancy:

A
  • pregnancy test positive

- investigation of choice: transvaginal ultrasound

59
Q

Expectant management ectopic pregnancy:

A
  • <35mm
  • unruptured
  • asymptomatic
  • no foetal heartbeat
  • serum bHCG <1000IU/L
  • compatible if another intrauterine pregnancy
  • closely monitor patient over 48 hours and if bHCG levels rise again or symptoms manifest intervention is performed
60
Q

Medical management ectopic pregnancy:

A
  • <35mm
  • unruptured
  • no significant pain
  • no foetal heartbeat
  • serum bHCG <1500IU/L
  • not suitable if intrauterine pregnancy
  • give patient methotrexate and follow up
61
Q

Surgical management ectopic pregnancy:

A
  • > 35mm
  • can be ruptured
  • pain
  • visible foetal heartbeat
  • serum bHCG >1500IU/L
  • compatible with another intrauterine pregnancy
  • surgical management involves salpingectomy or salpingostomy
62
Q

Where are most ectopic pregnancies?

A
  • 97% tubal (abortion, absorption or rupture)

- 3% ovary, cervix or peritoneum

63
Q

Where are ectopic pregnancies more dangerous?

A

isthmus

64
Q

In whom is endometrial cancer commonly seen?

A
  • post-menopausal
  • 25% before menopause
  • good prognosis due to early detection
65
Q

Risk factors endometrial cancer:

A
  • obestiy
  • nulliparity
  • early menarche
  • late menopause
  • unopposed oestrogen
  • diabetes mellitus
  • tamoxifen
  • PCOS
  • HNPOC
66
Q

Features of endometrial cancer:

A
  • postmenopausal bleeding
  • premenopausal: change intermenstural bleeding
  • pain and discharge
67
Q

Investigation endometrial cancer:

A
  • women >=55yo postmenopausal bleeding, suspected cancer pathway
  • first line investigation in trans vaginal US - normal endometrial thickness has high negative predictive value
  • hysteroscopy with endometrial biopsy
68
Q

Management endometrial cancer:

A
  • localised disease treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
  • high risk disease - post operative radiotherapy
  • progesterone therapy used in frail elderly women
69
Q

Clinical features endometriosis:

A
  • chronic pelvic pain
  • dysmenorrhoea
  • deep dyspareunia
  • subfertility
  • non-gynaecological: dysuria, urgency, haematuria, dyschezia
  • reduced organ mobility, tender modularity in posterior vaginal fornix, visible vaginal endometriosic lesions
70
Q

Investigation endometriosis:

A
  • laparoscopy

- little role for investigation in primary care

71
Q

Management endometriosis:

A
  • NSAIDs and/or paracetamol

- hormonal treatments such as COCP or progestogens

72
Q

Secondary treatments endometriosis:

A
  • GnRH analogues (pseudomenopause)

- surgery: laparoscopic excision and laser treatment of endometriosis ovarian cysts may improve fertility

Women's Health (5 decks)

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