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gynaecology Flashcards

1
Q

What is the definition of menopause?

A

No menses of 1 year after the age of 40

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2
Q

What are the physiological causes of menopause?

A

reduced oestogen levels due to decreased oarian function

Depletion of granulosa and thecal cells

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3
Q

What is the average age of menopause?

A

51 years old

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4
Q

What are the clinical findings in menopause?

A 
amenorrhea
Hot flushes
Night sweats
Atrophic vaginitis - pruritus, burning, dyspareunia
Mood swings - anxiety, depression
Urinary incontinence
Lethargy
Osteoporosis
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5
Q

What are the lab findings in menopause?

A

There is an increase in FSH and LH as oestrogen and progesterone fall

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6
Q

What is the treatment of menopause?

A

Oestrogen replacement if symptomatic

-With progesterone if uterus present to prevent endometrial adenocarcinoma

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7
Q

What are the risks of long term HRT?

A

Thromboembolism
Coronary heart disease, stroke
Slight risk of breast cancer
Increased risk of dementia in women over 65

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8
Q

What is virilisation?

A

It is the combination of hirsutism and male secondary sexual characteristics e.g. enlarged clitoris, acne, male hair distribution

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9
Q

What are the causes of virilisation?

A

Excess androgen production by adrenal or ovaries:

  • PCOS most common
  • idiopathic 5%-10%
  • Androgenital system - congenital adrenal hyperplasia
  • Drugs e.g. phenytoin
  • Ovarian tumour
  • Adrenal tumour
  • Obesity
  • Hypothyroid
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10
Q

What are the associations with PCOS?

A

Obesity
Insulin resistance
Acanthosis nigricans - darkening of skin in body folds

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11
Q

What is the pathophysiology behind PCOS?

A

Increased LH secretion compared to FSH causes hyperplasia of the ovarian theca cells causing increased production of androgens
This leads to anovulation

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12
Q

What are the clinical findings for PCOS?

A

Oligomenorrhoea
Hirutism
Endometrial hyperlasia/cancer (vaginal bleeding)

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13
Q

What are the lab findings for PCOS?

A

LH/FSH ratio >3
Increased serum testosterone
Decreased serum SHBG
Serum FSH normal to decreased

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14
Q

What is the treatment of PCOS?

A

Weight reduction in obses women
Reduce ovarian production of andogens with oral contraceptive
LH releasing hormone analogues

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15
Q

What are the rotterdam criteria for polycystic ovarian syndrome?

A

Need two of the three features to diagnose:

  • Oligomenorrhoea
  • Hyperandrogenism
  • Cystic ovaries on ultrasound
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16
Q

What is the gold standard for visualising the ovaries for polycystic ovarian syndrome?

A

A transvaginal ultrasound can be used to look for a string of pearls appearance or ovarian volume over 10 cm cubed

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17
Q

How is the risk of endometrial cancer managed in patients with PCOS?

A

They have the effect of unapposed oestrogen due to not producing sufficient progesterone
Can put in a mirena coil
Inducing withdrawl bleeds every 3-4 months with cyclical progesterones or the combined oral contraceptive pill

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18
Q

How can infertility be managed in PCOS?

A

Weight loss
Clomifene - oestrogen receptor modulator
Laproscopic ovarian drilling - puncturing holes in ovaries to improve fertility
IVF

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19
Q

What are the management options for hirsutism for PCOS?

A

Weight loss first line
Co-cyprindiol (Dianette) - COC pill for hirsutism - high VTE risk so usually stopped after 3 months of use
Topical efornithine can be used for facial hirsutism - takes 6-8 weeks to work
Spironolactone - anti androgen effects
Finasteride - 5 alpha reductase inhibitor that decreases testosterone production

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20
Q

What is the definition of Menorrhagia?

A

More than 80mL of blood loss per period

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21
Q

What are the symptoms of menorrhagia?

A

Staining of the sheets at night with heavy protection

Excessive passage of clots

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22
Q

What are the potential causes of menorrhagia?

A 
Fibroids
Endometriosis or adenomyosis
Pelvic inflammatory disease
Contraceptives e.g. copper coil
Anticoagulants
Bleeding disorders
PCOS
Endometrial hyperplasia or cancer
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23
Q

How should menorrhagia be investigated?

A

Pelvic examination with speculum and bimanual to assess for fibroids, ascites and cancer
FBC to look for anaemia
Outpatient hysteroscopy suspected endometrial pathology or persistent intermenstrual bleeding
Pelvic and transvaginal ultrasound if there is possible large fibroid or adenomyosis
Swabs, coag screen, ferritin, TFTs

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24
Q

What is the management of menorrhagia?

A

Exclude and treat underlying pathologies
Establish if contraception is required or acceptable
If contraception declined:
-Tranexamic acid - if no pain
-Mefamic acid - if pain -NSAID so reduces bleeding and pain
Contraceptive management:
-Mirena coil - 1st line
-COC
-Cyclical progesterone
If treatment unsuccessful then refer to secondary care for :
-endometrial ablation e.g. baloon thermal ablation
-hysterectomy

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25
Q

What is primary dysmenorrhoea and why does it happen?

A

This is during ovulatory cycles and is due to increased prostaglandins causing increased uterine contractions

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26
Q

What is secondary dysmenorrhoea?

A

This is painful periods caused by other disorders such as endometriosis or adenmyosis etc.

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27
Q

What is the treatment of primary and secondary dysmenorrhoea?

A

Primary - NSAIDs, OCPs, nifedipine

Secondary - Treat underlying disease

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28
Q

What is dysfunctional uterine bleeding?

A

This is abnormal bleeding with no anatomic cause
Results in different types of abnormal bleeding e.g. menorrhagia
Most cases occur in postmenarchal and perimenopausal women

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29
Q

What are the causes of abnormal bleeding in perpubertal girls?

A

Vulvovaginitis, infection e.g. gonorrhoea, sexual abuse, foreign bodies

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30
Q

What are the causes of abnormal bleeding in women from menarche to 20 years?

A

Anovulatory dysfuntional uterine bleeding e.g. no secretory phase of cycle causing endometrial hyperplasia and excessive bleeding
Von Willebrand disease

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31
Q

What are the causes of abnormal bleeding from 20-40 years in women?

A 
Preganacy and its complications
Ovulatory dysfunctional uterine bleeding - irregular shedding of endometrium due to inadequate luteal phase due to low progesterone production
PID
Hypothyroid
Endometriosis, adenomyosis
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32
Q

What are the common causes of abnormal bleeding in women over 40?

A

Anovulatory dysfuntional uterine bleeding - no secretory phase of cycle resulting in excessive bleeding from endometrial hyperplasia

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33
Q

What is primary amenorrhoea?

A

This is absence of periods by 13 with no other puberty signs or 15 with other puberty signs

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34
Q

What are the causes of primary amenorrhoea?

A

Constitutional delay - family history
Hypogonadism:
-Lack of sex hormone due to hypogonadotrophic hypogonadism - low LH and FSH e.g. pituitary dysfunction
-or hypergonadotrophic hypogonadism - no response to LH and FSH e.g. previous damage to ovaries or turners syndrome
Congential adrenal hyperpasia resulting in too much testosterone
Adrogen insensitivity syndrome - female phenotype but no internal female organs
Structual pathology e.g. imperforate hymen

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35
Q

What investigations are done for primary amenorrhoea?

A 
Blood tests:
-FBC, U and E, anti ttg for coeliac
Hormonal: 
-TFT, LF and FSH, IGF1 for GH deficiency, testosterone
Genetic testing for turners
Imaging to age bones
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36
Q

What is the management of primary amenrrhoea?

A

Constitutional delay requires reassurance
Treat underlying causes
Can use hormones to promote menarche
Pulsatile GnRH to induce normal cycles

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37
Q

What is endometritis?

A

This is an infection following delivery or abortion

38
Q

What bacteria commonly cause endometritis?

A

Group B strep or staph aureus

39
Q

What are the clinical findings in endometritis?

A

Fever
Uterine tenderness
Purulent vaginal discahrge
abdo pain

40
Q

How is endomettitis treated?

A

With Cefoxitin

41
Q

What is adenomyosis?

A

This is invagination of the endometrial tissue into the myometrium (muscle)
Cause not fully understood, hormone driven so tends to resolve after menopause

42
Q

What are the presenting symptoms in adenomyosis?

A

Menorrhagia
Dysmenorrhoea
Dyspareunia
Enlarged tender uterus on examination

43
Q

How is adenomysis investigated?

A

Transvaginal ultrasound

Myometrial biopsy for histology

44
Q

What is the management of adenomyosis?

A

The same as manorrhagia:

  • Contraception - mirena, COC
  • TXA or mefenamic acid
  • endometrial ablation or uterine artery embolisation
45
Q

What is endometriosis?

A

This is when endometrial tissue is outside of the uterus

Unclear cause however one theory is retrograde menstuation causes endoetrial tissue to seed in peritoneum

46
Q

Why does endometriosis cause pain?

A

The extra uterine endometrial tissue responds to hormones in the smae way so will bleed during menstruation
This causes cyclical pain due to irritation and inflammation
Adhesions between the surrounding structures can lead to continous non cyclical pain
It can also lead to reduced fertility

47
Q

What is the presentation of endometriosis?

A

pelvic pain
Dysmenorrhoea
Dyspareunia
haematuria or blood in stools

48
Q

What are the examination findings for endometriosis?

A

Endometrial tissue may be visible in the vagina
A fixed cervix on bimanual palpation
Tenderness in the vagina, cervix and adnexa

49
Q

How is a diagnosis of endometriosis made?

A

Pelvic ultrasound is often unremarkable
Laproscopic surgery is the gold standard
Biopsies can be taken and lesions can be removed

50
Q

How is endometriosis staged?

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

51
Q

What is the management of endometriosis?

A

Initial management involves pain management e.g. nsaids and paracetamol
Hormonal management - Hormonal contraceptives to reduce pain - reduces hormonal thickening
Surgical - laproscopic surgery to excise or ablate lesions
Hysterectomy

52
Q

What are fibroids?

A

They are smooth muscle tumours of the uterus

Affect 40-60% of women in later reproductive years

53
Q

What causes fibroids to grow?

A

They grow in response to oestrogen

54
Q

What are the types of fibroids?

A

Intramural - within the myometrium
Subserosal - just below the outer layer of the uterus
Submucosal - means just below the endometrium
Pedunculated - on a stalk

55
Q

What are the presentations of fibroids?

A 
They are often asymptomatic 
Can present with:
Heavy menstrual bleeding
Prolonged menstruation
Abdominal pain
56
Q

What are the investigations for fibroids?

A

Hysteroscopy is the inital investigation for submucosal fibroids with heavy menstrual bleeding
Pelvic ultrasound is the investigation for larger fibroids
MRI scanning can be done to plan surgical management

57
Q

What are the management of fibroids depending on their size?

A

Less than 3cm, the same as medical management of menorrhagia:
-Mirena coil
-Symptomatic - NSAIDs and TXA
-COC
-Cyclical oral progesterone
Or sugically:
-Endometrial ablation
-Resection
More than 3cm, refer to gynae for investigation and management:
-Medical management the same
-Surgical management - uterine artery embolisation or myomectomy
GnRH analogues such as goserelin can be used to reduce the fibroid size before surgery

58
Q

What is the presentation of red degeneration of fibroids?

A

This is when disruption of the blood supply to the fibroid causes ischaemia, infarction and necrosis
Usually occurs in larger fibroids during preganancy as they outgrow their blood supply
They have:
-Severe abdo pain
-low-grade fever
-tachycardia
It is managed supportively with rest, fluids and analgesia

59
Q

What hormone changes occur in menopause?

A

Oestrogen and preogesterone are low

LH and FSH are high in response to absence of negative feedback

60
Q

What are the perimenopausal symptoms?

A 
Hot flushes 
Emotional liability or low mood
irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
61
Q

What risks does low oestrogen caused by the menopause bring?

A

Cardiovascular risks
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

62
Q

How is a diagnosis of menopause made?

A

Retrospectively once the periods have stopped for 12 months
FSH blood test can be used in women under 40 with suspected premature menopause
Women 45-50 with irregular periods

63
Q

How long to women have to continue using contrception after menopause?

A

2 years after last period in women under 50

1 year after last period in women over 50

64
Q

What are the two key side effects of the depo progesterone injection?

A

Weight gain and osteoporosis

65
Q

What are some of the management options for perimenopausal symptoms?

A

Hormone replacement therapy
Clonidine (alpha agonist) helps with vasomotor symptoms
CBT
SSRIs such as fluoxetine or citalopram
testosterone cream for reduced libido
vaginal oestrogen for dryness and atrophy

66
Q

What is premature ovarian syndrome and what hormonal changes take place?

A

This is where there are menopausal symptoms before the age of 40 due to hypergonadotrophic hypogonadism
This causes a lack of negative feedback resulting in high FSH and LH and low oestrogen levels

67
Q

What are the causes of premature ovarian syndrome?

A

Idiopathic
Iatrogenic - post chemo, surgery etc
Autoimmune - assocaitions with coeliac, thyroid etc
Genetic - family history of conditions such as turners
Infections - e.g. mumps, tuberculosis

68
Q

What is the presentation of premature ovarian syndrome?

A

Irregular periods or Secondary amenorrhoea

Symptoms of low estrogen (vaginal dryness, hot flushes and night sweats)

69
Q

How can a diagnosis of premature ovarian syndrome be made?

A

With perimenopausal symptoms at younger than 40 and raised FSH

70
Q

What are the screening tests that are done for cervical cancer?

A

The testing is HPV first system

This involves testing for high risk strains of HPV and only if these are positive doing cytological examination

71
Q

What is the follow up for normal HPV cervical smear testing?

A

Return to routine recall every 3 years

72
Q

What is the follow up for a patient with positive HPV on cervical smear?

A

They examine the samples cytologically:
-If abnormal colposcopy
-If normal return in 12 months for repeat smear - if this is normal return to routine 3 yearly recall - If HPV still positive at 24 months then colposcopy
If the sample is inadequate then repeat in 3 months and if 2 samples inadequate then colposcopy

73
Q

What is the difference between stress and urge incontinence?

A

Stress incontinece is leakage of urine from increased intraabdominal pressure such as laughing or coughing - this is due to weakness in the pelvic floor and sphincter muscles
Urge incontinence is from detrusor overactivity causing a sudden urge to go to the toilet

74
Q

What is overflow incontinence?

A

This is where there is chronic urinary retention leading to leakage of urine without the urge to pass it
This occurs with anticholinergic medications and neurological conditions

75
Q

What are some of the risk factors for urinary incontinence?

A 
Increased age
Postmenopause
Increased BMI
Previous pregnancies
Prolapse
Previous pelvic floor surgery
Neuro conitions e.g. MS
Cognitive impairment and dementia
76
Q

What are the modifiable lifestyle factors for urinary incontinence?

A

Caffine use
BMI
Alcohol consuption
Medication

77
Q

What investigations should be done for urinary incontinence?

A

Examination bimanually to access pelvic floor tone - asking them to sqeeze and feeling the contraction
Bladder diary
Urine dip
Post void bladder scanning for incomplete emptying
Urodynamic testing when unclear diagnosis

78
Q

What is urodynamic testing?

A

Involves inserting catherters into bladder and rectum to measure pressures and compare
Bladder filled with liquid and flow rate measured and pressure at which bladder leaks etc.

79
Q

What is the management of stress incontinence?

A

Avoid caffine, diuretics and overfilling bladder
Avoid excessive fluid intake
Weight loss
supervised pelvic floor exercises for at least 3 months
Surgery:
-Tension free vaginal tape
-Sling procedures with fascia from abdominal wall
-Colpsosuspension - stiching vagina to symphesis around urethra to support it
-Intramural urethral bulking - injections around urethra to increase support
Duloxetine - SNRI used second line to surgery

80
Q

What is the management of urge incontinence?

A

Bladder retraining - increasing the time between voiding
Anticholinergic medication e.g. oxybutynin - anticholinergic side effects such as dry eyes, constipation - can cause cognitive decline and worsening of dementia
Mirabegron - beta 3 agonist so contraindicated in uncontrolled hypertension
Invasive options:
-Botulinum toxin injection
-Percutaneous sacral nerve stimulation
-Augementation cytoplasty - using bowel tissue to enlarge bladder size
-Urinary diversion to a urostomy

81
Q

What is vault prolapse?

A

This is when a women has had a hysterectomy and the top of the vagina (vault) prolapses downwards

82
Q

What is a rectocoele?

A

This is where a defect in the posterior vaginal wall allows the rectum to prolapse into the vagina

83
Q

What is the management of uterine prolapse?

A 
Conservative:
-Physio - pelvic floor exercises
-Weight loss
-Lifestyle changes - same as stress incontinence
-Vaginal oestrogen creams
Pessaries
-Ring
-Shelf - flat disc that sits below uterus
-Cube
-Donut - thick ring
-Hodge - rectangular
Should be removed cleaned and replaced every 4 months
Oestrogen cream protects the vaginal walls from irritation
Surgery - risks:
-Pain, bleeding, infection, DVT
-Damage to bladder or bowel
-Recurrence of prolapse
Mesh repairs should be avoided entirely:
-Chronic pain
-Urinary and bowel problems
84
Q

What are the risk factors for pelvic organ prolapse?

A 
It is caused by lengthening and weakening of the ligaments and muscles holding up the pelvic floor
Risk factors:
-Multiple vaginal deliveries
-Prolonged delivery or instrument use
-Advanced age and menopause
-Obesity
-COPD coughing
-Chronic constipation straining
85
Q

What is the presentation of pelvic organ prolapse?

A

A dragging or heavy sensation in the pelvis
Urinary symptoms - incontinence, urgency, frequency
Bowel symptoms - constipation, incontinence
Sexual dysfunction - pain, reduced enjoyment
May notice a lump in the vagina that they push back up themselves

86
Q

What is a vault prolapse?

A

This is when a women has had a hysterectomy and the top of the vagina (vault), descends into the vagina

87
Q

What is a rectocoele?

A

This is a defect in the posterior vaginal wall usually caused by chronic constipation
It causes a palpable lump and faecal loading causing worsened constipation

88
Q

What is a cystocoele?

A

This is an anterior vaginal wall defect that allows the bladder to prolapse backwards

89
Q

How are women examined for prolapse?

A

In either the dorsal (on back) or left lateral position

Use a sims speculum to examine the anterior and posterior vaginal walls seperately whilst asking the patient to cough

90
Q

What is the treatment of atrophic vaginitis?

A

Estrogen cream
Estrogen pessaries - used at night
Eastradiol tablets - vagifem

91
Q

What are the contraindications for topical oestrogen?

A

Breast cancer
Angina
Venous thromboembolism

92
Q

What is the treatment of bartholin cysts?

A

A word catheter can be placed under LA, uses a baloon to hold in place and then can be removed once epithelisation has occured
Marsupialisation - done under GA to remove cyst

Obs and gynae (8 decks)

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