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Obstetrics and Gynaecology > Gynaecology conditions > Flashcards

Gynaecology conditions Flashcards

1
Q

What is a fibroid?

Who are they more commonly seen in?

A

Benign smooth muscle tumour of uterus

More common in afro-caribbeans

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2
Q

What is the pathogenesis of fibroids?

A

Poorly understood but growth thought to be stimulated by oestrogen

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3
Q

What are the types of fibroids?

A

Subserosal - protrude into serial surface of uterus, can be pedunculated

Intramural - most common, confined to myemetrium

Submucosal - Develop immediately beneath endometrium and protrude into uterine cavity

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4
Q

How do fibroids present?

A

Often asymptomatic

Menorrhagia
Pelvic pain
Bloating/distention
Pressure –> constipation, urinary frequency and urgency
Fertility problems
!!Polycythaemia - due to the fibroids producing erythropoietin!!

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5
Q

How would fibroids present on examination?

A

Solid mass

Enlarged NON-TENDER uterus may be palpated

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6
Q

How are fibroids investigated?

A

Transvaginal USS

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7
Q

What are the medical options for fibroid management?

A

Symptom control:
IUS (mirena), NSAIDs, TXA, COCP

GnRH agonist (goserelin) - pre-op to reduce size
Ulipristal (selective progesterone receptor modulator) - reduce fibroid size and help with menorrhagia
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8
Q

What surgical options are there for fibroid management?

A

Myemectomy - if want to preserve uterus
Hysterectomy
Uterine artery embolisation

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9
Q

What normally happens to fibroids in menopause?

A

Regress

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10
Q

What complications are associated with fibroids?

A

Infertility

In pregnancy - miscarriage, fetal malpresentation, IUGR

Red degeneration - haemorrhage into fibroid

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11
Q

How does red degeneration (complication of fibroids) present?

A

Fever, pain and vomiting

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12
Q

What is endometriosis?

A

Endometrial tissue located at sites other than the uterine cavity

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13
Q

What are the most common sites for endometriosis to affect?

A

Lining of pelvis
Uterosacral ligament
Bladder
Ovary

Others include: intestines, Fallopian tubes, ureter, cervix etc.
Can go as far as lungs

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14
Q

What is the pathophysiology of endometriosis?

A

Retrograde menstruation - endometrial cells travel backwards from the uterus via the fallopian tubes to pelvic organs

Tissue sensitive to oestrogen so bleed during menstruation

Repeated inflammation and scarring lead to adhesions

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15
Q

What is the mean age of endometriosis diagnosis?

A

25-40yo

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16
Q

How does endometriosis present?

A

Cyclical pelvic pain beginning the day before menstruation

Dysmenorrhoea + dyspareunia + dysuria + dyschezia (painful bowel motions)

May be subfertility

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17
Q

What are the main risk factors for endometriosis?

A 
Early menarche
Short cycle
Long bleed time
Heavy bleeding
Family history
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18
Q

What can be seen on examination in endometriosis?

A

Fixed retroverted uterus
Uterosacral ligament nodules
General tenderness especially in the posterior vaginal fornix

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19
Q

How is endometriosis investigated? What are the results of these?

A

Laparoscopy

  • Chocolate cysts
  • Adhesions
  • Peritoneal deposits

Pelvis USS - kissing ovaries can be seen (adhesions)

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20
Q

What are the key differentials for endometriosis?

A

PID
Ectopic
Fibroids
IBS

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21
Q

How is endometriosis managed?

A
  1. NSAIDs +/- paracetamol
  2. COCP or progesterone’s (POP, injected or IUD)
  3. GnRH analogues, laser ablation or excision.
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22
Q

What is adenomyosis?

A

Functional endometrial tissue within myometrium of uterus

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23
Q

How does adenomyosis present?

A

Menorrhagia
Dysmenorrhoea - progress from cyclical to daily
Deep dyspareunia
Irregular bleeding

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24
Q

Who does adenomyosis affect?

A

Multiparous women at end of their reproductive life

Associated with fibroids

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25
Q

What is the pathophysiology of adenomyosis?

A

Thought to occur when endometrial connective and supportive tissue allowed to interact with myometrium after damage (childbirth, c-section, surgery)

Can occur anywhere but most often posterior uterine wall

Tissue responsive to hormones

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26
Q

How is adenomyosis diagnosed?

A

Histological diagnosis after hysterectomy

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27
Q

How is adenomyosis investigated? What do they show?

A

Transvaginal USS

  • globular uterine configuration
  • Poorly defined endometrial-myometrial interface
  • anterior-posterior myometrium asymmetry

Hysteroscopic biopsy

MRI - thickening of endo-myometrial junction zone

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28
Q

What is observed on examination of a lady with adenomyosis?

A

Enlarged, tender, boggy uterus

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29
Q

How is adenomyosis managed curatively?

A

Hysterectomy

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30
Q

What is the medical management for adenomyosis?

A

Similar to endometriosis

  • NSAIDs
  • COCP
  • Progesterone - oral, IUS, depot
  • GnRH agonist
  • Aromatase inhibitors
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31
Q

What surgical option is there for adenomyosis apart from hysterectomy?

A

Uterine artery embolisation

  • stop blood supply to adenomyosis causing it to shrink
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32
Q

What is a cervical polyp?

A

Benign growths due to hyperplasia of the endocervical epithelium
They arise from the inner surface of the cervix

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33
Q

What age is peak incidence of cervical polyps?

A

50-60 years old

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34
Q

How do cervical polyps present?

A

Generally asymptomatic and picked up on cervical screening

Can cause abnormal vaginal bleeding:

  • Menorrhagia
  • Post-coital
  • Intermenstrual
  • Post-menopausal
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35
Q

How are cervical polyps diagnosed?

A 
Histological examination after removal
May also do:
- Swab for infection
- Cervical smear - CIN
- USS if symptoms persist after removal ?endometrial polyp
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36
Q

How are cervical polyps managed?

A

Removal - small risk of malignant transformation

Can be done in primary care - twist polypectomy forceps
Larger/hard to access need diathermy in colposcopy clinic

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37
Q

What is cervical ectropion?

Who it is common in?

A

Eversion of the endocervix - metaplasia of stratified squamous (ectocervix) to glandular simple columnar (endocervix)

Common in teenagers, pregnancy and those on COCP

38
Q

What causes the metaplasia seen in ectropion?

A

High oestrogen levels

39
Q

How does cervical ectropion present?

A

Commonly asymptomatic

Discharge - increased glandular tissue
Post-coital bleeding - fine blood vessels in epithelium

40
Q

How is cervical ectropion investigated?

A

Rule out more sinister diagnosis:

  • Swabs - infection
  • Smear - CIN
  • Biopsy - if lesions seen
41
Q

How does a cervical ectropion appear on examination?

A

Ring of reddish tissue around external os

42
Q

How are cervical ectropion’s managed?

A

Stop any oestrogen containing medication

Cryotherapy can be used

43
Q

What happens in PCOS?

A

Excess androgen production and multiple immature follicles (cysts) in the ovaries

44
Q

What happens to the hormones in PCOS?

A

Increased frequency of GnRH pulses = increased LH = ovarian production of androgens

Insulin resistance means increased insulin secretion = suppression of sex hormone binding globulin = more free circulating androgens

Free circulating androgens suppress LH surge so follicles develop in ovaries but maturation arrest at early stage so remain visible as cysts in ovaries

45
Q

How does PCOS present?

A 
Oligo/amenorrhoea
Infertility
Chronic pelvic pain
Acne
Male pattern baldness
Hirsutism
Obesity
Depression
Acanthosis nigricans
46
Q

What are the main risk factors for PCOS?

A

Diabetes

Family history

47
Q

What are the main differentials for PCOS?

A

Hypothyroidism
Hyperprolactinaemia
Cushing’s

48
Q

What is the Rotterdam criteria for PCOS?

A

Need 2/3 for diagnosis:
>=12 cysts or ovarian volume >10cm3
Oligo/anovulation
Clinical or biochemical signs of hyperandrogenism

49
Q

What hormones would be raised in PCOS?

A

Testosterone
LH
LH:FSH

50
Q

What hormones would be low in PCOS?

A

Sex Hormone Binding Globulin

Progesterone

51
Q

How is amenorrhoea in PCOS managed? Why is this done?

A

COCP to induce at least 3 bleeds per year

Anovulatory cycles due to unopposed oestrogen lead to endometrial hyperplasia which can become malignant so bleeding must be induced

52
Q

How is weight controlled in PCOS?

A

Orlistate - can improve insulin resistance

53
Q

How is hirsutism in PCOS managed?

A
  1. COCP or co-cyprindiol
  2. Eflornithine topical cream
  3. Antiandrogens - spironolactone, finasteride
54
Q

How is infertility in PCOS managed? (2 drugs)

What are the risks of on of these drugs?

A

Clomifene - associated with multiple pregnancy, ovarian hyper stimulation syndrome and ovarian cancer
Metformin - particularly good in obese patients

55
Q

Where are the bartholin’s glands located?

A

Deep to posterior aspect of labia majora

Also called greater vestibular glands

56
Q

Where do the bartholin’s glands open?

A

Either side of vaginal orifice
Within vestibule - 4 o clock and 8 o clock
Just below hymenal ring

57
Q

What is the function of the bartholin’s glands?

A

Secrete mucus to lubricate vagina

58
Q

What is the pathophysiology of a bartholin’s cyst?

A

Build up of mucus secretions can cause duct of gland to become blocked - cyst develop

Cyst can become infected and if untreated develop into abscess

59
Q

What organisms can infect a bartholin’s cyst?

A

Usually aerobic

E.Coli, MRSA and STI’s most common

60
Q

Who gets bartholin’s cysts?

A

Nulliparous women of reproductive age

61
Q

How do bartholin’s cysts present?

A

Often asymptomatic
Vulval pain on sitting or walking
Superficial dyspareunia

Soft fluctuant and non tender mass

62
Q

How do bartholin’s abscesses present?

A

Acute onset of pain
Difficulty passing urine

Hard mass and surrounding cellulitis

63
Q

How are bartholin’s cysts diagnosed?

A

Clinical diagnosis

If >40yo a biopsy should be done - exclude vulval malignancy
If signs of STI - swab

64
Q

How are bartholin’s cysts managed?

A

Warm bath - aid spontaneous rupture in small asymptomatic cysts

NO SIMPLE INCISION AND DRAINAGE - reaccumulate

Either word catheter or marsupialisation

65
Q

Describe the use of word catheters for bartholin’s cysts

A

Catheter inserted into cyst and left in place for 4-6 weeks
Done under local anaesthetic
Risks - recurrence, dyspareunia, scarring

66
Q

Describe how marsupialisation is used for bartholin’s cysts

A

Incision into cyst allow drainage. Cyst wall everted and sutured to vaginal mucosa

General anaesthesia

Risks - hameatoma, dyspareunia

67
Q

What is lichen sclerosis?

A

Chronic inflammatory skin disease which has the potential to progress to squamous cell carcinoma

68
Q

What is the epidemiology of lichen sclerosis?

A

Bimodal incidence - prepubescent girls and post-menopausal women

69
Q

What is the pathophysiology of lichen sclerosis?

A

Atrophy of the epidermis - thin stratified squamous epithelium

Band-like infiltrate of chronic inflammatory cells beneath epithelial layer

70
Q

How would you investigate lichen sclerosis?

A

Biopsy

Only needed if suspicious of vulval cancer or not responding to treatment

71
Q

How does lichen sclerosis present?

A

White atrophic patches on skin - anogenital region
!!Itching!!
Skin may fissure/erode - pain
Dyspareunia

72
Q

What would be seen on examination of a woman with lichen sclerosis?

A 
White well defined lesions
Evidence of adhesions and/or scarring:
- clitoral hood fusion
- fusion of labia minora to labia majora
- posterior fusion - loss of vaginal opening
73
Q

What are the main differentials for lichen sclerosis?

A

Vitiligo
Vulval cancer
Candida

74
Q

How would you manage lichen sclerosis?

A

Topical steroids and emollients- clobetasol propionate

75
Q

Why is follow up important for lichen sclerosis?

A

Risk of developing squamous cell carcinoma (2-5% lifetime risk)

76
Q

What are the types of ovarian cyst?

A

Simple - fluid only

Complex - can vary but may be irregular, solid, have septations or a vascular supply

77
Q

What is a dermoid cyst?

A

Also called mature teratoma or benign germ cell

Lined with epithelial tissue - hair, teeth, fat etc.

Most likely to torsion

78
Q

What is an endometrioma?

A

“chocolate cysts” seen in patients with endometriosis

Blood in cyst

79
Q

What type of cyst is a follicular cyst? What causes it?

A

Commonest type of functional cyst/physiological

Non-rupture of dominant follicle or failure of atresia of non-dominant follicle

80
Q

What type of cyst is a corpus luteal cyst? What causes it? What complication can it lead to?

A

Functional cyst/physiological
Corpus luteum doesn’t break down, can fill with blood or fluid and become cyst

Can cause intra-peritoneal bleeding

81
Q

What are the types of benign epithelial cyst? Which is most common? Describe them?

A

Either mucinous cystadenoma or serous cystadenoma

Serous is most common

Mucinous - very large, can rupture and cause rare type of peritoneal cancer, common 20-40yo

Serous - bear resemblance to serous carcinoma, common 40-50yo

82
Q

How do ovarian cysts present?

A

Asymptomatic mostly - found incidentally

Dull ache in lower abdomen + back ache
Dyspareunia
Pressure effects on bladder
Acute events - torsion or rupture

83
Q

How do ovarian cysts present acutely?

A

Torsion - severe abdominal pain and fever

Rupture - peritonitis and shock

84
Q

What are the risk factors for ovarian cysts?

A

Obesity
Tamoxifen
Early menarche

85
Q

What investigations are requested for an ovarian cyst?

A

Transvaginal USS

  1. Biopsy
  2. Fine needle aspiration (second line as risk of spillage and malignancy spread)

CA125 not needed in premenopausal women
LDH, AFP, Beta HCG should be measured if <40yo

86
Q

What complications are associated with ovarian cysts?

A

Torsion
Rupture
Haemorrhage
Infertility - surgical management

87
Q

How are simple cysts in pre-menopausal women managed?

A

Malignancy unlikely - watchful waiting

Most disappear within 3 menstrual cycles

88
Q

How are larger cysts in pre-menopausal women managed?

A

> 5cm, complex or concern for malignancy

Surgical removal - cystectomy or oophorectomy

89
Q

How are cysts managed in post menopausal women?

A

Risk of malignancy index (RMI) based

RMI <25 - 1yr follow up USS and CA125 (<5cm)
RMI 25-250 - bilateral oophorectomy and if malignancy found then staging req. (with completion of surgery)
RMI > 250 - Referral for staging laparotomy

90
Q

How would an ovarian torsion present?

A

Often acute onset pain with exercise

N&V

91
Q

What would an USS of a tortioned ovary show?

A 
whirpool sign
free fluid (due to venous/lymph obstruction leading to transudate from the ovary leaking out)
92
Q

What constitutes a complex cyst?

A

solid mass within cyst

multi-loculated

Obstetrics and Gynaecology (21 decks)

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