Gynaecology Medicine 🚺 Flashcards
Extreme cervical motion tenderness is seen where? (Chandelier sign)
PID
Can PID be a clinical diagnosis?
Yes. Can do swab or US, but it’s not needed
Main use of US IN PID?
To check for tuboovarian abscess
First invx in PID suspect
HCG (you know the drill)
Outpatient treatment for PID?
Doxy Foxy
(IM Ceftriaxone and oral doxycycline)
When do we add metronidazole to PID therapy regime
If signs of vaginitis or recent gynae instrumentation
When to hospitalise a PID patient
Outpatient therapy didn’t work, non compliance risk, severe N/V, tuboovarian abscess, pregnancy
Inpatient PID therapy
IM doxy foxy (doxycycline and Ceftriaxone) for 7 days
What is uterine procidentia
Whole uterus has protruded out of level of introitus
Pelvic organ prolapse diagnosis?
Clinical!
Is the first line management for pelvic organ prolapse, conservative or surgery
Conservative
3 conservative treatment ideas for pelvic organ prolapse
Vaginal pessary (not long term Tx), reduce risk factors (weight loss, laxative), Kegels
When is surgery indicated for pelvic organ prolapse
If conservative treatment fails for symptomatic cases
Some surgeries for pelvic organ prolapse
Obliterative surgery (colpocleisis), or reconstructive surgery (sacrocolpexy, suspension, colporrhaphy,
Risk factors for ovarian cyst rupture
Large cysts, repro age, intercourse, physical activity
Imaging of choice to diagnose ovarian cyst rupture. And what do you see
Transabdominal or transvaginal US. See free fluid in pouch of Douglas
If transabd/transvag ultrasound non conclusive for ovarian cyst rupture, what invx can you do next
CT with IV contrast (see the hemoperitoneium)
Hemodynamically unstable case of ovarian cyst rupture. Mx? When do we do oophorectomy
Emergency exploratory laparotomy or laparoscopy to get hemostasis. Suture/cauterise where needed. Oophorectomy if intractable
Hemodynamically stable patient with ruptured ovarian cyst. We observe and give analgesics. When do we do do inpatient vs outpatient therapy
Outpatient: only small Hemoperitoneum and no ongoing bleeding
Inpatient: significant blood loss and/or it’s ongoing
Imaging of choice for ovarian torsion.
Transabd/transvag ultrasound with Doppler
First Mx (not Invx) of ovarian torsion patient (in all patients)
Emergency exploratory laparoscopy
Premenopausal woman comes with ovarian torsion. How should she be managed in Sx
detort, to preserve ovary. Only remove ovary if necrotic
Postmenapausal woman comes with ovarian torsion. How should she be managed in Sx
Salpingo oophorectomy
Initial diagnosis work up for adenomyosis.
Hx and Exam etc. transvaginal US (MRI ok too). Diagnosis is clinical though
How to confirm adenomyosis diagnosis
Histology
Conservative therapy options for adenomyosis
Prog only pill, COCP, NSAID
Definitive therapy for adenomyosis
Hysterectomy
Best initial test for endometriosis
Transvaginal US
Confirmatory test for endometriosis
Laparoscopy and biopsy (recall pathology)
Endometriosis medical therapy first line
COCP (can give NSAID too)
Endometriosis medical therapy (if patient wants pregnancy)
NSAID
Endometriosis medical therapy for severe cases
GnRH antag or ag
Endometriosis surgical therapy first line?
Laparoscopic excision and ablation of endometriosis implants. Done when medical therapy hasn’t helped
Endometriosis surgical therapy second line?
Open surgery with hysterectomy (+/-) bilateral salpingo oophorectomy
Definition of infertility
Cannot achieve pregnancy after 12 months of unprotected sex in women <35, and after 6 months in women >35 (times a tickin’)
Antibody to test for potential male infertility
Anti sperm ABs
Ways to invx potential male infertility
TSH, prolactin, karyotype, semen analysis
Name 5 hormone tests we could do to assess female infertility
Midluteal progesterone, androgen levels, early follicular FSH (high in ovarian insufficiency), TSH, prolactin
Aside from hormone tests, what else can be done to invx female infertility at first
Ovarian US (Antral follicle count), endometrial biopsy (done 1-3 days before Mense)
If initial female infertility workup is negative, how should we invx next? (note, initial workup usually looks at hormones)
Screen for tubal/uterine abnormalities
3 ways to invx for structural causes of female infertility
Hysterosalpingography, sonohysterosalpingography, hysteroscopy
4 drugs to help induce ovulation
Clomiphene, GnRH (pulsatile), gonadotropins, tamoxifen
In vitro fertilisation process
Follicular stimulation, retrieve egg, mix egg with sperm, transfer 2-5 embryos into mother
What is intracytoplasmic sperm injection
Single sperm injected into oocyte
What is intrauterine insemination
Washed and concentrated sperm introduced direct into uterus
Signs and symptoms of OHSS
Abdomen pain and distension, N/V, 3rd spacing. Ultrasound will show enlarged ovaries and maybe ascites
OHSS is due to what, and when
After HCG/clomifene treatment. Usually 3-9 days after
Management/monitoring and advice for mild/moderate OHSS
Outpatient.
Acetaminophen for pain. Limit activity, monitor body weight, and urine output.
Management for severe OHSS
Hospitalisation.
MDT approach
If have ovarian mass. First Invx?
US
Signs of concerning ovarian cyst on US
Thick septations, projections, papillae, >8cm
Signs of benign ovarian cyst on US
Round, thin wall, dark fluid, homogenous, <8cm
Management of concerning looking cyst on US?
Sx likely
Treatment of follicular cyst (generally)
No Tx
Patient has ovarian cyst with thin walls and little vasc. And has endometrial growth/irreg bleeding. Likely Dx?
Follicular cyst
Patient has ovarian cyst with thick walls and high vascularity. And has missed periods. Likely Dx?
Corpus luteal cyst
Ultrasound finding for Corpus luteal cyst
Ring of fire on Doppler
Patient had molar preg and now has bilateral ovarian cysts. Dx?
Theca luteal cysts
Simple cyst in premenopausal woman. < 5cm. Mx
Nothing, this is quite normal
Simple cyst in premenopausal woman. > 5cm. Mx
Follow up
Simple ovarian cyst in postmenapausal woman. < 3 cm. Mx
Quick CA 125 check
Simple cyst in postmenapausal woman. > 3 cm. Mx
Follow up (cancer risk)
Rotterdam criteria for PCOS
At least 2:
Oligo/anovulation
Hyperandrogenism signs
Enlarged ovaries on ultrasound or presence of cysts
Main lab study for PCOS patients
Confirm hyperandrogenism. And I guess an LH:FSH >2
What would you see in PCOS for progestin challenge
Patient will bleed. Sign of anovulation
What metabolic screening should we do in PCOS patients
Weight, height, waist circumference, BMI (if high, check lipids and sleep apnoea), BP, glycemic status
First line therapy for PCOS (not planning to conceive)
COCP
First line therapy for PCOS (planning to conceive)
Letrozole
Aside from PCOS treatment; some advice for patients
BMI < 25, eat well, excersize,
Endometrial hyperplasia and no atypia. Mx?
Observe +- progestins
Endometrial hyperplasia with atypia. Mx?
Hysterectomy (or progestins until had kids)
First imaging to explore endometrial cancer
Transvaginal US
How to Dx endometrial cancer
Biopsy
Endometrial cancer management in woman not intending pregnancy
Total hysterectomy and bilateral saloingooophorectomy
Management of endometrial cancer in early stage or wanting to preserve fertility if can
Progestins (with it without radio/chemo)
Pyometra diagnosis and treatment
Dx with imaging (US/CT), Tx with draining and cervical dilation
Pap testing summary (routine)
25-65 year olds every three years.
Once above 30, can do HPV test too (called a co test, and we do every 5 years).
Don’t screen less than 21
If patient has positive Pap test (atypical cells), do what?
Colposcopy and biopsy. If patient above 35, do endometrial biopsy too (can also be endometrial cells)
What is acetowhite epithelium in cervical cancer testing
During colposcopy, we add acetic acid to cervical cells, and see they become white if atypical/dysplastic. Requires 2-4 punch biopsies after
If inadequate PAP, do what? Then if inadequate again?
Repeat again in 3 mo. If again, do colposcopy.
Patient above 65. Do you Pap her?
Not if all previous tests were negative and she doesn’t smoke (and is not high risk)
If patient is HPV positive and Pap negative… do we do colposcopy?
No, only when Pap positive
If diagnosed cervical cancer, what management do we do?
Cold knife conization or loop electro surgical excision procedure (LEEP)
First line management of vulval carcinoma. When do radio/chemo therapy
Local excision and surgical resection. Do adjunct chemo/radio when there is mets
Lichen simplex chronicus Dx
Colposcopy and biopsy. Will have done this to rule out malignancy
Lichen simplex chronicus Mx
GC cream
VIN Mx
May excize or ablate… depends on severity
If do colposcopy on vagina and get abnormal cytology, despite no lesion per se… what do you do
Biopsy made every 6 mo for 2 years
Best treatment for vaginal carcinoma
Radiotherapy
1° amenorrhea definition
Not menses by 15 with normal sexual characteristics. Or 13 without sexual characteristics
First invx to check in amenorrhea
Pregnancy? HCG test
How to confirm constitutional delay of puberty
Bone age determination. If less than it should be = constitutional delay. If same, then shirt naturally
Definition of 2° amenorrhea, consider time frame if regular or irregular cycle
Cessation of menses for >3mo (regular cycle) or >6 mo (irregular cycle)
If progestin challenge leads to bleeding in an amenorrhea case, what does this mean
Anovulation amenorrhea
In primary (and 2° for that matter) amenorrhea, once ruled out pregnancy. Do what?
US
If ultrasound shows no uterus in primary amenorrhea, what test is best to next check
FSH
AUB case. Done Hx and exam, and ordered bloods. What invx next
US
When is the indication for an endometrial biopsy in AUB patients
Post menapause (>45)
Endometrium (>4mm)
Obese
Nullipartiy
Tamoxifen use
First line for AUB (if not too bad). If it’s just a heavy mense, give what instead
COCP. Give NSAID if menorrhagia
What classifies as heavy bleeding in AUB
More than 1 pad soaked per hour for several hours. Passing multiple large clots
Perimenapause definition
From when mense fluctuations start, to 1 year after menapause
Premenopause definition
When menses fluctuate to when they stop
Menopause definition
When menses cease (confirmed when 12 mo elapsed)
Post menopause definition
Time after 12 mo after last mense
How to diagnose menopause
Clinically, but E. P. Inhibin. FSH. can be useful. Vaginal pH will be high, and cholesterol high
How to establish menapause in patient with known mense cycle disorders or post hysterectomy
Need serum FSH levels (cannot based on bleeding)
How to establish menapause in patient on OCPs
Discontinue contraceptive and see if amenorrhea persists. Take FSH >4 weeks after
Is menopause usually treated
No
Indications to treat menopause
Severe symptoms, premature menopause, surgical menopause
HRT for menopause
Estrogen is had hysterectomy
E and P if patients have uterus
Contraindications for HRT in menopause (and generally)
Vaginal bleeding (unDx), pregnant, breast or endometrial cancer, liver disease, hyperlipidemia, DVT/stroke Hx, CAD.
Alternative to HRT for menopausal symptoms (kinda are Hormone based)
SERMs or paroxetine
How to diagnose ovarian insufficiency
Need two levels of FSH that are elevated, and two levels of estradiol that are low. All less than 1 mo apart, and after 3 months of mense irregularities. Women age less than 40. (1,2,3,40 rule)
Mx for ovarian failure
HRT (same as menopause)
Diagnostic criteria for prementrual syndrome
Symptoms begin <5 days before mense and end within 4days after. For >= 3 consecutive cycles
3 First line treatment for premenstrual syndrome
NSAID, OCP (Tanos says best), SSRI
Spirinolactone is water retention
Tuboovarian abscess management
Ampicillin and doxycycline parental (ampi doxy).
Surgical drainage laparoscopy (if ruptures)
Acute AUB in stable patient. Mx?
IV conjugated estrogen (fire with fire). Stabilises the endometrium.
Acute AUB in unstable patient. Mx?
Supportive. Fluid resus, blood transfusion, packing
When to do surgical Tx for AUB
If severe bleeding and patient unstable. Patient unresponsive to hormonal Tx/or cannot have hormonal treatment (breast/endometrial cancer)
AUB due to ovulation bleeding. How to Mx
OCP or progestin. NSAID/tranexamic avid are other options
AUB due to anovulatory bleeding, Mx?
Progestin PO for 10 days. Or IUD. (Convert proliferation endothelium into secretory!)
Surgical procedure for AUB, if patient wants to keep fertility
Dilation and curettage with hysteroscopy. (Diagnostic and therapeutic)
Surgical procedure for AUB, if patient can afford to lose fertility
Endometrial ablation. (CI - wants kids, pregnancy, endometrial hyperplasia
/CA)
2 times that uterine artery embolisation is the 1st line for AUB
In fibroids or AVM
1 time that hysteroscopy is the 1st line for AUB
Polyps
When is a hysterectomy good for patient with AUB
For patients unresponsive to other treatments, don’t desire fertility, or have symptomatic anemia
Initial diagnosis invx for endometrial polyp.
Transvag US
Good invx for endometrial polyp, that can also be used to remove it
Hysteroscopy
Mx for asymptomatic endometrial polyp
Obs and follow up
Mx for symptomatic endometrial polyp, or in post menapausal woman
Hysteroscopy (removal)
Best initial Invx for leiomyomas
US
Which invx is best to ID submucosal fibroids specifically
Hysteroscopy
Which imaging modality can be used to evaluate complicated surgical cases of leiomyomas…. And to differentiate leiomyomas/adenomyosis/etc.
MRI
How to manage asymptomatic fibroids
Doesn’t need Tx, but do follow ups with US
Two treatment options for fibroids in patients wanting to preserve fertility
Myomectomy and medical therapy
Fibroids 1st line aim?
First line medical therapies for fibroids. Good and bad bit of this treatment
Reduce bleeding and symptoms.
COCP and POP. They control bleeding but promote growth of leiomyomas.
Or progestin IUD (for fibroids not distorting inside of uterus). Antifibrinolytics (for those not wanting hormones), NSAIDs for pain.
Fibroids, second line consideration/priority?
Second line medical therapies for fibroids.
Reduce size/vascularity. 
GnRH agonists (amazing prior to surgery, not long term), GnRH antagonists, Danazol, selective progesterone receptor modulators (ulipristal).
When is myomectomy good for fibroids
If rapidly growing, and there is refractory bleeding after medical therapy.
When to do hysteroscopic vs abdominal myomectomy
Hysteroscopic when submucosal fibroids, or intramurals that are mainly intracavitary. Abdominal when subserosal or intramural
When would you do uterine artery embolization for fibroids?
Patient with no desire to preserve fertility, but wants to preserve the uterus/avoid Sx.
When would you do hysterectomy for fibroids?
Definitive treatment, for women not minding surgery, not wanting children and no needing to keep uterus
Superficial dyspareunia? Causes
Vaginal dryness. Vukvovaginal atrophy. Vulvovaginitis
Deep dyspareunia? Causes
Infection, congenital abnormality (like separate vagina), endometriosis, interstitial cystitis
Invx for dyspaerunia
Palpation of vulva and vaginal walls. See if reproduce pain.
Diagnostic criteria for dysparuenia
Pain in penetration, difficulty with penetration, anticipatory anxiety and tighten pelvic floor.
(At least one)
What is considered the best treatment option for dysparuenia (considering not a serious cause)
Pelvic floor excersizes and local desensitisation
Good symptomatic management for dysparuenia
Topical analgesics 10 mins before sex
what is the screening for ovarian cancer in BRCA? Is this the only screening for ovarian cancer?
Do US and CA125 annually. And do oophorectomy after 40. No other routine screening done
First invx for ovarian cancer suspicion
US
< 8cm Ovarian mass in premenopausal woman with benign signs. Mx
Close follow up (+-) Sx
> 8cm Ovarian mass in premenopausal woman with CA signs. Mx
Sx
When would you only observe a post menopausal woman with a ovarian mass. (consider size, markers, and one other aspect)… kyles rule of 5
If it’s <5cm, CA125 is normal, and is a5symp
Ovarian cancer management
Hysterectomy and BSO. One rectory and paraarotic LN’ectomy
Management of dermoid cyst
A mature teratoma should be removed due to risk of torsion
Tumour markers for dysgerminomas
LDH
Yolk sac tumour marker
AFP
Tumour marker for granulosa cell tumours
Inhibin
Signs and symptoms of a granulosa cell tumour
Precocious puberty or postmenapaual bleeding. Due to E. production
Ages where dysgerminomas are seen
Adolescents and young adults
Ages where yolk sac tumours are seen
Children and adolescents
Ages where granulosa cell tumours are seen
50 year olds
Gold standard to diagnose chlamydia STD
NAAT (PCR). Vaginal swab for women and first catch urine for men
3 Abx choices for chlamydia
Levofloxacin, Azithromycin, Doxycycline (LAD)
When treating Chlamydia… two other considerations ?
Treat partner. And give Azithromycin/ceftriaxone for gonorrhoea (unless ruled out)
Treatment of choice for pregnant women with chlamydia
Azithromycin
If patient positive for chlamydia, also test for?
HIV (and maybe other STDs)
Recommend annual screening for chlamydia, indicated for?
Sexually active woman <24. Or woman older who have risk factors
Two potential rheumatology complications of neisseria gonorrhoea
Arthritis dermatitis syndrome (polyarthralgia, tenosynovitis, dermatitis). Purulent gonococal arthritis
If gonorrhoea has disseminated, what two invx should be done
Arthrocentesis and blood culture
Test to check for gonorrhea STD
NAAT
1st line management for uncomplicated gonorrhoea
1 dose IM Ceftriaxone
Plus PO doxy if haven’t ruled out chlamydia (azithro if preg)
Disseminated gonorrhoea Tx
IV Ceftriaxone every day for 7 days. Drain joints. Consider chlamydia too
Diagnosis (invx) for trichomonas
Saline wet mount of vaginal smear. See motile trophozoites. Check pH of vaginal fluid also. If inconclusive, do culture
Management of trichomonas vaginitis. If allergic to first line?
7 days Oral metronidazole. If allergic, desensitise, since there are no other treatments
Diagnosis for syphilis
Serology
Summary of serology for syphilis
Non trep test false positives
Pregnancy, viral infection, SLE, drugs, rheumatic fever
Use of non trep test.
Screening and used to monitor response to treatment. It is our RPR (detects anti cardiolipin)
First line for syphilis treatment (1°, 2° or early latent).
Penicillin G, IM, one dose
First line for syphilis treatment (late latent, tertiary).
Weekly IM penicillin G (for 3 weeks)
Neuro syphilis treatment.
IV penicillin G for 10-14 days
Syphilis treatment, but patient allergic to penicillin
Doxy or ceftriaxone
Congenital syphilis treatment
10 day IV penicillin for newborn and mum
Treatment for Jarisch Herxheimer
NSAID (consider meptazinol)
Diagnosis for HSV STD
Clinical, plus Tzanck smear. Viral culture is more specific though.
Management for HSV STD
Oral acyclovir
Diagnosis of HPV.
Clinical inspection. Can add acetic acid (turns white.) see card on biopsy indication
When is a biopsy warranted for HPV anogenital warts
Immunodeficiency, atypical features of wart (bleeds, pigmented etc.), refractory to treatment
Management of HPV wart
Cryotherapy, or local 5FU, or salicylic acid. Unclear as to first line
Management of numerous warts
Curettage, laser, electrocoagulation
Amsels criteria for gardenerella
- Clue cells
- Fishy odour
- PH > 4.5
- Greyish Discharge
3/4 for Dx
How to invx gardenerella
Wet mount and whiff test
Asymptomatic gardenerella Mx
Reassure
Symptomatic gardenerella Mx
Oral metronidazole
Diagnosis of vaginal candidiasis
KOH wet mount (pseudohyphae)
Treatment for vaginal candidiasis
Topical azole or one dose oral fluconazole (if uncomplicated)
Treatment for preg woman with vaginal candidiasis
Topical azole (not oral!!)
First line for external genital warts
Imiquimod
First line for internal genital warts
Cryotherapy
Patient has endometriosis, What should actually be given before the COC P (according to Nice guidelines)
NSAIDs, see OCPs can be given after this
3 first lines for premenstrual syndrome
OCP, NSAID, SSRI (more second)
Patient does HPV test, which is positive. However cytology is negative. What do you do
Repeat smear in 12 months. If HPV is negative return to normal cycle. However if HPV is positive and histology is still normal, repeat in another 12 months. At the end of this if HPV is still positive colposcopy, if negative return to normal cycle
Although CA125 should not be used for screening of ovarian cancer, can it be used in symptomatic patients
Yes, in a patient who has suspicious signs of ovarian cancer, CA125 is often done initially before the ultrasound
Postmenopausal female has bleeding. Endometrial lining thickness was calculated using ultrasound and was increased. Next best step in investigation
Hysteroscopy and biopsy
What may we see on TVUS in PID
Fluid in PoD
PID treated… but fever not going… likely Dx?
TOA
What can be done after PID to assess fertility?
second look lap
Two main causes of AUB in teens
coag disorder, delayed menarche
AUB in repro age vs post menopause
repro age: PCOS, fibroids, polyp, cervicle CA
menopause: endometrial CA
at what cm and above do we consider a follicle a cyst?
above 3cm
If endometrial polyp is less than 10mm and assymp…. what do we do
expectant
The only effective treatment for large fibroids causing problems with fertility is what
myomectomy
risk factors for vulva ca
HPV, VIN, Lichen sclerosis
risk factors for vaginal ca
HPV, VaIN, Cervicle CA, STI, smoke
risk factors for cervical ca
CIN, HPV, STI, smoke
risk factors for endometrial ca
age, obese, pcos, lynch
risk factors for ovarian ca
age, obese, brca
risk factors for leiomyoma
age, high ldh
lady has premature contractions between 23-34 weeks. 3 preventative messures for the fetuses health
MgSO4 (prevent cerebral palsy), weekly hydroxyprogesterone to bulk up cervix, CSs if risk of delivering in week
General Tx for premature contractions
vaginal swabs (rule out infx), check cervical integrity, tocolysis, CSs 24 hours prior to delivery
Sudden one sided pain, and US shows adnexal mass with non visible ovary…. Dx?
likely torsion
If did laparoscopy for PID…. do what after to check for infertlity?
Tanos’s second look lap
