Gynaecology Part 2 Flashcards
Type 1 female genital mutilation:
partial or total removal of clitoris and/or prepuce
Type 2 female genital mutilation:
partial or total removal of clitoris and labia minora, with or without excision of labia majora
Type 3 female genital mutilation:
narrowing of vaginal orifice with creation of covering seal by cutting and positioning labia minora or majora, with or without excision of clitoris (infibulation)
Type 4 female genital mutilation:
all other harmful procedures to female genitalia: pricking, piercing, incising, scraping and cauterisation
How can fibroid degeneration come about and how does it present and treatment?
- sensitive to oestrogen so grows during pregnancy
- growth outstrips blood supply - red/carneous degeneration
- low grade fever, pain and vomiting
- manage conservatively with rest and analgesia (resolves within 4-7 days)
Features of Mittelschmerz:
- mid cycle pain
- sharp onset
- little systemic
- recurrent
- settles over 24-48 hours
Investigation and treatment of mittelschmerz:
- FBC normal
- US may show small quantity free fluid
- conservative management
Features of endometriosis pain:
- 25% asymptomatic
- menstrual irregularity, infertility, pain and deep dyspareunia
- intermittent small bowel obstruction
- intra abdominal bleeding - localised peritoneal inflammation
- recurrent episodes
Investigations endometriosis:
- US - free fluid
- laparoscopy - lesions
Features of ovarian torsion pain:
- suden onset
- deep seated colicky abdominal pain
- vomiting and distress
- adnexial tenderness
Investigation of ovarian torsion:
- US - free fluid
- laparoscopy diagnostic and therapeutic
Features of ectopic gestation pain:
- symptoms of pregnancy without evidence of intrauterine gestation
- emergency with evidence of rupture or impending rupture
- small amount of vaginal discharge
- adnexial tenderness
Investigation and management of ectopic gestation:
- US - no intrauterine pregnancy
- beta hCG elevated
- intra abdominal free fluid
- laparoscopy or laparotomy if harm-dynamically unstable
- salpingectomy usually
Features of PID pain:
- bilateral lower abdominal pain
- associated with vaginal discharge
- may also have dysuria
- peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis)
- may have RUQ discomfort
- fever >38 degrees
Investigation and management of PID:
- FBC: leucocytosis
- pregnancy test negative
- amylase - normal or slightly raised
- high vaginal and urethral swabs
- medical management
Investigations carried out if menorrhagia:
- FBC
- routine transvaginal US if symptoms suggest structural or histological abnormality
If a patient with menorrhagia does not require contraception, use:
mefenamic acid 500mg tds (especially if also dysmenorrhoea) or tranexamic acid 1g tds
If a patient with menorrhagia does require contraception, use:
- intrauterine (mirena) first line
- COCP
- long acting progestogens
What can be used as a short term option to rapidly stop heavy menstrual bleeding?
norethisterone 5mg tds
What is HRT typically used for in women?
small dose of oestrogen to help alleviate menopausal symptoms (also progestogen if uterus)
Side effects of HRT:
- nausea
- breast tenderness
- fluid retention and weight gain
Complications of HRT:
- increased risk breast cancer
- increased risk endometrial cancer
- increased risk of VTE
- increased risk of stroke
- increased risk of ischaemic heart disease if more than 10 years after menopause
In what way does HRT increase risk of breast cancer:
- increased by addition of progestogen
- increased risk with duration of use
- risk of breast cancer begins to decline when HRT stopped and reaches previous level after 5 years
How does HRT increase risk of endometrial cancer?
- oestrogen on its own should not be given as HRT to women with a womb
- reduced by the addition of progestogen but not eliminated
How does HRT increase risk of VTE?
- increased by addition of progestogen
- transdermal HRT does not increase risk
- refer to haematology before starting treatment if high risk
What is hyperemesis gravidarum thought to be due to?
raised beta hCG levels
Associations with hyperemesis gravidarum:
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
- smoking DECREASES incidence
Referral criteria for n&v in pregnancy:
- continued n&v and unable to keep down liquids or oral antiemetics
- continued n&v with ketonuria and/or weight loss, despite treatment with oral antiemetics
- confirmed or suspected comorbidity
What triad must be present before diagnosis of hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
What scoring system can be used to classify severity of NVP:
Pregnancy-Unique Quanitification of Emesis PUQE
Management of hyperemesis gravidarum:
- antihistamines first line
- cyclizine
- ondansetron and metoclopramide second line
- ginger and P6 (wrist) acupressure
- admission for IV hydration
Complications of hyperemesis gravidarum:
- Wernicke’s encephalopathy
- Mallory Weiss tear
- central pontine myelinolysis
- acute tubular necrosis
- foetal: small for gestational age, pre-term birth
Long term complications of hysterectomy:
- enterocoele
- vaginal vault prolapse
Acute complication of hysterectomy:
urinary retention
Causes of infertility:
- male factor 30%
- unexplained
- ovulation failure
- tubal damage
- other causes
Basic investigations of infertility:
- semen analysis
- serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, done on day 21
Interpretation of serum progestogen in infertility investigations:
- <16nmol/L - repeat if consistently low, refer to specialist
- 16-30nmol/L - repeat
- > 30nmol/L - ovulation
Average age for menopause:
51yo
Recommended time to use effective contraception until:
- 12 months after last period in women >50yo
- 24 months after last period in women <50yo
When can the clinical diagnosis of menopause be made?
no period for 12 months
Contraindications of using HRT for menopause symptoms:
- current or past breast cancer
- oestrogen sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
Management of vasomotor symptoms in menopause: (hot flushes, night sweats)
- fluoxetine
- citalopram
- venlafaxine
Management of vaginal dryness in menopause:
- vaginal lubricant
- moisturiser
How should HRT be stopped in menopause:
- gradually reducing HRT is effective at limiting recurrence in short term
- long term - no difference symptom control
Long term complications of menopause:
- osteoporosis
- increased risk ischaemic heart disease
Causes of menorrhagia:
- dysfunctional uterine bleeding
- anovulatory cycles
- uterine fibroids
- hypothyroidism
- intrauterine devices
- PID
- bleeding disorders e.g. VW disease
Threatened miscarriage:
- painless vaginal bleeding before 24 weeks (typically at 6-9)
- bleeding less than menstruation
- cervical os closed
- complicates 25% pregnancies
Missed (delayed) miscarriage:
- gestational sac which contains dead foetus before 20 weeks without expulsion symptoms
- may have light bleeding/discharge
- not usually pain
- closed cervical os
- when sac >25mm and no embryonic part seen - blighted ovum or anembryonic pregnancy
Inevitable miscarriage:
- heavy bleeding with clots and pain
- cervical os open
Incomplete miscarriage:
- not all products of conception expelled
- pain and bleeding
- open cervical os
What is abortion:
the expulsion of products of conception before 24 weeks
How many diagnosed pregnancies will miscarry in early stages?
15-20%
Miscarriages should be managed surgically or medically if:
- increased risk of haemorrhage (late first trimester, coagulopathies, unable to have blood transfusion)
- previous adverse experience
- evidence of infection
What kind of medical management can be used for miscarriages:
- vaginal misoprostol - prostaglandin analogue binds to myometrial cells to cause myometrial contractions
- oral mifepristone not added
- contact doctor if bleeding doesn’t start in 24 hours
- antiemetics and pain relief
What surgical management can be used for miscarriages:
- vacuum aspiration
- surgical in theatre
Risk factors of ovarian cancer:
- family history: mutations of BRCA1 or BRCA2 gene
- many ovulations: early menarche, late menopause, nulliparity
Clinical features of ovarian cancer:
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms
- early satiety
- diarrhoea
Investigations ovarian cancer:
-CA125
(do not use in asymptomatic women)
-US
-diagnosis: laparotomy
What can also raised CA125 other than ovarian cancer?
- endometriosis
- mensturation
- benign ovarian cysts
A CA125 above what level requires urgent US scan of the abdomen and pelvis?
> =35 IU/mL
Management ovarian cancer:
surgery and platinum based chemotherapy
What kind of ovarian cysts should be biopsied?
complex (multi-loculated) to exclude malignancy
What are the physiological cysts (functional cysts):
- follicular
- corpus luteum
What is a follicular ovarian cyst?
- most common
- non-rupture of dominant follicle or failure of atresia in non-dominant follicle
- commonly regress after several cycles
What is a corpus luteum cyst?
- during cycle if pregnancy does not occur, corpus luteum may fill with blood or fluid
- intraperitoneal bleeding more common than cyst
What is a benign germ cell ovarian tumour?
- dermoid cyst
- also mature cystic teratomas
- lined with epithelial tissue
- most common under 30yo
- bilateral in 10-20%
- usually asymptomatic (torsion more likely than with other tumours)
What are the benign epithelial tumours?
- serous cystadenoma
- mucinous cystadenoma
What is a serous cystadenoma?
- most benign epithelial tumour
- looks like most common type of cancer (serous carcinoma)
- bilateral 20%
What is a mutinous cystadenoma?
- large
- if rupture, may cause pseudomyxoma peritonei
What can initial imaging modality for suspected ovarian cysts/tumours reveal?
- ultrasound used
- simple: unilocular, more likely physiological or benign
- complex: multilocular, more likely to be malignant
Management of ovarian enlargement finding in premenopausal women:
- conservative if <35yo
- if cysts small <5cm and simple, likely to be benign
- repeat US for 8-12 weeks and referral if persistent
Management of ovarian enlargement finding in postmenopausal women:
- physiological cysts unlikely
- all referred to gynaecology
What is ovarian hyper stimulation syndrome?
- complication of some infertility treatment e.g. IVF
- multiple luteinised cysts in ovaries causes high oestrogen and progesterone and vasoactive substances such as VEGF
- increased membrane permeability and loss of fluid from intravascular compartment
Classification of OHSS:
- mild: pain, bloating
- moderate: n&v, as above, US ascites
- severe: as above, ascites, oliguria, haematocrit >45%, hypoproteinaemia
- critical: as above, ARDS, thromboembolism, anuria, tense ascites
What is ovarian torsion?
- partial or complete torsion of ovary on supporting ligaments
- can compromise blood supply
- if fallopian tube as well - adnexal torsion
Risk factors ovarian torsion:
- ovarian mass
- reproductive age
- pregnancy
- OHSS
Features of ovarian torsion:
- sudden onset deep colicky pain
- vomiting and distress
- fever in minority
- vaginal examination - adnexial tenderness
- US: free fluid or whirlpool sign
- laparoscopy - diagnostic and therapeutic
