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Women's Health > Gynaecology Part 3 > Flashcards

Gynaecology Part 3 Flashcards

1
Q

What are the 4 main types of ovarian tumours:

A
  • surface derived
  • germ cell
  • sex cord-stromal
  • metastasis
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2
Q

What is the most common type of ovarian tumour?

A

surface derived

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3
Q

Name all the surface derived tumours:

A
  • serous cystadenoma
  • serous cystadenocarcinoma
  • mucinous cystadenoma
  • mucinous cystadenocarcinoma
  • brenner tumour
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4
Q

What is a serous cystadenoma?

A
  • benign
  • most common benign ovarian tumour
  • often bilateral
  • cysts lined by ciliated cells (similar to fallopian tube)
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5
Q

What is a serous cystadenocarcinoma?

A
  • malignant

- often bilateral psammoma bodies (collection of calcium)

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6
Q

What is a mucinous cystadenoma?

A
  • benign

- cysts lined by mucous secreting epithelium (similar to endocervix)

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7
Q

What is a mucinous cystadenocarcinoma?

A

-malignant
-may be associated with pseudomyxoma peritonei
(mucinous tumour of appendix more common cause)

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8
Q

What is a Brenner tumour?

A
  • benign
  • contain Walthard cell rests (benign cluster of epithelial cells)
  • similar to transitional cell epithelium
  • coffee bean nuclei
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9
Q

In whom are germ cell tumours more common?

A

adolescent girls

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10
Q

What are the germ cell ovarian tumours?

A
  • teratoma
  • dysgerminoma
  • yolk sac tumour
  • choriocarcinoma
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11
Q

What is a teratoma?

A
  • mature teratoma (dermoid cysts) is most common - benign
  • immature teratoma - malignant
  • combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
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12
Q

What is a dysgerminoma?

A
  • malignant
  • most common malignant germ cell tumour
  • similar histologically to testicular seminoma
  • associated with Turner’s
  • typically secrete hCG and LDH
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13
Q

What is a yolk sac tumour?

A
  • malignant
  • secrete AFP
  • Schiller-Duval bodies on histology are pathognomonic
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14
Q

What is a choriocarcinoma?

A
  • malignant
  • rare (part of gestational trophoblastic disease)
  • typically increased hCG
  • often early haematogenous spread to lungs
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15
Q

What are the sex cord-stromal ovarian tumours?

A
  • granulosa cell tumour
  • sertoli Leydig cell tumour
  • fibroma
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16
Q

What is a granulosa cell tumour?

A
  • malignant
  • produces oestrogen - precocious puberty in children or endometrial hyperplasia in adults
  • Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
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17
Q

What is a Sertoli-Leydig cell tumour?

A
  • benign
  • produces androgens - masculinising
  • associated with Peutz-Jegher syndrome
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18
Q

What is a fibroma?

A
  • benign
  • associated with Meig’s syndrome (ascites, pleural effusion)
  • solid tumour - bundles of spindle shaped fibroblasts
  • typically around menopause
  • pulling sensation in pelvis
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19
Q

What is the ovarian metastatic tumour?

A
  • Krukenberg tumour
  • malignant
  • metastases from gastrointestinal tumour resulting in mucin-secreting signet ring cell adenocarcinoma
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20
Q

What happens in the early follicular phase?

A
  • increased in GnRH pulse frequency
  • this increase FSH and LH release
  • stimulation and development of multiple ovarian follicles
  • one will become dominant ovulatory follicle
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21
Q

What happens mid-follicular phase?

A
  • FSH gradually stimulates estradiol production

- estradiol produces negative feedback on hypothalamus and pituitary to decrease FSH and LH concentrations

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22
Q

What happens in the luteal phase?

A
  • switch from negative to positive feedback of estradiol
  • surge of LH secretion
  • follicular rupture and ovulation
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23
Q

Three main categories of anovulation:

A
  • Class I: hypogonadotrophic hypogonadal anovulation - hypothalamic amenorrhoea
  • Class II: normogonadotrophic normoestrogenic anovulation - PCOS (80%)
  • Class III: hypergonadotrophic normoestrogenic anovulation - premature ovarian insufficiency (requires IVF with donor oocytes)
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24
Q

Forms of ovulation induction:

A
  • exercise and weight loss (first line for PCOS)
  • Letrozole
  • Clomiphene citrate
  • gonadotropin therapy
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25
Q

How does Letrozole work as an ovulation inducer?

A
  • first line PCOS
  • reduces ADRs on endometrial and cervical mucous compared to clomiphene citrate and higher live birth rate
  • aromatase inhibitor - reduces negative feedback by oestrogen’s in pituitary so increased FSH
  • high rate of mono follicular development
  • some fatigue and dizziness possible
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26
Q

How does clompihene citrate work as an ovulation inducer?

A
  • SERM
  • acts on hypothalamus to block negative feedback of oestrogens
  • increase in GnRH pulse frequency etc.
  • ADR: hot flushes, abdominal distention, pain, n&v
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27
Q

How does gonadotropin therapy work as an ovulation inducer?

A
  • used mostly for women with class I ovulatory dysfunction
  • risk of multi follicular development and multiple pregnancy, OHSS
  • IV infusion of GnRH
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28
Q

What is the main life-threatening complication of ovulation induction?

A
  • ovarian hyperstimulation syndrome
  • multiple cystic spaces and increase in permeability of capillaries
  • shift of fluid from intra to extravascular space
  • hypovolaemic shock, acute renal failure, VTE
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29
Q

Management OHSS:

A
  • fluid and electrolyte replacement
  • anti-coagulation therapy
  • abdominal ascitic paracentesis
  • pregnancy termination
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30
Q

What is PID?

A
  • infection and inflammation of female pelvic organs
  • includes uterus, fallopian tubes, ovaries and surrounding peritoneum
  • usually from ascending infection form endocervic
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31
Q

What organisms typically cause PID?

A
  • Chlamydia trachomatis (most common)
  • Neisseria gonorrhoea
  • mycoplasma genitalium
  • mycoplasma hominis
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32
Q

Features of PID:

A
  • lower abdo pain
  • fever
  • deep dyspareunia
  • dysuria and menstrual irregularities
  • vaginal or cervical discharge
  • cervical excitation
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33
Q

Investigations in PID:

A
  • pregnancy test to exclude ectopic
  • high vaginal swab (often negative)
  • screen for Chlamydia and Gonorrhoea
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34
Q

Management of PID:

A

oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxycycline + oral metronidazole

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35
Q

Complications of PID:

A
  • perihepatitis (Fitz Hugh Curtis)
  • infertility
  • chronic pelvic pain
  • ectopic pregnancy
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36
Q

Acute causes of pelvic pain:

A
  • ectopic
  • UTI
  • appendicitis
  • PID
  • ovarian torsion
  • miscarriage
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37
Q

Chronic causes of pelvic pain:

A
  • endometriosis
  • IBS
  • ovarian cyst
  • urogenital prolapse
38
Q

What type of pain is experienced with ovarian cysts?

A
  • unilateral dull ache intermittent or during intercourse
  • torsion or rupture may lead to severe abdominal pain
  • large cysts may cause abdominal swelling or pressure effects on bladder
39
Q

Symptoms with urogenital prolapse:

A
  • older women
  • sensation or pressure, heaviness, bearing down
  • urinary symptoms: incontinence, frequency, urgency
40
Q

Features of PCOS:

A
  • subfertility and infertility
  • menstrual disturbances : oligomenorrhoea and amenorrhoea
  • hirsutism, acne (due to hyperandrogenism)
  • obesity
  • acanthosis nigricans
41
Q

Investigations PCOS:

A
  • pelvic ultrasound: multipel cysts on ovaries
  • FSH, LH, prolactin, TSH, testosterone (raised LH:FSH)
  • check for impaired glucose tolerance
42
Q

General management of PCOS:

A
  • weight reduction

- COCP

43
Q

Management of hirsutism and acne in PCOS:

A
  • COCP for hirsutism
  • third generation COCP has fewer androgenic effects or co-cyprindiol has anti-androgenic action
  • topical eflornithine
  • spirinolactone, flutamide, finasteride
44
Q

Management of infertility in PCOS:

A
  • weight reduction
  • clomifene most effective
  • metformin with or without clomifene
  • gonadotrophins
45
Q

What causes postcoital bleeding?

A
  • no pathology 50%
  • cervical ectropion (33%) - more common with COCP
  • cervicitis
  • cervical cancer
  • polyps
  • trauma
46
Q

All the different causes of postmenopausal bleeding:

A
  • vaginal atrophy
  • HRT
  • endometrial hyperplasia
  • endometrial cancer
  • cervical cancer
  • ovarian cancer
  • vaginal cancer
  • uncommon: trauma, vulval cancer, bleeding disorders
47
Q

Most common cause of postmenopausal bleeding:

A
  • vaginal atrophy

- thinning, drying and inflammation of walls due to reduction in oestrogen

48
Q

Risk factors of endometrial hyperplasia leading to postmenopausal bleeding:

A
  • obesity
  • unopposed oestrogen use
  • tamoxifen use
  • PCOS
  • diabetes
49
Q

Investigations post-menopausal bleeding:

A
  • > 55yo should be investigated within 2 weeks by US for endometrial cancer
  • vaginal and full abdominal examination
  • urine dipstick (haematuria or infection), FBC (anaemia or bleeding disorder, CA-125
  • cancer pathway referral: transvaginal US - asses endometrial thickness, should be <5mm
  • endometrial biopsy for definitive diagnosis (hysteroscopy or aspiration)
  • imaging in secondary (CT, MRI)
50
Q

What is premature ovarian failure?

A

onset of menopausal symptoms and elevated gonadotrophin levels before 40yo

51
Q

Causes of premature ovarian failure?

A
  • idiopathic (most common, family history)
  • bilateral oophorectomy
  • radiotherapy
  • chemotherapy
  • infection e.g. mumps
  • autoimmune disorders
  • resistant ovary syndrome: due to FSH receptor abnormalities
52
Q

Features of premature ovarian failure:

A
  • climacteric symptoms: hot flushes, night sweats
  • infertility
  • secondary amenorrhoea
  • raised FSH, LH levels
  • low oestradiol
53
Q

Management of mild PMS:

A

regular frequent, small, balanced meals rich in complex carbohydrates

54
Q

Management of moderate PMS:

A
  • new generation COCP

- Yasmin

55
Q

Management of severe PMS:

A

SSRI taken continuously or during luteal phase

56
Q

Causes of recurrent miscarriage:

A
  • antiphospholipid syndrome
  • endocrine disorders: poorly controlled diabetes/thyroid, PCOS
  • uterine abnormality e.g. uterine septum
  • parental chromosomal abnormalities
  • smoking
57
Q

What defines recurrent miscarriage?

A

3 or more consecutive spontaneous abortions

58
Q

How should semen analysis be performed?

A
  • after min 3 days and max 5 days of abstinence

- deliver to lab within 1 hour

59
Q

Normal semen analysis results:

A
  • volume >1.5ml
  • pH >7.2
  • sperm concentration >15 million/ml
  • morphology >4% normal forms
  • motility >32% progressive motility
  • vitality >58% live spermatozoa
60
Q

Legal points around termination of pregnancy:

A
  • 2 registered medical practitioners must sign legal document
  • 1 in an emergency
  • only registered medical practitioner
61
Q

How does gestation affect method of pregnancy termination:

A
  • less than 9 weeks: mifepristone followed 48 hours later by prostaglandins to stimulate uterine contractions
  • less than 13 weeks: surgical dilation and suction of uterine contents
  • more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion
62
Q

Upper limit of abortion:

A

24 weeks (unless to save life, extreme abnormality or serious physical or mental injury)

63
Q

Risk factors urinary incontinence:

A
  • advancing age
  • previous pregnancy and childbirth
  • high BMI
  • hysterectomy
  • family history
64
Q

Classification of urinary incontinence:

A
  • overactive bladder (OAV)/urge incontinence - detrusor overactivity
  • stress incontinence: small amounts leaking when coughing or laughing
  • mixed incontinence: urge and stress
  • overflow incontinence: bladder outlet obstruction e.g. due to prostate enlargement
65
Q

Initial investigations urinary incontinence:

A
  • bladder diaries for min 3 days
  • vaginal exam to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
  • urine dipstick and culture
  • urodynamic studies
66
Q

Management urinary incontinence:

A

-bladder retraining (min 6 weeks)
-bladder stabilising drugs: anti-muscarinics
oxybutinin - immediate release (avoid in older women), tolterodine - immediate, or darifenacin (once daily)
-mirabegron (useful if concern about anticholinergic side effects in elderly)

67
Q

If stress incontinence is predominant, what management options are there?

A
  • pelvic muscle training (8 contractions 3 times per day for 3 months)
  • surgical procedures e.g. retropubic mid-urethral tape
  • duloxetine - combined noradrenaline and serotonin reuptake inhibitor - increased synaptic concentration pudendal nerve
68
Q

Causes of vaginal discharge:

A
  • Candida
  • trichomonas vaginalis
  • vaginosis
  • gonorrhoea
  • chlamydia
  • ectropion
  • foreign body
  • cervical cancer
69
Q

What are the typical features of candida?

A
  • cottage cheese discharge
  • vulvitis
  • itch
70
Q

What are the typical features of trichomonas vaginalis?

A
  • offensive, yellow/green, frothy discharge
  • vulvovaginitis
  • strawberry cervix
71
Q

What are the typical features of bacterial vaginosis?

A
  • offensive
  • thin
  • white/grey
  • fishy discharge
72
Q

Types of urogenital prolapse:

A
  • cystocele, cystourethrocele
  • rectocele
  • uterine prolapse
  • less common: urethrocele, enterocoele (herniation of pouch of Douglas, including small intestine into vagina)
73
Q

Risk factors of urogenital prolapse:

A
  • increasing age
  • multiparity, vaginal deliveries
  • obesity
  • spina bifida
74
Q

Presentation of urogenital prolapse:

A
  • sensation of pressure, heaviness, bearing down

- urinary symptoms: incontinence, frequency, urgency

75
Q

Management of urogenital prolapse:

A
  • asymptomatic and mild prolapse then no treatment
  • conservative: weight loss, pelvic floor muscle exercises
  • ring pessary
  • surgery
76
Q

Surgical options urogenital prolapse:

A
  • cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • uterine prolapse: hysterectomy, sacrohysteropexy
  • rectocele: posterior colporrhaphy
77
Q

What are fibroids?

A

benign smooth muscle tumours of uterus

78
Q

Associations of uterine fibroids:

A
  • more common Afro-Caribbean women

- rare before puberty, develop in response to oestrogen

79
Q

Features of uterine fibroids:

A
  • asymptomatic
  • menorrhagia - iron-deficiency anaemia
  • lower abdominal pain: cramping, often during menstruation
  • bloating
  • urinary symptoms e.g. frequency, may occur with larger fibroids
  • subfertility
  • rare: polycythaemia secondary to autonomous production of erythropoietin
80
Q

Diagnosis of uterine fibroids:

A

transvaginal ultrasound

81
Q

Management of uterine fibroids:

A
  • asymptomatic: no treatment
  • menorrhagia: levonorgestrel intrauterine system, NSAIDs e.g. mefenamic acid, tranexamic acid, COCP, oral progestogen, injectable progestogen
  • treatment to shrink/remove fibroids
82
Q

What treatments to shrink/remove fibroids are there:

A
  • GnRH agonists reduce size as short term treatment
  • ulipristal acetate but serious liver toxicity possible
  • myomectomy
  • hyesteroscopic endometrial ablation
  • hysterectomy
  • uterine artery embolisation
83
Q

Complications of uterine fibroids:

A
  • subfertility
  • iron deficiency anaemia
  • red degeneration - haemorrhage into tumour. commonly occurs during pregnancy
84
Q

Risk factors vaginal candidiasis:

A
  • diabetes mellitus
  • drugs: antibiotics, steroids
  • pregnancy
  • immunosuppression: HIV
85
Q

Features vaginal candidiasis:

A
  • cottage cheese, non offensive discharge
  • vulvitis: superficial dyspareunia, dysuria
  • itch
  • vulval erythema, fissuring, satellite lesions
86
Q

Investigation vaginal candidiasis:

A

high vaginal swab is not routinely indicated if clinical features are consistent with candidiasis

87
Q

Management of vaginal candidiasis:

A
  • local: clotrimazole pessary e.g. clotrimazole 500mg PV stat
  • oral: itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
  • only local treatments if pregnant (oral contra)
88
Q

What is defined as recurrent vaginal candidiasis and how is it diagnosed? Treatment?

A
  • 4 or more episodes per year
  • check compliance with previous treatment
  • confirm with high vaginal swab for microscopy and culture, consider blood glucose test to exclude diabetes
  • exclude diff diagnoses such as lichen sclerosus
  • consider use of induction-maintenance regime
    induction: oral fluconazole every 3 days for 3 doses
    maintenance: oral fluconazole weekly for 6 months
89
Q

What type of cancer are vulval carcinomas?

A
  • 80% squamous cell carcinomas

- most in over 65yo

90
Q

Risk factors vulval carcinoma:

A
  • HPV infection
  • vulval intraepithelial neoplasia (VIN)
  • immunosuppression
  • lichen sclerosis
91
Q

Features of vulval carcinoma:

A
  • lump or ulcer on the labia majora

- may be associated with itching, irritation

Women's Health (5 decks)

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