Gynaecology Summary Flashcards
What is asked in a gynae history?
- Vaginal bleeding
- Menstrual hx: LMP, menopausal, pregnant, cycle, menorrhagia, age of menarche
- Pain: abdo pain or dyspareunia
- Vaginal discharge: colour, odour and amount
- Sexual hx: last cervical smear, sexually active, partners, contraception/HRT
- Obstetric history
- Constitutional: fever, weight loss, tired, appetite
What are the investigations for PV bleeding?
- Abdominal and pelvic examination - feel for pelvic masses
- PV exam: confirm it is a PV bleed, look for pathology
- Bloods: FBC, clotting, CA-125
- Urine beta-HCG (pregnancy test)
- STI screen - high vaginal and endocervical swabs
- Cervical smear
- Transvaginal USS - endometrial thickness
- Urgent USS - ectopic
What are the differentials for post menopausal PV bleeding?
- Endometrial Cancer – most important to rule out
- Atrophic Vaginitis - most common
- Endometrial Hyperplasia
- Endometrial Polyp
What are the differentials for inter-menopausal PV bleeding?
- Pregnant ?? Ectopic Pregnancy
- Endometriosis
- Pelvic Inflammatory disease
- Ovarian cyst rupture
- Uterine Fibroids
- Breakthrough bleeding after starting contraceptives
What are differentials for post-coital PV bleeding?
- Cervical Cancer
- Cervical ectropion
- Cervical polyp
What are the risk factors for endometrial cancer?
- Elderly
- Nulliparity
- DM
- Obesity
- Menstrual irregularity (early menarche/late menopause
- Oestrogen therapy (tamoxifen, oestrogen only HRT)
- Hypertension
- PCOS
What are the protective factors for endometrial cancer?
- COCP
- Mirena coil
- Increased pregnancies
- Smoking
What is the presentation of endometrial cancer?
- Unusually heavy menstrual bleeding
- Post coital bleeding
- Intermenstrual bleeding
- Abnormal vaginal discharge (unusual)
- Haematuria
- Anaemia
- Pain is rare
What are the investigations for endometrial cancer?
- TV USS
- Pipelle biopsy @ outpatient clinic, less invasive than hysteroscopy
- Hysteroscopy with endometrial biopsy
What is the management for endometrial cancer?
- Total abdo hysterectopy w/bilateral sapingo-oopherectomy
- May need radio/chemotherapy
What symptoms should be referred for TVUS in women >55 yrs?
- Unexplained vaginal discharge
- Visible haematuriaplus raised platelets, anaemia or elevated glucose levels
What is atrophic vaginitis?
- Dryness+atrophyof vaginal mucosa due to low oestrogen, thinner, less elastic, more dry mucosa, inflammation prone
- Changes in vaginal pHmicrobial flora, to localised infections.
- Risk factor is menopause
What is the presentation of atrophic vaginitis?
- Itching/dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding via localised inflammation
- Urinary incontinence + recurrent UTIs
- Examination: pale mucosa, thin skin, erythema / inflammation, dryness
What is the management of atrophic vaginitis?
- Vaginal lubricants - help dryness
- Topical oestrogen creams
What is the risk factors for ectopic pregnancy?
- Damage to tubes: PID, surgery
- Previous ectopic
- Endometriosis
- IUCD
What is the presentation of an ectopic pregnancy?
- Pain, usually 1st sx, constant, may be unilateral
- PV bleeding
- Recent amenorrhoea (6-8wks typically)
- Dizziness / fainting / syncope
- Peritoneal bleeding may indicate shoulder tip pain or dysuria
What is endometriosis?
- Ectopic endometrial tissue outside the uterus, may be due to retrograde menstruation.
- Tissue sheds + bleed (as in menstruation) which leads to irritation + inflammation
- Thus, it responds to hormones in same way
- Can develop adhesions – scar tissue that binds organs together
- Reduced fertility
What is the presentation of endometriosis?
- Cyclical abdominal or pelvic pain
- Deep dyspareunia
- Dysmenorrhoea
- Infertility
- Cyclical bleeding from other sites, such as haematuria
- Urinary Sx
- Bowel Sx
What are the investigations for endometriosis?
- Endometrial tissue on speculum exam
- Fixed cervix on bimanual
- Tenderness in vagina, cervix and adnexa
- Pelvic USS
- Laproscopy – gold standard
What is the management of endometriosis?
- Analgesia - NSAIDs
- Hormonal Tx including; COCP or Progestogens
- Surgery – Laproscopic to remove adhesions
- Hysterectomy
What is the presentation of PID?
- Non-Cyclical abdo/pelvic pain
- Abnormal vaginal discharge
- Fever
- Infertility
- Maybe dysuria, potential for ectopics
- Infertility
What are the investigations for PID?
- Cervical excitation
- Ovarian/fallopian tenderness and adnexa
- High Vaginal swab
- Pregnancy test – rule out ectopics
- Chalmydia/gonorrhea screen
What is the management of PID?
- Antibiotics – IM ceftriaxone or 14 day oral doxy/metro
- Consider IUD removal
What is the presentation of fibroids?
- Menorrhagia
- Prolonged menstruation, > 7 days
- Abdo pain, worse in menstruation
- Bloating
- Urinary/bowel Sx via pelvic pressure/fullness
- Deep dyspareunia
- Reduced fertility
What are the investigations for fibroids?
- Palpable pelvic mass
- Enlarged firm non tender uterus
- Transvaginal USS
What is the management of fibroids?
- Manage the menorrhagia w/ IUS, NSAIDs, transexamic acid, COCP
- Shrink fibroids w/ GnRH agonists or myomectomy
What are the differentials for menorrhagia/dysmenorrhoea?
- Dysfunctional uterine bleeding
- Anovulatory cycles - usually in the extremes of a woman’s reproductive life
- Uterine fibroids
- Hypothyroidism
- Intrauterine devices
- PID
- Bleeding disorders e.g. VW disease
- Endometriosis
What is stress incontinence?
- Leakage of urine on coughing/straining/sneezing/laughing
- Cause: damage to pelvic floor
- RFs: previous childbirth, multiple pregnancies, surgery, perineal tears, atrophic vaginitis
What is the management of stress incontinence?
- Reduce caffeine/no fluids before bed
- PELVIC FLOOR EXERCISES
- Duloxetine
What is urge incontinence?
- No reason for incontinence (i.e not coughing and straining)
- Cause: detrusor overactivity (overactive bladder)
- RFs: DM, MS, Parkinson’s, infection, constipation/stool impaction, BPH (men)
What is the management for urge incontinence?
- Reduce caffeine/no fluids before bed
- Bladder Retraining – 6 week training course to increase intervals
- Antimuscarinics – Oxybutynin/tolterodine (mirabegron (b3 agonist) in elderly)
What are the investigations for incontinence?
- Bladder diaries > 3 days
- Vaginal exam – exclude prolapse
- Urine dip/culture
- Urodynamic Studies
What are the risk factors for cervical cancer?
- Smoking
- HIV
- COCP
- Many sexual partners
- Low socioeconomic background
- High parity
What are the features of cervical cancer?
- Abnormal vaginal bleeding (can be PMB, IMB or post-coital)
- Discharge
- Usually detected on screening
What are the symptoms of PCOS?
- Androgens -> hirtuism, acne
- Periods: oligo/amenorrhoea
- Subfertility/infertility
- Obesity
- Acanthosis nigricans (insulin)
What are the investigations for PCOS?
- Normogonadoptrophic normogonadism
- High LH: FSH ratio (3:1)
- US shows ovarian cysts
What is the management for PCOS?
- General - weight loss; COCP (decreases androgen effects + if not wanting baby); Levon-IUS if severely obese
- Hirtiuism/acne- COCP or co-cyprindiol (anti-andronergic), topicaleflornithine; finasteride, flutamide,spironolactone
- Infertility – metformin if obese, otherwise clomephine
What is premature ovarian failure?
- Hypergonadotropic hydpogonadism - high LH/FSH
- Causes: idiopathic, excessive exercise, radiation, low BMI, marijuana, chemo/radiotherapy, chromosomal changes (e.g. Turner Syndrome), infections (mumps)
What are the features of premature ovarian failure?
- Menopausal symptoms before age of 40 – either via reduced follicles or dysfunctional follicles
- Secondary amenorrhea
- Night sweats
- Libido
- Weight gain
What is the management for premature ovarian failure?
- Replace hormones - HRT
- IVF
What are the symptoms of ovarian cancer?
- Constitutional PLUS abdo bloating/pain
- Ascites
- AUB
- Early satiety
- Pelvic pain/pressure
What are the risk factors for ovarian cancer?
- Smoking
- Drinking
- Early menarche
- Late menopause
- HNPCC (aka Lynch Syndrome)
- BRCA1/2
- Obesity
- REDUCES RISK: COCP, multiparity
What are the investigations for ovarian cancer?
- CA-125 /AFP/b-hCG
- TVUS (may be large, complex, multi-loculated cysts present, high suspicion for malignancy)
- Diagnostic LAPAROTOMY
What are the symptoms of ovarian torsion?
- Acute, colicky abdo pain
- N/V
- Adnexal mass
- Can get fever if adnexal necrosis via adnexal torsion
What is the investigations for ovarian torsion?
- USS (whirlwind presentation)
- Laparoscopy (also management)
What are differentials for pelvic pain?
- Ovarian torsion
- Ectopic
- Appendicitis
- PID
- Mittlschmerz - sharp mid cycle pain, settles after couple days, conservative management
What are the symptoms of PMS?
Before periods, patients might get different emotional + physical symptoms:
- Anxiety
- Stress
- Fatigue
- Mood Swings
- Bloating/ abdo pain
What is the presentation of atrophic vaginitis?
Atrophic vaginitis often occurs in women who are post-menopausal women. It presents with vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry.
What is the treatment of atrophic vaginitis?
Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
