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SON5022 Gyne > Gyne activity questions 1-4B > Flashcards

Gyne activity questions 1-4B Flashcards

1
Q

When is it appropriate to perform a TV ultrasound?

A

Transabdominal and transvaginal evaluation are complementary and both should be considered. In most situations
recommended that an abdominal approach is employed first
the best images of the pelvic organs are usually obtained using the transvaginal route.
Therefore, a transvaginal scan should be offered in most circumstances.

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2
Q

When is a TV ultrasound contraindicated?

A
  • When the patient may chooses to refuse
  • undue persuasion is inappropriate
  • may not be appropriate in minors or those not sexually active
  • when adequate information can be obtained by other methods.
  • The reason for not performing a transvaginal scan should be stated in the report
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3
Q

What are some strategies to ensure easy communication with a TVS patient

A
  • Explain the procedure at the beginning of the exam (including TAS and TVS)
  • Use layman’s terms
  • Concise language
  • Listen and ask questions
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4
Q

How do you ensure patient comfort throughout the procedure?

A
  • Warn patient in advance of significant movements
  • Provide patient with a gown to cover herself and a private place to change
  • Monitor any pain caused by transducer
  • Ensure the room is warm or provide blankets
  • Ensure the patient is ware they may terminate the procedure at any time
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5
Q

Describe the ligaments that support the female reproductive organs.

A

Posteriorly, the peritoneal reflection extends to the posterior fornix of the vagina, forming the rectouterine recess, or posterior cul-de-sac.
Laterally, the peritoneal reflection forms the broad ligaments, which extend from the lateral aspect of the uterus to the lateral pelvic side walls.
The round ligaments arise from the uterine cornua anterior to the fallopian tubes in the broad ligaments, extend anterolaterally, and course through the inguinal canals to insert into the fascia of the labia majora.

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6
Q

During a hysterectomy or oopherectomy the ureters are vulnerable to damage. Describe the reasons for this.

A
  • The ureter passes immediately inferior to the uterine artery near the lateral part of the fornix of the vagina.
  • This puts the ureter in danger of being inadvertently clamped, ligated or transected during a hysterectomy.
  • The ureter and ovarian vessels are very close to each other as they cross the pelvic brim
  • This puts the ureter in danger of being inadvertently clamped, ligated or transected during an oophorectomy.
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7
Q

When do you think you are most likely to consistently find free fluid in the pouch of Douglas on ultrasound examination in an asymptomatic young woman? Why is that?

A

Fluid in the cul-de-sac is a normal finding in the asymptomatic woman and can be seen during all phases of the menstrual cycle.
Possible sources include
- blood or fluid caused by follicular rupture
- blood from retrograde menstruation
- increased capillary permeability of the ovarian surface caused by the influence of estrogen.

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8
Q

report on a hypothetically normal gynaecological ultrasound of a 26-year-old asymptomatic patient on day 23 of her 28-day cycle. Give a systematic overview of the different elements you want to include in your ultrasound report and provide your anticipated normal findings for these various elements.

A

Uterus

  • Size: length 8 cm, width 5 cm, AP diameter 4 cm.
  • Position: anteflexed, anteverted, no deviation to left or right.
  • Endometrium: thickness 10 mm, hyperechoic appearance compatible with secretory phase.
  • Myometrium: homogeneous.
  • Cervix: normal

Pouch of Douglas
- No free fluid

Ovaries
Left
-	Size: normal, 3 cm x 2 cm x 1.5 cm.
-	Appearance: normal.
Right
-	Size: normal, 3 cm x 3 cm x 2 cm.
-	Appearance: contains a cystic structure of 2 cm diameter compatible with a corpus luteum.
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9
Q

What is the function of oesteradiol?

A

proliferation of the endometrium

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10
Q

What is the function of GnRH

A

stimulation of the release of pituitary hormones

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11
Q

What is the function of luteal hormone (LH)

A

stimulation of progesterone production, triggering ovulation

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12
Q

What is the function of FSH (follicle stimulating hormone)?

A

stimulation of oestrogen production, stimulation of ovarian follicle development

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13
Q

What is the function of progesterone

A

stimulation of the endometrium to secrete glycogen-rich material

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14
Q

What is the function of HCG

A

stimulation of the corpus luteum to continue oestrogen and progesterone production

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15
Q

Is the following statement true or false:

In a regular 28-day cycle, ovulation occurs on day 20

A

False, ovulation occurs 14 days before the next period, that is, on day 14 in a regular 28-day cycle.

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16
Q

Is the following statement true or false:

(b) Ovulation is triggered by a surge of LH production 12-24h prior to the ovulation.

A

True

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17
Q

Is the following statement true or false:

(c) In case of pregnancy, the corpus luteum starts to produce hCG.

A

False

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18
Q

Is the following statement true or false:

(d) GnRH is controlled by negative feedback of the gonadotropins.

A

True

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19
Q

Is the following statement true or false:

(e) Day 1 of the menstrual cycle is defined as the first day after cessation of the menstruation.

A

Day 1 is day 1 of menstruation

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20
Q

Is the following statement true or false:

(f) Changes in oestrogen and progesterone levels cause cyclic changes in the endometrium.

A

True

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21
Q

Is the following statement true or false:

(g) The ultrasonographic appearance of the uterus, endometrium and ovaries remains unchanged throughout the menstrual cycle.

A

False, in the first part of the cycle (proliferative phase) the endometrium has a proliferative appearance and in the ovary you first detect a number of small follicles that have been recruited. After a few days you can identify the dominant follicle increasing in size until ovulation. Ovulation usually occurs when the follicle is approximately 20-22 mm, after which you can visualise a corpus luteum in the ovary. The endometrium becomes secretory in appearance.

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22
Q

What hormone is produced by the

Placenta

A

HCG

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23
Q

What hormone is produced by the

hypothalamus

A

GnRH

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24
Q

What hormone is produced by the

uterus

A

Does not produce hormones listed

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25
Q

What hormone is produced by the

pituitary gland

A

LH FSH

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26
Q

What hormone is produced by the

ovaries

A

oestrogen progesterone

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27
Q

Is the following statement true or false:

A history of cyclic, predictable menses indicates:
normally functioning hypothalamus, pituitary gland and ovaries

A

True

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28
Q

Is the following statement true or false:

A history of cyclic, predictable menses indicates:
the presence of a uterus, cervix and vagina

A

True

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29
Q

Is the following statement true or false:

A history of cyclic, predictable menses indicates:
normal levels of FSH, LH, androgens and oestrogens

A

True

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30
Q

Is the following statement true or false:

A history of cyclic, predictable menses indicates:
capability of establishing a pregnancy

A

true

31
Q

On ultra sounding a young woman the uterus has a trilaminar appearance and there is a 15mm follicle in the ovary. What stage of her cycle is she at?

A

It would thus be reasonable to conclude that this woman would be between Day 8- Day 14 depending of her cyclical pattern.

32
Q

67-year-old PMB under HRT

A

Post menstrual bleeding under hormone replacement therapy

33
Q

23-year-old, regular cycle, LMP –10days IMB under OCP

A

Last menstrual period 10 days ago Inter menstrual bleeding under oral contraceptive

34
Q

34-year-old, menometrorrhagia and dysmenorrhoea IUCD in situ VE bulky uterus

A

Prolonged menstrual flow and intermenstrual bleeding and painful menstrual periods. Intr uterine contraceptive device in situ. Vaginal exam, bulky uterus.

35
Q

Can you explain why exogenous administration of oestrogen and progestogen inhibits ovulation?

A

Both oestrogen and progestogen have an inhibitory effect on the hypothalamus and pituitary resulting in an inhibition of gonadotropin production. Low FSH results in depressed follicular development but the dominant action for contraception is LH inhibition. If there is no mid-cycle LH peak, ovulation will be inhibited even if follicular development occurs.

36
Q

Hilary is a 64-year-old patient, referred for an ultrasound for postmenopausal bleeding. She reached her menopause at the age of 55. She used to have serious menopausal symptoms such as hot flushes and mood swings. On top of this, she has a high risk of osteoporosis. For these reasons, hormonal replacement therapy was started at the age of 56: a combination of transdermal oestrogen continuously and oral progestogen two weeks a month. Hilary noticed that she felt very depressed and tense when she was taking the progesterone tablets and decided to stop them. She felt great on the transdermal oestrogen and continued this regimen for seven years. She had never experienced any problems or bleeding until last week.
Describe your thought process. What are your anticipated ultrasound findings?

A
  • Oestrogen will prevent/reduce osteoporosis and solve any menopausal symptoms but increase the risk of endometrial cancer during and after use, unless it is taken with adequate progestogen.
  • Patients usually feel fine without the progesterone and it is only after a reasonably long period of time that problems will occur.
  • Thirty percent of patients will develop atypical endometrial hyperplasia, a premalignant lesion, after three years.
  • The least you expect to find on Hilary’s ultrasound is a thick hyperplastic endometrium (with or without cellular atypia) but you will need to exclude an endometrium carcinoma (a formal diagnosis is only possible with a biopsy).
37
Q

Summarise the possible advantages of tamoxifen treatment.

A
  • In postmenopausal women with breast cancer, tamoxifen reduces mortality by 25 percent and recurrence by 50 percent.
  • In healthy women at high risk of developing breast cancer, tamoxifen was found to reduce the oestrogen receptor positive breast cancer risk by 45 percent.
  • It has the ability of maintaining bone mineral density and therefore lowers the incidence of osteoporotic fractures in postmenopausal women.
  • It reduces cholesterol levels, especially LDL, with possibly a trend in lowering myocardial infarct incidence.
38
Q

Summarise the possible disadvantages of tamoxifen treatment.

A

• Vaginal dryness and discharge.
• Endometrial changes:
o increase in endometrial and endocervical polyps;
o increase in endometrial hyperplasia; and
o increase in endometrial carcinoma (very small).

39
Q

What is the role of ultrasound in the monitoring of patients on tamoxifen according to this article?

A
  • limited to the exclusion of pathology by visualising a thin endometrium.
  • Monitoring should happen pre-treatment
  • then yearly starting after two to three years of treatment in the asymptomatic patient
  • immediately in case of symptoms, such as spotting, bleeding.
  • can be done as a first step
  • If the endometrium is more than 5 mm (in 75% of asymptomatic patients on tamoxifen), the only way to obtain a correct diagnosis is to do hydrosonography or hysteroscopy.
40
Q

For each step in human embryonic development, select the time at which it can first be determined.

(a) Indifferent gonad
(b) Phenotypic sex
(c) Genetic sex

A. 1 week
B. 3-4 weeks
C. 6 weeks
D. 9 weeks
E. 12 weeks
A

For each step in human embryonic development, select the time at which it can first be determined.

(a) Indifferent gonad – 6 weeks C
(b) Phenotypic sex – 12 weeks E
(c) Genetic sex – 1 week A

41
Q

Which embryonic structure is associated with the ductus deferens?

A

mesonephric (Wolfian) ducts

42
Q

Which embryonic structure is associated with the uterus?

A

paramesonephric (mullerian) ducts

43
Q

Which embryonic structure is associated with the testes?

A

indifferent gonad

44
Q

Which embryonic structure is associated with the epididymis?

A

mesonephric (Wolfian) ducts

45
Q

Which embryonic structure is associated with the fallopian tubes?

A

paramesonephric (mullerian) ducts

46
Q

Which embryonic structure is associated with the uterus?

A

paramesonephric (mullerian) ducts and the urogenital sinus

47
Q

Which embryonic structure is associated with the Gartner duct cyst?

A

Gartner’s duct, also known as Gartner’s canal or the ductus longitudinalis epoophori, is a potential embryological remnant in human female development of the mesonephric (Wolfian) duct

48
Q

True or false
The Wolfian ducts play an important role in the development of the male reproductive system and the mullerian ducts have a leading role in the development of the female reproductive system.

A

True

49
Q

True or false

In the absence of hormones, sexual development will always be male.

A

False: Male differentiation only occurs in the presence of MIS (mullerian inhibitiing substane) and testosterone, produced by the testis, while female differentiation does not depend on the presence of ovaries or hormones.

50
Q

True or false
Fusion of the caudal part of the mullerian ducts will give rise to the tubes, the uterus, the broad ligaments, the rectouterine pouch and the vesicouterine pouch.

A

False: The tubes develop from the unfused cranial parts of the mullerian ducts and fusion of the caudal part of the mullerian ducts will give rise to the uterus, the broad ligaments, the rectouterine pouch and the vesicouterine pouch.

51
Q

True or false

In the absence of MIS, female internal genitalia will develop.

A

True

52
Q

True or false
Administration of female hormones to the pregnant mother will lead to the development of female external genitalia, even in a male fetus.

A

False: However, administration of male hormones to the pregnant mother will lead to the development of male external genitalia in a female fetus. Any situation where the female fetus is exposed to excessive androgens will lead to virilisation of the external genitalia.

53
Q

True or false
The presence of MIS and testosterone is essential for normal male sexual development, while normal female development depends on the absence of MIS and testosterone.

A

True

54
Q

You image what you think is a bicornate uterus, what is the most likely diferential?

A

an arcuate uterus or a sepatate uterus

55
Q

How can you differentiate a bi cornate and arcuate uterus?

A

in the arcuate uterus there is only a dent in the fundus of the uterus. There are normal transverse sections of the uterus on ultrasound once you are below that dent where as in bi cornate the uterus is separated and the fundus will disappear approximately on the mid line.

56
Q

How can you differentiate a bi cornate and a septate uterus?

A

the separation between the two halves of the uterus is thin. In the longitudinal plane, the fundus is always visible in the case of the septate uterus, while the fundus disappears approximately on the midline in case of a bicornuate uterus.

57
Q

Why is it important to differentiate between a septate and bi cornate uterus?

A

the therapeutic approach is completely different.

58
Q

What percentage of women has a uterine abnormality?

A

0.5%

59
Q

What is the most common abnormality?

A

bi cornate uterus

60
Q

How does a bi cornate uterus form?

A

The uterus is formed by fusion of the lower portions of the paramesonephric (mullerian) ducts. A bicornuate uterus is the result of a lack of fusion of a major part of the paramesonephric ducts.

61
Q

What are some problems associated with bi cornate uterus?

A

Associated problems include difficulties in becoming pregnant, increased incidence of spontaneous abortion, premature labour/delivery and malpresentation.

62
Q

How does didelphys uterus appear on ultrasound?

A

dual uteruses into the cervix.

63
Q

A 14-year-old girl presents with increasing right-sided pain, especially during her periods. Menarche occurred at 12 and she has regular periods. Clinical examination shows a right sided mass. A renal ultrasound has revealed an absent right kidney. Describe your thought process. What are your anticipated ultrasound findings?

A
  • An absent kidney always means that there is the possibility of a congenital abnormality of the uterus
  • The clinical scenario of normal periods, but increasing pain during the periods and a right-sided mass, raises the suspicion of a unicornuate uterus with a non-communicating rudimentary horn.
  • You expect to find a hematometra. This will be your most obvious finding but next to the hematometra, there is another uterus with a normal endometrium.
  • This is not the most common congenital abnormality but it is a clinically significant one because of its associated problems.
64
Q

What is a hematometra?

A

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

65
Q

What are the three types of fibroids?

A 
o	Intramural (within the myometrium)
o	Subserosal (involving the serosal surface)
o	Submucosal (abutting the endometrium)
66
Q

Why is it important to identify the vessels of a pedeunculated subserosal fibroid?

A

easily be mistaken for an adnexal mass

67
Q

What are the clinical symptoms of fibroids?

A
  • may be free of symptoms
  • may complain of a self-detected mass
  • abnormal uterine bleeding
  • acute or chronic pelvic pain
  • pressure symptoms or secondary symptoms.
68
Q

What is the classic appearance of a fibroid?

A

The is a round hypoechoic lesion. It is heterogenous, well defined with a small amount of posterior shadowing.

69
Q

What will a degenerating fibroid appear as?

A

complex mass
predominantly solid with cystic components.
It is rounded, well defined with through transmission of sound.
There is no significant colour flow.

70
Q

What are some helpful actions if you suspect a polyp?

A
  • dynamic evaluation of the endometrium
  • With gentle pressure and abdominal manipulation the walls of the endometrium can often be seen to be moving around the polyp.
  • Colour is another useful tool as polyps typically have a single vessel blood supply.
71
Q

What is sonohysterography?

A

o Sonographic imaging of the uterus aided by real time transcervical infusion of contrast media or water

72
Q

What is sonohysterosalpingography

A

o Sonographic imaging of fallopian tubes and determination of fallopian tubal patency by use of real-time transcervical infusion of contrast media or water

73
Q

What are typical endometrial changes in the use of tamoxifen?

A
  • marked thickening of the endometrium

- associated with cystic degeneration and underlying polypoid changes

74
Q

If you see a thickened endometrium and the woman is on OCP what should you do?

A

Report it for follow up. This is abnormal.

SON5022 Gyne (8 decks)

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