Gynecology 2 Flashcards
What is the main causes of intermenstrual bleeding?
Cervical
- Ectopy
- CIN
- Cancer
Uterine
- polyps
- fibroids
Infections
Hormonal
- contraception *breakthrough bleed
- Tamoxifen
Vaginal adenosis
What are the differentials for post-menopausal bleeding?
HRT
Atrophic vaginitis
Endometrial cancer
Cervical cancer
Infection
What are some differentials for a pelvic mass?
Ovarian tumour/ cyst
Uterine fibroids
Pelvic abscess
Pregnancy
Bowel
- Faecal loading
- Carcinoma
What are the symptoms of an ovarian mass?
Abdominal bloating/ distention
Pain
- Torsion
- Rupture
- Haemorrhagic cyst
Bowel obstruction
Altered menstrual cycle
Hormonal changes
What are some risk factors for prolapse?
Pelvic floor weakness
Multiparity
Oestrogen deprivation
- weakness of the vagina
Increased intrabdominal pressure
What are the differentials for a painful/ itchy vulo-vagina?
Infection
- HSV
- Gonorrhoea
Atrophic vaginitis
Lichen sclerosis
Vulvodynia
Vulva carcinoma
What are the main causes of infertility?
Anovulation Tubal pathology Male factors Endometriosis Unexplained
What are the main investigations into subfertility?
Females:
1
- FSH levels (day 3 of cycle)
- Anti-mullerian hormone
- Pelvic ultrasound/ TVS (fibroids, mass, cysts of ovaries)
- Day 21 progesterone
- tubal patency (hystro-salpingo contrast sonography/ Blue dye test)
Males:
- semen analysis (count, motility, morphology)
What are the main causes for a recurrent miscarriage?
Chromosomal abnormalities of the fetus
Immunological causes
- phospholipid syndrome
Endocrine factors
- hypo/hyperthyroidism *hypo more common
- PCOS
Uterine abnormalities
- Bicornate
- Separate Uteri
Infections
- rubella
- CMV
Environmental factors
Where are the locations for ectopic pregnancy?
Tubal - 99% of cases - Ampulla Ovarian Cervical Peritoneal Pregnancy of unknown location
By how much should hCG not rise by to suspect ectopic pregnancy?
66%
What are the complications of PID?
Subfertility
Recurrent pain
Ectopic pregnancy
Tubo-ovarian abscess
What are the top causes for a raised ca125?
Ovarian cancers (epithelial)
Other cancers:
- endometrial
- G.I
- Lung
- Breast
Endometriosis
Pregnancy
Peritoneal inflammation
- ascites
What is called when there is onset of symptoms causing
- physical
- psychological
- behavioural
symptoms during the menstrual cycle and when do they typically begin?
Pre- menstrual syndrome
during the luteal phase.
What are the management options for primary dysmenorrhoea?
Pain that starts in the first two years of menarche
NSAIDs
- Mefenamic acid
- ibuprofen
Combined oral contraceptive
Mirena coil
Injectable progesterone
What signs would you look for in cervical carcinoma?
Mass
Lymphadenopathy
Irregular discharge - blood stained
Ulceration
How is endomitosis descried as on laparoscopy?
burnt match heads
- areas of puckered redness
Chocolate cysts within the ovaries
Hemosiderin with peritoneum covering
Scarring
Which type of HRT is most appropriate for perimenopausal women?
Cyclical HRT
- if periods are still present then cyclical is best as it has predictable withdrawal bleeds`
List some causes of vaginal discharge:
Infections:
- Bacterial vaginosis
- Candida albicans
- Trichomonas vaginlis
Cervical infections:
- Chlamydia trachomatis
- N. Gonorrhoeae
Cervical ectopy
Retained tampons
What is the tests done into premature ovarian failure?
FSH levels 1-5 days into menstrual cycle. Usually levels should be starting to increase. In failure they will be very high.
other tests can include:
- Anti - Mullerian hormone
- Ultrasound of ovaries
What are the initial investigations that should be conducted into female infertility?
Bloods:
- FSH
- LH
- Oestradiol
- Anti-Mullerian hormone
- progesterone test for ovulation
Tubal patency testing:
- laparoscopic hydrotubation
- hysterosalpingo- contrast sonography
What are the major causes of female infertility?
Premature ovarian insufficiency/ ovarian reserve deficiency
Anovulation
- PCOS
- Amenorrhoea (primary/ secondary)
Tubal patency
- PID
- Endometriosis
- Adhesions
Structural
- fibroids
- Adhesions
- Vaginal septum
What are the methods to promote ovulation used?
Clomiphene
- induces ovulation
Exogenous gonadotrophins (exogenous hCG is used to promote LH surge)
Laparoscopic ovarian drilling
What are the various techniques used for assisted conception?
Intrauterine insemination
In vitro fertilisation
Intracytoplasmic sperm injection
What are the contraindications to HRT?
Previous breast cancer/ current breast cancer
Oestrogen sensitive tumour
Undiagnosed PV bleeding
Endometrial hyperplasia
Previous DVT
What are the risks of HRT?
Breast cancer
VTE
Stroke
Ovarian/ endometrial cancer
What are some non-hormonal treatments for menopause?
SSRIs for vasomotor symptoms
- fluoxetine
Vaginal moisturisers
CBT/ support groups - psychological symptoms
Satellite ganglion blockage
List some cause of post menopausal bleeding:
Vaginal atrophy
- most common cause
Endometrial cancer
- 10% of cases
HRT
- often causes small spotting etc
Cervical cancer
Ovarian Cancer
- especially oestrogen secreting
Bleeding disorders
What age group should be immediately referred for post menopausal bleeding and what age is this?
> 55 years should be referred within 2 weeks
- TVS (>5mm)
- Hysteroscopy
- Endometrial biopsy with pipelle
+/-
MRI
What are the typical symptoms of urogenital prolapses?
Sensation of heaviness in the vagina
Dragging/ something coming down in the vagina
Urinary symptoms
- UTIs
- Frequency
- Dysuria
Dyspareunia
What is the management options for prolapses?
Lifestyles changes
- weight loss
Pelvic floor exercises
Ring pessaries
Surgery
- Anterior Colporrhaphy/ colposuspension (Cystoceles)
- Utero-sacral ligament suspension Hysterectomy / sacrohysteropexy (Uterine)
- Posterior Colporrhaphy (rectocele)
List some causes of primary amenorrhoea:
Turner’s syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of genital tract
- imperforate hymen
- absent uterus
- vaginal atresia
- these the female will have normal secondary characteristics
Name a muscarinic inhibitor used for urge incontinence:
Oxybutynin
What investigations should be done into urinary incontinence?
Urinalysis
Bladder diary
- can help narrow down the type
Cystoscopy
- if haematuria
- recurrent STIs
Urodynamic studies
In someone with incontinence, where voiding diaries have been done and there is diagnostic uncertainty what would be the most appropriate next investigation?
Urodynamic studies
How can you differentiate between a vulva intra epithelium neoplasia and vulva carcinoma?
Carcinoma tends to ulcerate whereas VIN tends to be white or plaque like
What action should be undertaken when you discover someone to have had female genital mutilation?
Medical team and police
What is the most appropriate surgical treatment for vaginal vault prolapse?
Sacrocolpopexy
What score is used to establish the likely hood of malignancy in a cyst? and how do yo calculate it?
RIsk of Malignancy Index (RMI)
Ultrasound score x Menopausal status x Ca125
RMI >250 = 75% risk of cancer
Highlight some of the clinical symptoms and features of ovarian cyst, and how are they investigated?
- Asymptomatic (picked up incidentally)
- Dull ache
- Bloating
- Irregular bleeding
- intestinal obstruction
+/- - osteogen/ androgen effects
+/- - torsion
Pelvis mass
Abdominal mass
Ascites
Pleural effusion
Bloods:
- FBC
- Ca125
+/- CEA, AFP, hCG
Imaging:
- TVS
- MRI
What is the management of ovarian cysts?
Premenopausal:
- Low RMI and <5cm
- Rescan 6 weeks
- High RMI or >5cm
- Cystectomy
Postmenopausal:
- Low RMI
- 3-6 monthly Ca125
- Intermediate RMI :
- Bilateral oophorectomy (with follow on if cancerous)
- High risk RMI >250
- Referral to cancer centre
- laparotomy
Define primary and secondary dysmenorrhoea and highlight the treatment for primary:
Primary Dysmenorrhoea:
- painful periods, uncomfortable periods
- starts within 2 years of menstrual cycle
- no underlying pathology
Secondary dysmenorrhoea:
- underlying pathology
Treatment of primary:
- Mefenamic acid (NSAID)
- COCP
- Mirena coil
- Progesterone pill
List the causes of heavy menorrhagia and highlight the investigations:
Dysfunctional uterine bleeding
- no underlying pathology
Uterine fibroids
Endometriosis
Endometrial polyps
Hypothyroidism
Bleeding disorders
Investigations:
- FBC
- TFTs
- Oestrogen/ FSH/ LH
- Coagulation
Imaging:
- TVS
+/-
- Hysteroscopy +/- biopsy
List the management options for menorrhagia:
Hormonal:
- Mirena
- GnRH Analogues
- Progesterone
Non-hormonal:
- Tranexamic acid
- Mefenamic acid
Surgical:
- endometrial ablation
- hysterectomy
What are the two major classes of endometrial cancer?
Adenocarcinoma
- glandular from over over stimulation
- comes off atypical hyperplasia
Serous carcinoma
- sporadic
What are the main ovarian cancer genetics?
BRCA1
BRCA2
HNPCC
What staging is used for ovarian cancers?
FIGO I - limited to ovaries II - Limited to pelvis III - limited to abdomen including lymph nodes IV - distant metastases out of abdomen
What are the clinical appearances of cervical cancer on speculum?
Exophytic lesion
Infiltrating tumour
Ulcerative mass
What are the two major histological types of cervical cancer and What is the stating of cervical cancer?
Squamous
Adenocarcinoma
Ia - Identifiable microscopically
Ib - Identifiable macroscopically
II - Beyond cervix but within pelvic wall and may involve upper 1/3rd of vagina
III - Extends beyond pelvic wall and may involve upper 1/3rd of vagina
IV - Extends to bladder/ rectum/ metastasis
What investigations should be done into suspected cervical cancer?
STI screen
Colposcopy + biopsy
Pelvic MRI
CT chest/ Abdo/ Pelvis
Bloods:
- FBC
- LFTS (early mets)
- U&Es
What are the leading differentials for a patient presenting with severe pelvic pain during their menstrual cycle?
Endometriosis
PID
What are the leading differentials for post coital bleeding?
Cervical ectropion
Cervical polyp
Cervical carcinoma
Vaginitis
What are type of cancer is contraindicates the use of HRT?
Oestrogen dependent breast cancer
Endometrial - by undiagnosed PV bleeding
What are some alternatives to HRT?
Vasomotor symptoms:
- SSRIs - clonidine
Osteoporosis
- Bisphosphonates
- Vitamin D
Vaginal dryness
- Lubricants
- local oestrogen
Diet and exercise
CBT
What are the benefits of HRT?
improved genital urinary symptoms
Reduced osteoporosis
Reduced risk of colorectal cancer
- may offset Alzheimer’s
- may reduce cardiovascular disease
When are women considered not at risk of pregnancy during the menopause?
<50 years - 2 years since last period
> 50 years - 1 year since last period
What monitoring is needed when on HRT?
Breast
BP
Weight
Abnormal bleeding
