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Specialities > Gynecology 2 > Flashcards

Gynecology 2 Flashcards

1
Q

What is the main causes of intermenstrual bleeding?

A

Cervical

  • Ectopy
  • CIN
  • Cancer

Uterine

  • polyps
  • fibroids

Infections

Hormonal

  • contraception *breakthrough bleed
  • Tamoxifen

Vaginal adenosis

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2
Q

What are the differentials for post-menopausal bleeding?

A

HRT

Atrophic vaginitis

Endometrial cancer

Cervical cancer

Infection

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3
Q

What are some differentials for a pelvic mass?

A

Ovarian tumour/ cyst

Uterine fibroids

Pelvic abscess

Pregnancy

Bowel

  • Faecal loading
  • Carcinoma
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4
Q

What are the symptoms of an ovarian mass?

A

Abdominal bloating/ distention

Pain

  • Torsion
  • Rupture
  • Haemorrhagic cyst

Bowel obstruction

Altered menstrual cycle

Hormonal changes

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5
Q

What are some risk factors for prolapse?

A

Pelvic floor weakness

Multiparity

Oestrogen deprivation
- weakness of the vagina

Increased intrabdominal pressure

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6
Q

What are the differentials for a painful/ itchy vulo-vagina?

A

Infection

  • HSV
  • Gonorrhoea

Atrophic vaginitis

Lichen sclerosis

Vulvodynia

Vulva carcinoma

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7
Q

What are the main causes of infertility?

A 
Anovulation 
Tubal pathology 
Male factors 
Endometriosis 
Unexplained
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8
Q

What are the main investigations into subfertility?

A

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)

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9
Q

What are the main causes for a recurrent miscarriage?

A

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

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10
Q

Where are the locations for ectopic pregnancy?

A 
Tubal - 99% of cases - Ampulla 
Ovarian 
Cervical 
Peritoneal 
Pregnancy of unknown location
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11
Q

By how much should hCG not rise by to suspect ectopic pregnancy?

A

66%

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12
Q

What are the complications of PID?

A

Subfertility

Recurrent pain

Ectopic pregnancy

Tubo-ovarian abscess

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13
Q

What are the top causes for a raised ca125?

A

Ovarian cancers (epithelial)

Other cancers:

  • endometrial
  • G.I
  • Lung
  • Breast

Endometriosis

Pregnancy

Peritoneal inflammation
- ascites

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14
Q

What is called when there is onset of symptoms causing
- physical
- psychological
- behavioural
symptoms during the menstrual cycle and when do they typically begin?

A

Pre- menstrual syndrome

during the luteal phase.

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15
Q

What are the management options for primary dysmenorrhoea?

A

Pain that starts in the first two years of menarche

NSAIDs

  • Mefenamic acid
  • ibuprofen

Combined oral contraceptive

Mirena coil

Injectable progesterone

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16
Q

What signs would you look for in cervical carcinoma?

A

Mass
Lymphadenopathy
Irregular discharge - blood stained
Ulceration

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17
Q

How is endomitosis descried as on laparoscopy?

A

burnt match heads
- areas of puckered redness

Chocolate cysts within the ovaries

Hemosiderin with peritoneum covering

Scarring

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18
Q

Which type of HRT is most appropriate for perimenopausal women?

A

Cyclical HRT

- if periods are still present then cyclical is best as it has predictable withdrawal bleeds`

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19
Q

List some causes of vaginal discharge:

A

Infections:

  • Bacterial vaginosis
  • Candida albicans
  • Trichomonas vaginlis

Cervical infections:

  • Chlamydia trachomatis
  • N. Gonorrhoeae

Cervical ectopy

Retained tampons

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20
Q

What is the tests done into premature ovarian failure?

A

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
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21
Q

What are the initial investigations that should be conducted into female infertility?

A

Bloods:

  • FSH
  • LH
  • Oestradiol
  • Anti-Mullerian hormone
  • progesterone test for ovulation

Tubal patency testing:

  • laparoscopic hydrotubation
  • hysterosalpingo- contrast sonography
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22
Q

What are the major causes of female infertility?

A

Premature ovarian insufficiency/ ovarian reserve deficiency

Anovulation

  • PCOS
  • Amenorrhoea (primary/ secondary)

Tubal patency

  • PID
  • Endometriosis
  • Adhesions

Structural

  • fibroids
  • Adhesions
  • Vaginal septum
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23
Q

What are the methods to promote ovulation used?

A

Clomiphene
- induces ovulation

Exogenous gonadotrophins 
(exogenous hCG is used to promote LH surge)

Laparoscopic ovarian drilling

24
Q

What are the various techniques used for assisted conception?

A

Intrauterine insemination

In vitro fertilisation

Intracytoplasmic sperm injection

25
Q

What are the contraindications to HRT?

A

Previous breast cancer/ current breast cancer

Oestrogen sensitive tumour

Undiagnosed PV bleeding

Endometrial hyperplasia

Previous DVT

26
Q

What are the risks of HRT?

A

Breast cancer

VTE

Stroke

Ovarian/ endometrial cancer

27
Q

What are some non-hormonal treatments for menopause?

A

SSRIs for vasomotor symptoms
- fluoxetine

Vaginal moisturisers

CBT/ support groups - psychological symptoms

Satellite ganglion blockage

28
Q

List some cause of post menopausal bleeding:

A

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

29
Q

What age group should be immediately referred for post menopausal bleeding and what age is this?

A

> 55 years should be referred within 2 weeks

  • TVS (>5mm)
  • Hysteroscopy
  • Endometrial biopsy with pipelle
    +/-
    MRI
30
Q

What are the typical symptoms of urogenital prolapses?

A

Sensation of heaviness in the vagina

Dragging/ something coming down in the vagina

Urinary symptoms

  • UTIs
  • Frequency
  • Dysuria

Dyspareunia

31
Q

What is the management options for prolapses?

A

Lifestyles changes
- weight loss

Pelvic floor exercises

Ring pessaries

Surgery
- Anterior Colporrhaphy/ colposuspension (Cystoceles)

  • Utero-sacral ligament suspension Hysterectomy / sacrohysteropexy (Uterine)
  • Posterior Colporrhaphy (rectocele)
32
Q

List some causes of primary amenorrhoea:

A

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
33
Q

Name a muscarinic inhibitor used for urge incontinence:

A

Oxybutynin

34
Q

What investigations should be done into urinary incontinence?

A

Urinalysis

Bladder diary
- can help narrow down the type

Cystoscopy

  • if haematuria
  • recurrent STIs

Urodynamic studies

35
Q

In someone with incontinence, where voiding diaries have been done and there is diagnostic uncertainty what would be the most appropriate next investigation?

A

Urodynamic studies

36
Q

How can you differentiate between a vulva intra epithelium neoplasia and vulva carcinoma?

A

Carcinoma tends to ulcerate whereas VIN tends to be white or plaque like

37
Q

What action should be undertaken when you discover someone to have had female genital mutilation?

A

Medical team and police

38
Q

What is the most appropriate surgical treatment for vaginal vault prolapse?

A

Sacrocolpopexy

39
Q

What score is used to establish the likely hood of malignancy in a cyst? and how do yo calculate it?

A

RIsk of Malignancy Index (RMI)

Ultrasound score x Menopausal status x Ca125

RMI >250 = 75% risk of cancer

40
Q

Highlight some of the clinical symptoms and features of ovarian cyst, and how are they investigated?

A
  • 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
41
Q

What is the management of ovarian cysts?

A

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
42
Q

Define primary and secondary dysmenorrhoea and highlight the treatment for primary:

A

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
43
Q

List the causes of heavy menorrhagia and highlight the investigations:

A

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

44
Q

List the management options for menorrhagia:

A

Hormonal:

  • Mirena
  • GnRH Analogues
  • Progesterone

Non-hormonal:

  • Tranexamic acid
  • Mefenamic acid

Surgical:

  • endometrial ablation
  • hysterectomy
45
Q

What are the two major classes of endometrial cancer?

A

Adenocarcinoma

  • glandular from over over stimulation
  • comes off atypical hyperplasia

Serous carcinoma
- sporadic

46
Q

What are the main ovarian cancer genetics?

A

BRCA1
BRCA2
HNPCC

47
Q

What staging is used for ovarian cancers?

A 
FIGO 
I - limited to ovaries 
II - Limited to pelvis 
III - limited to abdomen including lymph nodes 
IV - distant metastases out of abdomen
48
Q

What are the clinical appearances of cervical cancer on speculum?

A

Exophytic lesion

Infiltrating tumour

Ulcerative mass

49
Q

What are the two major histological types of cervical cancer and What is the stating of cervical cancer?

A

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

50
Q

What investigations should be done into suspected cervical cancer?

A

STI screen
Colposcopy + biopsy
Pelvic MRI
CT chest/ Abdo/ Pelvis

Bloods:

  • FBC
  • LFTS (early mets)
  • U&Es
51
Q

What are the leading differentials for a patient presenting with severe pelvic pain during their menstrual cycle?

A

Endometriosis

PID

52
Q

What are the leading differentials for post coital bleeding?

A

Cervical ectropion

Cervical polyp

Cervical carcinoma

Vaginitis

53
Q

What are type of cancer is contraindicates the use of HRT?

A

Oestrogen dependent breast cancer

Endometrial - by undiagnosed PV bleeding

54
Q

What are some alternatives to HRT?

A

Vasomotor symptoms:
- SSRIs - clonidine

Osteoporosis

  • Bisphosphonates
  • Vitamin D

Vaginal dryness

  • Lubricants
  • local oestrogen

Diet and exercise

CBT

55
Q

What are the benefits of HRT?

A

improved genital urinary symptoms

Reduced osteoporosis

Reduced risk of colorectal cancer

  • may offset Alzheimer’s
  • may reduce cardiovascular disease
56
Q

When are women considered not at risk of pregnancy during the menopause?

A

<50 years - 2 years since last period

> 50 years - 1 year since last period

57
Q

What monitoring is needed when on HRT?

A

Breast

BP

Weight

Abnormal bleeding

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