Gynecology Flashcards
1
Q
What is the definition of asymptomatic endometrial thickening?
A
Endometrium of >5 mm discovered on US in postmenopausal women who is not bleeding
SOGC 249
2
Q
What is the incidence of endometrial thickening >4.5mm in postmenopausal women?
A
3-17%
SOGC 249
3
Q
What is the incidence of endometrial cancer in postmenopausal women?
A
1.3 to 1.7 per 1000
SOGC 249
4
Q
What is the “70-80-90” rule for endometrial cancer?
A
70% are Stage 1
80% are postmenopausal women
90% are symptomatic
SOGC 249
5
Q
What are risk factors for endometrial cancer? (7)
A
- obesity
- high fat diet
- nulliparity
- PCOS
- early menarche
- late menopause
- Tamoxifen use
SOGC 249
6
Q
Name the DDx of thickened endometrium in the postmenopausal women. (9)
A
- Proliferative endometrium
- Cystic hyperplasia
- Complex hyperplasia
- Atypical hyperplasia
- Carcinoma
- Uterine septum
- Submucous myoma
- Polyp
- Adenomyosis
SOGC 249
7
Q
What are some other US findings in the postmenopausal women that would mandate a referral to a gynecologist?
A
- increased vascularity
- inhomogeneity of endometrium
- particulate fluid
- Thickened endometrium >11mm (incidence of cancer is 6.7%
SOGC 249
8
Q
True or false. All postmenopausal women who have endometrial polyps need to have them resected.
A
False.
Not all postmenopausal women who have asymptomatic endometrial polyp require surgery. Women found to have asymptomatic polyp on US should be triaged for intervention according to size, age and other risk factors.
SOGC 249
9
Q
What is the rate of growth of endometrial thickness in women on tamoxifen?
A
increase by 0.75 mm/yr with tamoxifen.
Mean after 5 years was 12mm.
After discontinuation the ET decrease by 1.27 mm/yr
SOGC 249
10
Q
What is HNPCC?
A
Lynch syndrome.
Cumulative incidence of endoCA of 20-60% by 70 years old
Mean age of diagnosis is 48 (60 if non-HNPCC)
SOGC 249
11
Q
What are the lifetime risks of HGS cancers in women with BRCA mutations?
A
BRCA 1 : lifetime risk of HGS Ca 60%
BRCA 2 : lifetime risk of HGS Ca 30%
SOGC 344
12
Q
At the time of prophylactic BSO in BRCA mutated women, what percentage of patients already have HGS cancer?
A
5-15%
Premalignant epithelial changes (STIC) noted in 5-6%
SOGC 344
13
Q
In patients with BRCA mutation, what are the risks of future HGS cancers if only bilateral oophorectomy was performed? If BSO performed?
A
only oopherectomy, risk of future primary peritoneal HGSca is 11%, but if BSO, then 5%
SOGC 344
14
Q
What are some reasons the fimbriated ends of the Fallopian tubes are at higher risk of developing HGS cancers?
A
• higher surface area higher
• Mullerian cells (which the tubes are composed of) are more inclined to give rise to serous type cancers
• Fallopian tube bathed in pro-inflammatory environment (could promote p53 signatures and mutations)
○ With every ovulation, pro-inflammatory environment
▪ Extensive infiltration of leukocytes
▪ Inflammatory cytokines
▪ Reactive oxygen species
○ Continuous exposure to ovulatory environment can cause DNA damage and p53 mutations
SOGC 344
15
Q
What are some factors that decrease the risks of HGS cancers?
A
- OCP (5-8% risk reduction per year of use)
- Breastfeeding
- Increased parity
SOGC 344
16
Q
What is the lifetime reduction (%) of ovarian cancer in women who have used OCP for >10 years?
A
50%
SOGC 344
17
Q
What is the most common tumor that is inadvertently morcellated?
A
Endometrial cancer
SOGC 371
18
Q
What is the incidence of women who undergo hysterectomy or myomectomy for treatment of fibroids and will have unsuspected sarcoma?
A
1 in 350
SOGC 371
19
Q
What are 3 predictors of endometrial ablation failure, requiring further subsequent management?
A
- Age <40
- Prior tubal ligation
- Preoperative dysmenorrhea
SOGC 322
20
Q
What are some complications associated with pregnancies in women who have undergone endometrial ablation? (4)
A
- Preterm labor
- Uterine rupture
- Limb defects
- Maternal death
SOGC 322
21
Q
At what stage in the menstrual period would it be ideal to perform endometrial ablation?
A
In the post-menstrual phase
SOGC 322
22
Q
What are some advantages to hormonal preparation prior to endometrial ablation? (3)
A
- Shorter OR time
- Higher rates of amenorrhea at 12 and 24 months
- Reduced distention media absorption
Disadvantages
- Higher cost
- Medications side effects
SOGC 322
23
Q
What are absolute contraindications of endometrial ablation?(6)
A
- Pregnancy
- Desire to preserve fertility
- Known or suspected endometrial hyperplasia or cancer
- Cervical cancer
- Active pelvic infection
- Specific CI related to non-resectoscopic techniques
SOGC 322
24
Q
How does endometrial ablation work?
A
By destroying the basal endometrial layer and preventing further proliferation
SOGC 322
25
What is the effectiveness of 1st and 2nd generation endometrial ablation devices on heavy menstrual bleeding?
1st generation = resectoscopic
72.5-79.5% at 5 years
2nd generation = non-resectoscopic
86-99% at 1 year
SOGC 322
26
Fill in the blank.
| For every ____ of non-electrolyte solution absorbed, serum sodium falls by _____.
100ml
1 mEq
SOGC 322
27
What 3 steps can help prevent excessive fluid resorption during hysteroscopic procedures?
1. Pre-treatment of the endometrium
2. Intracervical injection of pressor agents
(E.g. vasopressin)
3. Keep intrauterine distension pressure < MAP
SOGC 322
28
What is post-ablation tubal sterilization syndrome? What is the incidence of this syndrome?
Syndrome whereby women who have had previous tubal ligations experience significant pain and cramping, due to bleeding trapped in the uterine cornua from active endometrium. This can happen up to 10% overall.
SOGC 322
29
What are the percentages of complications in a repeat endometrial ablation compared to a primary procedure?
Second procedure: 9.3-11%
Primary procedure: 20.5%
SOGC 322
30
What is the difference between contraceptive efficacy and effectiveness?
Contraceptive efficacy = how many pregnancies prevented during correct and consistent use of method (perfect use)
Contraceptive effectiveness = number of pregnancies prevented during typical use of method
SOGC 329-1
31
What are the 21 absolute contraindications for combined oral contraceptive (COC) use?
1. <4 weeks postpartum and breastfeeding
2. <21 days postpartum (not breastfeeding)
3. Smoker >35 years (>15 cigarettes/day)
4. Vascular disease
5. Hypertension (BP>160/100)
6. Acute DVT/PE
7. History of DVT/PE, not on anticoag, with risk of recurrence
8. Major surgery with prolonged immobilization
9. Known thrombophilia
10. Current and/or hx of ischemic heart disease
11. Hx of stroke
12. Complicated valvular heart disease
13. SLE with antiphospholipid antibodies
14. Migraine with aura
15. Peripartum cardiomyopathy with mod/severe impaired cardiac function
16. Peripartum cardiomyopathy with normal/mild impaired cardiac function <6 months
17. Current breast CA
18. Severe cirrhosis
19. Hepatocellular adenoma
20. Malignant hepatoma
21. Complicated solid organ transplantation
SOGC 329-9
32
What are non-contraceptive benefits to COC use?
- Cycle regulation
- Decreased menstrual flow/decreased anemia
- Increase bone mineral density
- Decrease dysmenorrhea and perimenopausal symptoms
- Decrease acne/hirsutism
- Decrease endometrial CA/Ovarian CA
- Decrease risks of fibroids
- Less functional cysts
- Lower risk of benign breast disease
- Decrease colorectal CA
SOGC 329-9
33
What are some of the most common causes of discontinuation of COC in the first 3 months?
1. AUB 12%
2. Nausea 7%
3. Weight gain 5%
4. Mood changes 5%
5. Breast tenderness 4%
6. Headaches 4%
SOGC 329-9
34
What is most common cause of unscheduled bleeding in women who previously had good cycle control on COC?
Chlamydia infection
(in up to 29% of these patients)
SOGC 329-9
35
What is the name of the dark facial skin pigmentation that can occur in COC users?
Chloasma
SOGC 329-9
36
What are the risks of VTE in the following:
1. Normal population
2. COC users
3. Pregnant women
4. Postpartum women
1. 4/10,000
2. 10/10,000
3. 30/10,000 (6.7 risk increase)
4. 400/10,000 (115 risk increase)
SOGC 329-9
37
True or False. Breast Cancer risks in COC users increases significantly and will never return to baseline.
False.
There is a slight increased risk of breast cancer (1.24 odds ratio) but the risk returns to normal after 10 years of discontinuing COC use.
SOGC 329-9
38
Which of the following may cause contraceptive failure?
- Antiepileptic drugs
- Amiodarone
- Erythromycin
- SSRI
- Hepatitis and HIV protease inhibitors
- Ulipristal acetate
May cause contraceptive failure:
- Antiepileptic drugs
- Hepatitis and HIV protease inhibitors
- Ulipristal acetate
May increase COC activity
- Amiodarone
- Erythromycin
- SSRI
SOGC 329-9
39
What is the most frequent inherited bleeding disorder?
Von Willebrand Disorder
SOGC 163
40
Name 4 clinical situations in which patients presenting with heavy menstrual bleeding may require more investigations for bleeding disorders.
1. Menorrhagia present since menarche
2. Evidence of anemia/iron deficiency
3. Personal or family hx of bleeding after hemostatic challenge (dental extraction, surgery, parturition) or family hx of menorrhagia
4. No local cause for menorrhagia
SOGC 163
41
Do combined oral contraceptives increase or decrease plasma levels of factor VIII and von Willebrand Factor?
Increase
Thereby decreasing heavy bleeding when COC used in patients with VWD
SOGC 163
42
What is the most common form of emergency contraception?
Copper IUD
Pregnancy estimated at 0.05%
SOGC 329
43
Name 3 options for hormonal emergency contraception.
1) Levonorgestrel (1.5mg PO) up to 72 hours after UPI
2) Ulipristal acetate 30mg PO up to 5 days after UPI
3) Yuzpe Method (100mcg ethinyl estradiol and 500mcg levonorgestrel) 12 hours apart
SOGC 329
44
What is the biggest risk factor for failed emergency contraception?
Subsequent unprotected intercourse
SOGC 329
45
Describe 2 mechanisms of action by which levonorgestrel acts as an emergency contraception.
1) Affects follicular development after the selection of the dominant follicle occurs
2) Influences muscular contractility of the Fallopian tubes
(also acts on the Glycodelin-A concentration, which is an inhibitor of sperm binding to the zona pellucida)
SOGC 329
46
Up to how many days can the copper IUD be inserted for emergency contraception?
Up to 7 days
SOGC 329
47
How soon can a woman start her oral contraceptive after hormonal emergency contraception?
1) LNG-EC
2) UPA-EC
1) Can start the same day or the following day
2) Need to wait 5 days prior to starting COC
SOGC 329
48
What is the reversible side effect of Depo-Provera that is the most concerning?
bone loss
3.1% at lumbar spine and 6.1% at the hip
SOGC 313
49
Prophylactic antibiotics should be given how long before skin incision?
15-60 minutes prior to skin incision
SOGC 275
50
Repeat doses of prophylactic antibiotics should be given intra-operatively in which two circumstances?
Procedure length >3 hours
Estimated blood loss >1500mL
SOGC 275
51
What is the percentage of anterior abdominal wall adhesions in laparoscopies?
10%
SOGC 193
52
What is the most common complication at laparoscopy?
Extraperitoneal insufflation
SOGC 193
53
What is the RMI score?
| Using the RMI II score, what is the cutoff to determine that an ovarian mass is high risk for malignancy or not?
Risk of malignancy index
Score of >200 is high risk for malignancy
RMI II has specificity of 89-92% and Positive predictive value of 80%
SOGC 230
54
What is the percentage of success and of complications with 1 attempt of Veress entry? 2? 3? More than 3?
Adequate placement in 85-87% at first attempt
○ 2 attempts in 8.5-11.6%
○ 3 attempts in 2.6-3%
○ >3 attempts in 0.3-1.6%
```
Complications rates (extraperiteonal insufflation, omental and bowel injuries and failed laparoscopy)
○ 0.8-16.3% at 1 attempt
○ 16.3-37.5 at 2 attempts
○ 33-64% at 3 attempts
○ 85-100% at more than 3 attempts
```
SOGC 193
55
What are certain conditions associated with higher levels of vWF? (7) And lower levels of vWF? (2)
Higher levels of vWF
- Aging
- Pregnancy or OCP
- Acute or chronic inflammation
- Diabetes
- Malignancy
- Stress or exercise
- Hyperthyroidism
Lower levels of vWF
- Hypothyroidism
- blood group O
56
What is the risk of PID with IUD insertion?
| When is the highest risk of PID in patients that got and IUD inserted?
0.5%
First 20 days after IUD insertion
SOGC 305
57
What are absolute contraindications to IUD insertion?
* Current PID
* Purulent cervicitis
* Current chlamydial and gonorrheal infection
SOGC 305
58
For patients with IUD in place who develop a PID, what are the 2 indications for removal of IUD?
1. Patient requests removal
2. Failure to improve after 72 hours of treatment
SOGC 305
59
True or false.
| HIV positivity is a risk factor for the development of PID during IUD insertion.
False.
Overall complication rate of IUD in women with or without HIV are similar
SOGC 305
60
Name 5 risk factors for STI, when evaluating patients for IUD insertion.
```
• Age <26 years old
• New partner
• More than 1 partner in the last 12 months
• History of STI
• Vulnerable populations
○ Injection drug users
○ Women who are incarcerated
```
SOGC 305
61
What is the percentage of ovarian masses causing ovarian torsion that are malignant in the adult population? In the postmenopausal population?
3% overall in the adult population
22% in the post-menopausal population
SOGC 341
62
If corpus luteum surgically removed early in the 1st trimester of pregnancy, until how many weeks does progesterone replacement need to be prescribed?
Until 10 weeks of gestational age
William's Gyn p.355
63
What is the definition of primary dysmenorrhea?
Menstrual pain in the absence of pelvic pathology.
Secondary dysmenorrhea is menstrual pain in the presence of pelvic pathology
SOGC 345
64
What are risk factors for primary dysmenorrhea?
* Age (younger age will often have more severe pain)
* Nulliparity (parous women less pain)
* Smoking
* Fewer social supports
* Frequent lifestyle changes
* Stressful close relationships
* Lower SES
* Mood disorders
SOGC 345
65
What is the mechanism of action of NSAIDs that helps with symptoms of dysmenorrhea?
Inhibit cyclooxygenase production and thus inhibits peripheral prostaglandins production
(Uterine prostaglandins overproduction is thought to cause dysmenorrhea)
SOGC 345
66
True or false.
| Each surgery for endometriosis will help improve fertility.
False.
Only the first surgery for endometriosis is found to help for patients with infertility.
Thus it is sometimes important to plan the timing of the surgery to fertility treatments
SOGC 345
67
What percent of patients with lichen sclerosis will transform to vulvar malignancy?
5%
Histologic cellular atypia may precede a diagnosis of invasive squamous cell carcinoma
William's Gyn p.89
68
What is the first-line therapy for the treatment of lichen sclerosis?
Clobetasol 0.05% ointment
William's Gyn p.89
69
Name 3 variants of vulvar lichen planus.
1) Erosive
2) Papulosquamous
3) hypertrophic
Erosive is the most common vulvovaginal form
William's Gyn p.92
70
What is the name of the lacy, white striations frequently found in conjunction with a diagnosis of lichen planus?
Wickham striae
Can often been seen on buccal mucosa
William's gyn p.92
71
At what age should we start to biopsy Bartholin cysts/abscess wall to rule out malignancy?
After 40 years old.
Incidence is low 0.1 per 100,000 women
William's gyn p.97
72
At how many weeks postpartum can combined hormonal contraception be prescribed in patients who are exclusively breastfeeding?
At 6 weeks.
If breastfeeding is already well established and infant's nutritional status is monitored.
William's Gyn p.106
73
What is the reason that progesterone-only pills should be taken at the same time daily?
The mucous changes and thickening that occur with progesterone pills do not persist beyond 24 hours.
William's gyn p.127
74
What is the name of the ingredient in spermicidal agents?
Nonoxynol-9
William's Gyn p.130
75
Complicated vulvovaginal candidiasis is defined as: (4)
1. Recurrent (4 or more episodes in 12 months)
2. Associated with severe symptoms
3. Result of non-albicans species
4. Present in compromised host
SOGC 320
76
What cardiac malformation is more likely when oral fluconazole is used in pregnancy?
Tetralogy of Fallot
SOGC 320
77
Name 2 treatments for
1) uncomplicated vulvovaginal candidiasis (VVC)
2) recurrent VVC
3) Non-albicans VCC
1) Clotrimazole cream/ointment 1% daily x 7 days OR Fluconazole 150mg PO x 1
2) For induction: Fluconazole 150mg PO x 3 days, q72hours OR Boric Acid 300-600mg PV daily x 14 days
For maintenance: Fluconazole 150mg PO once weekly OR Clotrimazole 500mg PV monthly x 6 months OR Boric Acid 300mg daily x 5 days at beginning at each menstrual cycle
3) Boric acid 300-600mg qHS x 14 days OR Nystatin suppository 100,000 units daily x 3-6 months
SOGC 320
78
What is the most common non-viral STI?
Trichomonas vaginalis
Prevalence is 3.1% amongst reproductive age women in the US
Treatment is:
Metronidazole 2g PO x 1 OR Metronidazole 500mg PO BID x 7 days
If resistant to above tx, Tinidazole 2g PO x 1
SOGC 320
79
What is the most common bacterial species found in the normal vaginal flora?
Lactobacillus species
Provides defence against infection by maintaining acidic pH in the vagina and ensuring hydrogen peroxide present in the environment
SOGC 320
80
What is the most common lower genital tract disorder among women of reproductive age?
Bacterial vaginosis
Polymicrobial state resulting from decreased lactobacillus and increase in pathogenic bacteria
Risk factors:
- Black women
- Smokers
- Women who use vaginal douches or intravaginal products
- Increase in number of sexual partners / frequency of intercourse
SOGC 320
81
What is the Amsel diagnostic criteria?
Clinical diagnostic criteria for bacterial vaginosis.
Positive diagnosis if 3 out of 4 of the following signs:
1) Adherent and homogeneous vaginal discharge
2) Vaginal pH >4.5
3) Detection of clue cells on wet mount
4) Amine odour after addition of KCL (Whiff test)
Nugent score is based on gram-stain vaginal smears
SOGC 320
82
What is the treatment for bacterial vaginosis? Name 2.
Recommended
- Metronidazole 500mg PO BID x 7 days
- Clindamycin 2% cream – 1 applicator PV daily x 7 days
- Metronidazole gel 0.75% - 1 applicator PV daily x 5 days
Alternatives
- Metronidazole 2g PO x 1
- Clindamycin 300mg PO BID x 7 days
SOGC 320
83
If a patient suffers from recurrent Bacterial vaginosis, what treatment plan should be used?
Continuous suppression of the growth of abnormal bacteria:
Metronidazole 500mg PO BID x 10-14 days
Metronidazole vaginal gel 0.75% 1 applicator daily x 10 days, then 2 times per week for 3-6 months
SOGC 320
84
Name 2 treatments of Bacterial vaginosis in pregnancy.
Metronidazole 500mg PO BID x 7 days
OR
Clindamycin 300mg PO BID x 7 days
SOGC 320
85
What are the main risk factors for post-operative nausea and vomiting? (4)
1) Female
2) Prior hx of motion sickness or post-op N/V
3) Non-smoker
4) Use of post-operative opioids
SOGC 209
86
True or False.
| General anesthesia decreases risks of N/V post-operatively.
False.
Compared to regional anesthesia, general anesthesia has 11% increase in post-op N/V
SOGC 209
87
How many cycles of ulipristal acetate are permitted in management of uterine fibroids?
No limitation in number of cycles. Health Canada has approved intermittent prolonged use of 5 mg daily
Studies have done 3 months continuous treatment with 2 months off to have menses (so 5-month courses)
SOGC 389
88
What life-threatening side effect is associated with use of SPRMs?
Hepatic impairment and liver toxicity
No clear association with treatment duration or number of courses
Discourage use in patients with high risk of liver impairment (EtOH abuse, known hepatitis, fatty liver)
SOGC 389
89
What cutoff of ALT and AST should be used to decide if a patient may start SPRMs?
Do not start if > 2x upper limit of normal
SOGC 389
90
What is the frequency of ALT/AST testing for SPRMs?
Prior to starting each course
Monthly during treatment
2-4 weeks after completing a treatment course (so minimum of 5 sets of blood tests per course)
Signs/symptoms of liver injury should prompt testing
SOGC 389
91
What is the threshold for ALT/AST levels to stop SPRM therapy?
> 3x upper limit of normal
You must also evaluate further
SOGC 389
92
Effects of ulipristal acetate in management of uterine fibroids (5)
1. Decrease in clinical bleeding (70% have amenorrhea)
2. Improve anemia
3. 72% reduction in fibroid volume after 4 cycles
4. 9% of biopsies show progestogen-associated endometrial changes
5. If used preoperatively, reduce OR blood loss and transfusions
SOGC 389
93
Effects of GNRH agonists in management of uterine fibroids (6)
1. Decrease fibroid size
2. Improve anemia
3. Reduce probability of blood transfusions
4. If used preoperatively, reduce blood loss and transfusions, 5. OR time, and 6. complication rates
SOGC 389
94
What is the maximum duration of GNRH agonist for management of fibroids?
May use for up to 3 months
SOGC 389
95
What is the definition of preoperative anemia?
Hgb < 120 g/dL
SOGC 389
96
What condition is associated with adverse outcomes up to 30 days postoperatively in patients undergoing elective gynaecologic surgery?
Preoperative anemia
SOGC 389
97
How might preoperative anemia be corrected? (2)
1. Menstrual suppression
2. Iron therapy (oral or parenteral)
SOGC 389
98
What are benefits of MIS over conventional procedures (4)?
1. Less pain
2. Shorter hospital stay
3. Quicker return to normal activities
4. Fewer perioperative complications
SOGC 377
99
Name the five most common indications to perform hysterectomy.
1. Uterine leiomyomas
2. AUB
3. Endometriosis
4. POP
5. Other CPP
SOGC 377
100
Name 3 factors influencing clinical decision making about route of hysterectomy.
1. Patient characteristics
- Choice
- Underlying pathology
- Previous surgeries
- Medical comorbidities
2. Physician preferences
- Training
- Experience
3. Availability of resources
- Facilities
- Equipment
- Support
SOGC 377
101
What is the definition of technicity index (TI)?
of MIS hysterectomies (vaginal, robotic, laparoscopic) divided by # of total hysterectomies (above + abdominal) in a given time period
SOGC 377
102
Is a 100% technicity index feasible?
| Who/where will have a higher index?
No
Higher volume hospitals and surgeons
SOGC 377
103
What is the average length of stay for:
1) laparoscopic hysterectomy?
2) vaginal hysterectomy?
3) abdominal hysterectomy?
1) LH = 1.4 days
2) VH = 1.8 days
3) AH = 3.4 days
SOGC 377
104
True or False. Same-day hyst has high patient satisfaction rating
True. They can be safely achieved without having negative impact on complication or readmission rates
SOGC 377
105
What is the recommended route of hysterectomy for benign gynaecologic indications?
Preferably vaginal, but laparoscopic an acceptable alternative
LH may be better for large uteri, limited vaginal accessibility, and concurrent pelvic pathology (e.g. endo, adhesive disease, adnexal lesions)
SOGC 377
106
What factors influence the choice of hysterectomy? (5)
1. Size and mobility of uterus
2. Extent of pelvic pathology & need for treatment
3. Additional surgical procedures required
4. Surgeon training, expertise, facilities, and access to technology
5. Patient preference
SOGC 377
107
Compare vaginal vs. laparoscopic hysterectomy (4)
1. Shorter operating time
2. Lower cost
3. More postop pain and analgesia use
4. Longer hospital stay
SOGC 377
108
Compare vaginal vs. abdominal hysterectomy (3)
1. Quicker return to normal activities
2. Shorter hospital stay
3. Fewer febrile episodes or unspecified infections
SOGC 377
109
Compare laparoscopic vs. abdominal hysterectomy (5)
1. Quicker return to normal activities
2. Increased rate of lower urinary tract injuries (this is nullified with surgeon experience)
3. Shorter hospital stay
4. Fewer wound infections
5. Fewer febrile episodes or unspecified infections
SOGC 377
110
Are there differences in outcomes between laparoscopic and robotic hysterectomies in benign disease?
No differences - including rates of urinary tract injuries
SOGC 377
111
Risk factors for urinary tract injury in benign hysterectomy (3)
1. Low volume of surgery or inexperience
2. Pelvic pathology (e.g. endometriosis, adhesions)
3. Prior CS or laparotomy
SOGC 377
112
Should a history of Caesarean section(s) influence the choice for route of hysterectomy?
Not necessarily; an MIS approach is still feasible (usually laparoscopic > vaginal)
VH/LH have lower reoperation risks than AH; previous CS increases risk of reoperation with all routes
SOGC 377
113
List reasons why abdominal hysterectomy or laparotomy would be indicated instead of MIS approach (4)
1. Vaginal route not accessible AND patient cannot tolerate pneumoperitoneum (e.g. heart/lung disease, obesity)
2. Very large uterus
3. Severe adhesions
4. Contraindications to morcellation
SOGC 377
114
How large is a mini-laparotomy?
4-9 cm
SOGC 377
115
What device can be used to improve visualization in open hysterectomy?
Wound retractor (Alexis)
SOGC 377
116
Closing vaginal vault, what makes barbed suture favourable over traditional suture? (3)
1. Improved tensile strength by mitigating the need for knots
2. Decreased procedure time
3. Reduced or no variation in postoperative complications
SOGC 377
117
What warning does barbed suture have?
SBO
"Cutting the end of the suture flush with the tissue or using accessory devices (adhesions barriers or suture clips) over the cut suture end may mitigate the risk of SBO, but this has not been well studied"
SOGC 377
118
What is the incidence of vaginal vault dehiscence?
0.24-0.31%
SOGC 377
119
Which route has more risk of vaginal vault dehiscence: laparoscopic/robotic or vaginal?
Conflicting conclusions in studies
SOGC 377
120
Describe technique to properly close vaginal vault (3)
1. Place sutures 5-10 mm from the vaginal edge and between throws
2. Incorporate vaginal epithelium for full thickness
3. Avoid excessive thermal injury and tissue strangulation
SOGC 377
121
Is there any benefit to performing supracervical over total hysterectomy?
No - only shorter OR time; all other outcomes the same, except more likely to have cyclical bleeding 2 years postop (OR = 16.0), and you still need to do Pap smears
SOGC 377
122
What test needs to be done preop the day of hysterectomy?
Pregnancy test
SOGC 377
123
GnRH agonist use as pretreatment to hysterectomy; what are 3 things it does?
1. Reduce fibroid size by 50%
2. Decrease uterine bleeding by 89%
3. Median time to amenorrhea = 21 days
SOGC 377
124
Ulipristal acetate use as pretreatment to hysterectomy; what are 3 things it does?
1. Reduce fibroid size by 20%
2. Decrease uterine bleeding by 90%
3. Median time to amenorrhea = 7 days
SOGC 377
125
Preop anemia, what are indications for IV instead of PO iron? (2)
1. Failed trial of PO
2. Malabsorption condition
SOGC 377
126
What antibiotic prophylaxis is suggested for hysterectomy? What is the timing?
1st generation cephalosporin, 15-60 min before first incision
SOGC 377
127
Indications to repeat antibiotic prophylaxis in gynaecologic surgery? (2)
Only for open cases:
- EBL > 1500 mL
- OR > 3 hours
SOGC 377
128
Risk of VTE in benign gynaecologic surgery?
| Risk, but now with intermittent pneumatic compression?
0-2%
< 1% with intermittent pneumatic compression
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Scoring systems for VTE risk in surgery (2)
1. Rogers
2. Caprini
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If a patient is high risk in the Rogers/Caprini scoring systems for VTE periop, what is recommended?o
Combined mechanical prophylaxis + LMWH/UFH
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Is routine bowel prep recommended for gynaecological procedures?
No: no benefit towards improved bowel handling or surgical view, and did not decrease operative time or complications
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Should the vagina be disinfected prior to hysterectomy? If so, with what, and for what reason?
Yes, with povidone-iodine, to decrease risk of infectious morbidity and pelvic abscess
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What serum level changes suggest that hysterectomy alone may reduce ovarian reserve and lead to earlier menopause?
Higher AMH levels in women who have had hysterectomies compared to those who have not had hysterectomies
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Lifetime risk for ovarian cancer in Canada?
1.4%
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Negative effects of BSO at time of premenopausal hysterectomy (11)
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1. Higher frequency & intensity of menopause symptoms, especially < 45 years
2. Increase in all-cause mortality
3. Increase in fatal & non-fatal coronary artery disease (CAD)
4. Increase in osteoporosis
5. Increase in cognitive decline
6. Increase in dementia
7. Negative effects on mood
8. Sexual problems
9. May accelerate the aging process in all body systems → increased morbidity
10. In women < 45, earlier death (HR = 1.41), earlier CAD (HR 1.26), and cardiovascular death (HR 1.84)
11. In women < 50, increase in dementia and Parkinson disease
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Positive effects of BSO in benign hysterectomy
1. Lower prevalence of ovarian cancer (0.02-0.04% instead of 0.14-0.7%)
2. Lower incidence of breast & total cancers, but not cancer mortality
3. Reduced prevalence of reoperation
4. Reduction of chronic pain
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Age cut-off for keeping/removing ovaries in benign hysterectomy
Generally, keep them in if < 50 years; however, can remove and give HRT until natural age of menopause (51-52)
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If doing BSO during hysterectomy, should you give HRT?
Generally, yes. Untreated symptoms can have major ramifications on quality of life and capacity to function
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If giving HRT after BSO, what routes work?
Systemic (PO, transdermal) and local (PV) are both effective in controlling symptoms and reducing morbidity
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Until what age should HRT be given following BSO?
Average age of natural menopause (51-52)
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Should you do salpingectomy at time of benign hysterectomy?
Yes, if easily accessible; theoretically reduces risk of high-grade serous ovarian cancer
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Should mode of hysterectomy be changed in order to concurrently do opportunistic salpingectomy?
No
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Does prophylactic salpingectomy increase the risk of intraoperative complications?
No. Only slightly longer OR time
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Are there long-term effects of prophylactic bilateral salpingectomy?
No; just make sure to minimize damage to ovaries when doing it
In fact, keeping tubes increases risk of reoperation for adnexal pathology
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In the absence of pelvic organ prolapse, is there a role for prophylactic uterosacral ligament fixation at time of benign hysterectomy?
No strong evidence
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Incidence of pelvic organ prolapse following hysterectomy
Likely 1-2%
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Risk of uterosacral ligament fixation at time of benign hysterectomy?
Urinary tract complications (risk of ureteral compromise = 4%)
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Best way to detect urologic injury during gynaecologic surgery?
Cystoscopy
Visual inspection and noting presence of ureteric vermiculation have low sensitivity
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Benefits of routine cystoscopy after benign hysterectomy (3)
1. Prompt recognition of urinary tract injury (up to 5x increase in detection)
2. Earlier repair
3. Improved patient outcomes
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Negative aspects of routine cystoscopy after benign hysterectomy (3)
1. Does not detect all injuries (delayed thermal injury, partial ureteric obstruction)
2. Longer OR time
3. Increased hospital costs
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Risk factors for urinary tract injury in gynaecologic surgery (5)
1. Enlarged uteri
2. Endometriosis
3. Extensive adhesive disease
4. Concurrent procedures (colposuspension, incontinence procedures, ureterolysis)
5. Surgical factors (laparoscopic approach, surgeon experience, skill level)
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When doing hysterectomy in patient with endometriosis, what additional steps should take place?
- Remove all endometriotic lesions
- Consider BSO to reduce risk of persistence/recurrence of endometriosis and risk of reoperation (however, risk of reoperation is low in general, so keep ovaries in young women)
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What % of patients with chronic pelvic pain still have symptoms following hysterectomy, if the etiology of the pain is unclear?
21-40%
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What might prevent total hysterectomy (can only do supracervical) in patients with endometriosis?
Severe adhesive disease in cul-de-sac; however, keeping cervix associated with high levels of persistent pain
Consider referral to a surgeon with expertise if cul-de-sac obliteration is suspected preop
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Additional risks for hysterectomy in endometriosis patients (2)
1. Longer OR time
2. 4x the risk of postop complications (ureteral injury, bowel perforation, pelvic abscess, postop fever, voiding dysfunction)
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Which asymptomatic gyn patients require an examination
```
need for Pap test
over 70yo (inspection of vulva/perineum/anus) only
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What examination is required prior to OCP Rx in an asymptomatic woman?
history and BP only
no pelvic exam
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Which gyn malignancies require screening
cervix: Pap test as per province guidelines
vulva: after 70 (inspection only, no frequency defined)
endometrium, ovary: no evidence
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T1 bleeding, US shows incomplete SAB.
| what are some reasons for speculum exam?
- removal of RPOC from os (decrease pain, PVB, vagal reaction)
- ensure no other source of bleeding
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What are adequate ways to screen for gono/chlam?
urine NAAT
self-collected culture
physician collected culture (not necessary)
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Which patients require screening for gono/chlam?
patients that are:
- pregnant
- less than 25yo
- new partner/non-barrier contraception
- multiple partners in the last year
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What is the role of gono/chlam screening in a non-pregnant patient?
- prevent PID
- prevent infertility
- prevent chronic pain
- prevent other long-term consequences of infection
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What are some arguments against pelvic exams in an asymptomatic woman?
- patient discomfort
- false reassurance
- work-up of incidental benign findings
- time limitations
- physicians unease
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What are some arguments for pelvic exams in an asymptomatic woman?
- reassurance of normalcy
- physician preservation of skills
- ability to distinguish normal vs abnormal
- establish communication with provider
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Why do patients seen in the gyne office with new GI symptoms require a pelvic exam?
rule out:
POP
deep infiltrating endo
gyn malignancy
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Should a pelvic exam be performed prior to HRT prescription?
yes.
symptoms such as hot flashes coincide with GUSM- menopausal patients might be unable to distinguish pathology from normal ageing process. vulvar inspection should be included.
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