Gynecology Flashcards
Define Primary and secondary amenorrhoea:
Primary:
- Absence of Menses by age 16 years.
- with secondary sexual characteristics
(imperforated hymen, Mullerian agenise, Transvaginal septae)
- Absence of menses by age 14 years
- without secondary sexual characteristics
(Turner’s syndrome, Kalmann’s syndrome, testicular feminisation syndrome)
Secondary:
- >3 months in a female who previously had regular cycles
- > 6 months in a female who previously had irregular cycles
What would you want to establish in this history of someone with heavy menstrual bleeding?
- regularity of bleeding
- amount
- how long they last
- date of last period
What are some investigations into heavy menstrual bleeding?
Bloods: - FBC \+/- - Hormones - TFTs - Coagulation
Orifices:
- Urine dipstick
- Hysteroscopy
X-rays:
- Transvaginal ultrasound scan
Special tests:
- Endometrial biopsy
**biopsy always in persistent bleeding and >45 years old.
What are the treatment options for heavy menstrual bleeding?
Non-hormonal:
- Mefenamic acid
- Tranexamic acid - used 5 days during menstrating
Hormonal:
- Combined pill
- Progesterone
- levonorgestrel releasing intra-uterine device - 1st line
GnRH analogues
Surgical:
- endometrial ablation
- Hysterectomy
+/-
- Uterine artery ablation for fibroids
What examination should be done into heavy menstrual bleeding?
Abdominal examination
Bimanual examination
Speculum
What is the criteria for PCOS?
Rotterdam Criteria:
- clinical evidence of high androgens
- Oligomenorrhoea
- Ultrasound of Cysts
How should intermenstrual bleeding be investigated?
Cervical smear
Bimanual examination and Speculum
+ Abdominal examination
STD Screen + treatment
Urine pregnancy test
TVS incase of endometrial pathology
How should post menopausal bleeding be investigated?
Transvaginal ultrasound
- Biopsy if Endometrium >4mm
- Biopsy if endometrium >8mm and on HRT
- Biopsy if on tamoxifen
**remember that this measurement is a double thickness layer. i.e. both sides of the endometrium are measured.
What staging is used for endometrial cancer?
International Federation of Obs and Gyn
What is the definition of PID?
Infection of the upper female reproductive organs which includes:
- uterus
- Fallopian tubes (salpingitis)
- ovaries (salpingo- oophoritis)
What are some risk factors for PID?
History of STIs
Multiple sexual partners
Lack of protection
What are the complications of PID?
Tubo-ovarian Abscess
Hydro-salpinx
Fitz- Hugh Curtis Syndrome
Subfertility
Ectopic pregnancy
How is PID treated?
Ceftriaxone 500mg IM STAT
followed by:
- Doxycycline
- Metronidazole
What is it called when there is fluid build up in the fallopian tube?
Hydro-salpinx
What are the classical symptoms of endometriosis?
Cyclical pain
- dysmenorrhoea
- dyspareunia
- dysuria
- dyschezia
- subfertility
Bleeding at distant sites. i.e.
- haemothorax
What things may be noted on a bimanual examination of the uterus in a patient with endometriosis?
Fixed retroverted uterus
Uterosacral ligament nodules
General tenderness
What are the differentials for endometriosis?
PID
Ectopic Pregnancy
Fibroids
IBS
What is the definitive diagnosis for endometriosis and what findings may be seen?
Laparoscopy
- Chocolate cysts
- Adhesions
- Peritoneal deposits
What is the normal position of the uterus?
Anteverted
- where it sits leaning forward
What are the markers for ovarian cysts/ tumours and which one’s specifically for teratomas?
Ca125
CEA
Alpha fetal protein
hCG
What are the genes associated with ovarian cancer?
BRCA -1
BRCA -2
Lynch syndrome -II / HNPCC
What staging is used for ovarian cancer?
FIGO staging
1 - limited to ovaries
2 - limited to pelvis
3 - limited to abdomen, including lymph nodes
4 - distant mets
What investigations should be conducted into suspected ovarian cancer?
Bloods:
- FBC
- LFTs
- U&Es
Tumour markers:
- Ca125
- CEA
- AFP
- LDH
- hCG
X-rays:
- TVS / Pelvic ultrasound
- MRI
- CT C/A/P
What is the treatment for ovarian cancer?
Full staging laparotomy
What are the types of prolapses that can occur?
cystocele
- bladder prolapse
Uterine Prolapse
Urethrocele
Rectocele
- rectum prolapses in
Enterocele
- part of the large bowel prolapses in
Vaginal vault prolapse
- this usually occurs following hysterectomy
How are prolapses graded?
Pelvic Organ Prolapse Quantification
What are some of the complications that can occur with ring pessaries used for prolapses?
Interfere with sex
Ulceration
Fistula formation
Infection
Difficult to remove
Define Menopause:
Diagnosis made >12 months after last period
What is the peri-menopausal period of time called?
Climacteric
What are the symptoms of menopause?
Vasomotor symptoms
- flushing
- heat intolerance
Vulvo-vaginal dryness
Sleep disturbance
Mood changes
Sexual dysfunction
What are some contraindications to HRT?
Recent VTE
Chronic liver disease
Undiagnosed PV bleeding
What are some of the complications of HRT:
Breast cancer
VTE
Endometrial cancer
What is the follow up of endometrial cancer?
Follow up for 5 years.
- 3 monthly appts
- 6 monthly appts
discharged at 5 years.
appts include:
- history taking
- bimanual examination
- coloscopy
What are the different types of cyst formations on the ovaries?
Functional cysts
- Follicular
- Corpus luteal cysts
Benign Teratoma cysts / Dermoid
Epithelial cysts
- serous
- Mucinous
- Endometroid
Sex-cord stromal
- fibroid
What are the options for treating CIN?
LLETZ - loop diathermy
Cone Biopsy
- done under GA
Cold Coagulation - heating to 120 Celsius
What should be done when there is a high grade (CIN II, III) found on a smear?
Referral for Colposcopy and staining with acetic acid.
+/-
Punch Biopsy (based on clinician preference)
What is the ligament that contains the vessels to the ovary?
Suspensory ligament of the ovary (infundibulopelvic ligament)
- a mass here can torsion in it.
What are the different subtypes of ovarian tumours?
Epithelial
- serous
- Mucinous
- Endometroid
- Brenner
Germ Cell
- Dysgerminoma
- Teratoma
- Yolk sac
- Choriocarcinoma
Sex cord:
- granulosa
- Sertoli - Leydig cell
Metastasis
- Krukenberg Tumour
Which type of ovarian tumour has Psammoma bodies?
Serous cystadenocarcinomas
Which type of ovarian tumour produces excessive thyroid hormones?
Struma Ovarri
Which type of ovarian tumour is described as resembling primitive glomeruli?
Yolk Sac tumours
Which type of ovarian tumour has Call exner bodies?
Granulosa cell
Which tumour can cause right sided pleural effusion and ascites?
Meig’s tumour
- ovarian fibroma (sex-chord stroma)
What are the clinical signs of vulva cancer? and what are the two major types of vulva cancer?
- Itch/ irritation
- ulceration
Types:
- VIN related
- Lichen sclerosis related
What is the treatment of vulva cancer?
WLE
or
Vulvectomy
> 1mm lesion then groin lymphectomy should be conducted.
What types of treatment should be done for a Bartholin cyst?
Marsupialisation **not a simple incision
or
Balloon catheter Insertion
What are the top causes of pelvic pain?
PID Endometriosis Pelvic adhesions Pelvic congestion Bowel pathology
What are the top causes for dysmenorrhoea?
Endometriosis Adenomyosis Intrauterine causes (polyps/ fibroids) Infections Copper IUD
What are the top causes of dyspareunia?
Superficial:
- vulvovaginitis
- Narrow of the introitus to vagina (FGM)
- Vagina atrophy
- Lichen sclerosis
Deep:
- Endometriosis
- Cervical cancer
- Retroverted uterus etc
What are the key investigations into Menorrhagia?
FBC
TFTs
TVS
Hysteroscopy
Biopsy
What is the management for adenomyosis?
GnRH
or
Hysterectomy
Where is the most likely location of an ectopic pregnancy?
Ampulla
What is a key risk factor for developing ovarian cancer?
Early menarche
What are the absolute contraindications to HRT?
Recent or reoccurring VTE Liver disease Undiagnosed vaginal bleeding Past or present breast cancer Endometrial cancer
Which type of HRT does not increase the risk of VTE? and what are the other options for HRT?
Transdermal
Oral tablet Gel Transdermal patch Subcut injection Vaginally - gels, pessary
Which other cancer is associated with endometrial cancer?
HNPCC
What investigations can be done into secondary amenorrhea?
- Pregnancy test
- Assess for underlying illness causing stress on body
Bloods
- TFTS
- FSH levels (high in premature ovarian failure)
Special tests:
- Prolactin test
- *prolactin is progesterone which is given for 10 days. if the ovaries have been responding to FSH normally they will have produced oestrogen which will (if the endometrium is working properly) will proliferate.
- given progesterone will inhibit the growth and maintain the endometrium.
- on removal of the progesterone there will be shedding
- *this demonstrate the ovaries are responding to oestrogen and the endometrium is able to proliferate.
- highly suggestive of PCOS (anovulation)
