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Year 5 - specialties > ICSM Year 5 Gynaecology > Flashcards

ICSM Year 5 Gynaecology Flashcards

1
Q

What is Asherman’s syndrome?

A

Presence of intrauterine adhesions that may partially/ completely occlude the uterine cavity

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2
Q

Recall 3 risk factors for Asherman’s syndrome

A

Endometrial resection
Dilation and curettage (for miscarriage)
Endometriosis

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3
Q

Recall 3 symptoms of Asherman’s syndrome

A

Amenorrhoea, subfertility, cyclical abdo pain

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4
Q

Recall what investigations should be done in suspected Asherman’s

A

Saline hysterosonography (HSG), TVUSS

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5
Q

What would be seen on TVUSS in Asherman’s syndrome?

A

Sub-endothelial linear striations + ‘boggy’ uterus

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6
Q

How is Asherman’s syndrome managed?

A

Initially: Hysteroscopic adhesionolysis + post-op copper IUD
Next: PO oestrogens and reasses cavity

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7
Q

Recall some complications of Asherman’s

A

Infertility, miscarriage, oligomenorrhoea

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8
Q

What is atrophic vaginitis?

A

Vaginal irritation caused by thinning of the vaginal epithelium

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9
Q

What is the cause of atrophic vaginitis?

A

Reduction in circulating oestrogen ie. Post-menopause

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10
Q

Give 3 signs of atrophic vaginitis

A

Irritation, dyspareunia, discharge (may be bloody)

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11
Q

How does atrophic vaginitis appear O/E?

A

Pale, thin vaginal walls with loss of rugal folds, cracks or fissures

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12
Q

What investigations would you order in suspected atrophic vaginitis?

A
  1. Clinical examination
  2. Swabs for potential infection
  3. Biopsy for potential malignancy/ ulcers
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13
Q

How is atrophic vaginitis managed?

A
  1. Systemic HRT

2. If bleeding on intercourse –> water based moisturisers and lubricants

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14
Q

What 8 things should be checked for when doing a history for gynaecological infections?

A 
Discharge (smell, consistency, colour, volume), Blood
Pain
Urinary symptoms
Itch
FLAWS
Pregnancy status
Sexual history
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15
Q

What investigations should be done in a suspected gynaecological infection?

A

pH, swabs (double or triple) and blood tests (for HIV/ syphilis)

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16
Q

What is the normal pH for the lateral wall of the vagina?

A

3.5-4.5 (due to lactobacilii in vagina)

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17
Q

What is a low vaginal pH indicative of?

A

Candida

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18
Q

What is a raised vaginal pH indicative of?

A

Contamination, BV or TV

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19
Q

Describe the method of ‘double swab’?

A
  1. Endocervical swab - tests for gonorrhoea and chlamydia

2. High vaginal swab, “charcoal swab” - fungal and bacterial (BV, TV, candida, GBS)

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20
Q

Describe the method of ‘triple swab’?

A
  1. Endocervical (for chlamydia)
  2. Endocervical charcoal swab (for gonorrhoea)
  3. High vaginal charcoal swab (for fungal/ bacterial infection)
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21
Q

What type of testing is done on the endocervical swab?

A

NAAT (nucleic acid amplification testing) for chlamydia/ gonorrhoea

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22
Q

What type of testing is done on the high vaginal swab?

A

MCandS

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23
Q

How does gonorrhoea appear under the microscope?

A

Gram neg diplococci

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24
Q

What is the most common cause of abnormal discharge?

A

BV

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25
Q

How does discharge appear in BV?

A

Thin and watery, grey/ white - FISHY SMELLING ODOUR

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26
Q

What are the symptoms of BV?

A

Just the discharge

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27
Q

What is the cause of BV?

A

Overgrowth of anaerobic bacteria

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28
Q

What is the most commonly implicated microbe in BV?

A

Gardinella vaginalis

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29
Q

What is required for BV diagnosis?

A

Clinical diagnosis + microscopy, can show high pH

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30
Q

What would be shown on microscopy in BV?

A

Clue cells - vaginal epithelium cells coated with lots of bacilli

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31
Q

What are the criteria for BV diagnosis confirmation?

A

Amsel’s criteria: need 3 out of 4 out of:

  1. Thin, white, homogeneous discharge
  2. Clue cells on microscopy
  3. Vaginal pH > 4.5
  4. Fishy odour on adding 10% KOH
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32
Q

How is BV managed?

A
  1. If asymptomatic, no treatment
  2. Metronidazole, PO, 400mg, BD, 7 days
    Second line: Intravaginal clindamycin PV cream, 5g 2% 7 days
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33
Q

Recall some complications of BV

A

Late miscarriage, preterm birth, PROM and postpartum endometritis

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34
Q

Recall the symptoms of trichomonas vaginalis

A

Asymptomatic in 50%
Discharge: green/ yellow, “frothy”, offensive odour
Dyspareunia
Vulval itch/ soreness

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35
Q

What is seen OE in trichomonas vaginalis?

A

Strawberry cervix

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36
Q

Recall some key investigations and results in trichomonas vaginalis?

A

High vaginal swab + direct microscopy shows flagellated organism
pH > 4.5 - it is only high in BV and TV

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37
Q

What is the treatment of trichomonas vaginalis?

A

First line: Metronidazole 400mg BD PO, 7 days

Second line: Metronidazole, 2g, PO stat

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38
Q

What are the causative organisms that can cause thrush?

A 
Candida albicans (in 90%)
Candida glabrata (in 5%)
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39
Q

What are the causes of candidiasis?

A

Can be spontaneous

Can be secondary to a disruption of normal vaginal flora

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40
Q

Recall some risk factors for vaginal candidiasis

A

Oestrogen exposure (eg pregnancy, intercourse, poorly-controlled diabetes, HIV, recent Abx (eg for a UTI))

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41
Q

What is the most tell-tale examination finding in vaginal candidiasis?

A

‘Cottage-cheese’ type discharge

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42
Q

What is the expected pH in thrush?

A

Low/ normal

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43
Q

What investigations would you do in suspected thrush?

A

Wouldn’t usually do any, but diagnostic is HVS MCandS showing speckled gram pos spores and pseudohyphae

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44
Q

What are pseudohyphae indicative of?

A

C. albicans infection specifically

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45
Q

How should thrush be managed?

A

1st line: clotrimazole pessary + 1% clotrimazole cream (BD)
2nd line/ severe: fluconazole PO STAT
If pregnant, use topical treatment only

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46
Q

What is the latin name for cutaneous warts?

A

Condylomata acuminate

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47
Q

What is the causative organism in cutaneous warts?

A

HPV 6 and 11

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48
Q

What is the name of the HPV vaccine?

A

Gardasil

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49
Q

Which seroforms of HPV cause cervical cancer vs cutaneous warts?

A

6 + 11 = cutaneous warts; 16 + 18 = cervical cancer

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50
Q

Recall the symptoms of cutaneous warts?

A

Generally painless warts but may itch/ bleed/ become inflamed

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51
Q

How do you investigate for cutaneous warts?

A

Usually a clinical diagnosis, but should also do an STI screen (triple swab: HIV, syphillis, HBV)

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52
Q

What sort of organism is chlamydia trachomatis?

A

Gram neg parasite - cannot be seen under microscope

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53
Q

What are the symptoms of chlamydia?

A

Asymptomatic in 75% of women - when sympatomatic –> purulent PV discharge, dyspareunia, IMB, PCB, abdo pain + dysuria

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54
Q

What investigations should be done in suspected chlamydia?

A

Unlike gonorrhoea, if there are signs and symptoms of chlamydia you can treat on suspicion alone
If not sure:
1. NAAT - vulvovaginal swab or first catch urine
2. Culture and sensitivities
Direct microscopy will show neutrophils but no organisms

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55
Q

How should chlamydia be managed?

A

1st line: doxycyline - but contraindicated in pregnancy and breastfeeding
2nd line/ pregnant/ breast-feeding: azithromycin (STAT)

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56
Q

Recall the signs and symptoms of gonorrhoea

A

Asymptomatic in 50%

If symptomatic, symptoms similar to chlamydia: PV discharge, IMB, PCB, dysuria, dyspareunia, lower abdo pain

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57
Q

Recall the findings on speculum examination in gonorrhoea

A

Mucopurulent endocervical discharge

Easily induced endocervical bleeding

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58
Q

Recall the findings on bimanual examination in gonorrhoea

A

Cervical motion/ adnexal tenderness

Uterine tenderness

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59
Q

When can empirical treatment be given in suspected gonorrhoea?

A

ONLY if recent sexual contact with confirmed gonorrhoeal infection

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60
Q

What would be seen on direct microscopy in gonorrhoea?

A

Neutrophils and gram neg diplococci

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61
Q

What other investigations can confirm gonorrhoea infection?

A

NAAT / culture and sensitivities

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62
Q

How should gonorrhoea be managed?

A

AFTER confirmation by NAAT/ MCandS/ direct microscopy (any will do)
Ceftriaxone 1g IM (NEW for 2019)
Then:
Screening for other STIs, abstain for 1 week, contact tracing - cure rate = 95% with treatment

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63
Q

Recall some of the complications of gonorrhoea

A

PID, or a version of PID with liver-abdo wall adhesions called Fitz-Hugh-Curtis syndrome
Disseminated disease in 1%

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64
Q

What is the causative organism in syhillis?

A

Treponema pallidum (gram neg spirochete)

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65
Q

What are the symptoms of primary syphillis?

A

Painless chancre and local lymphadenopathy

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66
Q

How long does primary syphillis last?

A

3-4 weeks

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67
Q

What are the symptoms of secondary syphillis?

A

ONLY 25% GET SYMPTOMS

Rough papulonodular rash, “snail track oral ulcer”, condylomata lata (really gross)

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68
Q

How long does secondary syphillis last, and after how long will it resolve?

A

It appears 4-10 weeks after the chancre, and resolves in 2 - 12 weeks before the infection becomes latent

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69
Q

How is latent syphilis categorised?

A

Early and late - which guides management

Early = exposure/ symtoms <2 years after infection, latent = >2 years

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70
Q

How long does tertiary syphillis last?

A

1-20 years

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71
Q

What % of untreated syphillis progresses to tertiary?

A

30%

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72
Q

Recall the subtypes of tertiary syphillis

A
  1. Gummatous: erosive skin and bone lesions
  2. Cardiovascular: early diastolic decrescendo from aortic regurgitation
  3. Neurosyphillis - might be meningovascular, general paresis or tabes dorsalis (lightening pains)
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73
Q

How can suspected syphillis be investigated for?

A
  1. Microbiology = if chancre/ chondylomata are present, the most sensitive one is the ‘dark ground’ method, if not, PCR
  2. Serology
    - Routine screening in pregnant women to detect treponemal antibodies
    - Can use a ‘treponomal test’ - eg. EIA, TPHA
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74
Q

Recall how syphillis is managed in adults

A

In primary/ secondary/ early latent:
Benzathine-Pen IM STAT OR doxycycline BD 14/7
If late latent/ non-neuro tertiary;
Benzathine-Pen IM OW 3/52, or doxycycline BD 28/7
If neurosyphillis, penicillin IV, 4-hourly, 14/7 or doxycycline BD 28/7

Prednisolone

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75
Q

What is the Jarish-Herxheimer reaction?

A

Release of proinflammatory cytokines in response to dying organisms
Signs and symptoms = 24 hours of febrile myalgia
May follow syphillis treatment

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76
Q

How does congenital syphillis appear?

A

Rash on soles of feet and hands +/- bone lesions

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77
Q

What is the cause of PID?

A

Ascending infection from the genital tract

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78
Q

What is the most common organism implicated in PID?

A

Chlamydia trachomatis

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79
Q

What are the symptoms of PID?

A

Often asymptomatic - but causes infertility and chronic pelvic pain
Acutely: BL lower abdo pain, PV discharge, fever, irregular PCB, dyspareunia

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80
Q

How should PID be investigated for?

A

Must start Abx before swabs

  • Triple swabs
  • Speculum (to look for signs of inflammation + discharge)
  • Bimanual (cervical excitation, adnexal masses (eg tuboovarian abscess)
  • If febrile do blood cultures
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81
Q

How should PID be managed?

A

First assess patient for admission - admit if pyrexial or septic
Otherwise
- Outpatient Abx, all 3 of ceftriaxone, doxycycline + metronidazole
- If inpatient, do IV cefoxitin + doxycycline
Remove any IUD, + other obvious stuff like STI screen, contact

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82
Q

What is the mechanism by which PID can cause ectopic pregnancy?

A

Paralysed cilia in fallopian tubes

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83
Q

What is Bartholin’s cyst?

A

A cyst/ abscess of bartholin’s gland (greater vestibular gland)
Likely to have overlying streptococcal/ GBS infection
= blockage of a duct to a gland in vagina which has become infected

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84
Q

What is the difference between Bartholin’s cyst and labial cysts?

A

Bartholin’s cysts may extend into the vaginal canal, but labial cysts will remain in labia

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85
Q

Recall the appropriate investigations in suspected Bartholin’s cyst

A

If person is >40, consider a vulval biopsy

If infected, MCandS from abscess - most are sterile but may help organism differentiation

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86
Q

How should Bartholin’s cysts be managed?

A

Conservatively if draining and the patient is well
If not, Incision and drainage + ‘word’ catheter + flucloxacillin OD
If not - marsupialisation (forming an open pouch to stop the cyst from reforming)

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87
Q

What is CIN?

A

Premalignant atypia in squamous lining of cervix (FIGO stage 0)

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88
Q

What serotypes of HPV are usually implicated in cervical cancer?

A

HPV 16 and 18

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89
Q

What is the peak age range of onset of CIN?

A

25-29 y/o

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90
Q

What are the dysplastic epithelial changes that occur in CIN?

A

Increased nuclear to cytoplasmic ratio

Abnormal nuclear shape: poikilocytosis

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91
Q

Recall the grading system for CIN

A

Grade 1 = mild dysplasia confined to lower 1/3 of epithelium
Grade 2 = Moderate dysplasia affecting 2/3 of epithelial thickness
Grade 3 = Severe dysplasia extending to the upper 1/3 of epithelium

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92
Q

What are the symptoms of CIN?

A

Same as cervical cancer symptoms: PV bleeding. IMB, PCB, PMB

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93
Q

If a smear test revealed CIN grade I, what should be done next?

A

An HPV test: If it’s positive, do a colposcopy, if it’s negative, do a routine recall

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94
Q

What does dyskaryosis mean?

A

Abnormal nucleus appearance

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95
Q

If a smear test revealed moderate to severe dyskaryosis (CIN grades II and III),
what should be done next?

A

Urgent colposcopy (within 2 weeks) followed by treatment if necessary

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96
Q

If a smear test revealed suspected invasive cancer, what should be done next?

A

Urgent colposcopy (<2 weeks)

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97
Q

How should CIN grade 1 be managed?

A

Smear in 12 months (conservative)

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98
Q

How can CIN be treated?

A

1st line: Large loop excision of the transformational zone (LLETZ - loop diathermy) - involves a wire loop with current running through that removes cells - however it is heavy on the side effects
Biggest risk = increases risk of miscarriage

2nd line - core biopsy - only performed if a large area needs to be removed, done under GA

Always do a follow-up test of cure 6 months later - smear and HPV test

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99
Q

What are the subtypes of cervical cancer and their relative prevalences?

A

Squamous (80%)

Adenocarcinoma (20%)

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100
Q

What is the staging sysytem used in cervical cancer?

A

FIGO

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101
Q

Recall the signs and symptoms of cervical cancer

A

PV discharge
PCB, IMB, PMB
Dyspareunia (deep)
Symptoms of late metastasis (ie SOB, DIC) + FLAWS

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102
Q

To which lymph nodes does cervical cancer metastasise?

A

Iliac (NOT para-aortic)

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103
Q

Other than the screening pathway, how can cervical cancer be investigated?

A

MRI is better than CT-CAP (whereas CT-CAP is better for ovarian cancer)
Bloods to show anaemia, UandEs showing obstructive picture, LFTs may show metastasis, clotting and group and save

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104
Q

Recall all the stages of cervical cancer and their management!

A

Stage Ia1 (microinvasive) - mx = LLETZ/ cone biopsy

Stage Ia2 to IIa - mx =

  • Fertility sparing: radical trachelectomy (removal of cervix) + BL pelvic node dissection
  • If tumour is <4cm: radical hysterectomy + BL pelvic node dissection (Wertheim’s)
  • If tumour is >4cm: chemoradiation

Stage IIb to IVa (locally advanced disease) - mx = chemoradiation

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105
Q

What types of radiotherapy can be useful in cervical cancer?

A
  1. External beam radiotherapy

2. Internal radiotherapy

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106
Q

What are the main complications of Wertheim’s hysterectomy to be aware of?

A

Bladder dysfunction (common, may require self-catheterisation), sexual dysfunction (due to vaginal shortening), lymphoedema - manage with leg elevation, good skin care + massage

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107
Q

Recall some side effects of radiotherapy for gynaecological cancer

A

Fatigue, skin erythema, infertility, dysuria, urgency, dyspareunia (due to vaginal stenosis), diarrhoea, incontinence

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108
Q

What is DUB (dusfunctional uterine bleeding)?

A

Abnormal uterine bleeding in the absence of organic pathology

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109
Q

What are the subtypes of DUB?

A

Anovulatory (90%) and ovulatory (10%)

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110
Q

What is the broad pathophysiology in anovulatory vs ovulatory DUB

A

Anovulatory: failure of follicular development –> no increase in progesterone –> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation –> heavy bleeds

Ovulatory: prolonged progesterone secretion –> irregular shedding

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111
Q

How is menorrhagia defined?

A

Whatever the woman defines as menorrhagia individually!

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112
Q

Recall some possible differentials that may cause DUB

A

Polyps, adenomyosis, leiomyoma, malignancy, iatrogenic, coagulopathy, endometriosis, PCOS, hypothyroid

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113
Q

What investigations should be done in DUB?

A

Speculum and bimanual first: bimanual will be bulky, may reveal fibroids
Next: bloods –> FBC (anaemia?), TFTs (hypothyroid?), clotting screen (VWD?)
2nd line (if cause not found): TVUSS (PCOS, fibroids, Ca?)
If still can’t find diagnosis: OPD hysterectomy, laparoscopy +/- biopsy (endometriosis?)

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114
Q

In what cases is DUB treated as a symptom, rather than just treating the cause?

A

No identified pathology/ fibroids are present <3cm, or patholgy is adenomysosis

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115
Q

How should DUB be managed?

A

1st line, if contraception is required: LNG IUS
2nd line, if fertility is required - tranexamic acid to treat bleed, mefenamic acid for pain
2nd line, if contraception is required but LNG IUS didn’t work: COCP/ cyclical oral progestogens
If it needs to be surgical: endometrial ablation/ hysterectomy

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116
Q

On what tissues is tamoxifen oestrogenic, and on which tissues is it anti-oestrogenic?

A

Oestrogenic on uterus and bone, anti-oestrogenic on breast

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117
Q

What are the risk factors for endometrial hyperplasia?

A

Oestrogen: so early menarche, late menopause, nulliparity, tamoxifen, HRT, COCP
PLUS
Increasing age, high insulin levels, obesity, smoking, FHx for ovarian Ca

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118
Q

What are the symptoms of endometrial hyperplasia?

A

PV bleeding, usually PMB

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119
Q

How should potential endometrial hyperplasia be investigated?

A 
1st line = TVUSS - if more than 4mm, --> hysteroscopy + biopsy
2nd line (and gold standard) = hysteroscopy + pipelle biopsy
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120
Q

How does presence/ absence of atypia in endometrial hyperplasia guide management?

A

If there is no atypia, <5% will become malignant in 20 years so it’s pretty chill, if there is atypia, that’s more suboptimal

Without atypia: 1st line = progestogens (either LNG-IUS (mirena) or oral non-cyclical), 2nd line = possible hysterectomy - review in 3-6 months

If there is atypia: 1st line is a hysterectomy, but if fertility needs to be spared then use progestogens - endometrial surveillance with biopsy every 3 months

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121
Q

Which symptom signals endometrial cancer until proven otherwise?

A

PMB

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122
Q

What are the subtypes of endometrial cancer?

A 
Type 1 (85%) - secretory, endometrioid, mucinous (SEM) carcinoma 
Type 2 (15%) - uterine papillary Serous carcinoma, Clear cell carcinoma (SC)
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123
Q

What are the main differences between the different types of endometrial cancer?

A

Type 1 = younger patients, oestrogen-dependent, superficially invade, lower grade
Type 2 = older patients, less oestrogen-dependent, deeper invasion, higher grade

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124
Q

Describe the genetic components of each type of endometrial Ca

A

Type 1 - need to acquire >= 4 mutations, most importantly PTEN and PI3KCA

Type 2 - P53 is very associated with SCC, Her-2 amplification is associated with both

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125
Q

To which lymph nodes does endometrial cancer metastasise?

A

Para-aortic LNs

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126
Q

Recall the general FIGO staging of Endometrial Ca

A

I - limited to uterus
II - spread to cervix
III - spread to adjacent
IV - distant spread

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127
Q

Which investigations are appropriate in endometrial Ca?

A

Similar to EH
1st line = TVUSS - >4mm –> hysteroscopy + biopsy
2nd line - hysteroscopy

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128
Q

What is the most useful investigation for deciding FIGO stage of ovarian cancer?

A

CT CAP (better than MRI in this case)

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129
Q

Recall the management of endometrial Ca depending on stage

A

Stage 1 - total abdominal hysterectomy, BL salpingoophrectomy + peritoneal washings
Stage 2+ - radical hysterectomy + radiotherapy adjunct

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130
Q

What are the symptoms of endometriosis?

A

Cyclical/ chronic pelvic pain before/ during menstruation, dyspareunia, dyschezia, dysmenorrhoea

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131
Q

What is the simplest way to differentiate endometriosis and fibroids clinically?

A

There is no menorrhagia in endometriosis

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132
Q

Which investigations are appropriate in suspected endometriosis?

A 
Bimanual and speculum 
TVUSS
HSG (hysterosalpingography)
HyCoSy (Hysterosalpingo Contrast Sonography) 
DIAGNOSTIC LAPAROSCOPY = GOLD STANDARD
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133
Q

What are the typical bimanual and speculum findings in endometriosis?

A

Reduced motility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions, fixed retroverted uterus

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134
Q

What would a diagnostic laparoscopy show in endometriosis?

A

Red vesicles or punctate marks on peritoneum

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135
Q

Recall the management protocol for endometriosis

A

1st line is a 3m trial of paracetamol + NSAIDs - avoid opiates to prevent constipation
OR 3m trial of COCP or progesterone (which induces amenorrhoea)

2nd line = surgical - laparoscopic ablation/ hysterectomy with BSO

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136
Q

What are the 4 main types of FGM?

A

Type 1: clitoridectomy
Type 2: Excision = removal of clitoris + labia minora +/- labia majora
Type 3: Infibulation - narrowing vaginal opening by creating a seal by cutting and repositioning the labia
Type 4: Any other mutilation

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137
Q

Recall some symptoms caused by FGM?

A

Constant pain, incontinence, dyspareunia, depression, bleeding, abscesses

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138
Q

Recall some options for management for FGM

A

Deinfibulation: offered to those unable to have sex/ pass urine
If <18, record in notes, report to police and social services
If >18, record in notes but no obligation to report - may offer deinfibulation

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139
Q

What are fibroids?

A

Benign tumours arising from the myometrium

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140
Q

What are the subtypes of fibroids?

A

Submucosal (within cavity), intramural, suberosal (can undergo secondary changes)

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141
Q

Recall the changes that fibroids go through

A
  1. Hyaline degeneration
  2. Calcification (post menopausal)
  3. Red degeneration (coagulative necrosis in pregnancy)
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142
Q

What is the aetiology of fibroids?

A

They are hormone dependent - they enlarge in pregnancy (due to oestrogen) but shrink in menopause

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143
Q

What are the signs and symptoms of fibroids?

A

May be asymptomatic and found OE (uterine enlargement, palpable pelvic masses)
Symptoms of DUB, miscarriage, sub-fertility
Signs –> abdominal swelling, pressure symptoms on bowel or bladder

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144
Q

Which investigations are appropriate in fibroids?

A

1st line is TVUSS

Otherwise, DUB investigations

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145
Q

What are some recognised risk and protective factors for fibroids?

A 
RISK = BONE: 
B - black women
O - obesity
N - nulliparity
E - expecting (pregnancy)
Protecting = SMC: 
S = smoking
M = multiparity
C = COCP
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146
Q

How should fibroids >3cm be managed?

A

1st line: (non-contraceptive)

  • Tranexamic acid
  • Mefenamic acid/ NSAIDs

1st line (contraceptive)

  • Mirena (NICE/PassMed)
  • COCP (WestMid tuition/Ludley’s notes)
  • Cyclical oral progestogens

Surgical/ radiological:

  • Prior to surgery: injectable GnRH agonist - induced menopausal state
  • Another short-term option = ulipristal acetate - as effective as GnRH agonists but does not induce a menopausal state

Surgical: hysteroscopic (if small submucosal or polypoid fibroid), myomectomy (best for improving fertility) or hysterectomy

Radiological: Uterine artery embolisation - it infarcts the fibroids, and may preserve fertility (but may also cause ovarian failure)

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147
Q

What are the symptoms of red degeneration of fibroids?

A

Low fever, pain and vomiting

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148
Q

What syndrome is associated with leiomyosarcoma?

A

Gardner’s syndrome (subtype of FAP with exta-colonic polyps)

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149
Q

What are the types of gynaecological polyp?

A

Cervical, endometrial, ectropion

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150
Q

What is the appearance of normal cervical epithelium?

A

Endocervix is columnar, ectocervix is squamous

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151
Q

How should gynaecological polyps be investigated?

A

Speculum for cervical polyps, TVUSS/ outpatient hysteroscopy for endometrial polyps

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152
Q

What is cervical ectropion?

A

Ectocervical migration of columnar epithelium (so columnar epithelium on the side of the cervix seen with the speculum)

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153
Q

What are the signs and symptoms of cervical ectropion?

A

IMB, PCB, increased discharge

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154
Q

What is the main risk factor associated with cervical ectropion?

A

Oestrogen - so pregnancy and COCP

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155
Q

How should cervical ectropion be managed?

A

Reassurance, cryotherapy + move from oestrogen-based contraceptives

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156
Q

What is a cervical polyp?

A

Overgrowth of endocervical columnar epithelium - benign and solitary

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157
Q

What are the signs and symptoms of cervical polyps?

A

Asymptomatic or small bleeding and discharge

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158
Q

How should cervical polyps be managed?

A

Reassurance, generally advised to be removed (if small can just be twisted off!)

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159
Q

How should endometrial polyps be managed?

A

May resolve spontaneously if small

If AUB symptoms, can have polypectomy

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160
Q

What are the subtypes of HPV, and which are high and low risk?

A

Low risk = 6 and 11 (benign genital warts)

High risk = 16 and 18 (CIN, VIN, VAIN)

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161
Q

What is the prevalence of HPV?

A

50% of sexually active adults

162
Q

What are the signs and symptoms of HPV?

A

May be asymptomatic

May present with genital warts

163
Q

What are the types of genital wart?

A

Small popular, cauliflower, keratotic, flat papules/ plaques

164
Q

How is HPV diagnosed?

A

Clinical diagnosis using dermatoscope
Histology = biopsy
Cytology = smear

165
Q

How should HPV warts be managed?

A

Medical mx = imiquimod cream or trichloroacetic acid
Surgical - cryotherapy/ laser
Prevention via vaccine

166
Q

What is lichen sclerosus?

A

Chronic inflammation of skin: usually genital skin and/or perineum

167
Q

Which age group is most likely to be affected by lichen sclerosus?

A

The very young and the elderly (0.1% of children, 3% of women >80)

168
Q

What are the signs and symptoms of lichen sclerosus?

A

Hypopigmentation
Pruritis
White/ shiny vulva (‘figure of 8’)
Dyspareunia

169
Q

How should lichen sclerosus be treated?

A 
1st line (3 months) = clobetasol propionate (strong steroid ointment) 
2nd line = tacrolimus (topical calcineurin inhibitor) + biopsy (if steroid-resistant)
170
Q

What is the most commonly-implicated pathogen in breast abscess?

A

S. aureus

171
Q

Who is mastitis most likely to affect?

A

Breastfeeding women due to backup of milk ducts

172
Q

Recall 2 RFs for mastitis?

A

Nipple injury

Smoking

173
Q

How should mastitis be investigated?

A

It’s a clinical diagnosis

174
Q

How should mastitis/ breast abscess be managed?

A

If non-severe/ lactational: simple analgesia and supportive care (warm compresses) - continue breastfeeding
If non-lactational/ severe = infected nipple fissure
1st line = flucloxacillin
2nd line = co-amox (if failed to settle 48 hours later)

175
Q

How is menopause defined?

A

Absence of menses for >12 months (retrospective diagnosis)

176
Q

Recall the signs and symptoms of menopause

A

Amenorrhoea
Vasomotor (hot flushes, night sweats, palpitations)
Urogenital (vaginal dryness, dyspareunia, recurrent UTI)
Psychological (poor concentration, lethargy, mood diturbance)

177
Q

What should the FSH/LH/ serum oestradiol be in menopause?

A

FSH/LH = high (as unopposed), oestradiol LOW

178
Q

How should menopause be managed?

A

If they have a uterus - systemic oestrogen combined with progesterone to protect against endometrial carcinoma
If they don’t have a uterus –> systemic oestrogen (note contraindications eg DVT)

179
Q

How can HRT be given if there is a history of DVT/ stroke?

A

Topically/ transdermally

180
Q

When should HRT be offered in menopause?

A

When lifestyle adaptations (eg exercise and alcohol reduction) have been insufficient

181
Q

When is cyclical/ sequential HRT indicated?

A

In perimenopausal women

182
Q

How should cyclical/ sequential HRT be administered?

A

If they are having regular periods: monthly - oesterogen every day + progesterone for last 14 days
If they are having irregular periods: oestrogen every day for 3 months + progesterone for last 14 days

183
Q

When should continuous HRT be used?

A

If post menopausal

184
Q

How should continuous HRT be administered?

A

Oestrogen and progesterone every day

185
Q

What are some absolute contraindications for HRT?

A 
Undiagnosed vaginal bleeding
Breast cancer
History of VTE
Pregnancy
Severe liver disease
Current thrombophilia (eg FV Leiden)
186
Q

What are some non-hormonal alternatives to HRT?

A

For vasomotor symptoms:
1st line = SSRIs (eg fluoxetine), 2nd line = citalopram/ venlaxafine
For vaginal dryness: lubricants
Osteoporosis treatments eg bisphosphonates

187
Q

Recall the subtypes of ovarian cyst

A

Follicular/ corpus luteal (physiological/functional)
Dermoid cyst/ mature cystic teratoma (benign germ cell)
Serous cystadenoma/ mucinous cystadenoma (benign epithelial)

188
Q

What is follicular cyst?

A

Failed rupture of dominant Graafian follicle, lined by granulosa cells

189
Q

Describe the composition/ appearance of dermoid cells

A

Lined by epithelial cells

May have Rokitansky protuberances = white shiny mass protruding out

190
Q

What is the consequence of rupture of a mucinous cystadenoma?

A

Pseudomyxoma peritonei (mucin in abdomen)

191
Q

What are the signs and symptoms of ovarian cysts?

A

Lower abdo pain
Swelling with pressure symptoms
Deep dyspareunia
Acute abdomen

192
Q

Which investigations are appropriate for suspected ovarian cyst?

A

Pregnancy test

TVUSS (outcome is dependent on menopausal status)

193
Q

How should ovarian cysts be managed premenopausally?

A

It’s based on size:
If <5cm: no follow-up
If 5-7cm: repeat USS yearly
If >7cm: MRI +/- surgery

If recurrent/ unresolved: COCP
Surgery (lararoscopic cystectomy) usually curative is suspicious/ multiloculated/ recurrent)

194
Q

What are the indications for watchful waiting in ovarian cysts?

A

Unilateral
Pre-MP
Normal Ca-125
No free fluid

195
Q

How should ovarian cysts be managed postmenopausally?

A

Managed always based on calculated RMI

RMI < 200: either repeat USS and Ca125 in 4-6 months - in which case it will either have resolved/ been unchanged (in which case repeat) or changed (in which case do a lap cystectomy)
If symptomatic/ complex/ >5cm –> BSO (BL salpingo-oophrectomy)

RMI >200: CT-AP + MDT management

196
Q

Which type of ovarian cyst is most likely to rupture?

A

Functional ones

197
Q

How shold ruptured ovarian cyst be managed?

A

Pain relief + watchful waiting - if evidence of actve bleeding –> laparoscopy + cautery

198
Q

Which type of ovarian cyst is most likely to cause a torsion?

A

Dermoid

199
Q

What are some protective factors against ovarian tumours?

A

Pregnancy, COCP

200
Q

What are some risk factors for ovarian tumour?

A

More ovulations eg nulliparity, early menarche, late menoapuse
Increasing age (obviously)
Endometriosis
Talcum powder?!

201
Q

Recall some genetic associations of ovarian Ca

A 
Lynch syndrome (Autosomal dominant HNPCC), BRCA1/2
Type 1 epithelial ovarian tumours: PTEN/P13KCA
Type 2 epithelial tumours: p53 mutation present in 95%
202
Q

What is the most common type of ovarian cancer?

A

Tumour of epithelial origin - most of which are benign

203
Q

Recall the type 1 ovarian epithelial tumour types

A 
These are low-grade 
Mnemonic = Less Exciting, More Cancers
L: low-grade serous
E: endometrioid
M: mucinous
C: clear cell tumour (only one that's not solid or cystic)
204
Q

Recall the subtypes of type 2 ovarian epithelial tumours

A

High grade serous (solid or cystic)

205
Q

If an ovarian tumour is malignant, what type is it most likely to be?

A

Epithelial

206
Q

Which type of germ cell ovarian tumour is most likely to be benign?

A

Teratoma

207
Q

Which types of germ cell ovarian tumour are most likely to be malignant?

A

Dysgerminoma
Endodermal sinus tumour
Choriocarcinoma

208
Q

What are the different types of sex-cord stromal tumour, and which of these are most likely to be benign?

A

Fibroma and thecoma (likely to be benign)

Granulosa cell/ sertoli-Leydig cell tumour

209
Q

Which type of ovarian tumour is associated with endometriosis?

A

Clear cell

210
Q

How does the maturity of teratoma affect prognosis?

A 
Mature = benign
Immature = malignant
211
Q

What is Meig’s syndrome?

A

Triad of benign ovarian fibroma, ascites and right-sided pleural effusion

212
Q

What is the krukenberg tumour?

A

BL metastasis from breast/ gastric cancer - mucin producing signet ring cell

213
Q

How are the symptoms and signs of ovarian and endometrial cancer different?

A

Ovarian: adnexal mass and no PV bleeding
Endometrial: uterine mass and PMB

214
Q

Recall the FIGO staging for ovarian tumours

A

Stage 1 = confined to ovary
Stage 2 = tumour within pelvis but outside ovary
Stage 3 = Outside pelvis but within abdomen
Stage 4 = distant metastasis

215
Q

Describe the appropriate investigations for Ovarian tumour

A

1st line = Ca125 tumour marker: >35IU/mL –> 2ww referral to O and G and TVUSS
TVUSS –> size, consistency, solid elements? UL/BL? Ascites?
Risk of malignant index (RMI) calculated from menopausal status, USS features and Ca125
Score >250 is considered hig
Do not biopsy - this can cause dissemination of maligant tissue

216
Q

With what scan is ovarian Ca staged?

A

CT CAP

217
Q

How should Ovarian Ca be managed?

A

1st line is surgery and chemo, 2nd line is just chemo
Chemo = platinum compound (usually carboplatin) with paclitaxel
Follow up with CT scan and Ca125 to assess response to treatment

218
Q

How does platinum treat ca?

A

Cross linkage of DNA –> cell cycle arrest

219
Q

What is the MOA of Paclitaxel?

A

Causes microtubular damage –> prevention of cell division

220
Q

What should be given alongside paclitaxel and why?

A

Pre-emptive steroids given - this reduces hypersensitivity reactions

221
Q

Recall some side effects of paclitaxel

A

Total loss of body hair, peripheral neuropathy, neutropaenia and myalgia

222
Q

Which drug is available for the treatment of recurrent Ovarian Ca and what is its MOA?

A

Bevacizumab

Monoclonal Ab directed against VEGF to inhibit angiogenesis

223
Q

Describe the surgical intervention in ovarian Ca

A

Laparotomy
Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)
Plus omentectomy
Plus extra debulking

224
Q

In what ovarian tumours is chemotherapy not useful?

A

Sex cord stromal tumours - so surgery is the mainstay

225
Q

What is the 5 year survival rate for ovarian Ca?

A

46% (stage 1 = 90%, stage 3 = 30%)

226
Q

What is the cause of ovarian torsion?

A

It’s a complication of something big being in the ovary that makes it twist round eg ovarian cyst/ tumour

227
Q

What type of cyst is most likely to undergo torsion?

A

Dermoid cysts

228
Q

What are the symptoms of ovarian torsion?

A

Severe RIF/LIF pain and vomiting

229
Q

What are some appropriate investigations in suspected ovarian torsion?

A 
Pregnancy test
FBC
Speculum (to exclude PID)
Bimanual examination to look for an adnexal mass
Urinalysis to exclude ureteric colic

USS with dopplers (although this may give false neg) - shows whirlpool sign

230
Q

How should ovarian torsion be managed?

A

1st line = laparoscopic detorsion +/- cystectomy

2nd line = salpingo-oophorectomy

231
Q

Recall and describe the 5 types of incontinence

A

Stress - increaed pressure on bladder causes small losses
Urge - string urge and not qiuck enough to loo –> large losses
Mixed - often stress and urge together
Overflow - difficulty emptying –> filling –> incontinence
Functional - due to difficulties in mobility

232
Q

Recall some appropriate investigations for incontinence

A

1st = speculum - exclude pelvic organ prolapse
- Ask pt to cough during exam (Valsalva) to check for fluid leakage
1st = urine dip (rule out DM or UTI)
1st - bladder diaries (3 days)
If inconclusive:
2nd - urodynamic testing - 3 pressures measured from inside rectum and uretha
Bladder pressure = detrusor + IAP

233
Q

How can stress incontinence be managed?

A

Check need for referral - trigone tumour needs to be checked
1st line = lifestyle advice and WL and pelvic floor exercises: 8 contractions, TDS, 3 months

2nd line - surgical treatment or SNRI duloxetine (if no surgery wanted)
Surgery = 1. Burch colpo

234
Q

How can urge incontinence be managed?

A

Check need for referral to specialist as trigone tumour needs to be checked
1st line is conservative: lifestyle advice and bladder training (6 weeks) and avoid fizzy drinks

2nd line = medical: antimuscarinic eg oxybutynin, tolterodine or AD

235
Q

Recall an important side effect of oxybutynin

A

Increased risk of falls

236
Q

How can overflow incontinence be managed?

A

Refer to a specialist urogynaecologist - 1st line treatment is timed voiding

237
Q

What should be suspected if there is dribbling incontinence after having a child?

A

Vesicovaginal fistula: do urinary dye studies

238
Q

Recall the name of the criteria used to diagnose PCOS, and the criteria themselves

A

Rotterdam criteria
Need >2 of the following:
1. oligo/anovulation
2. Clinical/ biochemical features of hyperandrogenism
3. Polycystic ovaries on USS (>12 measuring 2-9mm)

239
Q

Recall some signs and symptoms of PCOS

A

Hirsuitism, amenorrhoea, sub-fertility, WG, acne and insulin resistance

240
Q

What sign is seen on TVUSS In PCOS?

A

Pearl necklace sign

241
Q

Recall some appropriate investigations in PCOS

A
  1. TVUSS
  2. LH:FSH index of >1:1
  3. Testosterone/ SHBG/ prolactin
242
Q

What should be monitored for in PCOS?

A

DM and CVD

243
Q

Recall in detail the management of PCOS

A

To treat oligomenorrhoea/ amoenorrhoea: COCP/ cyclical progesterone/ LNG-IUS
To treat symptoms of hyperandrogenism: COCP or Co-cyprindiol (COCP with extra anti-androgenic effects)
To treat infertility:
1st line: WL
2nd line: (up to 6 months) clomiphene, then clomiphene and metformin
Clomiphene = SERM
3rd line = gonatrophins, IVF

244
Q

What is the main risk of IVF in PCOS?

A

Ovarian Hyperstimulation Syndrome (OHSS)

OHSS –> multiple luteinized cysts –> lots of oestrogen, progesterone, VEGF –> pain + bloating

245
Q

Define Premature Ovarian Insufficiency

A

Secondary amenorrhoea before the age of 40

246
Q

What are the causes of Premature Ovarian Insufficiency?

A
  1. Iatrogenic (eg oophrectomy)

2. Unknown! But Addisson’s produces steroid-cell antibodies which cross-react with granulosa cells and theca interna

247
Q

What is required for a diagnosis of premature ovarian insufficiency?

A

2 x FSH results >30 (4-6 weeks apart) and menopause symptoms

248
Q

How can premature ovairan insufficiency be managed?

A

Fertility management: Donor oocyte IVF/ surrogacy

Manage menopause as you normally would

249
Q

What is the main difference in how menopause and POI are diagnosed?

A

POI is diagnosed biochemically whereas menopause is a retrospective diagnosis

250
Q

What are some risk factors for PMS?

A

Obesity, lack of exercise, dietary, smoking FHX

251
Q

What is required for diagnosis of PMS?

A

Symptom diary over 2 cycles

252
Q

What should be included in the management of all cases of PMS regardless of severity?

A

Conservative lifestyle measures, painkillers

253
Q

How is moderate PMS defined and managed?

A

Definition: some impact on personal, social and professional life
Management: COCP + CBT

254
Q

How is severe PMS defined and managed?

A

Definition: withdrawal from social and professional activities, preventing normal functioning
Management: SSRI + CBT

255
Q

What is the most common cause of pruritis vulvae?

A

Vulvovaginitis (eg vulvovaginal candidiasis, atrophic vaginitis, vulvar vestibulitis and contact dermatitis)

256
Q

Describe the appearance of discharge in vulvovaginal candidiasis

A

Thick white curd-like

257
Q

Describe the signs of chronic vulvovaginal candidiasis

A

Grey-sheen of epithelium, severe pruritis, irritation and pain, lichenification of vulva

258
Q

In which type of pruritic vaginitis might you see burning leucorrhoea?

A

Atrophic vaginitis

259
Q

What are the symptoms of primary and secondary vulvar vestibulitis?

A

Primary: introital dyspareunia
Secondary: introital dyspareunia that develops after a period of comfortable sexual intercourse
Pain, soreness, burning, rawness

260
Q

What are the appropriate investigations for vulvovaginal candidiasis?

A

Wet-mount test or KOH preparation

261
Q

What are the appropriate investigations to do in a case of pruritis vulvae to rule out atrophic vaginitis?

A

Vaginal pH and wet-mount test
Wet mount test often shows white blood cells and paucity of lactobacillus - this is a NEGATIVE result, showing the cause may be atrophic vaginitis rather than TV/BV

262
Q

Recall the management of vulvovaginal candidiasis

A

Ketoconazole (400mg/ day) or fluconazole (100mg/ week) for 6 weeks
Cotrimazole 500mg suppositories once per week
nb: In Ludley’s notes this is different to thrush treatment

263
Q

Recall the management of atrophic vaginitis

A

Topical vaginal oestrogen or HRT

264
Q

Recall the management of vulvar vestibulitis

A

Pain management with sex therapy, behaviour modification, topical steroid, anaesthetic, petroleum jelly, anti-inflammatories
Surgical excision as last resort - success rate of 60-80%

265
Q

Recall the management of contact dermatitis

A

Remove itching agent
If mild: 1% hydrocortisone cream
If moderate: Betamethosone
Wet compresses of aluminium acetate for severe lesions

266
Q

Recall a possible complication of atrophic vaginitis

A

Superimposed infection due to raised vaginal pH

267
Q

How is sub-fertility defined?

A

A woman of reproductive age who has not conceived after 1 year of regular, unprotected sexual intercourse

268
Q

Recall the groups of ovulatory disorders that may contribute to sub-fertility

A

Group 1: hypothalamic-pituitary failure (low weight, Kallman’s, Sheehan’s)

Group 2: Hypothalamic-pituitary-ovarian dysfunction (PCOS)

Group 3: Ovarian failure (POI)

Group 4: Prolactinaemia, thyroid disease
(prolactinoma, primary hypothyroidism, CRF, drugs)

269
Q

Other than ovulatory disorders, what can cause sub-fertility in the female?

A

Tubal disorders

Cervical/ uterine (eg fibroids)

Genetic/ developmental (Turner’s/ CF)

Lifestyle/ functional (smoking, method of sex)

270
Q

Recall 3 structural causes of infertility in men

A

Cryptochordism, CF, varicocele

271
Q

What should be included in the history when investigating sub-fertility?

A

Duration and type of infertility, coital frequency, menstrual history, PCOS symptoms, contraceptive history, previous STI, PSHx, DHx, SHx (EtOH and smoking)

272
Q

What are the first-line basic tests to do in men and women to investigate sub-fertility?

A

Men: semen analysis (2 tests, 3m apart) and chlamydia screen

Women: Day 21 progesterone (>30 indicated ovulation has occurred), chlamydia screen, prolactin, TFTs, progesterone, LH/FSH

273
Q

What are the Ovarian Reserve Tests?

A

FSH at Day 3 (to find basal level)
Anti-Mullerian hormone (AMH)
Antral follicle count (using TVUSS)

274
Q

How can a tubal assesment be performed?

A 
If no other comorbidities: hysterosalpingography (HSG) to assess patency
If comorbidities (eg history of PID/ ectopics/ endometriosis) --> laparoscopy and dye
275
Q

What is the 1st line management for sub-fertility?

A

Wait for regular intercourse to be established for at least 12 months (every 2-3 days)
Key information: aim for BMI between 20-25, sufficient folic acid, sex 3 times per week, reduce EtOH, stop smoking
Perform investigations after 12 months

276
Q

What is the second-line management for sub-fertility?

A

If sub-fertility is unexplained, due to mild endometriosis or due to a ‘male factor’ –> try for another 12 months, after this you can consider IVF

277
Q

How can anovulation be managed in PCOS?

A

Ovulation induction:
1st line: clompihene (blocks oestrogen receptor to increase LH/FSH release)
2nd line: FSH/LH injections
3rd line: Pulsatille GnRH or DA agonists

278
Q

Which causes of sub-fertility can be managed surgically?

A

Operative laparoscopy for adhesions, cysts and endometriosis
Myomectomy for fibroids
Tubal surgery for blocked tubes that are amenable to repair
Laparoscopic ovarian drilling for PCOS

279
Q

Recall the 5 options for assisted conception

A
  1. Intrauterine insemination +/- LH/FSH
  2. IVF
  3. Intracytoplasmic sperm injection
  4. Donor insemination +/- LH/FSH
  5. Donor egg with IVF
280
Q

How is IVF performed?

A

Leave the egg and sperm in a petri dish and they fertilise each other

281
Q

What is the NICE guidance for availability of IVF?

A

Women <40 offered 3 cycles of IVF if

  1. Subfertile for 2 years
  2. Not pregnant after 12 cycles of artificial/ intrauterine insemination

Women 40-42 offered 1 cycle of IVF if:

  1. subfertile for 2 years and/ or after 12 cycles of AI
  2. never had IVF
  3. No evidence of low ovarian reserve
  4. Informed about additional implications of IVF at this age
282
Q

What are the indications for intracytoplasmic sperm injection?

A

Oligospermia, poor fertilisation (DM, erectile dysfunction)

283
Q

How is ICSI carried out?

A

Sperm directly injected into the egg

284
Q

What are some indications for donor egg with IVF treatment?

A

POI, BL oophrectomy, gonadal dysgenesis, high-risk genetic disorder

285
Q

What is TSS?

A

Septicaemia from toxin (TSST1) produced by staphylococcus and streptococcus bacteria
Staphylococcus –> exotoxins (TSS toxin 1)
Streptococcis –> inflammatory cascade initiation

286
Q

Recall some symptoms of TSS

A

Fever >39, DandV, desquamation of palms and soles, myalgia, sore throat, shock, diffuse red macular rash, headache

287
Q

Recall the appropriate investigations in suspected TSS

A

Bloods: FBC (high WCC, low platelets), UandEs (impaired renal fx), LFTs, raised CK, raised CRP
Microbiology: HVS, blood culture, culture of tampon

288
Q

How should TSS be managed?

A

ABCs and remove tampon

Abx (broad spectrum, IV)

289
Q

What is a uterine prolapse?

A

Prolapse of uterus into vagina

290
Q

What is a cystocele?

A

Prolapse anterior vaginal wall involving the bladder

291
Q

What is rectocele?

A

Prolapse of lower posterior vaginal wall involving the anterior wall of the rectum

292
Q

What is enterocele?

A

Prolapse of the upper posterior vaginal wall containing loops of small bowel

293
Q

What is a vault prolapse?

A

Prolapse of vaginal vault after hysterectomy

294
Q

Recall some signs and symptoms of urogenital prolapse

A

Feelings of heaviness of descent PV
Back pain + dyspareunia
Recurrent UTI
Urinary symptoms is cystocele/ constipation or incontinence if rectocele

295
Q

What is the NICE recommended grading system for urogenital prolapse? Describe it.

A

POP-Q

Position given as a coordinate relative to the pelvic organs

296
Q

What is the most frequently-used grading system for urogenital prolapse? Describe it.

A

Shaw’s
1st degree: descent to the introitus
2nd degree: extends to the introitus but descent past the introitus on straining
3rd degree: prolapse descends through the introitus

297
Q

Recall the step-wise managemet of urogenital prolapse

A

1st line is conservative: WL, minimise weightlifting, stop smoking

2nd line:

  • Pelvic floor exercies
  • Topical oestrogen in older patients
  • Pessary: Ring (doesn’t prevent sex), shelf (common, hard, prevents sex), gellhorn (like shelf but soft, also prevents sex). If more severe - Gehrung or cube (which uses suction to keep things in place)

3rd line - surgical options:

Uterine prolapse: depends on whether there is desire to preserve uterus
To preserve uterus:
- Vaginal sacrospinous hysteropexy with sutures
- Manchester repair, unless the woman may wish to have children in the future
- Sacro-hysteropexy with mesh (abdominal or laparoscopic)
Doesn’t preserve uterus:
- Vaginal hysterectomy, Manchester repair, VSH with sutures

Vault prolapse: Sacrolpopexy with mesh

Anterior/ posterior colporrhaphy without mesh for anterior/ posterior prolapses

298
Q

What staging system is used for vulval Ca?

A

FIGO

299
Q

What type of cancer is the majority of vulval cancers?

A

SSC (95%)

300
Q

Recall some risk factors for usual and differentiated types of vulval Ca

A

Usual type (warty/ basaloid) - VIN (HPV 16), immunosuppression, smoking

Differentiated (keratinised SCC) - lichen sclerosus

301
Q

What is the usual aetiology of vulval Ca?

A

Progression of certain vulval dermatoses or progresssion of VIN

302
Q

How is VIN classified?

A

Low grade squamous, high-grade squamous and differentiated VIN

303
Q

Recall some symptoms of vulval Ca

A

Vulvar swelling, pruritis, pain, bleeding, discharge
May be a nodule or ulcer visible on vulva (usually labia majora)
Inguinal lymphadenopathy

304
Q

What is the management for vulval ca?

A

Vulvectomy and BL inguinal lymphadenectomy
For stage 1a: wide local excision (10mm clear margin)
For >1a: radical vulvectomy + BL inguinal lymphadenectomy
Sentinel node can be identified using dye and radioactive nucleotide

If unsuitable for surgery, ra

305
Q

What are some general complications of all gynae procedures?

A

Infections, bleeding, failure, damage to local structures

306
Q

What is a colposcopy?

A

A diagnostic procedure obtaining a magnified view of the cervix, the lower part of the uterus and the vagina in order to examine the transformation zone and detect malignant or premalignant changes

307
Q

What is a cervical punch biopsy?

A

Small amount of tisue removed from the cervix

308
Q

What are some indications for colposcopy and cervical punch biopsy?

A

Moderate/severe dyskaryosis or mild dyskaryosis with positive HPV test
3 x inadequate smears
Glandular neoplasia on smear
Suspicious looking cervix

309
Q

Recall some possible complicatons of colposcopy

A

Few complications from colposcopy alone

Excisional treatments may cause bleeding and infection, cervical incompetence in future pregnancies

310
Q

What are the general indications for endometrial ablation?

A

Menorrhagia - removal of layers of endometrium make periods lighter
Post-menopausal bleeding of unknown origin
Bleeding with anovulation/ fibroids

311
Q

Recall some possible complications of endometrial ablation

A

General: infection, bleeding, failure, damage to local structures (all guessable!)

Minor side effects: cramping, nausea, frequent urination, watery discharge mixed with blood

Rarely - pulmonary oedema due to fluid used to expand uterus being absorbed into bloodstream

312
Q

What device is usually used for endometrial biopsy

A

Pipelle

313
Q

Recall the indications for endometrial biopsy

A

Under 55 and unexplained bleeding 12+ months after LMP

Over 55 and:

  • PMB
  • Unexplained discharge that is either new, has thrombocytosis or haematuria
  • Visible haematuria and low Hb, thrombocytosis and raised blood glucose
314
Q

What is the main trouble with the pipelle?

A

Has a poor negative predictive value

315
Q

How does epidural differ from a spinal?

A

Anaesthesia injected into epidural space

316
Q

Recall some possible complications of epidural

A

Urinary retention, shivering, pruritis, headache (from anaesthesia going to head)
Hypotension, epidural haematoma, epidural meningitis, respiratory depression (!)

317
Q

Recall 2 diagnostic indications for gynaecological laparoscopy

A

Pelvic pain, endometriosis diagnosis, infertility (dye test for tubal patency)

318
Q

Recall 5 therapeutic uses of gynaecological laparoscopy

A

Sterilisation, endometrial ablation, salpingectomy, ovarian cystectomy, adhesiolysis

319
Q

Recall 3 possible approaches for hysterectomy

A

Vaginal (removed through vagina)
Laparoscopic-assisted vaginal
Laparoscopic hysterectomy

320
Q

What is removed in a total hysterecotomy?

A

Uterus and cervix

321
Q

What is removed in a radical hysterectomy?

A

Removal of structures +/- BSO

Eg. Wertheim’s hysterectomy

322
Q

What is removed in a sub-total hysterectomy?

A

Upper part of uterus but cervix not removed so smears are needed

323
Q

In what situation would smears still be done in total/ radical hysterectomy (even though there’s no cervix to smear!)?

A

If the hysterectomy was due to cancer or CIN - do smears at 6 and 18 months

324
Q

Which type of hysterectomy has the quickest recovery?

A

Vaginal

325
Q

Recall 3 indications and 2 contraindications for vaginal hysterectomy

A

Indications: Menstrual disorders with uterus <12w size, microinvasive cervical carcinoma, uterovaginal prolapse
Contraindications: malignancy, uterus 12w+ pregnancy

326
Q

What is the name of the incision used in abdominal hysterectomy?

A

Pfannenstiel incision (although a midline incision is used if larger masses/ malignancy)

327
Q

Recall some indications for abdominal hysterectomy

A

Uterine/ ovarian/ fallopian tube carcinoma
Pelvic pain from chronic endometriosis or chronic PID where pelvis is froxen, so vaginal is impossible
Symptomatic fibroid uterus 12w+ in size

328
Q

What should always be given intra-operatively in a hysterectomy?

A

Augmentin (co-amoxiclav)

329
Q

How does a flexible and rigid hysteroscopy differ?

A

Flexible: can be done in OP setting with CO2 as filling medium
Rigid: use circulating fluids to visualise uterine cavity even if the woman is bleeding

330
Q

Recall 6 indications for hysteroscopy

A

PMB, PCB, IMB, menorrhagia and/or abnormal discharge, suspected uterine malformations or suspected Asherman’s

331
Q

What is a LLETZ?

A

Use of a small small wire diathermy to cut away affected cervical tissue and seal a wound

332
Q

Recall 2 indications for LLETZ

A
  1. High-grade squamous intraepithelial lesion of the cervix (CIN2/3)
  2. Persistent low-grade squamous intraepithelial lesion of the cervix (CIN1)
333
Q

What are the non-general complications of LLETZ?

A

Discharge for 3-4 weeks and bleeding

Avoid tampons, sex and swimming until discharge has stopped to prevent infection

334
Q

What is a myomectomy?

A

Surgical removal of fibroids from the uterus - prior to surgery GnRH analogues are used to shrink size to reduce bleeding

335
Q

What are the 3 methods of myomectomy?

A

Hysteroscopic, laparoscopic and open

336
Q

What are the indications for each of the different types of myomectomy?

A

Hysteroscopic: fibroids on inner wall
Laparoscopic: removing 1 or 2 fibroids of less than 2 inches that are growing outside the uterus
Open: large fibroids, many fibroids, fibroids that are deep into the uterine wall

337
Q

Recall the minimum size/ age of a cyst for indication of removal

A

Size: 7.6cm
Age: 2-3 months unresolved

338
Q

Other than larger/ older cysts, what else is an indication for cystectomy?

A

Diagnostic (to exclude ovarian Ca)
BL lesions
Symptomatic cysts

339
Q

Whata are the 3 main types of emergency contraception and the time-frame in
which they need to be used? Which is most effective?

A

Levonogesterol (Levonelle) - 72 hours
Ulipristal (ellaOne) - 120 hours
Copper IUD - 120 hours (works immediately) - most effective

340
Q

What is the MOA of levonorgesterol as an emergency contraception?

A

Stops ovulation and inhibits implantation

341
Q

What is the stat dose of levonorgesterol?

A

1.5mg (double dose if >70kg or BMI >26 BMI)

342
Q

When should the dose of levongorgesterol be repeated?

A

If vomiting within 2 hours of dose

343
Q

What is the MOA of ullipristal acetate?

A

elective progesterone receptor inhibitor

344
Q

What is the stat dose of ellaOne?

A

30mg

345
Q

Recall an important contraindication of ellaOne

A

Severe asthma

346
Q

What advice about hormonal contraception would you give to someone taking ellaOne?

A

If already on pill, restart 5 days after the morning-after pill (use barrier for 5 days)

347
Q

When should the dose of ullipristal acetate be repeated?

A

If vomiting within 3 hours

348
Q

What are the indications for the copper coil?

A

<5 days of last UPSI, or up to 5 days after the likely ovulation date

349
Q

What is the pearl index?

A

Describes the chance of becoming pregnant on contraception - number of pregnancies occuring per 100 woman-years
ie. Pearl of 2 = 2 pregnancies per year in 100 women

350
Q

How often does a transdermal patch need to be used to make it effective contraception?

A

Every week

351
Q

How often does a vaginal ring need to be used to make it effective as contraception?

A

3-weekly

352
Q

What is the MOA of the COCP?

A

Prevention of ovulation

353
Q

How quickly does the COCP connvey contraceptive protection?

A

If started on first 5 days of the cycle = immediate

If started at any other time, us additional measures for first 7 days

354
Q

What precaution should be taken if on the COCP and undergoing surgery?

A

Stop taking 4w before, restart 2w after

355
Q

Recall some absolute contraindications to any long term contraception that contains oestrogen

A 
CV: Ischaemic/ valvular HD, VTE history, HTN severe, TIA/ stroke history
Diabetes with complications
Migraine with aura
Liver tumour/ severe cirrhois 
Current brease Ca
356
Q

Recall the missed dose procedure for the COCP

A

1 pill missed: take last pill and current pill (even if 2 in one day)
2 pills missed: same as above, PLUS:
If in week one: consider emergency contraception
If in week two: no need for emergency contraception
If in week 3: finish current pack, start new pack without pill free break

357
Q

Recall the MOA of the POP

A

Thickens cervical mucus and primarily stops ovulation

358
Q

How should the POP be taken?

A

OD at the same time every day - no pill-free break

359
Q

What is the most common complaint with the POP?

A

Initial irregular bleeding

360
Q

What disorders does the POP increase the risk of?

A

Osteoporosis/ ovarian cyst

361
Q

Recall the missed dose protocol for the POP

A 
If <3 hours late, continue as normal
If 3+ hours late, take missed pill asap and take extra precautions until the pill has been re-established for 48 hours
With Cerazette (desogesterel) - can continue as normal if <12 hours late
362
Q

What is the MOA of the transdermal patch?

A

Thickens cervical mucus and prevents ovulation

363
Q

What is contained within Mirena?

A

Progesterone (levonorgesterol)

364
Q

For how long can mirena be left in?

A

3-5 years

365
Q

For how long after insertion is extra contraception needed for mirena?

A

7 days

366
Q

What are some risks of mirena?

A

Expulsion, infection, perforation

367
Q

How long does the copper coil last?

A

5-10 years

368
Q

Recall one important contraindication of the copper coil

A

Menorrhagia

369
Q

What is contained within the implant?

A

Progesterone (etonogestrel)

370
Q

How long does the implant last?

A

3 years

371
Q

Recall a contraindication of the implant

A

IHD

372
Q

What is in the contraceptive injection?

A

Progesterone

373
Q

How long does the contraceptive injection work for?

A

12-14 weeks

374
Q

How long does it take for fertility to return after last contraceptive injection?

A

6-12 months

375
Q

Recall two significant risk associations with the contraceptive injection

A

Weight gain and ectopic pregnancy

376
Q

What are some important elements of the history to ascertain when counselling
about contraception?

A

Previous FHx of VTE, migraine, Ca, stroke and HTN

377
Q

When around childbirth is the COCP contraindicated?

A

<6 weeks post-partum + breastfeeding

378
Q

When around childbirth is the POP contraindicated?

A

You can start any time, but if >21 days post-partum, use barrier for 2 days

379
Q

Which forms of contraception can be continued past 50 years old?

A

Implant, POP, IUS

380
Q

What are the Fraser guidelines?

A

Guidelines under which an under-age person is given contraception

381
Q

What is adenomyosis?

A

Similar to endometriosis - but endometriosis is endometrial cells existing outside the uterus whereas adenoyosis is endometrial cells existing inside the uterine muscular wall

382
Q

What are the signs/ symptoms of adenomyosis?

A

Menorrhagia/ dysmenorrhoea

Chonic pelvic pain

383
Q

What would be seen on USS in adenomyosis?

A

Haemorrhage-filled, distended endometrial glands

384
Q

What is the gold-standard investigation for adenomyosis?

A

MRI pelvis

385
Q

What is the only definitive treatment for adenomysosis?

A

Hysterectomy

386
Q

Recall the FIGO stages for endometrial cancer

A

Stage I: uterus
Stage II: uterus + cervix
Stage III: adnexa
Stage IV: distant metastasis

387
Q

Recall the FIGO stages for ovarian cancer

A

Stage I: limited to ovaries
Stage II: Pelvic extension (ie uterus)
Stage III: abdo extension (extra-pelvic)
Stage IV: distant metastasis

388
Q

Recall the FIGO stages of cervical cancer

A

Stage I: cervix
Stage II: beyond cervix, not into pelvic wall or lower 1/3 of vagina
Stage III: extends into pelvic wall or lower 1/3 of vagina +/- hydronephrosis
Stage IV: extend beyond pelvis + involves musosa of bladder/ rectum

389
Q

What are the 3 types of functional ovarian cyst - and which is most common?

A

Follicular (most common), corpus luteal and theca lutein

390
Q

How do follicular cysts appear on USS?

A

Thin walled, unilocular, anechoic

391
Q

What is the main risk with corpus luteal cysts?

A

Rupture at end of menstrual cycle

392
Q

How do corpus luteal cysts appear on USS?

A

Diffusely thick wall, <3cm, lacey pattern

393
Q

What are theca lutein cysts associated with?

A

Pregnancy

394
Q

How do theca lutein cysts appear on USS?

A

BL enlargement, multicystic ovaries, thin-walled and anechoic

395
Q

What are the types of inflammatory ovarian cyst?

A

Tubo-ovarian abscess, endometrioma

396
Q

Describe the USS appearance of the different types of inflammatory ovarian cyst

A

Tubo-ovarian abscess: ovary and tube cannot be distinguished from mass
Endometrioma: unilocular with ground-glass echoes

397
Q

What are germ cell ovarian cysts, and what are the subtypes?

A

Dermoid cysts

May be immature (embryonic elements may be seen) or mature (may contain teeth)

398
Q

What are the types of epithelial ovarian cysts, and which is most common?

A

Serous cystadenoma (most common), mucinous cystadenoma, Brenner’s tumour

399
Q

Which type of epithlial ovarian cyst is likely to be large?

A

Mucinous cystadenoma

400
Q

What is a Brenner’s tumour?

A

Type of epithelial ovarian tumour which contains uroepithlial-ike epithelium

401
Q

What are the subtypes of sex cord stromal ovarian tumour?

A

Fibroma, thecoma and granulosa cell

402
Q

Recall the elements of a vaginal examination

A

Outer vulval examination
Part labia and insert 2 fingers into the vagina to under the cervix
Left hand on top if tummy - all fingers pointing in same direction
Ballot uterus
Examine adnexa - stroke on each side of the cervix

Year 5 - specialties (10 decks)

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