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Gynaecology > Non-malignant disorders > Flashcards

Non-malignant disorders Flashcards

1
Q

What are some risk factors for Fibroids?

A

obesity

early menarche

increasing age

family history

afro-carribean

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2
Q

What are ‘protective’ against fibroids?

A

Parity

COCP

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3
Q

How do fibroids present?

A

50% asymp

Mennorhagia

Dysmenorrhoea

Frequency, retention, hydropnephrosis

Fertility sometimes affected

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4
Q

What problems can fibroids cause during pregnancy?

A

premature labour

malpresentations

transverse lie

obstructed labour

PPH

Red degeneration

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5
Q

How would you investigate suspected fibroids?

A

Transvaginal USS

MRI to differentiate from adenomyosis

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6
Q

What effect do fibroids have on Haemoglobin?

A

May be low because of bleeding

OR

High because fibroids can secrete erythropietin

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7
Q

How would you manage fibroids?

A

symptomatic management with a levonorgestrel-releasing intrauterine system

can use transexamic acid and COCP

GnRH agonists (Zolidex) - shrink

Hysteroscopy + trans-cervical resection

Myomectomy

Hysterectomy

Uterine Artery Embolisation

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8
Q

How do ovarian masses normally present?

A

normally silent

if present, they are very large and cause abdo distension

or if an accident (e.g. rupture)

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9
Q

What can cause an ovarian mass accident or make it more likely?

A

Endometrioma

Dermoid Cyst

Haemorrhage into a cyst/peritonieal cavity

Torsion of pedicle > infarction

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10
Q

What are some benign epithelial ovarian tumours?

A

Serous Cystadenoma - most common benign

Mucinous Cystadenoma - second most common, v. large, can rupture and cause pseudomyxoma peritonei

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11
Q

What are some benign ovarian germ cell tumours?

A

Teratoma/Dermoid - most common for u-30, more likely torsion, hair/teeth, rupture v painful

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12
Q

What are some benign sex cord tumours?

A

Thecomas

Fibromas - Associated with Meigs’ syndrome (ascites, pleural effusion) common around menopause

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13
Q

What are the most common vulval symptoms?

A

Pruritus

Soreness

Burning

Superficial Dyspareunia

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14
Q

What are Infectious causes of pruritus vulvae?

A

candidiasis

vulval warts

pubic lice

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15
Q

What are some Dermatological causes of pruritus vulvae?

A

eczema

psoriasis

lichen simplex

lichen sclerosus

lichen planus

contact dermatitis

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16
Q

What are neoplasial causes of pruritus vulvae?

A

carcinoma

premalignant disease (vulval intraepithelial neoplasia)

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17
Q

What are some RFs for lichen simplex, how does it present and how do you treat?

A

sensitive skin, eczema and dermatitis

severe itching, esp at night, inflammed and thickened labia majora

avoid irritants, use steroid cream and antihistamine

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18
Q

How does lichen planus present? How do you treat?

A

flat, papular, purple lesions which are erosive and painful

use high potency steroid creams

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19
Q

What are risk factors for lichen sclerosus? How does it present? How would you manage?

A

autoimmune, thyroid annd vitiligo

pinkish/white papules > parchment like fissured skin, itching

ultra-potent steroids

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20
Q

What are risks associated with lichen sclerosus?

A

5% will become vulval carcinoma therefor BIOPSY

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21
Q

What are bartholin’s cysts?

A

blockage of glands behind the labia minora that secrete lubricating mucus for coitus

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22
Q

How would you treat bartholin’s cysts?

A

incision and drainage

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23
Q

What is usual vulval intraepithelial neoplasia associated with?

A

HPV

Cervical intraepithelial neoplasia

Smoking

Chronic Immunosuppresion

linked to warty or basaloid squamous cell carcinomas

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24
Q

What is differentiated vulval intraepithelial neoplasia associated with?

A

lichen sclerosis

older women

linked to keratinizing squamous cell carcinomas

*higher risk of progression to cancer

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25
Q

How does vulval intraepithelial neoplasia present? What is the gold standard treatment?

A

pruritus and pain

local surgical incision and biopsy

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26
Q

What supports the upper, mid third, and lower third of vagina?

A

upper - cardinal and uterosacral ligament

middle - endopelvic fascia

lower - levator ani and perineal body

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27
Q

What are the following

urethrocoele :

cystocoele :

apical :

enterocoele :

rectocoele :

A

i) lower anterior vaginal wall involving urethra only
ii) cystocoele : upper anterior wall involving bladder
iii) apical : uterus, cervix and upper vagina
iv) enterocoele : upper posterior wall of vagina, may contain loops of bowel
v) rectocoele : lower posterior wall involving anterior wall of rectum

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28
Q

What system would you use to grade a prolapse? How does the grading work?

A

ICS Pelvic Organ Prolapse scoring system

0 - no descent of pelvic organs during straining

1 - leading surface of prolapse doesn’t descent below 1cm above the hymenal ring

2- leading edge extends from 1cm above to 1cm below the hymenal ring

  1. prolapse extends 1cm or more below hymenal ring w/ complete vaginal eversion
  2. vagina completely everted
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29
Q

What are some risk factors for prolapse?

A

vaginal delivery

pregnancy

congenital factors - Ehlers-Danos

menopause

chronic predisposing factor - obesity, cough, heavy lifting

iatrogenic - pelvic surgery

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30
Q

How would a prolapse present?

A

asymp

dragging sensation/lump

stress incontinence

frequency

incomplete emptying

can ulcerate and bleed

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31
Q

How would you manage a urogenital prolapse?

A

decrease weight

treat constipation

pelvic floor exercise

pessaries

surgery

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32
Q

What are disadvantages to some urogenital prolapse treatment measures?

A

Pessaries - pain, urinary retention, infection, can fall out

Surgery - fails to address underlying pelvic support deficiency > present w/ subsequent vaginal vault prolapse

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33
Q

What is endometriosis?

A

Presence and growth of tissue similar to endometrium outside the uterus

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34
Q

What hormone is endometriosis dependant on?

A

oestrogen, regresses after menopaue and during pregnancy

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35
Q

What causes endometriosis?

A

retrograde menstruation

if more distant may result from mechanical, lymphatic or blood borne spread

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36
Q

How does endometriosis present?

A

chronic pelvic pain that is cyclical

dysmenorrhoea before period

dyschezia

rupture of chocolate cysts can cause acute pain

subfertility

on exam : tenderness and/or thickening behind the uterus or in the adnexa

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37
Q

How would you investigate suspected endometriosis?

A

gold standard - laparoscopy and biopsy

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38
Q

How would you treat endometriosis?

A

NSAIDs

COCP or Progestogens

GnRH analogues (zoladex)

Surgery - laser or bipolar diathermy
hysterectomy and bilateral salpingo-oopherectomy

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39
Q

What are some causes of chronic pelvic pain?

A

Endometriosis

Adenomyosis

Gynae or Pelvic Adhesions

Depression

Abuse

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40
Q

What is the definition of menopause?

A

permanent cessation of menstruation resulting from loss of ovarian follicular activity

12 consecutive months of amenorrhoea

41
Q

What is the median age for menopause?

A

51 y/o

42
Q

What is perimenopause?

A

First feature of menopause and ends 12 months after last period

43
Q

What is defined as premature menopause?

A

occuring before 40

44
Q

When should someone who is around the menopausal age stop using contraception?

A

> 50 - after 12 months consecutive amenorrhoea

<50 - after 24 months consecutive amenorrhoea

45
Q

What are some causes of postmenopausal bleeding?

A

endometrial carcinoma

endometrial hyperplasia

cervical carcinoma

atrophic vaginitis

cervicitis

ovarain carcinoma

cervical polyps

46
Q

How would you investigate postmenopausal bleeding?

A

bimanual and speculum exam

cervical smear

transvaginal USS - if endometrium thick > endometrial biopsy +/- hysteroscopy

if malignancy is excluded atrophic vaginitis can be treated with topical oestrogen

47
Q

How would you investigate menopause?

A

FSH > increased levels mean fewer oocytes remaining in ovaries

anti-mullerian > direct measurement of ovarian reserve

TFTs

Cathecolamines

LH, Oestradiol and progesterone

48
Q

What are some non-medical ways to manage menopause?

A

Hot flushes
regular exercise, weight loss and reduce stress

Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene

Mood
sleep, regular exercise and relaxation

Cognitive symptoms
regular exercise and good sleep hygiene

49
Q

What are the approaches to HRT in menopause?

A

HRT - if still has Uterus - oral or transdermal combined HRT is given.

If no uterus - oestrogen alone can be given either orally or in a transdermal patch.

2-5 years

50
Q

What are the contra-indications of HRT?

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

51
Q

What are the risks associated with HRT?

A

Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.

52
Q

Why must the combined HRT be given to a women with a uterus?

A

increase her risk of endometrial cancer

53
Q

What are non-HRT medical management of menopause?

A

Vasomotor symptoms
fluoxetine, citalopram or venlafaxine

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

54
Q

What are the benefits of oestrogen in HRT?

A

treats hot flushes, vaginal dryness, superficial dyspareunia, urinary frequency and urgency

reduces risk of osteoporosis

reduces risk of colorectal cancer

55
Q

What is PCO and PCOS?

A

PCO - Transvaginal USS appearance of multipl (12 or more) small (2-8mm) follicles in an enlarged (>10mL volume) ovary

PCOS - is when there 2 of the following 3 are met

i) PCO on USS
ii) Irregular periods (>35 days apart)
iii) Hirsutism

56
Q

What is hirsutism?

A

Clinically - acne/excess body hair

Biochemically - raised serum test.

57
Q

What is the pathology of PCOS?

A

Disordered LH and Peripheral insulin resistance (increased insulin levels)

causes increased ovarian androgen production

which disrupts folliculogenesis

58
Q

How does PCOS present?

A

Obesity

Acne

Hirsutism

Oligomenorrhoea

Amenorrhoea

Miscarriage

acanthosis nigricans

59
Q

What would bloods would you run in PCOS? What would you expect to see

A

FSH - normal (raised in ovarian failure, decreased in hypothalamic disease)

LH - raised
raised LH:FSH ratio is a ‘classical’

Prolactin - normal/ mildly elevated

TSH

Testosterone - normal mildly elevated (Hirsutism)

60
Q

Besides bloods what other tests would you run in suspected PCOS?

A

USS

Screening diabetes and lipids

61
Q

What complications are associated with PCOS?

A

type 2 diabetes - 50%

Gestational diabetes - 30%

Endometrial cancer

62
Q

How would you manage PCOS?

A

Diet and Exercise

COCP - 3-4 bleeds/ year

Anti-androgens - cyproterone acetate

Metformin

Eflornithine - topical antiandrogen for facial hirsutism

63
Q

What is menorrhagia?

A

Excessive, menstrual blood loss that interferes with a woman’s physical, emotional, social and material quality of life

> 80 mL blood loss in otherwise normal menstrual cycle

64
Q

What are the causes of menorrhagia?

A

subtle abnormal of endometrial haemostasis

uterine fibroids

Polyps

hypothyroidism

intrauterine devices (copper)

pelvic inflammatory disease

bleeding disorders,

65
Q

What are some questions to ask during a history of menorrhagia?

A

Amount of bleeding

Timing of bleeding

Menstrual Calendar

Flooding and Large clots

Ask about contraception

66
Q

What investigations would you carry out for menorrhagia?

A

FBC - anaemia

Transvaginal USS if intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms

67
Q

How would you manage menorrhagia?

A

does not require contraception
mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well)

tranexamic acid 1 g tds. Both are started on the first day of the period

Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens

68
Q

What can be used as used as a short-term option to rapidly stop heavy menstrual bleeding?

A

Norethisterone

69
Q

When is an endometrial biopsy indicated?

A

Endo thickness - premenopausal (>10mm), postmenopausal (>4mm)

Age - >40 y/o

Menorrhagia w/ intermenstrual bleeding

Prior to endometrial ablation

70
Q

What are causes of irregular menstruation?

A

Anovulatory cycles - early and late reproductive age

Pelvic Pathology - fibroids, uterine and cervical polyps, adenomyosis, ovarian cysts and chronic pelvic infection

71
Q

What investigations would you run for irregular menstruation?

A

Hb
USS
Endo biopsy

72
Q

How would you manage irregular bleeding?

A

IUS

COCP

Progestogens

HRT if perimenopause

73
Q

What is primary and secondary amenorrhoea?

A

Primary - delayed puberty

Secondary - ceases for 6 months or more

74
Q

What is oligomenorrhoea?

A

Menstruation occurs every 35 days to 6 months

75
Q

What are some causes of physiological amenorrhoea?

A

Pregnancy

Post Menopause

lactation

76
Q

What are some causes of pathological amenorrhoea?

A

Hypothal - hypothalamic hypogonadism (psychological, low weight, excessive exercise)

Pituitary - hyperprolactinaemia (pituitary hyperplasia or benign adenomas)

Thyroid - hypo/hyper

Adrenals - over/under activity

ovary - PCOS, premature menopause

Uterus - imperforate hymen, transverse vaginal septum

77
Q

What are the most common causes of secondary amernorrhoea or oligomenorrhoea?

A

premature menopause

PCOS

hyperprolactinaemia

78
Q

What are causes of postcoital bleeding?

A

Cervical carcinoma

Cervical ectropion

Cervical polyps

Cervicitis

Vaginitis

79
Q

When is adenomyosis commonly seen?

A

around 40s

associated with endometriosis and fibroids

80
Q

What are some causes of adenomyosis?

A

pregnancy and labour

C-section

uterine surgery

termination/miscarriage

81
Q

How would adenomyosis present?

A

asymp

menorrhagia

dysmenorrhagia

deep dyspareunia

uterus can be enlarged or tender

82
Q

What is best investigation for adenomyosis?

A

MRI

83
Q

How would you manage adenomyosis?

A

GnRH agonists

hysterectomy

84
Q

What is cervical ectropion? What are some causes?

A

Columnar epithelium of endocervix visible as red area around OS due to eversion of cervix

OCP and pregnancy

85
Q

How does cervical ectropion present? How would you manage it?

A

discharge and post-coitus bleeding

86
Q

How would you manage cervical ectropion?

A

stop OCP

cryotherapy

smear/colposcopy

87
Q

What is a Nabothian follicle?

A

squamous epithelium formed by metaplasia over endocervical cells, blocking columnar secretions and causing retention cysts

88
Q

What is pelvic inflammatory disease?

A

infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix

can also be descending infection from appendix

89
Q

What are some risk factors for PID?

A

multiple partners

not using barrier contraception

termination

ERPC

laparoscopy

miscarriage

90
Q

What are the organisms responsible for PID?

A

Chlamydia trachomatis - the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

91
Q

How does PID present?

A

asymp

subfertility

menstrual problems

bilateral lower abdominal pain with deep dyspareunia
with abnormal vaginal bleeding or discharge - ‘CLASSICAL’

92
Q

How would you investigate PID?

A

endocervical swabs

blood cultures

WBC & CRP

Pelvic USS

*gold standard - laparoscopy with fimbrial biopsy and culture

93
Q

How would you treat PID?

A

analgesics

parenteral cephalosporin

if febrile - admit

if no improve in 24 hrs - laparoscopy

94
Q

What would be a complication of PID?

A

formation of abscess or pyasalpinx

tubal obstruction and subfertility

chronic PID

ectopic pregancy

95
Q

How would chronic PID present?

A

chronic pelvic pain

dysmenorrhoea

deep dyspareunia

heavy and irregular menstruation

chronic vaginal discharge

subfertility

96
Q

What does chronic PID cause?

A

dense pelvic adhesions, fallopian tubes can become obstructed and dilated (hydrosalpinx and pyosalpinx)

97
Q

What is the cause of clear vaginal discharge?

A

ectropion/eversion

atrophic vagina

98
Q

What is the cause of grey/white discharge?

A

bacterial vaginosis - grey-white, fishy smell

candidiasis - white, itching, imidazole

trichomoniasis - grey-green, itching, odour, abx treat

99
Q

What would cause red-brown vaginal discharge?

A

malignancy

Gynaecology (3 decks)

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