Obs/Gyn Flashcards
At what conceptational age is the primitive gonads evident?
5 weeks. On the mesonephric ridge
Lower part of the mullerian ducts fuse in the middle to form
- Uterus
- Upper part of vagina
Primordial follicles are at arrest in which part of the cell cycle
Prophase 1 (Meiotic divison 1)
Lower parts of the vagina develop from?
Sinovaginal bulbs
Inlet plane of the pelvis is from to where?
- From the sacral promontory to top of pubic symphysis
- Outlet is bottom of the coccyx to bottom of the pubic symphysis
Layers of the adult uterus
Peritoneum, myometrium and endometrium
Epithelium of the endocervix?
- The epithelium of the endocervix is columnar and is also ciliated in its upper two-thirds.
- This changes to stratified squamous epithelium around the region of the external os and the junction of these two types of epithelium is called the ‘squamocolumnar junction’.
Menstrual cycle: phases
Ovarian and Uterine
Oestrogen effects on LH
Low levels of oestrogen have an inhibitory effect on LH production (negative feedback), whereas high levels of oestrogen will increase LH production
This is how the contraceptive pill works
The positive feedback works by increasing GnRH receptors, negative feedback method is uncertain
Describe the menstrual cycle
- Start is the first day of menses
- Pre-ovulatory ovarian follicular phase= GnRH release causes FSH and LH to be secreted
- FSH causes follicles to mature, LH causes the theca cells to produce oestrogen. High levels of estrogen causes first a drop in FSH and LH. Only the follicle with most sensitivity to FSH grow to dominant follicle, then the increasing levels from the dominant cell causes a positive feedback on LH (surge), and oocyte is released
- Uterine cycle is happening alongside= high oestrogen means thickening endometrium, glands and thinning of cervical mucus
- The Graffian follicle turns into corpus luteum, which makes progestrone and inhibin which both inhibits FSH and LH . The uterus enters the secretory phase: thicker mucus and increase basal temp
- The lack of fertilisation means the corpus luteum changes to corpus albicans. Drop in progestrone means bleeding and FSH and LH released again
Menstrual phase, follicular, ovulation and luteal
What needs to happen before for progestrone to work ?
Oestrogen priming needs to happen
Which hormone keeps the corpus lutem alive?
hCG (human chorionic gonadotrophin)
Which hormone keeps the corpus lutem alive?
hCG (human chorionic gonadotrophin)
Which layer of endometrium is lost during menstruation ?
Functional layer
The theca cells and granulosa cells of the follicle secretes what during the preovulatory follicular phase ?
Theca cells= binds LH and secretes oestrogen
Granulosa cells= binds FSH and releases aromatase (which makes the oestrogen from the precursor made by theca cells)
Why is oestrogen also produced once corpus luteum has formed progestrone ?
The ratio of production is > for progestrone but some oestrogen is also produced
Dysmenorrhoea is split into ?
classification of cause
- Primary- absence of pathologic findings that could account for those symptoms
- Secondary- underlying conditions
Dysmenorrhoea: definition
Recurrent lower abdominal pain shortly before or during menstruation
Nulliparity: define
Never carried a pregnancy beyond a point of viability (20weeks gestation)
Primary dysmenorrhoea: pathophysiology
Increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction/ischemia and stronger, sustained uterine contractions (to prevent blood loss).
Primary dysmenorrhoea: Clinical features, dx and tx
- Clinical features= Spasmodic, crampy pain which happens during 1-3 of period, pelvic midline/ lower abdo, normal pelvic examination
- Dx= dx of exclusion
- Tx= symptomatics so give NSAIDs, topical application of heat, hormonal contraceptives
Secondary dysmenorrhoea: aetiology
- Uterine causes= PID Adenomyosis, cervical polyps
- Extrauterine= endometriosis, adhesions, functional ovarian cysts, IBD
How does secondary dysmenorrhoea differ from the primary
The onset. Secondary usually happens >25 years
Clinical features of secondary dysmenorrhoea
- Abnormal pelvic examination
- Irregular cycles
- Pain tends to get worse over time
- Dyspareunia or postcoital bleeding
- None/ little response to NSAIDs
Amenorrhoea: definition
Absence of menarche by 15yrs despite normal development of secondary sexual characteristics, no menses by 13 w/o secondary characteristics
Oligomenorrhoea: define
Irregular periods with cycles which are >35 days and only 1-9 periods/ year
Primary amenorrhoea
Aetiology
- Constitutional growth delay
- Hypogonadotropic hypogonadism- low GnRH release e.g. Kallmann syndrome, Prader willi, stress, hypopituitarism, damage to hypothalamus
- Hypergonadotropic hypogonadism- gonads not producing oestrogen/ progesterone due to dysgenesis e.g. in Turner syndrome (MC)
- Anatomical anomalies- mullerian agenesis
- Congenital adrenal hyperplasia
Kallmann syndrome: what is it?
Rare genetic condition characterized by anosmia (an inability to smell) and decreased production of GnRH from the hypothalamus, leading to delayed or absent puberty.
Primary amenorrhoea: Dx
- Check for presence of uterus. If not present then do karotyping and serum testosterone
- Look at LH/FSH levels
Secondary amenorrhoea: define
The absence of menses for more than 3 months in individuals with previously regular cycles, or 6 months in individuals with previously irregular cycles
MC of secondary amenorrhoea
Pregnancy
Progestin challenge: What is it and interpretation of results
A test used to help determine the cause of amenorrhea. A progesterone or a progesterone-like drug is given for 5-10 days.
If uterine bleeding does not occur within 2-7 days after progesterone cessation (physiological response), an underlying pathology is likely (e.g., low estrogen levels, abnormal uterine/endometrial anatomy, dysfunction of hypothalamic-pituitary axis).
Withdrawal bleeding induced= anovulation (e.g., PCOS, idiopathic anovulation, premature ovarian failure)
Female athelete triad: what is it?
Functional hypothalamic amenorrhea: low calorie intake/strenuous physical activity, low bone mineral density, and amenorrhea
Hypermenorrhoea is associated with
Hypothyroidism, endometrial cancer, endometriosis
Tanner staging
Girls
For girls two things: breast and pubic hair. 5 stages. Pubic hair is light then gets thicker and curly and crosses thigh etc
B1= Prepubertal/ slight to no elevation of nipple
B2= Enlarged mammary glands form a breast bud, slight increase in areolar diameter, nipple protrusion
B3=Breast bud extends beyond the areolar diameter
B4= Nipple and areola form a secondary mound which projects above the breast tissue
B5= Areola with projection of papilla only, Adult
Abnormal uterine bleeding: categories
- Frequency
- Regularity
- Duration
- Volume
- Intermenstural bleeding
Classification of abnormal uterine bleeding
- PALM-COEIN
- Structural causes: polyps, adenomyosis, leiomyomas, and malignancy and hyperplasia (PALM)
- Nonstructural causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified (COEIN)
Combined oral contraceptive pill (COCP): what does it contain?
- Oestrogen and progesterone
- The level of oestrogen is kept in the inhibitory level for LH and also stops endometrium thickening
- Progestrone makes the cervical mucus thicker
COCP: normal regime
21 days on/ 7 days off causing the bleed. Trade name uk: Microgynon, Rigevidon
There are newer guide lines for longer 63days/ 7 days
Contraindication of COCP
- Current breast cancer
- < 6/52 weeks postpartum
- > 35 yrs old and smokes more than 15 cigarettes/day
Enzyme inducer drugs is a relative
List 2 pros and 2 cons of COCP
- Pro= decreases dysmenorrhoea, decreases size of fibroids, decrease cancer of endometrial/ ovarian ca
- Cons= VTE/ stroke risk is increased, increased risk of breast cancer
Effectiveness of COCP
When to take in the cycle
Within the first 5 days (effective immediately) if taken after this an additional barrier contraception must be used for 7 days.
Missed pill rule of COCP
- Take pill ASAP even if that means taking 2 pills on one day
- If 2 or more consecutive days are missed, then use additional contraception e.g. male condoms
- If the 2 pills are missed in the first week following the pill free interval then use emergency contraception
- If the pills were missed during the last week then just miss the pill free interval
Evra patches: what do they contain
They are transdermal patches which contains oestrogen and progesterone, similar to COCP, 3 weeks on, and 1 week off
Progestrone pill: disadvantages
- Must be taken during the same time each day
- Increase chance of irregular bleeding
- Increases risk of ectopic pregnancy
- Weight gain, acne, mood changes
Safe to use in women who cant use oestrogen pills
Injectable progesterone depots are injected when?
Frequency
Every 12 weeks
Works by decreasing endometrial thickness, increase cervical mucus
What are some common side effects of progesterone containing contraceptions
- Weight gain
- Mood changes
- Acne
Subdermal progestin implant
How long does it last
3 years
Subdermal progestin implant contraindication
Breast Ca
Intrauterine copper device works how?
Inserted into the uterus and last 10 years, has spermicide which decreases motility and prevents implantation
This can be used as emergency contraception if used in 5/7 after UPSI
Intrauterine system (IUS)
works by?
Progestin (levonorgestrel) releasing
What are some risks of intrauterine systems (copper and progestin)
- PID
- Ectopic pregnancy
- Uterine perforation
- Uterine expulsion
Ullipristal acetate. Also known as?
Ellaone
What is cut during a vasectomy?
Vas deferens
Gillick competency. How does it work?
- Children under 16 years old are considered to be incompetent unless they show Gillick competency
- Gillick competency= understand, can’t persuade to tell parents, will have UPSI, risk to health
Endometriosis: what is it?
Endometrial tissue which is found outside of uterus in women of reproductive age
Endometriosis: aetiology
- Retrograde movement of menstural blood
- Dysfunction of immune system
- Coelemic metaplastic theory= peritoneal cells transform back into primitive origin then into endometrial cells
- Benign metastases theory= endometrial tissue travels to lungs etc
- Extrauterine stem cell theory
How are the endometriosis cells different from the endometrial cells?
- They contain more aromatase therefore produce more oestrogen
- Implanted cells produced pro-inflammation factors which can lead to adhesions which alters normal anatomy
- New blood vessels form to these implants
Endometriomas
What are they
These are endometrial implants on the ovaries. “Chocolate cysts”
Endometrosis: SSx, Dx and Tx
- SSx= Abdominal pain/ pelvic pain, back pain, infertility, dysmenorrhoea, postmentrual bleeding, dyspareunia, dyschezia
- Dx= Hx, transvaginal ultrasound, laproscopic examination is confirmatory
- Tx=NSAIDs, contraceptive pills. Severe= GnRH agonist, OCPs. Surgery (ablation/ hysterectomy/ salpingo-oophorectomy)
GnRH used to combat hypoestrogenic effects such as lipid abnormalities, oestoporosis, infertility
Dyschezia: what is it?
Pain whilst defecating (endometriosis tissue implants in the pouch of douglas)
DDx of endometriosis
- Adenomyosis- benign disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
- Colon Ca
- Ovarian Ca
- PID- adhesions
Uterine leiomyomas: classifed into
- Submucosal
- Intramural
- Subserosal
Uterine leiomyomas: define
Benign, hormonal- sensitive smooth muscle tumours
Predisposing factors for uterine leiomyomas
- Nulliparity
- Early menarche < 10 years old
- African american individuals
- Obesity
- FHx
Where do uterine leiomyomas occur most commonly ?
Intramural
Uterine leiomyomas: SSx, Dx, Tx
- SSx= Depends on size, number and location of tumour. Commonly= hypermenorrhoea, dysmenorrhoea, metrorrhagia, infertility, mass effect
- Dx= Ultrasound scan- hypoechoic solid mass, MRI with or without contract to characterise more
- Tx= shared decision making. If patient wishes fertility, keep uterus etc. You can do uterine artery embolisation
Mass effect= sympts due to mass. E.g. back pain etc. Location dependent
Metrorrhagia: define
Abnormal uterine bleeding between periods. Causes= cervical cancer, COCP
Which of the leiomyoma locations pose a risk to heavy menstural bleeding?
Submucosal, Intramural if pedunculated ++
What should indicate you towards a leiomyosarcoma ?
Hypervascularity within a solitary heterogeneous uterine mass
Pharmacological tx for leiomyomas
Used in expectant management?
* IUD
* Oral contraceptive pill
* GnRH anatagonists –> hormonal therapy too to counter hypoestrogenic effect
* GnRH agonist
Embolic agent used in uterine artery embolisation
Polyvinyl alcohol
Postembolisation syndrome: define
A common complication of transarterial embolization characterized by fever, pain, nausea, and vomiting within 72 hours after embolization in the absence of infection. Believed to be caused by inflammatory response to necrotic tissue. The condition is typically self-limited.
Pelvic inflammatory disease: define
Caused by a bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue.
MC pathogens causing PID
- Chlamydia trachomatis, Neisseria gonorrhoeae
- Coinfection with e.coli is possible
PID during pregnancy usually occurs when?
Before 12 weeks, before the mucus plug blocks the enterance
Risk factors of PID
List 3
- Multiple sexual partners
- Hx of STI or STI
- Vaginal dysbiosis (flora is imbalanced)
- IUDs
PID: SSx, Dx, Tx
- SSx= lower abdo pain, nausea/ vomiting, dysuria, metrorrhagia, menorrhagia, dyspareunia, abnormal discharge
- Dx= Hx (multiple sexual partner, lower abdo pain, cervical motion tenderness, purulent discharge. US can show free fluid
- One single dose of IM ceftriaxone and oral therapy with doxycycline
PID can lead to infertility, one of the most common reason. Tx quick. Fitz-Hugh Curtis is complication, basically this is adhesions from the Glissons capsule to the peritoneum due to infection
Culdocentesis: what is it?
Aspiration of intraperitoneal fluid from the pouch of Douglas. No longer routine!
Friable cervix: define
Bleeds very easily after slight touch
Urinary voiding symptoms
List 3
- Slow stream
- Splitting or spraying
- Teriminal dribble
- Hesitancy- delay in start to micturition
Urinary storage symptoms
List 3
- Frequency
- Nocturia- waking at night one or more times
- Urgency
- Nocturnal enuresis: the loss of urine occurring during sleep
Which sphincter is under voluntary control?
External sphincter muscle
Which part of the brain controls the voluntary release of urine
- Pons
- Pontine storage center can delay micturition
- Pontine micturition centre allows urination when we want to
Types of incontinence
- Urge = always need to go
- Stress = physical activity e.g sneeze or cough
- Mixed= stress + urge
- Overflow= due to bladder outlet obstruction, e.g. due to prostate enlargement. >200ml left in bladder post void
- Functional= pt has dementia
Aetiology of urinary incontinence
- Idiopathic
- Neurological= MS, spinal injury to s2-3, hydrocephalus
- Genitourinary= trauma to pelvic floor muscles, peliv fracture, pelvic floor weakness
- Transcient causes= UTI, drugs e.g. diuretics
DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.
Stress incontinence: mechanism
- Uretheral hypermobility
- Intrinsic sphincter deficiency
- Increase in intrabdominal pressure e.g. coughing/ laughing
Stress incontinence: Dx
+ve Bladder stress test. Leaking of urine after activity which increases intraabdominal pressure
Urge incontinence: mechanism
- Inflammatory condition
- Neurogenic disorder
These cause over contraction of the detrusor muscle or abnormal sphincter control
Mixed incontinence: mechanism
combination of both stress and urge
How do you manage urinary incontinence?
- Manage diet= reduce alcoholic/ carbonated drinks
- Smoking cessation
- Pelvic floor exercises
- Surgery using slings/ Burch (stress)
- Use of antimuscarinic for urge (oxybutynin)
Try 1- 3 for 6 weeks initially for urge/stress
Cervical cancer: epidemiology
- 3rd most common gyane malignancy
- 2 peaks. 30-39yrs, >70
- Developing world mainly
Cervical cancer: aetiology
- HPV (high risk types e.g. 16, 18, 31, 33)
- Risk factors= multiple sexual partners, early onset of sexual activity, immunosupression, cigarette smoke
Cervical cancer: clinical features
- Early symptoms= abnormal vaginal bleeding (postcoital), abnormal vaginal discharge(watery), dyspareunia, pelvic pain
- Late symptoms= hydronephrosis, lymphedema, fistula formation
- Cervical examination- shows induration, exophytic tumour
Cervical cancer: classification
- Bethesda system- The Bethesda system is a classification system used to report the results of cytological screening of cervical cancer
- Cervical intraepithelial neoplasia- grade 1 - 5. Looks at the amount of the epithelial layers which are dysplastic. Used to classify histological samples e.g. biopsy
- FIGO
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Cervix: the 3 different parts to know histological
- Endocervix- columnar epithelium produce mucus
- Ectocervix- mature squamous cell epithelium.
- Squamocolumnar junction
- Transformation zone- where the cells come together
Cervical cancer: pathogenesis
- HPV infection or other factor causes uncontrolled cell division usually at the basal layer of transformation zone
- This is called cervical intraepithelial neoplasia
- The HPV infection produces proteins which act on tumour suppressor genes
Majority of cervical cancers are which type
Squamous cell carcinoma, then adenocarcinoma
What is colposcopy ?
- A procedure using a colposcope to examine the cervix, vagina, vulva, and anus for precancerous lesions or abnormalities
- Procedure allows magnified visualization of the epithelium to guide biopsy sampling for histologic diagnosis.
Surgerical options for Tx of invasive cervical cancer
- Diagnostic excision procedure: Cold-knife conization and loop electrosurgical excision procedure (LEEP)
- Trachelectomy- Removal of the cervix, upper vagina, and parametrium (may also involve removal of pelvic lymph nodes)
- Pelvic exenteration- reproductive organs plus bladder, urethera, anus . Palliative.
- Hysterectomy
Tx for invasive cervical carcinoma?
- Chemotherapy/ radiation
- Surgery to remove the uterus and accompaning lymph nodes
How often should screening for cervical cancer take place?
- 25-49 yr old should have screen every 3 years
- 50- 64 every 5 years
- > 65 yrs only those with abnormal test results
During colposcopy which finds point to invasive cervical cancer?
- Gross exophytic or endophytic neoplasm
- Ulceration
- Necrosis
- Erosions
- Atypical growth of the vessels (e.g., corkscrew or comma-like shape)
Acetowhite epithelium: what is it? Indicates?
- An area of the cervical epithelium that appears white after the application of acetic acid
- Indicates atypical changes of the epithelium. Requires biopsy at least 2-4 targeted.
Types of cervical biopsy
- Punch
- Cone
- Endocervical curettage
Primary cervical cancer prevention vs secondary?
- Primary = HPV vaccination. 2 doses. Before getting sexually active. Doses need to be 6-12 months apart.
- Screening is the secondary method. Pap smear, HPV DNA testing, colposcopy
What are some contraindication for Pap smear?
- Endometrial cancer
- Hx of hysterectomy for nonmalignant disease
- > 65 years old
Types of hysterectomy
- Subtotal/ Supracervical- upper part of uterus removed, cervix intact
- Total- uterus plus cervix
- Radical- everything including upper portion of vagina, lymph nodes and fatty tissue, fallopian tubes and ovaries
Infertility: define
Inability to achieve pregnancy after 12 months of unprotected sex in women < 35 years and 6 months in women ≥ 35 years of age
2 types of infertility
- Primary= infertility in persons who have never achieved pregnancy
- Secondary= infertility in persons who have previously achieved at least one pregnancy
Female infertility can be divided into 4 broad groups which are?
- Ovary related
- Tubal/ pelvic
- Cervical factors
- Uterine factors
Ovary related reasons for infertility
List 3
- PCOS
- Pituitary adenoma
- Menstural cycle abnormalities (functional hypothalamic amenorrhea)
Tubal/ pelvic reasons for infertility
List 3
- PID
- Endometriosis
- Fallopian tube adhesions due to infection e.g. gonorrhoea or from obstruction e.g. from surgery
Cervical factors for infertility
List 2
- Antisperm antibodies in cervical mucus
- Trauma from conization
Uterine factors for infertility
List 2
- Leiomyoma
- Endometrial polyps
- Ashermans syndrome
Asherman syndrome
Define
A condition characterized by adhesions and/or fibrosis of the endometrium that can cause amenorrhea and infertility. Associated with intrauterine instrumentation (e.g., dilation and curettage), postpartum hemorrhage, or intrauterine infections.
Hormone levels vary the least during which days of the cycle?
3-5 days. Hormone variation at this stage suggests follicular maturation problems
High prolactin levels leads to
A condition of elevated serum prolactin, which causes galactorrhea in women, gynecomastia in men, and symptoms of hypogonadotropic hypogonadism (due to ↓ FSH and LH secretion) in both sexes.
Tx options for female infertility
- Lifestyle modification
- Tx underlying conditions (Levothyroxine for hypothyroidism, bromocriptine for hyperprolactinemia, metformin for PCOS)
- Ovulation induction e.g. with clomiphene citrate
- Assisted reproductive technology
Dx of male infertility
- Hx
- Semen analysis
- TSH, prolactin levels
- Karyotype testing for kleinfelter
Endometrial cancer: Types
- Type 1- cells of endometrioid origin
- Type 2- nonendometrioid cells, serous/ clear cells
Aetiology of endometrial cancer
- Type 1= direct long term exposure to oestrogen. Some genetic mutation such as PTEN
- Type 2= oestrogen independent, associated with endometrial atrophy, strong genetic predisposition (p53 mutation)
Risk factors for endometrial cancer?
- Nulliparity
- Early menarche and late menopause
- Polycystic ovary syndrome= no ovulation therefore no progesterone which is protective
- Metabolic syndrome (esp. obesity and diabetes mellitus type 2 )
- Hypertension
- Unopposed estrogen replacement therapy (e.g., for menopausal symptoms)
- History of breast cancer and tamoxifen treatment. Tamoxifen +ve on uterus oestrogen sensitivity
- Lynch syndrome
What is Lynch syndrome?
A hereditary cancer syndrome caused by a mutation in mismatch repair genes. Individuals have a significantly higher risk of developing colorectal, gastric, ovarian, and endometrial cancer.
Protective factors against endometrial cancer?
- Multiparity
- Combination oral contraceptive pills
- Regular physical exercise
- Lifelong soy-rich diet
- Smoking (more type 1, increases type 2)
Endometrial cancer: clinical features
- Abnormal uterine bleeding= postmenopausal, Premenopausal or perimenopausal, Intermenstrual bleeding
Heavy irregular menstrual bleeding - Regional extension= abdominal distension, pelvic pain, bowel/ bladder habit changes
- Metastatic= spread to retroperitoneal via lymphatics or to lung by haematogenous
Endometrial cancer: dx, tx
- Dx= TVUS (thickness < 4mm= high negative predicative value), biopsy to confirm (can be hysteroscopy Dilation&curettage, or in office), MRI pelvis/ PETCT scan
- Tx= total hysterectomy with bilateral salpingo-oophorectomy. High risk will receive radiation therapy too
Good prognosis
Clear cell and papillary serous carcinomas (type II) have an aggressive course and a poor prognosis.
Foetal orientation: the different components
- Foetal lie
- Presenting part
- Position
- Attitude of presenting part
- Station
Foetal lie: the different types
- Longitudinal = same as mother
- Transverse= foetus is at a 90° angle. This has many variation, depending on the relation of the back to the uterus, dorsosuperior, -inferior, -post, -anterior
- Oblique lie= foetus is at a 45° angle
Foetal presentation
- Definition: part of the fetus that overlies the maternal pelvic inlet
1. Cephalic
2. Breech: feet/ buttocks. Types=
3. Complete breech
4. Single footling
5. Double footling
6. Frank breech
7. Compound presentation
8. Shoulder presentation