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Obstetrics & gynaecology Flashcards

1
Q

What hormonal changes occur in pregnancy?

A

increased:
steroid hormones
T3/4
prolactin
melanocyte stimulating hormone
oestrogen
progesterone
HcG

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2
Q

What cardiovascular changes occur in pregnancy?

A

increased:
blood volume
plasma volume
cardiac output

decreased:
vascular resistance
blood pressure

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3
Q

What respiratory changes occur in pregnancy?

A

Increased:
tidal volume
resp rate

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4
Q

What renal changes occur in pregnancy?

A

Increased:
blood flow
GFR
sodium reabsorption
water reabsorption
protein excretion

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5
Q

What haematological changes occur in pregnancy?

A

Increased:
RBC production
WBC
Clotting factors
ALP

decreased:
Platelets
Haematocrit
Albumin

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6
Q

What skin changes occur in pregnancy?

A

Linear Nigra
melasma
striae gravidarum
spider naevi
Palmar erythema

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7
Q

When does labour and delivery normally occur?

A

between 37 and 42 weeks gestation

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8
Q

What are the 3 stages of labour?

A

The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
The second stage is from 10cm cervical dilatation to delivery of the baby.
The third stage is from delivery of the baby to delivery of the placenta.

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9
Q

What is the role of prostaglandins in labour?

A

Ripening of cervix
uterine contractions

can use prostaglandin E2 pessaries to induce labour

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10
Q

What are the 3 phases of the first stage of labour?

A

Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

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11
Q

What 3 factors does the second stage of labour depend on?

A

Power: strength of contraction
Passenger: size, attitude(posture), lie, presentation
Passage: size and shape of pelvis/birth canal

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12
Q

What are the 7 cardinal movements of labour?

A

Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution and external rotation
Expulsion

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13
Q

How is decent of the baby measured?

A

position of baby’s head in relation to ischial spines
-5: when the baby is high up at around the pelvic inlet
0: when the head is at the ischial spines (this is when the head is “engaged”)
+5: when the fetal head has descended further out

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14
Q

What 2 factors should prompt active management of the 3rd stage of labour?

A

Haemorrhage
more than 60 minute delay in delivery of placenta

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15
Q

What is active management of the 3rd stage of labour?

A

IM oxytocin
traction to the umbilical cord

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16
Q

What are some causes of primary amenorrhoea?

A

Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology

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17
Q

What is secondary amenorrhoea?

A

when the patient previously had periods that subsequently stopped

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18
Q

What are some causes of secondary amenorrhoea?

A

Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency
Thyroid hormone abnormalities
Excessive prolactin, from a prolactinoma
Cushing’s syndrome

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19
Q

What are some differentials for irregular menstruation?

A

Extremes of reproductive age
Polycystic ovarian syndrome
Physiological stress
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin

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20
Q

What are some differentials for intermenstrual bleeding?

A

Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants

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21
Q

What are some differentials for dysmenorrhoea (painful periods) ?

A

Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer

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22
Q

What are some differentials for menorrhagia?

A

Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome

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23
Q

What are some differentials for postcoital bleeding?

A

Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer

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24
Q

What are some differentials for pelvic pain?

A

Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)

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25
Q

What are some differentials for excessive, discoloured or foul-smelling discharge?

A

Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception

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26
Q

What are some causes of pruritis vulvae?

A

Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress

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27
Q

How do you define primary amenorrhoea?

A

Not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development

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28
Q

What is hypogonadotropic hypogonadism?

A

deficiency of LH and FSH

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29
Q

What is hypergonadotropic hypogonadism?

A

lack of response to LH and FSH by the gonads (the testes and ovaries)

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30
Q

What are some causes of hypogonadotropic hypogonadism?

A

Hypopituitarism
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting
Constitutional delay in growth and development
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome

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31
Q

What are some causes for hypergonadotropic hypogonadism?

A

Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)

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32
Q

What is Kallman syndrome?

A

genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia)

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33
Q

What causes congenital adrenal hyperplasia?

A

congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth
Autosomal recessive

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34
Q

What is androgen insensitivity syndrome?

A

tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop. It results in a female phenotype

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35
Q

What structural pathology can cause primary amenorrhoea?

A

Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation

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36
Q

What initial investigations should be done to assess for underlying medical conditions in primary amenorrhoea?

A

Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease

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37
Q

What blood tests can be done to assess for hormonal abnormalities in primary amenorrhoea?

A

FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
Thyroid function tests
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia

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38
Q

What imaging can be useful to assess causes of primary amenorrhoea?

A

Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
Pelvic ultrasound to assess the ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

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39
Q

What is the definition of secondary amenorrhoea?

A

no menstruation for more than three months after previous regular menstrual periods

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40
Q

What medication can be given to treat hyperprolactinaemia?

A

Dopamine agonists such as bromocriptine or cabergoline

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41
Q

What should an assessment of secondary amenorrhoea involve?

A

Detailed history and examination to assess for potential causes
Hormonal blood tests
Ultrasound of the pelvis to diagnose polycystic ovarian syndrome

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42
Q

What hormone tests suggest primary ovarian failure?

A

High FSH

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43
Q

What hormone tests suggest PCOS?

A

High LH, or LH:FSH ratio
raised testosterone

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44
Q

How can you reduce the risk of osteoporosis in secondary amenorrhoea?

A

adequate vitD and calcium
COCP or HRT

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45
Q

What is premenstrual syndrome?

A

psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

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46
Q

What are some symptoms of premenstrual syndrome?

A

Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido

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47
Q

What are the management options for premenstrual syndrome?

A

General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP)
RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.
SSRI antidepressants
Cognitive behavioural therapy (CBT)

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48
Q

What investigations can be done for heavy menstrual bleeding?

A

Pelvic examination with a speculum and bimanual
Full blood count, coag screen, ferritin
Outpatient hysteroscopy
Pelvic and transvaginal ultrasound

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49
Q

What are the management options for heavy menstrual bleeding when the patient does not want contraception?

A

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

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50
Q

What is the management of heavy menstrual bleeding when contraception is wanted?

A

Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)

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51
Q

When medical management has failed what are the options for treatment of heavy menstrual bleeding?

A

endometrial ablation and hysterectomy

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52
Q

What are the 4 types of fibroids?

A

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.

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53
Q

How may fibroids present?

A

Heavy menstrual bleeding
Prolonged menstruation
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility

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54
Q

what may abdominal and bimanual examination reveal in fibroids?

A

palpable pelvic mass or an enlarged firm non-tender uterus

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55
Q

What investigations can be done for fibroids?

A

Hysteroscopy
pelvic ultrasound
MRI

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56
Q

If fibroids are over 3cm what are the management options?

A

referral to gynaecology
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens

Surgical options for larger fibroids are:
Uterine artery embolisation
Myomectomy
Hysterectomy
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.

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57
Q

What are the potential complications of fibroids?

A

Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)

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58
Q

What is red degeneration of fibroids?

A

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia
common in pregnancy

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59
Q

What is endometriosis?

A

condition where there is ectopic endometrial tissue outside the uterus

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60
Q

What are chocolate cysts ?

A

Endometriomas in the ovaries

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61
Q

What are the symptoms of endometriosis?

A

Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria

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62
Q

What may examination reveal in endometriosis?

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa

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63
Q

How is endometriosis diagnosed?

A

Pelvic ultrasound
Laparoscopic surgery = gold standard

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64
Q

What staging system may be used for endometriosis?

A

American Society of Reproductive Medicine (ASRM)

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65
Q

What are the hormonal management options for endometriosis?

A

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists

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66
Q

What are the surgical management options for endometriosis?

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy

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67
Q

What is Adenomyosis?

A

endometrial tissue inside the myometrium (muscle layer of the uterus)

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68
Q

What are the presenting features of adenomyosis?

A

Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)

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69
Q

How is adenomyosis diagnosed?

A

1st line = transvaginal ultrasound
MRI/transabdominal ultrasound
Gold = histology following hysterectomy

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70
Q

What pregnancy complications are associated with adenomyosis?

A

Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage

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71
Q

when can a diagnosis of menopause be made?

A

after a woman has had no periods for 12 months

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72
Q

What is the average age of menopause?

A

51 years

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73
Q

what is postmenopause?

A

describes the period from 12 months after the final menstrual period onwards.

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74
Q

What is perimenopause?

A

time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards

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75
Q

What is premature menopause?

A

menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

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76
Q

What are the hormonal changes in menopause?

A

Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

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77
Q

describe the physiology of menopause

A

decline in development of follicles -> reduced production of oestrogen -> no negative feedback -> increased LH and FSH

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78
Q

Name some perimenopausal symptoms

A

Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido

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79
Q

What are you at increased risk of with low oestrogen e.g. menopause

A

Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

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80
Q

when is it recommended to do an FSH test to diagnose menopause?

A

Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

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81
Q

when is contraception required after menopause?

A

Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50

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82
Q

What are some management options for perimenopausal symptoms?

A

No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers

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83
Q

What are some causes of premature ovarian insufficiency?

A

Idiopathic (the cause is unknown in more than 50% of cases)
Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic, with a positive family history or conditions such as Turner’s syndrome
Infections such as mumps, tuberculosis or cytomegalovirus

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84
Q

What are the 2 HRT options for premature ovarian insufficiency?

A

Traditional hormone replacement therapy
Combined oral contraceptive pill

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85
Q

What are the risks of HRT?

A

breast cancer (particularly combined HRT)
endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
stroke and coronary artery disease with long term use in older women

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86
Q

How can you reduce the risks of HRT?

A

The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
The risk of VTE is reduced by using patches rather than pills

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87
Q

What are essential contraindications to HRT?

A

Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy

88
Q

What needs to be assessed before starting HRT?

A

Take a full history to ensure there are no contraindications
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Encourage lifestyle changes that are likely to improve symptoms and reduce risks

89
Q

What is essential when prescribing HRT to a woman with a uterus?

A

progesterone needed for endometrial protection

90
Q

How do you know when cyclical vs continuous HRT should be used?

A

Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT

91
Q

What are some side effects of HRT?

A

Oestrogenic side effects:
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps

Progestogenic side effects:
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin

92
Q

What criteria is used to diagnose PCOS?

A

Rotterdam Criteria
diagnosis requires at least two of the three key features

93
Q

What are the features of the Rotterdam criteria?

A

Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

94
Q

What are some key presenting features of PCOS?

A

Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern

95
Q

What are some differential diagnoses for hirsutism?

A

PCOS
Medications
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia

96
Q

What can help reduce insulin resistance in PCOS?

A

Diet, exercise and weight loss

97
Q

What blood tests are recommended to diagnose PCOS and exclude other pathology that may have a similar presentation?

A

Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone

98
Q

What will hormonal blood tests in PCOS typically show?

A

Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels

99
Q

What is the diagnostic criteria for ovarian cysts on PCOS?

A

12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3

100
Q

Options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS?

A

Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill

101
Q

What are the options for managing infertility in PCOS?

A

Weight loss
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)

102
Q

What are the management options for hirsutism in PCOS?

A

Co-cyprindiol (Dianette) is a combined oral contraceptive pill
Topical eflornithine

103
Q

what is the 1st line management option for acne in PCOS?

A

combined oral contraceptive pill

104
Q

What can multiple ovarian cysts appear as on ultrasound?

A

string of pearls

105
Q

What symptoms may ovarian cysts cause?

A

Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

106
Q

What are some non-malignant causes of a raised CA125

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

107
Q

What is the risk of malignancy index?

A

estimates the risk of an ovarian mass being malignant, taking account of three things:

Menopausal status
Ultrasound findings
CA125 level

108
Q

State 3 key complications of ovarian cysts

A

Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum

109
Q

What triad is seen in Meig’s syndrome?

A

Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites

110
Q

What is the main cause of ovarian torsion?

A

ovarian mass larger than 5cm, such as a cyst or a tumour

111
Q

What is the main presenting feature of ovarian torsion?

A

sudden onset severe unilateral pelvic pain.
The pain is constant, gets progressively worse and is associated with nausea and vomiting

112
Q

What will examination show in ovarian torsion?

A

localised tenderness
may be a palpable mass

113
Q

What is the 1st line investigation for ovarian torsion and what will it show

A

Pelvic ultrasound (ideally transvaginal)
will show whirlpool sign - free fluid and oedema or the ovary

114
Q

How is a definitive diagnosis of ovarian torsion made?

A

laparoscopic surgery

115
Q

What are the management options for ovarian torsion?

A

laparoscopic surgery to either:

Un-twist the ovary and fix it in place (detorsion)
Remove the affected ovary (oophorectomy)

116
Q

What is Asherman’s syndrome?

A

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus

117
Q

What are some risk factors for Asherman’s syndrome?

A

dilation and curettage
uterine surgery
severe pelvic infection

118
Q

What are the presenting features of Asherman’s syndrome?

A

Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
It may also present with infertility.

119
Q

What are the options for establishing a diagnosis of Asherman’s syndrome?

A

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan

120
Q

What is the management of Asherman’s syndrome?

A

dissecting the adhesions during hysteroscopy

121
Q

What is cervical ectropion?

A

columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).

122
Q

What are some risk factors for cervical ectropion?

A

younger women
COCP
pregnancy

123
Q

What are the presenting symptoms of a cervical ectropion?

A

increased vaginal discharge
vaginal bleeding (postcoital)
dyspareunia (pain during sex).

124
Q

What will speculum examination show in a patient with a cervical ectropion?

A

well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone

125
Q

what are the management options for cervical ectropion?

A

no treatment if not causing problems
if problematic bleeding - cauterisation with silver nitrate or cold coagulation during colposcopy

126
Q

What are Nabothian cysts?

A

fluid-filled cysts often seen on the surface of the cervix

127
Q

what is a uterine prolapse ?

A

uterus itself descends into the vagina

128
Q

What is a vault prolapse?

A

women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina

129
Q

What is a rectocele?

A

defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina

130
Q

What symptoms are particularly associated with rectoceles?

A

Constipation and faecal loading, urinary retention

131
Q

What is a cystocele?

A

defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

132
Q

What are some risk factors for a pelvic organ prolapse

A

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

133
Q

What are the presenting symptoms of a pelvic organ prolapse?

A

A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

134
Q

What can be used to grade the severity of a pelvic organ prolapse?

A

pelvic organ prolapse quantification (POP-Q) system:
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.

135
Q
A
136
Q

What are some conservative management options for a pelvic organ prolapse?

A

Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream

136
Q

What are the 3 management options for a pelvic organ prolapse?

A

Conservative management
Vaginal pessary
Surgery

137
Q

Name 4 types of vaginal pessaries

A

ring
shelf/gellhorn
cube
donut
hodge

137
Q

What are some possible complications of pelvic organ prolapse surgery?

A

Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex

138
Q

What are the 2 types of urinary incontinence?

A

urge
stress

139
Q

What causes urge incontinence?

A

overactivity of the detrusor muscle of the bladder

140
Q

What is the cause of stress incontinence?

A

weakness of the pelvic floor and sphincter muscles

141
Q

when does overflow incontinence occur?

A

chronic urinary retention due to an obstruction to the outflow of urine

142
Q

What are some risk factors for urinary incontinence?

A

Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia

143
Q

What are some modifiable lifestyle factors that can contribute to urinary incontinence?

A

Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)

144
Q

What grading system can be used to assess strength of pelvic muscles on bimanual examination?

A

modified Oxford grading system

145
Q

What investigations should be done for urinary incontinence?

A

bladder diary
urine dipstick
post-void residual bladder volume
Urodynamic testing

146
Q

What are the management options for stress incontinence?

A

Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

147
Q

What are some surgical options for stress incontinence?

A

Tension-free vaginal tape
autologous sling procedures
colposuspension
intermural urethral bulking

148
Q

what are the management options of urge incontinence?

A

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails

149
Q

What is Mirabegron contraindicated in?

A

uncontrolled hypertension

150
Q

What are some invasive options for treating urge incontinence?

A

Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
urinary diversion

151
Q

What is atrophic vaginitis?

A

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

152
Q
A
153
Q

What are some presenting symptoms of atrophic vaginitis?

A

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation

154
Q

what are the management options of atrophic vaginitis?

A

vaginal lubricants
topical oestrogen e.g. cream, pessary

154
Q

what will examination of atrophic vaginitis show?

A

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

155
Q

What areas does lichen sclerosis usually affect in women?

A

labia, perineum, perianal skin

156
Q

What is lichen sclerosis?

A

chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin

157
Q

What are the presenting symptoms of lichen sclerosis?

A

Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

158
Q

What is the appearance of lichen sclerosis?

A

“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques

159
Q

What is the management of lichen sclerosis?

A

potent topical steroids e.g. dermovate
Emollients

160
Q

What are some complications of lichen sclerosis?

A

SCC of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings

161
Q

What are the 4 types of female genital mutilation?

A

Type 1: Removal of part or all of the clitoris.
Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
Type 3: Narrowing or closing the vaginal orifice (infibulation).
Type 4: All other unnecessary procedures to the female genitalia.

162
Q

What are some immediate complications of female genital mutilation?

A

Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence

163
Q

What are some long term complications of female genital mutilation?

A

Vaginal infections, such as bacterial vaginosis
Pelvic infections
Urinary tract infections
Dysmenorrhea (painful menstruation)
Sexual dysfunction and dyspareunia (painful sex)
Infertility and pregnancy-related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening

164
Q

embryonically where does the upper vagina, cervix, uterus and fallopian tubes develop from?

A

paramesonephric ducts (Mullerian ducts)

165
Q

What are some typical complications of a Bicornuate uterus?

A

Miscarriage
Premature birth
Malpresentation

166
Q

What is the inheritance pattern of androgen insensitivity?

A

X-linked recessive

167
Q

What are the 2 main ways androgen insensitivity presents?

A

inguinal hernias containing testes in infancy
primary amenorrhoea

168
Q

What will hormonal tests show in androgen insensitivity syndrome?

A

Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)

169
Q

What is the genotype and phenotype in androgen insensitivity syndrome?

A

XY
female phenotype

170
Q

What is the management of androgen insensitivity syndrome?

A

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

171
Q

What type of cancer are 80% of cervical cancers?

A

squamous cell carcinoma

172
Q

What is cervical cancer strongly associated with?

A

human papilloma virus

173
Q

what are the 2 types of HPV responsible for the majority of cervical cancers?

A

type 16 and 18

174
Q

what are risk factors for catching HPV?

A

Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms

175
Q

Apart from contracting HPV what are some other risk factors for cervical cancer?

A

non-engagement with cervical screening
Smoking
HIV
COCP
Increases number of full term pregnancies
family history
exposure to diethylbestrol

176
Q

what are the presenting features of cervical cancer?

A

Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)

177
Q

What appearances on speculum examination may suggest cervical cancer?

A

Ulceration
Inflammation
Bleeding
Visible tumour

178
Q

what are the grades of cervical intraepithelial neoplasia?

A

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated

179
Q

who is invited for cervical cancer screening?

A

women (and transgender men that still have a cervix):

Every three years aged 25 – 49
Every five years aged 50 – 64

180
Q

how often are patients with HIV screened for cervical cancer?

A

annually

181
Q

how should different smear test results be managed?

A

Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy

182
Q

What are the FIGO stages for cervical cancer?

A

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

183
Q

what are the management options for cervical cancer?

A

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

184
Q

what strains of HPV cause genital warts?

A

6 and 11

185
Q

What type of cancer are the majority of endometrial cancers?

A

adenocarcinoma

186
Q

What is endometrial hyperplasia?

A

precancerous condition involving thickening of the endometrium

187
Q

How is endometrial hyperplasia managed?

A

Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

188
Q

what are the risk factors for endometrial cancer?

A

Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Type 2 diabetes
Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome

189
Q

What are some protective factors against endometrial cancer?

A

Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking

190
Q

what is the number 1 presenting symptoms of endometrial cancer?

A

postmenopausal bleeding

191
Q

Apart from post-menopausal bleeding what are some other symptoms of endometrial cancer?

A

Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count

192
Q

what investigations can be done to diagnose endometrial cancer?

A

Transvaginal ultrasound for endometrial thickness
Pipelle biopsy
Hysteroscopy

193
Q

What endometrial thickness is normal in post-menopausal women?

A

<4mm

194
Q

what are the FIGO stages of endometrial cancer?

A

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

195
Q

what is the main management of endometrial cancer

A

total abdominal hysterectomy with bilateral salpingo-oophorectomy

196
Q

state 3 types of ovarian cancer

A

Epithelial cell (most common)
dermoid cysts/germ cell tumours
sex cord-stromal tumours

197
Q

what is a Krukenberg tumour?

A

metastasis in the ovary, usually from a gastrointestinal tract cancer
“signet-ring” cells on histology

198
Q

what are the risk factors for ovarian cancer?

A

Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations (early-onset periods, late menopause, no pregnancies)
Obesity
Smoking
Recurrent use of clomifene

199
Q

what are some protective factors against ovarian cancer?

A

Combined contraceptive pill
Breastfeeding
Pregnancy

200
Q

what are some presenting features of ovarian cancer?

A

Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites

201
Q

what are the initial investigations for suspected ovarian cancer?

A

CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound

202
Q

What factors are taken into account in the risk malignancy index of ovarian cancer?

A

Menopausal status
Ultrasound findings
CA125 level

203
Q

Women under 40 years with a complex ovarian mass require which tumour markers for a possible germ cell tumour?

A

Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

204
Q

what are some non-malignant causes of a raised CA125?

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

205
Q

what are the FIGO stages of ovarian cancer?

A

Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)

206
Q

how is ovarian cancer managed?

A

combination of surgery and chemotherapy

207
Q

what type are 90% of vulval cancers?

A

squamous cell carcinomas

208
Q

what are the risk factors for vulval cancer?

A

Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus

209
Q

what is the management of vulval intraepithelial neoplasia?

A

Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation

210
Q

what are the symptoms of vulval cancer?

A

Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
Vulval cancer most frequently affects the labia majora, giving an appearance of:

Irregular mass
Fungating lesion
Ulceration
Bleeding

211
Q

what staging system is used for vulval cancer?

A

FIGO

212
Q

what are the management options for vulval cancer?

A

Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy

Finals (13 decks)

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