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Gynaecology > Ovary, vagina > Flashcards

Ovary, vagina Flashcards

1
Q

1st

A

1st

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2
Q

Simple anatomy of the ovaries

A 
Outer cortex (contains follicles and theca cells - produce hormones) and inner medulla (contains connective tissue and blood vessels) 
Cortex covered by germinal epithelium
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3
Q

What are ovarian cyst ‘accidents’

A

Acute presentation of ovarian cysts- often don’t present otherwise unless very large
Rupture of cyst, haemorrhage into a cyst or torsion of the pedicle

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4
Q

Presentation of ovarian cyst accidents

A

All cause intense pain - haemorrhage into peritoneal cavity can cause hypovolaemic shock

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5
Q

What are the 3 types of primary ovarian tumours?

A

Epithelial tumours
Germ cell tumours
Sex cord tumours
Benign and malignant are considered together because benign cyst can undergo malignant change

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6
Q

Which ovarian tumour type is more common in postmenopausal women

A

Epithelial tumours

or sex cord tumours

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7
Q

Which ovarian tumour type is more common in young premenopausal women

A

Germ cell tumours

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8
Q

Which cancers metastasise to the ovaries

A

Breast and GIT cancers

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9
Q

Prognosis with ovarian cancer?

A

Poor!

5-year survival rate is below 35% because they present late

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10
Q

Highest incidence for ovarian cancer at what age?

A

80-84

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11
Q

What are most ovarian cancers?

A

90% are epithelial carcinomas

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12
Q

Risk factors for ovarian cancer?

A

Number of ovulations - early menarche, late menopause, nulliparity

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13
Q

Protective factors for ovarian cancer?

A

Pregnancy
Lactation
Use of the pill

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14
Q

Inheritability of ovarian cancer

A

May be familial (5%) via BRCA 1 and 2 and HNPCC (Lynch syndrome)

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15
Q

Screening for ovarian cancer?

A

There is currently no screening program but it is under investigation as prognosis is much better if caught early - would be done with annual TV USS or CA 125 checks

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16
Q

When does ovarian cancer present

A

Symptoms are initially vague and/or absent and 70% present with Stage 3-4 cancer

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17
Q

Clinical presentation of ovarian cancer x4

A 
Abdominal distention (bloating)
Feeling full (early satiety) and/or loss of appetite
Pelvic or abdominal pain 
Increased urinary urgency and/or frequency
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18
Q

What is the presentation of ovarian cancer similar to?

A

IBS

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19
Q

What should you ask with possible ovarian cancer Dx?

A

GIT or breast symptoms because of mets

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20
Q

Examination findings in ovarian cancer? x3

A

May reveal cachexia
Abdominal or pelvic mass
Ascites

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21
Q

How does ovarian cancer spread?

A

Directly within pelvis and abdomen - transcoelomic spread

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22
Q

What is stage 1 ovarian cancer?

A

Disease is macroscopically confined to the ovaries
1a - one ovary - capsule intact
b - two ovaries - capsule intact
c - one or two - capsule not intact or malignant cells in abdominal cavity (ascites)

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23
Q

What is stage 2 ovarian cancer

A

Disease spread beyond ovaries but in pelvis

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24
Q

Stage 3 ovarian cancer?

A

Disease spread beyond pelvis but confined to abdomen (omentum, small bowel and peritoneum - frequently affected)

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25
Q

Stage 4 ovarian cancer

A

Spread outside of the abdominal cavity - eg. lungs or liver parenchyma

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26
Q

Investigations in suspected ovarian cancer

A

CA 125 levels - should be done in any woman >50 with abdominal symptoms
If >35IU/mL then ultrasound of abdomen/pelvis is done

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27
Q

What levels are raised in ovarian germ cell tumours?

A

AFP and hCG

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28
Q

What score is calculated to assess disease risk of ovarian cancer?

A

Risk of malignancy index - Ultrasound score, menopausal status and serum CA 125 level

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29
Q

What score on the RMI requires referral?

A

> 250

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30
Q

What is the surgical treatment for ovarian cancer?

A

Midline laparatomy - hysterectomy, bilateral salpingo-oopherectomy and partial omentectomy
Stage 2 and above the retroperitoneal lymph nodes are removed

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31
Q

When is chemotherapy used in ovarian cancer?

A

Stage 1c and above

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32
Q

What is used to monitor response to chemotherapy with ovarian cancer?

A

Levels of CA 125

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33
Q

What is commonly the cause of death with ovarian cancer?

A

Bowel obstruction or perforation

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34
Q

Where does the vulva lymph drainage go to?

A

Inguinal lymph nodes - these drain to the femoral and then external iliac

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35
Q

What are the most common vulval symptoms?

A

Pruritus, soreness, burning and superficial dyspareunia

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36
Q

What can cause vulval symptoms?

A 
Candidiasis 
Vulval warts 
Pubic lice, scabies 
Any dermatological disease 
Neoplasia - carcinoma or pre-malignant disease
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37
Q

What is lichen simplex?

A

Chronic vulval dermatitis

Chronic inflammatory skin condition of the vulva in women with sensitive skin, dermatitis or eczema

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38
Q

Symptoms of lichen simplex?

A

Severe intractable pruritus, esp. at night
Inflamed labia majora with hypo and hyper-pigmentation
Symptoms exacerbated by chemical or contact dermatitis
Sometimes symptoms are linked to stress

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39
Q

Management of lichen simplex

A

Emollients, steroid creams and antihistamines - used to aim to break itch-scratch cycle

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40
Q

How does lichen planus present in the vulva?

A

Flat, papular, purplish lesions

Can be erosive and more commonly associated with pain rather than pruritis

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41
Q

Treatment of lichen planus

A

High potency steroid cream

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42
Q

How does lichen sclerosus present?

A

Severe pruritis - worse at night
Uncontrollable scratching can cause trauma with bleeding and skin splitting
Pink-white papules - coalesce to form parchment-like skin with fissures

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43
Q

What can happen with lichen sclerosus

A

Inflammatory adhesions can form potentially causing fusion of the labia and narrowing of the introitus
Vulval carcinoma develops in 5%

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44
Q

Treatment of lichen sclerosus

A

Ultra-potent topical steroids

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45
Q

Who is candidiasis more common in?

A

Diabetics, obese, pregnancy, antibiotics, immunocompromised

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46
Q

What are the Bartholin glands?

A

They are two glands behind the labia minora which secrete lubricating mucus for coitus

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47
Q

When do Bartholin cysts arise? What can lead to

A

If blockage of the duct - cyst forms. If infection occurs (commonly staph.auerus or e.coli) abscess forms

48
Q

Presentation of Bartholin abscess?

A

Acutely painful and large tender red swelling

49
Q

Treatment of Bartholin abscess

A

Drainage and then incision is sutured open (marsupialisation) to reduce risk of reformation

50
Q

Details of vaginal cysts

A

Congenital cysts in vagina
Smooth white appearance - can be mistaken for prolapse
Remove if dyspareunia

51
Q

What is vulval intraepithelial neoplasia (VIN)?

A

Presence of atypical cells in the vulval epithelium - premalignant disease of the vulva

52
Q

What are the two types of VIN and which is more common?

A

Usual type VIN and differentiated type VIN - nearly all are usual type VIN

53
Q

Which type of VIN is seen with which age group?

A

Usual type more common in women 35-55

Differentiated type more common in older women

54
Q

What is usual type VIN associated with?

A

HPV, CIN, cigarette smoking and chronic immunosuppression

55
Q

Presentation of usual type VIN

A

May be multifocal - appearances vary widely

56
Q

What is differentiated type VIN associated with?

A

Lichen sclerosis

57
Q

Type of lesion in differentiated type VIN

A

Unifocal in the form of an ulcer or plaque

58
Q

Which VIN type has highest risk of progression to cancer?

A

Differentiated type VIN

59
Q

What are common symptoms which VIN?

A

Pruritus or pain

60
Q

Gold standard treatment for VIN?

A

Local surgical excision to relieve symptoms, confirm histology and exclude invasive disease

61
Q

When is carcinoma of the vulva most common?

A

After age 60

62
Q

What type of cancers are vulva carcinoma normally?

A

95% are squamous cell carcinomas

63
Q

What do carcinomas of the vulva usually arise due to?

A

Usually de novo despite VIN being a pre-malignant stage

64
Q

What is vulval carcinoma associated with?

A

Lichen sclerosis, immunosuppression, smoking and Pagets disease of the vulva

65
Q

Clinical features of vulval carcinoma?

A

Pruritus, bleeding or a discharge

May find a mass - but malignancy often presents late

66
Q

Examination in vulval carcinoma

A

Will reveal ulcer or mass - most commonly on labia majora or clitoris
Inguinal lymph nodes may be enlarged, hard and immobile

67
Q

How does vulval carcinoma spread?

A

Superficially and then to deep inguinal lymph nodes

68
Q

How is vulval carcinoma staged?

A

Surgically and histologically (After surgery)

69
Q

Stage 1a vulval carcinoma?

A

Tumour confined to vulval perineum

70
Q

Stage 1b vulval carcinoma

A

Tumour confined to vulval perineum >2cm in size or with stromal invasion >1mm

71
Q

Stage 2 vulval carcinoma

A

Adjacent spread to lower urethra/vagina or anus

72
Q

Stage 3 vulval carcinoma

A

Inguinofemoral nodes involved

73
Q

Stage 4 vulval cancer

A

Invades upper urethra/vagina, rectum. bladder, bone or distant mets

74
Q

Treatment of stage 1a vulval carcinoma

A

Wide local excision - without inguinal lymphadenopathy

75
Q

Treatment of all other stages of vulval carcinoma

A

Wide local excision - groin lymphadenectomy = triple incision radical vulvectomy

76
Q

When is radiotherapy used in vulval carcinoma x3

A

Prior to surgery to shrink large tumours or postoperatively if groin lymph nodes are positive
Or palliatively to treat severe symptoms

77
Q

Details of malignancies of vagina?

A

Primary carcinoma is 2% of genital tract malignancies - affects older women, generally squamous
Presents with bleeding or discharge - or mass/ulcer
Treatment with intravaginal radiotherapy or occasionally radical surgery

78
Q

What is a urethrocele?

A

Prolapse of the lower anterior vaginal wall, involving the urethra only

79
Q

What is a cystocele?

A

Prolapse of the upper anterior vaginal wall, involving the bladder

80
Q

What is a cystourethrocele?

A

Prolapse of the upper anterior wall + bladder often also has associated prolapse of urethra

81
Q

What is apical prolapse?

A

Term used to describe prolapse of the uterus, cervix and upper vagina

82
Q

What is a enterocele?

A

Prolapse of the upper posterior wall of the vagina

Resulting pouch usually contains loops of small bowel

83
Q

What is a rectocele?

A

Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum

84
Q

What must be used when the measurements of a prolapse exam are explained?

A

The condition of the examination must be explained, eg. position of the patient, at rest/straining and whether traction is employed

85
Q

What is 0 on ISC Pelvic Organ Prolapse (POP) scoring system?

A

No descent of pelvic organs during straining

86
Q

What is 1 on ISC POP score?

A

Leading surface of the prolapse does not descend below 1cm above the hymenal ring

87
Q

What is 2 on ISC POP score?

A

Leading edge of the prolapse extends from 1cm above to 1cm below the hymenal ring

88
Q

What is 3 on ISC POP score?

A

Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion

89
Q

What is 4 on ISC POP score?

A

Vagina completely everted (complete procidentia)

90
Q

Risk factors for prolapse x5

A 
Vaginal delivery and pregnancy 
Abnormal collagen disorders
Menopause 
Chronic increased abdominal pressure
Pelvic surgery
91
Q

What factors associated with pregnancy increase the risk of prolapse? x3

A

Large infants
Prolonged second stage
Instrumental delivery

92
Q

Why is menopause associated with prolapse

A

Thought to be due to the deterioration of collagenous connective tissue which occurs following oestrogen withdrawal

93
Q

Which factors associated with increased abdominal pressure increase risk of prolapse? x5

A 
Obesity
Chronic cough
Constipation 
Heavy lifting
Pelvic mass
94
Q

Clinical features of prolapse

A

Dragging sensation or sensation of a lump are common

Usually worse at the end of the day or standing up

95
Q

Clinical features of a severe prolapse

A

Can interfere with intercourse, can ulcerate and cause bleeding or discharge

96
Q

Clinical features of a cystourethrocele

A

Can cause urinary frequency and incomplete bladder emptying

Stress incontinence is common

97
Q

Examination of a prolapse

A

Abdomen exam to exclude pelvic masses

Sim’s speculum - asking patient to bear down

98
Q

How to differentiate between a rectocele and enterocele on examination

A

Finger in the rectum will be seen to bulge into a rectocele but not in an enterocele

99
Q

Symptoms of rectocele

A

Occasional difficulty in defacaeting

100
Q

Investigations with prolapse

A

US if pelvic mass is suspected

101
Q

Management of prolapse

A

Weight reduction
Smoking is discourage
Physiotherapy might help mild to moderate and reduce stress incontinence

102
Q

Non-surgical management of prolapse

A

Pessaries - in women who is unwilling or unfit for surgery

- act like an artificial pelvic floor placed in vagina behind symphysis pubis and in front of sacrum

103
Q

Two types of pessary for prolapse?

A

Most common - ring pessary

Shelf pessary - more effective for severe forms of prolapse

104
Q

How often are pessaries changed?

A

6-9 months

105
Q

What is needed with pessaries

A

Postmenopausal women may require oestrogen replacement, topical oestrogen or HRT to prevent vaginal ulceration

106
Q

Surgical treatment for uterine prolapse

A

Vaginal hysterectomy - traditional surgical treatment for uterovaginal prolapse but doesn’t treat underlying problem
Hysteropexy - uterus and cervix attached to sacrum using a bifurcated non-absorbable mesh

107
Q

Surgical treatment for vaginal vault prolapse

A

Sacrocolpopexy - fixes vault to sacrum using a mesh

Sacrospinous fixation suspends the vault to the sacrospinous ligament

108
Q

Surgical treatment for vaginal wall prolapse

A

Anterior and posterior repairs - used for the relevant prolapse

109
Q

Surgical treatment for urodynamic stress incontinence

A

Tension-free vaginal tape or

Trans-obturator tape procedures

110
Q

What is the most common ovarian cyst and details?

A

Follicular cyst - due to non-rupture of dominant follicle

Commonly regresses after several menstrual cycles

111
Q

Other physiological ovarian cyst?

A

Corpus luteum cyst - when corpus luteum doesn’t break down, may fill with blood or fluid and form cyst - more likely to present with intraperitoneal bleeding than follicular cysts

112
Q

Most common benign ovarian tumour in young women

A

Dermoid cyst - aka mature cystic teratoma- contains appendages etc

113
Q

What is Rokitansky protuberance

A

Collection of appendages, hair, teeth etc in ovarian teratoma

114
Q

What sort of tumour is dermoid cyst

A

Germ cell tumour - aka the ovarian tumour that occurs in young women

115
Q

Most common types of benign ovarian epithelial tumour

A

Serous cystadenoma (most common) - resembles serous carcinoma which is most common type of ovarian cancer

116
Q

Other benign epithelial ovarian tumour

A

Mucinous cystadenoma

- typically large and may become massive and rupture

Gynaecology (8 decks)

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