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Year 3 - Reproductive and Sexual Health (DP) > Post-Menopausal Health > Flashcards

Post-Menopausal Health Flashcards

1
Q

Where do the majority of the arteries supplying the lateral pelvic wall arise from?

A

Internal iliac artery

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2
Q

Where do the gonadal arteries arise?

A

L2 abdominal aorta

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3
Q

Where does the superior rectal artery arise?

A

Continuation of inferior mesenteric

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4
Q

What is the medial umbilical ligament?

A

Remnant of the umbilical artery

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5
Q

What does the lateral umbilical fold contain?

A

Inferior epigastric vessels

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6
Q

What is the median umbilical ligament?

A

Remnant of the urachus

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7
Q

What does the internal pudendal artery terminate as in males?

A

Dorsal artery

Deep artery of penis

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8
Q

What arteries branch off from the pudendal artery in the male perineum?

A

Perineal

Posterior scrotal

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9
Q

Where does the anterior scrotal artery arise from?

A

Common iliac

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10
Q

Where do most of the veins draining the lateral pelvic wall drain to?

A

Internal iliac vein

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11
Q

Veins of the lateral pelvic wall that drain via the superior rectal vein empty where?

A

Hepatic portal system

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12
Q

Veins of the lateral pelvic wall that drain via the lateral scrotal vein empty where?

A

Internal vertebral venous plexuses

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13
Q

Why is the left ureter more likely to be damaged than the right?

A

Right is constant and usually crosses external iliac

Left is more medial and crosses common iliac

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14
Q

Where does lymph from the superficial pelvic viscera drain to?

A

External iliac nodes:

  • Common iliac
  • Aortic
  • Thoracic duct
  • Venous system
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15
Q

Where does lymph from the inferior pelvis viscera drain to?

A

Deep perineum:

  • Internal iliac nodes
  • Common iliac
  • Aortic
  • Thoracic duct
  • Venous system
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16
Q

Where does lymph from the superficial perineum drain to?

A

Superficial inguinal nodes

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17
Q

What is the average age of menopause?

A

51 years

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18
Q

When is early menopause defined?

A

<45 years

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19
Q

When is premature menopause defined?

A

<40 years

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20
Q

When is late menopause defined?

A

> 54 years

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21
Q

What results in raised FSH and LH?

A 
Stopping:
- COC
- Depot
Breastfeeding
SSRIs
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22
Q

How long does a typical hot flush in menopause last?

A

3-5 minutes

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23
Q

How long do hot flushes persist for?

A

2yrs usually

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24
Q

How can menorrhagia in menopause be treated?

A 
Mefanamic or Tranexamic acid
Progesterones
IUS
Endometrial ablation
Hysterectomy
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25
Q

What protective features does HRT have?

A

Reduces osteoporotic fractures
Reduces bowel cancer
?Alzheimer’s and Parkinson’s protection

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26
Q

What are the risks of HRT?

A

VTE
CVA
Breast cancer
Gallbladder disease

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27
Q

When do endometrial polyps tend to occur in relation to menopause?

A

Around/After menopause

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28
Q

What may be a possible cause of endometrial hyperplasia?

A

Persistent oestrogen stimulation

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29
Q

What is the distribution of the three kinds of endometrial hyperplasia?

A 
Simple:
- General
Complex:
- Focal
Atypical:
- Focal
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30
Q

What are the components of the three kinds of endometrial hyperplasia?

A 
Simple:
- Glands and stroma
Complex:
- Glands
Atypical:
- Glands
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31
Q

What is the appearance of the glands in the three kinds of endometrial hyperplasia?

A 
Simple:
- Dilated
Complex:
- Crowded
Atypical:
- Crowded
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32
Q

What is the cytology of the three kinds of endometrial hyperplasia?

A 
Simple:
- Normal
Complex:
- Normal
Atypical:
- Atypical
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33
Q

When is the peak incidence for endometrial cancer?

A

50-60 years

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34
Q

What should be considered if endometrial cancer presents in a younger patient?

A

PCOS

Lynch Syndrome

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35
Q

What is the usual precursor of endometrial carcinoma?

A

Atypical hyperplasia

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36
Q

What is the usual precursor of an endometrial serous carcinoma?

A

Serous intraepithelial

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37
Q

How does endometrial carcinoma generally present?

A

Abnormal bleeding

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38
Q

How does an endometrial cancer appear macroscopically?

A

Large uterus

Polypoid

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39
Q

How does an endometrial cancer appear microscopically?

A

Most are adenocarcinomas

Most are well differentiated

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40
Q

How can endometrial cancers spread?

A 
Directly into:
- Myometrium
- Cervix
Lymphatic
Haematogenous
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41
Q

What are Type 1 endometrial carcinomas?

A

Endometroid (and mucinous)

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42
Q

What are Type 1 endometrial carcinomas related to and associated with?

A

Related to unopposed oestrogen

Associated with atypical hyperplasia

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43
Q

What percentage of endometrial carcinomas are type 1?

A

80%

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44
Q

What are Type 2 endometrial carcinomas?

A

Serous (and clear cell)

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45
Q

What are Type 2 endometrial carcinomas related to and associated with?

A

Not oestrogen associated
Associated with elderly postmenopausal women
TP53 often mutated

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46
Q

What mutations may be seen in Type 1 endometrial carcinomas?

A

PTEN
KRAS
PIK3CA

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47
Q

How is obesity linked to an increased risk of endometrial cancer?

A

Endocrine and inflammatory effects of adipose tissue

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48
Q

What do adipocytes contain that results in endometrial proliferation?

A

Aromatase:

- Converts ovarian androgens to oestrogens

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49
Q

How does obesity affect sex hormone binding globulins and what effect does this have?

A

Reduced levels:

- Increased levels of unbound, biologically active hormones

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50
Q

How does obesity affect insulin binding globulin levels and what effect does this have?

A

Reduced levels:

  • Increased free insulin levels
  • Proliferative effect on endometrium
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51
Q

What cancers does Lynch Syndrome predispose to?

A

Colorectal cancer
Endometrial cancer
Ovarian cancer

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52
Q

How is Lynch Syndrome inherited?

A

Autosomal dominant

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53
Q

How can Lynch Syndrome tumours be identified?

A

Immunohistochemistry staining

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54
Q

What is the instability found in Lynch Syndrome called?

A

Microsatellite instability

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55
Q

What are the precursor lesions to Type 2 endometrial tumours?

A

Serous endometrial intraepithelial carcinoma

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56
Q

How do Type 2 endometrial tumours spread?

A

Fallopian tube mucosa

Peritoneal surfaces

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57
Q

What endometrial tumours are more aggressive - Type 1 or Type 2?

A

Type 2

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58
Q

What is the structures of a serous endometrial carcinoma?

A

Complex papillary +/or glandular structure

Diffuse, marked nuclear polymorphism

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59
Q

How is a Grade 1 endometrial carcinoma defined?

A

=<5% solid growth

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60
Q

How is a Grade 2 endometrial carcinoma defined?

A

6-50% solid growth

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61
Q

How is a Grade 3 endometrial carcinoma defined?

A

> 50% solid growth

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62
Q

What types of endometrial carcinomas are not routinely graded?

A

Serous

Clear cell

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63
Q

What is Stage 1 of endometrial carcinoma?

A

Confined to uterus:

  • 1A = No/<50% myometrial invasion
  • 1B = >50% myometrial invasion
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64
Q

What is Stage 2 of endometrial carcinoma?

A

Tumour invades cervical strome

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65
Q

What is Stage 3 of endometrial carcinoma?

A

Local +/or regional tumour spread:

  • IIIA = Tumour invades serosa of uterus +/or adnexae
  • IIIB = Vaginal +/or parametrial involvement
  • IIIC = Mets. to pelvic +/or para-aortic nodes
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66
Q

What is Stage 4 of endometrial carcinoma?

A

Tumour invades:

  • Bladder +/or
  • Bowel mucosa (IVA) +/or
  • Distant metastases
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67
Q

How do endometrial stromal sarcomas spread?

A

Infiltrate myometrium and often lymphovascular spaces

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68
Q

What is the most important prognostic factor in endometrial stromal sarcomas?

A

Stage

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69
Q

What is an endometrial carcinosarcoma?

A

Mixed tumour:

  • Epithelial (carcinomatous) elements
  • Stromal (sarcomatous) elements
70
Q

What is the alternative name for endometrial carcinosarcoma?

A

Malignant Mixed Mullerian Tumour

71
Q

What are the heterologous elements that can appear in 50% of endometrial carcinosarcoma cases?

A

Rhabdomyosarcoma (worst prognosis)
Chondrosarcoma
Osteosarcoma

72
Q

How does an endometrial carcinosarcoma appear macroscopically?

A

Large bulky tumours
Filling cavity
Often protruded through cervical canal

73
Q

What symptoms are myometrial leiomyomas associated with?

A

Menorrhagia

Infertility

74
Q

What sort of morphology do leiomyosarcomas typically have?

A

Spindel cell

75
Q

In what women are leiomyosarcomas most common?

A

> 50 years

76
Q

What are the common symptoms of leiomyosarcomas?

A

Abnormal vaginal bleeding
Palpable pelvic mass
Pelvic pain

77
Q

What is the overall 5yr survival for endometrial leiomyosarcoma?

A

15-25%

78
Q

What is the strongest prognostic factor in leiomyosarcoma?

A

Stage

79
Q

What are uterine fibroids?

A

Leiomyomas

80
Q

In what age group are fibroids most common?

A

> 40 years

81
Q

How do uterine fibroids typically present?

A

Menorrhagia
Pelvic mass
Slight pain/tenderness
‘Pressure’ symptoms

82
Q

When might a fibroid be disproportionately painful or tender?

A

If ‘red degeneration’:

  • Pregnancy
  • Menopause
83
Q

In what populations are fibroids most common?

A

Afro-Caribbean

84
Q

How can fibroids be investigated?

A

Hb if high bleeding
USS is usually diagnostic
MRI for precise localisation

85
Q

How do fibroids appear on USS?

A

Smooth
Echogenic mass
(Often multiple)

86
Q

What can be used pre-op to shrink the size of a fibroid?

A

GnRH agonists:

- Mifepristone

87
Q

If a woman’s family is complete, what operation can be offered for fibroids?

A

Hysterectomy

88
Q

If a woman wishes to maintain her fertility, what operations can be offered for fibroids?

A

Myomectomy
Uterine artery embolisation
Hysteroscopic resection

89
Q

How does a hydrosalpinx present?

A

Longstanding tubal swelling - +/- pain

Usually incidental USS finding

90
Q

How does a pyosalpinx present?

A

Acute inflammation

Acute PID

91
Q

What are functional ovarian cysts related to?

A

Ovulation:

  • Follicular cysts
  • Luteal cysts
92
Q

What symptoms can functional cysts cause?

A

Menstrual disturbance
Bleed/rupture and pain:
- Mid cycle pain (Mittelschmerz)
(Often asymptomatic)

93
Q

What are endometriomas and how do they appear?

A

Blood-filled endometriotic cysts:

- ‘Chocolate’ cysts

94
Q

What are the signs and symptoms of endometriomas?

A 
Severe dysmenorrhoea
Premenstrual pain
Dyspareunia
Subfertility
Tender mass with 'nodularity' and tenderness behind uterus
95
Q

What is a dermoid cyst?

A

Benign ovarian cystic teratoma

96
Q

What are the types of primary ovarian tumours arising the the surface epithelium?

A 
Serous
Mucinous
Endometrioid
Clear cell
Brenner
97
Q

If a primary ovarian tumour arises from stromal granulosa cells, what may it secrete?

A

Oestrogens

98
Q

If a primary ovarian tumour arises from stromal theca/leydig cells, what may it secrete?

A

Androgens

99
Q

What syndrome are ovarian fibromas linked to?

A

Meig’s Syndrome

100
Q

What can a malignant germ cell tumour produce and how may this present?

A

hCG:
- False pregnancy test
AFP

101
Q

If a dermoid cyst differentiates into thyroid tissue, what can occur?

A

Thyrotoxicosis

102
Q

What does a dermoid cyst usually secrete?

A

AFP

no hCG if pure

103
Q

How does a dermoid cysts appear on a plain x-ray?

A

Rim calcification

104
Q

How can ovarian granulosa cell tumours present?

A

Precocious puberty

Postmenstrual bleeding

105
Q

How can ovarian thecal tumours present?

A

Hirsutism

Virilisation

106
Q

How does Meig’s Syndrome present?

A

Benign fibromas
Pleural effusion
Ascites

107
Q

What primary tumours can commonly metastasise to the ovaries?

A

Breast
Pancreas
Stomach
GI

108
Q

What sort of spread do malignant ovarian tumours display?

A

Early transperitoneal spreads (trans-coelomic):

  • Deposits on all peritoneal surfaces
  • Omental disease/infiltration
  • Malignant ascites with protein exudate
109
Q

What gene is linked to ovarian cancer?

A

HNPCC

110
Q

What are the risk factors for ovarian cancer?

A

Increasing age
Nulliparity
Family history

111
Q

What effect does COC (oestrogen) have on ovarian cancer?

A

Protective

112
Q

What tumour markers must be tested for in suspected ovarian cancer?

A

CA-125

Carcino-embryonic antigen

113
Q

When is CT used in the investigation of a suspected ovarian cancer?

A

Assessing:

  • Omental disease
  • Peritoneal disease
  • Lymph nodes
114
Q

In what proportion of ovarian cancers is CA-125 raised in?

A

80%

115
Q

What ovarian tumours raise carcinoembryonic antigen the most?

A

Mucinous tumours

116
Q

What is the main use of carcinoembryonic antigen?

A

Exclusion of metastases from GI primary

117
Q

What is the ‘risk of malignancy’ index?

A

Menopausal status x Serum CA-125 x US score

118
Q

How is a benign ovarian tumour treated?

A

Removal or drainage

119
Q

How is a malignant ovarian tumour treated?

A

Oophorectomy and hysterectomy
With removal/debulking of omentum
Tumour ‘debulking’

120
Q

How does cervical cancer present?

A

Screening
Post-coital bleeding/IMB/PMB
Acute renal failure

121
Q

What surgical treatments are available for cervical cancer?

A

Large Loop Excision of the Transitional Zone
Fertility sparing
Wertheim

122
Q

What chemotherapy agents can be used in cervical cancer?

A

Cisplatin:
- 40mg/m^2 weekly
Carboplatin/Paclitaxol

123
Q

What are the risk factors for ovarian cancer

A 
>50 years
Nulliparity (or low parity)
Delayed pregnancy
FHx of breast or ovarian cancer
BRCA1 and BRCA2
124
Q

What are the USS scores for calculating RMI?

A 
Features:
- Multilocular cysts
- Solid areas
- Bilateral lesions
- Ascites
- Intra-abdominal
0 = No features
1 = One abnormality
3 = Two or more abnormalities
125
Q

What are the menopausal scores for calculating RMI?

A 
Premenopausal = 1 point
Postmenopausal = 3 points
126
Q

What is the CA-125 score measured in for calculating RMI?

A

U/ml

127
Q

If there is an RMI score >200, what should be done?

A

Refer to gynaecology-oncology MDT

CT abdomen and pelvis

128
Q

What staging is used for ovarian cancer?

A

FIGO staging

129
Q

Where does ovarian cancer spread to haematogenously?

A

Liver
Lungs
Brain (2%)

130
Q

What are the first line chemotherapy agents in epithelial ovarian cancer?

A

Carboplatin +/- Paclitaxel (80mg/m^2)

131
Q

What other cytotoxic agents can be added if paclitaxel is not tolerated?

A

Doxorubicin
OR
Gemcitabine

132
Q

When is intraperitoneal chemotherapy considered?

A

Epithelial ovarian cancer and residual disease =<1cm after primary surgery

133
Q

If ovarian cancer relapses, what chemo regimen should be used?

A

If platinum sensitive, use cisplatin in combo with:

  • Paclitaxel or
  • PLDH or
  • Gemcitabine
134
Q

If ovarian cancer relapses and it is not platinum sensitive or the patient wants to avoid further chemo, how can it be treated

A

Tamoxifen

Aromatase inhibitor

135
Q

What tumours does Letrozole have an effect on and how long is it given for?

A

ER+ tumours

Maintained for >6 months

136
Q

What can cause impaired gastric emptying in gynaecological malignancy?

A

Locally advanced
Drugs (Opioids and anticholinergics)
Damage to gut
Autonomic neuropathy

137
Q

How does impaired gastric emptying in gynaecological malignancy present?

A

Not usually nauseated
Then very nauseated:
- Large volume vomits
- Feels better

138
Q

What causes regurgitation in gynaecological malignancy?

A

Obstruction/Compression of oesophagus

139
Q

How does regurgitation in gynaecological malignancy present?

A

Dysphagia
Pain
Coughing/Stridor

140
Q

What chemical or metabolic influences can result in vomiting in gynaecological malignancy?

A 
Medications (opioids and ABx)
Advanced cancer (esp. liver metastases)
Sepsis
Kidney/Liver impairment
Biochemical
141
Q

How do chemical or metabolic changes result in vomiting?

A

Hypercalcaemia
Hyponatraemia
Hypermagnesaemia
Uraemia

142
Q

How does chemical or metabolic vomiting present?

A

Persistent nausea

Little relief from vomiting

143
Q

How does bowel obstruction present?

A

Intermittent large volume vomits

Colic

144
Q

How does cerebral disease result in vomiting?

A

Compression/Irritation by tumour
Increased ICP
Anxiety

145
Q

How does vomiting induced by cerebral disease present?

A

Worse in the morning

Headache

146
Q

How does vestibular disease result in vomiting?

A

Base of skull/Brainstem disease
Ear infections
Motion sickness

147
Q

How does vomiting induced by vestibular disease present?

A

Worse on movement
Vertigo
Tinnitus

148
Q

What effects do steroids have in palliative care?

A

Anti-emetic

Anti-inflammatory (reduce peri-tumour oedema)

149
Q

What steroid can be prescribed in palliative care?

A

8-16mg CSCI/24 hours

150
Q

When is Hyoscine Butylbromide used?

A

Colic:

  • 20mg S/C bolus PRN
  • 60-120mg/24hrs CSCI
151
Q

When can anti-emetics be used in mechanical bowel obstruction?

A

If incomplete MBO and no colic

152
Q

What anti-emetic is used in mechanical bowel obstruction?

A

Metoclopramide:

- 30-100mg CSCI/24 hours

153
Q

What type of drug is Hyoscine hydrobromide? What dose is given?

A

Anti-secretory agent

0.4-2.4mg/24 hours CSCI

154
Q

What examination must be done before prescribing laxatives?

A

Faecal impaction on examination and AXR

155
Q

If there is partial obstruction, what can be prescribed as a laxative?

A

Sodium docusate

Movicol

156
Q

When is methylnaltrexone prescribed as a laxative?

A

In opioid-induced constipation

157
Q

What happens when follicular cysts form when ovulation doesn’t occur?

A

Polycystic ovaries

158
Q

What are the thin walls of a follicular cyst lined by?

A

Granulosa cells

159
Q

What are high grade malignant serous carcinomas known as?

A

Serous tubal intraepithelial carcinoma

160
Q

What are low grade malignant serous carcinomas known as?

A

Serous borderline tumour

161
Q

What ovarian tumours have a strong association with ovarian endometriosis?

A

Endometrioid

Clear cell

162
Q

What is a Brenner ovarian tumour?

A

A tumour of transitional-type epithelium

Usually benign

163
Q

What is ovarian cancer - FIGO Stage 1?

A 
1A = Limited to one ovary
1B = Limited to both ovaries
1C = Involving ovarian surface/rupture/surgical spill/tumour in washings
164
Q

What is ovarian cancer - FIGO Stage 2?

A 
2A = Extension or implants on uterus/fallopian tube
2B = Extension to other pelvic organ (bowel, bladder)
165
Q

What is ovarian cancer - FIGO Stage 3?

A 
3A = Retroperitoneal LN mets. or microscopic extrapelvic peritoneal involvement
3B = Macroscopic peritoneal mets beyond pelvis up to 2cm
3C = 3B but >2cm
166
Q

What is ovarian cancer - FIGO Stage 4?

A

Distant metastases

167
Q

When is a transabdominal USS used?

A

Established thick endometrium in PMP
Ensure no hydronephrosis
Detect early ascites
Ensure pelvic abnormality isn’t secondary to upper. abdo. pathology

168
Q

Why must a patient have a full bladder for transabdominal USS?

A

Acts as an ‘acoustic window’
Displaces gas filled bowel out of pelvis:
- Improves image quality

169
Q

When is CT used for gynaecological disease?

A 
2nd line for acute abdomen
Assess post-surgical complications:
- Small bowel obstruction due to adhesions
- Collections/Abscesses
Cancer staging
Assessing chemo/radiotherapy response
170
Q

When is MRI used for gynaecological disease?

A

Cancer staging (esp. cervical)
Characterising adnexal and uterine masses
Evaluating sub-fertility
Pituitary MR if prolactinoma

171
Q

What does hysterosalpingography used?

A

To assess tubal patency in infertility

Can assess outline of uterine cavity

172
Q

How long does a hysterosalpingogram take?

A

3-5 minutes

Year 3 - Reproductive and Sexual Health (DP) (7 decks)

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