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Reproduction/Sexual Health > Week 1 > Flashcards

Week 1 Flashcards

1
Q

What is the Graafian follicle?

A

The dominant of two follicles released each month
- the one which may be fertilised

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2
Q

What are progesterone and oestrogen secreted from?

A

Progesterone - corpus luteum
Oestrogen - granulosa cells

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3
Q

What s corpus albicans?

A

Degenerative corpus luteum

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4
Q

Effect of HCG on endometrium

A

Decidualisation
- endo getting stronger for pregnancy
- maintained by progesterone as well

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5
Q

Features of proliferative phase under microscope

A

Donut looking proliferations
Mitotically active cells

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6
Q

Features of secretory cells under microscope

A

Increasing tortuosity of glands and lumenal secretions

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7
Q

Features of menstrual phase under microscope

A

Endometrial stromal breakdown
Dense round clsters of stomal cells surrounded by inflam cells and blood

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8
Q

Features of decidual change udner microscope

A

Abundant eosinophilic cytoplasm of stroma

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9
Q

Features of endo atrophy on microscope

A

INactive low CC cells
Glands detach from stroma to form “hairpin” structures
May be caused by trauma of biopsy

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10
Q

Indications for endo sampling

A

Abnormal uterine bleeding (e.g. post-menopausal)

Investigation for infertility

Spontaneous and therapeutic abortion

Assessment of response to hormonal therapy

Endometrial ablation

Work up prior to hysterectomy for benign indications

Incidental finding of thickened endometrium on scan

Endometrial cancer screening in high risk patients (e.g. Lynch syndrome)

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11
Q

Causes of abnormal uterine bleding in early repro life/adolescence

A

DUB usually due to anovulatory cycles

Pregnancy/miscarriage

Endometritis

Bleeding disorders

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12
Q

Causes of AUB in reproductive life

A

Ado causes PLUS

Cancers (cervical/endometrial)
Endometriosis in myo layer
Exogenous hormone effects
Bleeding disorders
Hyperplasia

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13
Q

Causes of AUB post-meopause

A

Atrophy
Endometrial polyp
Exogenous hormones: HRT, tamoxifen
Endometritis
Bleeding disorders
Hyperplasia
Carcinoma/sarcoma

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14
Q

How is endometrium sampled?

A

Hysteroscopy
Endo pipelle
Dilatation and curretage

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15
Q

History aspects path needs for diagnostic sampling

A

Age
Date of LMP and length of cycle
Pattern of bleeding
Hormones
Recent pregnancy

Do not need to know number of pregnancies, drugs without hormonal influences etc.

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16
Q

Define dysfunctional uterine bleeding

A

irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining (no organic cause for bleeding)

most commonly due to anovulatory cycles, either end of repro life

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17
Q

Describe endometritis

A

abnormal pattern of inflammatory cells in endometrium (has oenetrated cervical mucus plug)

caused by e.g. actinomyes, neiserria, HSV, IUDs, post-partum, post-abortion, granulomatous, polyps

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18
Q

PLasma cells in endometrium means?

A

Chronic plasmacytic endometritis
- Infectious unless proved otherwise
- Associated with PID

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19
Q

Describe complete mole pregnancy

A

Complete
- Single or two sperm combining with egg that has lost its DNA, sperm reduplicates to form “complete” 46chrom set, only paternal DNA present
- Incr choriocrcnoma risk

Partial
- Egg fertilised by two sperm or one sperm which reduplicates itself causing triploid genotype 69XXY

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20
Q

Describe fibroid/leiomyoma

A

Benign smooth muscle tumour forming from myoetrium

Growth oestrogen dependent
Interlacing SM cells
Presents w haemorrhagia, infertility, mass effect

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21
Q

Describe features of folicular cysts

A

Physiological cyst
Form when ovulation doesn’t occur
(polycystic ovaries)
Follicle doesn’t rupture but grows until it becomes a cyst
Several cm, resolve over months
Thin walled, granulosa lining

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22
Q

Describe endometriosis and its presentation

A

Endometrial glands and stroma outside the uterine body, cycle in the same way as uterine tissue

Presenst with:
- pelvic inflam
- infertility (scarring and obstruction of uterine tube)
- pain

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23
Q

Where do endometrioma form?

A

– Ovary (‘chocolate’ cyst)
– Pouch of Douglas
– Peritoneal surfaces, including uterus
– Cervix, vulva, vagina
– Bladder, bowel etc

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24
Q

Macro and microscopic features of endo

A

Macroscopic
Peritoneal spots or nodules
Fibrous adhesions
Chocolate cysts

Microscopic
Endometrial glands and stroma
Haemorrhage, inflammation, fibrosis

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25
Q

Malignancy linked to endometriosis

A

Endometrioid carcinoma
- can be found outwith uterus

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26
Q

Types of epithelial ovarian tumour

A

Serous (lines tubes)
Mucinous (epi cells with mucin)
Endometrioid
Clear cell
Brenner (transitional epi, from bladder)
Undifferentiated carcinoma

Can be benign, borderline, malignant

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27
Q

Describe serous carcinoma of ovary

A

Most common, linked with BRACA mutation
Most originate in tubes
90% high grade, 5% low grade/borderline (with different path)

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28
Q

Describe endometrioid and clear cell carcinoma of ovary

A

Assoc with ovarian endometriosis and Lynch syndrome
Graded same way as uterine tumurs
Mostly low grade/early stage
Primary diag most often made on ascitic fluid

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29
Q

What key feature makes a neoplasm malignant?

A

Stromal invasion
- cells break through the basement membrane

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30
Q

Describe Brenner tumour of ovary

A

A tumour of transitional type epithelium, usually benign,
borderline and malignant variants are rare
Really solid tumour
Round nests of transitional cells

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31
Q

Describe germ cell tumours of ovary

A

Mostly benign mature cystic teratoma
- containing sebum, teeth, hair, tragus
- rarely malignant, but could get malignancy from tissue within teratoma e.g. SCC skin, thryroid ca

Rarely immature teratoma
- 8 week foetal tissue, really malignant

Others e.g. dysgerminoma (like testis seminoma), yolk sac, choriocarcinoma, mixed

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32
Q

Describe types of sex cord/stromal tumours

A

Fibroma/Thecoma
- Benign
- May produce oestrogen causing uterine bleeding

Granulosa cell tumour
- All are potentially malignant
- May be associated with oestrogenic manifestations

Sertoli-Leydig cell tumours
- Rare, may produce androgens

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33
Q

Figo staging of ovarian cancer

A

1A tumour limited to one ovaries
1B tumour limited to both ovaries
1C Cancer involving ovarian surface/
rupture/surgical spill/tumour in washings

2A Extension or implants on uterus/fallopian tube
2B Extension to other pelvic
intraperitoneal

3A Retroperitoneal lymph node
Metastasis or microscopic extrapelvic peritoneal involvement
3B Macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension
3C Macroscopic peritoneal metastasis >2cm in dimension

4 Distant metastasis

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34
Q

Why is Hb low in ovarian cancer?

A

Ovarian cancer cells hoard iron causing rest of body anaemia

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35
Q

CRP vs ESR

A

CRP - acute inflam
ESR - chronic inflam

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36
Q

Apperance of molar pregnancy on US

A

Snowstorm appearance

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37
Q

3 main abnormal pregnancy types

A

Miscarriage (normal, in uterus)
Ectopic (outwith uterus)
Molar (abnormal, in uterus)

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38
Q

Causes of early pregnancy bleeding

A

Implantation bleeding

Sub-chorionic haematoma

Cervical/vaginal causes:
Infection
Malignancy ( important to take a cervical smear history)
Cervical polyp

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39
Q

Types of miscarriage

A

Threatened Miscarriage
(risk to pregnancy)

Inevitable Miscarriage
(pregnancy can’t be saved)

Incomplete Miscarriage
(part of pregnancy is already expelled)

Complete Miscarriage
(all of pregnancy is expelled, uterus empty)

Early Fetal Demise/Non continuing pregnancy NCP (pregnancy in-situ, no heartbeat, >25 sac diameter, >7 fetal pole)

Anembryonic Pregnancy
(no fetus, empty sac)

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40
Q

Presentation of miscarriage

A

Pos preg test
Amennhoroea
Bleeding
Period type cramps

41
Q

Presentation of cervical shock

A

Acute clin emergency
Cramps
Nausea, vomting
Sweating, fainting

Remove preg poriducts from cerviz!!!!

Resus with IVI and uterotonics

42
Q

Causes of miscarriage

A

Embryonic abnormality : Chromosomal.
Immune cause : APS/Lupus
Infections : CMV, Rubella, etc
Severe emotional upsets, extreme physical stress.
Iatrogenic loss (after CVS)
“Associations”: heavy smoking, cocaine, alcohol misuse.
Uncontrolled Diabetes.
Cervical incompetence and shortened cervix.
Vaginal (bacterial) infections.

43
Q

Management of miscarriage

A

Ensure HD stability
FBC, group save, hCG, US< histology

Conservative
Medical - misoprostol
Surgical/MVA

Anti-D, emotional support

44
Q

Management of threatened miscarriage

A

Micronised Progesterone 400 mg PV b.d. till 16 weeks

(if viable IU preg on scan)

45
Q

When to refer about recurrent miscarriage

A

3 or more preg losses
or if 2 or more losses >35years

46
Q

Presentation of ectopic preg

A

Presentation: Pain > bleeding, dizziness / collapse / shoulder tip pain, short on breath, rare presentation diarrhoea.

Findings: Pallor, hemodynamic instability, signs of peritonism, guarding & tenderness.

47
Q

Red flag signs in ectopic pregnancy

A

Repeated pres of abdo/pelvic pain
Pain requiring opiates in a known pregnant person

48
Q

Investigation of ectopic pregnancy

A

Investigation: FBC, G&S, ẞhCG, Ultrasound

Trans-vaginal scan (TVS) is gold standard:
- empty uterus
- pseudosac
- free fluid pouch of Douglas
- mass in adenexa

Serum hCG
- 48h apart to assess doubling

49
Q

Manegment of ectopic

A

Surgical
- laparoscopic salpingectomy
- conservative salpingotomy to preserve tube

Medical
- stable pts with low hCG and small/unruptured ectopic
- methotrexate 1 or 2 doses

Conservative
- supportive management, not v common

50
Q

Describe pres and management of PUL

A

Amenorrhoea, abdominal pain.

Level of hCG confirming a pregnancy circumstance.

NO PREG IN UTERUS/TUBES/CERVIX ON SCAN

Manage conservatively with M6 model

51
Q

Describe the M6 management of PUL

A

Principle: level of Progesterone which guides the progress or regression of a pregnancy is used to add value to the pathway of follow up.

Outcome of follow up: may eventually evidence as an intrauterine pregnancy or an ectopic pregnancy on scan

Management : Medically with Methotrexate if no clinical deterioration.

52
Q

Describe molar pregnancy

A

Gestational Trophoblastic Disease

Outcome of a non-viable fertilised egg

Complete vs Partial

Complete has 2.5% risk of developing into choriocarcinoma

53
Q

Complete mole

A

Egg without DNA
1 or 2 sperms fertilise, result in diploid ( paternal contribution only)
No fetus
overgrowth of placental tissue

54
Q

Partial mole

A

Haploid egg
1 sperm ( reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy
May have fetus
Overgrowth of placental tissue

55
Q

Presentation of molar pregnancy

A

Hyperemesis, hyperthyroidism, early onset pre-ecclampsia
Varied bleeding and occasional history of passage of “grapelike tissue”
Fundus > dates on abdominal palpation.
Snowstorm on USS (with potential foetus, theca lutein cyst)
Rarely SoB or seizures from embo/mets

56
Q

Management of molar pregnancy

A

Surgical evacuation and histological tissue typing
Medical management in higher gestation with partial mole
Follow up with molar preg services

57
Q

Describe implantation bleeding

A

when the fertilised egg implants in the endometrial lining.

Timing is about 10 days post-ovulation.

Bleeding is light/brownish and self limiting, mistaken as period

Prgnancy signs emerge soon after

58
Q

Describe subchorionic haematoma

A

Pooling of blood between endometrium and the embryo due to separation : sub-chorionic haematoma

Bleeding, cramping, threatened miscarriage

Large haematomas can cause infection/irritability/cramping and miscarrige

59
Q

Cervical causes of early pregnancy bleeding

A

Ectopy/ectropion.

Infections: Chlamydia, Gonococcus or bacterial.

Polyp.

Malignancy

60
Q

Vaginal causes of early pregnancy bleeding

A

Infections:
- Trichomoniasis ( strawberry vagina)
- Bacterial vaginosis
- Chlamydia

Malignancy:
- Ulcers
- Rare cause of bleeding in repro ages

Forgotten tampon

61
Q

Managing infections in pregnancy

A

BV
- metronidazole 400mg bd 7 days
- vaginal gel, no alcohol

Chlamydia
- erthyromycin/amoxicillin
- test of cure at 3 weks
- contact tracing

62
Q

Causes of pain in pregnancy

A

Miscarriage (bleeding>pain)
Ectopic (main symptom, dull->sharp, peritonism)
Torsion of ovarian cyst (when uterus moves into abdo)
Cyst acident (IA bleeding)
Unrelated (UTI, appenidicitis)
Vaginal infections

63
Q

When is anti-D advised?

A

Surgical management of surgical removal of ectopic or molar pregnancy

500 IU given IM

64
Q

Presentation of hyperemesis gravidarum

A

Excessive and protracted N/V
Starts at first missed period, continues beyond 1st trimester
Severe impact on quality of life

Presents with:
- dehydration, keotsis, elec/nutrional abnormalities
- WL, altered liver function
- malnutrition
- mental health issues

65
Q

Management of HG

A

PUQE score for severity
Inpatient
- IV, NG< TPN
- parenteral antiemetics
- manage electrolytes, thyroid
- thromboprophylaxis
- sometimes termination

66
Q

Definition of infertility

A

inability to conceive after 12 months regular intercourse without contraception

Primary - no previous pregnancy
Secondary - to miscarriage, prev child etc

67
Q

What hormone does OTC fertility tests assess?

A

LH surge just before day 14
Not always reliable

68
Q

Assessing ovulation in clinic

A

Midluteal serum progresterone on day 21 (week before period)

  • look for value >30nmol/L
69
Q

Define azoospermia

A

No sperm in ejaculate

70
Q

Define asthenozoospermia

A

% progressive motile sperm below reference limit

71
Q

Define oligozoospermia

A

Total number / concentration of sperm below reference limit

72
Q

Define teratozoospermia

A

% morphologically normal sperm below reference limit

73
Q

Structural abnormalities causing infertility

A

Congenital uterine abnormalities
Fibroids
Endometrial polyp
Hydrosalpinx
Tubal patency issues
PCOS
Ovarian cyst

74
Q

Tubal patency testing

A

Hysterosalpingogram (HSG)
- XR with radioopaque dye
- no risk factors/pelvic pathology

Diag laparoscopy, hydrotubation (HTB)
- possible tubal disease, pelvic pain, prev abnormal HSG

75
Q

Role pf hysteroscopy in infertility

A

Cases with suspected/known endo pathology
e.g. uterine septum, adhesions, polyps

76
Q

Rotterdam criteria for PCOS

A

2 of:
1. oligo/amennhorhoea
2. polycystic ovaries on scan
3. clinical/biochem signs of hyperandrogenism

77
Q

How is ovulation induced?

A

Clomefine citrate or tamoxifen tablets
- first line
- days 2-6

Gonadotrophin injections
- recombinant FSH, risk of overstimulation and multiple pregnancy
- close monitoring

Lap ovarian diathermy
- needle heat treatment to ovary
- mainly singleton pregnancy

78
Q

How to manage clomifene resistance?

A

Weight loss
Adjuvant metformin: improves insulin resistance and reduces androgen production
Helps to improve sensitivity to meds and restore menstruation

79
Q

Investigatons of male infertility

A

Examination of male and testes volume
Check LH, FSH, testosterone, prolactin
Karyotype, CF mutation, Y microdeletions
Check meds or hormonal conditions

80
Q

Management of male infetrility

A

Intrauterine insemination (IUI)
In vitro fertilisation (IVF)
Intracytoplasmic sperm injection (ICSI)

81
Q

Standard IVF protocol

A

1st period
Decapeptyl IM day 21
2nd period
Basseline scan at 2 weeks
FSH injections daily
Action scan at 2 weeks
Ovitrielle hCG SC
Egg collection at 2 days
Progesterone PV daily
Embryo transfer at day 5
Continue progesterone next few weeks
Pregnancy test!!!!

82
Q

Effect on ovaries and uterus in menstrual phase

A

Ovary
- FSH causes primary follicles -> secondary follicles

Uterus
- decr oestogren and progesterone releases prostaglandins
- arterioles constrict
- stratum fucntionalis of endo sloughs off
- 50-150ml of blood/tissue etc shed through cervix and vagina

83
Q

Effect on ovaries and uterus in preovulatory phase

A

Ovary
- secondary follicles secrete oestogren
- one follicle becomes dominant graafian follicle

Uterus
- oestrogen stimulates growth of endo
- stratum basilis undergoes mitosis = new stratum fucntionalis
- endo thickness doubles to 4-10mm

84
Q

Effect on ovaries and uterus in ovulatory phase

A

Ovary
- oestrogen stimulates more GnRH release
- LH surges causes rupture of Graafian and explosion of secondary oocyte

Uterus
- prog/oestro continue to stimulate proliferation of endo

85
Q

Effect on ovaries and uterus in postovulatory phase

A

Ovaries
- collapsed follicle bceomes corpus luteum due to LH
- CL secretes prog/oestro/relaxin/inhibin
- decr agyer 2 weeks if no fertilisation

Uterus
- prog/oestro cause growth/coiling of endo glands, vascularisation, thickening of endo
- endo glands secrete glycogen

86
Q

Management of PMD in terms of Ovulation suppression

A
  • yasmin and eloine COC 1st line
  • GnRH agonisys
  • anazol (lots of SEs)
  • oestrogen (if incr chance of endo hyperplasia)
  • bilateral oopherectomy and hysterectomy with only oestrogen treatement
87
Q

Other management of PMD

A

SSRIs
- continuously or just luteal phase
Diuretics for physical symptoms
CBT for mental health symptoms
Supplements and vitamins

88
Q

Management of heavy menstrual bleeding

A

1st line mirena coil
2nd line tranexamic acid/COC
3rd line norethisterone/DMPA
4th line surgery/ref to gynae

89
Q

Causes of heavy menstrual bleeding

A

Fibroids
Polyps
Adenomyosis assoc with Hx preg, curettage
Coagulopathy e.g. von Willebrand’s
Malignancy

90
Q

Surgical management of heavy menstrual bleeding

A

Polypectomy
Endometrial ablation
Uterine artery embolization
Myomectomy
Hysterectomy

91
Q

What is a heterotopic pregnancy?

A

Twins where one fertilised egg implants in uterus and other implants in tube

92
Q

Why is methotrexate used in ectopics?

A

Helps to stop rapidly dividing cells

93
Q

Menstrual causes of acute bleeding

A

Anovulatory e.g. PCOS
Fibroids (more SA to bleed from)
Anticoagulant
Von Willebrand’s disease

94
Q

Non-menstrual causes of acute bleeding

A

Miscarriage
Cervical cancer
Endometrial cancer
Vaginal trauma

95
Q

Management of acute bleeding in gynaecology

A

Resuscitation
Tranexamic acid
Mefenamic acid
Norethisterone
IUS
COCP
GnRH analogues

96
Q

Effect of GnRH analogues on FSH and LH

A

Downregulation of LH and FSH
Causes mini pseudomenopause

97
Q

Describe pres and management of HSV infection of vulva

A

Pres
- pain, ulcers, discharge, dysuria, urinary retention

Inv
- HSV1&2, inguinal lymphadenopathy, viral swab

Manage
- aciclovir, bladder cath, local anaestehtic gel

98
Q

Describe pres and management of Bartholin’s abscess

A

Pres
- blocked duct at 5 and 7 oclock, infection, swelling pain

Inv
- swabs for micro

Manage
- conservative, broad spectrum antibiotics, word catheter, marsupialisation

99
Q
A

Reproduction/Sexual Health (9 decks)

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