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Week 204 - Gynaecology Flashcards

1
Q

Week 204 - Gynaecology: Give a definition of menorrhagia and give the objective definition.

A
  • Excessive loss of blood during menstruation.

* >80ml

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2
Q

Week 204 - Gynaecology: Give a definition of dysmenorrhea.

A

Painful menstrual periods.

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3
Q

Week 204 - Gynaecology: What is primary and secondary dysmenorrhea?

A
  • Primary - no associated with organic disease or psychological cause.
  • Secondary - A cause can be found (e.g. endometriosis, PID)
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4
Q

Week 204 - Gynaecology: What is Dyspareunia?

A

Pain during sexual intercourse.

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5
Q

Week 204 - Gynaecology: What are the three differentials for menorrhagia?

A
  • Dysfunctional uterine bleeding.
  • Uterine leiomyomas (Fibroids).
  • Endometriosis or Adenomyosis.
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6
Q

Week 204 - Gynaecology: What is the common name for uterine leiomyomas?

A

• Fibroids

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7
Q

Week 204 - Gynaecology: What is dysfunctional uterine bleeding?

A

This is heavy menstrual bleeding that is not associated with organic disease of the genital tract.

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8
Q

Week 204 - Gynaecology: What are fibroids? What is the medical term for them?

A
  • Uterine Leiomyomas.

* Benign growths in the uterus which can cause heavy menstrual bleeding.

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9
Q

Week 204 - Gynaecology: What is endometriosis?

A

This is where endometrial tissue is found outside of the uterus. It can cause heavy bleeding, persistent pain and infertility.

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10
Q

Week 204 - Gynaecology: What is adenomyosis?

A

This is where endometrial tissue grows within the myometrium.

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11
Q

Week 204 - Gynaecology: What key feature of examination is used to distinguish between fibroids and dysfunctional uterine bleeding?

A
  • The size of the uterus.

* DUB will typically be a normal sized uterus whilst fibroids will lead to an enlarged uterus.

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12
Q

Week 204 - Gynaecology: On examination you feel an enlarged uterus, what is your initial investigation?

A

• USS, this is to determine whether there are fibroids or an ovarian cyst.

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13
Q

Week 204 - Gynaecology: A 25yr olf lady presents with heavy menstrual bleeding? Is an endometrial biopsy required? When is a biopsy indicated?

A

No, this is normally only performed in patients over 40, since the risk of endometrial cancer increases after 40. It may indicated in a younger woman if she fails to respond to treatment.

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14
Q

Week 204 - Gynaecology: What initial investigation should be offered to women who experience heavy menstrual bleeding?

A

FBC - to identify anaemia.

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15
Q

Week 204 - Gynaecology: What are the five medical treatments for menorrhagia?

A
  • Tranexamic Acid
  • Mefenamic Acid
  • Combined Oral Contraceptive Pill
  • Oral Progesterones.
  • Mirena IUS
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16
Q

Week 204 - Gynaecology: What is the role of Tranexamic acid in the treatment of menorrhagia?

A
  • Antifibrinolytic.

* Taken during menstruation and can reduce blood loss by 50%.

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17
Q

Week 204 - Gynaecology: What is the role of Mefenamic Acid in the treatment of menorrhagia?

A
  • NSAID
  • Useful for dysmenorrhoea and also reduces blood loss.
  • Can be used in conjuction with Tranexamic acid.
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18
Q

Week 204 - Gynaecology: What is the role of the oral contraceptive pill in the treatment of menorrhagia?

A

Reduces blood loss by 10-20%, and also helps with dysmenorrhoea.

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19
Q

Week 204 - Gynaecology: What impact does the Mirena IUS have on menorrhagia?

A

• Reduces blood loss by 90% and at 1 year 30% are amenorrhoeic.

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20
Q

Week 204 - Gynaecology: In patients who are very anaemic or constantly bleeding what is the treatment aim? And what treatments are used?

A
  • To achieve Amenorrhoea rapidly.
  • GnRHa - Inhibits release of Gonadotrophins so inhibits the release of oestrogen and androgen.
  • High dose progesterones.
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21
Q

Week 204 - Gynaecology: When is the use of surgery indicated in the treatment of menorrhagia and what are the options?

A
  • Failure of medical treatment and when family is complete.
  • Endometrial ablation - destruction of endometrium.
  • Hysterectomy.
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22
Q

Week 204 - Gynaecology: Where are the six locations for an ectopic pregnancy and which is the most common?

A
  • Interstitial/Cornual
  • Isthmic Tubal
  • Infundibular Tubal
  • Ovarian
  • Abdomial
  • Ampullar Tubal (Most common, due to narrowing of fallopian tube).
23
Q

Week 204 - Gynaecology: What are the risk factors for developing fibroids?

A
  • Age (Later reproductive years)
  • Menarche (Early onset)
  • Race (African)
  • Hypertension / CV risk
  • Family History
  • Obesity
  • Tamoxifen
24
Q

Week 204 - Gynaecology: Which drug, used in the treatment of breast cancer, is a risk factor for developing fibroids?

25
Q

Week 204 - Gynaecology: What are the five locations of fibroids? Give a brief description of each.

A
  • Intramural - This is completely enclosed in the endometrium.
  • Submucosal - This is where it protrudes into the uterus but is covered by a layer of mucosa.
  • Subserosal - Opposite of a submucosal, protrudes out the external wall of the uterus, but it covered by serosa.
  • Pedunculated - Both subserosal and submucosal. Look like pendulums.
26
Q

Week 204 - Gynaecology: What are the symptoms of fibroids?

A
  • Asymptomatic - 50%
  • Heavy menstrual bleeding.
  • Haematological disorders.
  • Dysmenorrhoea.
  • Infertility.
27
Q

Week 204 - Gynaecology: What investigations should be performed for suspected fibroids?

A
  • FBC - Hb
  • Tumour Markers - Ca125, CEA
  • USS
  • Endometrial biopsy (Women over 40)
  • Hysteroscopy/Laparoscopy
28
Q

Week 204 - Gynaecology: What are the medical treatments available for fibroids?

A
  • Esmya
  • GnRH agonists. - Shrink fibroid and reduce vascularity.
  • Mirena IUS
29
Q

Week 204 - Gynaecology: How does Esmya treat fibroids?

A

Three modes of action-
• Acts on the fibroid by reducing progesterone receptors which reduces cell proliferation and induces apoptosis.
• Acts on the pituitary to reduce Gonadotrophin secretion..
• Acts on the endometrium to have a direct affect to reduce bleeding.

30
Q

Week 204 - Gynaecology: What are the surgical options for the treatment of fibroids?

A
  • Myomectomy - Surgical removal of fibroids.
  • Hysterectomy
  • Uterine Artery Embolisation - cut’s off blood supply to fibroid.
31
Q

Week 204 - Gynaecology: What are the complications of ovarian cysts?

A
  • Pain
  • Torsion
  • Rupture
  • Haemorrhage
  • Malignancy
  • Hormone Secretion
32
Q

Week 204 - Gynaecology: What are the main types of ovarian cysts?

A
  • Physiological - Follicular + Luteal
  • Endometriomas
  • Polycystic Ovaries
  • Germ cell tumours
  • Epithelial tumours
  • Sex cord stromal tumours
33
Q

Week 204 - Gynaecology: What is the Risk of Malignancy Index (For ovarian cysts)

A
  • This is calculation that identifies the risk of a cyst developing into a cancer.
  • RMI = U x M x CA125
  • U is uss features. (Either 0,1or3)
  • M is menopause (1 if pre, 3 if post)
  • CA125 (Serum level in IU/ml)
34
Q

Week 204 - Gynaecology: What are the USS features for RMI? How do they score?

A
  • Multiolocular cysts, Solid Areas, Metastases, Ascites, Bilateral lesions.
  • The presence of one scores one point.
  • The presence of 2 or more scores three points.
35
Q

Week 204 - Gynaecology: According to WHO in 2009, what should a good semen sample be? (Mls,Count,Motility,Normal)

A

Volume - 1.5ml to 6ml
Count - >15x10(6)/ml
Motility - >40%
Normal- >4%

36
Q

Week 204 - Gynaecology: What is the definition of subfertility?

A

Involuntary failure to conceive.

37
Q

Week 204 - Gynaecology: What are the causes of subfertility?

A
  • Ovulation Disorder - 25%
  • Sperm Dysfunction - 30%
  • Tubal disease - 20%
  • Endometriosis - 10%
  • Coital failure, uterine abnormalities - 10%
38
Q

Week 204 - Gynaecology: The menstrual cycle is divided into which three phases?

A
  • Follicular phase
  • Ovulatory phase
  • Luteal phase
39
Q

Week 204 - Gynaecology: What occurs during the Follicular phase of the menstrual cycle?

A
  • FSH slowly decrease, LH slowly increases.
  • The follicle matures.
  • Oestradiol slowly increase, progesterone remains at a low level.
  • The endometrium breaks down and begins to build up again.
40
Q

Week 204 - Gynaecology: What occurs during the ovulatory phase of the menstrual cycle?

A
  • LH spikes, FSH has a slight increase.
  • Ovulation
  • Oestradiol peaks and then drops off, progesterone slightly rises.
  • The endometrial wall is at its peak.
41
Q

Week 204 - Gynaecology: What occurs during the Luteal phase of the menstrual cycle?

A
  • LH and FSH starts low and slowly decreases.
  • The corpus luteum forms.
  • Progesterone reaches it’s peak and then drops off, Oestradiol slowly decreases.
  • The endometrium begins to breakdown.
42
Q

Week 204 - Gynaecology: Ovulation disorders can arise due to a disruption of the hypothalamus-pituitary-ovarian axis, in what ways?

A
  • Hypothalamus - Eating disorders, stress, exercise, underweight.
  • Pituitary - Prolactinomas, Sheehans, Craniopharyngomas, hypophysectomy, radiotherapy, idiopathic.
  • Ovarian - PCOS, Primary ovarian failure.
43
Q

Week 204 - Gynaecology: What is the medical treatment of ovulatory disorders?

A
  • Oestrogen antagonists.

* Gonadotrophins - FSH + LH

44
Q

Week 204 - Gynaecology: What are the leading pathological causes of tubal disease?

A
  • Infective - Chlamydia Trachomatis, Neisseria gonorrhoea.

* Inflammatory - Endometriosis

45
Q

Week 204 - Gynaecology: What are the indications for assisted conception?

A
  • Dysfunctional sperm
  • Tubal disease
  • Endometriosis
  • Prolonged unexplained infertility (>2yrs)
  • Preimplantation genetic diagnosis
  • Failed fertility treatments
46
Q

Week 204 - Gynaecology: Describe in vitro fertilisation.

A
  • Oocyte is recovered transvaginally.
  • Fertilised.
  • Cultured 2-5days.
  • Embryo transfer.
  • Freezing of remaining embryos.
47
Q

Week 204 - Gynaecology: What are the risks of assisted contraception?

A
  • Ovarian hyperstimulation syndrome - Massive ovarian cysts, ascites, pleural and pericardial effusion, hypovolaemia.
  • Multiple pregnancy.
  • Pelvic/ovarian sepsis.
  • Ovarian torsion.
48
Q

Week 204 - Gynaecology: What is a molar pregnancy?

A

This is overgrowth of the placenta, also known as trophoblastic disease.

49
Q

Week 204 - Gynaecology: If you were to have a woman with a +ve pregnancy test with an empty uterus on USS what are your differentials?

A
  • Ectopic pregnancy
  • Very early pregnancy
  • Complete miscarriage
50
Q

Week 204 - Gynaecology: What is the management of miscarriage?

A
  • Expectant
  • Medical with mifepristone and misoprostol
  • Surgical
51
Q

Week 204 - Gynaecology: In an intrauterine pregnancy what would you expect the HCG to rise by?

A

• >60% within 48hrs, if there is a suboptimal rise, suspect an ectopic pregnancy.

52
Q

Week 204 - Gynaecology: What are the three regimens of HRT?

A

1) E2 only - for hysterectomised women only.
2) Sequential - E2 every day with progesterone for 14days/month, have monthly withdrawal bleed.
3) Continuous combined - E2 and progesterone daily, only give if LMP >1yr ago. No bleed.

53
Q

Week 204 - Gynaecology: What are some of the risks of HRT?

A

• Slight increase in risk of breast cancer and venous thromboembolism.

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