Women's Health: Gynaecology Flashcards
How do the cancers present in terms of pain
Endometrial painless
Rest painful
How do the cancers compare in terms of bleeding
Endo: Post-menopausal
Ovarian: None
Cervical: Intermenstrual, postcoital, post-menopausal
Vulval: Bleeds
Early fullness and diarrhoea is most associated with which cancer?
Ovarian
Who gets urgent referral for endometrial cancer?
PMB > 12 months after last period
US if >55yrs with unexplained discharge or haematuria
Who gets urgent referral for ovarian cancer?
Ascites/mass/raised CA-125 (if symptoms)
Who gets urgent referral for cervical cancer?
Changes on colposcopy
Who gets urgent referral for vulval cancer?
Where suspected
What is the first line and gold standard investigation for endometrial cancer?
1st: TVUS
GS: Hysteroscopy with biopsy
What is the first line and gold standard investigation for Ovarian cancer?
1st: US
GS: Diagnostic laparotomy
What is the first line and gold standard investigation for cervical cancer?
Punch biopsy is both
Where is LLETZ used in cervical cancer?
Where CIN is found on colposcopy
NOT used for cervical cancer as can cause bleeding
Endometrial and ovarian cancers cause
x menarche
y menopause
z parity
Early menarche
Late menopause
Nulliparity
‘Longest time (gap between menarche and menopause) without having kids (nulliparity)’
Which cancer is associated with high parity?
Cervical
Unopposed oestrogen is most associated with which cancer?
Endometrial
Which cancer is associated with the BRCA genes?
Ovarian
How do you treat endometrial cancer if it is
Localised
High risk
Unsuitable for surgery
Local: Hysterectomy + bilateral salpingo-oophrectomy
High risk: surgery + adjuvant radiotherapy
Unsuitable: Progesterone therapy
How is cervical cancer treated if its
Local (IA/B)
Cervix-pelvic wall (II-III)
Beyond pelvis
Local: Hysterectomy + node clearance
Cervix-pelvis wall: Radio + chemo
Beyond pelvis: Radiation and chemo
What should be done if multifocal cysts are found on US?
Biopsied
Check for ovarian cancer
What ages and intervals should cervical smears be offered?
25-49: every 3 years
50-64: Every 5 years
hrHPV -ve
Normal recall
hrHPV +ve
Cytology
Cytology -ve
repeat in 12 months
12 month repeat HPV +ve but cyto -ve
Repeat in another 12 months
24 month repeat -ve
Normal recall
24 month repeat +ve
Colposcopy
Inadequate sample
Repeat 3 months
3 month sample repeat inadequate
Colposcopy
What is the definition of secondary amenorrhea?
3-6 month cessation in previously normal menstruation
6-12 months cessation if Hx oligomenorrhea
What is the definition of primary amenorrhea?
Failure to menstruate by 13 if no secondary sexual characteristics
What is the first line investigation for amenorrhea?
urinary/serum B-HCG to exclude pregnancy
How can you broadly group secondary amenorrhea?
Without or with androgen excess: body hair, acne, female pattern hair loss
How do you distinguish POF from PCOS in terms of
Presentation
FSH/LH
Oestrogen
Testosterone
PCOS // POF
Hairy, acne // night sweats, vaginal dryness
High // High
Normal // Low
High // normal
*PCOS is high testosterone, POF is low oestrogen*
How do you treat the following features of PCOS
Oligo/amenorrhea
Acne
Hirsuitism
Infertility
Oligomenorrhea
14 days progestogen inc withdrawal bleed then TVUS for endometrial thickness. Refer if >10mm
if normal: progestogen every 1-3m/low dose COC/IUS
Acne
- COC
+/- topical retinoids, Abx as per acne treatment line
Hirsutism
COC
Infertility
Clomifene, metformin
TLDR: POP 14 days then COC +/- acne treatment +/- clomifene or metformin
What is the treatment for POF?
HRT
COC pill if <50yrs for breast Ca and VTE risk
What ultrasound finding is in keeping with PCOS?
>=12 follicles (2-9mm) and/or volume >10cm3
What do the following hormone tests indicate
State
FSH
LH
Prolactin
Testosterone
1
Normal/low
Normal/low
High
Normal
2
High
High
Normal
Normal
3
Low/normal
Low/normal
Normal
Normal
4 Normal/increased Normal/increased Normal/increased Normal/moderate increase
- Prolactinoma: High prolactin causes -ve feedback of FSH/LH
- POF: High FSH/LH due to low oestrogen
- Hypothalamic: Low or normal FSH/LH without any causes of -ve feedback –> low pituitary action
- PCOS: FSH/LH tries to reverse high testosterone
How do you distinguish between Asherman’s and Sheehan’s syndrome clinically?
Asherman’s // Sheehan’s
Increased secretions, sore abdo + breasts, low mood and appetite // post-partum low BP
*Shee-has a baby now*
What lab findings are seen in Sheehan’s syndrome?
Low glucose, thyroid + pituitary symptoms
How do you distinguish between androgen insensitivity syndrome and congenital adrenal hyperplasia?
AIP // CAH
Undescended testes +/- breasts // Tall, beardy, deep voiced females
How do you distinguish between Turner’s syndrome and Kallman’s…
Clinically
Gonadotrophins
Genetically
Turners // Kallman’s
Short, wide chest, webbed neck // delayed puberty, lack of smell
FSH/LH high // low
45XO OR 45X // X-linked recesive
In oligomenorrhea/amenorrhea, who do you refer to?
Primary: Gyanecology
Secondary
Gynae // Endo
Elevated FSH/LH // Low
PCOS, infertility, cervix or uterine Ca Hx // High testosterone outside PCOS, Cushing’s features
What is menorrhagia?
Regular heavy menstrual blood loss affecting the woman’s life
What is primary and secondary dysmenorrhea?
Primary: pain 1-2 years after menarche, usually within a few hours from period onset
Secondary: Pain many years after menarche
How do you differentiate between endometriosis, adenomyosis and fibroids in terms of
Pain
Bleeding (outside heavy)
Associated features
Endo // Adeno // fibroids
cyclical, deep sex, toileting // periods + intercourse // lower abdo pain during period
haematuria // no // no
subfertility // Hx multiparity // bloating, mass, AC women
What cause of dysmenorrhea is most associated with fever, discharge and cervical excitation?
Pelvic inflammatory disease
What cancers should you rule out in menorrhagia?
Cervical: painful
Uterine: Painless
What is the general approach to investigating dysmenorrhea and menorrhagia?
Bimanual and speculum exam: Look for fibroids, ascites and cancer
FBC: iron deficiency anaemia
If structural pathology
1st line: TVUS for endo and adeno
GS: Surgical exploration
How does referral work for dysmenorrhea and menorrhagia?
Pelvic mass/ascites –> urgent
Pelvic mass + cancer features –> witihin 2 weeks
All secondary dysmenorrhea needs referred
What is the first line management for menorrhagia?
Contraceptive: mirena coil –> COC pill –> long progestogens
Non cnotraceptive: Mefenamic if painful, transexamic if not
Following inital therapy, what is the specific management for
Adenomyosis
Endometriosis
Fibroids
Adeno: GnRH agonists (-relins)
Endo: Ablation, hysterectomy
Fibroids: Myomectomy to remove +/- GnRH before to shrink
What is the treatment for PID?
SEPSIS 6
oral oflaxacin + metronidazole
OR
IM ceftriaxone + oral dox + oral metronidazole
How can you differentiate between Ovarian torsion, ectopic pregnancy and mittelschmirz since all cause pain without bleeding?
Pain
Tenderness
US
Treatment
Torsion // Ectopic // Mittelschmirz
Deep, colicky pain // sharp pain // mid cycle, sharp
Yes // yes // no
Whirpool // no pregnancy // free fluid
Laparoscopy // laparoscopy + salpingectomy // conservative
What is the process of the menopause
Declining ovarian development leads to
Reduced oesotrogen
Increased FSH/LH
Causing permanent cessation of menstruation
How do you diagnose perimenopause and menopause clinically?
Clinically
>=45yrs +
Perimenopause: vasomotor + irregular periods
Menopause: >12 months amenorrhea without contraception OR symptoms if no uterus
Investigationally
Use FSH in women
40-45yrs with menopausal symptoms AND cycle changes
<40yrs with suspected POF
What lifestyle changes can help with these menopausal symptoms
Hot flushes
Sleep problems
Hot flushes: Exercise, cooling rooms and clothes. Avoid caffeine, alcohol, spice and smoking
Sleep: Avoid caffeine and late exercise
What HRT and other drugs are available for the menopausal symptoms of
Vasomotor
Urogenital symptoms
Mood disorder
Vasomotor
HRT: TD/PO; combined if uterus, oesotrogen if not
Other: SSRIs/SNRIs/clonidine/Gabapentin
Urogenital
HRT: Vaginal oestrogens
Other: Lubricants, moisturisers
Mood
HRT Personal choice
Self help/CBT/anti-depressants
What are the 4 contraindications to HRT
- Breast cancer history
- Oestrogenergic cancers
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
What are the complications of the following HRT methods
All
Oral
Combined
All: Ovarian cancer
Oral: VTE, stroke if oestrogen
Combined: CHD, Breast Ca
What follow up is needed on commencement or change of HRT?
3 month check in then yearly review
How is stress and urge incontinence managed by
Lifestyle
Drugs
Urge // Stress
Bladder training 6 weeks // Pelvic floor training (8/day 3 months)
Anti-muscarinics (oxybutinin, tolteridone) // Taping or duloxetien
What do you give for HRT where
Oral is contraindicated
patient is still menstruating
Topical or patches
cyclical not continuous therapy
Pregnant patient presents with low grade fever, pain and vomiting. TVUS shows normal pregnancy and large fibroids
Red degeneration of fibroid
Fever + pain + vomiting
Manage conservatively
Rergarding ovarian cysts which…
require biopsy to exclude malignancy
are the most common
likely to have intraperitoneal bleeding
have other organ system tissues
Is associated with pseudomyxoma peritonei
Multi-locuated cysts
Follicular
Corpus luteum (failure of CL to break down)
Dermoid cysts
mucinous cystadenoma
What is the most common type of ovarian tumour
Serous carcinoma
Old woman with labial lump and raised nodes
Vulval carcinoma
Associated with HPV, VIN, IC
When are smears performed in pregnancy
3 months post-partum
Unless missed or previously abnormal
What are the 3 most common pathogens of pelvic inflammatory disease?
C. trachomatis
N. gonorrheae
M. genitalium
How do you manage premenstrual syndrome that is…
Mild
Moderate
Severe
Mild: 2-3hrly complex carb meals
Mod: new-gen combined pill (eg drospirenone + ethinylestradiol)
Severe: SSRI
What size of fibroid can you try medical treatment in?
<3cm with no distortion
