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MRCP Part 1 > Women's Health: Gynaecology > Flashcards

Women's Health: Gynaecology Flashcards

1
Q

How do the cancers present in terms of pain

A

Endometrial painless
Rest painful

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2
Q

How do the cancers compare in terms of bleeding

A

Endo: Post-menopausal
Ovarian: None
Cervical: Intermenstrual, postcoital, post-menopausal
Vulval: Bleeds

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3
Q

Early fullness and diarrhoea is most associated with which cancer?

A

Ovarian

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4
Q

Who gets urgent referral for endometrial cancer?

A

PMB > 12 months after last period
US if >55yrs with unexplained discharge or haematuria

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5
Q

Who gets urgent referral for ovarian cancer?

A

Ascites/mass/raised CA-125 (if symptoms)

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6
Q

Who gets urgent referral for cervical cancer?

A

Changes on colposcopy

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7
Q

Who gets urgent referral for vulval cancer?

A

Where suspected

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8
Q

What is the first line and gold standard investigation for endometrial cancer?

A

1st: TVUS
GS: Hysteroscopy with biopsy

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9
Q

What is the first line and gold standard investigation for Ovarian cancer?

A

1st: US
GS: Diagnostic laparotomy

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10
Q

What is the first line and gold standard investigation for cervical cancer?

A

Punch biopsy is both

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11
Q

Where is LLETZ used in cervical cancer?

A

Where CIN is found on colposcopy
NOT used for cervical cancer as can cause bleeding

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12
Q

Endometrial and ovarian cancers cause
x menarche
y menopause
z parity

A

Early menarche
Late menopause
Nulliparity

‘Longest time (gap between menarche and menopause) without having kids (nulliparity)’

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13
Q

Which cancer is associated with high parity?

A

Cervical

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14
Q

Unopposed oestrogen is most associated with which cancer?

A

Endometrial

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15
Q

Which cancer is associated with the BRCA genes?

A

Ovarian

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16
Q

How do you treat endometrial cancer if it is
Localised
High risk
Unsuitable for surgery

A

Local: Hysterectomy + bilateral salpingo-oophrectomy
High risk: surgery + adjuvant radiotherapy
Unsuitable: Progesterone therapy

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17
Q

How is cervical cancer treated if its
Local (IA/B)
Cervix-pelvic wall (II-III)
Beyond pelvis

A

Local: Hysterectomy + node clearance
Cervix-pelvis wall: Radio + chemo
Beyond pelvis: Radiation and chemo

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18
Q

What should be done if multifocal cysts are found on US?

A

Biopsied
Check for ovarian cancer

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19
Q

What ages and intervals should cervical smears be offered?

A

25-49: every 3 years
50-64: Every 5 years

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20
Q

hrHPV -ve

A

Normal recall

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21
Q

hrHPV +ve

A

Cytology

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22
Q

Cytology -ve

A

repeat in 12 months

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23
Q

12 month repeat HPV +ve but cyto -ve

A

Repeat in another 12 months

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24
Q

24 month repeat -ve

A

Normal recall

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25
Q

24 month repeat +ve

A

Colposcopy

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26
Q

Inadequate sample

A

Repeat 3 months

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27
Q

3 month sample repeat inadequate

A

Colposcopy

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28
Q

What is the definition of secondary amenorrhea?

A

3-6 month cessation in previously normal menstruation
6-12 months cessation if Hx oligomenorrhea

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29
Q

What is the definition of primary amenorrhea?

A

Failure to menstruate by 13 if no secondary sexual characteristics

30
Q

What is the first line investigation for amenorrhea?

A

urinary/serum B-HCG to exclude pregnancy

31
Q

How can you broadly group secondary amenorrhea?

A

Without or with androgen excess: body hair, acne, female pattern hair loss

32
Q

How do you distinguish POF from PCOS in terms of

Presentation

FSH/LH

Oestrogen

Testosterone

A

PCOS // POF

Hairy, acne // night sweats, vaginal dryness

High // High

Normal // Low

High // normal

*PCOS is high testosterone, POF is low oestrogen*

33
Q

How do you treat the following features of PCOS

Oligo/amenorrhea

Acne

Hirsuitism

Infertility

A

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

  1. 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

34
Q

What is the treatment for POF?

A

HRT

COC pill if <50yrs for breast Ca and VTE risk

35
Q

What ultrasound finding is in keeping with PCOS?

A

>=12 follicles (2-9mm) and/or volume >10cm3

36
Q

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

A
  1. Prolactinoma: High prolactin causes -ve feedback of FSH/LH
  2. POF: High FSH/LH due to low oestrogen
  3. Hypothalamic: Low or normal FSH/LH without any causes of -ve feedback –> low pituitary action
  4. PCOS: FSH/LH tries to reverse high testosterone
37
Q

How do you distinguish between Asherman’s and Sheehan’s syndrome clinically?

A

Asherman’s // Sheehan’s

Increased secretions, sore abdo + breasts, low mood and appetite // post-partum low BP

*Shee-has a baby now*

38
Q

What lab findings are seen in Sheehan’s syndrome?

A

Low glucose, thyroid + pituitary symptoms

39
Q

How do you distinguish between androgen insensitivity syndrome and congenital adrenal hyperplasia?

A

AIP // CAH

Undescended testes +/- breasts // Tall, beardy, deep voiced females

40
Q

How do you distinguish between Turner’s syndrome and Kallman’s…

Clinically

Gonadotrophins

Genetically

A

Turners // Kallman’s

Short, wide chest, webbed neck // delayed puberty, lack of smell

FSH/LH high // low

45XO OR 45X // X-linked recesive

41
Q

In oligomenorrhea/amenorrhea, who do you refer to?

A

Primary: Gyanecology

Secondary

Gynae // Endo

Elevated FSH/LH // Low

PCOS, infertility, cervix or uterine Ca Hx // High testosterone outside PCOS, Cushing’s features

42
Q

What is menorrhagia?

A

Regular heavy menstrual blood loss affecting the woman’s life

43
Q

What is primary and secondary dysmenorrhea?

A

Primary: pain 1-2 years after menarche, usually within a few hours from period onset

Secondary: Pain many years after menarche

44
Q

How do you differentiate between endometriosis, adenomyosis and fibroids in terms of

Pain

Bleeding (outside heavy)

Associated features

A

Endo // Adeno // fibroids

cyclical, deep sex, toileting // periods + intercourse // lower abdo pain during period

haematuria // no // no

subfertility // Hx multiparity // bloating, mass, AC women

45
Q

What cause of dysmenorrhea is most associated with fever, discharge and cervical excitation?

A

Pelvic inflammatory disease

46
Q

What cancers should you rule out in menorrhagia?

A

Cervical: painful

Uterine: Painless

47
Q

What is the general approach to investigating dysmenorrhea and menorrhagia?

A

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

48
Q

How does referral work for dysmenorrhea and menorrhagia?

A

Pelvic mass/ascites –> urgent

Pelvic mass + cancer features –> witihin 2 weeks

All secondary dysmenorrhea needs referred

49
Q

What is the first line management for menorrhagia?

A

Contraceptive: mirena coil –> COC pill –> long progestogens

Non cnotraceptive: Mefenamic if painful, transexamic if not

50
Q

Following inital therapy, what is the specific management for

Adenomyosis

Endometriosis

Fibroids

A

Adeno: GnRH agonists (-relins)

Endo: Ablation, hysterectomy

Fibroids: Myomectomy to remove +/- GnRH before to shrink

51
Q

What is the treatment for PID?

A

SEPSIS 6

oral oflaxacin + metronidazole

OR

IM ceftriaxone + oral dox + oral metronidazole

52
Q

How can you differentiate between Ovarian torsion, ectopic pregnancy and mittelschmirz since all cause pain without bleeding?

Pain

Tenderness

US

Treatment

A

Torsion // Ectopic // Mittelschmirz

Deep, colicky pain // sharp pain // mid cycle, sharp

Yes // yes // no

Whirpool // no pregnancy // free fluid

Laparoscopy // laparoscopy + salpingectomy // conservative

53
Q

What is the process of the menopause

A

Declining ovarian development leads to

Reduced oesotrogen

Increased FSH/LH

Causing permanent cessation of menstruation

54
Q

How do you diagnose perimenopause and menopause clinically?

A

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

55
Q

What lifestyle changes can help with these menopausal symptoms

Hot flushes

Sleep problems

A

Hot flushes: Exercise, cooling rooms and clothes. Avoid caffeine, alcohol, spice and smoking

Sleep: Avoid caffeine and late exercise

56
Q

What HRT and other drugs are available for the menopausal symptoms of

Vasomotor

Urogenital symptoms

Mood disorder

A

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

57
Q

What are the 4 contraindications to HRT

A
  • Breast cancer history
  • Oestrogenergic cancers
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
58
Q

What are the complications of the following HRT methods

All

Oral

Combined

A

All: Ovarian cancer

Oral: VTE, stroke if oestrogen

Combined: CHD, Breast Ca

59
Q

What follow up is needed on commencement or change of HRT?

A

3 month check in then yearly review

60
Q

How is stress and urge incontinence managed by

Lifestyle

Drugs

A

Urge // Stress

Bladder training 6 weeks // Pelvic floor training (8/day 3 months)

Anti-muscarinics (oxybutinin, tolteridone) // Taping or duloxetien

61
Q

What do you give for HRT where

Oral is contraindicated

patient is still menstruating

A

Topical or patches

cyclical not continuous therapy

62
Q

Pregnant patient presents with low grade fever, pain and vomiting. TVUS shows normal pregnancy and large fibroids

A

Red degeneration of fibroid

Fever + pain + vomiting

Manage conservatively

63
Q

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

A

Multi-locuated cysts

Follicular

Corpus luteum (failure of CL to break down)

Dermoid cysts

mucinous cystadenoma

64
Q

What is the most common type of ovarian tumour

A

Serous carcinoma

65
Q

Old woman with labial lump and raised nodes

A

Vulval carcinoma

Associated with HPV, VIN, IC

66
Q

When are smears performed in pregnancy

A

3 months post-partum

Unless missed or previously abnormal

67
Q

What are the 3 most common pathogens of pelvic inflammatory disease?

A

C. trachomatis

N. gonorrheae

M. genitalium

68
Q

How do you manage premenstrual syndrome that is…

Mild

Moderate

Severe

A

Mild: 2-3hrly complex carb meals

Mod: new-gen combined pill (eg drospirenone + ethinylestradiol)

Severe: SSRI

69
Q

What size of fibroid can you try medical treatment in?

A

<3cm with no distortion

70
Q
A

MRCP Part 1 (32 decks)

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