Z2F Gynaecology Flashcards
1
Q
Primary vs secondary amenorrhoea
A
Primary have never developed periods
2
Q
3 causes of primary amenorrhoea
A
Imperformate hymen Abnormal gonads (hypergonadotrophic hypogonadism) Abnormal hypothalamus or P gland (hypogonadotrophic hypogonadism)
3
Q
Periods should start by
A
13 if no signs of puberty
15 if signs of puberty
4
Q
Order of puberty development in girls
A
Breasts -> pubic hair -> periods
5
Q
What does kallman syndrome cause
A
Hypogonadotrophic hypogonadism (lack of FSH and LH)
6
Q
2 key symptoms of kallman syndrome
A
Failure to start puberty
Absent sense of smell
7
Q
Hypogonadotrophic hypogonadism effect on hormones
A
Low FSH and low LH
8
Q
Hypergonadotrophic hypogonadism hormone levels
A
High FSH and LH
Low oestrogen
9
Q
3 causes of hypergonadotrophic hypogonadism
A
Injury to gonads (cancer, mumps, torsion)
Congenital aplasia
Turners syndrom (XO)
10
Q
Does turners syndrome cause Hypo or hypergonadotrophic hypogonadism
A
Hypergonadotrophic hypogonadism
Hypothalamus still making gnrh and p making FSH and LH
No oestrogen negative feedback
11
Q
Androgen insensitivity syndrome presentation and cause
A
Unable to respond to androgens (testosterone)
Female phenotype with no female internal organs but vagina
12
Q
Cyclical abdominal pain but no menorrhagia: dx
A
Structual issues
Inperformate hymen/ FGM/ transverse vaginal septum
13
Q
Antibody test on girls aged 15 without periods
A
Anti TTG (coeliacs)
14
Q
Treatment for kallman syndrome
A
Pulsitile GnRH +/- COOP
15
Q
High isolated FSH suggests
A
Primary ovarian failure
16
Q
High LH isolated suggests
A
PCOS
17
Q
How to reduce risk of endometrial cancer in women with PCOS
A
Induce withdrawal bleed every 3-4 months
Either COOP use or medroxyprogesterone (DEPO as a pill) for 14 days
18
Q
Other than ca, amenorrhoea associated with low oestrogen is a risk for
A
Osteoporosis
19
Q
Treatment for PMS
A
Lifestyle
COOP - Yasmin/ contains drospierone
SSRI
CBT
20
Q
Treatment for physical symptoms of PMS after COOP, lifestyle and SSRI tried
A
Spirolactone
21
Q
Average menstrual blood loss
A
40mls
22
Q
Management of painful heavy periods in women who want to conceive vs non painful
A
Mefenamic acid (if pain) TXA (if no pain)
23
Q
Order of management of heavy periods in women who do not want to conceive
A
Mirena
COOP
Cyclical progesterones
24
Q
Fibroids are sensitive to which hormone
A
Oestrogen (shrink after menopause)
25
4 types of fibroids
Submucosal - just below lining of uterus
Intramural - in myometrium (distort uterus)
Subsersosal - outer layer of uterus (grow into abdo)
Pedunculated - on a stalk
26
Most common presentation of fibroids
Heavy menstrual bleeding
27
Fibroids on examination present as
NON tender mass on PV/ abdominal exam
28
Management of fibroids depends on ??
Size (less than 3cm)
29
Fibroid less than 3cm the management is same as ??
same as heavy menstural bleeding
Mirena
TXA/ NSAIDS
COOP
Cyclical progesterones
30
Fibroids greater than 3cm management
refer to gynaecologist
Same as less than 3cm medically
Surgical - ablation, hysterectomy, uterine artery embolisation, myomectomy etc
31
Only known treatment to improve fertility in women with fibroids
Myomectomy
32
Myomectomy is used to treat
Fibroids
| IN WOMEN WHO CANNOT CONCIEVE - only known treatment
33
Pregnant women with hx of fibroids presents with abdominal pain and low grade fever :dx
Red degeneration of fibroid (ischaemia due to lack of blood supply)
34
Red degeneration of fibroids risk factors
Greater than 5mm
| 2nd and 3rd trimester
35
Red degeneration of fibroids presentation
Severe abdo pain, low grade fever, tachycardia, vomiting
36
Chocolate cysts
Endometrial tissue in the ovaries
37
Adenomyosis
Endometrial tissue in myometrium
38
Gold standard endometriosis diagnosis
Laparoscopy
39
Management of endometriosis
```
NSAIDS
COOP (back to back)
trial of other hormonal contraception
Adhesionlysis
Induce menopause like state - GnRH analogues
```
40
Adenomyosis is more common in which women
Multiparous and late reproductive years
41
Adenomyosis symptoms triad:
dysmenorrhoea, menorrhagia, dyspareunia
42
Adenomyosis on examination
Tender and enlarged uterus
43
First line investigation for adenomyosis
TVUSS
44
Treatment for adenomyosis?
Same as menorrhagia
Mirena
TXA/ NSAIDS
COOP
Cyclical progesterones
45
Effects of adenomyosis on pregnancy
```
Bad things (same for endometriosis)
Infertility, miscarriage, PPROM, preterm labour, PPH
```
46
Menopause definition
12 months of amenorrhoea needed for dx but the menopause is the day of the last period
47
Premature menopause date
Before 40 years
48
Menopause hormone levels
Low oestrogen and progesterone
| High FSH and LH
49
Low oestrogen and progesteron
High FSH and LH
Indicates what
Menopause
50
What age do women need to use contraception until
Two years without a period if under 50
| One year without a period if over 50
51
Nice first line test for suspected menopause in under 45s
FSH blood test
52
COOP UKMEC after 40
UKMEC 2
53
Contraception that is not as good to use after 40 years
COOP - only UKMEC 2 age
(DEPO cause osteoporosis) shouldn't use after 45
54
Max age for DEPO
45 - osteoporosis
55
Two key side effects of DEPO and unique contraindication
Weight gain, osteoporosis, (delay to fertility)
Over 45s
56
Average length of perimenopausal symptoms
2-5 years
57
Unique treatment for reduced libido at menopause
Testosterone cream
58
Unique treatment for vaginal dryness and atrophy after menopause
Vaginal oestrogen
59
Premature ovarian insufficiency diagnosis is made by:
Under 40, low oestrogen symptoms, high FSH on two occasions with a 4 week gap
60
Premature ovarian insufficiency treatment
HRT - important to reduce risk of CVD and OP. Increased risk of breast ca and VTE if used in under 50s but lower BP
OR
COOP - contraception is still possible in POI
61
Risks of HRT in under 50s in comparison to over 50s
Increased risk of breast ca and VTE if used in under 50s
62
Which type of HRT: no uterus
Oestrogen only
63
Which type of HRT: still having periods
Cyclical progesterone and regular break through bleeds
Until 12 months without a period
64
Which type of HRT: women with a uterus and 12 months without a bleed
Combined
65
Non HRT, menopausal drug treatment for vasomotor symptoms
Clonidine
CANNOT withdraw suddenly
66
Key benefits of HRT
Improved QOL
| Reduced OP and fracture risk
67
What type of drug is clonidine
Alpha 2 adrengenic and imidazoline receptor agonist
68
Clonidine indications
Vasomotor symtom control
?PCOS
HTN
69
If women wanting HRT still have periods, what type of HRT must they have?
Cyclical HRT (with progesterone)
70
Cancer risks of HRT
Breast and endometrial
71
Non cancer risks of HRT
VTE, stroke, coronary artery disease
72
Oldest age for smears
65 unless 1 of last 3 abnormal
73
3 key questions in HRT counselling
Local or systemic symptoms?
Uterus or not?
Periods or not?
74
How many years is Mirena coil licensed for in HRT endometrial protection
4 years (5 normally)
75
Best way of delivering drugs in HRT
Oestrogen - patch (VTE risk lower)
| Progesterone - coil (breast cancer and MI risk)
76
How long for HRT to work
3-6 months
77
Criteria for diagnosing PCOS
Rotterdam criteria
78
PCOS definition by Rotterdam criteria
2/3 of:
| Anovulation, hyperandrogegism (acne, hirsutism) and PCO on USS
79
Skin change in PCOS
Acanthosis nigricans
80
4 ddx other than PCOS of hirsutism
Medications (phenytoin, ciclosporin, testosterone and steroids)
Ovarian or adrenals tumours
Cushings syndrome
Congential adrenal hyperplasia
81
SHBG levels in PCOS (sex hormone binding globulin)
Reduced
Insulin resistance -> increased insulin -> increased androgens
Insulin resistance -> increased insulin -> less negative feedback to SHBG -> less androgen blocking -> increased androgen levels
82
Increased androgen levels in PCOS physiology
Insulin resistance -> increased insulin -> increased androgens
Insulin resistance -> increased insulin -> less negative feedback to SHBG -> less androgen blocking -> increased androgen levels
83
TV USS appearance of PCOS
String of pearls
12 or more developing follicles per ovary or ovarian volume more than 10cm3
NOT reliable in adolescents
84
Drug used to help weight loss in women with PCOS
Orlistat (lipase inhibitor)
85
How to reduce risk of endometrial cancer in women with PCOS
```
Mirena coil
Cyclical progesterones (or COOP) to induce withdrawal bleed
```
86
Treatments for infertility in PCOS
Weight loss, clomifene, ovarian drilling, IVF
87
Treatment for hirsutism in PCOS
Weight loss, COOP, topical eflornithine, spirolactone
88
Management of acne in PCOS
COOP
| Then standard acne treatments: retinoid, abx, azelaic acid
89
Two types of functional ovarian cysts
Follicular: developing follicle that fails to rupture. Harmless and disappear after a few cycles
Corpus luteum: when luteum breaks down but fills with fluid. COMMON IN PREGNANCY
90
Type of tumour associated with ovarian torsion
Dermoid cysts/ germ cell tumour (type of teratomas)
91
Treatment for perimenopausal women with a simple cyst less than 5cm
No further investigation needed
92
Epithelial ovarian masses
Serous cystadenoma
Mucinous cyst adenoma - can become huge
93
Ovarian cancer tumour marker
Ca125
94
Other causes of Ca125
```
Endometriosis
Fibroids
Adenomyosis
PID
Liver disease
Pregnancy
```
95
Risk of malignancy index takes what into account
Menopause status (older -> high risk)
Ca125
US findings
96
Meig's syndrome
Ovarian fibroma (benign)
Pleural effusion
Ascites
Removal of tumour resolves symptoms
97
Dx: pleural effusion and ascites in a women with a ovarian tumour
Meigs syndrome (fibroma tumour)
98
Most common type of ovarian torsion
An ovarian mass normally larger than 5cm twists
Can happen in young girls with longer infundibulopelvic ligaments
99
Ovarian torsion presentation
Sudden onset severe unilateral pelvic pain - progressively gets worse and associated with N&V
100
USS finding in ovarian torsion
Whirlpool sign with free fluid in the pelvis and oedema of the ovaries
Dooplers may show lack of blood supply
101
Why can an ovarian torsion not be left
Becomes necrotic -> access -> sepsis/ peritonitis
102
Ashermans syndrome
Adhesions within the uterus (synechiae) following damage
103
When does Ashermans syndrome commonly occur after
Dilation and curettage procedures (removal of retained products), uterine surgery, pelvic infection
104
Management of POF
COOP or Traditional combined HRT
105
Ashermans syndorme presentation
Secondary amenorrhoea, lighter periods, dysmenorrhoea
Infertility
106
Ashermans syndrome management
Dissecting adhesions during hysteroscopy
107
Cell type of endocervix
Columnar epithelium
108
Cell type of ectocervix
Stratified squamous epithelium
109
Classical cervical ectropion presentation
Post coital bleeding
110
Risk factors for cervical ectropion
Higher oestrogen levels - young women, COOP and pregnancy
111
What is a nabothian cyst
fluid filled cyst on cervix
112
Nabothian cyst pathophysiology
Columnar epithelium of endocervix produces mucus (normal). Minor trauma (birth or infection) causes squamous cells of ectocervix to slightly cover columnar cells, trapping the mucus
113
Vault prolapse
Top of the vagina descends into the vagina in women who have had a hysterectomy
114
Management of nabothian cyst
No treatment required as long as sure on dx
Can therefore biopsy
115
How to grade uterine prolapse
POP-Q
Pelvic organ prolapse quantification system
0 normal
4 eversion of vagina
116
3 types of management in pelvic prolapse
1: conservative
2: vaginal pessary
3: surgery
117
What may you co-prescibe with a pessary
Vaginal oestrogen cream
Stops irritation of walls
118
4 causes for overflow incontinence
Anti-cholinergic meds
Fibroids
Pelvic tumours
Neurological (MS, poor DM, spinal cord injuries)
119
What sex is overflow incontience most common in
Men (very rare in women)
120
Key management of stress incontinence
Avoid caffeine, diuretics and over filling bladder
Weight loss
Pelvic floor exercises for 3 months min
Surgery
DULOXETINE
121
Key management of urge incontinence
```
Bladder retraining for 6 weeks
Anticholinergic medication (oxybutynin)
```
121
Key management of urge incontinence
Bladder retraining for 6 weeks
Anticholinergic medication (oxybutynin)
Mirabegron
Invasive procedures (botox and sacral nerve stimulation)
122
Common side effects of anti-cholinergic medications
Dry mouth, dry eyes, retention, constipation, hypotension
123
What is mirabegon and what is it used for
Beta 3 agonist
Used for urge incontinence when anti-ch is not tolerated
Contraindicated in HTN and BP must be monitored while on the drug
124
What must be monitored in patients on mirabegon
BP
Risk of HTN crisis
Used for urge incontinence
125
What is cause of atrophic vaginitis
Lack of oestrogen
126
Treatment for atrophic vaginitis
Topical oestrogen
| applied at night
127
How is oestrogen cream commonly given
Once daily at night using a syringe into the vagina
128
Role of bartholians gland
Produce mucus to help with vaginal lubrication
129
Classic presentation of a bartholins cyst
Swelling in posterior vaginal introitus 1-4cm
130
Treatment of bartholian cyst
Hygiene, analgesia and warm compress
Antibiotics (E.Coli most common cause)
Incision not used as often reoccur
131
When may a biopsy be taken of a ?bartholian cyst
Older women not improving ?vulva cancer
Not used to drain as reoccur
132
Difference between lichen simplex and lichen plants
Lichen simplex: chronic irritation by repeated scratching
Lichen planus: SKIN autoimmune disease that causes local chronic inflammation
133
What is lichen sclerosus
White patches of skin over vulvua or penis
Itching, soreness, tightness, erosions
134
What is the Koebner phenomenon
Signs or symptoms made worse my friction to skin
Seen in lichen sclerosus
135
Management of lichen sclerosus
Cannot be treated
Follow up every 6 months as increased risk of cancer (5% risk of squamous cell)
Potent topical steroids (clobetasol)
136
Do all cases of FGM need to be reported to police
ALL UNDER 18s
Not all over 18s. Review RCOG risk assessmemt
137
Why do males not develop a uterus
Anti-mullerian hormone
138
What do female genital organs develop from
Mullerian ducts
139
Complications of a bicornuate uterus
Miscarriage, premature birth, malpresentation
140
Why must a imperforate hymen be treated
Risk of retrograde menstruation which can lead to endometriosis
141
Chromosome type of patient with androgen insensitivity syndrome
46XY i.e genetically male
142
Young girl with an inguinal hernia and primary amenorrhoea
Androgen insensitivity syndrome
| hernias = testicles
143
What type of external genitalia do patients with androgen insensitivity syndrome have
Female external genitalia
No uterus, upper vagina, cervix, fallopian tubes or ovaries. Testes present
144
4 hormone test results in androgen insensitivity syndrome
Raised LH
Raised (or normal) FSH
Raised oestrogen levels
Raised testosterone levels
145
FSH and LH levels in menopause
Very high as no negative feedback from oestrogen
146
Two most common types of cervical cancer
Squamous cell carcinoma (80%)
| Adenocarcinoma
147
Why does HPV lead to an increased risk of cervical cancer
Inhibit tumour suppressor genes P53 and pRb
148
How long after pregnancy can you have a cervical smear
3 months
149
What does LLETZ stand for
Large loop excision of the transformation zone
150
What grade of CIN is cancer
None
CIN is dysplasia seen on colonoscopy (NOT SMEAR)
CIN 1 -3 are changes to cells which could progress to cancer
151
Treatment for CIN 3
LLETZ or cone biopsy
Not cancer but high cancer of progression to cancer
152
Treatment for Stage 1B - 2A cervical cancer
Radical hysterectomy
| Chemotherapy and radiotherapy
153
Cervical cancer stage 2B-4A
Chemo and radio only
154
Cervical cancer staging system
FIGO
1-4
4 is bladder, rectum or beyond pelvis
155
Two strains of HPV that cause genital warts
6 and 11
156
Two main risk factors in UK for endometrial cancer
Obesity and diabetes
Age, no pregnancies, PCOS, late menopause
157
How can non concerning endometrial hyperplasia be treated
Progesterones - IUS or mini pill
Careful follow up and monitoring
158
Why is obesity a risk factor for endometrial cancer
Adipose tissue has aromatase
Converts testosterone into oestrogen
Unopposed oestrogen as no corpus letum to produce progesterone
159
Why is it important to ask about breast cancer hx in an endometrial cancer hx
Tamoxifen has an anti-oestrogen effect on breast tissue only
160
4 key cancers associated with Lyncc syndrome
Colorectal
Endometrial
Gastric
Ovarian
161
How does smoking affect endometrial cancer risk
Increased pre menopause
May be protective after menopause as anti-oestrogen effects
162
In women with endometrial cancer, what is the surgical treatment
TAH BSO
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
163
What type of tumour would show Signet Rings on histology
Krukenburg
Mets in ovary from a GI cancer
164
Key RFs for ovarian cancer
```
Age
BRAC
Obesity
Smoking
Use of clomifine
```
Increased number of ovulations
165
Which guidelines for issuing contraception to young girls
Fraser
166
Why may ovarian cancer cause hip or groin pain
Pressing on obturator nerve
167
What does ovarian cancer RMI score use
Menopausal status
USS
CA125
168
What additional blood tests do women under 40 with ?ovarian cancer need
Germ cell tumour bloods
AFP and bHCG
169
Normal age of puberty in boys and girls
8-14 girls
| 9-15 boys
170
Genetic condition causing hypogonadotrophic hypogonadism
Kallaman
Loses sense of smell!!
171
What does congenital adrenal hyperplasia cause hormone levels to do
Low cortisol and aldosterone
172
First line investigation in PMS
2 cycle diary of mood etc
173
Drug used for physical symptoms of PMS
Spirolactone
174
What are fibroids sensitive to
Oestrogen
175
Over what size fibroid should women be referred to gynae
3cm
176
What blood test would you do in women under 40 with menopausal symptoms
FSH
177
Best imaging technique for adenomyosis
MRI
178
Chickenpox exposure in pregnancy > 20 weeks and not immune
either oral antivirals or VZIG
179
If cannot detect fetal hb on accus, what would you do next
USS
