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Prep for Phase 3A > Gynae > Flashcards

Gynae Flashcards

1
Q

What is PMS?

A

psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.

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2
Q

When do PMS symptoms resolve?

A

When menstruation begins

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3
Q

What causes PMS?

A

Fluctuation in oestrogen and progesterone. May be due to increased sensitivity to progesterone.

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4
Q

PMS presentation (7)

A 
Low mood
Anxiety
Fatigue
Mood swings
Irritability
Breast pain
Reduced Libido
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5
Q

Can PMS symptoms occur after hysterectomy/endometrial ablation/Mirena Coil? and Why?

A

Yes, since ovaries continue to function and hormonal cycle continues.

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6
Q

PMS diagnosis?

A

Symptom diary spanning 2 menstrual cycles.

Definitive diagnosis may be made with GnRH analogues to halt menstrual cycle and see if symptoms resolve.

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7
Q

PMS management? (4)

A

Lifestyle: Diet, exercise, alcohol, sleep
COCP
SSRI antidepressants
CBT

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8
Q

What COCP is recommended by RCOG?

A

COCP containing drospirenone (i.e. Yasmin), it contains anti-mineralocorticoid effects, similar to spironolactone

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9
Q

What is menorrhagia?

A

Heavy menstrual bleeding

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10
Q

What are some causes of menorrhagia? (7)

A

Dysfunctional uterine bleeding, Extremes of reproductive age, Fibroids, Endometriosis and Adenomyosis, Contraceptives (*copper coil), PCOS

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11
Q

Menorrhagia investigations? (4)

A

Pelvic examination with speculum and bimanual examination
FBC
Outpatient Hysteroscopy
Pelvic and transvaginal ultrasound

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12
Q

Menorrhagia management? (3)

A

Remove the cause

Tranexamic acid/Mefenamic acid
Mirena coil->COCP->Cyclical oral progestogens

Endometrial ablation and Hysterectomy

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13
Q

What are fibroids?

A

Benign smooth muscle tumours of uterus

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14
Q

What is the relationship between fibroids and oestrogen

A

Oestrogen sensitive -> grow in response to oestrogen

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15
Q

What are the types of fibroids

A

Intramural, Subserosal, Submucosal, Pedunculated

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16
Q

Fibroids presentation? (6)

A 
Menorrhagia
Prolonged menstruation
Abdominal pain
Bloating
Urinary/bowel
Deep Dyspareunia
Reduced Fertility
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17
Q

Fibroids investigation? (4)

A

Abdominal and bimanual examination (palpable pelvic mass/ enlarged non-tender uterus)
Hysteroscopy (submucosal fibroids)
Pelvic ultrasound
MRI (size, shape and supply to fibroids - before uterine artery embolisation)

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18
Q

Fibroids management <3cm ? (7)

A

Mirena coil
NSAIDs and Tranexamic acid
COCP
Cyclical oral progestogens

Endometrial ablation
Resection
Hysterectomy

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19
Q

Fibroids management >3cm? (3)

A

Uterine artery embolisation
Myomectomy
Hysterectomy

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20
Q

Name 2 GnRH

A

Goserelin, leuprorelin

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21
Q

What is red degeneration?

A

Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply

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22
Q

Red degeneration presentation? (4)

A

Severe abdominal pain, Low grade fever, tachycardia, vomiting

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23
Q

Red degeneration management?

A

Rest, Fluids, analgesia

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24
Q

What is endometriosis?

A

Condition where endometrial tissue present outside uterus

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25
Q

Endometriosis causes?

A

Unknown, theory is retrograde menstruation where endometrial lining flows backwards through fallopian tubes and into pelvic and peritoneum. Endometrial tissue seeds itself in pelvis and peritoneal cavity.

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26
Q

Pathophysiology of Endometriosis

A

Ectopic endometrial tissue responds similarly to regular endometrial tissue. During menstruation ectopic tissue also sheds and bleeds causing irritation and inflammation at sites

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27
Q

Endometriosis presentation (7)

A 
Cyclical abdominal/pelvic pain
Deep dyspareunia
Dysmenorrhea
Infertility
Haematuria
Urinary symptoms
Bowel Symptoms
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28
Q

Endometriosis investigations

A

Pelvic speculum and bimanual examination (vagina, cervix, adnexa tenderness, fixed cervix on BM examination, endometrial tissue visible on speculum examination)

Pelvic ultrasound (large endometriomas and chocolate cysts)

Laparoscopic surgery and biopsy

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29
Q

Endometriosis Staging?

A

S1-> small superficial lesions
S2->mild but deeper lesions than S1
S3-> Deeper lesions with lesions on ovaries and mild adhesions
S4-> Deep and large lesions affecting ovaries with extensive adhesions

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30
Q

Endometriosis management

A

Analgesia (NSAIDs, Paracetamol)

COCP, Mirena coil, Progesterone only pill, GnRH agonists, Medroxyprogesterone acetate injection (depo-Provera)

Laparoscopic excision/ablation, Hysterectomy and bilateral salpingo-ophrectomy

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31
Q

What is adenomyosis?

A

Endometrial tissue inside myometrium

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32
Q

Adenomyosis presentation

A

Dysmenorrhoea, Menorrhagia, Dyspareunia, potential infertility

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33
Q

Adenomyosis Investigation

A

Pelvic examination
Transvaginal ultrasound
MRI and transabdominal ultrasound
Histological examination through hysterectomy

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34
Q

Adenomyosis management

A

Tranexamic acid/Mefenamic acid
Mirena coil, COCP, COP

GnRH analogues, Endometrial ablation, Uterine artery embolisation, Hysterectomy

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35
Q

Complications of Adenomyosis (6)

A

Infertility, Misscarriage, preterm birth, Small gestational age, PROM, malpresentation

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36
Q

Menopause?

A

point at which menstruation stops

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37
Q

Age for menopause normally?

A

51.2 years

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38
Q

Menopause cause

A

Lack of ovarian follicular function so oestrogen, progesterone low /and FSH and LH high

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39
Q

Pathophysiology of menopause

A

Decline in development of ovarian follicles. Without growth, there is reduced oestrogen.

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40
Q

Perinmeopausal symptoms

A

Hot flushes, Irregular periods, joint pain, vaginal dryness and atrophy, reduced libido, emotional lability/low mood

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41
Q

Risks after menopause?

A

Cardiovascular disease and stroke, Osteoporosis, Pelvic organ prolapse, urinary incontinence

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42
Q

How is menopause diagnosed?

A

Made only in women over 45, using FSH

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43
Q

Depo-Provera side effects

A

Weight gain, osteoporosis

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44
Q

Perimenopausal management

A

HRT, Tibolone (steroid), Clonidine (alpha-adrenergic agonist), CBT, SSRI, Vaginal oestrogen

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45
Q

Premature ovarian insufficiency?

A

Menopause before the age of 40 years

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46
Q

Premature Ovarian Insufficiency causes

A

Idiopathic (50%), iatrogenic (chemo, radio, oophrectomy) , autoimmune, genetic, infections

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47
Q

Presentation of premature ovarian insufficiency

A

Irregular menstrual period, hot flushes, night sweats, vaginal dryness

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48
Q

Diagnosis of Premature ovarian insufficiency

A

FSH persistently raised on 2 consecutive samples 4 weeks apart (>25IU/L)

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49
Q

Management of Premature ovarian insufficiency

A

HRT

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50
Q

Clonidine side effects

A

dry mouth, headaches, dizziness and fatigue

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51
Q

PCOS?

A

condition causing metabolic and reproductive problems in women

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52
Q

What criteria used to diagnose PCOS and what are they?

A

Rotterdam Criteria - oligoovulation, anovulation + hyperandrogenism + Polycystic ovarians on ultrasound (ovarian volume >10cm3)

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53
Q

PCOS Presentation?

A 
Oligomenorrhoea/amenorrhoea
Infertility
Obesity
Hirsutism
Acne
Male pattern hair loss
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54
Q

PCOS investigations

A

Blood tests : Testosterone, SHBG, LH, FSH, Prolactin, TSH

raised LH:FSH, raised testosterone, raised insulin

Pelvic ultrasound: 12> follicles in one ovary/ >10cm3 ovary volume

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55
Q

PCOS management?

A 
Weight loss. orlistat, 
Mirena coil (for endometrial protection
metformin 
Ovarian drilling (infertility) 
Co-Cyprindiol (for hirsutism)
COCP (acne)
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56
Q

Ovarian torsion?

A

Condition where ovary twists in relation to surrounding connective tissue, fallopian tube and blood supply

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57
Q

Cause of ovarian torsion

A

Usually due to ovarian mass >5cm e.g. cyst, tumour

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58
Q

Ovarian torsion presentation

A

Sudden onset severe unilateral pelvic pain (constant, progressively worse)
Nausea, vomiting

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59
Q

Investigation Ovarian torsion?

A

Localised tenderness, palpable mass in pelvis

Pelvic ultrasound (possible whirlpool sign-free fluid and oedema in ovary)

Laparoscopy

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60
Q

Ovarian torsion management

A

Un-twist

Remove affected ovary

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61
Q

Ovarian torsion complication

A

Loss of function -> infertility, menopause

Infection->abscess->sepsis
Possible rupture->peritonitis and adhesions

62
Q

Asherman’s syndrome?

A

Adhesions form within uterus following damage

63
Q

Causes of asherman’s syndrome

A

Pregnancy related dilation and curettage (placental removal)
Uterine surgery
Pelvic infection

64
Q

Asherman’s syndrome presentation (4)

A

Secondary amenorrhoea
Significantly lighter periods
Dysmenorrhoea
Infertility

65
Q

Asherman’s syndrome diagnosis

A

Hysteroscopy (gold standard)
Hysterosalpingography
Sonohysterography
MRI scan

66
Q

Management Asherman’s syndrome

A

Dissection of adhesions during hysteroscopy

67
Q

Cervical ectropion?

A

When columnar epithelium of the endocervix has extended out to the ectocervix.

68
Q

Epidemiology of cervical ectropion

A

Common in younger women, use of COCP and pregnancy due to association with higher oestrogen levels

69
Q

Endocervix histology?

A

Columnar epithelium

70
Q

Ectocervix histology?

A

Stratified squamous epithelium

71
Q

Cervical ectropion presentation?

A

Increased vaginal discharge, vaginal bleeding, dyspareunia

72
Q

Cervical ectropion investigation?

A

Cervical examination (well demarcated border between redder, columnar and pink squamous epithelium)

73
Q

Cervical ectropion management?

A

Asymptomatic - no treatment required

Problematic bleeding -> cauterisation of ectropion using silver nitrate during colposcopy

74
Q

Nabothian cysts?

A

Fluid filled cysts seen on surface of the cervix

75
Q

Which epithelium produces cervical mucus?

A

Columnar epithelium of the endocervix

76
Q

Nabothian cysts presentation?

A

No symptoms normally. Might cause feeling of fullness in the pelvis.

77
Q

Nabothian cysts investigation

A

Smooth rounded bumps on cervix

78
Q

Nabothian cysts management

A

No treatment required if diagnosis clear, If unclear, refer to colposcopy to examine. Excision and biopsy may be required to rule out other pathologies.

79
Q

Pelvic organ prolapse?

A

Descent of pelvic organs into vagina

80
Q

What causes Pelvic organ prolapse

A

Weakness and lengthening of ligaments and muscles surrounding uterus, rectum and bladder

81
Q

Types of pelvic organ prolapse

A

Uterine, Vault, Rectocele, Cystocele

82
Q

Risk factors for pelvic organ prolapse (6)

A

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

83
Q

Presentation of pelvic organ prolapse

A 
something coming down feeling in vagina, dragging/heavy sensation in pelvis, Urinary symptoms (incontinence, urge, frequency, retention)
Bowel symptoms (constipation, incontinence, urgency)
Sexual dysfunction (pain, altered sensation, reduced enjoyment)
84
Q

Procedure Examination of pelvic organ prolapse?

A

Empty bladder/bowel - women asked to cough

85
Q

Grades of uterine prolapse

A 
G0: Normal
G1: Lowest part > 1cm above introitus
G2: Lowest part within 1cm of introitus
G3: Lowest part >1cm below introitus, but not fully descended
G4: Full descent with eversion of vagina
86
Q

Pelvic organ prolapse management

A

Conservative management
Vaginal pessary
Surgery (hysterectomy)

87
Q

Urinary incontinence

A

Loss of control of urination

88
Q

Types of urinary incontinence

A

Urge incontinence, stress incontinence

89
Q

Cause of urge incontinence

A

Overactivity of detrusor muscle of bladder

90
Q

Cause of stress incontinence

A

When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis.
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles.

91
Q

Mixed incontinence?

A

Combination of urge incontinence and stress incontinence

92
Q

Risk factors for Urinary Incontinence (8)

A 
Increased age
Postmenopausal status
Increased BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions i.e. MS
Cognitive impairment and dementia
93
Q

How to distinguish between the types of incontinence?

A

Medical history

94
Q

Examination for incontinence

A

Examination should assess for pelvic tone and examine for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic masses

95
Q

Investigation for urinary incontinence?

A

A bladder diary, urine dipstick, post-void residual bladder volume, urodynamic testing

96
Q

Urinary stress incontinence management

A

Avoid caffeine, diuretics, overfilling of bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises
Surgery
Duloxetine (SNRI depressant used second line where surgery is less preferred)

97
Q

Management of Urge incontinence

A

Bladder retraining for at least 6 weeks (first line)
Anticholinergic medication (oxybutynin, tolterodine)
Mirabegron (alternative to anticholinergic medications)
Invasive procedures (botulinum toxin type A, percutaneous sacral nerve stimulation)

98
Q

Atrophic vaginitis

A

Dryness and atrophy of the vaginal mucosa related to lack of oestrogen

99
Q

Relationship of oestrogen with incontinence and prolapse

A

Oestrogen helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence

100
Q

Atrophic vaginitis presentation

A

Itching, dryness, dyspareunia, bleeding due to localised inflammation

101
Q

Examination of atrophic vaginitis

A

Pale mucosa, thin skin, reduced skin folds, erythema and inflammation, dryness, sparse pubic hair

102
Q

Atrophic vaginitis management

A 
Vaginal lubricants (Sylk, Replens and YES)
Topical oestrogen
103
Q

Bartholin’s glands? Function?

A

Glands located either side of the posterior part of the vaginal introitus (vaginal opening)

They produce mucus to help with vaginal lubrication

104
Q

How does a Bartholin’s cyst happen?

A

When the ducts of the Bartholin glands become blocked, the glands can swell and become tender -> Bartholin’s cyst

105
Q

How is Bartholin’s cyst diagnosed?

A

Made clinically with history and examination

106
Q

Management of Bartholin’s cyst

A

Will usually resolve with good hygiene, analgesia, warm compresses.

Avoid incision as cyst will often reoccur.

Biopsy may be required if vulva malignancy needs to be excluded

107
Q

Management of Bartholin’s abscess

A

Antibiotics. A swab for culture (e.coli most common cause)

Surgery potentially (word catheter, marsupialisation)

108
Q

Lichen sclerosus?

A

Chronic inflammatory skin condition that presents with patches of shiny “porcelain white” skin.

109
Q

Lichen sclerosus association with aloplecia and hypothyroid?

A

It is associated with other autoimmune diseases such as type 1 diabetes, aloplecia, hypothyroid, vitiligo

110
Q

How is lichen sclerosus diagnosed

A

Clinically, based on history and examination findings.

Vulval biopsy where doubts

111
Q

Lichen Sclerosus presentation (6)

A 
Itching
Soreness and pain possibly worse at night
Skin tightness
Superficial dyspareunia
Erosions
Fissures

Koebner phenomenon (symptoms worse by friction to skin)

112
Q

Lichen Sclerosus appearance

A 
Porcelain white in colour
Shiny
Tight
Thin
Slightly raised
May be papules/plaques
113
Q

Lichen Sclerosus management

A

Cannot be cured

Potent topical steroids (clobetasol propionate 0.05%) aka dermovate.

Emollients

114
Q

Lichen Sclerosus complications

A

5% risk of SCC of vulva

Pain/discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal/urethral openings

115
Q

FGM?

A

Surgically changing the genitals for non-medical reasons.

116
Q

FGM common where?

A

African countries i.e., Somalia, Ethiopia, Sudan, Eritrea

117
Q

Types of FGM

A

T1: Removal of part or all of clitoris
T2: Removal of part of all of clitoris and labia minora. Labia majora may also be removed
T3: Narrowing/Closing of vaginal orifice (infibulation)
T4: All other unnecessary procedures to female genitalia

118
Q

FGM complications

A

Immediate: pain, bleeding, infection, swelling, urinary retention, urethral damage and incontinence

Long term: Vaginal, pelvic, UT infections, Dysmenorrhoea, Dyspareunia, Infertility, psychological issues and depression

119
Q

FGM management

A

De-infibulation surgical procedure in cases of type 3

120
Q

Cervical cancer types

A

Squamous cell carcinoma (80%)
Adenocarcinoma
Small cell cancer (rare)

121
Q

Cause of Cervical Cancer

A

HPV (16,18)

122
Q

Risk factors of Cervical Cancer

A 
Increased risks of catching HPV
Later detection of precancerous and cancerous changes
Smoking
HIV
Combined contraceptive pill
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol
123
Q

Cervical Cancer presentation

A

Abnormal vaginal bleeding, vaginal discharge, pelvic pain, dyspareunia

124
Q

Cervical cancer investigation

A

Colposcopy and biopsy with some
CT/MRI for staging
Urine pregnancy test, Vaginal swabs

125
Q

Staging for cervix

A

FIGO

1 Cervix
2 Upper 2/3 vagina
3 Lower 1/3 vagina
4 Bladder of rectum
4b Beyond
126
Q

Cervical screening program when?

A 
3 yrs (25-49)
5 yrs (50-64)
127
Q

Cervical cancer management?

A

CIN to early stage 1A - LLETZ/cone biopsy
Stage 1B-2A - Radical hysterectomy and removal of lymph nodes with chemotherapy,radiotherapy
Stage 2B-4A - Chemotherapy and radiotherapy
Stage 4B - combination of surgery, radiotherapy, chemotherapy and palliative

128
Q

Endometrial cancer main type?

A

Around 80% are adenocarcinoma

129
Q

Risk factors endometrial cancer

A

Unopposed oestrogen

increased age,
early onset menstruation
late menopause,
oestrogen only HRT
No pregnancies
Obesity
PCOS
Tamoxifen
130
Q

Protective factors for endometrial cancer

A

COCP
Mirena coil
Increased pregnancies
Cigarette smoking

131
Q

Endometrial cancer presentation

A 
Postmenopausal bleeding
Postcoital bleeding
intermenstrual bleeding
menorrhagia
abnormal vaginal discharge
haematuria
anaemia
132
Q

Referral criteria endometrial cancer

A

Postmenopausal bleeding

133
Q

Endometrial cancer investigations

A 
TVUS (<4mm)
Pipelle biopsy (endometrial hyperplasia/cancer)
Hysteroscopy with endometrial biopsy
134
Q

FIGO staging endometrial cancer

A

1 Uterus
2 Cervix
3 Ovaries, tubes, vagina, lymph nodes
4 Bowel, bladder, rectum, beyond pelvis

135
Q

Endometrial cancer management

A

Stage 1-2 -> total abdominal hysterectomy with bilateral salpino-oophrectomy

Radiotherapy, Chemotherapy

Progesterone may be used to slow progression of cancer

136
Q

Ovarian cancer types (4)?

A

Epithelial cell tumours, dermoid cysts/ germ cell tumours, sex cord-stromal tumours, metastasis

137
Q

Risk factors ovarian cancer

A

Age (60), BRCA1/2 genes, Increased number of ovulation, obesity, smoking, recurrent clomifene use

138
Q

Protective factors ovarian cancer

A

COCP
Breastfeeding
Pregnancy

139
Q

Presentation ovarian cancer

A 
Abdominal bleeding
Early satiety
Pelvic pain
Urinary symptoms
Weight loss
Abdominal mass
Ascites
140
Q

Ovarian mass complication

A

Mass may press on obturator nerve causing referred hip/groin pain

141
Q

Referral criteria ovarian cancer

A

Ascites, Pelvic mass, Abdominal mass

142
Q

Investigation ovarian cancer

A

CA125 (>35IU/mL)
Pelvic ultrasound
CT
Histology using CT guided biopsy/laparoscopy/laparotomy
Paracentesis to test for cancer cells in ascitic fluid

IF <40 yrs check for germ cell tumour markers i.e. AFP and HCG

143
Q

FIGO staging ovarian cancer

A
  1. Ovaries only
  2. Pelvis
  3. Past Pelvis but inside abdomen
  4. Distant metastasis
144
Q

Management ovarian cancer

A

Surgery and Chemotherapy

145
Q

Vulval cancer main type

A

90% SCC, less common is malignant melanomas

146
Q

Risk factors Vulval cancer

A

Advanced age > 75
Immunosuppression
HPV infection
Lichen sclerosus

147
Q

Vulval cancer presentation

A

vulval lump, ulceration, bleeding, pain, itching, lymphadenopathy in the groin

148
Q

Where does vulval cancer most frequently affect

A

labia majora

149
Q

Investigation of vulval cancer

A

Biopsy of lesion
Sentinel node biopsy
Further imaging for staging

150
Q

Management of vulval cancer

A

Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy

Prep for Phase 3A (6 decks)

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