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Year 4 - 1. Reproductive Health > Group A - Menstrual Disorders and Gynaecological Cancer > Flashcards

Group A - Menstrual Disorders and Gynaecological Cancer Flashcards

(68 cards)

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1
Q

Define dysfunctional uterine bleeding (DUB)

A

Heavy menstrual bleeding, with:
- No recognisable pelvic pathology
- No pregnancy
- No bleeding disorders

I.e. it is a diagnosis of exclusion

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2
Q

List some causes of abnormal/heavy menstrual bleeding

A

PALM COEIN

Polyps
Adenomyosis
Leiomyomas (fibroids)
Malignancy

Coagulation disorders
Ovulatory pathology
Endometriosis
Iatrogenic
Not yet classified

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3
Q

Outline the factors that determine whether a woman with HMB is low risk or high risk and what investigations they need based on their risk

A

Low risk:
< 45
No intermenstrual bleeding
No risk factors for endometrial cancer
Investigations: FBC only (anaemia) - then begin treatment for HMB

High risk:
> 45
Intermenstrual bleeding
Risk factors for endometrial cancer
Investigations: FBC (anaemia), ultrasound and hysteroscopy + biopsy
Then begin treatment for HMB

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4
Q

Outline the medical and surgical management of HMB

A

Medical:
- Tranexamic acid (symptomatic)
- Mefenamic acid (symptomatic)
- GnRH analogues or Ulipristal acetate (fibroids)
- Progesterone hormone products, Mirena coil 1st line
- COCP

Surgical:
- Hysteroscopic removal (polyps)
- Myomectomy (fibroids)
Risk of reducing children in future…
- Uterine artery embolisation
- Endometrial ablation
- Hysterectomy

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5
Q

Outline how to manage HMB in the short term / emergency

A
  • Tranexamic acid
  • Norethisterone (progesteron product)
  • GnRH analongues
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6
Q

Outline how tranexamic acid works in HMB

A

Inhibits plasminogen activation
Reduces fibrolysis (encourages clotting)
= Reduces menstrual loss

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7
Q

Outline how mefenamic acid works in HMB

A

NSAID - reduces production of prostaglandins
= Analgesia, anti inflammatory and reduces menstrual loss (although less effectively than tranexamic acid)

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8
Q

List the following cancers in most common to least common
- Endometrial
- Cervical
- Vulval
- Ovarian

A
  1. Endometrial
  2. Ovarian
  3. Cervical
  4. Vulval
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9
Q

For the following cancers, state the peak age of incidence:
- Endometrial
- Ovarian
- Cervical

A

Endometrial: 65-75 (declines after 80)
Ovarian: 70-75 years (mostly between 50-80)
Cervical: bimodal at 30s and 80s

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10
Q

Outline risk factors for endometrial cancer
Also list some protective factors

A

Risk factors:
Anything that causes endometrial hyperplasia!
- Obesity
- BRCA1/2
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- Unopposed oestrogen = PCOS or Tamoxifen
- Poorly controlled diabetes
- Untreated endometrial polyps

Protective factors:
- SMOKING
- Combined HRT
- COCP
- Physical activity

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11
Q

Briefly explain endometrial hyperplasia and its management

A
  • Precancerous condition, involving thickening of endometrium
  • 2 types:
    1. Hyperplasia without atypia
    2. Atypical hyperplasia

Most cases will return to normal over time, however <5% can become endometrial cancer
- Risk factors are similar to those for endometrial cancer

Management:
Depends on type of hyperplasia
1. Hyperplasia without atypia = progesterone (POP or Mirena coil)
2. Atypical hyperplasia = hysterectomy +/- bilateral salpingo oophorectomy

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12
Q

List red flag symptoms for endometrial cancer

A
  • Postmenopausal bleeding
  • Abnormal vaginal discharge

If premenopausal:
- Heavy vaginal bleeding
- Abnormal bleeding e.g. IMB, PCB

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13
Q

Outline the main cell type of endometrial carcinoma

A

80% = adenocarcinoma

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14
Q

Outline referral criteria for post-menopausal bleeding and diagnostic tests indicated

A

Automatic 2 week wait urgent gynae cancer referral for endometrial cancer

  • Transvaginal ultrasound (thickness > 4mm)
  • If >4mm: endometrial (Pipelle) biopsy
  • If high risk/suspicious: hysteroscopy + biopsy
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15
Q

Other than post-menopausal bleeding, suggest other presenting symptoms that prompt a referral for investigation of endometrial cancer in women over 55

A

In women over 55:
- Unexplained vaginal discharge
- Visible haematuria PLUS anaemia / raised platelets / raised glucose

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16
Q

Outline management options for endometrial cancer in terms of surgical and non-surgical options

A

Surgical:
- Total hysterectomy +/- bilateral salpingo oophorectomy

Non-surgical:
- Progestagens e.g. Mirena coil
- Primary radiotherapy

PLUS adjuvant therapies:
- External beam
- Brachytherapy

Depends on stage:
Stage 1 (localised) = total hysterectomy +/- bilateral salpingo oophorectomy with peritoneal wash out
Stage 2 = Radical hysterectomy and lymphadenectomy +/- adjuvant therapy
Stage 3 = Maximal debulking surgery + chemotherapy + radiotherapy
Stage 4 = Maximal debulking surgery / palliative approach

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17
Q

Outline the most common cell line types for ovarian cancer

A

Epithelial:
- Serous
- Mucinoid

Germ cell:
- Teratoma

Stomal / sex cord: rare!

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18
Q

Outline risk factors for ovarian cancer
Also list some protective factors

A

Risk factors:
- Obesity
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- BRCA1/2 or family history
- Unexposed oestrogen = PCOS or Tamoxifen
- Endometriosis

Protective factors:
- COCP
- Pregnancy / breastfeeding
- Oopherectomy (+/- hysterectomy)

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19
Q

Outline some red flag symptoms for a patient with ovarian cancer

A
  • Persistent abdominal bloating
  • Pain or dyspareunia
  • Anorexia
  • Nausea and vomiting
  • Weight loss
  • Vaginal bleeding
  • Increased urinary frequency
  • Bowel changes
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20
Q

Outline some diagnostic tests to consider for suspected ovarian cancer

A

Bloods:
- Ca125 tumour marker
- FBC / U&Es, LFTs (routine bloods)

Imaging:
- Ultrasound
- CT to assess for further disease
- Chest x-ray

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21
Q

Outline the possible management options for ovarian cancer: epithelial and non-epithelial

A

Epithelial:
- Surgery
- Chemotherapy (Platinum and Taxane)

Non-epithelial:
- Chemotherapy only (very chemo-sensitive)

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22
Q

Outline risk factors for cervical cancer
Also list some protective factors

A

Risk factors:
- Non-compliance with cervical screening
- Known diagnosis of CIN (premalignant changes)
- HPV positive
- Related to HPV exposure: early first sexual experience, multiple sexual partners, lack of barrier contraception
- Immunosuppression
- Smoking
- COCP long term

Protective factors:
- HPV vaccine!
- Compliance with cervical screening

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23
Q

Outline briefly how HPV increases the risk of cervical cancer

A
  • HPV produce E6 and E7 proteins
  • These proteins inhibit the tumour suppressor genes in keratinocytes
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24
Q

Briefly explain cervical intraepithelial neoplasia (CIN) and at which area of the cervix CIN occurs

A

CIN is a grading system for level of dysplasia / premalignant changes in the cells of the cervix
- Can be diagnosed during colposcopy
- Level of CIN grade, suggests the level of premalignant changes and the likely of progression to cervical cancer

Area of the cervix:
- Transformation zone

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25
List some red flag symptoms for cervical cancer
- Post-coital bleeding - Intermenstrual bleeding - Post menopausal bleeding - Dyspareunia - Blood stained vaginal discharge
26
Outline the FIGO staging of cervical cancer
Stage 1: confined to cervix Stage 2: beyond cervix, but not on side pelvic wall or lower 1/3 vagina Stage 3: spreads beyond cervix, on sides of pelvic wall or lower 1/3 vagina Stage 4: invades adjacent organs
27
Outline the management for cervical cancer in the following conditions: - CIN and early stage 1a (very early disease) - 1b to 2a (localised) - 2b to 4a (greater spread)
CIN and early stage 1a: - LLETZ procedure - Cone biopsy 1b to 2a (localised): - Radical hysterectomy and removal local lymph nodes with chemo and radio 2b to 4a (greater spread): - Chemotherapy - Radiotherapy
28
Outline some complications of surgical management and radiotherapy management of cervical cancer
Surgical: - General e.g. infection, VTE, haemorrhage - Vesicovaginal fistula - Bladder dysfunction - Short vagina Radiotherapy: - Vaginal dryness - Stenosis - Cystitis - Proctitis - Loss of ovarian function
29
Outline the frequency of cervical smears (for the 2 age groups)
25-50: every 3 years 50-65: every 5 years After 65: selected patients only
30
Outline some red flag symptoms for vulval cancer
- Vulval pain / soreness persistent vulval itching - Lump or thickened, raised patches (red, white or dark)
31
List some risk factors for vulval cancer
- Lichen sclerosus - HPV - Herpes simplex virus type 2 - Smoking - Immunosuppression - Chronic vulvar irritation
32
Briefly outline the following for lichen sclerosus: - Pathophysiology - Presentation - Management
Pathophysiology: - Chronic inflammatory skin disease in the anogenital region in women, possibly autoimmune - Bimodal: pre-puberty and post-menopausal - Can be debilitating - Potential to progress to squamous cell carcinoma (vulval cancer) Presentation: - White atrophic patches in anogenital region - Itching (associated excoriations and pain) - Fusion of vulval tissue - Dyspareunia - Can be asymptomatic Management: - Conservative e.g. avoid irritants - Topical steroids - Regular follow ups due to risk of squamous cell carcinoma
33
Outline the general management options for vulval cancer
- Wide local excision surgery +/- lymphadenectomy - Radiotherapy / chemotherapy
34
2 medications that can cause amenorrhoea
- Antipsychotics - Breast cancer treatment e.g. Tamoxifen Plus contraceptives! - Contraceptive pill - Mirena coil
35
State for what ages breast cancer screening is offered
Between 50-70
36
Outline how smears are conducted in terms of HPV testing and cytology
Initially tested for presence of HPV If HPV absent -> no further investigation, return to routine screening If HPV present -> cytology to look for dyskaryosis Cytology normal = recall in 12 months Cytology abnormal = refer for colposcopy
37
Outline the 2 liquids used in cytology to visualise cells and what colours they turn in normal and abnormal cells
1. Acetic acid Normal: no change Abnormal: white 2. Iodine Normal: brown Abnormal: no change / don't stain
38
Outline 2 future tests for biopsy in suspicious looking cells in colposcopy
1. Punch biopsy 2. LLETZ (large loop excision of transformation zone)
39
List some complications of a LLETZ procedure
- Risk of infection - Cervical stenosis - Cervical incompetence (pregnancy) Can make follow up smears more difficult
40
Outline some potential clinical signs (not symptoms) of cervical cancer
On speculum examination: - Visible irregularity of cervix e.g. ulceration - Evidence of discharge / bleeding - Cervical tenderness If advanced disease: - Pelvic mass - PR bleed / PR mass - Hydronephrosis - Hepatomegaly
41
Outline some potential clinical signs (not symptoms) of ovarian cancer
- Abdominal distension - Abdominal mass (axdendal) Advanced: - Pleural effusion - Ascites
42
Outline some potential clinical signs (not symptoms) of endometrial cancer
- Abdominal distension - Abdominal mass (axdendal) - Abdominal tenderness - Haematuria Laboratory: - Anaemia - Raised platelet count
43
Outline some potential clinical signs (not symptoms) of vulval cancer
- Ulceration +/- discharge - Skin changes e.g. thickened skin, colour change (red, white, dark brown) - Tenderness on palpation
44
List the 4 types of fibroid
- Intramural (within myometrium) - Subserosal (outside layer) - Submucosal (internal layer) - Pedunculated (on a stalk)
45
List some symptoms and signs of fibroids
Symptoms: - Heavy menstrual bleeding - Prolonged menstrual bleeding - Abdominal pain - Bloating / fullness / reduced appetite - Urinary or bowel symptoms - Deep dyspareunia - Fertility issues Signs: - Palpable pelvic mass (abdominal exam) - Enlarged firm non-tender uterus (bimanual exam)
46
List some investigations for suspected fibroids
- Hysteroscopy initially (if submucosal causing HMB) - Pelvic ultrasound if larger - MRI scan prior to surgical interventions
47
List some management options for fibroids
Conservative: - Leave if not causing problems - Symptomatic management with NSAIDs and tranexamic acid Medical: - Mirena coil (first line if small) - COCP / POP - GnRH analogues may be used short term Surgical: - Endometrial ablation - Resection during hysteroscopy if submucosal If >3cm - Uterine artery embolism - Myomectomy - Hysterectomy
48
List some complications of fibroids
- Heavy menstrual bleeding and anaemia - Infertility / impact on pregnancy - Constipation / urinary outflow obstruction - Red degeneration / ischaemia / necrosis - Torsion of fibroid if pedunculated - Malignant change (rare)
49
State the 3 Rotterdam features for diagnosis of PCOS
Need 2 of 3 features for a diagnosis of PCOS 1. Irregular periods (oligoovulation or anovulation) 2. Hirsutism 3. Polycystic ovaries on USS (>10cm or >12 cysts)
50
State presenting features of PCOS
- Irregular / absent periods - Infertility - Hirsutism - Acne - Obesity - Male pattern hair loss
51
State some blood tests and other investigations to do in suspected PCOS (also helps to rule out other conditions)
Bloods: - LH - FSH - Testosterone - Sex hormone binding globulin - Prolactin - Thyroid stimulating hormone Other investigations: - Pelvic ultrasound which shows 'string of pearls' (multiple cysts or large volume cyst) - OGTT
52
State the findings for the following blood tests in PCOS: - LH - LH:FSH ratio - Testosterone - Insulin - Oestrogen
LH = raised LH:FSH ratio = raised Testosterone = raised Insulin = raised Oestrogen = normal / raised
53
List some investigations for suspected endometriosis
- Transvaginal USS = rule out any ovarian masses or chocolate cysts - Laparoscopy = gold standard
54
State some presenting symptoms and signs of endometriosis
Symptoms: - Dysmenorrhoea - Cyclical abdominal / pelvic pain - Deep dyspareunia - Infertility - Cyclical bleeding from other sites e.g. haematuria Signs: - Fixed cervix - Presence of endometrial tissue in vagina - Tenderness of vagina, cervix and adnexa
55
State some presenting symptoms of endometrial polyps
- Irregular bleeding: PCB, PCB, postmenopausal bleeding - Heavy menstrual bleeding - Infertility - Dull pelvic pain
56
State common causative organisms for pelvic inflammatory disease
- Neisseria gonorrhoeae (more severe) - Chlamydia trachomatis - Mycoplasma genitalium Less common: - Gardnerella vaginalis - Haemophilus influenzae - E coli
57
State risk factors for pelvic inflammatory disease
- Previous PID - Existing sexually transmitted diseases - Intrauterine device Sexual risk: - Young age - Lack of barrier contraception - Multiple sexual partners
58
State some presenting symptoms and signs of pelvic inflammatory disease
Symptoms: - Lower abdo / pelvic pain - Abnormal discharge - Abnormal bleeding (IMB / PCB) - Dyspareunia - Fever - Dysuria Signs: - Cervical motion tenderness - Tenderness on palpation - Inflamed cervix - Purulent discharge
59
List some investigations for suspected pelvic inflammatory disease
- Pregnancy test - HVS for STI screen - Bloods for CRP and WCC
60
Outline management for pelvic inflammatory disease
Empirical antibiotic therapy: - IM Ceftriaxone - Doxycycline (14 days) - Metronidazole (14 days)
61
List some complications of pelvic inflammatory disease
- Infertility - Ectopic pregnancy - Chronic pelvic pain - Fitz-Hugh-Curtis syndrome - Abscess - Sepsis
62
State some initial investigations for primary amenorrhoea
Normal bloods: - FBC and ferritin (anaemia) - U&Es (CKD) - Thyroid function tests Reproductive bloods: - LH and FSH - Testosterone (PCOS) - Prolactin (hyperprolactinaemia) Specific bloods: - Coeliac disease - ILGF-1 (growth hormone deficiency)
63
State some initial investigations for secondary amenorrhoea
- Pregnancy test for pregnancy - LH and FSH for premature ovarian failure - Thyroid function tests - Testosterone for PCOS - Pelvis ultrasound for PCOS - Prolactin for hyperprolactinaemia
64
State some initial investigations for irregular periods
- Pregnancy test for pregnancy - LH and FSH for premature ovarian failure - Thyroid function tests - Testosterone for PCOS - Pelvis ultrasound for PCOS
65
State some initial investigations for menorrhagia or dysmenorrhoea
- Speculum examination - Bimanual examination - STI screen / swabs - Pregnancy test for pregnancy - Check up to date with cervical screening - FBC and ferritin for anaemia - LH and FSH for premature ovarian failure - Thyroid function tests - Testosterone for PCOS - Pelvic ultrasound - Hysteroscopy
66
State some management options for PCOS
Conservative: - Encourage a healthy lifestyle and optimal weight management (reduce risk of associated T2DM and cardiovascular disease) Medical: - Offer COCP - If acne, offer topical retinoids - If hirsutism, offer hair removal methods e.g. waxing
67
State some management options for endometriosis
Diagnostic laparoscopy Medical: - Analgesia - COCP / POP Surgical: - Laparoscopic endometrial ablation or excision (can add hormonal treatments) - Laparoscopic hysterectomy (+/- oophorectomy)
68
State some management options for endometrial polyps
Asymptomatic AND low-risk, may manage conservatively with observation If suspicious: - Hysteroscopy and biopsy, including removal of polyp - Consider use of POP/Mirena coil to prevent formation of future polyps

Year 4 - 1. Reproductive Health (7 decks)

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