Gynae Flashcards
Discuss ovarian torsion
Twisting of the ovary and fallopian tube on the axis between the uteroovarian and infundibuolopelvic ligaments
Commonly both structures are implicated
In ovarian torsion venous and lymphatic obstruction occurs initially with subsequent congestion and oedema of the ovary progressing to ischemia and necrosis
Due to the dual blood supply of the ovary from the uterine and ovarian arteries complete arterial obstruction is rare.
Can occur at any age but is most common in the reproductive years, becuase of the regular development of corpus luteal cysts
Most cases of torsion occur due to enlarged ovaries with sizes greater than 5cm being at risk of torsion. Benign neoplasm, cysts, hyperstimulation syndrome, PCOS all increase the risk of Torsion.
Discuss clinical features of torsion
Severe sharp unilateral lower abdominal pain and nausea.
Despite adequate imaging the pre-operative diagnosis rate only approaches 40%
Patient typically report pain for hours to days at presentation
Unilateral tenderness on abdominal palpation
Discuss IX of ovarian torsion
Bloods – nil specific, should have Bhcg abd G&H
US - primary modality of IX,
- enlargement of one ovary with a heterogeneous stroma secondary to oedema along with small peripherally displaced follicles is the classic US appearance.
- May reveal a mass in the ovary evidence of hemorrhage or free pelvic fluid
- doppler finding are inconsistent for diagnosis torsion, up to 60% of surgically proven torsion will have document blood flow on doppler examination.
- Despite the limitation to dopple finding of abnormal venous flow is suggestive of early torsion,
- Absent arterial flow is highly specific for torsion with PPV of 94% to 100%
- Visualisation of the twisting of the pedicle and coiled vessels is referred to as a whirlpool sign and has a 90% PPV for torsion
CT- if diagnosis is in doubt good for other DDX finding include
- enlargement of ovary
- associated mass
- thickening of the fallopian tube
- free pelvic fluid
- edema of the ovary
- deviation of the uterues to the affect side
- associated hemorrhage
MRI- Good
Laproscopy - gold standard investigative modality in who clinical suspicion is high
Discuss management and disposition of ovarian torsion
Once diagnosis made patient should be taken to OT as soon as possible
The ovary will often recover, even if black or dusky in appearance at time of surgery
Discuss ovarian cysts
Most common cause of gynaecological masses. They occur at any stage of life but are most frequent in the reproductive years due to cyclic changes in the ovary
Most cysts in the premenopausal and postmenopausal region resolve spontaneously - on occasion they be malignant or be complicated with haemorrhage or torsion
The most common type of cyst is a simple follicular cyst or functional cyst
The most common presentation is pelvic pain
- ruptured follicular cyst may produce transiet pelvic pain and by associated with dyspareunia - due to its thin wall it may rupture during sex or during vaginal examination
- corpus luteal cyst range from asymptomatic to chronic dull pain to acute severe pain. They can frequently be assoicated with significant degree of haemorrhage
Discuss IX of ovarian cysts
Lab tests - Bhcg, FBC for HB and haemotocrit specifically if luteal cyst rupture is considered, Ca125 for ovarina ca
US-
CT if diagnosis is unclear
Discuss the normal menstrual cycle
The menstrual cycle begins on the first day of menses. During the first part of the cycle the endometrium thickens under the influence of oestrogen and a dominant follicle develops releasing an ovum at the midpoint in the cycle.
After ovulation the ltueal phase begins characterized by the production of progesterone from the corpus luteum. This matures the lining of the uterus and if implantation does not occur the corpus luteam dies accompanied by a sharp drop in progesterone and eostrogen levels.
These changes are typically follwed by mensturation
Discuss clinical features of abnormaul uterine bleeding
Vaginal bleeding before the age of menarche is abnormal and may be the result of infection, trauma including sexual abuse or a foreign body, and structural lesions.
Women of reproductive age abnormal uterien bleeding includes a change in the frequency, duration and amount of bleeding or bleeding between menstrual cycles.
Any bleeding 12 months after a menapause is abnormal
Discuss DDX of abnormal uterine bleeding
Structural (PALM)
- polyps
- adenomyosis
- leiomyoma
- Malignancy and hyperplasia
Non-sturctural (COEIN)
- Coaguloapthy (von willibrand and all other)
- Ovulatory dysfunction
- Endometrial
- –any disruption to the hypothalamus-pituitary-ovarian pathway including (PCOS, anorexia nervosa, hyperprolactineameia and primary pituitary disease)
- Iatrogenic
- Not yet classified
Discuss management of abnormal uterine bleeding
NSAIDS are generally effective for the relief of associated cramping pain.
Anovuolatory bleeding —> OCP is effect to help regulate the cycle
Oral TXA can help mange excessive bleeding at a dose of 1.3G TDS for 5 days
Discuss emergency contraception
1.5mg or 2 doses of 0.75mg levonorgestrel and combined OCP
labled for use up to 72 hours after intercourse
Discuss bimanual examination
The index and middle fingers of the dominant hand are used to examine the vagina, cervix uterus and pelvic floor. Only a single finger can be inserted comfortably in patients with a narrow introitus.
The abdominal hand should be used to sweep the pelvic organs downward while the vaginal hand is simultaneously elevating them
The uterus is assess for
- size
- shape
- symmetry
- mobility
- position
- —axial: the axis of the uterus is the same as the vaginal axis
- —Version – postion of the entire uterus relative to the axis of the vagina (ante or retro)
- –Flexion - position of the uterine fundus relative to the axis of the cervix
- consistency
The adenxa areas are checkde for the presence of appriprately sixed mobile ovaries - palpable ovaries in postmenopausal pateints are not normal
Discuss vaginitis
General term for disorders of the vagina caused by infection, inflammation or changes in the normal vaginal flora
Symptoms include discharge, odor, pruritis and or discomfort
If discharge is present the three most common vaginal infections are
1) Bacterial vaginosis - malodoruous thing grey discharge
- –treat with metronidazole 500mg BD for 7 days, improved cure rates compared to 2gram once off dose
- – most common bacteria are gardnerella vaginalis, prevotella species, bacteroides, peptostreptococcus
2) Vaginal candidiasis - scant dsicharge that is thick white odorless and often curd like
- —-Miconazole
3) Trichomoniasis - purulent malodorous discharge accompanied by burning pruritis dysuria and frequency
- —- treat with metronidazole 500mg BD for 7 days, improved cure rates compared to 2gram once off dose
Vulvovaginal atrophy – lack of oestrogen
Describe the bartholin glands
Are the female homologue of the bulourethral glands. There main function is to secrete mucous to provide vaginal and vulvar lubciration
Each gland is approximatley 0.5cm in size and drains tiny drops of mucous into a duct 2.5cm long
The glands are deep to the posterior aspects of the labia majora
Discuss masses associated with the bartholin gland
Bartholin cyst – if the orifice to the bartholin duct becomes obstructed the mucous produced by the gland accumulates leading to cystic dilation procimal to the obstruction. - Cyst are usually sterile
Bartholin abcess- an obstructed dcut can become infected and form an abscess. The most common pathogen is E.coli, STI used to be identified in as many as one third of patients but this proportion has been declining. Other bacteria include (S. aureas, GBS, enterococcus)
Bartholin benign tumour - benign tumors of the bartholing gland are even rare than carcinoma
Bartholin gland carcinoma – rare accounting for 0.1 to 5% of vulvar malignancies
