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Gynae Flashcards

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1
Q

Follicular Stage ~ 14 days

Hormone Changes

A

FSH:​ Stim Follicles -> second Follicles (surrounded by Granulosa cells)​

(Granulosa cells release Oestrogen: => Decrease in GnRH/FSH/LH)​

LH:​ Surge (Past certain point Oestrog (+) feedbacks)
=> Release of Ovum​

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2
Q

Luteal Stage = 14 day
Hormone changes
If Ovum Fertilised/Non-Fert

A

Empty Follicle - > Corpus Luteum (Prod Oestrog + Prog)​

If ovum fertilised:​
-> Embryo (produces hCG -> maintains Corpus Luteum)​

If ovum not fertilised:​ (Degeneration of corpus Luteum):
Reduced Oestrog + Prog -> Increased GnRH (+FSH/LH)​
Breakdown of endometrium (-> Menstruation) ​

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3
Q

Menstrual Cycle Stages + Def

A

Follicular Stage:
Maturation of Follicle

Luteal Stage:
Movement of Follicle/Ovum +/- Menstruation

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4
Q

Hypogonadotropic/Hypergonadotropic Prim Amenorrhoea causes​

A

Hypogonadotropic: (Loss of LH/FSH)​
Damage to hypothalamus/ant Pit​, Hypo-Pit​
Chronic condition (CF, IBD)​
Excessive exercise/diet​

Hypergonadotropic: (Lack of Resp to LH/FSH)​
Damage to Gonads (Torsion, cancer, Inf)​, Congen Absence of Ovaries​
Turners Synd (45, XO – Growth Def in girls)​
CAH (21-Hydroxylase Def => Overproduct of Androgens)
AIS (Fail to Resp to Test => No descent of Testis)

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5
Q

Sx of Structural Causes of Prim Amenorrhoea

A

No Menses => Cyclical Abdo pain
Abnormal Genitalia/Pelvic Organs
(Normal Second sex Charact: Hair, Breasts, Growth)

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6
Q

Primary Amenorrhoea Ix - 7

A

Invest:​
bhCG - Pregnancy test
FBC (+ Fe) – Anaemia
U+Es – CKD
Anti-ttG – Coeliac D
TFTs, PRL – Prolactinoma (+/- MRI), LH/FSH, IGF-1 – GH Def​
Testosterone – Raised w/: PCOS, CAH, AIS​
Physical Ex/USS (If abnormal: Karyotype)​
(X-ray Bone age – Develop delay)​

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7
Q

Prim Amenorrhoea​ Mx
Conservative
Hypogonadotropic
Hypergonadotropic

A

Conservative:​
Wait, Reduce Stress, Increase BMI​, CBT

Hypogonadotropic:​
Pulsatile GnRH (Restores menses, no contraception)​
COCP (Restores menses w/ contraception)​

Hypergonadotropic:
COCP​

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8
Q

Second Amenorrhoea Def + causes​ - 5

A

Cessation of Reg menses > 3 months or Irreg menses > 6 months​

Pregnancy​, Menopause, Premature Ovarian Fail​, Hormonal contraception​
Prolactinoma (Hyper-PRL => Panhypo-Pit + Hypogonadotropic hypogonadism)​
Thyroid D​ (HypoTh)
PCOS
Stress ​(Low BMI/Excessive Exercise, Chronic cond -> Reduced GnRH)​

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9
Q

Second amenorrhoea Ix - 6

A

bhCG (Pregnancy test)​
LH/FSH (Raised LH: PCOS, Raised FSH: Prim Ovarian Fail)​
Testosterone (Raised w/: PCOS, CAH, AIS)​
PRL (Prolactinoma), MRI (Pit adenoma)​
TFTs​
Pelvic USS​

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10
Q

PMS Diagnosis + Timing Rules

A

Cyclical Sx spanning > 2 cycles​
(If Sx severe: Premenstrual Dysphoric Disorder)​

Timing:
Sx not present before menarche, during pregnancy, after menopause​
Can occur in response to HRT/COCP​
Can occur after surgery/hysterectomy (Ovaries cont to function)​

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11
Q

Menorrhagia Mx:
Contra not Req
Contra Req

A

Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid

Contraception required: 
Mirena Coil (IUS) 
COCP 
POP 
(Referral for Endometrial Ablation, Hysterectomy)
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12
Q

Fibrioids Def

A

Benign, Oestrog-Sens, SM Tumours – Leiomyomas

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13
Q

Fibrioids Mx:
Contra not Req
Contra Req

A

Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid

Contraception required:
Mirena Coil (IUS)
COCP
POP

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14
Q

Fibrioids Mx: Surg

A

Surg: (GnRH Agonist => Reduce Fibroid size):
Small (< 3cm): Endometrial Ablation, Resection, Hysterectomy
Large (> 3cm): Uterine A Embolization, Myomectomy, Hysterectomy

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15
Q

Endometriosis + Adenomyosis Def

A

Ectopic Endometrium,

Adenomyosis: Ectopic Endometrium w/in Myometrium

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16
Q

Endometriosis Mx

A

HRT (Sx control):
COCP, POP, Prog Inj, Prog Implant, IUS
GnRH Agonists (Induce Menopause)

Surg (Increase Fertility):
Lap (+/- Biopsy, Ablate/Excise, Remove Adhesions)
Hysterectomy + Bilat Salpingoopherectomy

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17
Q

Adenomyosis Mx:
Contra not Req
Contra Req
Surg

A

Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid

Contraception required: 
Mirena Coil (IUS) 
COCP 
POP 
Surg: Endometrial Ablation, Uterine A Embolization, Hysterectomy
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18
Q

Fibrioids vs Endometriosis vs Adenomyosis

A

Fibrioids: Cyclical pain, Menorrhagia, Enlarged/Firm/Tender Uterus
Endometriosis: Cyclical/Chronic (Cont) pain, Menorrhagia
Adenomyosis: Pain, Menorrhagia, Enlarged/Tender Uterus

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19
Q

Menorrhagia Ix

A 
Pelvic/Abdo Ex (Fibroids, Ascites, Cancer)​
FBC + Fe (Anaemia)​
Hysteroscopy​
Pelvic/Trans-vag USS​
Lap +/- Biopsy (Endometriosis)
Hysterectomy w/ Histology (Adenomyosis)
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20
Q

Menopause Def

Premature Menopause Def + Criteria

A

Menopause: Permanent end to Menses (> 12 months)

Premature: Ovarian Fail/Insuff (Menopause < 40yo)

Women < 40yo w/ typical menopausal Sx + Raised FSH

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21
Q

Premature Menopause Mx:
w/w/out Uterus
w/w/out Menses
Supp

A

HRT until Menopause Age: 50:
w/ Uterus: Oestrog + Prog (Req for Endometrial Protection)
(COCP not recommended; increased VTE risk)​
w/out Uterus: Oestrogen-only HRT (Patch)

w/ Menses: Cyclical w/ Reg Breakthrough bleeds
w/out Menses: Continuous HRT

Vag Lubricants, Oestrogen pessaries/gel​
CBT, SSRi, Mood stabilisers​
(Testosterone => Increase Libido)​

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22
Q

Premature Menopause Patho + Sx

A

Reduced Ovarian follicles -> Reduced Oestrogen =>​
Increase in FSH/LH​ =>

Anovulation/Amenorrhea/Irreg menses
Perimenopausal Sx​
​

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23
Q

PCOS Criteria

A

Oligoovulation/Anovulation​
Hyperandrogenism (Hirsuitism, Acne, Weight Gain)
Polycystic ovaries on USS​ (String of pearls: > 12, Ovarian Vol > 10cm3)
(+/- Infertility, Insulin-resistance)​

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24
Q

PCOS Ix

A

Hormone assay:​
Increased: Testosterone (excess androgens), LH/FSH, Insulin​
PRL (Hypopituitarism), TFTs (HypoTh)​

Pelvic/Transvag USS:​
Ovarian Vol > 10cm3​
> 12 developing follicles on an ovary (string of pearls around Periph)​

OGTT (screen for DM):​
Glu > 11mmol 2hrs after drink (Impaired tolerance)​

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25
PCOS Mx
Weight loss, Statins, Orlistat (Lipase Inhib: Reduce Absorption of fat w/in Intestines) Mirena Coil (oppose Oestrogen) COCP (Dianette: Anti-androgenic Effects)
26
Ovarian Cysts Ix
Pelvic USS: If simple: < 5cm: No f/up Req, If Complex: > 5cm: Tumour Markers Tumour Markers: aFP, LDH, hCG, CA-125
27
Meigs Synd
Ovarian Fibroma (Benign), Pleural Effusion, Ascites
28
Ovarian signs on USS: Ruptured Cyst Torsion
Ruptured Cyst: Free fluid w/in Peritoneum | Torsion: Free fluid w/in Peritoneum, Whirlpool Sign, Ovarian Oedema
29
Ashermans Syndrome Def + Sx​
Adhesions w/in Uterus (Inf, Trauma, Surg)​ Sx:​ Lighter periods, Second Amenorrhea Dysmenorrhea​ (Infertility, Recurrent miscarriages)​
30
Ashermans Syndrome Invest + Mx​
``` Invest:​ Hysteroscopy (w/ Dissection)​ Hysterosalpingography (X-ray w/ contrast)​ Sonohysterography (Pelvic USS w/ Fl)​ MRI​ ``` Mx:​ Dissection during hysteroscopy​
31
Incontinence Ix
``` Ex:​ (Pelvic tone​, Cough Impulse​) Bladder diary​ Urin dipstick​ Post-void Bladder scan​ Urodynamic tests​ ```
32
Incontinence Mx (Conservative)
Lifestyle changes: Reduce Caffeine/Alcohol Reduce BMI Stop Meds (Diuretics)
33
Stress Incontinence Mx
Pelvic floor exercises​ Surg (mesh, stitches, bulking)​ Duloxetine (SNRi AntiD)​
34
Urge Incontinence Mx
Bladder retraining (Increase time btw voids)​ Anti-cholinergics (Oxybutynin)​ Mirabegron (Beta3 Agonist)​
35
COCP UKMEC4 - 7
``` Uncontrolled HT, IHD/AF/Cardiomyopathy Vasc D/Stroke, Hx of VTE Migraine w/ Aura Age > 35 + Smoking > 15/day Maj Surg w/ prolonged Immobility Liver Cirrhosis/Tumours SLE, Anti-phospholipid Synd ```
36
Rules governing contra for Adolescents
Refer to Fraser guidelines and ensure patient is gilick competent:​ Understands advice​ Encouraged to involve parents​ (-) physical/mental effect if advice/treatment withheld​ Action is in best interests​
37
Methods of Postpartum Contra
Emergency contraception only needed past 21 days 1): Lactational amenorrhoea:​ Anovulation since delivery​, Fully breastfeeding​, Infant < 6 months​ 2) : POP/implant (safe whilst breastfeeding)​ 3) : COCP (Avoid while breastfeeding, UKMEC2 after 6wks)​ 4) : IUD/IUS (Inserted w/in 48hrs or > 4wks – otherwise expulsion likely)​
38
IUD/IUS lost threads Invest​, Timing
``` Pregnancy test​ Exploration w/ narrow A forceps​ USS, AXR​ Hysteroscopy, Lap surg​ ​ (Excl: Expulsion, Pregnancy, Uterine perforation​) ``` IUD: (Lasts 5-10yrs) IUS: (Lasts 5yrs)
39
Emergency Contra
IUD (wait 5 days) IUS/Mirena (w/in 72hrs) Ulipristal Acetate (w/in 120hrs/5 days): (Avoid Bfeeding for 1wk, Avoid in Asthma, Delay COCP/POP for 5 day)
40
Missed Pill Rules
If miss pill/DnV => Take extra pill​ If +/- 5 days from Day 14 seek Emergency Contra If miss multiple pills => Skip pill-free period + take extra contraception
41
COCP SE:
Breast tenderness, Headaches, N+V VTE Risk, Breast Ca Risk
42
Prog SE:
``` Breast tenderness, Headaches, N+V Weight gain Acne Abnormal Bleeding (Pill: 1/3, Inj/Implant: Problematic - COCP) ```
43
IUD/IUS SE
Problematic Bleeding (COCP) Pelvic Pain Expulsion Increased risk of Ectopics
44
Coil Contras
PID/STI Pregnancy Pelvic Ca Uterine distortion (Fibroids) IUD: Wilsons D IUS: Cervical/Endometrial Ca
45
HPV => Cerv Ca Patho
HPV 16/18 infects cervix + releases:​ E6: Inhibs p53​ E7: Inhibs pRb ​
46
Cerv Screening (Smear)
Smear: Collection of cells tested for HPV + Cytology (Assess Dyskariosis: Pre-cancerous changes) If 25-49: Every 3yrs If 50-65: Every 5yrs (If Preg: Wait 12wks) Inadequate sample: Repeat after 3 months HPV(-): Continue normal screening HPV(+) w/ normal cytology: Repeat after 12 months HPV(+) w/ abnormal cytology: Refer for Colposcopy
47
Cerv Screening (Colposcopy)
Biopsy taken + sent for Histopathological grading of Dysplasia: CIN 1: Mild (1/3) CIN 2: Mod (2/3) CIN 3: Severe (+/- => Cancer)
48
Cervical Ca FIGO Staging
S1: Confined to cervix​ S2: Invades uterus/upper Vag​ S3: Invades Pelvic wall/lower Vag​ S4: Invades pelvic organs (Bladder, Rectum, Pelvis)​
49
Cerv Ca Mx + Prevention
CIN, S1: LLETZ, Cone Biopsy​ S1 – 2a: Radical Hysterectomy (+ removal of L.Ns)​ S2b – 4: Surg, Radio/ChemoTx, Palliative​ (Adv cancer: Pelvic Exenteration:​ Rad Surg to Remove all pelvic organs: Vag, Cervix, Uterus, Fallopian tubes, Ovaries, Bladder, Rectum)​ Prevention: Gardasil (HPV Vaccine)
50
Endometrial Hyperplasia Def, Risk F + Mx
Pre-cancerous condition w/ 2 types:​ Hyperplasia w/ out Atypia​ Atypical hyperplasia​ (Risk F: Unopposed oestrogen​) Mx:​ IUS (Mirena coil)​ PO Prog​
51
Endometrial Ca Referral
PM bleeding (> 12 months since LMP) => 2 week wait​ Unexplained Vag discharge/Visible Haematuria in women > 55yo => Trans-Vag USS​
52
Endometrial Ca Ix
TV-USS (Nomal Endo Thickness: < 4mm) Pipelle Biopsy (w/ Speculum) Hysteroscopy (w/ Endometrial Biopsy)
53
Endometrial Ca FIGO Staging
S1: Confined to Uterus S2: Invades Cervix S3: Invades Ovaries/Fallopian tubes/Vag/LN’s S4: Invades other Pelvic Organs
54
Endometrial Ca Mx
S1+2: TAH + BSO (+/- Radio/ChemoTx) | +/- Prog: Slow Cancer
55
Ovarian Ca Referral
Ascites, Abdo/Pelvic masses: 2wk-wait Change in bowel habit, Weight loss, Bloating, Pelvic pain, Urin Sx: CA-125
56
Ovarian Ca Ix
(RMI: Risk of Malig Index): Menopausal Status USS Findings CA-125 level (> 35 IU/ml) (Women < 40yo w/ complex ovarian mass: (GCs): aFP, hCG )​
57
Ovarian FIGO Staging
S1: Confined to Ovaries S2: Spread, w/in Pelvis S3: Spread, w/in Abdo S4: Dist Metastasises
58
Ovarian Ca Mx
Surg + Chemo
59
Vulval Ca/VIN Risk F
Adv Age (> 75yo), Immunosuppression, HPV Inf Lichen Sclerosus
60
VIN Mx
``` (Diagnosed via Biopsy) Watch+wait Wide Local Excision Imiquimod cream (Immune modulator) Laser Ablation ```
61
Vulval Ca Ix + Mx
2wk-wait w/ Biopsy (Incl Sentinel LN's) (Staging CT Abdo/Pelvis) Wide-local Excision +/- LN dissection Chemo/RadioTx
62
BV Features
``` Discharge w/ Fish smell Vag swab (Clue cells, pH > 4.5) Mx: Metronidazole ```
63
Candidiasis Features
Thick discharge, Itch + Pain | Mx: Vag/Top Cotrimoxazole, PO Fluconazole
64
Chlamydia Features
Abnormal discharge/bleeding, Pain | Mx: PO Doxy 100mg BD 7 days
65
Chlamydia Complication
LGV (Lymphogranuloma Venereum) => Painless Ulcer, Lymphadenitis, Proctitis/Proctocolitis Mx: PO Doxy 100mg BD 21 days
66
Gonorrhoea Features
Green/Yellow Discharge, Pain | Mx: IM Ceftriaxone 1g
67
Mycoplasma Genitalum Features
Urethritis (Excl Gonnorhoea: NAAT Vag swab) | Mx: Doxy 100mg 7 days, Azithromycin 1g and 500mg OD 2 days
68
Trichomonas Features
Frothy discharge, Itch/Pain +/- Smell (Strawberry Cervix, pH >4.5) Mx: Metronidazole
69
HSV Features
Reg Aciclovir | Sores: Instillagel
70
Syphilis Features
Painless Ulcer, Rash, Lymphadenopathy (Ab testing for T. Pallidum) Mx: Deep IM Benzylpenicillin, Full STI Screen
71
Disseminated Gonococcal Inf Triad
Tenosynovitis Migratory Polyarthritis Dermatitis
72
Prim Amenorrhoea Def
Fail to menstruate by 15yo (w/ normal Second Sex characteristics) or by 13yo (w/ no Second Sex characteristics) or no progress for > 2yrs
73
Dysmenorrhea Mx
NSAID (Mefenamic Acid), Paracetamol COCP POP/Implant IUS

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