Gynae Flashcards
(194 cards)
1
Q
adenomyosis is endometrial tissue within
A
myometrium
2
Q
panful periods (dysmenorrhoea) is a hallmark feature of
A
adenomyosis
3
Q
what is the uterus like in adenomyosis
A
enlarged and boggy
4
Q
first lin ix for adenomysosi
A
transvaginal US
5
Q
only defintiive mx for adenomyosis
A
hysterectomy
6
Q
prmary amenorrhoea if not got period by
A
15 with normal ther ssexual charactersitis eg breast
13 with no secondry sexual characteristics
7
Q
most common cause of primary amenorrhoea
A
Turners sydnrome
8
Q
primary amenorrhoea but with painful cycles suggest
A
imperforate hymen
9
Q
initial ix in amenorrhoea
A
exclude preg
fbc, u&es coelaic screen, thyroid fucntion tests
gondotrophins
10
Q
low gonadotrophins suggest hypothalmic cuase
A
raised suggests ovarian problem
11
Q
Turners syndrome has raised Lh/FSH
A
12
Q
turners or premature ovarian failure likely to benefit from
A
HRT (prevent osteoporosis)
13
Q
hypothyroidism can cause
A
amenorrhoea
14
Q
genotically male children with female phenotype
A
androgen insensitivity syndrome
15
Q
priamry amenorrhoea, little or no axilalry and pubic hair, undesceended testses causing groin swellings
A
androgen insenitivity sydnrome
16
Q
dx androgen insensitivity syndrome
A
chromosal analysis to reveal 46XY gentype
mx - bilateral orchidectomy (as increased risk of testicualr cancer due to undescended testes)
17
Q
assisted reproduction
A
intrauterine insemination - sperm collected following masturbation and put into womens uterus
IVF- egg and sperm put into dish
18
Q
IVF can be offered to women
A
<43 who have tried for 2 years
19
Q
In IVF can get genetic testing on embryos that tests for
A
600 conditions
20
Q
even in surrogacy the women giving birth to the child is its legal mother
A
21
Q
vaginal dryness, sore and ocassional spotting
A
atrophic vaginitis
22
Q
women bleeding and over 6 weeks
A
referred to early pregnancy assessment and do transvaginal US
23
Q
women with bleeding less than 6 weeks but no pain or other rf for ectopic then
A
expectant management. women should be advised to return if bleeding continues or pain develops, repeat preg test 7-10 days laters and return if positive
neg preg test means she has miscarried
24
Q
COCP increases risk of
A
cervical cancer
25
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
26
annoying thing about smears
dont pick up on cervical adenocarcinomas
27
what on smears indicates cervical intraepithelial neoplasia
dyskaryosis
28
smear in scotland is
25-64 every 5 years
29
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
30
cervical screening in pregnancy is usually delayed until ----months post-partum unless missed screening or previous abnormal smears.
3
31
who can opt out of smears
if never been sexually active
32
what women get smear test every year and regardless of what age they are
HIV as at increased risk
33
if abnoral cytology tehn
colposcopy
34
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
35
when is the best time to take a smear
around mid cycle
36
if treated for CIN1,2,3 should be invited -- months after treatment for test of cure
6
37
if HPV pos but ytology normal =
12 months repeat
38
if HPV pos at 24 months
do colposcopy
39
if sample 'inadequate' repeat
3 months
40
if get 2 inadequate samples then
colposcopy
41
treatment of CIN
large loop excision of transformation zone
42
what staging used for mx of cervical cancer
Figo
43
mx of mild cervical cnacer is want to maintain fertility
cone biopsy
44
what is the commonly used chemotherapeutic agent in cervical cancer
Cisplatin
45
This operation involves the removal of the cervix, surrounding tissue, and the upper part of the vagina while leaving the uterus intact
trachelectomy A2 tumours
46
what might increase risk of preterm birth in future
cone biopsies and radical trachelectomy
47
ectropion
more of outer so more columnar
48
featires of cervical ectropion
vaginal discharge, post coital bleeding
49
mx of cervical ectropion
ablative treatment so cold coagualtion if troublesome symptoms
50
features of complete hydatidiform mole
vaginal bleeding
uterus size greater than expected for gestation age
abnormally high hCG
US shoes snow storm appearance of mixed echogenicity
51
Delayed puberty with short stature
Turner's syndrome
Prader-Willi syndrome
Noonan's syndrome
Delayed puberty with normal stature
polycystic ovarian syndrome
androgen insensitivity
Kallman's syndrome
Klinefelter's syndrome
52
dysmenorrhoea describes
excessive pain during menstrual period
53
first line for primary dysmenrorhoea
Nsaids such as mefenamic acid and ibuprofen (inhinbit prostalandin production)
COCP secodn lien
54
secondary dysmenorrhoea develips many years after the menarche. cuases include
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices (just copper coils ) (as mirena can help)
fibroids
55
difference in osnet of pain in dysmenorrhoea
primary - within a few hrs of starting period
secodnary - a few days before osnet of period
56
all women with secodnary amenorrhoea shoul dbe
referred to gynae
57
blood from ectopic can be
dark brown in colour
58
if been more than 10 weeks
doesnt suggest ectopic more suggests other ie inevitable abortion
59
why can ectopic get shoulder tip pain or pain on peeing.pooing
perotnoeal bleeding
60
what not to do in ectopic peg
examine for adnexal mass as more likely to rupture but you can check for cerical excitation
61
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
62
PID is a rf for
ectopic preg
63
ix of chocie for ectopic
transvaginal US
64
need surgery for ectopic if
>35mm
pain
visible heart beat
hcg>5000
65
why cant you do medical mx for intrauterine ectopic
risk of svere haemorrhage as where its implanted abnormally is highly vascualr
66
medical mx of ectopic involves giving
methotrexate
(but can only be done if the patietn is willing to attend follow up
67
first line surgical mx of ectopic
salpingectomy
68
mx for ectopic if want to preserve fertility
salpingotomy ( around 1 in 5 women who get this require further treatemtn eg methotrexate or salpingectomy)
69
most ectopic are in ampulla but its more dnagerous if its in
isthmus
70
what cancer has the strongest link to excess oestroen
endometrial
71
tamofen is a rf for
endoemtrial cancer
72
protective factors for endometrial cancer
multiparity
COCP
smoking (reasons are unclear)
73
post menopuasual bleeeding
endoemtrial cancer
74
all women >55 who present with post menopausal bleeding should be referred via cancer pathway
75
referral for endometrial cacner fiest line involbes
transvaginal US (normal thickness <4mm)
then hysteroscopy with endometiral biopsy
76
The mainstay of management for endometrial cancer is surgery.
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
progesterone therapy is sometimes used in frail edlerly women not consdiered suitable for surgery
77
abnormal vaginal bleeding eg intermenstrual may be
endometrial hyperplasia
78
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
79
tender nodularity in posterior vaginal fornix
endometriosis
80
first and 2 nd line for endometriosis
firt - nsaids and or paracetomol
2- COCP
3 refer to secodnary care
81
what in secodnary care might they start for endoemtriosi s
GnRH analgue - enduces a pseudomenopause
82
preg women with low grade fever pain and vomiting may be
fibroid degeneration
83
what happens to fibroids during preg
they grow
84
mx of fibroid degeneration
analgesia and should resolve within 4-7 days
85
mid cycle pain
Mittelschmerz - settles itself
86
US in endometriosis may show
free fluid
87
mmx of ovarian torsion
laparatomy
88
bilateral low abdo pain with vaginal discharge
PID
89
fitz hugh curtis syndrome PID symptoms with disocmfot
in RUQ
90
ix for menorrhagia
FBC, transvaginal US if got symptoms
91
menorrhagia and not wanting contraception
mefenamic acid or transexamic acid - both are started on first day of period
92
if menorrhagia and requires contraception
Mirena first line
93
what can be used as a short term option to rapidly stop heavy menstrual bleeding
norethisterone
94
nausea
breast tenderness
fluid retention and weight gain
s/e of
HRT
95
adding what to HRT increases the risk of
breast cnacer
96
risk of breast cancer declines when stop using HRT
97
HRT increases risk of
breast +endometrial cancer + VTE
98
what HRT does not icnrease risk of VTE
transdermal
99
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to --- weeks.
20
100
what is associated with a decreased risk of hyperemesis
smoking
101
triad for hyperemesis gavidarum to be made
5% weight lsos
dehydration
electrolye imbalance
102
mx of hypereemsis gavdairum
plain food, ginger, wrist acupressure
first line meds - antihostmaines
sec- ondandetrin (increased risk of cleft lip/palate)
metocloparmide can cause extra pyramidal s/e so shouldnt be used for more than 5 days
103
fluid for hyperemesis gavidarum if need
normal saline with added potassium
104
what can occur acutely after hysterectomy
urianry retention
105
2 common ling term complciations of hysterectomy
enterocele and vaginal vault prolapse
106
basic investigation for infertility
semen analysis
serum progesterone 7 days prior to next period so day 21 of cycle
107
counsellign for infertility
folic acid
BMI - 20-25
sexual intercourse every 2-3 days
smoking/ drinking advise
108
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
contraception in menoapsue
109
menopause is loss of
follicular activity
110
menopause
not had period for 12 months
111
menopasue symptosm typcially last for
7 years
112
general mx of menopause
exercise, weight loss, reduce stress, good sleep hygiene,
113
Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
to HRT
114
no increased risk of VTE in HRT if
transdermal
115
increased risk of what cancers with HRT
breast and ovarian
116
mx for menopusal symptoms if dont want HRT
SSRI for vasomotor
117
dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology.
accounts for approx half of pts with menorrhagia
118
anovulatory cycles: these are more common at the extremes of a women's reproductive life
cause of menorrhagia
119
menorrhagi cuases
copper coil
dysfunctional uterine bleeding
fibroids
anovualtory cyceles
hypothyroidism
PID
Von willebrands
120
what accounts for 50% of early msicarriages
50%
121
expectant mx for miscarriage first line involves waiting
7-15 dyas
122
Some situations are better managed medically or surgically. NICE list the following:
increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection
so dont do expectant mx of miscarriage in these cases
123
missed miscarriage
mifepristone then 48hrs lateral misoprostolol
if after taking misoprostol bleeding not started after 48hrs they should contact their healthcare professional
123
124
incomplete miscarriage
misoprostolol
125
after medical mx for miscarriage when do preg test
3 weeks
126
women udenrgoign miscarriage should get
antiemetics and pain relief
127
surgical mx of msicarriage
vaccum aspiration (under local anaestehtic as an outpt) or theatre
128
90% of ovarian cancers are
epithelial in origin
often in distal end of fallopain tube
129
inital ix if suspect ovarian cancer
CA 125 if rasied then urgent abdo US and pelvis
130
diagnosis of ovarian cacner usually involves
diagnsotic laparotomy
131
mx of ovarian cancer
combo of surgery and platinum based chemo
132
having lots of kids protects you from
oavrain cancer
133
complex ovarian cysts should be
biopsied to exclude malignancy
134
commonest type of ovarian cyst
follicular - commonly regresses after several menstrual cycles
135
ovarian cyst with hair and teeth
dermoid cyst (mature cystic teratoma)
136
benign ovarian tumour
most common = serous cystadenoma (pelvic pressure or discomfort)
137
Pseudomyxoma peritonei (PMP) is a rare clinical condition characterised by the accumulation of mucinous ascites within the peritoneal cavity. It is relevant in the context of ovarian cysts because mucinous ovarian tumours, particularly borderline or malignant mucinous cystadenomas, can be associated with PMP.
mucous cystadenoma
138
initial imaging for ovarian cyst/ tumour is
US
139
postmenopausal women with ovarian cyst
refer to gynae
140
very wide range of symptoms for ovarian hyperstimualtion syndrome mild include
abdo pain and blaoting
141
ovarian torsion more likley if there is a
cyst or tumour
142
in ovarian torsion there is often a hisotry of recent vigorous activity then colciky abdo pain
143
US may show free fluid or whirlpool sign in
ovarian torsion
144
There are three main categories of anovulation:
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
145
first lien for getting preg in PCOS
exercise and weight loss
146
first lien medical tehrapy for PCOS to induce ovualtion
LEtrozole (no longer clomiphene citrate)
147
gonadotrophin therapy mainly used for women in
class 1 ovualtory dysfunction
148
Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries.
The early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.
In the mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.
In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.
149
high vaginal swabs in PID are often
neg
150
first line for pID
IM ceftriazone + 14 days of doxy _ oral metronidzaole
151
perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
complciation of PID
152
Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz).
153
Unilateral chronic dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
ovarian cyst
154
PCOS
pelvic US to see cysts
155
raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis
in PCOS
156
SHBG is normal to low in women with PCOS
157
the Rotterdam criteria state that a diagnosis of PCOS can be made if 2 of the following 3 are present:
infrequent or no ovulation (usually manifested as infrequent or no menstruation)
clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
PCOS
158
high levels of LH and insulin are seen in
PCOS
159
general for PCOS
weight loss and COCP may regulate her cycle
160
hisutism and ance in PCOS
COC eg co-cyprindol
topical eflornithine
161
post coital bleeding
after sexual intercourse
162
most common identifiable cause
cervical ectropion
163
premature ovarian faulure
premature menopuase and elevelated gonatrdophin before 40
164
elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart
Premature ovarian failure FSH>30
165
mx for preamture ovarian fialure
HRT or OCCP until age of 51
166
mx of premenstrual syndrome
regular small balances meals rick in complex carbs
COCP
SSRI- this cna be taken contunoisly or just during luteal phase eg days 15-28 of cycle)
167
most common cause of
pruritus vulvae = irritant contact dermatits
- take showers rather than baths
emolient to clean vulva
clean only once aday
168
Recurrent miscarriage is defined as---- or more consecutive spontaneous abortions.
3
169
Semen analysis should be performed after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour
170
termiantion of preg up to
24 weeks
171
General issues
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation
172
medical option for abortion
same as for miscarriage ie mifepristone then 48ghrs later misprostol
173
surgery for abortion
Surgical options
use of transcervical procedures to end a pregnancy, including manual
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
174
womens choice to have surgery or medical abortion up to 24 weeks, after 9 weeks medcial abortion become less common
if done before 10 weeks usually doen at home
175
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
urine dipstick and culture
urodynamic studies
bladder incontinence
176
stress incontiencne mx
pelvic floor muscle taining - 8 contraction 3 times per day for minimum of 3 months
surgery
duloxetine
177
mx of urge inconteinecne
bladder reatraining
anti muscrinis eg oxybutynin(avoid in frail older women) or tolterodine
frail older women use mirabegron
troublesoeme nocturoa - desmopressin
botulinim toxin injection
178
Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery
prolapse
179
smooth muscel tumours of uterus
fibrodis
180
rare feature of fibroids
polycythaemia
181
ix fo fibroids
transvaginal US
182
mx of fibroids - Mirena
nsaids
183
what reduces size of fibroid
GnRH agonists - however only used short temr due to s/e of menopasual symptoms and loss of bone mineral density
184
surgery for fibroids
myomectomy
185
fibroids generally regress after
menoapuse
186
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
fibroids
187
satellite lesions
fungal
188
Investigations
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
189
first lien for vaginal candidiasis
oral fluconazole
if preg - no oral and give cream or pessary
190
recurrent vaginal canddiasis
blood glcuose to exlcude diabetes
induction adn mainetenance regime
191
trichomonas vaginalsi
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
192
vulval intraepithelial neoplasia
itching burning, raised well defined skin lesions
do biopsy
193
mx for VIN
topcial imiquimod or 5 fluorouracil
