Gynae Flashcards
(94 cards)
1
Q
Symptoms of cervical ectropions
A
Normally asyx
PCB, vaginal discharge
2
Q
Treatment of ectropion
A
Cryotherapy w/out anaesthesia once smear/colposcopy -ve for malignancy
3
Q
Causes of cervicitis (acute and chronic)
A
Acute: STD, ulceration and infection often prolapsed
Chronic: inflammation/infection ie of ectropion
4
Q
Treatment of cervicitis
A
Inflammatory smear + discharge
Tx with avulsion but still investigate bleeding
5
Q
Cervical polyps: epi, syx and tx
A
Common after 40, usually
6
Q
What is a nabothian follicle?
A
Squamous epithelium over columnar = blocks glands –> white glands and opaque swelling on ectocervix
Tx if syx
7
Q
Definition and Classification of CIN
A
Definition: atypical cells in Sq epi - larger nuclei + dyskaryosis (atypia)
I - mild - lower 1/3 of epithelium
II - moderate - lower 2/3
III - severe - full thickness (malignant like cells without invasion)
Malignancy = invasion of Basement membrane
8
Q
Epi of CIN
A
1/3 of III will get cervical cancer within 10 years
Peak 25-29
HPV 16, 18, 31, 33 - (16+18 vaccinated now before first sex)
OCP and smoking
Immunodef ie steroids or HIV
9
Q
Pathology of CIN
A
Columnar to Sq in TZ
HPV turns off tumour suppressor genes and hides cells from immune system
NB CIN is premalignant and predicts risk of developing cervical cancer
10
Q
Screening schedule for CIN
A
Smear every 3 years from 25-49, 5 years 50-64, >65 if no smear since 50 or previously abnormal
80% acception rate
11
Q
Smear test procedure
A
Cusco speculum and brush –> liquid based cytology (only 2.5% failure) + HPV test
12
Q
Smear test results (mild/CGIN)
A
Detects atypical cells not histo abnormalities
Mild = HPV test –> high risk HPV = colposcopy, low/no HPV = back to normal schedule of 3/5y
CGIN = cone biopsy
13
Q
Smear test results (II/III)
A
Colposcopy w/ tx - TZ excised w/diathermy/LLETZ = dx and tx
Risk of haemorrhage and preterm delivery
14
Q
Cervical cancer: Epidemiology
A
Peak 30s/80s esp 25-29
90% SCC, 10% adenocarcinoma (worse prognosis)
All have HPV - same risks as CIN as it’s premalignant
Inadequate screening and FHx are common
15
Q
What is a cervical ectropion and what is the cause?
A
Columnar epithelium visible around the os caused by eversion in pregnancy or puberty
16
Q
Epidemiology of cervical cancer
A
Peak 30s and 80s (25-49, esp 25-29)
90% SCC 10% adeno from columnar: worse prognosis
17
Q
Aetiology of cervical cancer
A
HPV in ALL cervical cancer
HIV/immunodef
smoking
inadequate screening
18
Q
Clinical features of cervical cancer: Hx and Ex
A
Occult: asyx but dx on biopsy/LLETZ
Hx: PCB, IMB, PMB, offensive discharge. PAIN is UNCOMMON
Late: uraemia and haematuria, rectal bleeding and pain (ureters, bladder, rectum and nerves)
Ex: ulcer or mass on cervix or may look normal
19
Q
Staging of cervical cancer
A
1ai: dx on microscopy: invasion 4cm diameter
2ai: upper 2/3 vagina w/o parametrial involvement 4cm
2b: parametrium
3: lower vagina or pelvic wall or ureteric obstruction
4: bladder or rectum or pelvis
20
Q
Anatomy of uterus
A
Myometrium (smooth muscle) and Endometrium (glandular)
Supported by uterosacral and cardinal (like cervix)
Broad = continuous with pelvic side wall and F tubes
Round = little support but holds blood supply
EM responds to oestrogen and progesterone, basal + spiral arterioles
21
Q
Fibroids Pathology and Epidemiology
A
25% of women, esp near menopause, decreased in nulliparous + OCP - oestrogen driven, regress postmenopausally
Benign tumour of the myometrium
Variable size, intramural, subserosal, submucosal (polyp)
22
Q
Fibroid syx
A
50% asyx - syx due to size
30% get HMB, IMB if submucosal/polypoid
Pain is rare unless torsion, sarcoma or red degeneration
Urinary if pressure on tract
Reduced fertility esp implantation and tube blocking
23
Q
Progression of fibroids
A
Slow growing, calcify post menopausally, HRT increases growth
Degenerate if poor blood supply - red = haemorrhage and necrosis, hyaline = fluid filled
24
Q
Fibroids in pregnancy
A
Red degeneration, premature, malpresentation, abnormal lie, obstruction, PPH
Don’t remove at section due to bleeding
25
Investigation of fibroids
USS
MRI/lap may be needed (MRI sees adenomyosis)
Hysterectomy = visualise change - esp fertility
Hb - bleed = decrease, EPO secretion by fibroids = increase
26
Tx of fibroids
Asyx = none (monitor for malignancy if large)
Medical: tranexamic acid, NSAIDs and progestogens (often not enough if HMB) but try 1st line
GnRH = decreased fibroid size (menopausal state) - 6m only, 2y with add-back HRT
Surgical: Up to 3cm - remove via hysteroscopy if polypoid/submucosal
Pretreat with GnRH
Myomectomy if medical fails and fertility needed (heavy blood loss)
Complications: section in future due to rupture risk, adhesions
27
Adenomyosis Pathology
EM and stroma in myometrium
Common around 40y, assoc with EMosis and fibroids
Syx subside after menopause
EM blood can pool in MyoM - chocolate cyst
28
Clinical features and diagnosis of adenomyosis
May be asyx
Painful, regular HMB common
Uterus enlarged and tender
MRI is dx
29
Treatment of adenomyosis
IUS or COCP +/- NSAIDs to control HMB
Hysterectomy often required
GnRH trial to see if hysterectomy will work
30
EM polyps Epidemiology, dx and tx
Benign, common 40-50y, increased oestrogen= cause
Esp tamoxifen postmenopausally
Can contain hyperplasia/carcinoma = HMB/IMB
Dx = hysteroscopy/USS
Tx = avulsion/ resection
31
Haematometra Path and Syx
Blood accumulation in the uterus
Causes: fibroids, post EM resection, carcinoma, cone biopsy
Congenital imperforate hymen, blind horn - primary amenorrhea
32
Congenital uterine malformations causes and tx
Failure or mullerian duct fusion @9wk
Renal and pregnancy problems
Malpresenation, transverse lie, preterm, miscarriage, retained placenta
Hysteroscopic tx = septa, lap/open = horns, bicorn = not opened
33
EM carcinoma Epidemiology
Most common genital tract cancer
| 60y, 15% premenopausal (1%
34
Aetiology of EM carcinoma
High oestrogen: progesterone ratio ie unopposed oestrogen
Exogenous oest without prog
Obesity
PCOS/ prolonged amenorrhea, nulliparous, late menopause
tamoxifen = oestrogen agonist in postmen uterus
COCP is protective
35
Premalignant EM epi and clinical
Epi: 1st cystic then atypical glandular
Rare in reproductive age women - tx with progestogens if uterus needed + 6m EM biopsy
Clinical: PMB (10% risk carcinoma), increasing with age, Premen IMB or recent HMB, CGIN smear and Ex normal
36
EM carcinoma staging
```
Stage 1 - confined to uterus
a - EM only, b - 1/2
Stage 2 - cervix also
a - cervical glands, b - cervical stromal invasion
Stage 3 - through uterus
a - serosa or adnexae, b - vag/parametrium, c - pelvic nodes, d - paraaortic
Stage 4 - distant
a - bowel/bladder, b - distant
```
37
Ix of EM carcinoma
Abnormal vaginal bleed as for pre/postmen bleed
USS/biopsy EM depending on risk
Staging only possible post-hysterectomy
MRI in those @ risk and suspected spread
38
Management of EM carcinoma
Surgery: 75% present Stg1 = hysterect + oophrec
Estimate further risk for radio (may be stg 3)
Radio if high risk of LN involvement
High risk LN +ve: deep myometrial invasion, poor histology, grade, stg 2+
39
Prognosis of EM carcinoma
Recurrence usually in vault in 1st 3y
| Poor prog factors: old, advanced, deep myometrial invasion in stg 1/2, adenosquamous
40
Uterine sarcoma Types, syx and Tx
Leiomyo - malignant fibroids
EM stromal - perimenopausal
Mixed mullerian - from embryo elements - old age
Presents: IMB PMB and rapid painful enlargement of fibroid
Tx: hysterec +/- chemo + radio
30% survival at 5y
41
Vaginal support anatomy
cervix and upper 1/3 - cardinal and uterosacral
mid - endofascial condensation
lower 1/2 - lev ani and perineal body
42
Types of prolapse
```
Urethocele
Cystocele
Apical - cervix and upper vagina/vault
enterocele
rectocele
```
43
Grading of prolapse
```
0 - no decent of viscera on straining
1 - leading surface >1cm above hymenal ring
2 - 1cm above to 1cm below
3 - >1cm below
4 - vagina everted (complete procidenta)
```
44
Epi and Aetio of prolapse
Epi: 1/2 of all parous women to some degree (10-20% present)
Aetio: Vaginal delivery, pregnancy, prolonged 2nd stage, instrumental, congenital connective tissue disease (ehler danlos), menopause (decreased oestrogen) = tissue deterioration, obesity, cough, constipation (increased IAPressure), surgery/continence procedures
45
Clinical presentation of prolapse
Asyx or dragging/lump at end of day or standing
Back pain and intercourse problems
Ulcer and bleeding/ discharge
Cele specific ie urinary
May need to reduce before urination/defecation
Ex: abdo and bimanual for masses, sims for vag wall, rectocele exam
46
Ix and prevention of prolapse
Pelvic USS for mass/urodynamic test for incontinence
Prevented by avoiding obstructed labour and XS long 2nd stage, doing pelvic floor exercises
47
Management of prolapse
General: weight loss, stop smoking, physio
Pessaries, rings (cones/shelves), topical oestrogen/HRT to stop ulcers, Pain, infection and retention can occur
Surgical: hysteropexy - fix cervix and uterus to sacrum with mesh, sacropexy - vault to sacrum or sacrospinous ligament (less effective)
Urinary incontinence = tension free vag tape or TOT
48
Risk factors for STIs
Young, single, >2 partners in 6m, new partner, non-barrier C, inner city, syx in partner, current STI, Hx STI, ethnicity, MSM/contact with MSM
49
Chlamydia Epi, Clinical features, Complications, Dx and Tx
5-10% women aged 20-30 have been infected
Usually asyx
Pelvic inf (can be silent), tubal damage, Reiters triad: urethritis, arthritis and conjunctivitis
Dx: NAAT ie PCR on urine
Tx: doxy/azithro
50
Gonorrhea Clinical, Dx and Tx
Asyx in women normally, may have, vag discharge, cervicitis, urethritis, pelvic inf, Bartholinitis, systemic bacteraemia/monoarthritis/septic arth
Men get urethritis
Dx = culture endocervical swab
Tx = cephtriaxone (pen and cipro res increasing), partner notification
51
Genital warts virus, Clinical, Tx
HPV - common, 16+18 assoc with CIN
Clinical: variable size, usually multiple vesicles on cervix
Tx: topical podophylin or imiquimod cream for external, cryo/electrocautery if resistant
52
Genital herpes virus, clinical, Dx and Tx
HSV2 (and 1 increasing)
Clinical: small, painful vesicles and ulcers around introitus, local lymphadenopathy, dysuria and systemic inf, secondary bacterial infections ie acute aseptic meningitis
75% reactivate; less painful, less severe, preceded by tingling
Dx: vag swab and exam
Tx: aciclovir if severe infection
53
Trichomoniasis protozoa clinical, Dx and Tx
Offensive grey green discharge, vulval irritatino and superficial dyspareunia, can be asyx
Dx: wet film microscopy
Tx: metronidazole
54
Syphilis Clinical, Complications, Dx and Tx
Primary: solitary painless vulval ulcer (chancre)
Secondary (untreated): rash, flu-like sex, warty genital/perioral growth (condylomata lata)
Both 1o and 2o can cause congenital infection in preg
Complications: aortic regurge, dementia, tabes dorsalis, gumata in skin and bone
Dx: enzyme immunoassay, venerial disease research lab tests
Tx: IM penicillin (parenteral)
55
HIV Epi, Risks, Clinical, Tx
80% heteros dx in UK contracted it abroad
Risk: STI risk factors and Africa
Clinical: Asyx then flulike on seroconversion
Dx of AIDS: Opportunistic inf or CD4
56
Non-infectious DD for vaginal discharge
Physiological (most common) - usually non-offensive: esp in ovulation, preg and COCP use
Ectropion
Atrophic vaginitis: (dec oest esp cervical carcinoma/other genital tract malignancy
57
Infectious DD of vaginal discharge
Bacterial vaginosis: fishy odour, grey white discharge. NOT red/itchy, clue cells, increased vag pH. Tx metro/clinda, Dx +ve whiff test
Candidiasis: cottage cheese, itch+vulval irritation, Dx by culture. Tx canestan/fluconazole
Chlamydia/Gon/tric can all cause discharge
58
DD of urethral discharge
Gonococcal: 2-5d incubation, purulent discharge (95%), anal inf, epididymal spread late
Non-gonococcal (NSUrethritis): most common - chlamydia or mycoplasma, may not have had sexual contact, blamed on soap/irritants
59
DD of pelvic pain
PID, UTI, miscarriage,m ectopic, torsion/rupture of ov. cyst, red degen of fibroid
60
DD of scrotal pain
```
Testicular torsion: acute pain
Epididymitis: Gradual
Fourniers gangrene: aggressive perineal inf, fever, intense pain
Inguinal hernia
Hydrocele/varicocele
```
61
Causes of genital lumps
Inf: warts, syphilis, HSV
Neoplastic
Benign: cyst, angioma, mollusca
62
Ix of STIs
```
Screen for concurrent disease (can have >1)
Urine dip and culture
Preg test
Swab for microscopy and culture
HIV/Hep B bloods
```
63
7 steps of STI management
1. Tx with correct Abx/Antivirals
2. Screen for concurrent inf + awareness of pregnancy risk
3. Tx partner
4. Partner notification (with permission)
5. Maintain confidentiality
6. Educate risks of STIs
7. Promote barrier contraception
64
Pelvic inflammatory Disease Path and Epi
STI, assoc with endometritis, bilat salpingitis, parametritis
Epi: 2% women. Young, poor, sex active, nulliparous increase risk
65
Causes of PID
Ascending: 80% sexual (increased risk if GUM risk present) COCP protective. Chlamydia and gon common - non-STIs seldom spread into pelvis
Descending: from visceral ie appendicitis or blood
66
Clinical features of PID
Usually silent if chlamydia
| Bilateral abdo pain and deep dyspareunia, vag discharge, fever, erratic bleeding
67
Ix, Tx and Complications of PID
Ix: swab, FBC, CRP, lap if doubt/poor tx response, preg test
Tx: analgesia + Abx (metronidazole and ciprofloxacin
Complications: abscess, chronic PID, CPP, subfertility, ectopic
68
Endometritis definition, causes, presentation, Ix and Tx
Inf of uterine cavity only - spread if untreated
Causes: instrumental, preg comp ie RPOC (chlam, gon, E.coli, staph, clostridium)
Present: HVagB, persistent pain, tender uterus, open os, fever
Ix: swab and FBC
Tx: Broad Abx, ERPC if needed
69
DD of colicky abdo pain
Obstetric: labour (uterine contractions), torted ovary/cyst (uterus relaxed)
Urinary: colic - loin to groin and haematuria
GI: sigmoid volvulus, billiary colic
70
DD of peritonism, fever and abdo pain
Obstetric: Chorioamnionitis: Hx ROM +/- discharge, tender uterus, maternal and fetal tachycardia
Urinary: pyelonephritis: loin pain and fever, cloudy urine
GI: appendix, cholecystitis, pancreatitis (inc amylase)
71
Other causes of abdo pain
Abruption: constant pain + bleed PV + abnormal CTG
Uterine rupture: fetal parts felt, abnormal CTG
HELLP: hep tender, blood indices abnormal
Splenic aneurysm rupture: sudden pain and hypovolaemia
72
Ix of abdo pain
Blood: UE, LFT, FBC, amylase, glucose, clotting
Urine: analysis and preg test
Culture: swab + blood
Radio: USS AXR CXR IV pyelogram CT
Other: ECG, cardiac enz, peritoneal lavage
73
Presentation of chronic ovarian cyst
May be asyx
Pain, discomfort, bloating, swelling in abdomen
Irreg periods, frequency due to pressure on bladder
Breast tenderness and hair growth
N+V, subfertility
74
Presentation of ovarian cysts acutely
Rupture: sudden unilateral pain, usually disappears after 6h
Heavy menstrual loss - USS normal
Fluid seen in pouch of Douglas
Haemorhagic cyst: acute v severe pain, persists longer
Torted ovarian cyst: cutting off blood supply to ovary! - acute severe pain, urgent surgery and detorsion to save ovary
75
Ix and Diagnosis of ovarian cysts
Hx: pain, duration, menstrual cycle relationship, age (malig rare in young), assoc bowel and urinary syx, Breast or GI (mets), FHx
Ex: palpable mass, liver enlargement or ascites
Ix: Bloods in hCG to exclude choriocarcinoma/yolk sac tumour, CA125
Radio: USS: risk features are:
multilocular, solid/separate, bilateral, ascites, abnormal dopplers
MRI: LN
Lap if >5cm, persistent or rapid growth ---> laparotomy if malig
76
What is RMI and how is it calculated?
RMI = CA125 x USS points x menstrual status
USS: multilocular, solid, bilateral, ascites, IA masses (0=0, 1=1, >1=3)
Menstrual status: pre=1, post=3
>200=high risk, 25-200 = monitor
77
Classification of ovarian masses
Physiological: Follicular and luteal (persistence) - COCP protective
Benign:
Epi: serous cystadenoma (uniloc, straw coloured fluid filled), mucinous cystadenoma (90% benign, multiloc, unilat, mucin filled)
Sex cord: Granulosa (slow growing malig, release oest and inhibin), thecoma (benign, release oest and androgen), fibroma (rare benign, Meig syndrome - pleural effusion + small ovarian masses)
Germ cell: teratoma/dermoid: young, premen, bilat, small asyx, rupture = pain
EMoma: chocolate cysts due to EMosis: rupture = v painful
78
Malignant Ovarian Tumours types
Epi: serous cystadenocarcinoma: most common (50%)
Mucinous CAC: 10% - pseudomyxoma = mucin throughout peritoneum)
EMoid (25%): hist similar to EM carcinoma
Clear cell: 10% but aggressive and poor prognosis
Sex cord: granulosa - slow growing, inhibin to monitor, oestrogen secreting
Germ cell: dysgerminoma - most common in younger women, radiosensitive
79
Bartholin cyst definition, path and tx
Defintion: blockage of mucus secreting gland behind lab minora
abscess if infected - v painful and tender swelling
Tx: incision and drainage, suture open = stop reaccumulation
80
Endometriosis definition and epi
EM tissue outside uterus
1-2% women (more as asyx often)
30-45 nulliparous most common
81
Endometriosis Pathology
```
Oestrogen dependent (regress postmen and in preg)
Most common behing ovaries and in uterosacral ligaments but can be anywhere even lungs
Accumulated blood = choc cysts and EMosis in ovaries
Causes inflammation, fibrosis and adhesions (frozen pelvis if bad)
```
82
Aetiology of EMosis
Retrograde menstruation, inherited predisposal + retro men may not cause EMosis
NB: Syx don't = severity of disease
83
Clinical features of EMosis
Hx: asyx or cyclical pelvic pain, dysmenorrhea before menstruation, deep dyspar, subfertility, pain on defecation. Choc cyst rupture = v painful
Cyclical haematuria, rectal/umbilical bleed if severe
Ex: Tender, thick behind uterus and adnexae, retroverted, immobile uterus if bad, rectovaginal felt on DRE, normal if mild
84
Ix of EMosis
visualise and biopsy for dx
active lesions = red, less active = brown powder burn
extensive adhesions seen on TVUSS, MRI for adenomyosis and bowel infiltration
85
Medical Management of EMosis
Asyx = don't tx, 50% regress or don't progress - common incidental finding
Medical: NSAIDs, paracetamol, opiates + ovary suppressors (pill, GnRH or androgen danazol)
COCP: NB CIs - continuous 2-3 back to back
Progestogen: Continuous/cyclical: good by premen syndrome + erratic bleeding, weight gain
GnRH: overstimulate pit = decrease GnRH receptors = decreased ov. hormones 6m/2y with add back HRT due to bone demineralisation
IUS: decreased pain and control syx for 5y
86
Surgical Management of EMosis
See and tx @ lap - laser, dia, scissors
Better fertility but hard surgery as anatomy distorted
Radical surgery if ovary involved - strip away/ablate
70% syx better and longer lasting
Hystero + BSO last resort (HRT needed) - support with COCP to stop unopposed oestrogen
F tubes affected = need IVF, F tubes not = surgery effective for treating subfertility
87
CPP definition and presentation
>6m intermittent or continuous lower abdo pain not cyclical or intercourse related
Presents as migrain/lower back pain, 15% women
Exclude non-gynae causes first - detailed hx of ideas from pt - psych assoc
88
Causes of CPP
EMosis/adenomyosis if varying with cycle
Oestrogen activity vital: postmen = cancer or adhesions with ov tissue stuck in them causing pain - tx oophrectomy + adhesiolysis
IBS/Icystitis
Depression, psych/ abuse causes
89
Management of CPP
IBS style: analgesics and antispasmodics
Cyclical - COCP, GnRH + addback, IUS
Lap, counselling, psychotherapy
Gabapentin/TCAs used if neuropathic
90
EMosis syx
```
Pelvic pain
Dysmenorrhea
Dyschezia
Dyspareunia
Subfertility
```
91
EMosis tx
Medical: ov suppression: COCP, progestogens, GnRH + HRT
Surgical: Lap ablation +- adhesiolysis, ovarian cystectomy, HBSO
92
Tx of cervical cancer
Stage 1ai - cone biopsy
Other 1&2 - LN involvement - radiochemo and LN excision - radical Hysterectomy and BSO (unless young and SCC) if -ve nodes
Radical trachelectomy for fertility retention
>2b - radiochemo and look for mets
recur - pelvic exeneration - take everything possible
Review at 3m, 6m then 6mthly
93
Staging of ovarian cancer
Stage 1 - confined to ovaries (a - 1ovary, capsule intact, b - 2 bilateral, capsule intact, c - capsule not intact/cells in abdo cavity - ascites)
2 - beyond ovaries, confined to pelvis
3 - beyond pelvic, confined to abdomen (most common)
4 - beyond abdomen
94
Management of ovarian cancer
Midline lap - total BSO and hysterectomy with omentectomy and biopsy any deposits/LN
Stg 1 - retroperitoneal LN
Stg 2 - block dissection
Borderline = ovary alone removed
Chemo once dx confirmed on biopsy (no chemo if 1a/b)
1c - 6 cycles of carboplatin
2+ add in paclitaxel to cis/carboplatin - monitor with CA125
