Gynae Flashcards
(108 cards)
1
Q
What are some common causes of intermenstrual bleeding?
A
Physiological - hormonal fluctuation around menopause
Vaginal - vaginitis
Cervical - STI, ectropion, polyps, cancer
Uterine - fibroids, polyps, cancer, endometriosis
Iatrogenic - missed pill, post-smear
2
Q
Define a ‘complete’ abortion and its clinical features
A
- Complete evacuation of all POC
- Some light bleeding and minimal pain
- Os remains closed
3
Q
Define an ‘incomplete’ abortion and its clinical features
A
- Incomplete evacuation of POC
- Heavier bleeding
- Os is dilated, can be obstructed with POC
- Uterus is small
4
Q
Define a ‘missed’ abortion and its clinical features
A
- Foetus has died but there have been no signs
- Pregnancy continues but not with normal growth
- Occurs <20weeks
- Light bleeding, loss of symptoms of pregnancy
5
Q
Define a ‘threatened’ abortion and its clinical features
A
- Clinical symptoms of miscarriage (bleeding and pain) but cervix is closed
- Light bleeding, minimal pain
- Size of uterus consistent with pregnancy
6
Q
Define a ‘inevitable’ abortion and its clinical features
A
- Continuation of threatened abortion (miscarriage basically)
- Painful contractions
- Heavier bleeding, may have clots
- Cervix is open
7
Q
Define an ‘septic’ abortion and its clinical features
A
- Infection of retained POC or damage caused during TOP
- Fever, bleeding, pain
- “Boggy” uterus
- Cervix is open
8
Q
What are some causes of spontaneous abortion?
A
- Chromosomal abnormalities
- Anatomical uterine defects (congenital or acquired (fibroids, adhesions))
- Systemic disease (thyroid dysfunction, diabetes, PCOS)
- Iatrogenic
- Trauma (CVS, amniocentesis)
- Infection
- Thrombophillia
- Cervical incompetence
9
Q
What is the definition of spontaneous abortion and how is it monitored?
A
- Expulsion of products of conception before viability
- <20 weeks or <400g
- Monitor with daily hCG assays
10
Q
What is cervical incompetence and how is it managed?
A
- Abnormal weakness of cervix causing painless dilation during pregnancy
- As intrauterine pressure increases –> membranes rupture –> miscarriage
- Manage using cervical circlage at internal os, non-absorbable stitch
11
Q
How are spontaneous abortions managed?
A
- Take daily hCG to determine non-progression of pregnancy
- Surgical: dilatation and curettage or suction under U/S
- Medical: misoprostol (PGE1)
12
Q
What are some signs on U/S of poor prognosis that may result in miscarriage?
A
- FHR <100 (50% demise), <85 (100% demise)
- Sac size <5mm
- Subchorionic haematoma
13
Q
Why should CA125 NOT be used as a screening tool for ovarian cancer?
A
- It is elevated in normal menstruation, ovarian cysts, endometriosis
- It is not raised in up to 50% of women who DO have ovarian cancer
14
Q
What are some risk factors for ectopic pregnancy?
A
Previous ectopic Chronic salpingitis PID STI IUD Tubal surgery Most happen in patients with NO risk factors
15
Q
What are the important clinical features of ectopic pregnancy?
A
Sudden onset, severe, stabbing abdo pain
Nausea +/- vomiting
Rupture: tachy, hypotensive, peritonitis, shoulder tip pain
16
Q
How does B-HCG change with a viable pregnancy?
A
Should double every 48hrs
17
Q
What are the management options for ectopic pregnancy?
A
- Watchful waiting if caught early
- Pharmacologic: methotrexate
- Inhibit folic acid synthesis –> inhibit rapidly dividing cells –> stop growth of embryo - Surgical: salpingectomy or salpingostomy (partial removal)
- Laparoscopic or laparotomy
**Serial HCGs until gone
18
Q
What are the complications of ectopic pregnancy?
A
- Persistent ectopic
- Rupture
- Recurrence
19
Q
Where can ectopic pregnancies reside?
A
95% in fallopian tube, most commonly ampulla
Abdo cavity
Cervix
Ovaries
20
Q
What investigations are required for suspected ectopic?
A
- Positive pregnancy test (serum beta HCG)
- Ultrasound - transvaginal –> no intrauterine pregnancy detected (can sometimes visualise ectopic gestation sac)
- Intrauterine pregnancy excludes diagnosis
- Serum progesterone
- FBC (infection, anaemia)
- LFTs (biliary colic), EUCs (kidney stones)
21
Q
What does pregnancy look like on ultrasound?
A
True gestational sac - double echogenic ring
- Present 4.5-5.5 weeks
Yolk sac is present up to 10 weeks
Cardiac viability at 5.5-6 weeks
22
Q
What are the 3 characteristics of PCOS?
A
- Signs of cysts (follicles) on ovaries (identified on U/S)
- 12 or more, 2-9mm - Hyperandrogenism
- Anovulation
23
Q
What is the basic pathophysiology of PCOS?
A
Insulin resistance –> hyperinsulinaemia –> increased androgen production
- -> increased LH and decreased FSH –> poor follicular development (development of cysts) + anovulation
- -> increased testosterone –> hyperandrogenism symptoms + prevents ovulation
- -> poor follicular development –> no development of corpus luteum –> reduced progesterone and therefore increased unopposed estrogen –> increased endometrial cancer risk
24
Q
What are some causes of amenorrhoea?
A
Pregnancy, ectopic, molar Contraception Excessive exercise, very low BMI PCOS Menopause Hyperprolactinaemia, breastfeeding Hyper/hypothyroid
25
What investigations are required for PCOS?
```
Transvaginal ultrasound
BSL, OGTT
FBC
Lipid profile
TFTs
Free androgen index
Testosterone
DHEAS
17-OH Progesterone (rule out adrenal hyperplasia)
Prolactin
```
26
What are the clinical features for PCOS?
Hyperandrogenism = acne, hirsuitism (hair on face, arms, back, linea alba, chest)
Central obesity
Anovulation (infertility)
Menstrual irregularity, menorrhagia/oligomenorrhoea
- Insulin resistance, hyperlipidaemia
- Cysts on ovaries
27
What are the treatment options for PCOS?
Weight loss
Add metformin if appropriate
Fertility: clomifene (stimulates follicular development)
Non-fertility: OCP, antiandrogens
28
What is the mechanism of action of 5a reductase inhibitors? What are they used for?
Prevents conversion of testosterone into DHT - precursor to other androgens)
PCOS
- Antiandrogen
BPH
- reduce prostate size (DHT promotes growth)
29
What are the theories for the pathophysiology of endometriosis?
1. Retrograde menstruation: flow of menses back through fallopian tubes to abdo cavity, does not account for distal sites of endometrium (e.g. lung)
2. Coeliomic metaplasia: metaplasia of peritoneal mesothelium into endometrium
3. Induction theory: Differentiation of undifferentiated peritoneal cells into endometrial tissue
30
What are the features on history and examination for a diagnosis of endometriosis?
1. Dysmenorrhoea
2. Dyspareunia
3. Dysuria
4. Dyschezia
5. Dolor (chronic pelvic pain)
Exam: PV exam - fixed adnexal mass (endometrioma), nodules over uterosacral ligaments and POD
31
What are the 3 different kinds of endometriosis?
Superficial peritoneal endometriosis = white plaques/scarring on ovaries, peritoneum (can also be red)
Endometrioma (chocolate cyst) = contain thick fluid, densley adherent to peritoneum on ovarian fossa
Deep infiltrating endometriosis = nodules extend >5mm below surface of peritoneum --> affects bladder, bowel, vagina, ureters
32
What are the treatment options for endometriosis?
Analgesia: NSAIDs, panadol
COCP - suppress HPO axis --> reduce E/P secretion --> atrophy of ectopic implants, skip periods (avoid pain)
GnRH agonists --> as above
Surgery - remove ectopic endometrial lesions
33
Compare and contrast complete and partial hyatidiform moles
COMPLETE: Fertilisation of egg without a nucleus --> entirely paternal information
- No fetus present
- VERY high B-HCG
- Multi-vascular mass of trophoblastic tissue and hydropic change
PARTIAL: Fertilisation of normal egg with 2 sperm --> triploidy
- (usually) Non-viable fetus present
- B-HCG can be normal
- Some proliferation and hydropic change
34
What is gestational trophoblastic disease?
Tumours of fetal tissue, represents failure of embryogenesis
| - Includes benign trophoblastic tumours, hyatidiform moles, neoplasia (e.g. choriocarcinoma)
35
What is a choriocarcinoma?
Tumour of trophoblastic cells --> secrete HCG
| - Occur when molar pregnancies do not regress after surgery
36
What are hyatidiform moles?
Chromosomally abnormal pregnancies that have potential to become malignant
37
How do complete and partial hyatidiform moles differ on ultrasound?
COMPLETE
- No fetus present
- Entire uterus is filled with 'moles' - looks like grapes
PARTIAL
- Non-viable fetus is visible
- Uterus partially filled with grapes
38
What investigations need to be performed when expecting a molar pregnancy?
```
Trans-vaginal ultrasound
B-HCG - weekly
FBC (anaemia), blood group and Rh, group and hold
TFTs
Histological examination of endometrium
```
39
How long must B-HCG monitoring continue after molar pregnancy?
Until negative for 3 consecutive weeks
40
What are the treatment options for molar pregnancies?
Fertility: D&C, methotrexate (if persistent GTN after molar pregnancy)
Non-fertility: Hysterectomy
41
What are some complications of GTD?
```
Hyperemesis gravidarum, thyrotoxicosis
Active bleeding
Pre-eclampsia
Asherman's syndrome post-D&C
Choriocarcinoma
Metastases
```
42
What are the clinical features that make you think molar pregnancy?
```
PV bleeding
Pelvic pain/pressure
VERY high levels of B-HCG
Hyperemesis gravidarum
Uterus palpated at greater than dates
Pre-eclampsia, hyperthyroidism, anaemia
```
43
What are some differentials for a large uterus?
Twins
Wrong dates
Fibroids
Molar pregnancy
44
What is the triad of symptoms to look for with adenomyosis?
1. Menorrhagia
2. Dysmenorrhoea
- Often post-menopausal bleeding
3. Dyspareunia
+
Symmetrically bulky uterus on exam
Usually occurring in older women
45
How do you define adenomysosis?
Ectopic endometrium implanting into the myometrium
46
What is a fibroid? What are the different types?
Leiomyoma - benign tumour of the smooth muscle cells of the uterus
Submucosal - under endometrial lining growing into the uterine cavity
Intramural - within uterine wall
Subserosal - underneath uterine serosa, can grow outwards and pedunculate into abdo cavity
47
How does fibroid present on examination? What investigations are required?
Asymmetrically bulky uterus, firm and non-tender, large for dates if pregnant
Pelvic ultrasound, endometrial biopsy
48
What are the other clinical features of fibroids?
Menorrhagia, dysmenorrhoea, signs of anaemia
Pelvic mass - can press on ureters (LUTS)
Subfertility (esp submucosal)
Pelvic pain
49
What are the treatment options for fibroids?
Desiring fertility:
- IUD
- Surgical: Transcervical resection of fibroids (TCRF), Myomectomy (pre-surgical GnRH agonist will shrink fibroid before surgery)
Do not desire fertility
- Uterine artery embolism
- Myomectomy
- Hysterecomy
50
What are some differentials for a central pelvic mass?
```
Pregnancy
Molar pregnancy
Fibroids
Endometrial cancer
Adenomyosis
Bladder cancer or normal full bladder!
GIT - stool, inflammatory abscesses
```
51
What are some differentials for a lateral pelvic mass?
```
Ovarian cyst
Pedunculated fibroid
Ovarian cancer
Endometrioma (chocolate cyst)
Theca lutein cyst
Pelvic kidney
PID with tubo-ovarian abscess
Ectopic pregnancy
GIT (appendicitis, Crohn's, diverticula, GI cancer)
```
52
What are the different kinds of prolapse?
```
Rectocele - prolapse of rectum/large bowel
Cystocele - prolapse of bladder
Enterocele - prolapse of small bowel
Uterine prolapse
Vaginal vault prolapse
```
53
What are some risk factors for prolapse?
Any factors that weaken / damage the normal pelvic support system can lead to prolapse and urinary stress incontinence
- Childbirth (macrosomy, episiotomy, forceps)
- Hysterectomy
- Connective tissue defects (Ehler's Danlos)
- Factors that put STRESS on pelvic floor (prolonged physical labour, constipation, COPD, obesity)
- Postmenopausal atrophy (less vascularised)
54
Briefly explain the pathogenesis of prolapse
Stress and straining
Bony pelvis, Broad ligament, Uterosacral and cardinal lig, Urogenital diaphragm, Pelvic diaphragm (levator ani), Perineum
- Rupture of these ligaments
- Stretching of fascia
- Weakening of connective tissues
Loosens the 'hammock' of muscles making up the pelvic floor that hold up the bladder, pelvic structures, etc.
55
What are the common symptoms of prolapse?
```
Asymptomatic
Feeling of heaviness in vagina/rectum
Dyspareunia
Pain at end of day
Straining with incomplete evacuation, may need to use fingers to help
Feeling as though there is a mass present
Dysuria / dyschezia / incontinence
Visually observing the prolapse
```
56
What are the management options for prolapse?
Non-surgical: pessaries, physio for pelvic floor strengthening, topical estrogen
Surgical: using a mesh to reattach
57
What are the options for emergency contraception?
1. Progesterone-only 'morning after pill' (3 days)
| 2. Copper IUD (5 days)
58
How do hormonal contraceptives work?
1. Prevent ovulation through disruption of hypothalamic-pituitary-ovarian axis (inhibit FSH and LH release)
2. Thicken cervical mucus
3. Endometrial atrophy
59
What is the definition of infertility?
Failure to conceive after 12 months of consistent unprotected sex
- Primary - no other pregnancies
- Secondary - other successful pregnancies
60
What are some male factors causing infertility?
Azoospermia
Low sperm count
○ Seminiferous tubule dysfunction (60-80%)
○ Post-testicular defects -disorder of sperm transport (10-20%)
○ Primary hypogonadism (10-15%)
○ Hypothalamic pituitary disease -secondary hypogonadism (1-2%)
Previous infection - orchitis, mumps
Radiation exposure - testicular cancer, leukaemia
CBAVD
Smoking, alcohol, obesity
61
What are some female factors causing infertility?
Ovulatory dysfunction
- Increasing age - decreasing egg number and viability, PCOS
Tubal disease - STI causing salpingitis and scarring
Anatomical
- Congenital: uterine didelphys, bicornate, septate
- Acquired: tubal surgery, submucosal / large intramural fibroids, Asherman's
Unexplained
Smoking, alcohol, obesity
62
What is the definition of subfertility?
Failure to conceive after 2 years of regular unprotected sex AND despite normal investigations
63
What is fecundity? How does it change over time?
Potential reproductive capacity of an individual
- Females per month change of conception:
○ Age 21 = 25% chance (peak)
○ Age 35 = 12%
○ Age 40 = <5%
- Males is consistent over time
64
What questions are required for the male on a fertility history?
```
- Developmental history
• Testicular descent
• Pubertal development
• Loss of body hair
• Decrease in shaving history
- Chronic medical illness
- Infections
• Mumps orchitis
• CF
• STIs
• UTIs
• Prostatitis
- Surgical history
• Vasectomy
• Orchiectomy
Any children with another partner, any previous investigations
Smoking, alcohol, steroids, chemo
```
65
What questions are required for the female on a fertility history?
```
Full menstrual history history
Full obstetric history - any previous pregnancies/ miscarriages/ terminations
Sexual history and STIs
Contraceptive history
Pap smears
Screen for PCOS symptoms
PMHx (tubal surgery, SLE, thyroid disorder, DM)
FHx (infertility, chromosomal disorders)
```
66
What investigations are required for infertility?
Male:
- Sperm sampling
- Bloods: FSH, LH, PRL, testosterone, anti-sperm antibodies
Female:
- Bloods: FBC, coags, LSH, FSH, TSH, testosterone, DHEAS, lipid profile, HbA1c
- Rubella screen
- Imaging: TV ultrasound
*Karyotype for both
67
Describe the differences in appearance of cervical os in nulliparous and parous women.
Nulliparous
- Barrel shaped, small circular external os
Multiparous
- Cervix is bulky and external os looks like a slit
68
What is a cervical ectropion?
Where the endocervical columnar epithelium extends out through external os --> undergoes squamous metaplasia --> becomes stratified squamous epithelium
- Common with OCP
69
What are the different types of HPV? Which ones cause which kinds of warts?
```
- HPV
○ Cancer 16, 18
○ Genital warts 6, 11
○ These 4 covered by gardasil vaccination
○ Other warts 1, 2
```
70
What is CIN? How is it detected?
```
Cervical intraepithelial neoplasia (pre-invasive lesion)
Need cytological investigation
○ CIN 1
§ Mild dysplasia
§ Affects lower 1/3 of epithelium
○ CIN 2
§ Moderate dysplasia
§ Lower 2/3
○ CIN 3
§ Severe dysplasia
§ Full thickness
§ Carcinoma in situ
If they invade through BM --> cervical cancer
```
71
Explain pathway for pap smear results
CIN1/low-grade changes --> repeat in 12mo
○ --> CIN1 again --> culposcopy
○ normal --> repeat 12mo
○ --> normal --> 2 yearly
○ --> CIN1 again --> culposcopy
CIN2-3/high-grade changes --> straight to culposcopy
72
What is the most common type of cervical cancer?
Squamous cell carcinoma is the most common type of cervical cancer
73
Which cells are being sampled on a pap smear?
Cells from transformation zone
| Glandular --> transformation --> squamous
74
What kind of prolapse commonly occurs following hysterectomy?
Vaginal vault prolapse commonly occurs following a hysterectomy (removal of the uterus (womb)). Because the uterus provides support for the top of the vagina, this condition occurs in up to 40% of women after a hysterectomy.
75
What are the 6 anatomical systems required for pelvic support?
```
Six different systems: BBUUPP
1• Bony Pelvis
2• Broad Ligaments
3•Cardinal and Uterosacral Ligaments.
4• Urogenital Diaphragm.
5• Pelvic Diaphragm including Levator Ani Muscles.
6• Perineum including the Perineal Body
```
76
What is a cystocele?
Protrusion of the bladder into the vagina due to defects in pelvic support.
The bladder base descends below the inferior ramus of the symphysis pubis at rest or with straining.
77
What are the grades of cystocele?
1. Descending towards introitus with straining
2. Descends to level of introitus with straining
3. Descends outside of introitus with straining
4. Outside of introitus at rest
78
What is an enterocele?
An enterocele is essentially a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space.
79
What surgery is used to treat vaginal vault prolapse?
The McColl procedure
| It is the re-approximation of the Cardinal and Uterosacral ligaments to the vaginal apex
80
Why does prolapse cause incontinence?
- If patient coughs (applies pressure) urethra pushed downwards from pressure
○ Comes against resistance of hammock
○ Occludes the urethra
- If suspension system is ruptured, when apply pressure (jump, cough, etc.)
○ Urethra goes down and nothing to support hammock
○ Urethra does not collapse --> few drops come out
81
What are some contraindications to taking the oral contraceptive pill?
DVT/PE, migraines, breast cancer history, pro-thrombotic disorders, poor compliance issues, CV risk factors (HTN, DM, arterial disease), hepatic impairment, BMI >35
82
Describe the differences in discharge between bacterial vaginosis, candidiasis, chlamydia, trichomoniasis
Bacterial vaginosis: thin white/grey/green, strong fishy odour
Candida/thrush: thick white, cheesy, usually odourless
Chlamydia: yellow mucopurulent
Trichomoniasis: grey frothy, can be fishy
83
What kind of cells are present in microscopic investigation of bacterial vaginosis discharge?
Clue cells
84
What are you measuring on TV U/S when looking for adenomyosis?
Junctional zone between endometrium and myometrium is >12mm
85
How does an endometrioma appear on ultrasound?
Large complex ovarian cyst
| Ground glass appearance but homogenous
86
What is the best way to remove a large ovarian cyst?
Best way is vaginal hysterectomy, also consider laparoscopic and abdominal
- may be too big
87
What is the differente between total and subtotal hysterectomy?
Total = remove cervix
with or without bilateral salpingo-oopherectomy (= radial hysterectomy)
Subtotal = leave cervix
88
What is the most common presentation for a polyp?
IMB, any time in cycle, lighter than period, no pain, sometimes post-coital, normal smears
89
What is the classic appearance of polyp on ultrasound?
Hyperechoic mass with feeder vessel
- Looks like a chickpea
Myometrial growth depends on cycle - changes the echogenicity
90
What is the gold standard treatment for polyps?
Hysteroscopy, polypectomy under direct visual guidance (no dilation required)
- If polyp is too big can cut up and remove in smaller pieces
91
What is the definition of dysfunctional uterine bleeding?
Excessive bleeding not due to pregnancy, pelvic pathology or systemic disease
92
What is the best treatment for dysfunctional uterine bleeding?
Not desiring fertility: ablation of endometrial lining
| - Always do hysteroscopy first before burning to sample and make sure not cancer
93
What is the best way to diagnose endometrial cancer?
Ultrasound - thickness >5mm
Hysteroscopy and curettage
- Looks fluffy and vascularised
94
How do overweight women end up with increased endometrial thickness?
Fat --> produces androgens --> estrogens --> promote growth of endometrium without the balance of progesterone (no longer ovulating)
○ Adipose hyperandrogenism
○ Usually just hyperplasia BUT can be bad times
95
What are the choices of treatment for endometrial cancer?
1. Hormonotherapy with mirena (good if cannot operate or young, still need hysteroscopy and curettage every 3 mo)
2. Radiotherapy
3. Total hysterectomy with BSO and lymphadenectomy
96
What is the treatment for cervical cancer?
Radial hysterectomy
| - Uterus, cervix, parametrium, top of vagina
97
What are the risk factors for endometrial cancer?
```
Post-menopausal
Nulliparous
Obesity
Unopposed estrogen (HRT)
Lynch syndrome
PCOS
```
98
What is the treatment for fibroids? What is a complication?
Hysteroscopic resection
| TURP syndrome - reabsorbing too much glycine causing a hyponatraemia
99
What are the risks of a laparoscopic myomectomy?
A. Transfusion - bleeds more than hysterectomy
B. Rupture of uterus- big scar on uterus, if become pregnant, do not let them labour, prophylactic caesar
C. Adhesions - use anti-adhesion fluid on the scar
D. Spreading of cancer - the instrument propel little bits of cancer everywhere
E. Incisional hernia
100
What is the antibiotic treatment for gonorrhoea?
Ceftriaxone 125mg IMI
| Doxycycline 100mg bd orally for 7 days treats Chlamydia which is frequently also present
101
What is PID
PID refers to acute infection of the upper genital tract structures in women, involving any or all of the uterus, oviducts, and ovaries and sometimes other surrounding pelvic organs
102
How do you diagnose PID?
Clinical diagnosis:
| - Pelvic pain + cervical motion / adnexal tenderness + risk factors, fever, positive cultures, inflammatory mass on U/A
103
How does PID present?
Risk factors: young, multiple sex partners, previous STI, TOP
Symptoms: recent onset, usually constant & aching, bilateral, post-coital bleeding
Exam: cervical motion tenderness, adnexal tenderness, cervical mucopurulent discharge on spec
104
What investigations are required for PID?
Pregnancy test
Microscopy of vaginal discharge
NAATs chlamydia, gonorrhoea, M. genitalium
HIV screening
Syphilis serology
Can consider ultrasound to rule out other pelvic pathology causing s
105
What is the treatment for chlamydia?
Azithromycin 1g PO STAT
106
What is the treatment for gonorrhoea?
Ceftriaxone 500mg IMI STAT
| usually also give azithromycin 1g PO STAT
107
What is the treatment for genital herpes?
Initial episode: 500mg valcyclovir PO daily for 5-10 days
Following episodes: 3 days
Preventative: daily therapy for 6 months
108
What are the complications of PID?
TOA, TOA rupture
Fitz Hugh Curtis syndrome
Infertility, ectopic
