Gynae Flashcards
(60 cards)
What to do in borderline/mild dyskaryosis? Moderate? Severe? Suspected invasive cancer? Inadequate?
The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis Consistent with CIN II. Refer for colposcopy
Severe dyskaryosis Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks**)
Suspected invasive cancer Refer for urgent colposcopy (within 2 weeks)
Inadequate Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy
Mechanism of HPV causing cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
Primary secondary causes of amenorrhea?
Initial ix?
Causes of primary amenorrhoea Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital trac
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Initial investigations
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
Endometriosis 1st? 2nd? 3rd? If not wanting to conceive
COCP back to back
Progesterone only - depot / POP OR mirena
GnRH analogues
Mefanamic acid / NSDAISs are good for dysmenorrhea.
How do they work? What is the second line?
Inhibit prostaglandin production
COCP
An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates a voiding detrusor pressure of 90 cm H20 (normal value < 70 cm H2O) and peak flow rate of 5 mL/second (normal value > 15 mL/second). What is the most likely diagnosis?
Overflow incontinence
What happens to Women with a cervix that cannot be visualised
Refered to colposcopy
What happens to women who have cervical stenosis
referred to the colposcopy clinic for consideration of cervical dilatation.
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC?
Higher sensitivity and specificity
Less inadequate smears
Most likely location of ectopic? RF?
Ampulla of Fallopian tube
Risk factors (anything slowing the ovum's passage to the uterus) damage to tubes (salpingitis, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic)
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
What should be done?
Urinary dye studies
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
A 56-year-old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive.
What should be done
Urodynamic studies
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
In urge incontinence bladder stabilising drugs are used after 6 weeks of bladder retraining
What needs to be avoided in ‘frail older women’
Immediate release oxybutin
-use darifenacin
[bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’]
Initial ix in incontinence ?
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
Management of urge incontinence ?
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
Management of stress incontinence
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain. The pain came on gradually and has been getting progressively worse for 3 days. She is nauseated and has vomited twice this morning. She has a temperature of 38.4ºC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute. The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler. On speculum examination the cervix is closed and there is no blood. She has a history of menorrhagia due to uterine fibroids. This is her first pregnancy. What is the most likely diagnosis?
Why? Mx?
Fibroid degeneration
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Mx of fibroids
symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
other options include tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy
uterine artery embolization
A 25-year-old female student was brought in to the Emergency Department. She complains of a severe abdominal pain. The pain started suddenly 3 hours ago while she was shopping .Further questioning reveals that she has not had her periods for 7 weeks and is currently sexually active. She also reported a history of pelvic inflammatory disease 5 years ago. Abdominal examination reveals generalised guarding and signs of peritonism. An urgent ultrasound scan was ordered and showed free fluid in the pouch of Douglas with an empty uterine. Urine βhCG was positive. Other basic bloods are sent.
While in the emergency department, she suddenly became very ill. Her observations were; Blood pressure 85/50 mmHg, Heart Rate -122/min, Respiratory Rate-20/min, O2 saturation 94%.
What is the next appropriate action?
Resuscitate and arrange for emergency laparotomy
A 30-year-old woman is 24 weeks pregnant and she receives a letter about her routine cervical smear. She asks her GP if she should make an appointment for her smear. All her smears in the past have been negative. What should the GP advise?
smear 12 weeks after delivery
If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first?
Second?
Management? What if they are old and frail?
TVUS
2- Hysteroscopy with endometrial biopsy
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
A 17-year-old female comes to your GP clinic. She has recently travelled to Egypt to see her family, and now has come to visit as she is suffering with per vaginal bleeding and urinary incontinence.
She consents to examination with a chaperone present and you identify signs that suggest there have been recent trauma to the genitalia. You suspect this is a case of female genital mutilation.
What is the most appropriate course of action?
Report to the police as <18
Long term complications of PCOS ?
Subfertility Diabetes mellitus Stroke & transient ischaemic attack Coronary artery disease Obstructive sleep apnoea Endometrial cancer
PCOS increases risk of endometrial Ca. Why?
How can you limit this?
Oligo/amenorrhea with pre-menopausal levels of oestrogen
Induce withdrawal bleed every 1-3 months using COCP or insertion of mirena coil
