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3a obs and gynae > Gynae > Flashcards

Gynae Flashcards

PID, prolapse, endometriosis, fibroids, cancers, ovarian cysts (92 cards)

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1
Q

Define acute pelvic pain

A

short duration of pain lasting less than 3 months

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2
Q

Define chronic pelvic pain

A

intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6 months duration, at least 1 in 7 days a week

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3
Q

List the gynaecological causes of acute pelvic pain

A

early pregnancy complications - ectopic, miscarriage
PID
endometriosis
adenomyosis
ovarian cyst torsion, haemorrhage or rupture
primary dysmenorrhoea
torsion of the fallopian tube

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4
Q

List the non gynaecological causes of acute pelvic pain

A 
UTI 
steric stones
diverticular disease
peritonitis 
appendicitis 
aortic aneurysm
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5
Q

List the gynaecological causes of chronic pelvic pain

A 
adenomyosis 
endometriosis
adhesions - from previous surgery 
chronic PID
pelvic organ prolapse
fibroids
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6
Q

List the non gynaecological causes of chronic pelvic pain

A 
IBS
constipation
hernia
fibromyalgia
psychological - depression
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7
Q

What are the red flags for someone presenting with pelvic pain?

A 
weight loss
reduced appetite 
post coital bleeding
pelvic mass
new bowel symptoms >50 y/o
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8
Q

Define Pelvic Inflammatory Disease

A

infection of the upper genital tract - either ascending infection from endocervix or descending infection from other organs

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9
Q

What are the risk factors for pelvic inflammatory disease?

A

age <25
previous STI
new sexual partner /multiple sexual partner
uterine instrumentation e.g. intrauterine contraception, laparoscopy, termination of pregnancy
post partum endometritis
complications of child birth and miscarriage

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10
Q

What are the common causative factors for PID?

A

chlamydia trachomatis (60%)
neisseria gonorrhoea
anaerobes

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11
Q

How does PID clinically present?

A 
asymptomatic 
bilateral pelvic pain 
deep dyspareunia 
vaginal discharge 
irregular or more painful menses 
fever
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12
Q

What are the signs seen in PID?

A

cervical motion pain
adnexal tenderness
elevated temp -> sign of fever
bilateral lower abdominal tenderness

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13
Q

How does chronic pelvic inflammatory pain occur and what are the main symptoms?

A

persisting infection resulting my non treatment or inadequate treatment of an acute PID

chronic pelvic pain, dysmenorrhoea, deep dyspareunia, sub fertility

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14
Q

Which investigations are necessary for diagnosing PID?

A

Laparoscopy with fimbrial biopsy **- gold standard but only done when diagnosis uncertain
pelvic ultrasound

FBC and blood cultures if fever
endocervical swabs to check for STIs

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15
Q

How is pelvic inflammatory disease managed as an inpatient and outpatient?

A

Inpatient: IV ceftriazone 2g od + IV doxycycline 100mg bd / oral doxycycline 100mg bd 14 days + oral metronidazole 400mg bd 14 days

outpatient: IM ceftriaxone 500mg stat + oral doxycycline 100mg bd 14 days + oral metronidazole 400mg pd 14 days

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16
Q

Define endometriosis

A

endometrial tissue outside the endometrium cavity

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17
Q

What are the possible locations of endometriosis?

A 
pelvis ** - pouch of douglas, uterosacral ligaments, bladder, peritoneum 
lungs
brain
muscle
eye
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18
Q

describe the signs O/E of endometriosis

A

fixed retroverted uterus
tenderness in posterior vaginal fornix
adnexal mass
tenderness of uterosacral ligaments

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19
Q

What are the symptoms of endometriosis

A

Dyspareunia
Dysmenorrhoea - cyclical, pain worse on periods
Dyschezia - pain in passing stools during menses
Dysuria - if endometriosis in bladder

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20
Q

How is endometriosis caused?

A

retrograde menstruation

family history

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21
Q

Describe endometriosis’s appearance

A

peritoneal endometriotic lesions
ovarian endometriotric cysts - >10cm, brown coloured fluid
fibrosis and adhesions

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22
Q

List the differentials for endometriosis

A 
fibroids 
polyps 
pelvic inflammatory disease 
ovarian cancer 
adenomyosis
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23
Q

What examinations would you appropriate for a diagnosis of endometriosis?

A

1st line = transvaginal ultrasound scan

gold standard = laparoscopy with biopsy* - resect >3cm to rule out malignancy - MRI and CA125

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24
Q

What is the medical management for endometriosis

A
  1. abolish cyclicality
    1st line = COCP triphasing- 3 months continuous back to back pill, but do NOT give to women who want to get pregnant
  2. Glandular atrophy
    oral progestogens, depot provera , mirena
    aromatase inhibitors

if after 6 months of care, refer to gynaecology

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25
What is the surgical management for endometriosis
surgery for women who want children and cannot take the medication: ablation and excision surgery for women who have had their family: oophorectomy or pelvic clearance
26
What are fibroids
** benign tumours of the myometrium ** vary in size from mm -> large tumours can be intramural, subserousal (extend into peritoneal cavity) or submucosal (extend into uterine cavity) oestrogen dependent so regress after menopause, grow in pregnancy
27
What are the risk factors for fibroids?
pre menopausal afro caribbean women family history
28
What are the protective factors for fibroids?
porous women COCP injectable progestogens
29
How does someone with fibroids present?
asymptomatic (50%) pain - dysmenorrhoea**, usually causes pain when complications occur bleeding problems - menorrhagia**, miscarriages, anaemia sub fertility
30
What are the potential complications with fibroids?
1. torsion of fibroid 2. enlargement which puts pressure on other organs 3. progress to malignancy in 0.1% - leiomyosarcoma 4. degeneration - during pregnancy , fibroids grow due to the oestrogen and cause degeneration = fever + pain + vomiting
31
Which investigations are necessary for fibroids?
Imaging - ultrasound** | examination - solid knobbly mass palpable , "whorled appearance histologically"
32
How are fibroids managed?
Conservative - if asymptomatic no treatment, analgesia if necessary Medical - transexamic acid, NSAIDs, progestogens +/- GnRH agonists Surgical - hysteroscopic surgery or open laparoscopic myomectomy
33
Define prolapse
protrusion of the uterus +/- vagina beyond normal anatomical confines
34
What is the aetiology of a prolapse?
pregnancy and vaginal delivery - big babies, instrumental delivery, prolonged labour, multiparous women congenital factors - Ehlers Danlos syndrome menopause - age iatrogenic - pelvic surgery, hysterectomy, continence procedures chronic factors - obesity, chronic cough, constipation, heavy lifting
35
How is the vagina supported at 3 levels from the side walls of the pelvis?
Level 1: cervix and upper 1/3 vagina supported by cardinal and uterosacral ligaments Level 2: middle of vagina attached by endofascialg fascia laterally of pelvic side walls Level 3: the lower 1/3 of vagina supported by levator and muscles and perineal body
36
What is the clinical presentation of a prolapse?
``` dragging sensation, discomfort feelings of a "lump coming down" backache dyspareunia symptoms worse at the end of the day ```
37
How might a cyst-urethrocele present?
urinary urgency and frequency incomplete bladder emptying urinary retention or reduced flow
38
How might a rectocele present?
constipation | difficulty with defection
39
How are prolapses classified?
cystocele = prolapse of the upper anterior vaginal wall involving the bladder urethrocoele = prolapse of the lower anterior vaginal wall, involving the urethra apical/uterine = prolapse of the uterus, cervix and upper vagina enterocoele = prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel rectocele= prolapse of the lower posterior was of the vagina, involving anterior wall of the rectum
40
How are prolapses investigated?
abdominal and bimanual examination vaginal examination with speculum - examine anterior and posterior vaginal walls assessment of pelvic floor strength
41
How is pelvic organ prolapse prevented?
reduction of prolonged labour reduction of trauma by instrumental delivery weight reduction treat chronic constipation, chronic cough
42
How is prolapse managed?
CONSERVATIVE 1. weight reduction 2. stop smoking 3. physiotherapy - pelvic floor muscle exercises, vaginal cones 4. intravaginal devices (pessaries) - ring pessary, shelf pessary, doughnut pessary
43
What are some of the possible causes of ovarian cancer?
Gene mutations - HNPCC and BRCA1/2 increased risk by multiple ovulations e.g. nulliparity, late menopause, early menarche ovarian cyst
44
What is the prognosis for ovarian cancer?
poor prognosis - 5 year survival at 35% | leading cause of death from gynaecological malignancy
45
How is ovarian cancer commonly presented?
non specific/vague/common symptoms resulting in misdiagnosis... IBS/ bowel changes in older women* abnormal vaginal bleeding detection of pelvic mass urinary symptoms - late
46
How is ovarian cancer diagnosed?
CA125 - tumour marker - measure in >50 y/o with vague symptoms abdominal/ pelvic ultrasound +/- CT
47
How is ovarian cancer treated?
SURGERY - staging laparotomy**, TAH, bilateral salpino-oophorectomy NEOADJUTANT CHEMOTHERAPY
48
What are the risk factors for cervical cancer?
HPV exposure (16,18,33) *** e.g. multiple sexual partners, early first sexual experience, non barrier contraception COCP smoking immunosuppressed e.g. HIV, transplant patients
49
How is cervical cancer prevented?
HPV vaccine | attending screening
50
What is the most common type of cancer in cervical cancer?
squamous cell carcinoma = 90% | adenocarcinoma = 10%
51
How does cervical cancer present?
asymptomatic - incidental finding or picked up in screening bleeding - post coital**, during intercourse, post menopausal offensive vaginal discharge
52
Who qualifies for cervical cancer screening?
25- 50 y/o = every 3 years | 50-64 y/o =every 5 years
53
What is involved in cervical cancer screening?
smear = speculum examination | brush around the external os and rinsed in preserving fluid for liquid cytology
54
Define dyskaryosis
abnormal cytological changes of squamous epithelial cells | characterised by hyper chromatic nuclei +/- irregular nuclei chromatin
55
What happens if cervical cancer screening comes back abnormal?
``` 95%= normal 5%= dyskaryosis ``` if HPV +ve, then need colposcopy if severe dyskaryois/ suspect invasive cancer, need colposcopy within 2 weeks +/- hysteroscopy if HPV -ve and borderline, return to normal routine callback
56
How is cervical cancer diagnosed?
colposcopy + biopsy ** + MRI/ cystoscopy to stage
57
How is cervical cancer managed, depending on its stage?
1a (i) = cone biopsy / simple hysterectomy = LARGE LOOP EXCISION OF TRANSFORMATIONAL ZONE 1a (ii) - 1b = laparoscopic lymphadenectomy 1a (ii)-2a = Wertheims hysterectomy or chemo-radiotherapy
58
Define cervical intraepithelial neoplasia
histologically abnormality of the cervix in which abnormal epithelial cells occupy
59
What is the most common type of vulval cancer?
``` 90%= squamous cell carcinoma 10% = melanomas, basal cell, sarcomas, bartholins gland carcinoma ```
60
How is vulval cancer caused?
de novo = lichens sclerosis*, smoking*, pages disease, immunosuppression predisposing conditions = oncogenic HPV, vulval intraepithelial neoplasia
61
How does vulval cancer present?
non specific symptoms = lump, ulcer, bleeding, irritation, pain
62
How is vulval cancer diagnosed?
clinical examination | biopsy and histology = squamous cell carcinoma
63
How is vulval cancer managed?
surgery | radiotherapy +/- chemotherapy
64
What is endometrial cancer caused by?
presence of unopposed oestrogen (high ratio of oestrogen to progesterone): ENDOGENOUS - obesity, PCOS, nulliparity, late menopause, oestrogen producing tumour EXOGENOUS - oestrogen only HRT, tamoxifen MISC. - type 2 diabetes, hypertension, HNPCC gene, breast cancer
65
What is the most common type of endometrial cancer
endometrial adenocarcinoma = 87%
66
How does endometrial cancer commonly present?
post menopausal bleeding ** menstrual disturbance PV diacharge
67
How is endometrial cancer diagnosed?
transvaginal ultrasound if <4mm endometrial thickness = low risk fo pathology if >4mm endometrial thickness = endometrial biopsy and hysteroscopy
68
How is endometrial cancer treated?
surgery - TAH + BSO total abdominal hysterectomy and bilateral salpingo oophorectomy adjuvant radiotherapy hormonal - high dose progestogens
69
What is an ovarian cyst?
>3cm fluid filled cyst benign ovarian tumour very common
70
What are the two types of physiological cysts?
physiological cysts form during menstrual cycle 1. Follicular (<3cm) : form due to failure of Graafian follicle to rupture, regress in subsequent cycles 2. Corpus luteal (<5cm) : may fill with blood or fluid, expanding to cause a cyst
71
What are non -gynaecological causes of a pelvic mass?
bladder tumour intestinal tumour diverticular disease
72
How does an ovarian cyst present?
asymptomatic chronic pain - dull ache pressure on other organs - e.g. urinary frequency, bowel disturbance abdominal uterine bleeding
73
When do you get acute pain with an ovarian cyst and describe the pain?
During an ovarian accident (rupture of the contents of the ovarian cyst into the peritoneal cavity) e.g. torsion, haemorrhage, rupture acute pain - intense, hypovolaemic shock
74
How is the "modified risk of malignant index (RMI)" calculated?
RMI = U x M x CA125 U= ultrasound score (1pt for solid area, ascites, multi locular cysts, bilateral lesions, mets) M= menopausal status (1pt = premenopausal, 3= post menopausal) CA125= serum cancer antigen 125 level
75
How are ovarian cysts investigated?
transvaginal ultrasound CA125 risk of malignancy index
76
What is a serous cystadenoma?
most common ovarian epithelial neoplasm | 20-25% malignant
77
What is a mutinous cyst adenoma
often multinucleate | also found in appendix, pancreas and liver
78
What is an endometrioma?
due to endometrial tissue in ovaries that haemorrhages | "chocolate cyst"
79
What is a dermoid cyst?
common, benign neoplasm in pre menopausal women | may contain fully differential tissue, classically hair, teeth and skin
80
How are ovarian cysts managed?
exclude malignancy rescan in 6 weeks - monitor with ultrasound and CA125 at 3 and 6 months transvaginal cyst aspiration or laparoscopic cystectomy if persist
81
what can cause CA125 to raise?
``` ovarian cancer endometriosis fibroids pregnancy menstruation PI ```
82
Define adenomyosis
presence of endometrium within the myometrium (oestrogen dependent)
83
Describe the features of adenomyosis?
menorrhagia + dysmenorrhoea
84
How is adenomyosis diagnosed?
MRI
85
How is adenomyosis treated?
1. IUS or COCP +/- NSAIDs
86
define intrauterine polyps
small benign tumours that grow into the uterine cavities | - arise due to to disordered cycles of apoptosis and regrow in the endometrium
87
How do intrauterine polyps present?
menorrhagia and IMB
88
How are intrauterine polyps diagnosed?
USS + hysteroscopy
89
how does lichen sclerosus present?
itch ** - worse at night, uncontrollable scratching causing bleeding white papules/ plaques
90
How is lichen sclerosis diagnosed?
clinical examination and history - biopsy
91
How is lichen sclerosis treated?
topical steroids and emollients
92
List the differentials for post coital bleeding?
cervical cancer * - must be ruled out | cervical ectropion * cervical polyps

3a obs and gynae (5 decks)

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