gynae Flashcards
(393 cards)
1
Q
what things should be asked in a woman’s menstrual history
A
date of last / first cycle length regular heavy - how many tampons/ pads painful affect QOL
2
Q
what things should be asked in a woman’s obstetric history
A
how many children (parity + gravidity)
for each pregnancy - antenatal problems, delivery type, gestation, outcome, weight, complications
terminations - what stage and how
3
Q
what is the main difference between ovarian and uterine pain
A
ovarian - felt in iliac fossa and radiates down front of the things to knee
uterine - colicky and felt in sacrum/ groin
4
Q
what questions should you ask about dyspareunia (pain on intercourse)
A
superficial (entrance) or deep inside
5
Q
What things should you ask about vaginal discharge
A
amount, colour, smell, consistency, itch, timing
6
Q
what is the main difference between stress and urge incontinence
A
stress is losing urine when coughing/ laughing
urge incontinence is needing to pee ASAP
7
Q
what are the 4 extra’s in a gynaecology history
A
menstraul history
obstetric history
sex and contraception
symptoms
8
Q
what things should you comment on about the uterus after examination
A
position (anteverted) size of uterus (grapefruit) mobility of uterus adnexal masses tenderness cervical excitation
9
Q
what does cervical excitation suggest
A
pelvic inflammatory disease
10
Q
what speculum is used for assessing prolapse
A
Simms
11
Q
how should present a pregnant abdomen
A
- abdomen distended compatible with pregnancy
- fundal height is X (in keeping with gestation)
- the lie of the baby is X
- the presentation of the baby is X
- the head is /5th palpable
- FHR heard over anterior shoulder (120-160bpm)
12
Q
what percentage of woman have a retroverted retroflexed abdomen
A
20%
13
Q
when may a retroverted, retroflexed uterus cause a problem
A
may fail to lift out pelvis at 12 weeks
inflammation in pelvis may cause adhesions
(normally fully mobile and cause no problems)
14
Q
at what age does normal menustration normally start and end
A
start - 13
end - 51
15
Q
what is the normal menstrual cycle (cycle K)
A
bleed 4-5 days of a 21-35 day cycle
normal to bleed for 2-7 days
16
Q
how long would an irregular cycle be
A
40-90 days
17
Q
what triggers menustration
A
fall in progesterone 2 weeks after ovulation when the endometrium sheds a a result of not being pregnant
18
Q
what is the average blood loss during a period
A
30-40 ml - rest of volume made up by glandular secretions
19
Q
what is primary amenorrhoea
A
failure to start menstruating
20
Q
when does primary amenorrhoea need investigation
A
a 16 year old
14 year old with no secondary sexual characteristics - breast / pubic hair development
21
Q
what is secondary amenorrhoea
A
period stops for >6 months other than due to pregnancy
22
Q
what is oligomenorrhoea
A
infrequent periods
common at extremes of reproductive age
23
Q
what things may cause ovarian failure
A
chemotherapy, radiotherapy, surgery
genetic disorders
24
Q
what is a common cause of oligomenorrhoea
A
polycystic ovarian syndrome
25
what is menorrhagia
heavy periods - excess blood loss >80ml/ cycle
26
what is dysmenorrhoea
painful periods
27
what is the difference between primary and secondary dysmenorrhoea
primary - no organ pathology
| secondary - pathology e.g adenomyosis, endometriosis, chronic infection, fibroids
28
when in the cycle is dysmenorrhea worst
first day or 2
| excess prostaglandins cause painful uterine contractions, producing ischaemic pain (cramps, ache in back or groin
29
what may be a physiological cause for intermenstraul bleeding
mid cycle fall in oestrogen
30
what are causes of intermenstraul bleeding
cervical polyps, cancer
cervicitis, vaginitis,
hormonal contraception (spotting)
chlamydia
31
what is post coital bleeding
bleeding after intercourse
32
list causes of post coital bleeding
chlamydia, cervical trauma, polyps, cervicitis , cancer
33
what is postmenopausal bleeding
bleeding occurring >1 year after last period
34
what is the cause of postmenopausal bleeding until proven otherwise
endometrial carcinoma
35
what are causes of postmenopausal bleeding
```
endometrial cancer
vaginits
foreign bodies
endometrial/ cervical polyps
oestrogen withdrawal (HRT therapy)
```
36
how would you investigate heavy periods
FBC
thyroid - if history tired, weight gain
coagulation
endometrial biopsy
37
how would you investigate intermenstraul or post coital bleeding
chlamydia swab
pregnancy test
transvaginal ultramundo scan
hysteroscopy
38
what is the FIGO classification for abnormal uterine bleeding (PALMCOEIN)
```
polyps
adenomyosis
leiomyoma (fibroids)
malignancy / hyperplasia
coagulation - haemophilia, VWD
ovarian - polycystic
endocrine - thyroid
iatrogenic - warfarin , anticoagulant
n - not classified
```
39
what is dysfunctional uterine bleeding
abnormal bleeding with no structural/ endocrine/ neoplastic/ infectious cause
40
what is the most common reason for menstraul disorders
dysfunctional uterine bleeding
41
when should dysfunctional uterine bleeding (DUB) be treated
when affecting quality of life
42
how should dysfunctional uterine bleeding be treated if the person is still trying to get pregnant
non- hormonal
tranexamic - reduces blood loss by 60%
mefanamic - prostaglandin inhibitor controls pain
43
how is dysfunctional uterine bleeding treated if the person is not trying to get pregnant
POP
IUD/ injections
(regulate cycle and reduce bleeding)
44
what is the end stage treatment for dysfunctional uterine bleeding
hysterectomy
45
what is the surgical treatment for dysfunctional uterine bleeding
endometrial ablation
(1st generation - diathermy, 2nd generation thermal balloon/ radio frequency)
hysterectomy
46
what is the menopause
last ever period
47
how long does perimenopause last for roughly
5 years
48
when is menopause regarded as premature
occurs before 40
49
what are iatrogenic causes of menopause
oophorectomy
chemotherapy
radiotherapy
50
what hormone drop causes the symptoms of menopause
oestoradial
51
why does FSH rise in menopause
lack in oestrogen makes brain try to produce more
52
why do heavier women have less hot flushes/ sweat
still have oestrogen in peripheral circulation from conversion of adrenal androgens in fat
53
what are the 7 dwarf symptoms of menopause
itchy, bitchy, sweaty, sleepy, bloated, forgetful, psycho
54
why do the genitalia, breasts and skin atrophy in menopause
oestrogen dependent tissues
55
how can osteoporosis be prevented in menopausal women
exercise
adequate calcium and vit D
HRT
56
what are risk factors for menopausal woman to develop osteoporosis
thin , caucasian, smoker
alcohol, family history, amenorrhoea
malabsorption of vit D/ Ca, long term steroids, HRT
57
what are vasomotor symptoms of menopause
sweats, hot flushes, palpitations
| occur in 80% of women
58
how long do vasomotor symptoms of menopause last
2-5 years - may continue for 10
59
what are symptoms of menopause
```
sweats, hot flush, palpitations
vaginal dryness
low lobido
muscle/ joint aches
low mood
osteoporosis
```
60
what local hormonal replacement therapy can be given in menopause
vaginal oestrogen in pessary/ ring/ cream
61
what is the nice guideline for menopause symptoms
use HRT for treatment of vasomotor symptoms and review benefits annually
62
what different therapies can be given to help treat the menopause
```
hormone replacement therapy
SERMS
SSRI/ SNRI
natural foods
non hormonal lubricants
contraception
```
63
what is andropause
after 30 testosterone levels fall by 1% a year - gradual and no impact on fertility
64
why do SERMS work in management of menopause
| e.g. tibolone (selective oestrogen receptor molecules)
oestrogen effect on organs
protects bones and reduces breast/ endometrial cancer risk
ineffective for flushes
65
what natural methods may be used to manage the menopause
```
phytoestrogen food - soya
herbs like red clover
hypnotherapy
exercise
CBT - low mood
```
66
what should be used to treat vagina symptoms in menopause
vaginal oestrogen - cream, ring, pessary
67
what HRT should be given to a women with a uterus and without a uterus
no - oestrogen
| got - oestrogen + progesterone
68
why do woman with a uterus need both oestrogen and progesterone hormone replacement therapy
prevent endometrial hyperplasia / cancer
69
what are contraindications of HRT
current hormone dependent cancer (breast/ endometrium)
current acute liver disease
uninvestigated abnormal bleeding
advice if previous VTE/ PE, thrombophilia, FH of VTE or previous Br Ca
70
what are benefits of hormone replacement therapy
vasomotor symptoms relief
local genital symptom relief
reduce osteoporosis
reduce UTI and urgency symptoms
71
what are risks of hormone replacement therapy
breast Ca if combined - disappears after 5 years
ovarian Ca
venous thromboembolism if oral
endometrial cancer if not paired with progesterone
72
what HRT should be given to a women with some ovarian function (perimenopause)
cyclical combined 14 days E then 14 days E + P
| withdrawal bleed after progesterone
73
what HRT should be given to a women with no ovarian function (>1 year menopause) or 54+
continuous combined 28 days E +P
| bleed free after 3 months
74
does HRT increase your chance of VTE if its by the transdermal route
no
75
what does HRT do to your chances of a femur fracture and colon Ca
reduces both
76
what are hypothalamic- pituitary- ovarian causes of secondary amenorrhoea
```
stress
weight change
excessive exercise (low oestrogen and FSH)
```
77
what are ovarian causes of secondary amenorrhoea
polycystic ovaries
ovarian insufficiency
premature menopause
78
what are contraception causes of secondary amenorrhoea
current use
| 6-9 months after depoprovera (jag)
79
what are metabolic causes of secondary amenorrhoea
```
thyroid
cushings
raised prolactin
androgen secreting tumours - testosterone > 5 mg/l
sheehans syndromen - pituitary failure
```
80
what is sheehan's syndrome
pituitary failure
81
how would you investigate secondary amenorrhoea
```
urinary - pregnancy, glucose
blood - serum androgens (raised in PCO)
FSH/ LH - low if hypothalamic cause
prolactin
thryoid
testosterone - androgen secreting tumour
```
82
how would you treat premature ovarian insufficiency
HRT till 50
83
how would you treat secondary amenorrhoea
treat cause
aim for BMI 20-25
use contraception
84
what is important in adolescent gynaecological history
```
cycle regularity
age of menarche
pain
sexual history
contraception
weight gain/ loss
```
85
what is Gillick competence when giving consent
child <16 years can give/ withhold consent if doctor feels she fully understands what is involved in an intervention
86
when is contraception advice given to girls under 16 (fraser competence)
- mature enough to understand advice and implication of treatment
- girl likely to begin or continue to have sex with or without treatment
- persuade to tell parents
- girls health would suffer without treatment/ advice
- in girls best interest to give advice or treatment
87
what are possible causes for primary amenorrhoea
outflow tract obstruction - mass, unperforated hymen,
not enough oestrogen - pituitary/ ovaries
hypergalactorrhoea
88
how would you induce puberty in primary amenorrhoe
gradual increase in oestrogen
| once max height reached add progesterone (epiphyseal plates fuse)
89
how would you investigate primary amenorrhoea
hormones - oestrogen, progesterone, testosterone, LH/ FSH, prolactin
pelvic USG
90
what investigation go you avoid on virgin girls
transvaginal US
| USS TAS only
91
how may a accident to a cyst present in an adolescent
acute history - tender to one side of pelvis/ one side of uterus
(cyst can tort, turn gangrenous or rupture)
92
what is the most common presentation of a labial adhesion
adhesion of labia minor in the midline
| vertical line
93
what are complications of labia adhesions
retention of urine and vaginal secretions (vulvovaginitis/ UTIs)
94
how are labia adhesions treated
lubricate labia with bland ointment
topical oestrogen
surgical seperation - rare/ legal complications
(only if chronic vulvovaginitis or difficulty urinating)
95
what must you be aware of in abnormal vaginal discharge in an adolescent
sexual abuse
96
what conditions may result in a pathological discharge in adolescents
infectiosn - e.coli, pseudomonas
hemolytic streptococcla vaginitis
a foreign body
97
what is a normal discharge in adolescents
mucoid
<2 weeks after birth - maternal oestrogen
prepubertal girls - maturing ovaries
98
what are reasons for physiological discharge
pregnancy
sexual arousal
puberty
pill
99
what is the main cause of vaginal thrush in woman
```
candida albicans (95%)
other 5% candida glabrata (harder to treat)
```
100
what are risk factors for candida thrush
```
pregnancy
contraceptive
steroid
immunodeficieny
antibiotics
diabetes
```
101
how may candida thrush present
discharge white curds
| vulva/ vagina may be red, fissured and sore
102
how is candida albicans vaginal thrush treated
topical clotrimazole
| oral fluconazole
103
what type of discharge does trichomoniasis (STI) give
bubbly, thin, fishy smelling discharge
+ vaginitis
treat with metronidazole
104
what is the most common cause of discharge
bacterial vaginosis
| prevalence ~10%
105
what are symptoms of bacterial vaginosis
mostly asymptomatic
fishy odour
vaginal ph> 4.5, not inflamed, not itchy
altered bacterial flora
106
what is the treatment of bacterial vaginosis
metronidazole
107
what are complications of bacterial vaginosis
increased risk of pr-term labour, intra-amniotic infection in pregnancy, susceptibility to HIV and post-termination of sepsis
108
what 3 things compose polycystic ovarian syndrome
oligo-ovulation/ amenorrhoea
hyperandrogenism
polycystic ovaries of ultrasound
109
what are features of polycystic ovarian syndrome
```
oligo-ovulation/ amenorrhoea
hyperandrogenism
polycystic ovaries of ultrasound
darkened skin - acanhtosis nigricans
infertility
hyperinsulinaemia - diabetes
endometrial hyperplasia
```
110
what skin change may be seen in PCO syndrome
acanthosis nigricans - darkened skin on neck and skin flexures due to hyperinsulinaemia
111
does PCO cause weight gain
no
| gaining weight alters hormone balance which makes symptoms worse
112
how would you investigate polycystic ovarian syndrome
pelvic ultrasound
| hormone profile - SHBG, oestrogen, progesterone, testosterone, FSH/ LH< prolactin, Thyroid, cortisol
113
what ultrasound finding indicates polycystic ovaries
>12 peripheral ovarian follicles or increased ovarian volume >12cm3
(~20% have this but no syndrome)
114
what is the lifestyle management of polycystic ovaries
weight loss/ exercise - keep BMI <30
| stop smoking
115
why does exercise help symptoms of polycystic ovarian syndrome
increases levels of Sex hormone binding globulin (SHBG) so less free androgens
116
how is clomiphene taken in polycystic ovarian syndromes
| selective oestrogen receptor modulator
SERM induces ovulation
taken day 2-7 of cycle
monitor by scanning follicles - may need dose adjustment
117
what drugs can be taken to manage polycystic ovarian syndrome
metformin
SERM - clomiphene
anti-androgen
progesterone - endometrial protection
118
why should progesterone be given in polycystic ovarian syndrome
endometrial protection - unopposed oestrogen can lead to endometrial hyperplasia and cancer
mirena coil, POP, COCP
119
what is adenomyosis
presence of endometrial tissue within the muscle wall (myometrium)
occurs more in parous women in 30/40s
120
what are symptoms / signs of adenomyosis
heavy, painful periods
| bulky tender uterus
121
how is adenomyosis diagnosed
MRI may suggest
| usually diagnosed post hysterectomy by histology
122
how is adenomyosis treated
hormonal contraception - IUS (mirena) , progesterones, COCP
endometrial ablation
hysterectomy
123
what are side effects of clomiphene (selected oestrogen receptor modulator)
visual
vasomotor - sweats, hot flushes
multiple pregnancy
ovarian hyperstimulation
124
what is endometriosis
endometrial glandular tissue occurring beyond the uterine cavity, leading to inflammation and scarring
125
where may endometriosis occur
```
ovary (chocoalte cyst)
recto-vaginal pouch
uterosacral ligaments
pelvic peritoneum
lower abdominal scars
distant organs - lungs
```
126
what hormone is endometriosis dependent to
oestrogen - tissue grows and shreds with oestrogen effects
127
what does free blood do to the endometriosis tissue
causes irritation, provoking fibrosis, adhesions and subfrtility
128
what are causes of endometrisos
```
cell arrests
retrograde menstraution
environmental factors
genetic component
autoantibody association
```
129
how may endometriosis present
asymptomatic - even at late stage
pelvic pain at time of menstruation
secondary amennorhoea, deep dyspareunia
sub fertility
130
how common is endometriosis
~10% of all women
131
what test may see a chocolate cyst in the ovary (endometriosis)
Ultrasound - cyst filled with chocolate coloured blood
132
how would you treat asymptomatic endometriosis
don't
133
what are complications of endometriosis
obstruction - GI, ureteric, fallopian
ovarian/ endometrial cancer
disease reoccurs after treatment
134
what percentage of endometriosis reoccurs 2 years after treatment
80%
| 2 our of 3 repeat surgery
135
how would you investigate endometriosis
per vaginam examination - tender, limited mobility, adnexal mass
laparoscopy - cycsts, adhesions, peritoneal despots (biopsy)
136
what is the medical treatment of endometriosis
analgesia and manage stress (Excaerbates)
hormonal therapy - suppress ovulation (CPOP / POP)
GnRH analogues - induce atrophy
137
what is the surgical treatment of endometriosis
excision of deposits
diathermy/ laser ablation - destruction by electric curretns
removal of ovaries +/- hysterectomy
138
what are fibroids
benign smooth muscle tumours of the uterus
| often multiple raging from seed size to watermelon, occupying a large part of the abdomen
139
how common are fibroids
20% of women have fibroids
140
what race has the highest incidence of fibroids
afro-caribbean women 90%
141
what other conditions are fibroids associated with
gene for fumarate hydrates
skin and uterine leiomyomata
renal cell cancer
142
what hormone are fibroids dependent to
oestrogen - enlarge in pregnancy and combined pill
143
what is red degeneration of fibroids
when they disappear suddenly
144
what are womb stones
when fibroids calcify
145
what is the difference between submucous, intramural and sub serous fibroids
submucosal - protrude into uterine cavity
intramural - within uterine wall (heavy bleeding)
sub serous - project out of uterus into peritoneal cavity
146
what is the most symptomatic place of fibroids
submucosal - protrude into uterine cavity
| heavy bleeding/ pain
147
where are asymptomatic fibroids most likely to me
sub serous - in the peritoneal cavity
148
how may fibroids present
menorrhagia - heavy an long periods
fertility problems
pain
masses
149
how are fibroids diagnosed
clinical exam - uterus >12 weeks
ultrasound - uterus >16 weeks
hysteroscopy if inside uterine cavity
150
what is the medical treatement for fibroids
Mirena IUD - decrease size and control menorrhagia
| GnRH analogues - reversible menopause state
151
what is the surgical treatment for fibroids
myomectomy - shell out fibroids
| hysterectomy (use GnRH before to shrink)
152
why do fibroids produce heavy and long periods
enlarge uterine cavity - more surface area to send
153
which type of fibroids may cause fertility problems
submucosal may interfere with implantation
154
what is a prolapse
protrusion of an organ or structure beyond its normal anatomical confines
155
what is a female pelvic organ prolapse
descent of pelvic organs towards or through the vaginal wall
156
what is a urethrocele
prolapse of the lower anterior vaginal wall involving only the urethra - impairs sphincter leading to stress incontinence
157
what is a cystocele
prolapse of the upper anterior vaginal wall involving the bladder
158
what is a uterovaginal prolapse
term used to describe prolapse of the uterus, cervix and upper vagina
159
what is an enterocoele
prolapse of the upper posterior wall of the vagina usually containing loops of small bowel from the pouch of Douglas
160
what is a rectocele
prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
161
what is the estimated incidence of prolapse in multiparous woman
12-30%
| approx 50% of porous woman will have some degree of prolapse but only 10-20% will seek medical help
162
why are the pelvic viscera described as dynamic
ability to inflate - bladder 7x, rectum 2x , uterus pregnant
163
if the pelvic floor is normal, what position will the pelvic organs be in when the intra-abdominal pressure is increased
fixed position
164
what are the 3 layers of the pelvic floor
endo-pelvic fascia
pelvic diaphragm
urogenital diaphragm
165
which is the weakest layer of the pelvic floor
urogenital diaphragm
166
what is the endo-pelvic fascia layer of the pelvic floor
network of stretchy, fibro-muscualr connective type tissue that has a hammock like configuration and surrounds carious visceral structures to keep them in place
(utero-sacral ligaments, pubocervical fascia, rectovaginla fascia)
167
what forms the pelvic diaphragm of the pelvic floor
striated muscle (levitator ani and coccygeus)
168
what are the 3 levels of endo-pelvic support
1 - utero-sacral ligaments
2- para-vagina to arcus tendinous fascia (pubocervical/ rectovaginal fascia)
3- urogenital diaphragm, perineal body
169
what are risk factors for pelvic organ prolapse
```
pregnancy
vaginal birth/ forceps delivery
advancing age
obesity - increase pressure on pelvic floor
previous pelvic surgery
large baby, prolonged 2nd stage of labour
constipation
quality of connective tissue
weight lifting
```
170
what pelvic surgeries may lead to a pelvic organ prolapse
continence procedure
burchi colposuspension
hysterectomy
171
what fascia provides most support to the anterior vaginal wall
pubocervical fascia - trapezio fibromuscular tissue
172
what are vaginal symptoms of a pelvic organ prolapse
sensation of bulge/ protrusion (golf ball / boiled egg)
pressure
heaviness
difficulty inserting tampons
173
what are urinary symptoms of a pelvic organ prolapse
urinary incontinence
frequency/ urgency
weak or prolonged stream / hesitancy/ feeling of incomplete emptying
need manual reduction to start voiding
174
what are bowel symptoms of a pelvic organ prolapse
incontinence of flatus, liquid or solid stool
feeling of incomplete emptying/ straining
urgency
digital evacuation to complete defecation
175
how would you investigate a POP
examination - exclude pelvic mass
Simms speculum examination - bear down/ cough
quality of life
176
what grading score is used to assess pelvic organ prolapse objectively
```
POPQ score (gold standard)
Baden - walker halfawy grading
```
177
what is the only investigation of a pelvic organ prolapse
clinical examination
178
what investigations would you do to assess the complications of a pelvic organ prolapse
USS/ MRI - allow identification of fascial defects/ measurement of levitator ani thickness
urodynamics - incontinence
IVU or renal USS (suspect ureteric obstruction)
179
how is pelvic orgaann prolapse prevented
```
pelvic floor exercises
avoid constipation
effective management of chronic chest pathology (COPD and asthma) - cough increase intra abdominal pressure
reduce parity
antenatal pelvic floor training
```
180
how are pelvic organ prolapses treated
physiotherapy - pelvic floor muscle training
pessaries
surgical treatment
181
how does pelvic floor muscle training teat pelvic organ prolapse
increases pelvic floor strength and bulk - receives tension on ligaments
182
what are advantages of vaginal pessaries being made form silicon
long shelf-life
resistance to autoclaving and repeated cleaning
non - absorbent towards secretions and odours
inertness
hypoallergenic
183
where are vaginal pessaries inserted
posterior fornix
| leave for 8-9 months
184
what are SE of vaginal pessaries
vaginal discharge, infection, discomfort
185
what is more effective treatment of POP at 1 year, pessary or surgery
both the same
186
how long does surgical treatment of POP take to be successful
3 months
187
what is the aim of surgery to treat POP
receive symptoms
restore/ maintain bladder and bowel function
maintain vaginal capacity for sexual function
188
what should you do first on a POP before surgery if there is ulceration
oestrogen packing
189
what should be remembered during pelvic surgery
prophylactic antibiotic and VTE
190
what make up the upper and lower unitary tracts
upper - kidney and ureter
| lower - bladder and uterus
191
what is movement called of urine down the urinary tract
peristalsis
192
at what rate does the bladder fill
0.5-5 mls/ min
193
what nerves control storage of urine in the bladder
hypogastric nerve
| sympathetic T10 -L2
194
what nerves control voiding of the bladder
pelvic nerve
| parasympathetic S2-4
195
what nerves control the external urinary sphincter
pudendal nerve
| somatic S2-4
196
what is the muscle of the bladder called
detrouser
197
does the detrouser relax or contract to empty the bladder
contracts
| urethras relax
198
what is the cortical activity during bladder filling
activates reciprocal guarding reflex by rhabdosphincter contraction
increases resistance
199
is bladder emptying parasympathetic or sympathetic
parasympathetic
200
what is stress incontinence (SUI)
involuntary leakage on effort or exertion, on sneezing for coughing
increased intra-abdominal pressure exceeds urethral pressure resulting in leakage
201
what is urge urinary incontinence (UUI)
involuntary leakage accompanied by or immediately preceded by urgency
202
what is the prevalence of urinary incontinece in over and under 60's
under - 10-25%
| over - 15-40%
203
what are some impacts of urinary incontinence on a patient
```
impari QoL
reduce social activities
impair sex life
impair psychological well being
embarassment
```
204
what are risk factors for urinary incontinence
parity, age, menopause, smoking, obesity, pelvic floor trauma
increased abdo pressure - chronic cough, heavy lifting
hysterectomy
205
what is the main risk factor for urinary incontinence
parity
206
how would you find out the severity of urinary incontinence
effect on QOL 1-10
how many pads
3 day urinary diary
207
what are the symptoms of overactive bladder syndrome
urgency assoicated with frequency, nocturia and urge incontinance
208
how may someone with urianry incontincne present
increased frequency, nocturne, dysuria, haematuria
| straining to void/ interrupted flow
209
what medical conditions may lead to urinary incontinence
```
DM
anti- hypertension
glaucoma
heart/ kidney/liver
cognitive problems
anti-depressants
```
210
how would you investigate urinary incontinence
3 day urinary diary
urinalysis
post voiding residual volume assessment (scanning)
Urodynamics - only for surgical cases
211
what is the 1st line treatment for female urinary incontinence
lifestyle changes - lose weight, stop smoking, eat healthy to avoid constipation, stop drinking alcohol and caffeine
212
what physiotherapy do people with urinary incontinence receive and what is the point
pelvic floor muscle training - 5x a day
- reinforcement of cortical awareness of muscle groups
- hypertrophy of existing muscle fibres
- general increase in muscle tone and strength
213
what is the medical treatment of urinary incontinence
duloxetine (yentreve)
214
what surgical procedures are available for the treatment of urinary incontinence
colposuspension - raise bladder neck
| recto= pubic tension free vaginal tape (TVT)
215
what is more affective for urinary incontinence , culcosuspension or TVT
TVT - minimally invasive
| polypropylene permanent synthetic tape
216
what is overactive bladder syndrome
symptom complex usually related to urodynamically demonstrable detrouser overactivity (DO)
217
what is detrouser overactivity (DO)
urodynamic parameter characterised by involuntary detoruser contractions during filling that are either spontaneous or provoked
218
what is nocturne
indicial has to wake at night one or more time to void
219
what are risk factors for overactive bladder syndrome
advanced age
diabetes
urinary tract infection
smoking
220
what is the non- invasive management of overactive bladder syndrome
lifestyle - normalise fluid intake, reduce caffeine/ fizzy drinks/ chocolate, stop smoking, weight loss
bladder training programme - timed voiding with gradually increasing intervals
221
what is the pharmacological management of overactive bladder syndrome
antimuscarinics - oral solifenacin, fesoteridine
transdermal - kentera
tricyclic anti-depressants - imipramine
222
what are recent advances in the treatment of overactive bladder syndrome
botox - botulinum , lasts 6-9 months
| neuromodulation - needle stimulation , reflex inhibition to detrusor muscle
223
why is ovarian cancer the 5th commonest cancer death in females
~80% few symptoms until it has metastasised so present with advanced disease
224
what is the 5 year survival of ovarian cancer
30%
225
what genes are associated with ovarian cancer
HNPCC (lynch)
| BRAC1 /2
226
what is incessant ovulation (risk factor for ovarian cancer)
women always ovulating - don't get pregnant or use contraception
227
what may be presenting symptoms of ovarian cancer
```
indigestion/ early satiety/ poor appetite
altered bowel habit
abdominal or pelvic pain
bloating/ discomfort
fatigue
pelvic mass
```
228
what is the diagnosis of ovarian cancer made on
histology
229
how would you investigate ovarian cancer
US scan abdo/ pelvis
CT abdo/ pelvis
CA 125
surgery - biopsy
230
what marker is usually raised in ovarian cancer
CA 125 (glycoproteins-protein antigen)
231
why is CA 125 not specific enough to diagnose ovarian cancer
raised in anything that affects the peritoneum - menustration, endometriosis, PID< liver disease, recent surgery, effusions
232
how is the RMI (risk malignancy index) calculated for ovarian cancer
U x M x CA 125
ultrasound feutres - 1-3
menopausal status 1-3
CA 125 level
233
what are ultrasound features of ovarian cancer
```
multi- locular
solid area
bilateral
ascites
intra-abdominal
```
234
what is ovarian cancer stage on
pathological biopsy after laparotomy
235
describe ovarian cancer stage I-IV
1- disease limited to 1 ovary to both but capsule intact
2- growth extends beyond ovaries but confined to pelvic
3 - growth outside pelvis / retroperitoneal/ inguinal nodes
4- distant metastases
236
what is the treatment for ovarian cancer
surgical clearance - all naked eye / debullk
| chemotherapy - adjuvant after surgery and neoadjuvent before (decrease size)
237
what is first line chemotherapy for ovarian cancer
platinum and taxmen (taxol)
238
what are the cure rates of each stage of ovarian cancer
```
1- 85%
2- 47%
3- 15%
4- 10%
(3 and 4 present most)
```
239
how is recurrence of ovarian cancer treated
2nd ine chemo - platinum/ tamoxifen if not surgery
palliation - symptomatic recurrence
surgery if resectable
240
what women are screened for ovarian cancer
high risk women - cancer gene mutation carriers, 2 or more relatives
regular pelvic examination , US scanning, CA 125 check
241
what procedure may women with BRAC1/2 get to prevent their risk of ovarian cancer
oophorectomy and salpingectomy
242
what is ascites and its causes
accumulation of fluid within the abdominal cavity
| heart disease, liver disease, peritoneal irritation (tumour deposits/ inflammation
243
how is ascites tested
need 15 ml fluid for cytology
| US guided needle core biopsy
244
what is the lifetime risk of ovarian cancer is people with the BRAC1/2 gene
15-45%
245
what is the most common histological classification of ovarian cancer
high grade serous
246
where should you take a biopsy from an ovarian tumour
every 1 cm
247
what are the cure rates for endometrial cancer (by stage)
```
1B - 85%
2A - 75%
2B - 60%
3B - 30%
4 - 21%
```
248
is endometrial cancer more common than cervical
no
249
what are risk factors for endometrial cancer
```
post menopausal women
high circulating oestrogen - obesity, PCOS, HRT
atypical endometrial hyperplasia
FH of breast, ovary or colon cancer
pelvic radiation
```
250
what are symptoms of endometrial cancer
psot menopausal bleeding - goes from occasional to heavy and frequent
8% with PMB will have endometrial cancer
251
how is endometrial cancer investigated
clinical exam
trans-vaginal USS - thickness nad contour
histology of endometrium
hysteroscopy
252
describe the stages of endometrial cancer
1 - body of uterus only
1a - inner half of myometrium, 1b - outer half of myometrium
2 - body of cervix
3 - beyond uterus but not pelvis
a - serosa, b- vagina. c- pelvic nodes
4 - extending outside the pelvis - bowel, bladder, inguinal nodes
253
what is type 1 endometrial cancer
endometriosis adenocarcinoma
caused by unopposed oestrogen
hyperplasia with atypic precursor
254
what is type 2 endometrial cancer
uterine serous and clear cell carcinoma
high grade, more aggressive, worse prognosis
older ladies
255
what are 4 pathological prognostic features in endometrial cancer
1 - histological type
2- histological grade
3- stage
4 - LVSI - lymphovascular space invasion
256
what is the treatment for early stage endometrial cancer
surgery - total abdominal hysterectomy + bilateral salpingo- oophorectomy + peritoneal washings
257
what is removed in a bilateral salpingo- oophorectomy
ovaries and fallopian tubes
258
what is treatment of advanced stage endometrial cancer
radiotherapy - reduce risk of local recurrence
259
what therapy shrinks an endometrial tumour
progesterone
260
what is a sub total hysterectomy
remove uterus but leave cervix
261
what is LVSI (endometrial cancer)
lymhpvascular space invasion - tumour in blood vessels may metastases all over body
262
how is MRI used to stage endometrial cancer
depth of myometrial invasion
cervical involvement
lymph node involvement
263
what is the most common histological type of endometrial cancer
endometriosis endometrial adenocarcinoma
264
what is the diagnosis of endometrial cancer made on
uterine sampling or curettage of aLL parts
265
what are other causes of post menopausal bleeding other thane endometrial cancer
```
HRT
peri-menopausal bleeding
atrophic vaginitis
polyps
other cancers
```
266
when is peak prevalence of HPV
15-25 years - prime sexual activity
267
what does HPV increase your chances of
developing high grade CIN or cancer - viral DNA integrates into host cell genome with over expression of viral e6 and e7 protein to deregulate host cells
268
what are the high risk strains of HPV
16, 18
| 31, 45
269
what are the low risk strings of HPV
6 , 11 (genital warts)
| 42, 44
270
what strains of HPV are associated with genital warts
6, 11
271
what is the normal lining of the cervix
squamous epithelium
272
what is detected on a smear of an early HPV lesion
squamous intraepithelial lesion (SIL)
| high grade HSIL or low grade LSIL
273
what is the name of abnormal cells in the cervic detected by biopsy an histological examination
cervical intraepithelial neoplasia (CIN)
| graded 1-3 on proportion of cervix affected
274
what is the main cause of cervical cancer
infection with papilloma virus type 16 and 18
275
how long do most low grade SIL last
6-12 months - immunological intervention
276
what percentage of high grade SIL progress to carcinoma
40%
277
what 2 protein products of HPV virus deregulate the host cell cycle
E6 - inhibits cell death
| E7 - presents cell cycle arrest
278
what cancers other than cervical is GPV associated with
anus, penus, vulva, oropharynx
279
what is the transformation zone of the cervix
surround the squamous columnar junction where the epithelium changes from squamous vagina (ectocervix) to columnar of cervix (endocervix)
280
what is the epithelium of the ectocervic and endocervix
ectocervix - squamos
| endocervix - columnar
281
which layer of cells in the cervix does the HPV infection infect
basal
282
why is the transitional zone vulnerable to HPV infection
immat cells
| unstable hormonal environment
283
what is produced by lactobacilli that causes metaplasia of columnar to squamous epithelium in the cervix
lactic acid
284
what is CIN
abnormal proliferation of cells in squamous epithelium (cervical intraepithelial neoplasia) invisible to the naked eye
285
what is CIN 1
undifferentiated cells occupy lowest 1/3 of epithelium and surface cells can still mature to big flat cells
286
what is CIN 2
undifferentiated cells occupy 2/3 of thickness and only top layers show maturation to medium size cells
287
what is CIN 3
neoplastic cells or undifferentiated cells fill full thickness of epithelium , no normal differentiated cells seen
288
what percentage of CIN 3 progress to invasive cancer over 10-20 years if untreated
20-30%
289
what is the primary prevention of cervical cancer
vaccinate girls agains HPV 16/18 - quadrivalent vaccine
290
what is the secondary prevention of cervical cancer
cervical screening
291
what is the aim of cervical screening
reduce risk of cervical cancer
292
what HPV strains does the quadrivalent HPV vaccinate agist
16, 18, 6, 11
293
what women receive cervical screening
25-64 year old woman
3 yearly till 50 then 5 yearly
(soon to be 5 yearly)
294
what is the process of cervical screening analysis
liquid based cytology (LBC) done to test for high risk HPV, from a swab of the transformation zone of the cervix
295
what happens in the laboratory if cells from the transitional zone are tested positive for Hr HPV
reflex cytology
296
what is a HPV test
molecular test done on liquid based cytology samples by hybridisation/ PCR to identify high risk type HPV viral DNA
297
what is dyskaryosis
abnormal cells
nuclear features include increased size and nuclear cytoplasmic ratio, variation in size, shape and outline, coarse, irregular chromatin, nucleoli
298
what are HPV samples stained with for viewing does the microscope
papanicolaou (PAP)
299
what does presence of kilobytes on cytology reflect
HPV infection - multiple wrinkled nucleus and perinuclear halo
300
what happens if a cervical screen is negative for hrHPV
routine recall in 5 years
301
what happens if a cervical screen is positive for hrHPV but negative for cytology
repeat in 1 year
302
what happens if a cervical screen is positive for hrHPV and cytology reveals dykaryosis
refer to colposcopy
303
what can be done on colposcopy to diagnose CIN
punch biopsy
304
what are low grade and high grade changes seen on colposcopy
low grade - geographical borders, satellite changes
| high grade - snowy dense, capillary network
305
what is the treatment of CIN
LLETZ - large loop excision of transformation zone (loop diathermy)
cold coagulation
laser ablation
306
what percentage of CIN returns after 3-5 years
5%
307
after treatment for CIN when should woman be followed up
6 months - cytology and hrHPV
308
what is the main cause of cervical cancer
HPV 16 and 18
| human papilloma virus
309
what is the peak age of cervical cancer
45 - 55 years
310
why are rates of cervical cancer declining
vaccination programme
311
what are symptoms of cervical cancer
```
abnormal vaginal bleeding - post coital, intermenstraul, post menopausal
discharge
pain (rare)
```
312
what are risk factors for developing cervical cancer
```
prolonged pill use
high parity
many sexual partners
STIs
HIV immunodeficiecny
smoking
```
313
why is there a higher prevalence of cervical cancer is lower social classes
less screening uptake
more smoking
present at a later stage
314
how is the diagnosis made of cervicla cancer
histopathological - biopsy
315
how would you investigate cervical cancer
clinical speculum exam
PET CT? MRI to stage
EUA
316
what is a differential diagnosis for cervical cancer
chlamydia cervicitis - more inflamed
317
what are the 2 possible histological classifications of cervicla cancer
```
squamos cells (transitional zone)
adaneocarcinoma - endocervical ring
```
318
what is the most common histological type of cervical cancer
squamose carcinoma (80%)
319
how does cervicla cancer spread
local -
lymphatic - pelvic nodes
blood - liver, lungs, bones
320
describe the stages of cervical cancer
```
1A - invasive cancer microscopically
1a1 - <3mm x 7mm, a2 - <5mm x 7mm
1B - clinical tumour confined to cervix
2 - spread to upper 2/3 vagina
3 - lower vagina/ pelvis
4 - spread to bladder/ rectum
```
321
what stage do most cervical cancers present at
1 or 2
322
what stage do most ovarian cancer present at
3 or 4
323
what is the treatment of stage 1a1 cervical cancer
excision of cervical TZ
| hysterectomy
324
what is the treatment of stage 1b- 2a cervical cancer
radical hysterectomy with pelvic lymphadenectomy (removal of uterus cervix, upper vagina, parametric and pelvic nodes)
325
what is the treatment of stage 2b-4 cervical cancer
radiotherapy
+ chemotherapy (cisplatin)
caesium insertion 24 hours
326
what is the cure rate of each stage of cervical cancer
1 - almost 100%
2 - 85%
3- 75%
4- 35%
327
what are risk factors for vulval intraepithelial neoplasia
smoking
328
what is the difference in vulval intraepithelial neoplasia in older and younger women
younger - multi-focal , HPV +ve
| older - uni-focal
329
describe the clinical appearance of VIN
raised papular or plaques lesions
erosions, nodules, warty (keratitis roughened appearance)
sharp border
discolouration - red, white, brown
330
how is the histological diagnosis of vulval intraepithelial neoplasia made
punch biopsy under LA
331
what is the risk of invasion in untreated vulval intraepithelial neoplasia
20-40%
332
what are the management aims of vulval intraepithelial neoplasia
eliminate symptoms - severe irritractable itch
preserve sexual function
preserve body image
333
what are the main treatments for vulval intraepithelial neoplasia
topical - imiquimod (genital warts) , photodynamic therapy
5FU, alpha interferon, cidofivir
laser ablation - CO2 laser (high recurrence)
surgical resection
334
what is the most common histological class of vulval cancer
squamose cell carcinoma
| may be BCC, melanoma, Bartholin's glands
335
what age does vulval cancer present at
```
mostly 75 (75% over 60)
(prevalence increasing as people live longer)
```
336
how may vulval cancer present
pain
irretractable itch
bleeding - underwear
lump/ ulcer
337
what lymph nodes may be involved in vaginal cancer
inguinal
upper femoral
pelvic
338
what is the survival rates of the different stages of vulval cancer
1 - 97%
2- 85%
3- 46%
4- 50%
339
describe each stage of vulval cancer
```
1a - micro-invasion <1mm
1 - < 2cm
2 - > 2cm
3- local spread, unilateral nodes
4- distant or advanced local spread, pelvic nodes
```
340
what is the treatment of vulval cancer
surgery
radiotherapy
groin node dissection - inguinal, upper femoral
341
why is groin node dissection associated with significant morbidity
wound infection
lymphocytes - accumulation of lymph fluid form moving nodes
nerve damage
342
where is vaginal cancer most common
upper 1/3 of vagina - squamous cell
343
what chemical intrauterine exposure is associated with clear cell vaginal adenocarcinoma
diethylstilboestrol
344
what is the treatment of vaginal cancer
radiotherapy
345
what is the prognosis of vaginal cancer
poor - 58% 5 year survival for squamos
| 34% adenocarcinoma
346
what is the main symptom of vaginal cancer
bleeding
347
what is the only treatment that guarantees cure of menstraul problems
hysterectomy
348
what is the difference between a subtotal and total hysterectomy
total - cervix and uterus removed
| subtotal - cervix remains
349
what is removed in a total hysterectomy with bilateral salpingo -oopherectomy
uterus, cervic, fallopian tubes, ovaries
350
what is removed in a wertheim's hysterectomy (cervical cancer)
uterus, cervix, fallopian tubes, ovaries, parametrium (tissue surrounding uterus and upper vagina)
351
what are complications of a hysterectomy
```
infection
CVT
bladder, bowel, vessel injury
altered bladder fucntion
adhesions
residual ovary syndrome
```
352
why is there a high risk of menopause in 2 years after hysterectomy
compromised blood supply
353
what are disadvantages of an oopherectomy
immediate menopause - need HRT till 51
354
what is infertility defined as
disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse
355
how common is infertility
1 in 7 couples
356
what are the 3 questions in an infertility consultation to investigate
are there eggs available?
are sperm available?
can they meet?
(can they implant in utero)
357
how would you investigate if a woman had eggs
serum progesterone in mid luteal phase of cycle (day 21-28) to confirm ovulation
if irregular cycle - track 7 days before expected period and repeat weekly
358
what are causes of azoospermia
```
absence of vas deferent
hypogonadotrophic hypogonadism
small testicle size
mumps
smoking
exposure to heat or chemical radiation
CF
Klinefelter syndorme
```
359
how would investigate its the man had sperm
computerised seem analysis
360
what are causes of fallopian tubal blocks
pelvic inflammatory disease
STIs
fibroid compression
endometrrosis
361
what would you ask a female that had presented with infertility
```
duration of infertility
previous contraception used
previous fertility / pregnancies/ complications
menstraul history
medical/ surgical history
sexual history
psychological (stress)
```
362
what would you examine in a woman who presented with infertility
weight / height - BMI <30
fat and hair distribution
hormone profile
abdominal exam - scars, acanthosis nigricans (androgen excess)
pelvic exam - masses, distortion, fibroids
363
what must a womans BMI be to be eligible for NHS IVF
<30
364
what score system is used to assess hirtuism in women
ferryman gallwey score
| <8 no disease, 8-16 mild, 16-25 moderate, >25 severe
365
what would you ask a man who presented with infertility
previous fertility
previous medical/ surgical history - varicocele
social - drugs, alcohol, steroids, chemotherapy
sexual - STIs
Kinefelter syndrome
366
what is Klinefelter syndrome associated with
infertility in males
hypogonadism
low testosterone
small testicles
367
what would you examine in a man who presented with infertility
weight and height - BMI
fat and hair distribution (hypoandrogenism)
abdo/ inguinal examination - mass
genital examination
368
how may CF lead to infertility in males
absence of vas deferens
369
when should you refer someone for help with infertility
after 1 year
| unless >35 - 6 months
370
what are baseline investigations for female infertility
female - rubella, chlamydia, TSH,
mid luteal progesterone if period regular, if irregular so day 1-5 FSH, LH, PRL , testosterone
pelvic ultrasound - masses, anatomy abnormality, fibroids endometriosis
371
describe the process of IVF
woman takes gonadotrophin injections to stimulate ovaries, ultrasound guidance to retrieve eggs, male produce sperm sample, fertilised in vito , female embryo transfer
372
what is the criteria for NHS IVF treatment
non smoker
couple with no kids
BMI < 30
373
what is the process in which embryos are frozen
cryopreservation
| IVF unsuccessful, cancer etc.
374
what are some tubal patency tests
hysterosalpingiogram - contrast xray
HyCoSy - ultrasound
laparoscopy procedure
375
what are baseline investigations for male infertility
semen analysis
seprm count - 3 months apart
FSH, LH, testosterone, PRL
CF screen , karyotype
376
what is female genital mutilation (FGM)
all procedures that involve partial or total removal of external female genitalia, or other injury to the female genital organs for cultural or non- medical reasons
377
when is the most common age for FGM
4-10
378
what countries have the highest prevalence of FGM
indonesia
ethiopia
egypt
379
what is de-infibulation and re-infibulation
de-infibulation - open up a closed vagina before labour
| re-infibulation - re-stitching of FGM type 3 to recluse the vagina after childbirth
380
is re-infibulation legal in the UK
no - constitutes FGM
381
what is a type 1 FGM
clitoridectomy - partial or total removal of the clitoris or prepuce
382
what is a type 2 FGM
excision - partial or total removal of the clitoris and the labia minor with or without excision of the labia majora
383
what is a type 3 FGM
MOST RADICAL
infibulation - narrowing of the vaginal opening through the creation of a covering seal - formed by cutting and repositioning the labia with or without removal of the clitoris
small hole left for urine and menustration
384
what is a type 4 FGM
all other harmful procedures to the female genitalia for non- medical purposes e.g. pricking, piercing, incising, scraping
385
what are some people's justifications for FGM
```
preservation of viriginity/ chasity
religion
social acceptance
fear of social exclusion
improve marriage prospect
hygeine/ cleanliness
increase sexual pleasure
```
386
who performs most fGM
'cutters' in the community
| 18% by healthcare professionals
387
what are short term health impacts of FGM
```
severe pain and shock
infection
injury to adjacent tissues
injuries form being restrained
immediate haemorrhage - may be fatal
lBBV - share instruments
```
388
what are long term health impacts of FGM
```
urine retention
menstrauation difficulties
uterine, vaginal and and pelvic infections
cysts and neuromas
risk of fistula
PTSD
sexual dysfunction
```
389
what are complications of FGM in pregnancy and childbirth
inability to perform vaginal examinations
can't induce with porstaglandins
difficult to evacuate if miscarriage
difficult to identify obstetric emergencies such as cord prolapse
prolonged labour - risk of episiotomy and PPH
390
what are psychological effects of FGM
```
post traumatic stress
depression/ anxiety
loss of trust
fear of intimacy
nightmares
flashbacks
```
391
what is the law for FGM in the UK
illegal since 1985
prohibition of FGM (scotland) act 2005:
illegal to perform an action on the labia majora, labia minor, clitoris, or vagina
illegal to aid and abet FGM
392
what are key risk factors for FGM
mother has FGM - request re-infibulation
older sister/ cousins have FGM
parents show views that they support practice
girl withdraw form school
393
what are signs of imminent risk of FGM
girl withdrawn form school
elder from family visiting
'something special' happening ' going to be a woman soon'
forced marriage
