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Gynae Flashcards

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1
Q

How can bicornuate and unicornuate uterus be diagnosed?

A

Hysterosalpingogram

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2
Q

How can imperforate hymen present?

A

Primary amenorrhoea

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3
Q

How can imperforate hymen be relieved?

A

Cruciate incision

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4
Q

Describe the ovaries in Turner’s:

A

Thin, rudimentary ‘streak’ ovaries

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5
Q

What is FGM?

A

Removal or partial removal of external female genitalia, or injury to internal genital organs, for cultural or non-therapeutic reasons

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6
Q

If you see a patient under 18 with FGM, what should you do?

A

Report the case to the police

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7
Q

In the classification of FGM, what is type I?

A

Clitoridectomy

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8
Q

In the classification of FGM, what is type II?

A

Partial or total removal of clitoris and labia minora +/- labia majora

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9
Q

In the classification of FGM, what is type III?

A

Narrowing of vaginal orifice, apportioning of labia minora and/or labia majora +/- excision of clitoris

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10
Q

In the classification of FGM, what is type IV?

A

Any other harmful procedure to female genitalia

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11
Q

What are some acute complications of FGM?

A

Death, blood loss, sepsis, pain, urinary retention, blood borne viruses

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12
Q

What are some long term sequelae of FGM?

A

Apareunia, dyspareunia, sexual dysfunction, scarring, chronic pain, infections

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13
Q

What is a surgical management of FGM?

A

Defibulation - surgical opening of labia

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14
Q

What is primary amenorrhoea?

A

Failure to commence menses

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15
Q

What is secondary amenorrhoea?

A

Cessation of periods for >6m other than due to pregnancy

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16
Q

What is oligomenorrhoea?

A

Infrequent and irregular periods. >35d between cycles and <9 periods a year

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17
Q

What are some causes of amenorrhoea?

A 
Eating disorders
Prolactinoma 
PCOS
Turner’s
Asherman’s
Congenital adrenal hyperplasia
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18
Q

What tests may be performed to investigate amenorrhoea?

A 
bHCG 
FSH, LH, oestradiol, progesterone, testosterone 
Serum free androgen index
Prolactin
TFTs
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19
Q

What is dysmenorrhea?

A

Painful periods - cramps lower abdo pain

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20
Q

What is the management of dysmenorrhea?

A

Mefenamic acid during menstruation

Combined pill/Mirena coil

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21
Q

What is the Rotterdam criteria for diagnosis of PCOS?

A

Polycystic ovaries (12+)
Oligomenorrhoea/amenorrhoea
Hyperandrogenism

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22
Q

What are some other features of PCOS (not core 3)?

A 
Obesity 
Acne
Acanthosis nigricans 
Chronic pelvic pain
Depression
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23
Q

What is the management of PCOS?

A 
Weight loss, exercise, smoking cessation 
Metformin
Clomifene
COCP
Anti-androgen
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24
Q

What is menorrhagia?

A

Excessive menstrual loss that interferes with QoL

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25
What are some causes of menorrhagia?
``` Polyps Adenomyosis Fibroids Malignancy Coagulopathy Dysfunctional uterine bleeding ```
26
What investigations should be considered in a pt presenting with menorrhagia?
``` FBC Haematinics TFTs Smear STI screen Coag screen ```
27
What investigations should be considered in a pt aged >45y presenting with menorrhagia?
TVUS Pipelle endometrial biopsy Hysteroscopy + biopsy
28
What are some medical management options for menorrhagia?
Mirena IUS Tranexamic acid Mefenamic acid COCP
29
What are some surgical management options for menorrhagia?
Endometrial ablation Fibroids - myomectomy or uterine artery embolisation Hysterectomy
30
What are some symptoms of the menopause?
``` Menstrual irregularity Sweats Palpitations Flushes Vaginal dryness Atrophy of breasts and genitalia ```
31
What HRT should be given to someone with a uterus? | And why?
Combined HRT | Unopposed oestrogen is rf for endometrial Ca
32
What are some contraindications to use of HRT?
Oestrogen dependent cancer Past PE Undiagnosed PV bleed Raised LFTs
33
What are some side effects of HRT?
``` Fluid retention Bloating Breast tenderness Nausea Headaches Leg cramps Mood swings ```
34
What are some risks of HRT?
Increased risk of breast Ca Unopposed oestrogen increases risk of endometrial CA VTE risk Gallbladder disease
35
What is the medical method of termination of pregnancy?
Mifepristone followed by misoprostol
36
What are the surgical methods of TOP?
Suction (7-14w) | Dilatation and evacuation (13-24w)
37
What are some complications of TOP?
``` Failed TOP Infection Haemorrhage Uterine perforation Cervical trauma Retained POC ```
38
What is a miscarriage?
Loss of pregnancy before 24w gestation
39
What is a threatened miscarriage?
Bleeding and/or pain with closed cervical os
40
What is an inevitable miscarriage?
Severe symptoms with open cervical os
41
What is an incomplete miscarriage?
Some POC passed and os open. Echogenic mass within uterine cavity >20mm in AP diameter
42
What is a complete miscarriage?
All POC passed. Bleeding and pain reducing, cervix closed
43
What is a missed miscarriage?
Foetus dies but remains in utero, cervix closed
44
How can a missed miscarriage be confirmed?
US: fetal pole >7mm with no fetal heart activity OR mean gestation sac diameter >25mm with no fetal pole or yolk sac
45
What are some maternal risk factors for miscarriage?
Increasing age, previous miscarriage, smoking, alcohol, diabetes, HTN
46
What is the expectant management for miscarriage?
Wait for POC to pass for 2 weeks
47
What is the medical management of miscarriage?
Misoprostol (oral or PV)
48
What is the surgical management of miscarriage?
Suction evacuation (usually under GA)
49
What is the definition of recurrent miscarriage?
Loss of 3 or more consecutive pregnancies with same partner
50
What are some causes of recurrent miscarriage?
``` Infection Parental chromosomal abnormality (balanced reciprocal or Robertsonian translocation) Uterine abormality Antiphospholipid syndrome Thrombophilia ```
51
What prophylaxis should be given to a woman with antiphospholipid syndrome that has a positive pregnancy test?
Daily aspirin and LMWH
52
What is an ectopic pregnancy?
When the fertilised ovum implants outside of the uterine cavity
53
What factors can predispose to an ectopic?
``` Damage to tubes (PID, previous surgery) Previous ectopic Endometriosis IUCD, POP Smoking IVF ```
54
What is the most common location for an ectopic?
Ampulla
55
Where is the most dangerous location for an ectopic?
Isthmus
56
What are some possible presentations for an ectopic pregnancy?
``` Amenorrhoea Pain (unilateral, iliac fossa) PV bleed Dizziness Shoulder tip pain D+V ```
57
What investigations should be performed if an ectopic is suspected?
``` FBC G+S bHCG Serum progesterone TVS Speculum ```
58
What are the management options for an ectopic pregnancy?
Expectant Methotrexate Laparoscopic surgery or laparotomy
59
What are the surgical options for an ectopic pregnancy?
Salpingectomy if contralateral tube is healthy | Salpingotomy if not
60
What is the definition for a pregnancy of unknown location?
No sign of intrauterine or ectopic pregnancy or retained POC in presence of a positive pregnancy test
61
What are some outcomes for a pregnancy of unknown location?
``` Early intrauterine pregnancy Complete miscarriage Failing PUL Ectopic Persistent PUL ```
62
What are the differences between partial and complete moles?
Partial are triploid, complete diploid | Partial are more common, grow slower, present later and less often malignant
63
What are some features of molar pregnancy?
``` Early pregnancy failure Heavy bleeding Abdo pain Severe morning sickness Uterus large for dates Hyperthyroidism ```
64
What are some investigations to be performed in suspected molar pregnancy?
bHCG US Histology of POC If mets: MRI and CT
65
What is the management of molar pregnancy?
Removal of molar tissue by suction curettage
66
What are some features of choriocarcinoma?
Malaise Uterine bleeding Features of mets (lung)
67
What is the management of choriocarcinoma?
Combination chemo based on methotrexate
68
How does lichen sclerosis present?
White, flat, shiny skin in hourglass around vulva and anus Intensely itchy May be fissures or erosions
69
What is the management for lichen sclerosis?
Clobetasol propionate cream
70
What are some causes of VIN?
HPV 16, 18, 33
71
What can be used to assist in visualisation of VIN?
5% acetic acid
72
What are some management options for VIN?
Surveillance Surgical removal 5% imiquimod cream
73
What is a Bartholin’s cyst?
Blockage of ducts in Bartholin’s glands under labia minora
74
What is the treatment for an abscess in Bartholin’s gland?
Incision and permanent drainage by marsupialisation or balloon catheter insertion
75
What are some management options for vulval herpes simplex?
Analgesia Lidocaine gel Salt baths Oral aciclovir if recurrent
76
What are some ways in which vulval carcinoma may present?
Lump Indurated ulcer with itching Inguinal LN involvement
77
What is the cause of cervical ectropion?
Endocervical epithelium extends into ectocervix and is prone to bleeding, excess mucus production and infection
78
What can cause temporary ectropion extension?
Hormonal influence during puberty, pregnancy, COCP
79
What are some management options for symptomatic cervical ectropion?
Stop COCP | Cautery with diathermy
80
What are cervical polyps associated with?
Endometrial polyps
81
What are the management options for cervical polyps?
Polypectomy - avulsion by twisting | Diathermy loop excision
82
What ages are women eligible for the cervical screening programme?
25-64
83
How often do women get cervical smears?
3 yearly between 25 and 50 | 5 yearly until 64
84
How often should HIV +ve women have cervical smears?
Annually
85
If a women’s smear shows borderline or mild dyskaryosis, what should be the next step?
Test for high risk HPV. If positive, refer for colposcopy
86
If a women’s smear shows moderate or severe dyskaryosis, what should be the next step?
Refer for colposcopy (2WW)
87
Describe the staging of CIN:
I - affects lower basal third of cervical epithelium II - affects <2/3rds III - affects >2/3rds or full thickness of epithelium
88
What are some risk factors for cervical cancer?
``` Persistent high risk HPV infection Smoking Multiple partners Immunocompromise High parity ```
89
What is the management for CIN I?
Usually regresses | If HPV +ve offer 6 monthly colposcopy and LLETZ if persistent
90
What is the management for CIN II + III?
LLETZ
91
What are some complications of LLETZ?
``` Haemorrhage Infection Vasovagal symptoms Cervical stenosis Cervical incompetence ```
92
What are some features of cervical cancer?
``` Abnormal smear PCB PMB Watery vaginal discharge Weight loss ```
93
Describe the staging of cervical cancer:
I - confined to cervix II - extended to upper 2/3rds of vagina III - lower 1/3rd vagina IV - spread to bladder or rectum
94
What are the management options for cervical cancer?
Hysterectomy (Wertheim’s) | Chemoradiotherapy
95
What are some complications of hysterectomy?
``` Bleeding Infection VTE Ureteric fistula Bladder dysfunction ```
96
What are some complications of cervical radiotherapy?
``` Acute bladder and bowel dysfunction Mucositis Bleeding Ulceration Fistula Vaginal stenosis, shortening and dryness ```
97
When is endometritis more common?
Barrier to ascending infection (vaginal pH and cervical mucus) is broken e.g. after miscarriage, TOP, birth, IUCD insertion or surgery
98
How does endometritis present?
Lower abdo pain Fever Uterine tenderness on bimanual Offensive vaginal discharge
99
How should endometritis be treated?
Antibiotics e.g. cefalexin and metronidazole
100
What are some risk factors for endometrial cancer?
``` Obesity, T2DM, HTN (increased peripheral oestrogens) Nulliparity Anovulatory cycles, such as PCOS Early menarche/late menopause HNPCC (Lynch syndrome) Breast cancer Oestrogen only HRT ```
101
How does endometrial cancer commonly present?
PMB
102
How is endometrial cancer diagnosed?
TVUS showing endometrial thickness >4mm, biopsy, hysteroscopy
103
How is endometrial cancer staged?
I – in body of uterus only II – in body and cervix III – advancing beyond uterus but not beyond pelvis IV – extending outside of pelvis (e.g. bowel and bladder)
104
What is the management of endometrial cancer?
Total hysterectomy with bilateral salpingo-oophorectomy | Adjuvant radiotherapy
105
What are fibroids?
Benign smooth muscle tumours of the uterus (leiomyomas)
106
How may fibroids present?
``` Incidental finding Menorrhagia Fertility problems Pain Mass ```
107
What are some medical treatment options for fibroids?
Mirena Tranexamic acid Goserelin Ullipristal acetate
108
What are some surgical treatment options for fibroids?
Myomectomy Uterine artery embolisation Hysterectomy
109
How may ovarian cysts present?
``` Incidental finding Chronic cyclical pain Dyspareunia Acute pain due to torsion, bleeding, rupture PV bleed Mass ```
110
What are some risk factors for ovarian cancer?
Nulliparity Early menarche/late menopause BRCA1 and BRCA2 mutations Lynch syndrome
111
How many ovarian cancer present?
``` Often vague, GI-like symptoms Bloating Unexplained weight loss, loss of appetite Fatigue Urinary frequency and urgency Change in bowel habit Abdo or pelvic pain PV bleed Pelvic mass ```
112
What investigations may you perform on someone with suspected ovarian cancer?
FBC, U+Es, LFTs, CA125, CA19-9, TVS, US abdo, CXR, CT abdo/pelvis, MRI, cytology of ascites
113
What is the FIGO staging for ovarian cancer?
1. Limited to one or both ovaries 2. Limited to pelvis 3. Limited to abdomen including regional LNs 4. Distant mets outside of abdomen
114
What are some features of PID?
``` Lower abdo pain Deep dyspareunia Vaginal discharge IMB or PCB Dysmenorrhoea Dysuria Cervical motion tenderness ```
115
What investigations should be performed in suspected PID?
Endocervical swabs Full STI screen Urine dip Pregnancy test
116
What are some complications of PID?
``` Tubo-ovarian abscess Fitz-Hugh-Curtis syndrome Recurrent PID Ectopic Subfertility ```
117
How should PID be treated as an outpatient?
Ceftriaxone 1g IM/azithromycin 1g PO plus doxycycline 100mg for 14d and metronidazole 400mg for 14d
118
How should PID be treated as an inpatient?
Ceftriaxone 2g IV plus doxycycline 100mg IV followed by doxycycline 100mg for 14d and metronidazole 400mg for 14d
119
What is endometriosis?
Presence of endometriotic tissue outside of the uterus
120
How can endometriosis present?
``` Cyclical pain Constant pain due to adhesions Severe dysmenorrhoea Deep dyspareunia Dysuria or pain on defection Subfertility Asymptomatic Fixed retroverted uterus ```
121
What is the gold standard investigation for endometriosis
Laparoscopy with biopsy
122
What management options are available for endometriosis?
``` NSAIDs/paracetamol for pain COCP Progestogens Mirena IUS Goserelin in subfertility ```
123
What is adenomyosis?
Presence of functional endometrial tissue within the myometrium
124
What are some features of adenomyosis?
``` Menorrhagia Dysmenorrhoea Deep dyspareunia Irregular bleeding Enlarged boggy uterus ```
125
What management options are available for adneomyosis?
NSAIDs and analgesia COCP, progestogens, GnRH agonists and aromatase inhibitors Hysterectomy
126
What are some risk factors for prolapse?
``` Prolonged labour Trauma from delivery Pelvic floor muscle weakness Obesity Chronic cough Constipation ```
127
Describe the grading for uterine prolapse:
First degree: lowest part descends halfway down vaginal axis to the introitus Second degree: lowest part to level of introitus and through on straining Third degree: lowest part extends through introitus and out of vagina Procidentia: uterus outside of vagina
128
What symptoms may a woman with a prolapse describe?
``` Dragging sensation Discomfort Lump ‘coming down’ Dyspareunia Backache Incontinence ```
129
What are some conservative management options for prolapse?
Lose weight Stop smoking Stop straining Improve muscle tone
130
What are some medical + surgical management options for prolapse?
Pessaries Surgical repair Hysterectomy
131
What are some signs and symptoms of incontinence?
``` Frequency Nocturia Urgency Voiding difficulties (hesitancy, straining, slow stream) Feeling of incomplete emptying Dysuria Recurrent UTI ```
132
What is stress incontinence?
Involuntary leakage of urine on effort or exertion, or on sneezing or cough
133
What are some causes of stress incontinence?
``` Pregnancy Menopause Radiotherapy or surgery Chronic cough Obesity Prolapse ```
134
What is the conservative management for stress incontinence?
Weight loss, smoking cessation, treatment for chronic cough or constipation Pelvic floor exercises
135
What are some surgical management options for stress incontinence?
Bulking agents | Tension free vaginal tape
136
What is urge incontinence?
Involuntary leakage of urine with a strong desire to pass urine
137
What is the conservative management for urge incontinence?
Avoid excessive fluid intake esp. caffeine | Bladder retraining
138
What is the medical management for urge incontinence?
Anticholinergics e.g oxybutynin Mirabegron Botox
139
What investigations can be done in primary care for subfertility?
``` Chlamydia screening FSH, LH TSH, prolactin, testosterone and rubella Mid-luteal progesterone Semen analysis ```
140
What investigations can be done in secondary care for subfertility?
TVS | Hysterosalpingogram (HSG)
141
What lifestyle changes can be made as part of the management of subfertility?
``` Weight loss Healthy diet Stop smoking, reduce alcohol Regular exercise Regular intercourse (every 2-3 days) ```
142
What some methods of inducing ovulation in those that suffering from subfertility?
``` Weight loss or gain Clomifene citrate Laparoscopic ovarian drilling (in PCOS) Gonadotropins Metformin (in PCOS) ```
143
What are some indications for IVF?
Tubal disease Male factor subfertility Endometriosis Unexplained >2 years
144
What are the values in normal semen analysis? (volume, concentration, progressive motility, total motility and normal forms)
``` Volume >1.5ml Concentration >15 x10^6/ml Progressive motility >32% Total motility >40% Normal forms >4% ```
145
What investigations can be performed for male subfertility?
Testicular volume FSH, testosterone, LH Karyotyping
146
What are some management options for male subfertility?
Lifestyle, optimise medical conditions, multivitamin (zinc, selenium, vit C) Intracytoplasmic sperm injection (into egg)
147
What is the difference between a total and subtotal hysterectomy?
Subtotal, cervix is left
148
What are the risks associated with a hysterectomy?
``` Bleeding, infection Injury to bladder, bowels, vessels or ureters VTE Early menopause If vaginal, vaginal vault prolapse ```
149
What are the risks associated with endometrial ablation?
Bleeding, infection, uterine perforation, failed procedure, haematometra
150
What is the pathophysiology of ovarian hyperstimulation syndrome?
Complication of ovulation induction or superovulation Ovarian enlargement and fluid shift to extravascular space leading to accumulation in peritoneal and pleural spaces and hypercoagulability
151
How may an individual suffering from ovarian hyperstimulation syndrome present?
Abdo discomfort, N+V, abdo distension, dyspnoea
152
What general considerations should be thought about in the management of ovarian hyperstimulation?
Fluid balance VTE prophylaxis Drainage of ascites and pleural effusions
153
What is the calculation for risk malignancy index?
RMI = Ultrasound result x menopausal status x CA125
154
How is the ultrasound result scored in RMI?
1 point for each of: multilocular cysts, solid areas, mets, ascites, bilateral lesions U = 1 for 0-1 U= 3 for 2-5
155
How is menopausal status scored in RMI?
``` 1 = pre-menopausal 3 = post-menopausal ```
156
What are the cut offs for RMI?
<200 is low risk of malignancy | >200 is high risk, refer to gynae/cancer centre for management

Obs + Gynae (4 decks)

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