Gynaecological Flashcards
(168 cards)
1
Q
what is the aetiology of Asherman’s syndrome?
A
trauma, infection causing damage to the basal layer of the endometrium
= fibrosis and adhesion formation
2
Q
what are the double swabs?
A
- endocervical (NAAT) = gonorrhoea, chlamydia
- high vaginal charcoal swab = BV, TV, Candida, GBS
3
Q
what are the triple swabs?
A
- endocervical = chlamydia
- endocervical charcoal = gonorrhoea
- high vaginal charcoal = fungal and bacterialwh
4
Q
what are clue cells?
A
vaginal epithelium cells coated with lots of bacilli
5
Q
what PACES advice should you give in BV?
A
- avoid vaginal douching
- avoid shower gel
- avoid use of shampoo in bath
6
Q
what type of organism is TV?
A
flagellated protozoan
7
Q
what is the definition of recurrent thrush? what management?
A
4+ proven symptomatic episodes
check adherence, recheck initial diagnosis
Tx: induction and maintenance flucanozale
8
Q
what is the medical treatment of cutaneous warts?
A
- keratinised warts: imiquimod cream
- non-keratinised warts: podophyllin/tri-cholor-acetic acid
9
Q
when is the medical treatment of cutaneous warts contraindicated?
A
pregnancy
10
Q
what is the chlamydia management?
A
- doxycycline 100mg BD for 7 days
- contact tracing for 6 months
- STI screen
- avoid sex until treatment completed
- F/U appointment by 5 weeks
11
Q
what is the management of gonorrhoea?
A
- 1g ceftriaxone IM
- STI screen
- contact trace
- avoid sex for 1 week
- F/U in 1 week
12
Q
what is the cure rate for gonorrhoea?
A
95% with treatment
13
Q
what type of organism is syphillis?
A
gram negative spirochete (Treponema pallidum)
14
Q
what are the different syphillis investigations?
A
- microbiology = dark ground, PCR
- serology = non-treponemal tests or treponemal tests
15
Q
how long does it take for syphillis to become positive in serology?
A
3/12
16
Q
what are the non-treponemal tests?
A
high false positive rates due to cross reactivity
- RPR
- VDLR
17
Q
what are the treponemal tests?
A
- EIA (sensitive and specific)
- TPHA/ TPPA
- FTA-ABS
18
Q
what is the syphilis F/U?
A
partner notifications
repeat bloods at 3/12
19
Q
what is the management of PID?
A
- admit if >38 degrees or septic
- outpt: ceftriaxone IM, doxy and metronidazole 14/7
- input: IV cefoxitin and IV doxycycline
20
Q
what can cause an inadequate smear result?
A
- inflammation
- age-related atrophic change
- blood on smear
21
Q
what further tests do you do if CIN1, 2 or 3 is detected on the smear?
A
- CIN1: HPV test +ve = colposcopy, -ve test = routine recall
- CIN 2/3: urgent colposcopy
22
Q
what should you do if you get an inadequate smear?
A
repeat
if x3 inadequate smears = colposcopy
23
Q
what follow up tests should you do if someone has a hysterectomy for CIN?
A
vault smear at 6m and 18m
24
Q
what is important to do after treating for CIN?
A
follow up test of cure (6 months later) = smear + HPV test
if negative = routine recall (3yrs irrespective of age)
if positive = repeat colposcopy to identify residual CIN
25
what is 20% of cervical cancer?
adenocarcinoma from CGIN
26
where does cervical cancer metastasie to?
illiac LNs
27
how can you treat cervical cancer stage 1a2 to IIa (early) to allow for fertility to be spared?
radical trachelectomy and bilateral pelvic node dissection
28
what type of chemo used in cervical cancer?
cisplastin based chemo
29
how do you treat endometrial hyperplasia without atypia?
- reverse RFs (e.g. obesity, HRT)
- endometrial surveillance every 6 months
- 1st line: progestogens (or observation)
- 2nd line: hysterectomy
30
what mutations are associated with type 1 endometrial cancer?
4+ mutations
| PTEN, PI3KCA, K-Ras, P53
31
which mutation is associated with type 2 endometrial cancer?
p53 in 90%
32
where does endometrial cancer metastasize to?
para-aortic LNs
33
what is the treatment of endometrial cancer?
Total abdominal hysterectomy + BSO + peritoneal washings
34
what types of endometrial cancer is endometriosis associated with?
clear cell ovarian carcinomas
| endometrioid ovarian carcinoma
35
how can ulipristal acetate be used in fibroids?
- short term selective progesterone receptor modulator
- shrinks fibroids
- not widely used
- associated with liver damage in long term
36
what is a leiomyosarcoma?
very rare
smooth muscle cancer of uterus
associated with Gardner's syndrome
37
what are the cell types of endocervix and ectocervix?
- endocervix = columnar
| - ectocervix = squamous
38
what is a cervical ectropion?
ectocervical migration of columnar epithelium
39
what are the different types of genital warts?
- small popular
- cauliflower
- keratotic
- flat papules/plaques
40
management of lichen sclerosis
1. clobestasol propionate
| 2. tacrolimus and biopsy
41
what are the risks of HRT?
increased breast and endometrial cancer
| increased VTE
42
what are the risk factors for ovarian cysts?
- PCOS
- Endometriosis
- Pregnancy
43
what are the types of ovarian cysts?
- Functional (Follicular, Corpus Luteal)
- Benign (Dermoid/ Mature Cystic Teratoma)
- Benign Epithelial (Serous Cystadenoma, Mucinous Cystadenoma)
44
what are the characteristics of follicualr cysts?
- failed rupture of dominant Graafin follicle
- lined by Granulosa cells
- may continue to produce oestrogen --> lead to EH
45
what are the characteristics of luteal cysts?
- following rupture, follicle reseals
- distends with fluid
- lined by luteal cells
- normal in early pregnancy
46
what are haemorrhagic cysts?
bleeding into functional cysts
47
what are the features of dermoid/mature cystic teratoma?
- lined by epithelial cells
- most likely to tort
- Rokitansky protruberances (white shiny masses that protrude out)
- most common benign tumours <30 years
48
what are the benign epithelial cysts?
- serous cystadenoma
| - mucinous cystadenoma
49
what happens if the mucinous cystadenoma rupture?
pseudomyxoma peritoni
50
what is the management of ovarian cysts in pre-menopausal women? if they are simple/ unilocular ?
```
<5cm = no follow up
5-7cm = repeat USS yearly
>7cm = MRI +/- surgery
```
51
what is the management of ovarian cysts in pre-menopausal women? if recurrent/unresolved?
COCP
52
what is the management of ovarian cysts in pre-menopausal women? if recurrent/sustained, >5cm, suspicious/multiloculated?
lap cystectomy
53
what is the first step to management of ovarian cysts in post-menopausal women?
RMI calculated: USS score, menopausal status, CA-125 score
54
what if the RMI < 200?
- if asymptomatic, uncomplicated, <5cm: repeat USS, CA125 in 4-6m, if it has then changed = lap cystectomy
- if symptomatic, complex, bilateral, >5cm; TAH, BSO, +/- omentectomy
55
what are most ovarian tumours?
epithelial origin
56
what are the germ cell ovarian tumours?
- teratoma
- dysgerminoma
- endodermal sinus tumour
- choriocarcinoma
57
what are the sex-cord stromal tumours?
- fibroma
- thecoma
- granulosa cell tumour
- sertoli-leydig cell tumour
58
what are the benign ovarian tumours?
- serous cystadenomas
- mucinous cystadenomas
- cystadenofibromas
- brenner tumour
59
what are the features of mucinous tumours?
resemble gastric/cervical epithelium
60
what is the feature of serous tumours?
psammoma bodies
61
what happens if the CA125 >35 IU/ml?
2 week wait referral to O&G and TVUSS
62
what else can cause a raised CA125?
- pregnancy
- endometriosis
- alcoholic liver disease
63
what is the ovarian cancer chemo regime?
platinum compound with paclitaxel
platinum = cross-linkage of DNA = cell cycle arrest
paclitaxel = prevent cell division
64
what are the RFs for ovarian torsion?
- ovarian cysts or tumours
- long ovarian ligaments
- pregnancy
- tubal ligaments
65
what does urodynamic testing measure?
3 pressures measured from inside rectum and urtherta
66
what are the surgical management options of stress incontinence?
1. Burch colposuspension (stitching the neck of the bladder higher)
2. Autologous rectus fascial sling (sling placed around the neck of the bladder)
3. Bulking agents (put bulking agents into uretheral wall to provide more force)
67
what are the medical management options for urge incontinencce?
1. Antimuscarinic e.g. oxybutyrin, ADH analogue e.g. desmopressin
2. Beta-3 agonist e.g. Micrabegron (used if concern for frail, older women)
68
what are the surgical management options for urge incontinence?
- botox injection
- sacral nerve stimulation
- cystoplasty
- urinary diversion
69
what is the prevalence of PCOS?
1-2 in every 10 women
70
what investigations should you do in PCOS?
- TVUSS: polycystic ovaries = "Pearl necklace sign"
- LH:FSH index >1:1
- High testosterone and prolactin, low SHBG
71
what are the complications of PCOS?
- metabolic syndrome (DM + Heart disease)
- CVD
- sleep apnoea
- endometrial cancer
- subfertility
- recommend withdrawal bleed every 3-4 months
72
management of infertility in PCOS?
1. weight loss
2. clomiphene and metformin (after 3 failed clomiphene cycles)
3. gonadotrophins, IVF
4. laparoscopic ovarian drilling
73
what is the MOA of clomiphene?
SERM
blocks ER in hypothalamus
more GnRH pulsatile
74
what s the risk of gonadotrophins/ IVF?
OHSS
75
what does laparoscopic ovarian drilling do?
destroy ovarian stroma
| prompt cycles
76
how can Addison's cause POI?
steroid cell autoantibodies cross react with granulosa cells and theca interna
77
when does PMS occur?
occurs in luteal phase
78
what does atrophic vaginits?
burning leucorrhoea (white mucous discharge)
79
what are the symptoms of vulvar vestibulitis?
introital dyspareunia
80
what is the management of vulvar vestibulitis?
pain management with sex therapy
behaviour modifications
topical steroids
anti-inflammatories
81
what are the groups of ovulatory disorders causing female infertility?
1. hypothalamic-pituitary failure (hypogonadotrophic hypogonadism)
2. hypothalamic-pituitary ovarian dysfunction
3. ovarian failure
4. prolactinaemia, thyroid disease, chronic renal disease, drugs
82
what are the causes of hypothalamic-pituitary failure?
low gonadotrophins, low oestrogens
1. low weight
2. excessive exercise
3. Kallman's syndrome
4. Sheehan's syndrome
83
what is an example of a hypothalamic-pituitary-ovarian dysfunction?
normal gonadotrophins, normal oestrogen
| e.g. PCOS
84
what are the measures of ovarian reserve?
- FSH = raised
- AMH = low
- TVUSS = Antral Follicle Count (<4 = poor, 16+ = good)
85
what are the different assisted contraception methods?
1. intrauterine insemination
2. IVF
3. intracytoplasmic sperm injection
4. donor insemination
5. donor egg with IVF
86
when is intrauterine insemination used?
- idiopathic
- anovulation unresponsive to OI
- mild male factor
- minimal to mild endometriosis
87
what are the indications for IVF?
blocked tubes
male minor factor
unsuccessful OI or intrauterine insemination
88
what are the indications for intracytoplasmic sperm injection?
- oligospermia
- poor fertilisation (DM, erectile dysfunction)
= most common treatment for male infertility
89
what are the RFs for infertility?
- advanced maternal age
- smoking/alcohol use
- obesity
- irregular periods
- STI
90
how many couples fail to conceive after 1 year?
15%
91
what is the process of ovarian hyperstimulation syndrome?
1. ovaries become hyperstimulated
2. exposure to hCG
3. pro-inflammatory mediators
4. ovarian enlargement, inc vascular permeability, prothrombotic state
92
what are the S/S of OHSS?
abdominal pain and distention
nausea and vomiting
SOB
Oedema/Ascites
93
what is the management of OHSS?
symptomatic, fluid replacement, VTE prophylaxis
94
bugs causing TSS
- staphylococcus: exotoxin (e.g. TSS toxin 1)
| - streptococcus: inflammatory cascade initiation
95
Signs and symptoms of TSS
- fever (>39 degrees)
- D+V
- Myalgia
- Sore throat
- Desquamation of palms and soles
- shock
- diffuse red macular rash
- headache
96
what is vault prolapse?
prolapse of vaginal vault after hysterectomy
97
what are the risk factors for urogenital prolapse?
- increasing age
- parity
- menopause
- obesity
- pelvic surgery
- pelvic surgery
- chronic cough
- constipation
- heavy lifting
98
what are the 2 prolapse grading systems?
- POP-Q
| - Shaw's
99
what does POP-Q look at?
measures different anatomical landmarks in relation to hymen
100
what does Shaw's look at?
- looks at extent of descent prolapse
101
what are the degrees of Shaw's?
1st degree: descent at introitus
2nd degree: extends to introitus but past introitus on straining
3rd degree: prolapse descends through introitus
102
Surgical options for uterine prolapse that does not preserve uterus?
- vaginal hysterectomy +/- vaginal sacrospinus fixation
- vaginal sacrospinus hysteropexy with sutures
- Manchester repair
103
Surgical options for uterine prolapse that does not preserve uterus?
- vaginal sacrospinus hysteropexy with sutures
| - sacro-hysteropexy with mesh
104
what is the surgery for vault prolapse?
sacrocolopexy with mesh
105
what is the surgery for anterior or posterior prolapse?
anterior/ posterior colporrhaphy (without mesh)
106
what are the conservative measures for prolapse?
- weight loss
- minimise weight lifting
- stop smoking
- pelvic floor exercises
- topical oestrogens
+ PESSARY
107
what are the RFs for usual type (warty/basaloid SCC)?
- VIN (HPV 16)
- immunosuppression
- smoking
108
what are the RFs for differentiated type (keratinised SCC)?
lichen sclerosis
109
what are the categories of VIN?
- low grade squamous
- high grade squamous
- differentiated (keratinised)
110
what is the management of 1a vulvar cancer?
wide local excision +/- chemo
111
what is the management of >1a vulvar cancer?
radical vulvectomy + bilateral inguinal lymphadenectomy
112
what are the complications of endometrial ablation?
- general: infection, bleeding, failure, damage to nearby structures
- minor: cramping, nausea, frequent urination, watery discharge mixed with blood
- rare: pulmonary oedema
113
what is a total hysterectomy? smears?
uterus and cervix
| no smears needed
114
what is a radical hysterectomy? smears?
removal of structures +/- BSO
| no smears
115
what is a subtotal hysterectomy?
upper part of uterus removed
| NEED SMEAR
116
when is a smear needed for total or radical smear?
if total or radical AND due to cancer/CIN, smears done at 6 and 18 months
117
what are the indications for vaginal hysterectomy?
- menstrual disorders with uterus <12 weeks
- micro invasive cervical carcinoma
- uterovaginal prolapse
118
what are the indications for abdominal hysterectomy?
- larger masses
- carcinoma
- if pelvis is frozen
- symptomatic fibroid uterus 12w+
119
what is the indication for a hysteroscopic myomectomy?
fibroids on inner wall
120
what is the indication for a laparoscopic myomectomy?
removing 1 or 2 fibroids <2 inches that are growing outside uterus
121
what is the indication for an open myomectomy?
large fibroids
many fibroids
fibroids deep into uterine wall
122
what is the MOA of levonorgesterol?
- stops ovulation, inhibits implantation
123
dosing of levonorgesterol
1.5mg (double dose if overweight)
>1 use in each cycle
if vomiting within 2 hours, repeat dose
124
what is the MOA of ulipristal acetate?
selective progesterone receptor modulator
| inhibits ovulation
125
dosage of ulipristal acetate
30mg
126
cautions with ulipristal acetate
not to be used alongside levonorgestrel
severe asthma
restart hormonal contraception 5 days after
vomiting within 3 hours, repeat dose
127
how does the COCP work?
prevents ovulation
128
what does COCP inc/dec the risk of?
- decreased risk of ovarian, endometrial and bowel cancer
| - increased risk of VTE, breast, cervical cancer
129
what should be done with the COCP regarding surgery?
stops 4 weeks before surgery
restart 2 weeks after
switch to POP
130
how can you explain the COCP VTE risk to patients?
instead of 1 person in Wembley stadium getting a blood clot, 2 people will
131
what is the MOA of POP?
- thickens cervical mucous
| - antibiotics = no effect
132
what does the POP increase the risk of?
- increased risk of osteoporosis and ovarian cysts
133
what is the window for taking cerazette?
12 hours
134
what are the precautions if the patch is changed late but within 48 hours?
change immediately, no further precautions
135
what is the MOA of the hormonal ring?
thickens cervical mucous
| prevents ovulation
136
what is the MOA of LNG-IUS
- prevents endometrial thickening
| - thickens cervical mucous
137
what is the MOA of the implant?
- prevents ovulation, thickens cervical mucous
138
what is a contraindication for the implant?
IHD
139
when can you fit the IUD/IUS post-partum?
within 48 hours of childhood OR after 4 weeks
140
when should COCP/injection be stopped in women?
>50 years
| switch to POP/IUS/implant
141
what are the bimanual findings in adenomyosis?
bulky boggy uterus
142
what are the USS findings of adenomyosis?
haemorrhage-filled distended endometrial glands
143
what is the gold standard investigation in adenomyosis?
MRI pelvis
144
what is the FIGO staging in endometrial cancer?
```
I = uterus
II = uterus + cervix
III = adnexa
IV = distant mets/bladder/bowel
```
145
what is the FIGO staging in ovarian cancer?
```
I = ovaries
II = pelvic extension (uterus)
III = abdo extension (extra pelvic)
IV = distant mets
```
146
what is the FIGO staging in cervical cancer?
```
I = cervix
II = invade beyond cervix, not into pelvic wall or lower 1/3rd of vagina
III = extend to pelvic wall +/- lower 1/3rd vagina + hydronephrosis
IV = extend beyond pelvis and involves mucous of bladder or rectum
```
147
what are the USS findings in follicular cysts?
thin walled
unilocular
anechoic
148
what are the USS findings of corpus luteal cysts?
diffusely thick wall
<3cm
lacy pattern
149
what are the USS findings in theca lutein cysts?
```
ass/ w/ pregnancy
bilaterally enlarged
multicystic ovaries
thin walled
anechoic
```
150
what are the 2 types of inflammatory cysts?
- tubo-ovarian abscess
| - endometrioma
151
what is tubo-ovarian abscess?
PID, tender adnexal mass
| USS: ovary and tube cannot be distinguished from mass
152
what is an endometrioma?
chocolate cyst
| associated with endometriosis
153
USS findings of endometrioma
unilocular
| ground glass echoes
154
what are the types of dermoid cyst?
mature
| immature
155
mature dermoid cyst findings
```
benign, solid, cystic
USS:
- unilocular,
- diffusely echogenic,
- may contain teeth
- no internal vascularity
```
156
what are the features of immature dermoid cysts?
contain embryonic elements
| malignant
157
serous cystadenoma USS findings
unilocular
anechoic
no flow on colour doppler
158
mucinous cystadenoma USS findings
multiloculated
many thin separations
low echogenicity due to mucin
159
what is a Brenner's tumour?
small urothelial like epithelium
160
what are the USS findings of Brenner's tumour?
hypoechoic
| some calcifications
161
primary causes of amenorrhoea
- Turner's
- Testicular feminisation
- CAH
- congenital malformation of genital tract
162
what are the secondary causes of amenorrhea?
- hypothalamic
- PCOS
- hyperprolactinaemia
- POI
- thyrotoxicosis
- Sheehan's
- Asherman's
163
what are the 3 stages to the menstrual cycle?
- proliferative
- secretory
- menstrual
164
what is the proliferative phase?
hyperplasia of endometrium
165
what is the secretory phase?
maintain endometrium
166
what is the menstrual phase?
- drop in progesterone
- zona compacta
- spongiosa shedding
167
what do theca cells respond to? what do they produce?
respond to LH
| produce androgen
168
what do granulosa cells respond to? what do they produce?
respond to FSH
produce aromatase (convert androgen to oestriol)
produce progesterone
