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Cross reference - year 5 > Gynaecological > Flashcards

Gynaecological Flashcards

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

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2
Q

what are the double swabs?

A
  • endocervical (NAAT) = gonorrhoea, chlamydia

- high vaginal charcoal swab = BV, TV, Candida, GBS

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3
Q

what are the triple swabs?

A
  • endocervical = chlamydia
  • endocervical charcoal = gonorrhoea
  • high vaginal charcoal = fungal and bacterialwh
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4
Q

what are clue cells?

A

vaginal epithelium cells coated with lots of bacilli

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5
Q

what PACES advice should you give in BV?

A
  • avoid vaginal douching
  • avoid shower gel
  • avoid use of shampoo in bath
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6
Q

what type of organism is TV?

A

flagellated protozoan

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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

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8
Q

what is the medical treatment of cutaneous warts?

A
  • keratinised warts: imiquimod cream

- non-keratinised warts: podophyllin/tri-cholor-acetic acid

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9
Q

when is the medical treatment of cutaneous warts contraindicated?

A

pregnancy

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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
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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
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12
Q

what is the cure rate for gonorrhoea?

A

95% with treatment

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13
Q

what type of organism is syphillis?

A

gram negative spirochete (Treponema pallidum)

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14
Q

what are the different syphillis investigations?

A
  • microbiology = dark ground, PCR

- serology = non-treponemal tests or treponemal tests

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15
Q

how long does it take for syphillis to become positive in serology?

A

3/12

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16
Q

what are the non-treponemal tests?

A

high false positive rates due to cross reactivity

  • RPR
  • VDLR
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17
Q

what are the treponemal tests?

A
  • EIA (sensitive and specific)
  • TPHA/ TPPA
  • FTA-ABS
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18
Q

what is the syphilis F/U?

A

partner notifications

repeat bloods at 3/12

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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
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20
Q

what can cause an inadequate smear result?

A
  • inflammation
  • age-related atrophic change
  • blood on smear
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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

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22
Q

what should you do if you get an inadequate smear?

A

repeat

if x3 inadequate smears = colposcopy

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23
Q

what follow up tests should you do if someone has a hysterectomy for CIN?

A

vault smear at 6m and 18m

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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

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25
Q

what is 20% of cervical cancer?

A

adenocarcinoma from CGIN

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26
Q

where does cervical cancer metastasie to?

A

illiac LNs

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27
Q

how can you treat cervical cancer stage 1a2 to IIa (early) to allow for fertility to be spared?

A

radical trachelectomy and bilateral pelvic node dissection

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28
Q

what type of chemo used in cervical cancer?

A

cisplastin based chemo

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29
Q

how do you treat endometrial hyperplasia without atypia?

A
  • reverse RFs (e.g. obesity, HRT)
  • endometrial surveillance every 6 months
  • 1st line: progestogens (or observation)
  • 2nd line: hysterectomy
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30
Q

what mutations are associated with type 1 endometrial cancer?

A

4+ mutations

PTEN, PI3KCA, K-Ras, P53

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31
Q

which mutation is associated with type 2 endometrial cancer?

A

p53 in 90%

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32
Q

where does endometrial cancer metastasize to?

A

para-aortic LNs

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33
Q

what is the treatment of endometrial cancer?

A

Total abdominal hysterectomy + BSO + peritoneal washings

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34
Q

what types of endometrial cancer is endometriosis associated with?

A

clear cell ovarian carcinomas

endometrioid ovarian carcinoma

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35
Q

how can ulipristal acetate be used in fibroids?

A
  • short term selective progesterone receptor modulator
  • shrinks fibroids
  • not widely used
  • associated with liver damage in long term
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36
Q

what is a leiomyosarcoma?

A

very rare
smooth muscle cancer of uterus
associated with Gardner’s syndrome

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37
Q

what are the cell types of endocervix and ectocervix?

A
  • endocervix = columnar

- ectocervix = squamous

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38
Q

what is a cervical ectropion?

A

ectocervical migration of columnar epithelium

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39
Q

what are the different types of genital warts?

A
  • small popular
  • cauliflower
  • keratotic
  • flat papules/plaques
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40
Q

management of lichen sclerosis

A
  1. clobestasol propionate

2. tacrolimus and biopsy

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41
Q

what are the risks of HRT?

A

increased breast and endometrial cancer

increased VTE

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42
Q

what are the risk factors for ovarian cysts?

A
  • PCOS
  • Endometriosis
  • Pregnancy
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43
Q

what are the types of ovarian cysts?

A
  • Functional (Follicular, Corpus Luteal)
  • Benign (Dermoid/ Mature Cystic Teratoma)
  • Benign Epithelial (Serous Cystadenoma, Mucinous Cystadenoma)
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44
Q

what are the characteristics of follicualr cysts?

A
  • failed rupture of dominant Graafin follicle
  • lined by Granulosa cells
  • may continue to produce oestrogen –> lead to EH
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45
Q

what are the characteristics of luteal cysts?

A
  • following rupture, follicle reseals
  • distends with fluid
  • lined by luteal cells
  • normal in early pregnancy
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46
Q

what are haemorrhagic cysts?

A

bleeding into functional cysts

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47
Q

what are the features of dermoid/mature cystic teratoma?

A
  • lined by epithelial cells
  • most likely to tort
  • Rokitansky protruberances (white shiny masses that protrude out)
  • most common benign tumours <30 years
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48
Q

what are the benign epithelial cysts?

A
  • serous cystadenoma

- mucinous cystadenoma

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49
Q

what happens if the mucinous cystadenoma rupture?

A

pseudomyxoma peritoni

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50
Q

what is the management of ovarian cysts in pre-menopausal women? if they are simple/ unilocular ?

A 
<5cm = no follow up
5-7cm = repeat USS yearly
>7cm = MRI +/- surgery
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51
Q

what is the management of ovarian cysts in pre-menopausal women? if recurrent/unresolved?

A

COCP

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52
Q

what is the management of ovarian cysts in pre-menopausal women? if recurrent/sustained, >5cm, suspicious/multiloculated?

A

lap cystectomy

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53
Q

what is the first step to management of ovarian cysts in post-menopausal women?

A

RMI calculated: USS score, menopausal status, CA-125 score

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54
Q

what if the RMI < 200?

A
  • 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
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55
Q

what are most ovarian tumours?

A

epithelial origin

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56
Q

what are the germ cell ovarian tumours?

A
  • teratoma
  • dysgerminoma
  • endodermal sinus tumour
  • choriocarcinoma
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57
Q

what are the sex-cord stromal tumours?

A
  • fibroma
  • thecoma
  • granulosa cell tumour
  • sertoli-leydig cell tumour
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58
Q

what are the benign ovarian tumours?

A
  • serous cystadenomas
  • mucinous cystadenomas
  • cystadenofibromas
  • brenner tumour
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59
Q

what are the features of mucinous tumours?

A

resemble gastric/cervical epithelium

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60
Q

what is the feature of serous tumours?

A

psammoma bodies

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61
Q

what happens if the CA125 >35 IU/ml?

A

2 week wait referral to O&G and TVUSS

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62
Q

what else can cause a raised CA125?

A
  • pregnancy
  • endometriosis
  • alcoholic liver disease
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63
Q

what is the ovarian cancer chemo regime?

A

platinum compound with paclitaxel
platinum = cross-linkage of DNA = cell cycle arrest
paclitaxel = prevent cell division

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64
Q

what are the RFs for ovarian torsion?

A
  • ovarian cysts or tumours
  • long ovarian ligaments
  • pregnancy
  • tubal ligaments
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65
Q

what does urodynamic testing measure?

A

3 pressures measured from inside rectum and urtherta

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66
Q

what are the surgical management options of stress incontinence?

A
  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)
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67
Q

what are the medical management options for urge incontinencce?

A
  1. Antimuscarinic e.g. oxybutyrin, ADH analogue e.g. desmopressin
  2. Beta-3 agonist e.g. Micrabegron (used if concern for frail, older women)
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68
Q

what are the surgical management options for urge incontinence?

A
  • botox injection
  • sacral nerve stimulation
  • cystoplasty
  • urinary diversion
69
Q

what is the prevalence of PCOS?

A

1-2 in every 10 women

70
Q

what investigations should you do in PCOS?

A
  • TVUSS: polycystic ovaries = “Pearl necklace sign”
  • LH:FSH index >1:1
  • High testosterone and prolactin, low SHBG
71
Q

what are the complications of PCOS?

A
  • metabolic syndrome (DM + Heart disease)
  • CVD
  • sleep apnoea
  • endometrial cancer
  • subfertility
  • recommend withdrawal bleed every 3-4 months
72
Q

management of infertility in PCOS?

A
  1. weight loss
  2. clomiphene and metformin (after 3 failed clomiphene cycles)
  3. gonadotrophins, IVF
  4. laparoscopic ovarian drilling
73
Q

what is the MOA of clomiphene?

A

SERM
blocks ER in hypothalamus
more GnRH pulsatile

74
Q

what s the risk of gonadotrophins/ IVF?

A

OHSS

75
Q

what does laparoscopic ovarian drilling do?

A

destroy ovarian stroma

prompt cycles

76
Q

how can Addison’s cause POI?

A

steroid cell autoantibodies cross react with granulosa cells and theca interna

77
Q

when does PMS occur?

A

occurs in luteal phase

78
Q

what does atrophic vaginits?

A

burning leucorrhoea (white mucous discharge)

79
Q

what are the symptoms of vulvar vestibulitis?

A

introital dyspareunia

80
Q

what is the management of vulvar vestibulitis?

A

pain management with sex therapy
behaviour modifications
topical steroids
anti-inflammatories

81
Q

what are the groups of ovulatory disorders causing female infertility?

A
  1. hypothalamic-pituitary failure (hypogonadotrophic hypogonadism)
  2. hypothalamic-pituitary ovarian dysfunction
  3. ovarian failure
  4. prolactinaemia, thyroid disease, chronic renal disease, drugs
82
Q

what are the causes of hypothalamic-pituitary failure?

A

low gonadotrophins, low oestrogens

  1. low weight
  2. excessive exercise
  3. Kallman’s syndrome
  4. Sheehan’s syndrome
83
Q

what is an example of a hypothalamic-pituitary-ovarian dysfunction?

A

normal gonadotrophins, normal oestrogen

e.g. PCOS

84
Q

what are the measures of ovarian reserve?

A
  • FSH = raised
  • AMH = low
  • TVUSS = Antral Follicle Count (<4 = poor, 16+ = good)
85
Q

what are the different assisted contraception methods?

A
  1. intrauterine insemination
  2. IVF
  3. intracytoplasmic sperm injection
  4. donor insemination
  5. donor egg with IVF
86
Q

when is intrauterine insemination used?

A
  • idiopathic
  • anovulation unresponsive to OI
  • mild male factor
  • minimal to mild endometriosis
87
Q

what are the indications for IVF?

A

blocked tubes
male minor factor
unsuccessful OI or intrauterine insemination

88
Q

what are the indications for intracytoplasmic sperm injection?

A
  • oligospermia
  • poor fertilisation (DM, erectile dysfunction)
    = most common treatment for male infertility
89
Q

what are the RFs for infertility?

A
  • advanced maternal age
  • smoking/alcohol use
  • obesity
  • irregular periods
  • STI
90
Q

how many couples fail to conceive after 1 year?

A

15%

91
Q

what is the process of ovarian hyperstimulation syndrome?

A
  1. ovaries become hyperstimulated
  2. exposure to hCG
  3. pro-inflammatory mediators
  4. ovarian enlargement, inc vascular permeability, prothrombotic state
92
Q

what are the S/S of OHSS?

A

abdominal pain and distention
nausea and vomiting
SOB
Oedema/Ascites

93
Q

what is the management of OHSS?

A

symptomatic, fluid replacement, VTE prophylaxis

94
Q

bugs causing TSS

A
  • staphylococcus: exotoxin (e.g. TSS toxin 1)

- streptococcus: inflammatory cascade initiation

95
Q

Signs and symptoms of TSS

A
  • fever (>39 degrees)
  • D+V
  • Myalgia
  • Sore throat
  • Desquamation of palms and soles
  • shock
  • diffuse red macular rash
  • headache
96
Q

what is vault prolapse?

A

prolapse of vaginal vault after hysterectomy

97
Q

what are the risk factors for urogenital prolapse?

A
  • increasing age
  • parity
  • menopause
  • obesity
  • pelvic surgery
  • pelvic surgery
  • chronic cough
  • constipation
  • heavy lifting
98
Q

what are the 2 prolapse grading systems?

A
  • POP-Q

- Shaw’s

99
Q

what does POP-Q look at?

A

measures different anatomical landmarks in relation to hymen

100
Q

what does Shaw’s look at?

A
  • looks at extent of descent prolapse
101
Q

what are the degrees of Shaw’s?

A

1st degree: descent at introitus
2nd degree: extends to introitus but past introitus on straining
3rd degree: prolapse descends through introitus

102
Q

Surgical options for uterine prolapse that does not preserve uterus?

A
  • vaginal hysterectomy +/- vaginal sacrospinus fixation
  • vaginal sacrospinus hysteropexy with sutures
  • Manchester repair
103
Q

Surgical options for uterine prolapse that does not preserve uterus?

A
  • vaginal sacrospinus hysteropexy with sutures

- sacro-hysteropexy with mesh

104
Q

what is the surgery for vault prolapse?

A

sacrocolopexy with mesh

105
Q

what is the surgery for anterior or posterior prolapse?

A

anterior/ posterior colporrhaphy (without mesh)

106
Q

what are the conservative measures for prolapse?

A
  • weight loss
  • minimise weight lifting
  • stop smoking
  • pelvic floor exercises
  • topical oestrogens
    + PESSARY
107
Q

what are the RFs for usual type (warty/basaloid SCC)?

A
  • VIN (HPV 16)
  • immunosuppression
  • smoking
108
Q

what are the RFs for differentiated type (keratinised SCC)?

A

lichen sclerosis

109
Q

what are the categories of VIN?

A
  • low grade squamous
  • high grade squamous
  • differentiated (keratinised)
110
Q

what is the management of 1a vulvar cancer?

A

wide local excision +/- chemo

111
Q

what is the management of >1a vulvar cancer?

A

radical vulvectomy + bilateral inguinal lymphadenectomy

112
Q

what are the complications of endometrial ablation?

A
  • general: infection, bleeding, failure, damage to nearby structures
  • minor: cramping, nausea, frequent urination, watery discharge mixed with blood
  • rare: pulmonary oedema
113
Q

what is a total hysterectomy? smears?

A

uterus and cervix

no smears needed

114
Q

what is a radical hysterectomy? smears?

A

removal of structures +/- BSO

no smears

115
Q

what is a subtotal hysterectomy?

A

upper part of uterus removed

NEED SMEAR

116
Q

when is a smear needed for total or radical smear?

A

if total or radical AND due to cancer/CIN, smears done at 6 and 18 months

117
Q

what are the indications for vaginal hysterectomy?

A
  • menstrual disorders with uterus <12 weeks
  • micro invasive cervical carcinoma
  • uterovaginal prolapse
118
Q

what are the indications for abdominal hysterectomy?

A
  • larger masses
  • carcinoma
  • if pelvis is frozen
  • symptomatic fibroid uterus 12w+
119
Q

what is the indication for a hysteroscopic myomectomy?

A

fibroids on inner wall

120
Q

what is the indication for a laparoscopic myomectomy?

A

removing 1 or 2 fibroids <2 inches that are growing outside uterus

121
Q

what is the indication for an open myomectomy?

A

large fibroids
many fibroids
fibroids deep into uterine wall

122
Q

what is the MOA of levonorgesterol?

A
  • stops ovulation, inhibits implantation
123
Q

dosing of levonorgesterol

A

1.5mg (double dose if overweight)
>1 use in each cycle
if vomiting within 2 hours, repeat dose

124
Q

what is the MOA of ulipristal acetate?

A

selective progesterone receptor modulator

inhibits ovulation

125
Q

dosage of ulipristal acetate

A

30mg

126
Q

cautions with ulipristal acetate

A

not to be used alongside levonorgestrel
severe asthma
restart hormonal contraception 5 days after
vomiting within 3 hours, repeat dose

127
Q

how does the COCP work?

A

prevents ovulation

128
Q

what does COCP inc/dec the risk of?

A
  • decreased risk of ovarian, endometrial and bowel cancer

- increased risk of VTE, breast, cervical cancer

129
Q

what should be done with the COCP regarding surgery?

A

stops 4 weeks before surgery
restart 2 weeks after
switch to POP

130
Q

how can you explain the COCP VTE risk to patients?

A

instead of 1 person in Wembley stadium getting a blood clot, 2 people will

131
Q

what is the MOA of POP?

A
  • thickens cervical mucous

- antibiotics = no effect

132
Q

what does the POP increase the risk of?

A
  • increased risk of osteoporosis and ovarian cysts
133
Q

what is the window for taking cerazette?

A

12 hours

134
Q

what are the precautions if the patch is changed late but within 48 hours?

A

change immediately, no further precautions

135
Q

what is the MOA of the hormonal ring?

A

thickens cervical mucous

prevents ovulation

136
Q

what is the MOA of LNG-IUS

A
  • prevents endometrial thickening

- thickens cervical mucous

137
Q

what is the MOA of the implant?

A
  • prevents ovulation, thickens cervical mucous
138
Q

what is a contraindication for the implant?

A

IHD

139
Q

when can you fit the IUD/IUS post-partum?

A

within 48 hours of childhood OR after 4 weeks

140
Q

when should COCP/injection be stopped in women?

A

> 50 years

switch to POP/IUS/implant

141
Q

what are the bimanual findings in adenomyosis?

A

bulky boggy uterus

142
Q

what are the USS findings of adenomyosis?

A

haemorrhage-filled distended endometrial glands

143
Q

what is the gold standard investigation in adenomyosis?

A

MRI pelvis

144
Q

what is the FIGO staging in endometrial cancer?

A 
I = uterus
II = uterus + cervix
III = adnexa
IV = distant mets/bladder/bowel
145
Q

what is the FIGO staging in ovarian cancer?

A 
I = ovaries
II = pelvic extension (uterus)
III = abdo extension (extra pelvic)
IV = distant mets
146
Q

what is the FIGO staging in cervical cancer?

A 
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
Q

what are the USS findings in follicular cysts?

A

thin walled
unilocular
anechoic

148
Q

what are the USS findings of corpus luteal cysts?

A

diffusely thick wall
<3cm
lacy pattern

149
Q

what are the USS findings in theca lutein cysts?

A 
ass/ w/ pregnancy
bilaterally enlarged
multicystic ovaries
thin walled
anechoic
150
Q

what are the 2 types of inflammatory cysts?

A
  • tubo-ovarian abscess

- endometrioma

151
Q

what is tubo-ovarian abscess?

A

PID, tender adnexal mass

USS: ovary and tube cannot be distinguished from mass

152
Q

what is an endometrioma?

A

chocolate cyst

associated with endometriosis

153
Q

USS findings of endometrioma

A

unilocular

ground glass echoes

154
Q

what are the types of dermoid cyst?

A

mature

immature

155
Q

mature dermoid cyst findings

A 
benign, solid, cystic
USS: 
- unilocular, 
- diffusely echogenic, 
- may contain teeth
- no internal vascularity
156
Q

what are the features of immature dermoid cysts?

A

contain embryonic elements

malignant

157
Q

serous cystadenoma USS findings

A

unilocular
anechoic
no flow on colour doppler

158
Q

mucinous cystadenoma USS findings

A

multiloculated
many thin separations
low echogenicity due to mucin

159
Q

what is a Brenner’s tumour?

A

small urothelial like epithelium

160
Q

what are the USS findings of Brenner’s tumour?

A

hypoechoic

some calcifications

161
Q

primary causes of amenorrhoea

A
  • Turner’s
  • Testicular feminisation
  • CAH
  • congenital malformation of genital tract
162
Q

what are the secondary causes of amenorrhea?

A
  • hypothalamic
  • PCOS
  • hyperprolactinaemia
  • POI
  • thyrotoxicosis
  • Sheehan’s
  • Asherman’s
163
Q

what are the 3 stages to the menstrual cycle?

A
  • proliferative
  • secretory
  • menstrual
164
Q

what is the proliferative phase?

A

hyperplasia of endometrium

165
Q

what is the secretory phase?

A

maintain endometrium

166
Q

what is the menstrual phase?

A
  • drop in progesterone
  • zona compacta
  • spongiosa shedding
167
Q

what do theca cells respond to? what do they produce?

A

respond to LH

produce androgen

168
Q

what do granulosa cells respond to? what do they produce?

A

respond to FSH
produce aromatase (convert androgen to oestriol)
produce progesterone

Cross reference - year 5 (22 decks)

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