Gynaecological problems Flashcards by Tom Grainger

How should the increased risk of endometrial hyperplasia in PCOS be managed?

Progestogens should be used to induce a withdrawal bleed at least every 3-4 months

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How should women with PCOS be screened for T2DM?

If they have both PCOS and are overweight or have PCOS plus additional risk factors, they should be offered an OGTT

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What is the link between PCOS and both breast and ovarian cancers?

There does not appear to be an association between PCOS and breast and ovarian cancer

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What are the Rotterdam criteria for diagnosis of PCOS?

polycystic ovaries with either 12 or more follicles, or ovarian volume >10cm
Oligo-ovulation or anovulation
Clinical and/or biochemical signs of hyperandrogenism

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How can CAH be investigated for in rapidly progressing hirsuitism?

17-Hydroxyprogesterone is measured in the follicular phase and will be raised in CAH

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If 17-hydroxyprogesterone is borderline, which test is used to confirm diagnosis of CAH?

ACTH stimulation test

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What is the incidence of symptomatic ovarian cysts in premenopausal women being malignant?

1:1,000

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What percentage of suspected ovarian masses are ultimately found to be non-ovarian in origin?

10%

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What is the management of a simple ovarian cyst <50mm in a pre-menopausal woman?

Conservative: the majority will resolve over 2-3 menstrual cycles without intervention

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What is the role of LDH, afp and hCG measurement in evaluation of cysts in pre-menopausal women?

Should be undertaken for all women under 40 with complex ovarian mass due to the risk of germ cell tumours

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CA125 is primarily a marker for which ovarian cancer?

Epithelial ovarian carcinoma

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Which scoring system does GTG advocate for assessing risk of malignancy and how is it calculated?

RMI 1:
RMI = U x M x CA125

1 point for premenopausal, 3 points for postmenopausal
1 point for ultrasound score 1, 3 points for ultrasound score 2-5

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What are the sensitivity and specificity of using RMI 200 as a cut off for malignancy?

Sensitivity 78%
Specificity 87%

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What are the sensitivity and specificity of using IOTA rules for classifying masses as benign or malignant?

Sensitivity 95%
Specificity 91%

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What are the M-rules for IOTA classification?

Irregular solid tumour
Ascites
At least 4 papillary structures
Irregular multilocular solid tumour with largest diameter >=100mm
very strong blood flow

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How should premenopausal women with simple cysts of 50-70mm be managed?

With yearly followup ultrasound

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How should premenopausal women with simple cysts >70mm be managed?

Either MRI or surgical management

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How should women with a cyst growing between interval scans be managed?

RMI score followed by operative management

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What is the effect of COCP on functional ovarian cysts?

COCP does not promote the resolution of functional ovarian cysts

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What is the range of recurrence rate for ovarian cysts following needle aspiration?

Between 53-84%

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What are the first and second line investigations for pre-menstrual syndrome?

Symptom diary
GnRH analogues for 3 months

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What 3 treatments should be trialed in primary care prior to secondary referral for pre-menstrual syndrome?

COCP
Vitamin B6
SSRI

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Which COCPs should be considered first line for pre-menstrual syndrome?

Drospirenone-containing COCP

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Should COCP be taken continuously or cyclically for women with PMS?

Continuously

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Which medications need to be used with caution for women with PMS?

Progestogens (though micronised progestogens may be better)

Which medication given for PMS requires barrier contraception and why?

Danazol; it may cause virilisation of a female fetus

Which monitoring test is required for women on long term GnRH analogues for PMS and how often?

DEXA should be performed yearly

What advice should women on SSRIs for PMS be given when they fall pregnant?

They should stop SSRIs in pregnancy as their PMS symptoms will cease

Why is bilateral oophorectomy without hysterectomy not recommended for management of PMS?

This would necessitate progesterone replacement for endometrial protection and would risk stimulating PMS

What percentage of women experience symptoms of PMS?

40%

Of women who experience PMS, what percentage (range) suffer from severe PMS?

5-8%

What is the most reliable questionnaire used for a PMS symptoms diary called?

The Daily Record of Severity of Problems

What is the daily dose of Vitamin B6 restricted to and why?

10mg due to risk of peripheral neuropathy at higher doses

What should women be warned of when using the Levonorgestrel-releasing IUS for the progestogenic component of PMS treatment?

The low levels of progesterone in the coil may initially cause some PMS symptoms

Which diuretic can be used for PMS symptoms?

Spironolactone

What is the lifetime prevalence of fibroids?

30%

Aside from ethnicity, what are the risk factors for development of fibroids?

Obesity Nulliparity

What proportion of women with fibroids are symptomatic?

25%

By what percentage did fibroids shrink after 12 weeks of GnRH treatment in the Cochrane review?

36%

Why is Ullipristal Acetate no longer used for uterine fibroids?

Long term usage carriers a risk of liver failure

What is the Odds Ratio for reintervention after uterine artery embolisation compared to myomectomy?

10.45

How should a unilocular, simple ovarian cyst of less than 5cm diameter be managed in a postmenopausal woman, when the CA125 is low?

Surveillance ultrasound at 4-6 months Can discharge after 1 year if no interval growth

What operation should be performed for a symptomatic postmenopausal woman with a simple, low risk cyst?

Laparoscopic bilateral salpingo-oophorectomy

What operation should be performed for a postmenopausal woman with RMI I >200?

Staging laparotomy

CA125 is raised in over 80% of which ovarian cancers?

Epithelial ovarian cancer

CA125 is not usually raised in which type of ovarian cancer?

Primary mucinous ovarian cancer

CA125 alone has a pooled sensitivity and specificity of what for differentiating benign from malignant masses?

78%

What are the 5 features of simple cysts on TVUSS?

1. Round or oval shape 2. Thin or imperceptible wall 3. Posterior acoustic enhancement 4. Anechoic fluid 5. Absence of septations or nodules

What are the 3 ultrasound features of complex ovarian cysts?

1. Complete septation 2. Solid nodules 3. Papillary projections

What percentage of simple cysts <5cm in postmenopausal women will disappear by 24 months?

53%

What features on ultrasound contribute to the "ultrasound score" portion of RMI?

Multilocular Solid areas Metastases Ascites Bilateral lesions

What is the sensitivity and specificity of RMI when a cutoff off 250 is used?

70% sensitivity and 90% specificity

What should be included in staging laparotomy?

Laparotomy Cytology from either ascites or washings TAH, BSO and omentectomy Biopsies from any suspicious areas

What 5 criteria can be used to stratify risk of ovarian torsion?

1. Unilateral lumbar or abdominal pain 2. Pain duration <8 hours 3. Vomiting 4. Absence or leucorrhea/metorrhagia 5. Ovarian cyst >5cm

Ovarian cysts are seen in what percentage of pregnancies?

up to 5%

How should cystectomy be performed in the context of torsion?

Interval cystectomy 2-3 weeks after detorsion

What proportion of TOAs occur in nulliparous women?

60%

What is the mortality rate of TOA when associated with severe systemic sepsis?

5-10%

What proportion of women being treated for proven PID will be diagnosed with a TOA?

15-35%

Which two symptoms/signs are more common in women with TOA than PID?

Fever Diarrhoea

What is the most sensitive predictor of a TOA?

High CRP along with clinical signs

What is a cogwheel sign thought to be pathognomonic of?

Acute tubal inflammation (as seen in TOA)

Which CT finding is usually associated with bowel-associated abscesses and is uncommon in TOA?

Internal gas bubbles

What structure, if seen entering an adnexal mass on CT, allows for differentiation between TOA and periappendicular abscess?

The ovarian vein

Which antibiotics have higher abscess cavity penetration and have been shown to reduce abscess size?

Clindamycin Metronidazole Cefoxitin

Which factors are associated with poor prognosis for recovery after TOA?

Abscess >5cm Age >40 Smoking Higher initial WCC

What is the likelihood of postmenopausal women with TOA having an associated malignancy?

47%

Why rare complications of TOA should be imaged for in women who do not improve following surgery with sustained pyrexia?

Subphrenic abscess Intrathoracic abscess

What percentage of women with TOA who undergo percutaneous drainage are able to avoid surgery?

81%

Risk of pregnancy when removing an IUS/IUD from a woman with TOA should be considered if the women has had unprotected intercourse within how many days?

Which antibiotics does Actinomyces commonly respond to?

Penicillin

Approximately what percentage of women on HRT will experience unscheduled bleeding?

40%

What are the major risk factors for endometrial cancer?

BMI >=40 Lynch syndrome Cowden syndrome

What are the minor risk factors for endometrial cancer?

BMI 30-39 Diabetes PCOS

What are the options for progesterone regimes used as part of sHRT for women with a uterus?

minimum 10 days Norethisterone/Provera or 12 days micronised progesterone

When should women be changed from sHRT to ccHRT?

After 5 years use or by age 54

How should a woman with unscheduled bleeding on HRT with no risk factors, occuring within 6 months of starting HRT or persisting 3 months after a change in HRT be assessed/managed?

Offer adjustments in the HRT or Progesterone preparation for up to 6 months

How should a woman be managed if she has unscheduled bleeding persisting beyond 6 months of HRT adjustments in the absence of risk factors?

Offer either: a. Urgent TVUSS within 6 weeks b. Wean off HRT and consider non-hormonal options

How should a woman be managed if unscheduled bleeding occurs more than 6 months after starting or more than 3 months after changing HRT, in the absence of risk factors?

Urgent TVUSS within 6 weeks

How should a woman be managed if she has unscheduled bleeding on HRT that either is heavy/prolonged, or if she has 2 minor risk factors for endometrial cancer?

Offer urgent TVUSS within 6 weeks

How should a woman with unscheduled bleeding on HRT with 1 major or >=3 minor risk factors for endometrial cancer be assessed/managed?

2WW referral Adjust progestogen or stop HRT whilst awaiting assessment

How long can a woman be reassured by a normal pipelle endometrial biopsy?

3 months

How long can a woman be reassured following normal hysteroscopy and endometrial biopsy?

6 months

What is the most effective way of reducing unscheduled bleeding on HRT?

52mg LNG-IUS (Mirena)

How is chronic pelvic pain defined

Pelvic pain lasting >6 months and not solely associated with intercourse or menstruation

What is the evidence for adhesiolysis in management of chronic pelvic pain?

There is no evidence to support division of fine adhesions Division of dense vascular adhesions is associated with pain relief and should be offered

Injury to which muscles may result in chronic pelvic pain which in some cases can be relieved with botox injection?

Levator ani

What is the percentage risk of nerve entrapment following one Pfannenstiel incision?

3.7%

Women experiencing bloating, early satiety, pelvic pain or urinary frequency or urgency more than how many times per month should have CA125 measured?

>12 times per month

Which smooth muscle relaxant may be beneficial for chronic pelvic pain related to IBS?

Mebeverine

By what percentage of size can fibroids be expected to shrink by 12 weeks after Goserelin injection?

35%

What is the risk of RPOC following SMM?

What is the risk of ureteric injury at laparoscopic resection of endometriosis with associated hydronephrosis?

20%

What are the IOTA B-rules?

Unilocular cyst Presence of solid components where the largest solid component is <7mm Presence of acoustic shadowing Smooth multilocular tumour with a largest diameter <100mm

What are the IOTA M rules?

Irregular solid tumour Ascites At least 4 papillary structures Irregular multilocular solid tumour with largest diameter >100mm Very strong blood flow

What percentage of women will have vaginal discharge within 12 months of having uterine artery embolisation?

15%

What percentage of women will be asymptomatic or have significantly improved symptoms at 1 year post uterine artery embolisation?

80-90%

What proportion of women will need repeat treatment within 5 years of uterine artery embolisation?

1 in 3

What are the contraindications to uterine artery embolisation?

Pregnancy PID

What is the rate of endometritis following uterine artery embolisation?

0.5%

What is the rate of hysterectomy following uterine artery embolisation?

2.9%

What side effect is associated with high doses of vitamin B6?

Peripheral neuropathy

What is the rate of haemorrhage at hysterectomy for benign conditions?

23 in 1,000 (common)

What are the risks associated with HRT?

VTE Stroke Breast cancer Endometrial cancer Ovarian cancer Gallbladder disease

Gynaecological problems Flashcards

(105 cards)