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Flashcards in Gynaecology 1 Deck (177):
1

What days is menstruation during the menstrual cycle?

1-4

2

What is the first half of the menstrual cycle called? What days is it? What hormone predominates?

Proliferative (follicular) phase days 5-13
Oestrogen predominates to thicken the endometrium
FH > LSH

3

What hormonal change marks oocyte release from a follicle and what day is this?

LH surge on 14 days (matches up with oestrogen bump)

4

What is the second half of the menstrual cycle called? What days is it? What hormone predominates?

Proliferative (luteal) phase days 14-28
Progesterone dominates to form a secretory endometrium
LH > FSH relatively

5

Define irregular periods?

Outside normal range of 23-35 days, variability of >7 days between shortest and longest

6

What is oligomenorrhoea?

Infrequent periods, between 35 days - 6m

7

What is primary amenorrhea?

Periods never start by age 16

8

What is secondary amenorrhea?

Periods stop for > 6m

9

What is Postmenopausal bleeding?

Bleeding that occurs >1 year after LMP

10

What is the objective definition of menorrhagia but what is normally considered?

>80ml blood loss in one normal period, which could lead to an IDA
Normally just when heavy enough to interfere with everyday life

11

Most common causes of menorrhagia?

Idiopathic
Fibroids
Polyps

12

What does tenderness when examining for menorrhagia indicate?

More likely adenomyosis

13

3 most appropriate investigations for menorrhagia?

TVUSS +/- endometrial pipelle biopsy +/- hysteroscopy

14

First line management for menorrhagia if patient not wanting to get pregnant?

Mirena coil IUS

15

What drugs are second line for menorrhagia after IUS/if fertility desired?

Tranexamic acid, an antifibrinolytic
NSAIDs

16

What is third line management for menorrhagia?

Progestogens to induce artificial amenorrhea
GnRH analogues to induce artificial menopause

If fail, surgery

17

Most common causes of irregular periods and IMB?

Fibroids, adenomyosis
Polyps
Ovarian cysts
PID

18

What are more likely causes of IMB and irregular menses in older women?

Endometrial, ovarian and cervical cancer

19

What drugs can be given to induce artificial amenorrhea and are therefore used for menorrhagia, IMB, irregular menses and occasionally dysmenorrhea?

Progestogens and CoCP

20

First line management for menstrual disturbance when fertility not required?

IUS or CoCP

21

Physiological causes of amenorrhea?

Pregnancy
Lactation

22

6 areas of causes of amenorrhea/oligomenorrhoea?

Drugs e.g. Progestogens, GnRH agonists, antipsychotics
Hypothalamic hypogonadism
Pituitary - hyperprolactinaemia
Adrenals/thyroid - hypothyroidism
Ovary - PCOS, prem menopause, Turners
Outflow tract disturbance

23

3 most common causes of amenorrhea/oligomenorrhoea? Which most commonly causes oligomenorrhoea?

PCOS - normally oligo
Premature menopause
Hyperprolactinaemia

24

What can hypothalamic hypogonadism be caused by?

Losing loads of weight, anorexia, exercise

25

Is PCB ever 'normal'? What are the most common causes?

No
Most commonly cervical e.g. Ectropion, polyps, Cancer
Can be atrophic vaginitis in older women

26

Why does dysmenorrhea happen and what are the 2 types?

High prostaglandins causing contraction and uterine ischaemia
Primary = no organic cause
Secondary = secondary to pelvic pathology

27

Characteristics of primary dysmenorrhea?

No organic cause
Normally at start of menstruation
Often responds to NSAIDs or ovulatory suppression (COCP)

28

Most common causes of secondary dysmenorrhea?

Fibroids
Adenomyosis, endometriosis
PID

29

Characteristics of secondary dysmenorrhea?

Often precedes menstruation
Commonly coexists with deep dyspareunia, menorrhagia, irregular menses
Requires PUS and laparoscopy

30

What is the premenstrual syndrome?

Sx worsening in luteal phase of cycle, resolve by end of menstruation
Tension, irritability, aggression, depression
IBS like symptoms, breast pain

31

Management of premenstrual syndrome?

SSRIs (duloxetine) are useful
Cycle ablation - COCP, GnRH analogues with add back HRT

32

What is the relationship between fibroids and adenomyosis?

Fibroids (leiomyomata) are benign myometrial tumours
Adenomyosis is endometriosis which deposits within the myometrium
Both can cause menorrhagia, irregular/IMB, dysmenorrhea

33

What effect does progesterone have on the endometrium and how does it relate to menstruation?

Causes gland swelling and vascularisation
Falls at the end of the cycle causing decrease in blood supply, ischaemia and menstruation

34

What do fibroids depend on for growth and therefore what is protective against them?

Oestrogen and progesterone (so common just pre-menopause and normally regress during pregnancy, post-menopause)
Pregnancy, COCP, Progestogens are protective

35

3 types of fibroids and how do they relate to polyps?

Subserous fibroids
Intramural fibroids
Submucosal fibroids
Intracavity polyps
Subserous polyps

36

What polyps and fibroids are related in terms of location and symptomlogy?

Intracavity polyps and submucosal fibroids both push into uterine cavity
Subserous fibroids and subserous polyps both push out of uterus and make the outside of it bumpy

37

When can fibroids grow during pregnancy and what problems can arise?

Can grow mid-pregnancy second trimester
-> preterm labour, malpresentation, transverse lie, PPH
Red degeneration (severe pain)
Pedunculated fibroid torsion

38

What is the cancerous change that arises from fibroids?

Leiomyosarcoma

39

Why can Hb be high with fibroids?

They can secrete erythropoietin

40

Investigations for fibroids?

TVUS +/- MRI +/- laparoscopy

41

Medical management of fibroids if not trying to conceive?

GnRH agonists to induce temporary menopause with add back HRT

42

Alternative surgical management for fibroids if wanting to preserve fertility?

Pretreatment GnRH agonists followed by hysteroscopy and TCRF for submucosal/intracavity polyp
Myomectomy - open laparotomy or laparoscopic for intramural/subserous

43

What is umbilical artery embolization UAE used for?

Fibroids shrinkage in those that don't want kids

44

What can haematometra occur as a result of?

Fibrosis post-endometrial resection, cone biopsy
Carcinoma
Congenital malformation or imperforate hymen (1* amenorrhea)

45

What is the commonest genital tract cancer in women?

Endometrial cancer

46

Who does endometrial cancer occur most commonly in?

Older women > 60

47

What histological type are the majority of endometrial cancers?

Adenocarcinoma of columnar endometrial gland cells

48

What is the major risk factor for endometrial cancer and what 2 types can this broadly be split into?

Unopposed oestrogen/high oestrogen:prog ratio
Split into exogenous and endogenous oestrogen excess

49

Exogenous oestrogen RFs for endometrial cancer?

Tamoxifen for breast cancer
Unopposed oestrogen therapy

50

Endogenous oestrogen sources as risk factors for endometrial cancer?

Obesity (androgen->oestrogen conversion)
PCOS
Nulliparity
Late menopause
Oestrogen secreting (ovarian) tumours

51

What is Lynch type II syndrome?

Hereditary Non-Polyposis Colorectal Cancer
Risks of colorectal, endometrial and ovarian cancer

52

What is the premalignant disease for endometrial cancer?

Endometrial hyperplasia with atypia
Requires hysterectomy if possible

53

What is the biggest presenting picture for endometrial cancer?

PMB - increasing likelihood of cancer with age
If pre-menopausal - rare but IMB/irregular menses or oligomenorrhoea

54

What cervical pathology may coexist with endometrial cancer?

Cervical Glandular Intraepithelial Neoplasia CGIN

55

How is FIGO staging for endometrial cancer carried out?

USS + endometrial pipelle biopsy +/- hysteroscopy
Staging can only be done post-hysterectomy

56

Stages for endometrial cancer?

Stage 1 - uterus only (75% at presentation)
Stage 2 - uterus and cervix
Stage 3 - invasive through uterus into adnexae, vagina, LNs
Stage 4 - bowel or bladder spread or distant mets

57

Stage 1 management for endometrial cancer?

H+BSO
If turns out subsequently to be stage 3 -> ?radiotherapy

58

Recurrence for endometrial cancer?

Most commonly vaginal vault - VGIN

59

Moist Smelly Stuff is Gynae Basics of gynae history?

Menstrual questions
Sexual Hx
Smear Hx
Genitourinary Sx incl discharge
Bowel Sx

60

What is cervical ectropion?

Visible endocervical columnar epithelium as redness around external os
More common during pregnancy, COCP

61

Other than asymptomatic, how can cervical ectropion present?

Discharge
Post-coital bleeding

62

Management of cervical ectropion?

Cryotherapy after exclusion of carcinoma by smear/colposcopy

63

What is chronic cervicitis?

A common cause of discharge, often due to chronic STI of cervical ectropion

64

What are cervical polyps?

Benign endocervical epithelial tumours most common in older women

65

Apart from asymptomatic, how can cervical polyps present?

Post-coital bleeding, Intermenstrual bleeding

66

Management of cervical polyps?

Avulsion + histological analysis

67

What are Nabothian follicles?

Columnar cell secretions trapped under squamous epithelium leading to white/opaque swellings in ectocervix. Commonly asymptomatic

68

What is the most common histological type of cervical cancer?

Squamous cell carcinoma

69

What are CIN I-III and what do they represent?

Dysplasia of cervical intraepithelial cells; I is atypical cells at lower 1/3 of epithelium only, II is 2/3 and III is full thickness

70

What is another term form CIN III and how does it progress to malignant disease?

Carcinoma in situ -> invasion through basement membrane

71

What HPV serotypes are most implicated in cervical cancer?

16, 18, 31 and 33

72

Besides HPV RFs, RFs for cervical cancer?

Smoking
Immunocompromise

73

What is the screening programme for cervical cancer?

3 yearly from 25-49
5 yearly from 49-64

74

What is the lowest level of dyskaryosis in CIN which, when combined with a positive HPV titre, should prompt a colposcopy?

CIN I + positive HPV -> colposcopy

75

What is HPV screening used for in CIN?

As HPV triage and also test of cure

76

What can presence of CGIN indicate?

Cervical/endometrial adenocarcinoma so should prompt colposcopy and endometrial biopsy

77

What do confirmed CIN II and III have to be treated with? What risk does this hold for future pregnancies?

LLETZ
Slight risk of preterm labour in future

78

Other than asymptomatic, how can cervical cancer present?

PCB, IMB, PM, offensive discharge
Pain, GI/GU Sx

79

FIGO stage 1-4 for cervical cancer?

1 - cancer confined to cervix
2 - local spread into vagina but not pelvic side wall
3 - spread to lower vagina or pelvic walls or ureteric obstruction
4 - invasion of bladder, rectum or beyond

80

Management of cervical cancer with increasing grade at presentation?

Come biopsy/hysterectomy -> radical hysterectomy -> chemo/radiotherapy

81

What are common ovarian symptoms?

None! Often silent
With increasing size, can eventually cause abdominal distension and bloating

82

What is an ovarian accident?

Acute rupture, haemorrhage, torsion or infarct of an ovarian mass (usually cyst)

83

What is PCO?

Term descriptive of the characteristic TVUS appearance: >12 small follicles in an enlarged ovary

84

What can prompt a woman with PCO to develop PCOS?

Weight gain

85

Major diagnostic features of PCOS?

Anovulation
Hirsutism either clinically or as high serum testosterone
Oligomenorrhoea/irregular periods
PCO on TVUS

86

What is the pathophysiological background of PCOS?

Genetic susceptibility leading to increased LH production and peripheral insulin resistance
LH and insulin act on PCO causing ovarian androgen production and disruption of folliculogenesis

87

What FH condition is common with PCOS?

DM2

88

3 long term risks of PCOS?

Endometrial cancer (anovulation leading to unopposed oestrogen)
DM2
GDM and miscarriage during pregnancy

89

First line management of PCOS?

Lifestyle - weight loss

90

Management of PCOS if wanting fertility?

Clomifene
Metformin
Gonadotrophins, IVF

91

Management of PCOS if fertility not desired?

Symptomatic relief - COCP or Mirena to regulate menstruation and treat hirsutism
Anti androgens (systemic or topical)

92

What is premature menopause defined as?

Menopause before age of 40

93

What is the most common congenital cause of gonadal dysgenesis?

Turners syndrome 45XO

94

What are the 3 major types of primary ovarian carcinoma?

Epithelial tumours
Germ cell tumours
Sex cord tumours

95

What are the most common malignant primary ovarian cancers?

Epithelial cell cancers - serous cystadenoma/adenocarcinoma

96

What are the 5 types of ovarian epithelial carcinoma?

Serous cystadenoma
Mucinous cystadenoma
Endometrioid carcinoma
Clear cell carcinoma
Brenner tumour

97

From what ovarian tumour can pseudomyxoma peritonei originate?

Borderline mucinous cystadenoma

98

In whom are germ cell ovarian tumours more common?

Women under 30

99

2 types of germ cell ovarian tumour? What is the most common malignant ovarian cancer in younger women?

Teratoma/dermoid cyst
Dysgerminoma (most common)

100

3 types of ovarian sex cord tumour?

Granulosa cell tumours
Thecomas
Fibromas

101

What do granulosa cell tumours secrete?

Oestrogen and inhibin
Thus causing endometrial hyperplasia/cancer or precocious puberty

102

What is Meig's syndrome?

Fibroma, ascites and right sided pleural effusion

103

What are the 2 most common primary sites for ovarian secondary malignancies?

Breast
GI cancers

104

2 major cyst conditions of ovaries?

Endometriotic (chocolate) cysts
Functional cysts - follicular/lutein cysts

105

What is protective vs functional ovarian cysts?

COCP

106

RFs for ovarian cancer?

Related to increasing number of ovulations:
Early menarche
Late menopause
Nulliparity

107

Protective factors against ovarian cancer?

Pregnancy
Lactation
COCP

108

Familial links for ovarian cancer?

BRCA 1+2
HNPCC (lynch syndrome type II)

109

What 3 cancers is lynch II (HNPCC) implicated in?

Ovarian
Endometrial
Colorectal

110

What common GI disease manifestation does ovarian cancer often mimic?

IBS

111

What is used to assess ovarian cancer possibility in secondary care? How is it calculated?

Risk of Malignancy Index
RMI = Ca125 x US x Menopausal Status

112

What specific bloods may be useful to investigate ovarian cancer in women under 40 at increased risk of germ cell tumours?

Alpha feto-protein
hCG

113

Cut off RMI value for referral to specialist MDT?

250

114

FIGO staging for ovarian cancer?

1 ovarian only
2 beyond ovaries but pelvis only
3 beyond pelvis but abdomen only
4 beyond abdomen

115

3 general areas of causes of pruritis vulvae?

Infection
Dermatological
Neoplasia

116

Which of the lichen conditions most mimics dermatitis or eczema?

Lichen simplex

117

Which of the lichen conditions mostly affects mucosa (mouth and genital)?

Lichen planus - causing painful, erosive flat papules

118

Which of the lichen conditions has an autoimmune link and may be associated with thyroid disease and vitiligo?

Lichen sclerosus

119

Who does lichen sclerosus mostly affect and how does it present?

Postmenopausal women
Severe pruritis -> thinning skin, adhesions, fissures
Labial fusion and introital narrowing

120

Which of the lichen conditions carries a risk of vulval carcinoma?

Lichen sclerosus

121

What do Bartholin's glands normally do? How do they form cysts/abscesses?

Normally secrete lubricant for vulva
Blockage leads to cyst formation, can become infected with staph/E coli etc.

122

How do bartholin's gland abscesses present?

Acute pain, large red tender swelling

123

What is the drainage method for bartholin's gland cysts called?

Incise, drain and leave open (marsupialisation)

124

In what age is primary dysmenorrhea most common? When does it tend to recede?

15-25, symptoms decrease with age and tend to stop after childbirth

125

Pain associated with primary dysmenorrhea?

Crampy pains starting within 24 hours of menstruation, stop within 2-3 days

126

In what age is secondary dysmenorrhea most common?

Over 30s

127

What device can cause secondary dysmenorrhea within first few months of insertion?

IUD

128

Pain associated with secondary dysmenorrhea?

Starts at least 2 days before menstruation and continues whole way through
Associated with other Sx e.g. Dyspareunia

129

Metabolic cause of menorrhagia?

Hypothyroidism

130

What is the general cause of physiological leucorrhoea? Relation to causes of increased discharge?

High oestrogen
So increased in pregnancy, CoCP, around time of ovulation

131

What medical procedure can encourage growth of follicular ovarian cysts?

Clomiphene ovulatory induction

132

What ovarian benign ovarian cysts can secrete lots of oestrogen?

Follicular cysts

133

What 3 item criteria is used to define PCOS? What are they?

Rotterdam criteria
PCO as defined by at least 12 follicles or increased ovarian size
Oligo/anovulation
Clinical or biochemical evidence of hyperandrogenism

134

What is co-cyprindol?

Drug used for symptom management of PCOS

135

2 drugs suitable for PCOS in women wanting to get pregnant?

Metformin
Clomiphene

136

What cancer is PCOS a risk factor for?

Endometrial

137

Large doughy uterus, uterine contractions with persistent bleeds and expulsion of grape like material. Diagnosis?

Molar pregnancy

138

What is ptyalism?

Excessive salivation

139

What does an unsatisfactory cervical smear result mean?

Incorrect processing or not enough cells
Repeat in 4 weeks

140

What does an inconclusive cervical smear result suggest?

Infection - treat and repeat

141

What happens if woman has normal smear but is positive for HPV?

Retest every 6m til negative
Then yearly for 2 years
Then 2 yearly

142

With what infection is strawberry cervix associated with?

Thrichomoniasis

143

Differentials for cervical motion tenderness/cervical excitation?

Classical of PID
To a lesser extent ectopic pregnancy

144

Boggy, tender uterus on Bimanual exam?

Adenomyosis
Uterine atony (postpartum)

145

Differentials for an adnexal mass on bimanual?

Ovarian - cysts, tumours, PCOS
Ectopic pregnancy
Abscess

146

Which of gonorrhoea and chlamydia in women typically causes malodourous, purulent discharge?

Chlamydia

147

4 infections detectable via high vaginal swab?

BV
Trichomonas
Candida
Group B Strep

148

2 infections detected by endocervical swab? Which uses charcoal media?

Gonorrhoea (charcoal media)
Chlamydia

149

What is more suggestive of PID than endometriosis?

Fever
Vaginal discharge

150

What type of cervical cancer is associated with COCP use?

CGIN

151

What is virilisation?

Mega high androgens (e.g. From adrenal hyperplasia or androgen secreting tumour) causing irreversible male changes in women e.g. Clitoromegaly and vocal deepening

152

What is the difference between virilisation and hirsutism?

Both hyperandrogenism but hirsutism is milder and reversible
Virilisation mega and irreversible

153

What is acanthosis nigricans?

Darkly pigmented velvety skin in skin flexures (nape of neck, skin folds, elbow creases) associated with PCOS and DM

154

What skin change may be associated with DM and PCOS?

Acanthosis nigricans

155

What is the progestogen challenge test used for?

5 day course of prog should induce withdrawal bleed when stopped - used for detecting patency of connection between uterus cervix and vagina and an oestrogenised uterus

156

What 2 conditions can progestogen challenge test highlight?

Asherman's syndrome
Cervical stenosis

157

What heart auscultation findings are common in pregnancy?

Ejection systolic murmur and S3 gallop due to hyperdynamic circulation

158

What does uterine fibroid embolization herald a risk of in future?

Premature ovarian failure - 1%

159

What pregnancy interval is a RF for pre-eclampsia?

10 years (likely nulliparity)

160

How can vaginal pH be used to differentiate between causes of vaginal discharge?

BV and trichomonas have alkaline pH (>4.5)
Candida has acidic or normal

161

What pH do BV and trichomonas share?

Over 4.5 alkaline

162

What does asymmetric IUGR suggest?

Placental insufficiency

163

What is granuloma inguinale?

Painless slow growing ulcerative lesions with no regional lymphadenopathy caused by Klebsiella granulomatis

164

Painless, slow growing genital ulcer with no associated regional lymphadenopathy?

Granuloma inguinale

165

Sx associated with lymphogranuloma?

Unilateral tender inguinal or femoral lymphadenopathy
Self limiting, papule like ulcer

166

Unilateral tender inguinal and femoral lymphadenopathy with papule-like ulcer?

Lymphogranuloma

167

What Ix is best for detecting early Syphillis infection from lesion exudate or tissue?

Darkfield examination

168

What is Darkfield examination used for?

Early Syphillis infection isolate from tissue exudate

169

Sx of chancroid?

Painful general ulcer with tender suppurative lymphadenopathy

170

Painful genital ulcer plus tender suppurative lymphadenopathy?

Chancroid

171

7 steps of vertex delivery?

Engagement
Descent
Flexion of head
Internal rotation
Extension and restitution
External rotation
Expulsion

172

Describe complete hyatid moles?

Diploid (46 chromosomes) with paternal origin only
No Fetal tissue
Higher risk of need for chemo

173

Describe partial hyatid moles?

Triploid - 69 chromosomes with full paternal and half maternal
Identifiable Fetal tissue

174

3 early pregnancy Sx of hyatid moles?

Early hyperthyroidism, pre-eclampsia and hyperemesis

175

What 2 Sx typify Kallmans syndrome?

Hypothalamic (hypogonadotrophic) hypogonadism
Anosmia

176

Is smoking a RF for placenta praevia?

Nope

177

Most common oestrogen secreting ovarian tumour? How does this present?

Mucinous cystadenoma - young woman with PV bleed