Flashcards in Gynaecology 1 Deck (177):
What days is menstruation during the menstrual cycle?
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
What hormonal change marks oocyte release from a follicle and what day is this?
LH surge on 14 days (matches up with oestrogen bump)
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
Define irregular periods?
Outside normal range of 23-35 days, variability of >7 days between shortest and longest
What is oligomenorrhoea?
Infrequent periods, between 35 days - 6m
What is primary amenorrhea?
Periods never start by age 16
What is secondary amenorrhea?
Periods stop for > 6m
What is Postmenopausal bleeding?
Bleeding that occurs >1 year after LMP
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
Most common causes of menorrhagia?
What does tenderness when examining for menorrhagia indicate?
More likely adenomyosis
3 most appropriate investigations for menorrhagia?
TVUSS +/- endometrial pipelle biopsy +/- hysteroscopy
First line management for menorrhagia if patient not wanting to get pregnant?
Mirena coil IUS
What drugs are second line for menorrhagia after IUS/if fertility desired?
Tranexamic acid, an antifibrinolytic
What is third line management for menorrhagia?
Progestogens to induce artificial amenorrhea
GnRH analogues to induce artificial menopause
If fail, surgery
Most common causes of irregular periods and IMB?
What are more likely causes of IMB and irregular menses in older women?
Endometrial, ovarian and cervical cancer
What drugs can be given to induce artificial amenorrhea and are therefore used for menorrhagia, IMB, irregular menses and occasionally dysmenorrhea?
Progestogens and CoCP
First line management for menstrual disturbance when fertility not required?
IUS or CoCP
Physiological causes of amenorrhea?
6 areas of causes of amenorrhea/oligomenorrhoea?
Drugs e.g. Progestogens, GnRH agonists, antipsychotics
Pituitary - hyperprolactinaemia
Adrenals/thyroid - hypothyroidism
Ovary - PCOS, prem menopause, Turners
Outflow tract disturbance
3 most common causes of amenorrhea/oligomenorrhoea? Which most commonly causes oligomenorrhoea?
PCOS - normally oligo
What can hypothalamic hypogonadism be caused by?
Losing loads of weight, anorexia, exercise
Is PCB ever 'normal'? What are the most common causes?
Most commonly cervical e.g. Ectropion, polyps, Cancer
Can be atrophic vaginitis in older women
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
Characteristics of primary dysmenorrhea?
No organic cause
Normally at start of menstruation
Often responds to NSAIDs or ovulatory suppression (COCP)
Most common causes of secondary dysmenorrhea?
Characteristics of secondary dysmenorrhea?
Often precedes menstruation
Commonly coexists with deep dyspareunia, menorrhagia, irregular menses
Requires PUS and laparoscopy
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
Management of premenstrual syndrome?
SSRIs (duloxetine) are useful
Cycle ablation - COCP, GnRH analogues with add back HRT
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
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
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
3 types of fibroids and how do they relate to polyps?
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
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
What is the cancerous change that arises from fibroids?
Why can Hb be high with fibroids?
They can secrete erythropoietin
Investigations for fibroids?
TVUS +/- MRI +/- laparoscopy
Medical management of fibroids if not trying to conceive?
GnRH agonists to induce temporary menopause with add back HRT
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
What is umbilical artery embolization UAE used for?
Fibroids shrinkage in those that don't want kids
What can haematometra occur as a result of?
Fibrosis post-endometrial resection, cone biopsy
Congenital malformation or imperforate hymen (1* amenorrhea)
What is the commonest genital tract cancer in women?
Who does endometrial cancer occur most commonly in?
Older women > 60
What histological type are the majority of endometrial cancers?
Adenocarcinoma of columnar endometrial gland cells
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
Exogenous oestrogen RFs for endometrial cancer?
Tamoxifen for breast cancer
Unopposed oestrogen therapy
Endogenous oestrogen sources as risk factors for endometrial cancer?
Obesity (androgen->oestrogen conversion)
Oestrogen secreting (ovarian) tumours
What is Lynch type II syndrome?
Hereditary Non-Polyposis Colorectal Cancer
Risks of colorectal, endometrial and ovarian cancer
What is the premalignant disease for endometrial cancer?
Endometrial hyperplasia with atypia
Requires hysterectomy if possible
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
What cervical pathology may coexist with endometrial cancer?
Cervical Glandular Intraepithelial Neoplasia CGIN
How is FIGO staging for endometrial cancer carried out?
USS + endometrial pipelle biopsy +/- hysteroscopy
Staging can only be done post-hysterectomy
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
Stage 1 management for endometrial cancer?
If turns out subsequently to be stage 3 -> ?radiotherapy
Recurrence for endometrial cancer?
Most commonly vaginal vault - VGIN
Moist Smelly Stuff is Gynae Basics of gynae history?
Genitourinary Sx incl discharge
What is cervical ectropion?
Visible endocervical columnar epithelium as redness around external os
More common during pregnancy, COCP
Other than asymptomatic, how can cervical ectropion present?
Management of cervical ectropion?
Cryotherapy after exclusion of carcinoma by smear/colposcopy
What is chronic cervicitis?
A common cause of discharge, often due to chronic STI of cervical ectropion
What are cervical polyps?
Benign endocervical epithelial tumours most common in older women
Apart from asymptomatic, how can cervical polyps present?
Post-coital bleeding, Intermenstrual bleeding
Management of cervical polyps?
Avulsion + histological analysis
What are Nabothian follicles?
Columnar cell secretions trapped under squamous epithelium leading to white/opaque swellings in ectocervix. Commonly asymptomatic
What is the most common histological type of cervical cancer?
Squamous cell carcinoma
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
What is another term form CIN III and how does it progress to malignant disease?
Carcinoma in situ -> invasion through basement membrane
What HPV serotypes are most implicated in cervical cancer?
16, 18, 31 and 33
Besides HPV RFs, RFs for cervical cancer?
What is the screening programme for cervical cancer?
3 yearly from 25-49
5 yearly from 49-64
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
What is HPV screening used for in CIN?
As HPV triage and also test of cure
What can presence of CGIN indicate?
Cervical/endometrial adenocarcinoma so should prompt colposcopy and endometrial biopsy
What do confirmed CIN II and III have to be treated with? What risk does this hold for future pregnancies?
Slight risk of preterm labour in future
Other than asymptomatic, how can cervical cancer present?
PCB, IMB, PM, offensive discharge
Pain, GI/GU Sx
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
Management of cervical cancer with increasing grade at presentation?
Come biopsy/hysterectomy -> radical hysterectomy -> chemo/radiotherapy
What are common ovarian symptoms?
None! Often silent
With increasing size, can eventually cause abdominal distension and bloating
What is an ovarian accident?
Acute rupture, haemorrhage, torsion or infarct of an ovarian mass (usually cyst)
What is PCO?
Term descriptive of the characteristic TVUS appearance: >12 small follicles in an enlarged ovary
What can prompt a woman with PCO to develop PCOS?
Major diagnostic features of PCOS?
Hirsutism either clinically or as high serum testosterone
PCO on TVUS
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
What FH condition is common with PCOS?
3 long term risks of PCOS?
Endometrial cancer (anovulation leading to unopposed oestrogen)
GDM and miscarriage during pregnancy
First line management of PCOS?
Lifestyle - weight loss
Management of PCOS if wanting fertility?
Management of PCOS if fertility not desired?
Symptomatic relief - COCP or Mirena to regulate menstruation and treat hirsutism
Anti androgens (systemic or topical)
What is premature menopause defined as?
Menopause before age of 40
What is the most common congenital cause of gonadal dysgenesis?
Turners syndrome 45XO
What are the 3 major types of primary ovarian carcinoma?
Germ cell tumours
Sex cord tumours
What are the most common malignant primary ovarian cancers?
Epithelial cell cancers - serous cystadenoma/adenocarcinoma
What are the 5 types of ovarian epithelial carcinoma?
Clear cell carcinoma
From what ovarian tumour can pseudomyxoma peritonei originate?
Borderline mucinous cystadenoma
In whom are germ cell ovarian tumours more common?
Women under 30
2 types of germ cell ovarian tumour? What is the most common malignant ovarian cancer in younger women?
Dysgerminoma (most common)
3 types of ovarian sex cord tumour?
Granulosa cell tumours
What do granulosa cell tumours secrete?
Oestrogen and inhibin
Thus causing endometrial hyperplasia/cancer or precocious puberty
What is Meig's syndrome?
Fibroma, ascites and right sided pleural effusion
What are the 2 most common primary sites for ovarian secondary malignancies?
2 major cyst conditions of ovaries?
Endometriotic (chocolate) cysts
Functional cysts - follicular/lutein cysts
What is protective vs functional ovarian cysts?
RFs for ovarian cancer?
Related to increasing number of ovulations:
Protective factors against ovarian cancer?
Familial links for ovarian cancer?
HNPCC (lynch syndrome type II)
What 3 cancers is lynch II (HNPCC) implicated in?
What common GI disease manifestation does ovarian cancer often mimic?
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
What specific bloods may be useful to investigate ovarian cancer in women under 40 at increased risk of germ cell tumours?
Cut off RMI value for referral to specialist MDT?
FIGO staging for ovarian cancer?
1 ovarian only
2 beyond ovaries but pelvis only
3 beyond pelvis but abdomen only
4 beyond abdomen
3 general areas of causes of pruritis vulvae?
Which of the lichen conditions most mimics dermatitis or eczema?
Which of the lichen conditions mostly affects mucosa (mouth and genital)?
Lichen planus - causing painful, erosive flat papules
Which of the lichen conditions has an autoimmune link and may be associated with thyroid disease and vitiligo?
Who does lichen sclerosus mostly affect and how does it present?
Severe pruritis -> thinning skin, adhesions, fissures
Labial fusion and introital narrowing
Which of the lichen conditions carries a risk of vulval carcinoma?
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.
How do bartholin's gland abscesses present?
Acute pain, large red tender swelling
What is the drainage method for bartholin's gland cysts called?
Incise, drain and leave open (marsupialisation)
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
Pain associated with primary dysmenorrhea?
Crampy pains starting within 24 hours of menstruation, stop within 2-3 days
In what age is secondary dysmenorrhea most common?
What device can cause secondary dysmenorrhea within first few months of insertion?
Pain associated with secondary dysmenorrhea?
Starts at least 2 days before menstruation and continues whole way through
Associated with other Sx e.g. Dyspareunia
Metabolic cause of menorrhagia?
What is the general cause of physiological leucorrhoea? Relation to causes of increased discharge?
So increased in pregnancy, CoCP, around time of ovulation
What medical procedure can encourage growth of follicular ovarian cysts?
Clomiphene ovulatory induction
What ovarian benign ovarian cysts can secrete lots of oestrogen?
What 3 item criteria is used to define PCOS? What are they?
PCO as defined by at least 12 follicles or increased ovarian size
Clinical or biochemical evidence of hyperandrogenism
What is co-cyprindol?
Drug used for symptom management of PCOS
2 drugs suitable for PCOS in women wanting to get pregnant?
What cancer is PCOS a risk factor for?
Large doughy uterus, uterine contractions with persistent bleeds and expulsion of grape like material. Diagnosis?
What is ptyalism?
What does an unsatisfactory cervical smear result mean?
Incorrect processing or not enough cells
Repeat in 4 weeks
What does an inconclusive cervical smear result suggest?
Infection - treat and repeat
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
With what infection is strawberry cervix associated with?
Differentials for cervical motion tenderness/cervical excitation?
Classical of PID
To a lesser extent ectopic pregnancy
Boggy, tender uterus on Bimanual exam?
Uterine atony (postpartum)
Differentials for an adnexal mass on bimanual?
Ovarian - cysts, tumours, PCOS
Which of gonorrhoea and chlamydia in women typically causes malodourous, purulent discharge?
4 infections detectable via high vaginal swab?
Group B Strep
2 infections detected by endocervical swab? Which uses charcoal media?
Gonorrhoea (charcoal media)
What is more suggestive of PID than endometriosis?
What type of cervical cancer is associated with COCP use?
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
What is the difference between virilisation and hirsutism?
Both hyperandrogenism but hirsutism is milder and reversible
Virilisation mega and irreversible
What is acanthosis nigricans?
Darkly pigmented velvety skin in skin flexures (nape of neck, skin folds, elbow creases) associated with PCOS and DM
What skin change may be associated with DM and PCOS?
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
What 2 conditions can progestogen challenge test highlight?
What heart auscultation findings are common in pregnancy?
Ejection systolic murmur and S3 gallop due to hyperdynamic circulation
What does uterine fibroid embolization herald a risk of in future?
Premature ovarian failure - 1%
What pregnancy interval is a RF for pre-eclampsia?
10 years (likely nulliparity)
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
What pH do BV and trichomonas share?
Over 4.5 alkaline
What does asymmetric IUGR suggest?
What is granuloma inguinale?
Painless slow growing ulcerative lesions with no regional lymphadenopathy caused by Klebsiella granulomatis
Painless, slow growing genital ulcer with no associated regional lymphadenopathy?
Sx associated with lymphogranuloma?
Unilateral tender inguinal or femoral lymphadenopathy
Self limiting, papule like ulcer
Unilateral tender inguinal and femoral lymphadenopathy with papule-like ulcer?
What Ix is best for detecting early Syphillis infection from lesion exudate or tissue?
What is Darkfield examination used for?
Early Syphillis infection isolate from tissue exudate
Sx of chancroid?
Painful general ulcer with tender suppurative lymphadenopathy
Painful genital ulcer plus tender suppurative lymphadenopathy?
7 steps of vertex delivery?
Flexion of head
Extension and restitution
Describe complete hyatid moles?
Diploid (46 chromosomes) with paternal origin only
No Fetal tissue
Higher risk of need for chemo
Describe partial hyatid moles?
Triploid - 69 chromosomes with full paternal and half maternal
Identifiable Fetal tissue
3 early pregnancy Sx of hyatid moles?
Early hyperthyroidism, pre-eclampsia and hyperemesis
What 2 Sx typify Kallmans syndrome?
Hypothalamic (hypogonadotrophic) hypogonadism
Is smoking a RF for placenta praevia?