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Obs and gynae > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is amenorrhoea

A

Absence of menstrual periods

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2
Q

What are the 2 types of amenorrhoea

A

Primary

Secondary

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3
Q

What is primary amenorrhoea

A

Failure to start having periods

  • In presence of secondary sexual characteristics by 16+
  • In absence of secondary sexual characteristics at 14-16
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4
Q

What is secondary amenorrhoea

A

Cessation of periods for over 6 months

After pregnancy has been excluded

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5
Q

What is oligomenorrhoea

A

Irregular periods

Menstrual cycle >35 days

<9 periods per year

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6
Q

What are the 4 groups of hypothalamic causes for amenorrhoea

A
  • Reduced secretion of GnRH
  • Functional disorders
  • Severe chronic conditions
  • Kallmann syndrome
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7
Q

Why is reduced secretion of GnRH a hypothalamic cause of amenorrhoea

A

Decreased pulsatile release of LH and FSH from anterior pituitary

Causes anovulation

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8
Q

What are the functional disorders that are hypothalamic causes of amenorrhoea

A

High levels of exercise

Eating disorders

Suppression of GnRH (due to ghrelin and leptin levels)

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9
Q

What are the severe chronic conditions that are hypothalamic causes of amenorrhoea

A

Psychiatric disorders

Thyroid disease

Sarcoidosis

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10
Q

What is Kallmann syndrome and how is it a hypothalamic cause of amenorrhoea

A

X-linked recessive disorder

Failure of migration of GnRH cells

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11
Q

What are the 5 pituitary causes of amenorrhoea

A
  • Prolactinomas
  • Other pituitary disorders
  • Sheehan’s syndrome
  • Destruction of pituitary gland
  • Post-contraception amenorrhoea
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12
Q

What is a prolactinoma and how is it a pituitary cause of amenorrhoea

A

Pituitary tumour

Secretes high levels of prolactin (suppressing GnRH release)

Causes anovulation, amenorrhoea, and galactorrhoea

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13
Q

How do non-prolactinoma tumours of the pituitary cause amenorrhoea

A

Get gonadotropin deficiency from mass effect of tumour

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14
Q

What is Sheehan’s syndrome and how is it a pituitary cause of amenorrhoea

A

Post-partum pituitary necrosis

Due to massive obstetric haemorrhage

Get varying degrees of anterior pituitary hormone deficiency

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15
Q

What are the causes of pituitary gland destruction that can cause amenorrhoea

A

Radiation

Autoimmune disease

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16
Q

What is post-contraception amenorrhoea and how is it a pituitary cause of amenorrhoea

A

Due to prolonged use of contraceptives

Get downregulation of pituitary gland

Mostly seen in depo-provera (can take 18 months for periods to return)

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17
Q

What are the 3 ovarian causes of amenorrhoea

A

PCOS

Turner’s syndrome

Premature ovarian failure

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18
Q

How is PCOS an ovarian cause of amenorrhoea

A

Usually more associated with oligomenorrhoea

High androgen levels

Also get hirsutism, acne, and weight gain

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19
Q

What is Turner’s syndrome and how is it an ovarian cause of amenorrhoea

A

45 XO

Get amenorrhoea, but have secondary sexual characteristics

Almost universal infertility

Associated with short stature, webbed neck, aortic coarctation

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20
Q

What is primary ovarian failure and how is it a cause of amenorrhoea

A

Premature ovarian insufficiency before age 40

Get menopause symptoms

Have low oestrogen, high FSH

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21
Q

What is the adrenal gland cause of amenorrhoea

A

Late onset/mild congenital adrenal hyperplasia

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22
Q

What is late onset/mild congenital adrenal hyperplasia and how is it a cause of amenorrhoea

A

Partial deficiency of 21 hydroxylase (needed for cortisol and aldosterone production)

Presentation: early development of pubic hair, irregular/absent periods, hirsutism, acne

Have high levels of 17-hydroxyprogesterone in blood

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23
Q

What are the genital tract abnormalities that can cause amenorrhoea

A

Ashermann’s syndrome

Imperforate hymen/transverse vaginal septum

Mayer-Rokitansky-Kuster-Hauser syndrome

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24
Q

What is Ashermann’s syndrome and how is it a genital tract abnormality cause of amenorrhoea

A

Secondary to uterus instrumentation

Usually after surgical management of miscarriage

Have damage to basal layer of endometrium

Get intrauterine adhesions

Get failure to respond to oestrogen stimulus

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25
Q

How are imperforate hymen and transverse vaginal septum genital tract abnormality causes of amenorrhoea

A

Have a mechanical obstruction

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26
Q

What is Mayer-Rokitansky-Kuster-Hauser syndrome and how is it a genital tract abnormality cause of amenorrhoea

A

Agenesis of Mullerian duct

Congenital absence of uterus and upper 2/3 of vagina

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27
Q

What are the common causes of oligomenorrhoea

A

PCOS

Contraceptive/hormonal treatment

Perimenopause

Thyroid disease

Diabetes

Eating disorder/excessive exercise

Medications (antipsychotics, antiepileptics)

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28
Q

What are the investigations used for amenorrhoea

A

Pregnancy test

Bloods (TFTs, prolactin, FSH, LH, oestradiol, progesterone, testosterone)

Karyotyping

Ultrasound

Progesterone challenge

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29
Q

What is the progesterone challenge used to look for causes of oligo/amenorrhoea

A

Give progesterone

  • If able to elicit a withdrawal bleed, means that levels of oestrogen are high enough but still not getting ovulation
  • If get no withdrawal bleed, means that there is low oestrogen or an outflow obstruction
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30
Q

What are the broad categories of management of oligo/amenorrhoea

A

Regulation of periods

Hormone replacement

Symptom control

Lifestyle advice

Treat underlying cause

Improve fertility

Surgery

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31
Q

How is regulation of periods achieved in the management of oligo/amenorrhoea

A

COCP/POP - keep endometrial lining thin

IUS - reduces flow/stops periods

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32
Q

How is hormone replacement therapy used in the management of oligo/amenorrhoea

A

For patients with premature ovarian failure/insufficiency

Cyclical oestrogen (+/- progesterone)

Treats symptoms of menopause

Advantages: decreases cardiovascular risk, maintains bone density prevents osteoporosis

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33
Q

What are the methods of symptom control used in oligo/amenorrhoea

A

Manage excessive hair growth with COCPs

Acne treatment (antibiotics, benzoyl peroxide, retinoids)

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34
Q

What are the methods of improving fertility that are used in the management of oligo/amenorrhoea

A

Clomifene - stimulates ovulation

Metformin - induces ovulation in PCOS

IVF

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35
Q

How is surgery used in the management of oligo/amenorrhoea

A

Remove tumours

Correct genital tract abnormalities

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36
Q

What is heavy menstrual bleeding

A

Excessive menstrual loss that interferes with the patient’s quality of life

Abnormal uterine bleeding

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37
Q

What are the causes of heavy menstrual bleeding

A

PALM-COEIN

Structural causes

  • Polyp
  • Adenomyosis
  • Leiomyoma (fibroids)
  • Malignancy and hyperplasia

Non-structural causes

  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified
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38
Q

What are the risk factors for heavy menstrual bleeding

A

Age (around menarche and menopause)

Obesity

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39
Q

How may a woman with heavy menstrual bleeding present

A

Excessive bleeding (for patient)

Fatigue

Shortness of breath

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40
Q

What would you look for on examination of a woman with heavy menstrual bleeding

A

Pallor

Palpable uterus or pelvic mass

Tender uterus/cervix (specific to adenomyosis and endometriosis)

Cervical changes (inflammation, polyps, tumour)

Vaginal tumour

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41
Q

What are the differential diagnoses for heavy menstrual bleeding

A

Pregnancy

Endometrial/cervical polyps

Adenomyosis

Fibroids

Endometrial malignancy or hyperplasia

Coagulopathies (usually Von Willebrand’s disease)

Ovarian dysfunction

Iatrogenic

Endometriosis

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42
Q

What investigations would you use for heavy menstrual bleeding

A

Pregnancy test

Bloods (FBC, TFTs, coagulation studies…)

USS (transvaginal/pelvic)

Cervical smear (if not up to date)

Pipelle endometrial biopsy

Hysteroscopy and endometrial biopsy

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43
Q

What is a pipelle biopsy and what are the indications for its use

A

Endometrial biopsy for heavy menstrual bleeding

Indications

  • Persistent intermenstrual bleeding
  • Age >45
  • Failure of pharmacological treatment
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44
Q

What is the pharmacological management for heavy menstrual bleeding

A

Levonorgestrel-releasing IUS (LNG-IUS)
- Also contraceptive, thins endometrium, can shrink fibroids

Tranexamic acid
- Only during menses (reduces bleeding)

Mefenamic acid
- NSAID

COCP/POP

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45
Q

What is the surgical management for heavy menstrual bleeding

A

Endometrial ablation (not able to get pregnancy after this)

Hysterectomy (definitive management)

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46
Q

What is dysmenorrhoea

A

Painful periods

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47
Q

What is the difference between primary and secondary dysmenorrhoea

A

Primary
- Menstrual pain with no underlying pathology

Secondary
- Menstrual pain associated with pelvic pathology

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48
Q

What is the pathophysiology of dysmenorrhoea

A

Regression of corpus luteum if no fertilisation

Get a drop in oestrogen and progesterone

Endometrial cells sensitive to drop in progesterone

Endometrial cells release prostaglandins

Prostaglandins cause spiral artery vasospasm and increase myometrial contraction

Primary dysmenorrhoea is due to excessive prostaglandin release

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49
Q

What are the risk factors for dysmenorrhoea

A

Early menarche

Long menstrual phase

Heavy periods

Smoking

Nulliparity

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50
Q

How may a woman with dysmenorrhoea present?

A

Crampy lower abdominal pain

May have radiation to back/anterior thigh

Lasts 48-72 hours

Non-specific symptoms: malaise, nausea, vomiting, diarrhoea, dizziness

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51
Q

What are the differential diagnoses for dysmenorrhoea

A

Primary dysmenorrhoea
- Diagnosis of exclusion

Secondary dysmenorrhoea
- Endometriosis, adenomyosis, PID, adhesions

Non-gynaecological
- IBD, IBS

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52
Q

What are the investigations to use in dysmenorrhoea

A

Focussed on ruling out pathology

High risk of STIs
- High vaginal and endocervical swabs

Pelvic mass palpated
- Transvaginal USS

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53
Q

What is the pharmacological management for dysmenorrhoea

A

Analgesia
- Paracetamol, NSAIDs

Hormonal contraceptives

  • 3-6 month trial
  • Monophasic COCP or IUS
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54
Q

What is the non-pharmacological management for dysmenorrhoea

A

Smoking cessation

Local heat application

TENS machine

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55
Q

What is adenomyosis

A

Endometrial tissue in myometrium of uterus

Variant of endometriosis

Main symptoms: menorrhagia, dysmenorrhoea

Often found alongside fibroids

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56
Q

What is the aetiology and pathophysiology of adenomyosis

A

Endometrial stroma communicates with myometrium after uterine damage

Associated with: pregnancy and childbirth, C-section, uterine surgery, termination of pregnancy

Mostly in posterior wall

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57
Q

What are the risk factors for adenomyosis

A

High parity

Uterine surgery

Previous C-section

Hereditary

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58
Q

How may a woman with adenomyosis present

A

Menorrhagia

Dysmenorrhoea

Deep dyspareunia

Irregular bleeding

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59
Q

What would you find on examination of a woman with adenomyosis

A

Symmetrically enlarged, tender uterus

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60
Q

What are the differential diagnoses for adenomyosis

A

Endometriosis

Fibroids

Endometrial hyperplasia/carcinoma

Endometrial polyps

PID

Hyperthyroidism

Coagulation disorders

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61
Q

What are the investigations for adenomyosis

A

Definitive diagnosis
- Histology after hysterectomy

Transvaginal USS

  • Globular uterus
  • Poor definition of endometrial-myometrial interface
  • Intramyometrial cyst

MRI
- Endo-myometrial junction zone thickening

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62
Q

What is the management of adenomyosis

A

Curative therapy: hysterectomy

Simple analgesia

Hormonal

  • Reduce proliferation of ectopic endometrial cells
  • COCP, POP, IUS, GnRH agonist, aromatase inhibitor

Non-hormonal
- Uterine artery embolisation (if wanting to preserve fertility), endometrial ablation, tissue resection, laparoscopic excision

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63
Q

How common is endometrial cancer and when is the peak age of diagnosis

A

4th most common cancer of women in the UK

Peak age 65-75

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64
Q

What is the most common form of endometrial cancer, what is the pathophysiology

A

Adenocarcinoma

Due to stimulation of endometrium by unopposed oestrogen

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65
Q

What are the risk factors for endometrial cancer

A

Anovulation
- Early menarche/late menopause, low parity, PCOS, HRT, tamoxifen

Age
- Peak at 65-75, low risk in <45

Obesity
- More peripheral fat, faster peripheral aromatisation of androgens and oestrogen

Hereditary

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66
Q

How may a woman with endometrial cancer present

A

Post-menopausal bleeding

Clear/white vaginal discharge

Abnormal cervical smear

In advanced disease: abdominal pain, weight loss

67
Q

What might you find on examination of a woman with endometrial cancer

A

Abdominal/pelvic mass

Vaginal/vulval atrophy

Cervical lesions

68
Q

What are the differential diagnoses for endometrial cancer

A

Vulval causes
- Atrophy, malignant/pre-malignant conditions

Cervical causes
- Polyps, cancer

Endometrial causes
- Hyperplasia without malignancy, benign polyps, atrophy

69
Q

What are the investigations for endometrial cancer

A

Transvaginal ultrasound (first line)

Endometrial biopsy (if >4mm on ultrasound)

Hysteroscopy with biopsy

Staging CT/MRI

70
Q

What is the FIGO staging for endometrial cancer

A

Stage 1
- Carcinoma confined to uterine body

Stage 2
- Carcinoma extends to cervix, but not beyond uterus

Stage 3
- Carcinoma goes beyond uterus, but confined to pelvis

Stage 4
- Carcinoma involves bladder/bowel, or has metastasised to distal sites

71
Q

What is the management of endometrial hyperplasia

A

Typical
- Mirena coil, surveillance biopsies

Atypical
- Total abdominal hysterectomy and bilateral salpingo-oophorectomy

72
Q

What is the management of endometrial cancer

A

Stage 1
- Total abdominal hysterectomy and bilateral salpingo-oophorectomy

Stage 2
- Radical hysterectomy (also remove supporting tissue of uterus and vaginal tissue around cervix)

Stage 3

  • Maximal de-bulking surgery
  • Chemoradiotherapy

Stage 4

  • Maximal de-bulking surgery
  • Usually need palliative approach
73
Q

What are the common sites of endometrial tissue in endometriosis

A

Ovaries

Pouch of Douglas

Uterosacral ligaments

Pelvic peritoneum

Bladder

Umbilicus

Lungs

74
Q

At what age is endometriosis most commonly diagnosed

A

25-40

75
Q

What are the risk factors for endometriosis

A

Early menarche

Family history

Short menstrual cycle

Long duration of menstrual bleeding

Heavy menstrual bleeding

Defects in uterus/fallopian tube

76
Q

How may a woman with endometriosis present

A

Cyclical pelvic pain (can be constant with adhesions)

Dysmenorrhoea

Dyspareunia

Dyschezia (painful defecation)

Subfertility

Signs related to ectopic sites
- Haemothorax…

77
Q

What would you find on bimanual examination of a woman with endometriosis

A

Fixed, retroverted uterus

Uterosacral ligament nodules

Genital tenderness

78
Q

What are the differential diagnoses for endometriosis

A

Pelvic inflammatory disease

Ectopic pregnancy

Fibroids

IBS

79
Q

What are the investigations for endometriosis

A

Laparoscopic visualisation

  • Gold standard
  • Chocolate cysts, adhesions, peritoneal deposits

Pelvic ultrasound

  • To determine severity
  • May see ‘kissing ovaries’ (bilateral endometrioma adhered together)
80
Q

What is the management for endometriosis

A

No treatment for asymptomatic patients

Analgesia

Suppress ovulation

  • For 6-12 months
  • Get atrophy of endometrial tissue
  • Low dose COCP, norethisterone, injections, coils

Surgery

  • Excision, ablation
  • Definitive management: hysterectomy and bilateral oophorectomy
81
Q

What are fibroids

A

Aka leiomyomas

Benign smooth muscle tumours of uterus

82
Q

How are uterine fibroids classified

A

Based on position on uterine wall

Intramural
- Most common, confined to myometrium

Submucosal
- Immediately beneath endometrium, protrude into uterine cavity

Subserosal
- Protrude into serosal surface, may be pedunculated

83
Q

What stimulates the growth of fibroids

A

Oestrogen

84
Q

What are the risk factors for developing fibroids

A

Obesity

Early menarche

Increasing age

Family history

Ethnicity (African-American)

85
Q

How may a woman with uterine fibroids present

A

Pressure symptoms (urinary frequency/retention)

Abdominal distention

Heavy menstrual bleeding

Subfertility (obstructive effect)

Acute pelvic pain (only if torsion of pedunculated fibroid)

86
Q

What would you find on examination of a woman with fibroids

A

Solid mass

Non-tender uterus

87
Q

What are the differential diagnoses for fibroids

A

Endometrial polyps

Ovarian tumours

Leiomyosarcoma (malignancy of myometrium)

Adenomyosis

88
Q

What investigations are used in fibroids

A

Pelvic USS

Consider MRI if suspecting sarcoma

89
Q

What is the medical management for fibroids

A

Tranexamic/mefanamic acid

Hormonal contraceptives

GnRH analogues (Zolidex)

  • Suppresses ovulation, get temporary menopausal state
  • Pre-op, to reduce size of fibroid
  • Maximum use 6 months

Selective progesterone receptor modulators (ulipristal)

  • Reduces size of fibroids
  • Severe risk of liver injury
90
Q

What is the surgical management for fibroids

A

Hysteroscopy and transcervical resection (TCRF)

Myomectomy (if want to preserve uterus)

Uterine artery embolisation

Hysterectomy

91
Q

What are cervical polyps

A

Benign growths protruding from inner surface of cervix

Usually asymptomatic

Can undergo malignant changes

92
Q

What are the causes of cervical polyps

A

Chronic inflammation

Abnormal response to oestrogen

Localised congestion of cervical vasculature

93
Q

How might a woman with cervical polyps present

A

Abnormal vaginal bleeding (menorrhagia, intermenstrual, post-coital, post-menopausal)

Increased vaginal discharge

Infertility (may block cervical canal)

94
Q

What would you see on speculum examination of a woman with cervical polyps

A

Polypoid growths

Projections through external os

95
Q

What are the differential diagnoses for cervical polyps

A

Cervical cancer

STIs

Fibroids

Endometritis

Pregnancy-related

Endometrial carcinoma

Endometrial polyps

96
Q

What are the investigations for cervical polyps

A

Definitive diagnosis: histological examination of polyp after removal

Triple swab (rule out infection)

Cervical smear (rule out cervical intraepithelial neoplasia)

97
Q

What is the management for cervical polyps

A

Remove, to prevent malignant transformation

Small polyps
- Remove in primary care (polypectomy forceps, twist off)

Large polyps
- Colposcopy clinic (diathermy loop excision)

Send polyps for histology

98
Q

What is cervical ectropion

A

Cervical erosion

Evasion of endocervix, exposing columnar cells to vagina

Benign condition

99
Q

What is the pathophysiology of cervical ectropion

A

Stratified squamous cells undergo metaplastic change to become simple columnar

Induced by high oestrogen levels

100
Q

What are the risk factors for cervical ectropion

A

Use of COCP

Pregnancy

Adolescence

Childbearing age

101
Q

How might a woman with cervical ectropion present

A

Mostly asymptomatic

Post-coital bleeding

Intermenstrual bleeding

Excessive discharge

102
Q

What would you find on speculum examination of a woman with cervical extropian

A

Everted columnar epithelium

Reddish appearance
- A ring around the external os

103
Q

What are the differential diagnoses for cervical ectropion

A

Cervical cancer

Cervical intraepithelial neoplasia

Cervicitis

Pregnancy

104
Q

What investigations would you use for cervical ectropion

A

Rule out other potential causes

  • Pregnancy test
  • Triple swab
  • Cervical smear
105
Q

What is the management of cervical ectropion

A

No treatment for asymptomatic

Stop oestrogen-containing medications (COCP)

Columnar epithelium ablation

Boric acid pessaries (acidify vaginal pH)

106
Q

Who is cervical cancer most commonly diagnosed in

A

Half before age 47

Peak age 25-29

107
Q

How long does it usually take cervical intraepithelial neoplasia to progress to cervical cancer

A

10-20 years

108
Q

What are the risk factors for cervical cancer

A

HPV infection

Smoking

Other STIs

Long term COCP use (>8 years)

Immunodeficiency

109
Q

How may a woman with cervical cancer present

A

Abnormal vaginal bleeding

Blood-stained/foul smelling discharge

Dyspareunia

Pelvic pain

Advanced disease: weight loss, oedema, loin pain, rectal bleeding, radiculopathy, haematuria

110
Q

What would you find on examination of a woman with cervical cancer

A

Speculum
- Evidence of bleeding, discharge, ulceration

Bimanual
- Pelvic mass

GI
- Rectal bleeding, mass on PR

111
Q

What are the differential diagnoses for cervical cancer

A

STI

Cervical ectropion

Polyps

Fibroids

Pregnancy-related bleeding

Endometrial cancer

112
Q

What are the investigations for cervical cancer

A

Pre-menopausal
- Check for chlamydia. If negative, colposcopy and biopsy

Post-menopausal
- Urgent colposcopy and biopsy

If cancer confirmed, staging CT

113
Q

What are the stages of cervical cancer

A

Stage 0
- Carcinoma in-situ

Stage 1
- Confined to cervix

Stage 2
- Beyond cervix, but not pelvic sidewall. Involves upper 2/3 of vagina

Stage 3
- Extends to pelvic sidewalls, involves whole vagina

Stage 4
- Extends to bladder/rectum, metastases

114
Q

What is the surgical management of cervical cancer

A

Stage 1
- Radical trachelectomy (remove cervix and upper vagina)

Stage 2
- Radical hysterectomy

Stage 4
- Total removal, including parts of bladder and rectum

115
Q

What is the non-surgical management for cervical cancer

A

Radiotherapy

Chemotherapy

Follow-up

  • Every 4 months for 2 years after treatment
  • Every 6-12 months for 3 years
116
Q

How is PCOS characterised

A

Excess androgen production

Multiple immature follicles (cysts) in ovaries

117
Q

What are the common hormonal abnormalities found in PCOS

A

Excessive LH
- Stimulates ovaries to produce androgens

Insulin resistance
- High insulin production, suppresses hepatic production of sex hormone binding globulin, get high free circulating androgens

118
Q

What happens to androgen levels in PCOS, how does this affect ovulation

A

High circulating androgens

Suppress LH surge
- Follicles begin to develop, but then arrested, become cysts

119
Q

What are the risk factors for PCOS

A

Diabetes

Irregular menstruation

Family history

120
Q

What are the most common symptoms of PCOS

A

Oligomenorrhoea/amenorrhoea

Infertility

Hirsutism

Obesity

Chronic pelvic pain

Depression

121
Q

What would you find on examination of a patient with PCOS

A

Hirsutism

Acne

Acanthosis nigrans

Male pattern hair loss

Obesity

Hypertension

122
Q

What are the differential diagnoses for PCOS

A

Hypothyroidism

Hyperprolactinaemia

Cushing’s disease

123
Q

What investigations are used for PCOS

A

Bloods
- High testosterone, low sex hormone binding globulin, high LH, normal FSH, low progesterone

Consider oral glucose tolerance test

Ultrasound of ovaries

124
Q

What is the criteria for diagnosing PCOS

A

2/3 of:

  • Oligo/anovulation
  • Clinical/biochemical signs of hyperandrogenism
  • Polycystic ovaries on imaging
125
Q

What is the management for PCOS

A

Treat underlying condition

Oligomenorrhoea/amenorrhoea
- COCP, dydrogesterone (progesterone analogue)

Weight loss

Infertility treatment

Hirsutism treatment

126
Q

How is infertility due to PCOS managed

A

Clomifene and metformin

  • Induce ovulation
  • Maximum of 6 cycles

Laparoscopic ovarian drilling

127
Q

How is hirsutism in PCOS managed

A

Anti-androgen medication

  • Eflornithine (face cream)
  • Contraindicated in pregnancy (teratogenic)
128
Q

What are ovarian cysts

A

Fluid-filled sac within ovary

Common (pre-menopausal women)

Benign

129
Q

What are the risk factors for ovarian cysts and tumours

A

Nulliparity

Early menarche

Late menopause

Oestrogen-only HRT

Smoking

Obesity

Genetic mutations (BRCA1,2)

130
Q

What are the protective factors for PCOS

A

Multiparity

COCP

Breastfeeding

131
Q

What are the clinical features of ovarian cysts and tumours

A

Often asymptomatic

Chronic pain (pressure on surroundings)

Acute pain (bleeding, rupture, torsion)

Bleeding per vagina

132
Q

What are the classifications of ovarian cysts

A

Non-neoplastic
- No malignant potential

Neoplastic
- Can become malignant

Simple
- Fluid only

Complex
- Irregular, solid material, blood, septation

133
Q

What are the types of non-neoplastic ovarian cysts

A

Functional
- Follicular cysts, corpus luteum cysts

Pathological
- Endometrioma, polycystic ovaries, theca lutein cysts

134
Q

What are the types of benign neoplastic ovarian cysts

A

Epithelial
- Serous cystadenoma, mucinous cystadenoma, Brenner tumour

Benign germ cell tumours
- Mature cystic teratoma (dermoid cyst)

Sex-cord stromal tumour
- Fibroma

135
Q

What is the management of ovarian cysts in pre-menopausal women

A

No need to measure CA125

Measure lactate dehydrogenase, AFP, and BhCG

Re-scan in 6 weeks

If persistent

  • USS and CA125 at 3-6 months
  • Still persisting or >5cm, consider laparoscopic cystectomy and oophorectomy
136
Q

What is the management of ovarian cysts in post-menopausal women

A

Low risk malignancy index (RMI)
- Follow up in 1 year with USS and CA125

Moderate RMI

  • Bilateral oophorectomy
  • If malignancy found, staging

High RMI
- Staging laparoscopy

137
Q

What are the investigations for ovarian cancer

A

Bloods

Pelvic ultrasound

Staging CT

138
Q

What is the management for ovarian cancer

A

Surgery

Adjuvant chemotherapy

Follow up (examination, CA125, for 5 years)

139
Q

What is stress incontinence

A

Involuntary leakage of urine during increased intra-abdominal pressure, in absence of detrusor contraction

Usually after childbirth (denervation of pelvic floor)

140
Q

What are the risk factors for stress incontinence

A

Childbirth

Oestrogen deficient state

Pelvic surgery

Pelvic irradiation

141
Q

What is urge incontinence

A

Overactive bladder syndrome

Urgency, frequency, nocturia

Absence of UTI

Usually idiopathic (sometimes due to neurological conditions or pelvic surgery)

142
Q

What are the main causes of urinary incontinence

A

Stress incontinence

Urge incontinence

Overflow incontinence

Bladder fistulae

Urethral diverticulum

Congenital anomalies

Functional incontinence

143
Q

What are the clinical features of stress incontinence

A

Leakage on coughing/sneezing/exercise

Small volumes

May have prolapse

144
Q

What are the clinical features of urge incontinence

A

Urgency

Frequency

Nocturia

145
Q

What investigations are used for urinary incontinence

A

Urine dip (exclude infection)

Frequency/volume chart (normal in stress, increased in urge)

Urodynamic studies (rule out detrusor overactivity in stress)

146
Q

What is the non-surgical management of stress incontinence

A

Conservative

  • Weight loss
  • Smoking cessation
  • Treat risk factors
  • Pelvic floor muscle exercises

Medical
- Duloxetine (moderate/severe symptoms)

147
Q

What is the surgical management of stress incontinence

A

Burch colposuspension

Laparoscopic colposuspension

Peri-urethral injection (those unfit for surgery)

Tension-free vaginal tape (tape under mid urethra)

Transobturator mid-urethral sling

148
Q

What is the non-medical management for urge incontinence

A

Conservative

  • Sensible fluid intake
  • Avoid caffeine/diuretics
  • Bladder retraining

Surgical
- Detrusor myomectomy and augmentation cystoplasty

149
Q

What is the medical management for urge incontinence

A

Anticholinergics
- Oxybutynine, solifenacin, tolterodine

Intravaginal oestrogen
- If have vaginal atrophy

Botulinum toxin A

Neuromodulators and sacral nerve stimulation

150
Q

What is a Bartholin’s cyst

A

Fluid-filled sac within a bartholin’s gland of the vagina (on either side of vaginal orifice, deep to labia majora, within vestibule)

151
Q

What are the common causative organisms of Bartholin’s cysts

A

E.coli

MRSA

STIs

152
Q

What are the risk factors for Bartholin’s cyst

A

Nulliparous

Childbearing age

Personal history

Sexually active

Previous vulval surgery

153
Q

What are the clinical features of a Bartholin’s cyst

A

Often asymptomatic if small

If large: vulval pain, superficial dyspareunia

Can rupture

Bartholin’s abscess (acute onset pain, difficulty passing urine)

154
Q

What would you find on examination of a Bartholin’s cyst

A

Unilateral labial mass

Arising from posterior labia majora

Bartholin’s cyst: soft, fluctuant, non-tender

Bartholin’s abscess: tender, hard, surrounding cellulitis

155
Q

What are the differential diagnoses for Bartholin’s cysts

A

Bartholin’s gland carcinoma

Bartholin’s benign tumour

Other cysts: sebaceous, Skene’s, mucous

Other solid masses: fibroma, lipoma, leiomyoma

156
Q

What are the investigations for Bartholin’s cyst

A

Clinical diagnosis

> 40s, consider biopsy

Swab if suspecting STI

157
Q

What is the management for Bartholin’s cyst

A

Warm baths (if small)

Word catheter (in place for 4-6 weeks, not suitable for deep cysts)

Marsupialisation (incision in cyst, spontaneous drainage, cyst wall sutured to vaginal mucosa)

Silver nitrate cautery, CO2 laser, needle aspiration

158
Q

What is lichen sclerosus

A

Chronic inflammatory skin disease of female anogenital region

Mostly in pre-pubescent girls and post-menopausal women

Can progress to squamous cell carcinoma

159
Q

What are the risk factors for lichen sclerosus

A

Family history

Other autoimmune disorders

160
Q

How might a patient with lichen sclerosus

present

A

White atrophic patches on skin of anogenital region

Itching

Fissuring/erosion of skin

Dyspareunia

161
Q

What would you find on examination of a woman with lichen sclerosus

A

Clitoral hood fusion

Fusion of labia minora and labia majora

Posterior fusion (loss of vaginal opening)

162
Q

Differential diagnoses for lichen sclerosus

A

Lichen simplex

Vitiligo

Vulvar cancer/intraepithelial neoplasia

Candidiasis

Post-inflammatory hypopigmentation

163
Q

What are the investigations for lichen sclerosus

A

Clinical diagnosis

Biopsy (if uncertain)

164
Q

What is the management of lichen sclerosus

A

Immunosuppression (topical steroids)

Avoid irritants to area

Follow up if chronic (risk of developing squamous cell carcinoma)

Obs and gynae (6 decks)

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