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Flashcards in Gynaecology Deck (80)
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1
Q

Describe the physical, psychological, and behavioural changes observed in PMD (prev. PMS).

A
  • physical: headache, mastalgia, weight gain, fluid retention, joint/skin pain
  • psychological: irritability, emotional lability, low mood, tension
  • behavioural: sleep disturbance, change in appetite, restlessness, poor conc., confusion, social withdrawal
2
Q

What is the difference between PMD and PMDD?

A
  • postmenopausal dysphoric disorder: occurs with accompanying mood swings, anxiety, and/or depression
  • SSRIs can benefit
3
Q

Describe the management options for PMD.

A
  • 1st line: despiramine-containing COC (Yasmin, Eloine)
  • 2nd line: GnRH agonists [can cause vasomotor symptoms, such as hot flushes, & osteoporosis]
  • additional: vitamin B6, oil of evening primrose, oestrogen patches/implants
  • SSRIs / psychotherapy for PMDD
4
Q

Define heavy menstrual bleeding (HMB).

A

Blood loss that interferes with physical, social, emotional or material aspect of a woman’s life.

  • accounts for 20% of gynae appts.
  • most common cause of iron deficiency anaemia
5
Q

What are the key causes of HMB?

A
  • organic: fibroids, polyps, adenomyosis, age
  • gynae: curettage (biopsy), surgical TOP, hormones (oestrogen/tamoxifen)
  • haematological: bleeding disorders (coagulopathy)
  • other: medication, malignancy
6
Q

Describe the management options for HMB.

A
  • 1st line: Mirena coil (LNG-IUS)
  • 2nd line: tranexamic acid (anti-fibrinolytic) / COC
  • 3rd line: DMPA
  • 4th line: surgery
7
Q

Name and describe the main types of miscarriage.

A

Miscarriage: pregnancy that ends spontaneously before the foetus reaches a viable age (<24wks)

  • threatened: cervical os closed, foetus inferior uterus
  • inevitable: cervical os opened, foetus at os
  • incomplete: cervical os opened, products of conception in both uterus and cervix
  • complete: cervical os closed, foetus in cervix
  • anembryonic: empty gestational sac, no pole
8
Q

Name the causes, investigation and management of miscarriage.

A
  • causes: chromosomal abnormality, APLS, infection (CMV, rubella, toxoplasmosis, listeria), after CVS, smoking/alcohol etc.
  • ABCDE, urgent evacuation if heavy bleed / haematological instability: misoprostol +/- mifeprisone to allow MVA/EPRC
  • FBC, G&S, HCG, USS
  • progesterone pessaries useful in unexplained cases
9
Q

What is the most common cause of recurrent miscarriage, and how can it be reduced?

A

APLS: low dose aspirin + heparin allows live birth rate >75%

10
Q

What are the symptoms of ectopic pregnancy?

A
  • pain > bleeding
  • dizziness, eclampsia, shoulder tip pain, dyspnoea
  • pallor, haemodynamic instability, peritonism
  • red flag: abdominal/pelvic pain requiring opiates
11
Q

What is pregnancy of unknown location (PUL), and how is it managed?

A
  • a halfway diagnosis of ectopic pregnancy (i.e., not found on any scans)
  • M6 model: measurement of progesterone guides follow-up management
  • theoretically reveal IU/ectopic pregnancy
  • can be managed with methotrexate
12
Q

Describe the management of ectopic pregnancy.

A
  • acutely unwell: laparoscopic salpingectomy (98% of ectopic pregnancies are in Fallopian tubes)
  • stable: manage with methotrexate
  • GEM II: adds gefitinib to MTX; may reduce surgery
13
Q

Describe the pathological and radiological appearances of molar pregnancy.

A
  • pathological: grape-like clusters

- radiological: ‘snowstorm’ like appearance on USS

14
Q

Name the two types of molar pregnancy, and how they arise.

A
  • complete: sperm fertilises egg w/out female DNA; sperm duplicates within egg, leaving only paternal DNA -> 46
  • partial: 2 sperm (or 1 that duplicates) fertilises an egg with 1 set of female DNA -> 69
15
Q

Define hyperemesis gravidarum, and its main symptoms.

A

Excessive, protracted vomiting that alters QoL Diagnosis of exclusion (e.g., UTI, pancreatitis, hepatitis)

  • dehydration, ketosis, electrolyte/nutritional disturbances
  • in some: weight loss, altered liver function
  • severe: malnutrition, emotional instability, anxiety
16
Q

Describe the management options for hyperemesis gravidarum.

A
  • rehydration, electrolyte replacement, antiemetic, nutritional support, thiamine & thromboprophylaxis
  • 1st line: cyclizine, prochlorperazine
  • 2nd line: metaclopromide (risk oculomotor crisis, which is treated with atropine)
  • oral prednisolone can be considered
17
Q

Name the differential for unilateral pelvic pain in the female.

A
  • ectopic pregnancy
  • appendicitis
  • ovarian torsion, cyst accident, fibroid degeneration
  • renal calculi
18
Q

Name the differential for diffuse pelvic pain in the female.

A
  • miscarriage
  • PID, UTI, diverticulitis
  • endometriosis
  • constipation, IBS, urinary retention
19
Q

What is the likely diagnosis for a female who experiences sudden unilateral pelvic pain after sexual intercourse or contact sport?

A

Cyst rupture/accident

20
Q

What are the main causes of abnormal uterine bleeding (AUB, aka DUB)?

A
  • uterine: anovulatory cycles, pregnancy, miscarriage, endometritis, polyp, leiomyoma, adenomyosis
  • endocrine: PCOS, thyroid disorders, hyper PRL, hormone changes
  • bleeding disorders
  • hyperplasia, neoplasia
21
Q

Describe the process by which one would take a uterine biopsy.

A
  • TVUS prior to biopsy; >4mm postmenopausal or >16mm premenopausal indication for biopsy
    • pipette: outpatient procedure, does not need anaesthesia or dilatation
    • dilatation & curettage: most accurate method
22
Q

Describe the histological findings of endometritis.

A
  • mucous plug (cystic dilatation), w/ glandular nests
  • periglandular fibrosis (chronic)
  • presence of plasma cells
23
Q

Describe the histological findings of molar pregnancy.

A

Hydropic villi (enlarged, dilated, oedematous, avascular)

  • cavitation/cisterns present
  • increase in synctio- and cytotrophoblast layers
24
Q

Define adenomyosis and leiomyoma.

A
  • adenomyosis: presence of endometrial tissue in the myometrium
  • leiomyoma: benign, smooth muscle tumour
25
Q

Define infertility and its initial investigation (e.g., at the GP).

A

Inability to conceive after 12m of regular unprotected intercourse. Female investigations:
- midluteal (e.g. day 21 in a 28 day cycle) progesterone
- follicular phase LH, FSH, E2; testosterone and SHBG (giving FAI); PRL
- TSH, TFTs
- Rubella, Chlamydia screen
Male investigations:
- sperm analysis. normal parameters 16million/ml, 30% progressive motility, 4% normal visible morphology

26
Q

Define the following terms.

  • azoospermia
  • oligozoospermia
  • asthenozoospermia
  • teratozoospermia
A
  • azoospermia: no sperm in ejaculate
  • oligozoospermia: reduced conc. in ejaculate (e.g., under 16 million/ml)
  • asthenospermia: reduced progressive motility (e.g., under 30%)
  • teratozoospermia: reduced normal morphology (e.g., under 4%)
27
Q

Name some infertility tests in secondary care.

A
  • USS (anatomical/congenital abnormalities)
  • hysterosalpingogram (HSG)
  • laparascopic hydrotubation (HTB)
  • hysteroscopy
28
Q

Describe the Rotterdam criteria. Which condition are they used to diagnose?

A

PCOS. 2/3 is diagnostic

  • oligo/amenorrhoea
  • polycystic ovaries on scans (12+ follicles, volume >10ml)
  • signs of hyperandrogenism (acne, hirsutism)
29
Q

Describe the management options for PCOS.

A
  • 1st line: clomifene citrate (30-40% conceive)
  • 2nd line: tamoxifen (can be improved with weight loss and adjuvant metformin)
  • 3rd line: [recombinant FSH] gonadotrophin injection (60-70% conceive)
  • 4th line: laparascopic ovarian diathermy
30
Q

Describe the management options for tubal infertility problems.

A
  • generally no management options, requiring ART
  • prior sterilisation may possibly be reversed; however, this is generally considered irreversible
  • proximal blockage may be managed by cannulation with a guidewire/microcatheter
31
Q

Describe the criteria for assisted reproductive technology, ART.

A
  • female health: <40yr, BMI 18.5-30, non-smoker (3/12), no illegal or abusive substances (inc. methadone)
  • relationship: stable >2yr, no biological children, neither sterilised, unexplained infertility >2yr
32
Q

Describe the rough timeline for a woman undergoing ART.

A
  • day 21: buserelin [GRH agonist, nasal spray] 4/day for 2/3 weeks
  • baseline scan for downregulation
  • FSH/HMG injection for 8-9 nights
  • once ready, stop FSH/HMG, give one HCG injection late night to simulate LH surge
  • 36hr after HCG injection -> harvest/fertilise eggs
33
Q

How can the hormones oestrogen and progesterone be used to provide contraception?

A
  • oestrogen: blocks FSH & follicle development
  • progesterone: blocks LH surge, thickens mucous
  • both: prevents implantation
34
Q

Name the six categories of contraception.

A
  • hormonal [pills, rod, DMPA/depo]
  • barrier methods [condoms, cervical cap]
  • intrauterine [copper coil, hormone coil]
  • permanent [sterilisation]
  • fertility awareness [calendar etc.]
  • emergency [copper coil, oral]
35
Q

What is the most successful method of contraception?

A

The rod (Nexplanon)

36
Q

What are the non-contraceptive uses of the Mirena coil?

A

HMB, HRT, endometriosis, hyperplasia

37
Q

How are the contraceptive pills initiated?

A

Start within 5 days of first period, or when sure not pregnant + 7 days of condom use
Taken daily for 21 days, then break for 7 days

38
Q

What are the minor side effects of the COC?

A
  • weight gain, nausea
  • flushing, pigmentation
  • mastaglia
39
Q

What are the major side effects of the COC?

A
  • VTE (smokers, >35yr, HTN, obesity)
  • HTN (BP checked annually)
  • ischaemic stroke (contraindicated in migraine with aura)
  • risk of breast/cervical cancer [1.26 relative risk]
40
Q

What are the three options for emergency contraception?

A
  • copper coil
  • ulipristal acetate
  • levonogestrol
41
Q

What are the risks associated with unplanned pregnancy?

A
  • inc: preterm birth, postpartum depression/ substance misuse, neglect/child abuse
  • dec: antenatal care, birthweight, breastfeeding/bonding, developmental outcomes
42
Q

Describe the legislation surrounding abortion.

A
  • Human Fertilisation & Embryology Act 1990 contains exemptions to Offences Against the Person Act 1861
  • standard form: HSA1 via clause C (98%) or clause E (2% - mental or physical anomalies)
  • emergency form: HSA2
  • all abortions must be reported to CMO via HSA4
43
Q

Describe the clinical pathway for those wishing an abortion.

A
  • referral by self, GP, or RSH. aim for <5d between referral and initial consultation
  • gestation is estimated by LMP +/- UPT
  • USS is used for risk assessment, including ectopics, unsure about dates, or prior to STOP
44
Q

MTOP (medical termination of pregnancy) is based on gestational dates. What are these and how does management differ?

A
  • note: above timeframe extends to 21+6 during COVID
45
Q

STOP (surgical termination of pregnancy) is based on gestational dates. What are these and how does management differ?

A
  • cervical priming undertaken via miso or osmotic dilators to reduce risk of cervical injury
  • <10wk: manual vacuum aspiration (LA)
  • <14wk: electrical vacuum aspiration (GA)
  • > 14wk: dilatation and evacuation
46
Q

Abortion is generally very safe procedure; what are the rare complications that may arise?

A
  • most common: haemorrhage (STOP > MTOP)
  • infection (covered by doxycycline in COVID times)
  • STOP-only: uterine perforation, cervical trauma
  • may be a Rhesus sensitising event: ensure anti-D given
47
Q

Describe the timeline associated with menopause and its different syndromes. Describe also their investigations.

A
  • <40yr (1%): premature ovarian insufficiency (POI). autoimmune tests, FSH, E2, TFTs, glucose, FAI
  • 40-45yr (57%): early menopause. FSH x2/wk
  • 45-55yr (average 51). FSH x2/6wk if atypical
48
Q

Name some of the symptoms associated with the menopause.

A
  • hot flushes
  • breast atrophy
  • loss of libido
  • aches and pains
  • sleep disturbance
  • irritability, depression
  • loss of concentration
  • weight gain
  • vaginal dryness, dyspareunia
49
Q

Name some of the non-hormonal management options for menopause.

A
  • healthy diet (including phytooestrogens)
  • healthy weight, exercise, smoking cessation
  • good sleep hygiene, reduced alcohol/caffeine, stress
  • cooler ambient temperature, ventilation, suitable clothing, neck cooling fans ec.
  • ? herbal remedies, including St John Wort
  • ? complementary therapies
50
Q

Describe the benefits, risks, and contraindications for hormone replacement therapy (HRT).

A
  • benefits: symptomatic, protects against osteoporosis, increases mental/sexual health
  • risks: increased breast and endometrial cancer, VTE, stroke, and withdrawal bleed
  • contraindications: history of breast cancer, coronary heart disease, TIA/stroke, unexplained vaginal bleeding, acute liver disease
51
Q

Describe the oestrogenic and progestogenic side effects of HRT.

A
  • oestrogen: bloating, breast enlargement, mastalgia, fluid retention, headache, leg cramp, mood swings, N&V
  • progesterone: acne, anxiety, bloating, depression, headache, hirsutism, abdominal/ pelvic/ back pain, mood swings
52
Q

Regarding a pelvic mass, the pelvis can be split into 4 main compartments. What are these, and what are the main pathologies that can affect each?

A
  • anterior (bladder): bladder tumour, distension
  • middle (uterus): fibroids, adenomyosis, carcinoma, sarcoma
  • posterior (bowel): bowel tumours, appendiceal mass, hernia, diverticular abscess
  • lateral (adnexae): ovarian, tubal mass, hydrosalpinx, ectopic pregnancy
53
Q

Name the five main categories of ovarian malignancy.

A
  • epithelial: serous, mucinous, endometrioid, clear cell, Brenner, undifferentiated
  • germ cell: mature cystic teratoma (‘dermoid cyst’), immature teratoma (embryonal), dysgerminoma, yolk sac, choriocarcinoma
  • stromal: fibroma, thecoma, granulosa, Sertoli, Sertoli-Leydig, steroid
  • metastatic
  • miscellaneous
54
Q

Name the main pathologies affecting the Fallopian tubes.

A
  • salpingitis, cysts, tumours, endometriosis, ectopic pregnancy
  • ectopic pregnancy: implantation of conceptus outside endometrial cavity
  • rupture may cause fatal haemorrhage
  • consider the diagnosis in any female of reproductive age with amenorrhoea, pelvic pain, or acute abdomen
55
Q

Name the tumour markers that are associated with ovarian cancers.

A
  • CA-125 (produced by mesothelium, increased in mucinous cancers)
  • CEA (most useful with CA-125/CEA ratio, suspicious when <25)
  • AFP, HCG, LDH
56
Q

Describe the risk of malignancy index (RMI) score used for ovarian cancer risk.

A
  • premenopausal, postmenopausal [1, 3]
  • USS findings (multiloculated, solid areas, bilateral, ascites, metastases) [none 0, 1 = 1, >1 = 3]
  • serum CA-125 [absolute level]
  • RMI = above 3 parameters multiplied
57
Q

Describe ovarian cysts.

A
  • follicular, luteal, endometriotic, epithelial, mesothelial
  • follicular cysts are very common, occurring when menstruation doesn’t
  • rarely >5cm, formed of thin-walled granulosa cells
  • may cause menstrual disturbance, may bleed/rupture, may cause acute abdomen, may be incidental
58
Q

Describe the pathology, clinical features, and complications of endometriosis

A
  • glands/stroma present outside the uterine body
  • may occur with regurgitation of endometrial tissue through the tubes, or with metaplasia of vascular dissemination
  • ovarian chocolate cysts - dysmenorrhoea, deep dyspareunia, subfertility, retrouterine tenderness
  • look out for peritoneal spots/nodules, fibrous adhesions etc.
  • complications: pain, adhesions, infertility, ectopics, malignancy
59
Q

Describe the pathology and clinical features of dermoid cysts.

A
  • formed from pluripotent stem cells (germ cells), material can include teeth, sebaceous tissue, thyroid tissue etc.
  • may be asymptomatic, pelvic pain, dyspareunia etc.
60
Q

Describe the more unusual presentations of ovarian cancer, including those who we should test.

A
  • persistent abdominal distention (bloating)
  • early satiety
  • pelvic/abdominal pain
  • urinary frequency/urgency
  • in women >50 with ‘IBS’
61
Q

Describe the management options for ovarian cancer.

A
  • staging laparotomy first used, where abdomen and pelvis are assessed for deposits and allow staging
  • early: open hysterectomy, BSO, infracolic omentectomy
  • late: radical debulking with aggressive cytoreduction
  • neoadjuvant chemo
62
Q

What is a Kruckenberg tumour?

A

Has a characteristic signet ring histology which metastasise from the GI tract (usually the stomach).

63
Q

Describe the classification of endometrial hyperplasia.

A
  • simple: general distribution, dilated glands, normal cytology
  • complex: foetal, crowded glands, normal cytology
  • atypical: atypical cytology, cancer precursor
64
Q

Describe the classification of uterine adenocarcinoma.

A
  • type 1: endometrioid, mucinous - unopposed oestrogen, atypical hyperplasia, PTEN, KRAS, PK3CA
  • type 2: serous, clear cell - elderly postmenopausal women, more aggressive
65
Q

How does obesity increase the risk of uterine adenocarcinoma?

A
  • endocrine and inflammatory changes to adipocytes, which express aromatase
  • dec. SHBG (inc. free biologically active hormone)
  • altered insulin (IGF can then exert effects of the endometrium)
66
Q

Describe the management options for uterine malignancy, including the complications.

A
  • surgical removal of uterus and cervix, traditionally by open approach
  • other options: BSO and/or PLND
  • complications: haemorrhage, infection, bladder/bowel problems, DVT/PE, hernias etc.
67
Q

Name and describe the main histological areas of the cervix.

A
  • endocervix (inner): mainly glandular
  • ectocervix (outer): squamous epithelium
  • transitional zone (squamocolumnar junction): between ecto- and endo-, most likely to be infected by HPV
68
Q

Describe the categories of pathology affecting the cervix.

A
  • inflammation (cervicitis, follicular, chlamydia, HSV)
  • CIN (HPV 16/18, many sexual partners, young at first intercourse etc.)
  • condylomata acuminatum (HPV 6/11; thickened papillomatous squamous epithelium with cytoplasmic vacuolisation ‘koilocytosis’)
  • cervical cancers (SCC 75-95%, adenocarcinoma 5-25%)
69
Q

Describe the histological findings and classification of cervical intraepithelial neoplasia (CIN).

A
  • delayed maturation and differentiation (immature basal cells)
  • nucleolar hyperchromasia, increased N:C ratio, pleomorphism)
  • excess mitotic activity
  • CIN I, II, III (basal 1/3, extends to middle 1/3, then full thickness)
70
Q

Cervical SCC is commonly asymptomatic and is highly preventable by screening. What are the possible presentations?

A
  • AUB (PCB/PMB)
  • brownish/blood staining
  • contact bleeding due to friable epithelium
  • pelvic pain
  • haematuria, UTI
  • ureteric obstruction, renal failure etc.
71
Q

Describe the different types of vulvar pathology.

A
  • VIN: usual-type (HPV-driven), dVIN (differentiated, independent of HPV)
  • vulvar invasive SCC
  • vulvar Paget’s (crusting rash with sharp demarcation, pruritis, and pain). may be primary (intraepithelial glandular) or secondary (colorectal, urothelial)
  • candida
  • Bartholin gland abscess
  • dermatoses (lichen sclerosis, planus, psoriasis)
  • vulvovaginal atrophy
72
Q

Describe the surgical management of cervical cancer.

A
  • stage 1a, 2: LLTEZ, coneloscopy (fertility desired); hysterectomy (family completed)
  • stage Ib: trachelectomy (fertility), radical hysterectomy (family completed)
  • > stage Ib: chemotherapy
73
Q

Describe the surgical management of vulvar cancer.

A
  • wide local incision of vulval lesions with 1cm free margin

- if depth >1mm, surgery should involve groin node removal (unilateral / bilateral depending on site)

74
Q

Regarding public health and cervical pathology:

  • who is eligible for screening?
  • who is now vaccinated against HPV?
  • why are both vaccination and screening required?
A
  • all women or those with a cervix aged 25-64
  • girls and boys of school age (12-13); two doses separated by 6 months
  • the vaccination (HPV16/18) only offers protection against 70% of cancers, as 30% are not caused by these subtypes
75
Q

Describe the screening pathway associated with cervical screening.

A

speculum exam, brush sample of transformation zone, testing for HPV 16/18

  • negative: repeat 5y
  • positive: perform cytology test
    • positive: colposcopy
    • negative: repeat screen 12m
76
Q

Describe the risk factors for prolapse.

A

female sex, childbirth, forceps delivery, obesity

  • stressors (smokers cough, COPD, heavy lifting, constipation)
  • Marfan’s, Ehlers-Danlos
77
Q

Describe the symptoms and classification of uterine prolapse.

A
  • heaviness/pressure, bulging, tissue protrusion, urinary incontinence / retention, splinting, vaginal wall, trouble with bowel movements, dyspareunia
  • 1st degree: within the vagina
  • 2nd: at the introitus
  • 3rd: outside the vagina
  • 4th / proincidenta: entirely outside without the vagina
78
Q

Describe the management options for gynaecological prolapse [3+3].

A
  • lifestyle: weight loss, smoking cessation, avoiding heavy lifting, caffeine reduction etc.
  • physiotherapy, pessaries etc.
  • surgeries:
    • cystocele: anterior colporrhaphy
    • rectocele: posterior colporrhaphy
    • uterine: sacrospinous fixation, mesh treatment etc.
79
Q

Regarding ultrasound:
- describe the benefits and difficulties
- describe the two O&G approaches and their differences
[4]

A
  • benefits: cheap and safe (no ionising radiation), very good definition of different pelvic organs and can be used as an adjunct to clinical examination
  • difficulties: obesity, gaseous distension, operator dependant
  • TA (transabdominal): requires full bladder, good initial view
  • TV (transvaginal): requires empty bladder, higher frequency and spatial resolution, can be used to evaluate ovarian volume
80
Q

Describe the key indications for CT [4], MRI [3], and HSG [1] in O&G disease.

A
  • CT: acute abdomen (after USS), post-surgical complications, staging malignancy, assessing response to cancer treatment
  • MRI: cervical cancer staging, evaluation of adnexal masses, subfertility (in conjunction with pituitary MRI)
  • HSG (hysterosalpingogram): infertility by tubal patency