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Obstetrics and Gynaecology > Gynaecology > Flashcards

Gynaecology Flashcards

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1
Q

Androgen insensitivity syndrome

A

X-linked recessive condition caused by a mutation in the androgen receptor gene which results in cells being unable to respond to androgen hormones due to lack of androgen receptors. Extra androgens are converted to oestrogen giving female sexual characteristics. Patients are genetically male. Patients have testes in the abdomen but female external genitalia.

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2
Q

Presentation of androgen insensitivity syndrome

A

Presents in infancy with inguinal hernias containing testis.
In puberty presents with primary amenorrhoea

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3
Q

Hormone test results for patients with androgen insensitivity syndrome

A

Raised LH
Normal or raised FSH
Normal or raised testosterone (for a male)
Raised oestrogen levels for a male

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4
Q

Management of androgen insensitivity syndrome

A

Bilateral orchidectomy
Oestrogen therapy
Vaginal dilators or vaginal surgery
Support and counselling

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5
Q

Typical complications of bicornate uterus

A

Miscarriage
Premature birth
Malpresentation

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6
Q

Imperforate hymen - what is it? how does it present and diagnosed? how is it treated? complications?

A

Imperforate hymen is where the hymen at the entrance of the vagina is fully formed without an opening.

Presents with cyclical pain and cramping that would ordinarily be associated with menstruation but without ny vaginal bleeding

Diagnosed on clinical examination

Surgically managed by creating an opening in the hymen.

Complications: can lead to endometriosis

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7
Q

Transverse vaginal septae - what is it? what types are there? how would they present? how is it treated? complications?

A

Caused by an error in development where a septum forms transversely across the vagina. Septum can be either imperforate or perforate.

If perforate, then girls will still menstruate but can have difficulty with intercourse or tampon use.

If imperforate, it will present similarly to an imperforate hymen with cyclical pain and cramping without menstruation.

Diagnosis is by examination, USS or MRI.

Treatment is surgical.

Complications: vaginal stenosis and recurrence of the septa

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8
Q

Immediate complications of female genital mutilation

A

Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence

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9
Q

Long term complications of FGM

A

Vaginal infections
Pelvic infections
UTIs
Dysmenorrhoea
Sexual dysfunction and dyspareunia
Infertility and pregnancy-related complications
Significant psychological issues and depression

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10
Q

Management of FGM

A

Report all cases of FGM and refer to FGM specialist.

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11
Q

What is Lichen Sclerosis?

A

Chronic inflammatory autoimmune skin condition which presents with patches of shiny white skin.

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12
Q

What areas does lichen sclerosis affect?

A

Labia, perineum and perianal skin in women.

In men, foreskin and glans of penis

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13
Q

How does lichen sclerosis present?

A

Itching
Soreness and pain - possibly worse at night
Skin tightness
Painful sex
Erosions
Fissures

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14
Q

How would lichen sclerosis appear on the skin?

A

Porceline-white in colour
Shiny
Tight
Thin
Slightly raised

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15
Q

Management of lichen sclerosis

A

No cure. Followed up every 3-6 months

Topical steroids are main treatment - OD for 4 weeks.

Emollients as well used regularly

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16
Q

Complications of lichen sclerosis

A

Squamous cell carcinoma of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings

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17
Q

Bartholin’s Cyst/abscess

A

Blockage of the bartholin’s glands which are located on either side of the vaginal opening. Ducts can become blocked and cause the glands to swell forming a cyst. Cysts can become infected and form an abscess.

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18
Q

Management of bartholin’s cyst/abscess

A

Cysts usually resolve
Biopsy may be required to exclude vulval malignancy in women over 40.
Abscess will require antibiotics - swab of pus or fluid can be taken for culture and sensitivity.

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19
Q

Most common cause of bartholin abscess (organism)

A

E.coli

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20
Q

What is urge incontinence?

A

Overactivity of the detrusor muscle.

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21
Q

What is stress incontinence?

A

Due to weakness of the pelvic floor and sphincter muscles which allows urine to lead at times of increased pressure on the bladder.

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22
Q

What is mixed incontinence?

A

Combination of urge and stress incontinence

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23
Q

What is overflow incontinence?

A

Occurs when there is chronic urinary retention due to an obstruction to the outflow of urine.

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24
Q

Causes of overflow incontinence

A

Fibroids, pelvic tumours, neurological conditions such as MS, diabetic neuropathy and spinal cord injuries

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25
Risk factors for urinary incontinence
Increased age Postmenopausal status Increased BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions such as MS
26
Investigations for urinary incontinence
A bladder diary - for at least 3 days Urine dipstick testing - assess for infection, microscopic haematuria Post-void residual bladder volume - should be measured using a bladder scan to assess for incomplete emptying Urodynamic testing
27
Describe urodynamic testing
Assesses the presence and severity of urinary symptoms. Catheter inserted into the bladder and another into the rectum to measure the pressures in the bladder and rectum for comparison. The bladder is then filled with liquid and various measures are taken.
28
Management of stress incontinence
Avoid caffeine, diuretics and overfilling bladder Weight loss Supervised pelvic floor exercises at least 3 months before surgery Surgery Duloxetine (SNRI)
29
Management of urge incontinence
Bladder retraining (for at least 6 weeks - first line) Anticholinergic medication - oxybutinin, tolterodine and solifenacin Mirabegron Invasive procedures - Botulism toxin type A, percutaneous sacral nerve stimulation, urinary diversion (involves redirecting urinary flow to a urostomy on the abdomen)
30
Side-effects of anticholinergics (e.g. oxybutinin, tolterodine and solifenacin)
Dry eyes, dry mouth, urinary retention, constipation and postural hypotension. Cognitive decline, memory problems and worsening dementia
31
What is a vault prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus. The top of the vagina descends into the vagina.
32
What is a rectocele? What are they associated with?
Rectoceles are caused by a defect in the posterior vaginal wall which allows the rectum to prolapse forward into the vagina. They are associated with constipation.
33
What is a cystocele?
Caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
34
What is a prolapse of both the bladder and urethra called?
Cystourethrocele
35
Risk factors or pelvic organ prolapse
Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and post menopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining
36
How would a pelvic organ prolapse present?
Feeling something coming down the vagina Dragging or heavy sensation in the pelvis Urinary symptoms - incontinence, urgency, frequency, weak stream, retention Bowel symptoms - constipation, incontinence and urgency Sexual dysfunction - pain, altered sensation and reduced enjoyment
37
How would you examine someone that has a pelvic organ prolapse?
Use a sim's speculum to support the anterior and posterior vaginal wall whilst the other vaginal walls are examined. Women can be asked to cough to assess the full descent of the prolapse.
38
Grading for uterine prolapses
POP-Q - pelvic organ prolapse quantification system Grade 0 - Normal Grade 1: The lowest part is more than 1 cm above the introitus Grade 2: the lowest part is within 1 cm of the introitus (above or below) Grade 3: the lowest part is more than 1 cm below the intoitus but not fully descended Grade 4: Full descent with eversion of the vagina
39
Management options for vaginal prolapses
1. Conservative management 2. Vaginal pessary 3. Surgery
40
How do you conservatively manage vaginal prolapses and who are they for?
For women with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management includes: 1. Physio 2. Weight loss 3. Treat related symptoms 4. Vaginal oestrogen cream
41
Types of vaginal pessaries
Ring Shelf Cube Donut
42
Complications of surgery for vaginal prolapse
Pain, bleeding, infection, DVT and anaesthetic risk Damage to the bladder or bowel Recurrence of prolapse Altered experience of sex
43
What is cervical ectropion?
When the columnar epithelia of the endocervix extends out to the ectocervix
44
Cervical ectropion presentation?
Most are asymptomatic and found incidentally during speculum examination. Increased vaginal discharge Vaginal bleeding Dyspareunia Postcoital bleeding
45
Management of cervical ectropion
Asymptomatic - no treatment required Problematic bleeding - cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
46
What is Asherman's syndrome?
It is when adhesions form within the uterus following damage. Adhesions form physical obstructions and distort the pelvic organs.
47
What usually causes Asherman's syndrome?
Pregnancy related dilatation and curettage procedure e.g. from treatment of retained products of contraception. Uterine surgery or several pelvic infection
48
Complications of Asherman's syndrome
Menstruation abnormalities, infertility and recurrent miscarriages.
49
How would Asherman's syndrome present?
Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods) Infertility
50
How would you diagnose Asherman's syndrome?
Hysteroscopy (gold-standard) Hysterosalpingograph (contrast injected into uterus and imaged with x-rays) Sonohysterography - uterus filled with fluid and a pelvic ultrasound performed MRI scan
51
Management of Asherman's syndrome
Dissecting adhesions during hysteroscopy. Recurrence of adhesions is common.
52
Ovarian torsion is usually caused by?
ovarian masses larger than 5cm - tumour or cyst.
53
Why is ovarian torsion more common in in girls prior to menarche?
Because they have longer infundibulopelvic ligaments which can twist more easily
54
Why is ovarian torsion an emergency?
Twisting of the adnexa (Fallopian tubes and surrounding tissue) and blood supply with cause ischaemia -> necrosis -> emergency
55
How would ovarian torsion present?
Sudden onset severe unilateral pelvic pain which gets progressively worse and is associated with nausea and vomiting.
56
What would you find on examination if you suspect ovarian torsion?
Localised tenderness +/- palpable mass
57
How would you diagnose ovarian torsion?
Pelvic USS (initial investigation of choice) Transvaginal is ideal -> Whirlpool sign - free fluid in pelvic and oedema around the ovary. Definitive diagnosis - laparoscopic surgery
58
How would you manage ovarian torsion?
Laparoscopic surgery to either - untwist the ovary and fix it in place or remove the affected ovary (oophorectomy)
59
Complications of ovarian torsion
If necrotic ovary is not removed -> it will become infected which will form an abscess and lead to sepsis. It could also rupture causing peritonitis and adhesions
60
Are ovarian cysts a cause for concern?
In premenopausal women -> no In postmenopausal women -> yes and warrants further investigations
61
How would ovarian cysts present?
Most are asymptomatic. Pelvic pain Bloating Fullness in abdomen Palpable pelvic mass
62
What are serous cystadenomas?
Benign tumours of epithelial cells
63
What are mutinous cystadenomas?
Benign tumours of epithelial cells which can become huge and take up lots of space in the pelvic and abdomen
64
What are endometriomas?
Lumps of endometrial tissue within the ovary - occurring in patients with endometriosis
65
What are germ cell tumours?
Dermoid cysts (teratomas) - they contain various tissue types such as skin, teeth, hair and bone
66
How would you assess whether an ovarian cyst is benign or malignant?
Abdominal bloating Reduced appetite Early satiety Weight loss Urinary symptoms Pain Ascites Lymphadenopathy
67
Risk factors for ovarian malignancy
Age Post menopause Increased number of ovulations Obesity HRT Smoking BRCA1 and BRCA2 genes
68
Investigations for ovarian cysts
Premenopausal -> USS and no more investigations Postmenopausal: Tumour markers: CA124, LDH, AFP. HCG
69
Causes of raised CA125
Fibroids Endometriosis Adenomyosis Pelvic inflammation Liver disease Pregnancy
70
Management of ovarian cysts
Possible ovarian cancer -> 2 week wait referral Dermoid cyst - refer to gynae Simple cyst <5cm - no follow up 5-7cm - will require routine referral to gynae and yearly USS monitoring >7cm - consider MRI and surgical evaluation post menopausal women - CA125 result and refer to gynae, if raised -> 2 week wait referral Simple cyst under 5cm with normal CA125 - USS monitoring every 4-6 months
71
Complications of ovarian cysts
Torsion Haemorrhage Rupture
72
What is Meig's syndrome?
PAO! Triad of: Ovarian fibroma Pleural effusion Ascites
73
Characteristic features of PCOS
Multiple ovarian cysts Infertility Oligomenorrhea Hyperandrogenism Insulin resistance
74
Diagnostic system for PCOS
Rotterdam criteria requires at least two of the three key features: - Oligoovulation or an ovulation - irregular or absent menstrual periods - Hyperandrogenism - hirsutism and acne - Polycystic ovaries on USS
75
Presentation of PCOS
Oligomenorrhoea or amenorrhoea Infertility Obesity Hirsutism Acne Hair loss in a male pattern Insulin resistance and diabetes Acanthosis nigricans Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia and cancer Obstructive sleep apnoea Depression and anxiety Sexual problems
76
Investigations for PCOS
Testosterone LH FSH Prolactin TSH Pelvic USS. Transvaginal USS is gold standard - 'string of pearls' appearance
77
Management for PCOS
Weight loss Exercise Smoking cessation
78
Complications of PCOS
Endometrial hyperplasia and cancer Infertility Hirsutism Acne Obstructive sleep apnoea Depression and anxiety
79
How would you manage endometrial cancer risk in women with PCOS?
Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3-4 months with either cyclical progestogens or COCP
80
How would you manage infertility in women with PCOS?
Weight loss. Clomifene Laparoscopic ovarian drilling IVF Metformin
81
How would you manage hirsutism in women with PCOS?
Weight loss COCP Topical eflornithine (takes 6-8 weeks to see significant improvement) Laser hair removal Spironolactone Finasteride
82
How would you manage acne in women with PCOS?
COCP (first-line)
83
Why do you give progesterone to women with uteruses in HRT?
To prevent endometrial hyperplasia and endometrial cancer
84
What are non-hormonal treatment for menopausal symptoms?
Diet Exercise CBT Clonidine SSRI (fluoxetine) Venlafaxine (SNRI) Gabapentin
85
What is clonidine and how does it manage menopausal symptoms?
It is an alpha 2 adrenergic receptor agonist. It lowers blood pressure, heart rate and helpful for vasomotor symptoms and hot flushes
86
Indications for HRT
Replacement of hormones in premature ovarian insufficiency Reducing vasomotor symptoms - hot flushes and night sweats Improves symptoms such as low mood, decreased libido, poor sleep and joint pain Reduces the risk of osteoporosis
87
Risks of HRT
Increases risk of breast cancer (combined HRT - lower in oestrogen only HRT) Increased risk of endometrial cancer (without oestrogen) Increased risk of VTE Increased risk of stroke
88
Contraindications for HRT
Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled HTN VTE Liver disease Pregnancy
89
What is premature ovarian insufficiency?
Menopause before the age of 40
90
Causes of premature ovarian insufficiency
Idiopathic Iatrogenic - due to chemo, radiotherapy, or surgery Autoimmune - coeliac, adrenal insufficiency, T1DM, thyroid disease Genetic Infections
91
Presentation of premature ovarian insufficiency
Irregular periods, secondary amenorrhoea Hot flushes Night sweats Vaginal dryness
92
How would you diagnose premature ovarian insufficiency?
Women <40 years Typical menopause symptoms Elevated FSH
93
Management of premature ovarian insufficiency
HRT
94
What is menopause?
Lack of periods for 12 months
95
What would hormonal blood results show in someone experiencing menopause?
Low oestrogen and progesterone High LH and FSH
96
Perimenopausal symptoms
Hot flushes Low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness Reduced libido Night sweats
97
How do you diagnose menopause?
Diagnosis can be made in women over 45 with typical symptoms without performing any investigations
98
Management of perimenopausal symptoms
No treatment HRT Tibolone Clonidine CBT SSRI - fluoxetine Vaginal oestrogen cream or tablets
99
What is adenomyosis?
Endometrial tissue inside the myometrium
100
How does adenomyosis present?
Dysmenorrhoea Heavy periods Dyspareunia 1/3 of patients are asymptomatic
101
How would you diagnose adenomyosis?
Transvaginal USS is first-line investigation MRI and transabdominal USS are alternatives Gold standard - histological examination of uterus after hysterectomy
102
Management of adenomyosis
Women who do not want contraception: no associated pain - tranexamic acid associated pain - mefenamic acid When contraception is wanted: Mirena (first-line) COCP Progestogens
103
Adenomyosis is associated with:
Infertility Miscarriage Preterm birth Small for gestational age Malpresentation Need for Caesarean section Postpartum haemorrhage
104
What is endometriosis?
Where there is ectopic endometrial tissue outside the uterus
105
How does endometriosis present?
Cyclical abdominal pain or pelvic pain Deep dyspareunia Dysmenorrhoea Infertility
106
What would you find on examination of a patient with endometriosis?
Endometrial tissue visible in the vagina on speculum examination Tenderness in the vagina, cervix and adnexa
107
How would you diagnose endometriosis?
Pelvic USS Laparoscopic surgery is gold standard Definitive diagnosis can be established with a biopsy
108
How would you manage endometriosis?
NSAIDS and paracetamol (first-line) Hormonal management: COCP, POP, depo, implant, mirena coil Surgical: laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions. Hysterectomy.
109
What are fibroids made of?
Smooth muscle
110
Types of fibroids
Pedunculated Intramural Subserosal Submucosal
111
Presentation of fibroids
Normally asymptomatic Menorrhoea Abdominal pain Bloating Urinary or bowel symptoms Deep dyspareunia Reduced fertility
112
Investigations of fibroids
Hysteroscopy - submucosal fibroids presenting with heavy menstrual bleeding Pelvic USS - investigation of choice for larger fibroids MRI scanning - prior to surgery
113
Management of fibroids <3cm
<3cm: Mirena coil (first-line) Symptomatic management with NSAIDs and tranexamic acid COCP Cyclical oral progestogens
114
Management of fibroids >3 cm
Refer to gynae Symptomatic - NSAIDs and tranexamic acid Mirena coil COCP Cyclical oral progestogens
115
Surgical management of large fibroids
Uterine artery embolisation Myomectomy Hysterectomy
116
What can be given prior to surgical removal of fibroids?
GnRH agonists such as goserelin to reduce the size of the fibroid prior to surgery
117
Placenta praevia - labour options
Women with grade III/IV placenta praevia should be offered an elective caesarean section at 37-38 weeks

Obstetrics and Gynaecology (9 decks)

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