Gynaecology Flashcards
(158 cards)
1
Q
What are the CFs of PCOS?
A
- Menstrual irregularity - oligo/amenorrhoea
- Hyperandrogenism - acne, hirsuitism
- Anovulatory infertility - oligo/anovulation
- Increased risk of pregnancy complications eg. spont abortion, gestational diabetes, pre term labour
- Insulin resistance - obesity and T2DM, acanthosis nigricans
2
Q
What is the theorised pathogenesis behind PCOS?
A
- Genetic link
- Increased LH and increased LH receptors = increased LH:FSH = excess androgen production
- Insulin resistance = hyperinsulinaemia to compensate for resistance, stimulates theca cells = increased androgen secretion
3
Q
What are the stages of the menstrual cycle?
A
- Follicular phase
- Ovulation
- Luteal phase
- Secretory phase
4
Q
Describe the pre ovulatory phase of the menstrual cycle
A
- Pulsatile GnRH causes FSH and LH release frm the ant pit
- Follicle grows due to FSH release
- LH releases androgen which is converted to oestrogen by aromatase = increased O
5
Q
Describe how ovulation occurs
A
High levels of oestrogen act as positive feedback on FSH and LH - surge of LH causes ovulation, happens at Day 14.
6
Q
What is the uterus doing around the time of ovulation?
A
From day 11-15 the uterus is preparing for implantation and fertilisation of the egg:
- Spiral arteries grow
- Endometrium thickens
- Cervical mucus thins to allow sperm to pass
7
Q
What happens in the luteal phase?
A
Corpus luteum continues producing oestrogen but lutenised granulosa cells produce lots and lots of progesterone so it is the dominant hormone.
Progesterone and inhibin -ve feedback LH and FSH causing reduced oestrogen - this signifies ovulation has taken place.
8
Q
What do high levels of progesterone do to the uterus?
A
Prepares the uterus to thick its cervical mucus = once oocyte fertilised don’t want to let any more sperm through and coil its spiral arteries = once oocyte is fertilised will implant.
9
Q
What happens in the secretory phase/menstruation?
A
Corpus luteum changes to the corpus albican which is basically dead - no oestrogen or progesterone produced. Spiral arteries collapse and the lining sheds = menstruation.
10
Q
What bloods are involved in ix PCOS?
A
- Total testosterone
- LH (often elevated)/FSH (elevated in premature ovarian failure, differential for PCOS)
- Prolactin - hyperprolactinaemia can cause oligomenorrhoea
- Thyroid profile - often causes irreg periods
- Free androgen index - if raised is diagnostic of PCOS
11
Q
What is the Rotterdam criteria?
A
- Transvaginal USS reveals 12 or more cysts on one ovary or increased ovarian volume
- Oligo/anovulation
- Clinical or biochemical signs of hyperandrogenism
12
Q
How do you treat menstrual irreg in PCOS? Why does it need treating?
A
Causes endometrial hyperplasia = possible increased risk endometrial cancer. Therapies prevent endometrial thickening.
- Cyclical progestogen
- COCP
- Levonorgestrel IUS = Mirena
13
Q
What is PCOS?
A
Polycystic ovary syndrome: menstrual dysfunction and hyperandrogenism
14
Q
What is the treatment of fertility in PCOS?
A
Induce normal ovulatory cycles:
- Letrozole - aromatase inhib
- Clomiphene - SERM, selective oestrogen receptor modulator
15
Q
How do you treat the metabolic complications of PCOS?
A
- Weight loss can reduce metabolic risks and hyperandrogenism as well as restore ovulatory cycles
- Quit smoking
- Screen for diabetes, dyslipidaemia and HTN
- Metformin - used to be used but not routinely anymore
16
Q
What are fibroids?
A
Uterine leiomyomas - benign monoclonal tumours of the smooth muscle cells of the uterine myometrium.
17
Q
What is the classification of fibroids?
A
- Intramural - most
- Submucosal - growing into the uterine cavity, may protrude through the cervical os
- Subserosal - growing outwards from the uterus
18
Q
What are the RF and protective factors of fibroids?
A
RF - obesity, early menarche, FH, HTN, alcohol consumption, poor diet
Protective - exercise, increased parity, cigarettes
19
Q
What is the presentation of fibroids?
A
- Asymptomatic
- Excessive or prolonged heavy periods - Fe def anaemia
- Intermenstrual bleeding
- Compressive sx - pelvic pain, constipation, urinary sx
- Recurrent miscarriage or infertility
20
Q
What do you find o/e of PCOS?
A
- Palpable abdo mass arising from pelvis
- Enlarged, irreg, firm, non tender uterus palpable on bimanual pelvic exam
- Signs of anaemia due to menorrhagia
21
Q
What are the ix into fibroids?
A
- Pregnancy test
- FBC
- Transvaginal US or pelvic US
- MRI - only if US is not definitive
- Endo metrial sampling for histology
- Hysteroscopy w biopsy
22
Q
What is the management of fibroids?
A
- NSAIDs - reduce menstrual blood loss when cause is unknown but less evidence in fibroids
- Tranexamic acid
- COCP or Levonorgestrel IUS
- Mifepristone = progesterone receptor inhib
- Ulipristal acetate
- Surgery
23
Q
When is surgery indicated in fibroids? What surgery is done?
A
- Excessively enlarged uterine size
- Pressure sx
- Med management not controlling sx
- Reduced fertility
Surgery - myomectomy, hysteroscopic endometrial ablation, total hysterectomy
24
Q
What is endometriosis?
A
Extrauterine implantation and growth of endometrial tissue. Deposits more freq on pelvic structures, most commonly the ovaries. Commonly causes pain but also may lead to reduced fertility and adhesion formation.
25
Define adenomyosis and endometrioma
Adenomyosis - deposits of endometrial tissue in myometrium of uterus
Endometrioma - cystic structures developing on ovaries = chocolate cysts
26
What are the RF of endometriosis?
- Early menarche
- Late menopause
- Nulliparity
- Delayed childbearing
- Short menstrual cycle
- FH
27
What are the CF of endometriosis?
- Chronic pelvic pain
- Dysmenorrhoea
- Irreg periods
- Dyspareunia
- Dyschezia - cyclical (pain pooing)
- Bloating, nausea - cyclical
- LUTS - cyclical
- Infertility/sub fertility
- Fixed retroverted uterus
28
What are the ix into endometriosis?
- Laparoscopy - gold standard
- USS - initial, excludes other causes
- MRI - used in suspected deep endometriosis, esp bowel bladder or ureter
29
What is the conservative management of endometriosis?
- Pain management - simple analgesics, hormonal therapies reduced pain sometimes - COCP, POP, implant and mirena
- GNRH analogues - reduce O and induce annovulation = hopefully prevent periods and the associated pelvic pain
- Psychological treatment - depression and anxiety commonly in endometriosis pt
30
What is the surgical management of pt w endometriosis?
- Excision or ablation of endometriomas
- 3 months of GnRH agonists pre operative in bowel bladder ureter endometriosis
- Hysterectomy
31
What is the management of infertility in pt w endometriosis?
- Excision or ablation of endometriosis and adhesiolysis
- Ovarian cystectomy
32
What is pre menstrual dysphoric disorder?
PMS = normal psychological and physical sx experienced by woman premenstrually, PMDD is severe PMS and is abnormal.
33
What are the symptoms of PMDD?
- Symptoms at worst in the 6 days leading up to period (luteal phase)
- Symptoms cause difficulties coping with workplace or domestic demands, causing problems w relationships
- Emotional sx - irritability, labile affect, low mood, anxiety, lassitude, suicidal feelings
- Physical sx - breast tenderness, bloating, clumsiness, fluid retention
34
How do you manage PMDD?
- Ask pt to keep sx diary for 2 complete cycles
- Reassurance and explanation help woman often
- CBT
- SSRIs eg. Fluoextine
- Transdermal oestrogen, given with progestogen if has a uterus
- IUS Mirena coil
35
What is menorrhagia and how is it defined?
Excessive abnormal uterine bleeding over several consecutive cycles interfering physical, emotional, social QOL.
- Increased freq of bleeding
- Blood loss leaving 80ml
- Bleeding for more than 5 days
- Consistently having blood soaked pads/tampons
- Blood loss interfering w daily activities
36
What are ovarian and uterine causes of menorrhagia?
- Leiomyomas/fibroids - pelvic pain/pressure sx
- Endometriosis - dyspareunia
- Pelvic inflam disease
- Polyps and endometrial hyperplasia - post coital bleeding, inter menstrual bleeding
- PCOS - hirsuitism, acne
37
What are some systemic disorders that may cause menorrhagia?
- Coagulation disorders - bruises
- Hypothyroidism
- Liver/renal disease
38
What are some other causes of menorrhagia?
- Anticoagulants
- IUD contraceptive
- Dysfunctional uterine bleeding - no cause
39
What are the ix into menorrhagia?
- Pregnancy test
- FBC, exclude Fe def anaemia
- Pelvic USS - assess for structural causes
- If suspect gynaecological malignancy need to be referred for specialist assessment
40
What are the options in primary care for management of menorrhagia?
- IUS Mirena coil - for those not trying to conceive, thins the endometrium lining
- Tranexamic acid - inibits plasminogen activation, prevents fibrinolysis
- Oral norethisterone - stops menstrual bleeding, used when other options unsuitable
- Long acting progestogen eg. IM medroxyprogesterone acetate every 12 weeks for prevention
41
What are the options in secondary care for the management of menorrhagia?
- GnRH analogues induce hypogonadal state - false menopause, no ovulation
- Surgical - endometrial ablation, hysterectomy
42
What is amenorrhoea?
Primary - not started period by the time they are 15 w normal secondary sexual characteristics or 13 w/o secondary sexual characteristics
Secondary - cessation of menstruation for 3-6 months
43
What are the causes of primary amenorrhoea w normal sexual characateristics?
- Imperforate hymen
- Transverse septum
- Absent vagina or uterus
- Hypothyroidism, hyperthyroidism, hyperprolactinoma, Cushing's
44
What are the causes of primary amenorrhoea w/o normal sexual characteristics?
- Primary ovarian insufficiency - Turner's syndrome
- Hypothalamic pit dysfunc eg. stress, weight loss, excessive exercise
45
What are some causes of secondary amenorrhoea?
- Menopause, lactation, pregnancy
- Stress, weight loss, excessive exercise - hypothalamic dysfunction
- POI - chemo, RT, autoimmune disease
- PCOS
- Cushing's
- Late onset adrenal hyperplasia
46
What are the ix into amenorrhoea?
- Need examination - excessive androgens, thyroid disease, Cushing's, vaginal exam, secondary sexual characteristics
- Pregnancy test
- USS
- Bloods - prolactin, TFTs, LH, FSH, total testosterone
47
What is the treatment amenorrhoea?
- If concerned about fertility - fertility clinic - GnRH therapy
- Increase weight, reduce stress and exercise, need eating disorder team
- HRT if premature ovarian failure <40 years until avg age of menopause - 50 years old
- Constitutional late puberty requires reassurance and waiting
- Structural abnormalities may be amenable to surgery
- Bone protection, reduced oestrogen = RF for osteoporosis, need assessment and adequate treatment
- Dopamine agonists for hyperprolactinaemia
- Treat thyroid dysfunction
48
What are the CFs of Turner syndrome?
- Growth failure and short stature
- Gonadal dysgenesis - ovaries don't develop properly and can cause premature ovarian failure
- Ovarian failure = no O+P to develop secondary sexual characteristics
- Learning disabilities
- Short webbed neck, low hairline, low set ears, nails turned upwards, wide spaced nipples - shield chest, swollen hands and feet
- Congenital heart defects - bicuspid aortic valve
- Horse shoe kidneys/absent kidneys
- Hypothyroidism
49
What is the pathophysiology of Turner syndrome?
Partial or complete loss of the second sex chromosome. On karyotypye tests patients have X karyotype not XX which is normal in females.
50
What is androgen insensitivity syndrome?
People with this syndrome are genetically male - XY karyotype but their bodies don't respond to androgens (male hormones) so they have physical traits of a woman.
51
What are the CFs of androgen insensitivity syndrome?
- Abnormal female internal genitalia - uterine malformations, aplasia/hypoplasia of fallopian tube and uterus
- Or ambiguous genitalia
- Absent axillary hair and pubic hair
- Undescended testes - cryptorchidism
- Delayed puberty
- Infertility
52
What is the treatment of genetic causes of amenorrhoea?
- Turner syndrome - growth hormone and monitor cardiac, renal or thyroid abnormalities, HRT, oral contraceptives
- Androgen insensitivity - remove residual gonadal tissue to avoid risk of malignancy, psychological support, hernia repair, surgeries to dilate vagina or descend testes if a boy, oestrogen for women once testes removed
53
What are the causes of dysmenorrhoea?
- Primary dysmenorrhoea = no pelvic pathology, often begins with first menses and there is no cause
Secondary dysmenorrheoa = often pelvic pathology, occurs years after menses:
- Endometriosis
- PID
- Fibroids
- Adhesions
- Developmental abnormalities
- Copper IUD in first few months
54
What is the management of primary dysmenorrhoea?
- Lifestyle changes - stopping smoking reduces risk of dysmenorrhoea
- Exercise during periods may cause reduction in pain intensity
- Locally applied heat, transcutaneous electrical nerve stim, camomile tea
- NSAIDs eg. ibuprofen, mefanamic acid, naproxen
- Hormonal contraception - COCP, POP, depop injection makes many women amenorrhoeic w/i a year of starting treatment, IUS - if not trying to conceive
- Laparoscopic uterine nerve ablation in severe cases but not v effective
- Hysterectomy can be considered in severe cases - if finished family
55
What is letrozole and how does it work?
Non steroidal aromatase inhibitor - decreases oestrogen produced by body. Used to prevent growth of breast cancers that are oestrogen receptive and induces ovulation. Decreased O = increased FSH = stimulates follicles and aids ovulation.
56
What is clomiphene and how does it work?
Is a SERM - blocks oestrogen redceptors, blocking acting of oestrogen. Causes increased FSH and LH - induces ovulation in women who's infertility is caused by annovulation.
57
What is mifespristone and how does it work?
Used to end early pregnancy. Is an antiprogestational steroid, blocks progesterone which is the hormone that is increased to indicate that you are pregnant and pregnancy should be continued.
There is also evidence that is has been shown to decrease fibroid size.
58
What is ulipristal acetate and how does it work?
Selective progesterone receptor modulator. Used for emergency contraception after unprotected intercourse. Is also used to treat fibroids.
MOA - inhibits ovulation by suppressing LH surge and thins the endometrium to inhibit implantation by binding to progesterone receptors.
59
What is norethisterone?
Is a progestogen - stops the lining of your womb from shedding. Used to delay periods and can be used in menorrhagia.
60
What are the hormonal changes behind menopause?
- Supply of oocytes falls as a women ages
- Follicular activity falls = reduced oestrogen and inhibin
- Negative feedback lost so LH and FSH increase
61
What are the CFs of menopause?
- Menstrual irregularity - cycles become longer, shorter or variable
- Vasomotor sx - hot flushes, night sweats
- Urogenital sx - vaginal dryness, dyspareunia, UTIs
- Anxiety/depression
- Difficulty conc
- Sleep disturbance
- Reduced libido
- MSK pains
62
How is menopause diagnosed?
- Perimenopause based on vasomotor sx and irregular periods
- menopause in women who haven't had a period for at least 12 months and aren't using hormonal contraception
- Menopause based on sx in women without a uterus
63
What are the different types of HRT?
- Women w a uterus - combined oestrogen and progesterone HRT, unopposed oestrogen is a RF for endometrial cancer
- Women w/o uterus - oestrogen only HRT
64
What are the benefits and risks of HRT?
- Breast cancer - combined HRT has increased risk
- Ovarian cancer - small increased risk from HRT
- VTE - increased w oral HRT but not w transdermal
- Coronary heart disease - no improvement from HRT
- Stroke - oral oestrogen associated w increased risk of stroke, transdermal no risk
- Risk of fragility fractures reduced while taking HRT
65
What should you advise a menopausal woman about contraception?
- HRT doesn't act as contraception
- May still be fertile under 50 for 2 years after their last period
- May still be fertile over 50 for a year after their last period
66
What is the specific symptom management of menopause?
- Vasomotor sx - HRT after risk education, lifestyle mods also need to be discussed
- Urogenital atrophy - vaginal oestrogen, need to warn that pt should report unexpected vaginal bleeding to their GP
- Psychological sx - HRT, CBT, antidepressants
67
What are the RF of endometrial hyperplasia?
- Obesity - androgens converted to oestrogen in adipose tissue
- Unopposed oestrogen use
- Oestrogen secreting ovarian tumour
- Tamoxifen use - anti oestrogen effect on breasts but pro oestrogen effect on uterus and bones
- PCOS - due to annovulation
- Nulliparity
- HNPCC
- DM
68
What are the symptoms of endometrial hyperplasia?
Abnormal vaginal bleeding - intermenstrual bleeding, irregular bleeding, menorrhagia, post menopasual bleeding
69
What are the ix into endometrial hyperplasia?
- Women 55+ w postmenopausal bleeding - refer to cancer 2WW
- Endometrial biopsy
- Hysteroscopy and biopsy
- Transvaginal US
70
What is the management of endometrial hyperplasia?
- Reassure low risk of developing cancer
- Address RF
- Watchful waiting
- Progestogen treatment - IUS, medroxyprogesterone, norethisterone
- 5 monthly biospies until 2 consecutive biopsies negative
- Hysterectomy - if change to atypical hyperplasia, relapse, no regression after 1 yr of progestogen
71
What is the management of atypical hyperplasia?
- Total hysterectomy due to risk of malignant progression, w bilat salpingo oophorectomy if you are post menopause
- If wish to preserve fertility - progestogen options w 3 monthly endometrial biopsy then hysterectomy as soon as no longer need to be fertile
- 40% of women w atypical hyperplasia have concurrent carcinoma or at significant risk of developing
72
What infections can cause menstrual irregularity and what sx do they cause?
- STIs eg. gonorrhoea and chlamydia cause post coital bleeding
- Pelvic inflammatory disease
73
What is PID? What are the causes?
Pelvic inflam disease - infection spreads from vagina through the cervix and into the upper genital tract. Commonly caused by STIs, most commonly chlamydia but gonorrhoea is increasing.
74
What are the CFs of PID?
Sx - bilat abdo pain, purulent discharge, post coital bleeding, deep dyspareunia
Signs - adnexal tenderness (pain in area of the uterus), cervical motion tenderness on bimanual, fever
10% of pt present w RUQ pain - secondary to inflam or the liver capsule = Fitz Hugh Curtis syndrome
75
What are the ix into PID?
- Pregnancy test - exclude ectopic pregnancy as a differential
- Cervical and endocervical swab for gonorrhoea and chlamydia
- Bloods - FBS, CRP, etc
- Transvaginal USS
- Laparocsopy w direct visualisation of the fallopian tubes is diagnostic but not routinely done
- Urinalysis to exclude UTI
76
What is the management of PID?
- IM 1g ceftriazone single dose, oral doxycycline 100mg BD and metronidazole 400mg BD 14 days
- 2nd line - ofloxacin 40mg BD and metronidazole 400mg BD for 14 days, treat early and even w negative swabs
- Analgesia
- Review in 4 weeks
77
What are the complications of PID?
- Chronic pelvic pain 40%
- Infertility - can cause adhesions of the fallopian tubes, preventing oocyte moving down through them
- Ectopic pregnancy
- Fitz Hugh Curtis syndrome
78
What are some causes of acute pelvic pain?
- Ectopic pregnancy
- PID
- Ovarian cyst rupture
- Miscarriage/threatened miscarriage
- UTI
- Appendicitis
- Ovarian torsion
79
What are some causes of chronic pelvic pain?
- Endometriosis
- Post PID chronic pelvic pain
- Fibroids
- Dysmenorrhoea if cyclical
- Endometrial polyps
- Gynaecological malignancy
80
What are the ix into acute pelvic pain?
Bedside - pregnancy test, urine dip and send for MSU, obs
Lab - bloods = FBC, U+E, CRP, coag, swab for STIs
Imaging - USS, CT abdo pelvis once pregnancy ruled out?
81
What are the ix into chronic pelvic pain?
- Transvaginal USS
- MRI
- Laparoscopy
- Cervical smear
82
What are some of the functional ovarian cysts?
Ovaries grow small cysts = follicles each month which rupture to release can egg.
- Follicular cyst - when the follicle doesn't rupture but instead continues to grow
- Corpus luteum cyst - follicle releases the egg and the opening is blocked so fluid builds up = cyst
- Usually harmless and rarely cause pain
83
What are the pathological ovarian cysts?
- Dermoid cyst - teratoma, formed from germ cells that make eggs, can continue tissue eg. hair, skin and teeth
- Cystadenoma - from cells on surgace of ovary, can be fulled w fluid/mucous material
- Endometrioma
- Dermoid cysts and cystadenomas can grow v large and move the ovary out of position, increases the chance of ovarian torsion
84
What are the different areas of the vagina that can be prolapsed?
- Ant vaginal wall
- Post vaginal wall
- Apical vaginal wall
85
What genital prolapses can you get of the ant vaginal wall?
- Cystocele - bladder, may lead to stress incontinence
- Urethrocele - urethra, often associated w stress incontinence
- Cystourethrocele - bladder and urethra, most common
86
What genital prolapses can you get of the post vaginal wall?
- Enterocele - small intestines
- Rectocele - rectum
87
What genital prolapses can you get of the apical vaginal wall?
- Uterine prolapse
- Vaginal vault prolapse - roof of vagina, common after hysterectomy
88
What are the RFs of prolapse?
Modifiable - obesity, smoking, lack of exercise, constipation, diabetes
Non modifiable - increasing age, FH, gynaecological cancer, associated treatments and surgery, fibromyalgia, pregnancy
Related to labour - assisted vaginal birth, occipitoposterior vaginal birth, active second stage of labour takes more than an hour, anal sphincter injury during birth
89
How are prolapses graded?
Pelvic organ prolapse quantification - POP-Q:
Stage 0 - not prolapse
Stage 1 - more than 1cm above the hymen
Stage 2 - w/i 1 cm proximal or distal to hymen
Stage 3 - 1cm below the hymen but no more than 2cm total length of vagina
Stage 4 - complete eversion of vagina
90
What are the symptoms of genitourinary prolapse?
Vaginal - fullness and coming down, difficulty retaining tampon, spotting if ulcer, seeing or feeling bulge
Urinary - incontinence, freq, urgency, feeling of incomplete bladder emptying
Coital difficulty - dyspareunia, loss of vaginal sensation, vaginal flatus, loss of arousal
Bowel - constipation, urgency, incontinence, incomplete evacuation, need to able pressure or perineum or post vaginal wall or digital evacuation to pass stool
91
How do you examine genitourinary prolapse?
- Ask women to strain, both standing and lying
- Sims' speculum - pt strain
- Determine the parts of the vagina the prolapse affects and the degree
- Can get ulceration and hypertrophy of the cervix or vaginal mucosa if prolapse goes beyond hymen
- Rectal exam if bowel sx
92
What is the conservative management of genitourinary prolpase? When do you only do conservative management?
- Weight loss and diet and reduce caffeine and fluids
- Supervised pelvic floor muscle training for 4 months
- Intravaginal pessaries - needs to be changed every 6 months
- Oestrogen releasing ring or vaginal oestrogen cream
Reasons - mild prolapse, want future pregnancies, frail, high anaesthetic risk, don't want pregnancy
93
What are the complications of intravaginal pessaries?
- Vaginal discharge and odour
- Vesicovaginal and recto vaginal fistula
- Faecal impaction
- Hydronephrosis and urosepsis
94
What are the indications for surgery in prolapse?
- Failure of conservative treatment
- Presence of voiding problems or obstructed defecation
- Recurrence of prolapse after surgery
- Ulceration
- Irreducible prolapse
95
What are the surgeries for bladder/urethral prolapse?
- Ant colporrhaphy -
- Colposuspension - ?
96
What are the surgeries for uterine prolapse?
- Hysterectomy
- Open abdo or lap sacrohysteropexy if woman wishes to retain her uterus
- Sacrospinous fixation
97
What is the surgery for rectocele/enterocele?
Post colporrhaphy
98
How can genitourinary prolapse be prevented?
- Life style advice
- Keep doing pelvic floor exercises even if not pregnant or never been pregnant
- Reduce intra abdo pressure - treat constipation throughout life, stop smoking to avoid chronic cough
99
What are the different types of urinary incontinence?
- Stress incontinence - related to increased intra abdo pressure
- Urgency incontinence - related to overactive bladder
- Mixed incontinence
- Overflow incontinence - secondary to urinary retention
- UTI can cause temporary incontinence
100
What are the ix into urinary incontinence?
- Bedside = urine dip and MSU to rule out UTI, bladder scan to rule out urinary retention
- Bladder diaries and QOL assessments
- Urodynamic testing eg. cytometry but invasive and unpleasant
101
What is the management of stress incontinence?
- Lifestyle - drink 2 litres, not excess and not insufficient, weight loss, stop smoking, avoid caffeine
- Pelvic floor muscle training - trial for 3 months to see if improves sx
- Colposuspension - stitches bladder neck in place upwards
- Autologous rectus fascial sling - support urethra and pelvic floor muscles
- bulking agent
- Duloxetine
102
What is duloxetine?
SNRI for patients who don't want surgery. Has lots of SEs - dry mouth, headache, dizziness, nausea, sexual dysfunction, increased risk of suicide.
MOA - increases activity of nerve that stimulates the urethral sphincter, improves its function
Contraindications - SIADH, mania and manic depression
103
What is the management of urgency incontinence?
- Normal lifestyle measures
- Bladder training - holding it and increasing volumes of urine bladder can hold
- Oxybutynin - SE - dry mouth, constipation, urinary retention, confusion, not in retention, narrow angle glaucoma, gastric dysmotility, relaxes bladder detrusor muscle
104
What is the management of overflow incontinence?
- Need to ix and exclude obstructive causes, may need surgery
- Intermittent/indwelling/suprapubic catheterisation when retention leading to UTIs and renal impairment
105
What are womens health related screening programmes for gynaecology?
Cervical smear:
- From ages of 25-64, every 3 years age 25-49 and every 5 years afed 50-64
- Cervix is checked for HPV - if found then checked for cervical cancer or CIN on cytology
- If +ve HPV but -ve cytology - repeat in 12 months
106
What is the normal cell composition of the cervix?
Endocervical canal between the two os - lined by simple columnar epithelium
Ectocervix - vaginal facing, lined by stratified squamous non keratinised epithelium
Squamocolumnar junction is the interface between the columnar and squamous epithelium. Position varies dep on age, menstrual and pregnancy status.
107
What is ectropion?
Eversion of endocervical columnar epithelium onto the ectocervix. Is a normal physiological process that occurs at different stages of life eg. during pregnancy and post menarche. It is squamous metaplasia and the area it occurs is the transformation zone - area most cervical cancers arise.
108
What is HPV?
Human papilloma virus - suppresses p53 tumour suppressor gene, esp subtypes 16 and 18.
Is common to be infection in late teens and early twenties, infection lasts 8 months ish and is cleared by the immune system normally, cervical cancer is a rare complication of infection.
Can be vaccinated against it to prevent most cases of cervical carcinoma.
109
HPV vs CIN
CIN - cervical intraepithelial neoplasia - asymptomatic, can regress, persist or progress to cancer.
HPV - asymptomatic, can be cleared or persist or cause CIN.
110
What is CIN?
Cervical intraepithelial neoplasia - pre malignant cervical dysplasia at the transformation zone.
CIN 1 - mild dysplasia, unlikely to become malignant, most self resolve, 12 month review
CIN 2 - mod dysplasia, higher risk of malignancy, normally remove
CIN 3 - severe dysplasia, highest risk of malignancy, always remove
111
What is the management of CIN?
- Knife cone biopsy
- Laser conisation
- Large loop excision of transformation zone - LLETZ
112
What is colposcopy?
Procedure to allow optimal visualisation of the cervix - speculum to identify cervix and then use colposcope for magnified view of cervix.
- Liquid tests - iodine test to see if cervix stains, if does = squamous epithelium and normal, if doesn't = CIN, cancer or columnar epithelium
- Biopsy taken
113
What are reasons to delay cervical cancer screening?
- Currently menstruating
- Abnormal vaginal discharge/pelvic infection
- Less than 12 weeks post natal
- Less than 12 weeks after termination or miscarriage
- Total hysterectomy - don't have a cervix
114
What do you do extra cervical cancer screening?
- Renal failure requiring dialysis or other disease w high chance of organ transplantation - will be immunosuppressed
- Planned to have organ transplant - need screen in 12 months leading uo
- HIV - screen at diagnosis and then yearly after
115
What is the presentation of cervical cancer?
Post coital bleeding
Post menstrual bleeding
Inter menstrual bleeding
Blood stained vaginal discharge
Malodorous discharge
Dyspareunia
Advanced disease - fistulae, renal fail, nerve root pain, lower limb oedema
116
What is the treatment of cervical cancer?
Stage IA1 micro invasive - conservative, if want to remain fertile = knife cone biopsy or LLETZ, if family complete = hysterectomy
Stage IA2-IIA - radical hysterectomy w lymphadenectomy or if >4cm chemoradiation
Stage IIB- IVA, adv clinical lesions - chemoRT
Stage IVB, mets - chemo, palliative RT
Give post op RT if LM involvement
117
What are the complications of cervical cancer treatment?
Surgery - infection, VTE, haemorrhage, vesicovaginal fistula, bladder dysfunc, lymphocyst, short vagina
RT - vaginal dryness and stenosis, radiation cystitis and procitits, loss of ovarian func
118
What are the RFs of endometrial cancer?
- Obesity
- Early menarche, late menopause
- Nulliparity
- PCOS
- Unopposed oestrogen and tamoxifen
- Previous breast or ovarian cancer, BRCA 1/2
- Endometrial polyps
- Diabetes
119
What are the protective factors against endometrial cancer?
- Cont combined HRT
- COCP
- Smoking
- Physical activity
- Coffee and tea
120
What is the presentation of endometrial cancer?
Pre menopausal - prolonged, freq vaginal bleeding, intermenstrual bleeding
Post menopausal - PMB, less commonly blood stained, watery or purulent vaginal discharge
O/E - normal but may have fixed, hard uterus in adv disease
121
What is whirlpool sign a sign of ?
On CT - ovarian torsion
122
What are the ix into endometrial cancer?
- Endometrial sampling by Pipelle
- Hysteroscopy - gold standard to assess uterine cavity
- Transvaginal US, useful to ix PMB, measures endometrial thickness - <4mm no more ix, >4mm need endometrial sampling
- CT chest abdo pelvis to identify mets
- MRI pelvis
123
What is the surgical treatment of endometrial cancer?
Hysterectomy +/- bilateral salpingo oophorectomy, peritoneal washings
Can give adjuvant RT if high risk of recurrence
124
What are the non surgical options for endometrial cancer?
- Primary radiotherapy
- Chemo
- Hormones - progestogens or aromatase inhib
- Palliative care
125
What are the RF of ovarian cancer?
- Nulliparity
- Early menarche, late menopause
- Unopposed oestrogen HRT
- FH, BRCA 1/2
- Endometriosis
126
What protects against ovarian cancer?
- COCP
- Pregnancy
- Breastfeeding
- Hysterectomy
- Oophorectomy
- Sterilisation
Anything that prevents ovulation
127
What is the presentation of ovarian cancer?
- Non specific symptoms
- Can be incidental findings
- Pain and abdo swelling in half of pt
- Can get anorexia, N+V, weight loss, vaginal bleeding, change in bowel habit, urinary sx
128
What are the ix into ovarian cancer?
- Pelvic exam
- US
- FBC, U+E, LFT
- CA125 is the tumour marker
- Cytology of ascitic tap
- CXR and CT to assess peritoneal, omental and retroperitoneal disease
- Surgical exploration
- AFP and nCG for non epithelial cancers eg. germ cell
129
What are other casues of raised Ca125?
- Endometrial, fallopian tube, lung, breast and GI cancer
- Endometriosis, PID, menstruation and pregnancy
- Any inflam condition in abdo area
130
What is the treatment of epithelial ovarian cancer?
90% are epithelial, most of these are serous
- Surgery and chemo
- Staging laparotomy - TAH and BSO and debulking
- Platinum - cisplatin and carboplatin and taxane
- Women of reproductive age, tumour only in one ovary = can consider oophorectomy
131
What is the treatment of non epithelial tumours?
- Often in young women and are extremely chemo sensitive eg. germ cell
- Conservative surgery and chemo
132
How do u treat recurrent ovarian cancer?
Palliative chemotherapy
133
What are the RFs of cervical cancer?
- Missed screening
- Smoking
- High parity
- FH
- COCP
- Immunosuppression
134
What is the main type of cervical cancer?
Squamous cell
135
What are the ix into cervical cancer?
Colposcopy +/- biopsy
Bloods - FBC, U+E, LFT
CT MRI and PET can be used to assess disease burden. andspread
136
What is FIGO staging?
Stage 1, IA - invasion <5mm, IB - invasion >5mm, lesion limited to cervix uteri
Stage 2, IIA - involvement in upper 2/3 vagina w/o parametrial involvement, IIB - w parametrial involvement
Stage 3, IIIA - lower 1/3 vagina involved, IIIB - extends to pelvic wall and effects kidney, IIIC - involves pelvic and para aortic LM
Stage 4, IVA - spread to adjacent pelvic organs, IVB - spread to distant organs
137
What is the most common type of endometrial cancer?
Endometriod, stimulated by oestrogen and normally after endometrial hyperplasia
138
What is lynch syndrome?
Inherited cancer syndrome due. tomutation. ofDNA mismatch repair genes - results in DNA replication erros called microsatellite instability, leads to early onset endometrial and colorectal cancer
139
Who is referred on 2WW for PMB?
>55 w PMB, consider <55 w PMB
140
What is the criteria for referral of ovarian cancer?
Urgent referral if ascites or pelvic/abdo mass.
Offer ix if persistent abdo distension/bloating, early satiety, pelvic/abdo pain, increase urinary urge/freq
141
What is a Bartholin gland cyst?
Gland on vulva that will form a cyst if obstructed, will form an abscess if infection.
142
hat are the CF of Bartholin gland cysts?
- Unilateral painless swelling
- Discomfort and disfiguring
- Soft non tender mass
143
What are the CF of Bartholin gland abscesses?
- Unilateral painful swelling
- Difficult sitting, walking, having sex
- Surrounding erythema
- Fever but unocmmon
- Purulent exudate
- Soft fluctuant tender mass
144
What is the management of Bartholin's cysts?
<3cm - if asymptomatic can leave, warm compresses and baths to aid drainage
>3cm or any abscess - I+D, can also have a Word catheter in for 4 weeks to ensure tract open or marsupialisation = open cyst and suture edges
145
What is Lichen sclerosus?
Chronic, progressive skin disorder affecting the genitalia and perianal area, x10 times more common in women
146
What are the signs and sx of lichen sclerosus?
Sx - asymptomatic, pruritis, soreness, dysuria, dyspareunia, anal sx = bleed, fissure, painful defecation, painful erections
Signs - white atrophic plaques are typical, can get haemorrhagic lesions, bullae, ulcers, lichenification, adhesions, phismosis
147
What are the ix into lichen sclerosus?
Punch biopsy and histology
148
Lichen sclerosus vs lichen planus
Lichen sclerosus - white plaques
Lichen planus - pruritis vulval disorder, erythematous patchs w white lace pattern, anal involvement uncommon
149
What is the management of lichen sclerosus?
Conservative - good hygiene, avoid tight clothing, reduce scratching
Medical - emllients, topical corticosteroids eg. clobetasol, can inject if don't respond to topical, topical calcineurin inhib
Surgery - high graded dysplasia or malignancy
150
When do you give sequential HRT vs cont HRT?
Sequential = <12 months ammenorrhoea, to avoid heavy bleeding
Continuous = >12 months
151
What makes a smear inadequate?
- Failure to sample 360 degrees of the os
- Blood on smear
- Cervical inflam
- Age related atrophic changes
152
What are some complications of LLETZ?
- Cervical stenosis and incompetence
- Pyometra - pus in uterus
- Follow up smear difficult
- Not the whole area of CIN etc removed
153
Where does ovarian cancer most commonly met?
Peritoneum and para aortic nodes
154
What are the classic findings of endometriosis on laparoscopy?
Powder burn spot - black, dark brown, blue
White fibrotic lesions - scarring
Red/clear vesicles
155
What cancers do COCP cause?
COCP
Causes
Outside - cervix and breast
Cancers
Predominantly
156
What can you restart hormonal contraception after emergency contraception?
Ulipristal acetate - need to wait 5 days as COCP can cause it to be less effective
Levonergestral - start immediately
157
What are some complications of hysterectomy?
Bleed infection VTE
Damage to surrounding organs
Sexual dysfunc
158
What are some complications of surgical evac?
Asherman's syndrome - adhesions w/i uterus and cervix
Perforation of uterus
Cervix injury
Bleed infection
