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Year 4 - ObGyn > Gynaecology > Flashcards

Gynaecology Flashcards

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1
Q

Gynae
- Benign
- Oncology

A

Gynae

  • Benign
    1. Fibroids
    2. Pelvic pain
    3. Menstrual problems
  • Oncology
    1. Cervical screening
    2. Colposcopy
    3. Postmenopausal bleeding
    4. Cancers
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2
Q

Obstetrics
- Care indications

A

Obstetrics
- Care indications

  1. Pre-conceptual/Antenatal
  2. High risk pregnancy
  3. Labour and delivery
  4. Puerperium
  5. Emergencies
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3
Q

Gynae History
- Structure

A

Gynae History
- Structure

  1. Reason for attendance
  2. Menstrual history
    - First day of LMP
    - Number of days and flow
    - Cycle
    - Bleeding (inter/post coit)
    - Menarche age
    - Pain
  3. Contraception/HRT
  4. Previous gynae history
    - Smear and result
    - Problems and treatments/operations
    - (PID, STI, cysts, smear, myomectomy/hysterectomy/prolapse)
  5. Obstetric history
    - Gravidity and parity
    - Pregnancy outcomes/modes
    - Birth weights
  6. Medical and surgical
    - Blood transfusion/complication
    - Anaesthesia/complication
  7. Medications/allergies
  8. Social history
    - Support
    - Social services, domestic violence, MH
    - Smoking/drugs/alcohol
  9. Sexual
    - STI
    - Partners
  10. FH
    - Cancers
    - DM, HTN, CVD, VTE
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4
Q

Gynaecology
- Common complaints

A

Gynaecology
- Common complaints

  1. Periods
    - painful/heavy/irregular
  2. Pain
    - Pelvic/on intercourse
  3. Urinary incontinence
  4. Prolapse
  5. Infertility/Sterilisation
  6. Bleeding
    - Pregnancy/postmenopausal
  7. PID/discharge
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5
Q

Menstrual cycle
- HPA Hormones

A

Menstrual cycle
- Hormones

  1. GnRH
    - Hypothalamus
  2. LH/FST
    - Pituitary
  3. Oestrogen/progesterone
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6
Q

Menstrual cycle
- Start event

A

Menstrual cycle
- Start event

  1. First day of menses
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7
Q

Menstrual cycle
- Phases

A

Menstrual cycle
- Phases

  1. Follicular
    - proliferative
  2. Luteal
    - Secretory
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8
Q

Follicular phase
- Development of….

A

Follicular phase
- Development of….

  1. Dominant follicle
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9
Q

Luteal phase
- Development of…

A

Luteal phase
- Development of

  1. Corpus luteum
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10
Q

Menstrual hormone peaks

  1. FSH
  2. LH
  3. E2
  4. P
A

Menstrual hormone peaks

  1. FSH
    - First day of menses (day 0)
    - Ovulation (14)
  2. LH
    - Ovulation (14)
  3. E2
    - Before ovulation (before 14)
    - before menses
  4. P
    - Luteal phase
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11
Q

Normal cycles
- Length
- Regularity
- MBL

A

Normal cycles

  • Length
    1. 24-32
  • Regularity
    2. Best aged 20-40y
    3. Shorter pre-menopause, longer post-
  • MBL
  • 37-43ml
  • 9-14% >80ml (likely anaemic)
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12
Q

Menstrual blood loss
- Factors

A

Menstrual blood loss
- Factors

  1. Age - increases
  2. Genetics (twin-studies)
  3. Parity (+ve correlation)
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13
Q

Menstrual acronyms

  1. HMB
  2. Metro
  3. IMB
  4. PCB
  5. Oligo
  6. Amen
A

Menstrual acronyms

  1. HMB
    - menorrhagia
  2. Metrorrhagia
    - irregular
  3. IMB
    - Inter-menstrual
  4. PCB
    - Post-coital
  5. Oligomenorrhea
    - Infrequent
  6. Amenorrhoea
    - Absent
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14
Q

DUB

  • 60% is…
  • Definition
A

DUB

  1. Heavy menstrual bleeding
    - no recognisable pelvic pathology
    - no pregnancy/bleeding disorders
    - Exclusion
  2. 60% is Primary Menorrhagia
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15
Q

AUB/HMB

  • Pathologies
  • Medical/clotting
  • Other
A

AUB/HMB

  • Pathologies
    1. Fibroids
    2. Adenomyosis/endometriosis
    3. IUCD
    4. PID
    5. Polyps
  • Medical/clotting
    1. Hypothyroid
    2. Liver
    3. Von Willebrand’s
    4. Thrombocytopenia/ leukaemia
    5. Platelets/coags
  • Other
    1. Cancer
    2. Hyperplasia
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16
Q

AUB
- Clinical Assessment

A

AUB
- Clinical Assessment

Subjective
1. Only 50% have greater than normal loss
2. Only 60% with MBL<80ml consider them heavy

Best measure
1. QoL
- Work/social/clothing/bedding/sleep

  1. Anaemia
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17
Q

HMB
- Assessment

A

HMB
- Assessment

  • Low risk
    1. <45y, No IMB, No RFs for endometrial cancer
    2. History +Exam + FBC
    3. First line treatment
  • High risk
    1. >45y, IMB, Suspicious, RFs
    2. Hx + Ex + FBC + USS + Hysteroscopy & Biopsy
    3. First line treatment
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18
Q

HMB
Medical Mx

A

HMB Medical Mx

  • Symptomatic
    1. Tranexamic acid
    2. mefenamic acid
  • Fibroids
    1. GnRH analogues
    2. Esmya (ulipristal acetate)
  • Hormonal control
    1. POP
    2. LARC (long-acting reversible)
    eg. Mirena (prog)
    3. Implant
    4. Depo-Provera
  • Hormonal control-combined
    1. COCP
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19
Q

HMB
- Surgical Mx

A

HMB Surgical Mx

  • Polyps
    1. Hysteroscopic removal
    (MYOSURE)
  • Fibroids
    1. Myomectomy
    2. Uterine artery embolization
  • Family complete
    1. Endometrial ablation
    (NOVAURE)
    2. Hysterectomy
    (Lap or open)
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20
Q

HMB
- Emergency management

A

HMB
- Emergency management

  1. Tranexamic acid
  2. Norethisterone
    - 5mg po dts
    - up to 7 days or 3 weeks on, 1 week off
  3. GnRH analogues
    - Monthly injection
    - downregulate cycle (medical menopause)
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21
Q

Tranexamic acid
- effects

A

Tranexamic acid (anti-fibrinolytic)
- effects

  1. Plasminogen inhibition (tPA)
  2. Reduces MBL by 50%
  3. ADRs
    - Nausea, abdo cramp
    - Dizziness, tinnitus
    - Rash
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22
Q

Mefenamic acid
- Effects

A

Mefenamic acid
- Effects

  1. NSAID
    - Inhibit PG production
  2. Reduces MBL by 20-44%
  3. ADRs
    - GI
    - Dizziness/headaches
    - Liver
    - Asthma & Renal
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23
Q

Infrequent/absent periods
- Definitions

A

Infrequent/absent periods

Oligomenorrhea
1. Cycle is slow
- 35 days - 6 months

Amenorrhoea
1º No menarche by 16

2º Absent for 3/12 if regular
- Absent for 6/12 if oligomenorrheic

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24
Q

Oligomenorrhea
- Causes

A

Oligomenorrhea
- Causes

  1. Constitutional
  • Anovulation
    1. PCOS
    2. Thyroid
    3. Prolactinoma
    4. CAH
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25
Amenorrhoea - Causes
Amenorrhoea - Causes - Physiological 1. Pre-pubertal 2. Pregnancy 3. Menopause Pathological 1. Cryptomenorrhea - Hematocolpos - Hematometra 2. Uterine/endometrial cause 3. Ovarian 4. Pituitary/hypothalamic
26
Amenorrhoea - Primary causes
Amenorrhoea - Primary causes 1. Delayed puberty 2. Imperforate hymen 3. Absent vagina 4. Mullerian agenesis 5. Turner 6. PCOS (rare primary) 7. CAH
27
Amenorrhoea causes - Secondary
Secondary amenorrhoea 1. Pregnancy 2. PCOS 3. Premature menopause 4. Prolactinoma 5. Thyroid disease 6. Cushing's 7. EDs 8. Syndromes - Asherman (scarring) - Sheehan (bleeding)
28
Amenorrhoea - FSH investigation
Amenorrhoea - FSH investigation 1. Pituitary/hypothalamus - Low FSH 2. Ovary - High FSH
29
Primary Amenorrhoea - Primary Ix pathway
Primary Amenorrhoea - Ix 1. Pregnancy test 2. TSH 3. Prolactin 4. LH/FSH a. Low FSH - constitutional delay, ED, exercise, stress, illness b. High FSH - Uterus? (Mullerian agenesis XX, androgen insensitivity XY) - Karyotyping? (Turner Xo, Premature menopause XX)
30
Secondary Amenorrhoea - Ix
Secondary Amenorrhoea - Ix 1. Pregnancy 2. TSH 3. Prolactin 4. High FSH - Premature menopause - Turner mosai 5. Normal FSH - PCOS - Uterine adhesions 6. Low FSH - ED, exercise, stress, illness, sheehan
31
PCOS - Features
PCOS - Features 1. Hyperandrogenism - Acne - Hirsutism - Obesity 2. Anovulation - Oligo/amenorrhoea - Multiple follicles on US (12+ in one or both ovaries) and/or - Increased ovarian volume (>10cm3)
32
Rotterdam criteria - PCOS
Rotterdam criteria - PCOS Two or more of: 1. Clinical/biochemical signs of hyperandrogenism 2. Oligo/amenorrhoea 3. US features
33
PCOS - DDx
PCOS - DDx 1. Obesity 2. Premature ovarian failure 3. Thyroid 4. Prolactinoma 5. CAH/ Androgen tumour/ Cushing's
34
PCOS - Ix
PCOS - Ix 1. SHBG - Sex hormone binding globulin 2. Total testosterone 3. FAI - Free androgen index 4. FSH/LH 5. TFT 6. Prolactin
35
PCOS - General Mx
PCOS - General Mx 1. Weight loss 2. Healthy lifestyle 3. Glucose tolerance screening 4. MH screening
36
PCOS - Specific Mx 1. Periods 2. Conception 3. Androgenism
PCOS - Specific Mx - Periods 1. COCP 2. Cyclical progestogens - Conception 1. BMI 2. Folic acid 3. Fertility + semenalysis 4. Fertility referral 5. Ovulation induction - Androgenism 1. COCP 2. Acne standards 3. Hair removal
37
Gynae cancer - Locations
Gynae cancer - Locations 1. Cervix 2. Uterus 3. Ovary 4. Vagina and vulval
38
Cervical cancer 1. Deaths/Annual incidence 2. Preventability
Cervical cancer 1. Deaths/annual incidence 850/3,100 2. Preventability 99.8%
39
Uterine cancer 1. Deaths/Annual incidence 2. Preventability
Uterine cancer 1. Deaths/Annual incidence - 2,400/9,000 2. Preventability - 34%
40
Ovarian cancer 1. Deaths/Annual incidence 2. Preventability
Ovarian cancer 1. Deaths/Annual incidence - 4,200/7,300 2. Preventability - 11%
41
Vagina 1. Deaths/Annual incidence 2. Preventability
Vagina 1. Deaths/Annual incidence - 100/230 2. Preventability - 75%
42
Uterine cancer - Peak age
Uterine cancer - Peak age 75-79yo
43
Endometrial ca - Peak age
Endometrial ca - Peak age 64-74
44
Endometrial ca - Increased risk - Lowered risk
Endometrial ca - Increased risk Unopposed oestrogen 1. Obesity 2. Early menarche/late menopause 3. Nulliparity 4. PCOS 5. Tamoxifen 6. Endometrial polyps 7. BRCA 8. DM, PD - Reduced risk 1. Continuous combined HRT 2. COCP 3. Physical activity 4. Smoking 5. Tea&coffee - Lowered risk
45
Endometrial cancer - Presentation
Endometrial cancer - Presentation 0. Present Early - Pre-menopausal (1% risk) 1. Prolonged, frequent bleeding 2. IMB - Post menopausal 1. PMB (10% risk) 2. Discharge - Blood-stained, water, purulent
46
Endometrial pathologies - Pre-malignant - Malignant
Endometrial pathologies - Pre-malignant 1. Endometrial hyperplasia - Malignant 1. Type I (80%) - Adenocarcinoma 2. Type II (20%) - Papillary Serous - Clear Cell - Carcinosarcoma 3. Sarcoma (rare)
47
Endometrial hyperplasia - Subtypes - Mx
Endometrial hyperplasia - Subtypes 1. Complex or without atypia 2. Atypical (25-50% coexistent malignancy) - Mx 1. Progestagens 2. Surgery
48
FIGO - Staging - 5 year survival
FIGO Staging 1. Limited to myometrium - 80% 2. Cervical spread - 60% 3. Uterine serosa - 40% 4. Bladder/bowel/distant - 20%
49
Endometrial cancers - Dx
Endometrial cancers - Dx 1. Endometrial sampling - Pipelle or D&C 2. Hysteroscopy - Gold standard 3. Transvaginal US - PMB - >5mm endometrial thickness cutoff
50
Endometrial cancer - Treatment
Endometrial cancer - Treatment 1. Surgical (80%) - Hysterectomy + salpingo-oopherectomy - Laparo/open 2. Non-surgical - Progestagens - Primary radiotherapy 3. Adjuvant radiotherapy (high risk) - External beam - Brachytherapy 4. Palliation - Chemo, radio - Hormonal, palliative
51
One-stop PMB clinic - Ix
One-stop PMB clinic - Ix 1. Hx&Ex 2. FBC 3. TUS 4. Hysteroscopy and Endo biopsy
52
Ovarian cancer - Peak age
Ovarian cancer - Peak age 70-74yo
53
Ovarian cancer - Cell lines
Ovarian cancer - Cell lines 1. Surface epithelium (85-90%) - Serous (50%) (B or M) - Mucinous (10%) (B or M) - Endometriod (10%) - Clear cell (5%) - Brenner tumours 2. Germ cells - Teratoma (B) - Dysgerminoma (HCG) - Yolk sac (AFP) - Choriocarcinoma 3. Stroma/sex cord - Granulosa cell - Theca cell (B) - Sertoli-Leydic Cell - Fibroma 4. Misc/meta - Lymphoma - Metastasis - Krukenberg (Mucinous signet ring)
54
Ovarian cancer - Risk factors
Ovarian cancer - Risk factors 0. Unopposed oestrogen 1. Nulliparity 2. Many menses 3. Family Hx 4. BRCA 5. Endometriosis
55
Ovarian cancer - Genetic risk 1. BRCA 1 2. BRCA 2 3. Two relatives 4. One relative 5. HNPCC
Ovarian cancer - Genetic risk 1. BRCA 1 (50%) 2. BRCA 2 (27%) 3. Two relatives (23%) 4. One relative (10%) 5. HNPCC (12%)
56
Ovarian cancer - Presentation
Ovarian cancer - Presentation 1. Abdo swelling (50%) 2. Pain (50%) 3. Anorexia (20%) 4. N&V (20%) 5. Weight loss (15%) 6. Vaginal bleeding (15%)
57
Ovarian cancer - Workup
Ovarian cancer - Workup 1. Pelvic Ex 2. US 3. FBC, UE, LFT 4. CA125 5. CT 6. Ascitic tap cytology 7. Surgical exploration 8. Histopathology
58
Ovarian cancer - Staging and survival
Ovarian cancer - Staging and survival 1. Ovary (90%) 2. Pelvic organs (60%) 3. Peritoneal cavity (30%) 4. Distant metastasis (5%)
59
Ovarian cancer - Treatment
Ovarian cancer - Treatment 1. Surgery + chemo - TAH + BSO and debulking - Platinum and Taxane - Consider oophorectomy only 2. Non-epithelial tumours - Conservative surgery - Chemo 3. Recurrent disease - Palliative chemo
60
Ovarian cancer - Presentation
Ovarian cancer - Presentation 1. Older patient, high BMI 2. Abdominal distension, anorexia, change in bowel habit 3. Nulliparous - unsuccessful infertility treatment 4. Family history of ovarian and endometrial
61
Ovarian cancer - Dx
Ovarian cancer - Dx 1. Hx & Ex 2. Ca125 3. US abdo/pelvis
62
Cervical cancer - Age distribution - Histology
Cervical cancer - Age distribution 1. Bimodal 2. 30s and 80s - Histology 1. 66% squamous 2. 15% adenocarcinoma
63
Cervical cancer - RFs
Cervical cancer - RFs 1. Young age first intercourse 2. Multiple sex partners 3. No barrier 4. Smoking 5. COCP long-term 6. Immunosuppression/HIV 7. Not screened or vacinated
64
HPV 1. Oncogenic types 2. Low risk types
HPV 1. Oncogenic types - 16, 18 - 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 2. Low risk types - 6, 11 - 42, 43, 44
65
HPV - Pathology - Infection course - Prevalence age 50
HPV - Pathology 1. Proteins E6 & E7 2. Suppression of p53 tumour suppressor gene 3. Keratinocytes - Infection course 1. 8 months on average 2. Late teens and early twenties common - Prevalence age 50 1. Down to 5%
66
Cervical cancer natural history - HPV - CIN
Cervical cancer natural history - HPV 1. Asymptomatic 2. Cleared or persists - CIN 1. Asymptomatic 2. Regress, persists, or progress - 60% CIN1 spontaneous regression - 30% of CIN3 invasion over 5-10 years
67
CIN - Condition - Location - Symptoms
CIN - Condition 1. Pre-malignant - Location 2. TZ junction (transitional zone) - Symptoms 0. Asymptomatic 1. PCB/PMB 2. IMB/blood stained discharge 3. Advanced - Fistulae, renal failure, radiculopathy, lower limb oedema
68
CIN - Classification
CIN - Classification 1. CIN1 - <33% of BM involvement 2. CIN2 - <66% of BM involvement 1. CIN3 - >66% of BM involvement
69
Cervical ca - Staging
Cervical ca - Staging 1. Confined to cervix A Microinvasive (<5mm d x 7mm w) B Clinical lesion 2. Beyond cervix A Upper 1/3 vagina b Parametrium 3. Pelvic spread A Lower 1/3 of vagina B Pelvic side wall 4. Distant spread A Adjacent organs B Distant sites
70
Cervical cancer Mx - Micro invasive - Clinical lesions (1b-2a) - Clinical lesions beyond stage 2a - Lymph nodal involvement - Recurrent disease
Cervical cancer mx - Micro invasive 1. Conservative - Cone biopsy 3. Hysterectomy - Clinical lesions (1b-2a) 1. Wertheim's (radical) hysterectomy 2. Or Chemo-radio - Clinical lesions beyond stage 2a 1. Chemo-radio - Lymph nodal involvement 1. Post-op radiotherapy - Recurrent disease 1. Radio 2. Chemo 3. Exenteration 4. Palliation
71
Cervical cancer - Treatment complications 1. Surgery 2. Radiotherapy
Cervical cancer - Treatment complications 1. Surgery - Infection/VTE/Haemorrhage - Vesicovaginal fistula - Bladder dysfunction - Lymphocyst formation - Short vagina 2. Radiotherapy - Vaginal dryness/stenosis - Cystitis/proctitis - Loss of ovarian function
72
Cervical cancer - Staging - 5 year survival
Cervical cancer IA - 86-99% IB - 80-90% II - 65-69% III - 40-43% IV - 15-20%
73
Cervical screening - Invitation frequency
Cervical screening - Invitation frequency 25-50 - 3 yearly 50-65 - 5 yearly 65+ - Selected patients
74
Cervical cytology - Classifications
Cervical cytology - Classifications 0. Inadequate 1. Normal 2. Borderline 3. Mild dyskaryosis 4. Moderate dyskaryosis 5. Severe dyskaryosis 6. Possible invasion
75
Colposcopy - Equipment - Indication
Colposcopy - Equipment 1. Low-power binocular microscopy - Indication 2. Look for features suggestive of CIN or invasion - Abnormal vascular pattern eg. mosaicism or punctuation - Abnormal staining eg. aceto-white, brown iodine
76
Cervical CIN - Treatment
Cervical CIN - Treatment 1. See-and-treat 2. Excisional - LLETZ - Large loop excision of transformation zone - Cold knife cone 3. Destructive - Cryocautery - Diathermy - Laser vaporisation 4. Follow-up colposcopy
77
CIN - Diagnosis stages
CIN - Diagnosis stages 1. Smear - Cytology - Dyskaryosis 2. Colposcopy - Opinion on visual assessment 3. Biopsy - Histological diagnosis - CIN 1/2/3
78
HSV vaccination - Regimen
HSV vaccination - Regimen 1. Gardasil 6, 11, 16, 18 (Cervarix 16,18) 2. 3 injections - over 6 months - Prior to SI - 5 years protection .
79
VIN - Condition - Symptoms - Treatment
VIN - Condition 1. Vulvar intraepithelial neoplasia 2. Premalignant - can resolve or progress - Symptoms 0. None 1. Itching/burning/pain - Treatment 1. Antihistamine 2. Imiquimod 3. Surgical excision
80
VIN - RFs
VIN - RFs 1. HPV 2. HSV 2 3. Immunosuppression 4. Chronic irritation 5. Lichen sclerosus
81
Vulval cancer - Epidemiology - Types - Treatment
Vulval cancer - Epidemiology 1. Very rare 2. Elderly patients - Types 1. Usually SCC - 50% HPV - 50% chronic skin disease - Treatment 0. 75% 5 year survival 1. Surgery 2. Chemo-radio
82
Menarche -Precocious - Late
Menarche -Precocious 1. Age 8 - Late 2. 14 with no 2° 3. 16 with 2°
83
Ovarian cancers - Type by age
Ovarian cancers - Type by age 1. Young - Germ cell 2. Middle - Stromal 3. Older - Epithelial
84
BRCA1 & BRCA 2 - Lifetime ovarian risk
BRCA1 & BRCA 2 - Lifetime ovarian risk 1. BRCA 1 - 50% risk 2. BRCA 2 - 27% risk
85
CA125 - Tumor marker
CA125 - Tumor marker 1. Epithelial tumors
86
Germ Cell Tumor - markers
Germ Cell Tumor - markers 1. BetaHCG 2. AFP 3. LDH
87
Cervical - Virology - Cytology - Histology
Cervical - Virology 1. +Ve or -ve - Cytology 1. Low grade dyskariosis 2. High grade dyskariosis - Moderate or severe - Histology CIN 1 (will regress) CIN 2 or 3 - treat before progression
88
Gynae cancer mainstays - Uterus - ovary - cervix
Gynae cancer mainstays - Uterus 1. Surgery - ovary 1. Surgery and chemo (radio) - cervix 1. Early surgery 2. Later chemo(radio)

Year 4 - ObGyn (10 decks)

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