Gynaecology Flashcards
(243 cards)
1
Q
What is polycystic ovarian syndrome?
A
- condition causing metabolic and reproductive problems in women
2
Q
What are the Rotterdam criteria?
A
- requires at least 2 of 3 key features to make a diagnosis of PCOS
- Oligoovulation/anovulation
- hyperandrogenism
- polycystic ovaries on ultrasound
3
Q
What is anovulation?
A
- absence of ovulation
4
Q
What is oligoovulation?
A
- irregular, infrequent ovulation
5
Q
What is amenorrhoea?
A
- absence of menstrual periods
6
Q
What are androgens?
A
- male sex hormones, e.g. testosterone
7
Q
What is hyperandrogenism?
A
- effects of high levels of androgens
- characterised by hirsutism and acne
8
Q
What is hirsutism?
A
- thick dark hair growth in a male pattern
9
Q
How does PCOS present?
A
- oligomenorrhoea/amenorrhoea
- infertility
- obesity
- hirsutism
- acne
- male pattern hair loss
10
Q
What are other common features of PCOS?
A
- insulin resistance and diabetes
- acanthosis nigricans
- CVD + high cholesterol
- obstructive sleep apnoea
- endometrial hyperplasia and cancer
- depression and anxiety
11
Q
What is Acanthosis nigricans?
A
- thickened, rough, velvety skin
- typically found in axilla and on elbows
12
Q
Why is insulin resistance related to PCOS?
A
- insulin promotes the release of androgens from ovaries and adrenal glands
- higher insulin > higher androgens
- also suppresses sex hormone-binding globulin production by liver
- SHBG normally suppresses androgens so there is hyperandrogenism
- high insulin > halts development of follicles in ovary
- leads to anovulation and partially developed follicles
13
Q
What blood tests are done for PCOS?
A
- testosterone
- SHBG
- LH
- FSH
- Prolactin
- TSH
14
Q
What do hormonal blood tests show in PCOS?
A
- raised LH
- raised LH to FSH ratio
- raised testosterone
- raised insulin
- normal/raised oestrogen
15
Q
What scans are done in PCOS investigations?
A
- Pelvic ultrasound
- GOLD: transvaginal ultrasound
- follicles arranged around periphery of ovary giving a string of pearls appearance
16
Q
What are the diagnostic criteria in ultrasound for PCOS?
A
- 12 or more developing follicles in one ovary
- ovarian volume of 10cm3+
17
Q
How is diabetes screened for in PCOS?
A
- 2hr 75g oral glucose tolerance test
- take a baseline fasting plasma glucose and give glucose drink
- measure plasma glucose 2hrs later
18
Q
What are the results of an OGTT?
A
- impaired fasting glucose: 6.1-6.9 mmol/l
- impaired glucose tolerance: 7.8-11.1mmol/l
- plasma glucose above 11.1mmol/l
19
Q
What is the general management for PCOS?
A
- weight loss
- low glycaemic index
- exercise
- smoking cessation
- antihypertensives + statins where indicated
20
Q
What medication can be used for weight loss/insulin resistance in PCOS?
A
- orlistat
- if BMI above 30
- lipase inhibitor stopping fat absorption in intestines
21
Q
How is infertility managed in women with PCOS?
A
- weight loss
- clomifene
- laparoscopic ovarian drilling
- IVF
- metformin and letrozole to restore ovulation
22
Q
What should women with PCOS who become pregnant be screened for?
A
- gestational diabetes
- oral glucose tolerance test
- before pregnancy and at 24-28 weeks gestation
23
Q
What risk factors for endometrial cancer do women with PCOS have?
A
- obesity
- diabetes
- insulin resistance
- amenorrhoea
24
Q
What is the physiology behind the increased risk of endometrial cancer in women with PCOS?
A
- normally: corpus luteum releases progesterone after ovulation
- infrequent ovulation > low progesterone and unopposed oestrogen
- endometrial hyperplasia and risk of cancer
25
How is endometrial cancer risk reduced in PCOS?
- mirena coil
- inducing withdrawal bleed every 3-4 months: cyclical progestogens or cocp
26
How and when is amenorrhoea investigated?
- for inc endometrial cancer risk
- periods with gaps of 3+ months
- pelvic USS for endometrial thickness
- cyclical progestogen to induce bleed before scan
- if >10mm then refer for biopsy
27
How is acne managed in PCOS?
- 1st line: cocp
- co-cyprindiol (VTE risk)
- topical Abx (clindamycin w/ benzyl peroxide)
28
How is hirsutism managed?
- weight loss
- co-cyprindiol (cocp - anti-androgenic effect)
- topical eflornithine
- electrolysis/laser
- spironolactone
- finasteride
29
What is menopause?
- the point at which menstruation stops
- a retrospective diagnosis
- no periods for 12 months
- permanent end to menstruation
30
What is postmenopause?
- the period from 12 months after the final menstrual period
31
What is perimenopause?
- includes time leading up to last period and 12 months afterwards
- may experience vasomotor symptoms and irregular periods
- typically in women over 45
32
What is premature menopause?
- menopause before 40 y/o
- result of premature ovarian insufficiency
33
What is the cause of menopause?
- lack of ovarian follicular function
- low oestrogen and progesterone levels
- LH and FSH high in response to an absence of negative feedback
34
What are some perimenopausal symptoms and what causes these?
- lack of oestrogen
- hot flushes
- low mood
- irregular/lighter/heavier periods
- joint pains
- vaginal dryness + atrophy
- reduced libido
35
Risk of which conditions are increased due to a lack of oestrogen?
- CVD and stroke
- osteoporosis
- pelvic organ prolapse
- urinary incontinence
36
How is menopause diagnosed in women over 45?
- without typical symptoms and no investigations
37
When is an FSH blood test used?
- women under 40 with suspected premature menopause
- women 40-45 with menopausal symptoms/change in menstrual cycle
38
How long do women need to keep using contraception in menopause?
- 2yrs after last period if <50
- 1yr after last period if >50
39
What are good contraceptive options for women approaching menopause?
- barrier methods
- Mirena/copper coil
- mini pill/implant
- depo injection (<45)
- sterilisation
40
Which is the best type of contraceptive pill in menopause?
- cocp is UKMEC2 aged 40-50
- consider pills containing norethisterone or levonorgestrel >40 due to lower risk of VTE
41
How does hormonal contraception affect women approaching menopause?
- doesn't affect when it occurs/how long it lasts
- masks symptoms
- makes diagnosis more difficult
42
Why shouldn't depo injection be used in women over 45/50?
- weight gain
- reduced bone mineral density > osteoporosis
- DEXA scan
43
How can perimenopausal symptoms be managed?
- HRT
- tibolone (cont comb HRT)
- clonidine
- CBT
- SSRIs
- testosterone (for dec libido)
- vaginal oestrogen/moisturisers
44
What is endometriosis?
- ectopic endometrial tissue outside the uterus
- lump is called endometrioma
45
What are endometriomas?
- lumps of endometrial tissue
- in ovaries: chocolate cysts
46
What is retrograde menstruation as a theory for the aetiology of endometriosis?
- endometrial lining flows backwards
- through fallopian tubes and out into pelvis and perineum
- seeds itself in the cavity
47
What is the pathophysiology of endometriosis?
- ectopic endometrial tissue cells respond to hormones in same way
- also sheds and bleeds during menstruation
- causes irritation and inflammation
- leads to cyclical, heavy pain
48
What are adhesions in endometriosis?
- caused by localised bleeding and inflammation
- scar tissue binds organs e.g. ovaries with peritoneum
- causes chronic, non-cyclical pain
- sharp, stabbing and associated with nausea
49
Why does endometriosis reduce fertility?
- adhesions around ovaries and fallopian tubes obstruct route to uterus
- endometriomas in ovaries damage eggs/prevent ovulation
50
What is the presentation of endometriosis?
- abdominal or pelvic pain
- dysmenorrhoea
- dyspareunia
- infertility
- cyclical bleeding
- urinary or bowel symptoms
51
What would be seen on examination in endometriosis?
- endometrial tissue in vaginal exam, esp in posterior fornix
- fixed cervix on bimanual exam
- tenderness in vagina, cervix and adnexa
52
How is endometriosis diagnosed?
- pelvic USS: can show large endometriomas and chocolate cysts
- GOLD: laparoscopic surgery: biopsy of lesions and removal of deposits
53
How is endometriosis managed (hormonal)?
- analgesia
- cocp, mini pill, depo injection
- implant
- mirena
- GnRH agonist
54
What are surgical management options for endometriosis?
- laparoscopic surgery to excise or ablate tissue and remove adhesions
- hysterectomy
55
What is urge incontinence?
- overactivity of the detrusor muscle
- causes sudden urge to pass urine
56
What is stress incontinence?
- weakness of pelvic floor and sphincter muscles
- allows leakage of urine at times of increased pressure on the bladder
- typically occurs when laughing, coughing or surprised
57
What is mixed incontinence?
- combination of urge and stress incontinence
58
What is overflow incontinence?
- occurs with chronic urinary retention due to obstruction of outflow of urine
59
What are possible causes of overflow incontinence?
- anticholinergic meds
- fibroids
- pelvic tumours
- MS
- diabetic nephropathy
- spinal cord injury
60
What is the epidemiology of overflow incontinence?
- more common in men
- rare in women so they should be referred for urodynamic testing
61
What are some risk factors for urinary incontinence?
- increased age
- postmenopausal
- high BMI
- previous pregnancies/vaginal delivery
- pelvic organ prolapse or surgery
- dementia
- MS
62
How is incontinence investigated?
- bladder diary: fluid intake, urination and incontinence
- urine dipstick
- post-void residual bladder volume
- urodynamic testing
63
What modifiable lifestyle factors can contribute to incontinence?
- caffeine + alcohol consumption
- medications
- BMI
64
How is severity of incontinence assessed?
- frequency of urination
- frequency of incontinence
- nighttime urination
- use of pads and change of clothing
65
What should be assessed in pelvic examination for incontinence?
- pelvic organ prolapse
- atrophic vaginitis
- urethral diverticulum
- pelvic masses
66
How are strength of pelvic muscle contractions graded in bimanual examination?
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
67
What is cystometry?
- measures detrusor contraction and pressure
68
What is uroflowmetry?
measures flow rate
69
What is leak point pressure?
- point at which bladder pressure results in leakage of urine
- patient is asked to cough, move, jump with bladder filled to various capacities
70
What does post-void residual bladder volume test?
- test for incomplete emptying of the bladder
71
What is video urodynamic testing?
- filling bladder with contrast and taking x-ray images as it is emptied
- only performed where necessary
72
How is stress incontinence managed?
- avoid caffeine
- restrict fluid intake
- pelvic floor exercises
- surgery
- duloxetine
73
What are surgical options for stress incontinence?
- tension-free vaginal tape
- retropubic mid urethral tape
74
How is urge incontinence managed?
- bladder retraining (min 6 weeks)
- anticholinergics
- mirabegron
- invasive procedures
75
What anticholinergics are used in urge incontinence?
- oxybutinin
- tolterodine
- solefenacin
76
What are side effects of anticholinergics?
- dry eyes and mouth
- urinary retention
- constipation
- postural hypotension
- can lead to cognitive decline, memory problems, worsening dementia
77
When is mirabegron contraindicated?
- uncontrolled hypertension
- β-3 agonist
- stimulates sympathetic nervous system
- can lead to inc risk of TIA and stroke
78
What are invasive procedures for urge incontinence?
- botulinum toxin type A
- sacral nerve stimulation
- augmentation cystoplasty
- urinary diversion
79
Describe the epidemiology of breast cancer
- most common form of cancer in UK
- around 1 in 8 women will develop breast cancer
80
What are risk factors for breast cancer?
- female (99% cases)
- increased oestrogen exposure (earlier menarche and later menopause)
- obesity
- smoking
- family history (1º relative)
81
How do contraception/HRT affect breast cancer risk?
- COCP: small increase in risk, returns to normal 10 years after stopping
- HRT: inc risk of breast cancer, esp combined HRT
82
What is BRCA?
- BReast CAncer gene
- tumour suppressor genes
- mutations lead to inc risk of breast and ovarian cancer among others
83
What is BRCA1?
- on chromosome 17
- 70% develop breast cancer by age 80
- 50% develop ovarian cancer
- inc risk of bowel and prostate cancer
84
What is BRCA2?
- on chromosome 13
- 60% develop breast cancer by age 80
- 20% develop ovarian cancer
85
Describe ductal carcinoma in situ
- pre-cancerous or cancerous ductal epithelial cells
- localised to single area
- often picked up by mammogram
- potential to spread locally
- potential to become invasive (30%)
- good prognosis if excised and adjuvant therapy
86
Describe lobal carcinoma in situ
- pre-cancerous
- asymptomatic and undetectable on mammogram
- usually incidental on biopsy
- represents inc risk of invasive breast cancer in future
- managed with close monitoring
87
What is a vault prolapse?
- occurs in women with hysterectomy
- vault of vagina descends into vagina
88
What is a cystocele?
- defect in anterior vaginal wall
- bladder prolapses into vagina
89
What is a urethrocele and what is a cystourethrocele?
- prolapse of urethra
- prolapse of bladder and urethra
90
What are risk factors for pelvic organ prolapse?
- multiple vaginal deliveries
- instrumental/prolonged delivery
- age and post menopause
- obesity
- coughing and straining
91
What is a rectocele and what are the symptoms?
- defect in posterior vaginal wall
- rectum prolapses into vagina
- women can develop facial loading > constipation, urinary retention and palpable lump
- press lump back to open bowel
92
What is the presentation of prolapse?
- feeling of something coming down
- heavy or dragging pelvic sensation
- urinary symptoms
- bowel symptoms
- sexual dysfunciton
93
How are prolapses examined?
- empty bladder and bowel before exam
- dorsal and left lateral position
- Sim's speculum (U-shaped single-blade)
- held on anterior wall for rectocele and posterior for cystocele
- asked to cough
94
How are prolapses graded?
- 0: normal
- 1: lowest part >1cm above introitus
- 2: lowest part within 1cm of introitus
- 3: lowest part >1cm below introitus
- 4: full descent and eversion of vagina
95
What is conservative management of prolapse?
- weight loss
- pelvic floor exercises
- lifestyle changes: dec caffeine intake
- vaginal oestrogen cream
- treat related symptoms e.g. anticholinergics for stress incontinence
96
Describe the types of vaginal pessaries:
- ring: sit around cervix and hold up uterus
- Shelf/Gellhorn: flat disc with stem
- cube
- donut
- hodge: rectangular hooking around posterior cervix and extending into vagina
97
How and why should pessaries be changed?
- comfort and symptom relief
- cleaned
- cause vaginal irritation and erosion
- oestrogen cream protects from irritation
98
What are fibroids?
- benign smooth muscle tumours
- also called uterine leiomyomas
- oestrogen sensitive
99
What is an intramural fibroid?
- within the myometrium
- changes shape and distorts uterus as it grows
100
What is a subserosal fibroid?
- just below outer layer of uterus
- grows outwards and becomes large
- fills abdominal cavity
101
What is a submucosal fibroid?
- grows below lining of uterus in endometrium
- projects into uterus
102
What is a pedunculated fibroid?
- grows on a stalk
103
How do fibroids present?
- often asymptomatic
- menorrhagia
- prolonged menstruation
- abdo pain and bloating
- urinary/bowel symptoms
- deep dyspareunia
- reduced fertility
104
What is felt on examination with fibroids?
- abdominal and bimanual
- palpable pelvic mass
- enlarged, firm, non-tender uterus
- bulky
105
How are fibroids investigated?
- hysteroscopy (submucosal)
- pelvic USS (larger fibroids)
- MRI before surgery
106
What is the management of fibroids?
- mirena (1st line if <3cm)
- NSAIDs and tranexamic acid (1st line if >3cm)
- cocp
- cyclical oral progestogens
107
What are surgical options for fibroids <3cm?
- endometrial ablation
- resection if submucosal during hysteroscopy
- hysterectomy
108
What are surgical options for fibroids >3cm?
- uterine artery embolisation
- myomectomy
- hysterectomy
109
How can fibroid size be reduced pre-surgery?
- GnRH agonists: Zoladex, Prostate
- induce a menopause like state
- reduce oestrogen maintaining fibroid
110
How does uterine artery embolisation work?
- catheter into femoral artery
- particles injected causing blockage
- starves fibroid of oxygen
- causes shrinkage
111
What is myomectomy?
- surgical removal of fibroids - laparoscopic or laparotomy
- improves fertility
112
What is endometrial ablation?
- destroys endometrium
- balloon thermal ablation
- insert balloon and fill with high-temp fluid
- burns endometrial lining
113
What are complications of fibroids?
- menorrhagia w/ iron deficiency anaemia
- reduced fertility
- constipation
- pregnancy complications
- torsion
114
What is red degeneration of fibroids?
- ischaemia, infarction and necrosis of fibroids
- occurs in >5cm during 2nd and 3rd trimester
- fibroid enlarges and outgrows its blood supply
115
How does red degeneration present?
- severe abdo pain
- low-grade fever
- tachycardia
- vomiting
116
How is red degeneration managed?
- rest
- fluids
- analgesia
117
What is an ovarian cyst?
- fluid filled sac
- related to hormones of menstrual cycle
118
What is the epidemiology of ovarian cysts?
- v common in premenopausal women
- postmenopausal: concerning for malignancy
119
How do ovarian cysts present?
- pelvic pain
- bloating
- fullness in abdomen
- palpable pelvic mass
120
When can cysts present with acute pelvic pain?
- ovarian torsion
- haemorrhage
- rupture
121
What are the two types of functional cysts?
- follicular
- corpus luteum
122
What is a follicular cyst?
- form from developing follicle
- failure to rupture and release egg > persistence of cyst
- most common type
- thin walls and no internal structure
123
What is a corpus luteum cyst?
- corpus luteum fails to break down
- fills with fluid
- cause pelvic discomfort, pain and delayed menstruation
- seen in early pregnancy
124
What is a serous cystadenoma?
benign tumour of epithelial cells
125
What is a dermoid cyst?
- germ cell tumour (teratoma)
- benign
- can contain various tissue types: skin, hair, bone, teeth
- associated with ovarian torsion
126
What are risk factors for ovarian malignancy?
- age
- post menopause
- increased no of ovulations
- obesity
- HRT
- smoking
- FHx of BRCA
127
How does ovulation correlate with ovarian cancer?
- more ovulations = inc risk
- reduced by later menarche, early menopause, pregnancies, use of cocp
128
Which factors can cause a raised CA125?
- endometriosis
- fibroids
- adenomyosis
- pelvic infection
- liver disease
- pregnancy
129
What bloods are done for women <40 with a complex ovarian mass?
- LDH
- AFP
- hCG
130
What factors are taken into account in the risk of malignancy index?
- menopausal status
- USS findings
- CA125 level
131
How are dermoid cysts managed?
- referral to gynae
- for further investigation and consideration of surgery
132
How are cysts in post menopausal women managed?
- correlation with CA125
- referral to gynae
- if raised then 2ww pathway
- <5cm then monitor with USS every 4-6mo
133
How are ovarian cysts managed surgically?
- laparoscopy
- ovarian cystectomy
- oophorectomy if necessary
134
How are simple ovarian cysts in premenopausal women managed?
- <5cm = resolves within 3 cycle
- 5-7cm = referral to gynae and yearly USS monitoring
- >7cm = consider MRI or surgical eval
135
What are complications of an ovarian cyst?
- torsion
- haemorrhage
- rupture
136
What is Meig's syndrome?
- ovarian fibroma
- pleural effusion
- ascites
137
How is ovarian cancer staged?
1. confined to ovary
2. past ovary but in pelvis
3. past pelvis but inside abdomen
4. outside abdomen
138
What is lichen sclerosus?
- chronic inflammatory skin
- autoimmune
139
Where does lichen sclerosus present in women?
- labia
- perineum
- perianal skin
- potentially axilla and thighs
140
Where does lichen sclerosus present in men?
- foreskin
- glans of penis
141
Which other autoimmune diseases is lichen sclerosus associated with?
- T1DM
- alopecia
- hypothyroid
- vitiligo
142
How does lichen sclerosus present?
- itching
- soreness
- pain worse at night
- skin tightness
- superficial dyspareunia
- erosions
- fissures
143
What is the Koebner phenomenon?
- signs and symptoms made worse by friction to skin
- made worse by tight underwear, urinary incontinence and scratching
144
Describe the appearance of lichen sclerosus
- 'porcelain white'
- shiny
- tight
- thin
- slightly raised
- papules or plaques
145
How is lichen sclerosus managed?
- cannot be cured; symptoms controlled
- FU every 3-6 months
- clobetasol propionate 0.05% (dermovate)
- is a potent topical steroid
- used OD for 4 weeks
- also use emollients
146
What is a critical complication of lichen sclerosus?
- 5% risk of squamous cell carcinoma of vulva
147
What are other complications of lichen sclerosus?
- pain and discomfort
- sexual dysfunction
- bleeding
- narrowing of urethral or vaginal openings
148
What is pelvic inflammatory disease (PID)?
- inflammation and infection of pelvic organs
- caused by infection spreading up through cervix
149
What is a key complication of PID?
- tubular infertility
- chronic pelvic pain
150
Which infections cause PID?
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Mycoplasma genitalium
151
Which non-sexually transmitted infections can cause PID?
- gardnerella vaginalis
- H. influenzae
- E. coli
152
What are the risk factors for PID?
- not using barrier contraception
- multiple partners
- younger age
- existing STIs
- previous PID
- IUD
153
How does PID present?
- pelvic or lower abdo pain
- abnormal discharge or bleeding
- dyspareunia
- dysuria
- fever
154
What is found on examination in PID?
- pelvic tenderness
- cervical motion tenderness
- inflamed cervix
- purulent discharge
155
How should patients with PID be tested?
- NAAT swabs for chlamydia and gonorrhoea
- HIV test
- syphilis test
- HVS
- inflammatory markers (CRP/ESR)
156
What does a high vaginal swab test for?
- bacterial vaginosis
- candidiasis
- trichomoniasis
157
How is PID managed?
- GUM specialist
- contact tracing
- Abx empirically
- admit if septic or pregnant
158
What are the guidelines for Abx for PID?
- single dose IM ceftriaxone
- doxycycline 100mg BD for 14 days (chlamydia and Mycoplasma)
- metronidazole 400mg BD for 14 days (anaerobes)
159
What are possible complications of PID?
- sepsis
- abscess
- infertility
- chronic pelvic pain
- ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
160
What is Fitz-Hugh-Curtis syndrome?
- inflammation and infection of liver capsule
- leads to adhesions between liver and peritoneum
- bacteria may spread via peritoneal cavity, lymphatics or blood
161
What is the presentation of Fitz-Hugh-Curtis syndrome?
- RUQ pain
- R shoulder tip pain
162
What is the management of Fitz-Hugh-Curtis syndrome?
- laparoscopy
- adhesiolysis
163
What is adenomyosis?
- endometrial tissue in the myometrium
- more common in older age and multiparous
- hormone dependent
164
How does adenomyosis present?
- dysmenorrhoea
- menorrhagia
- dyspareunia
- may present with infertility or pregnancy complications
165
What is seen on examination in adenomyosis?
- enlarged and tender uterus
- more soft than fibroid uterus
166
How is adenomyosis diagnosed?
- transvaginal ultrasound
- MRI/transabdo USS are alternatives
- GOLD: histological after hysterectomy
167
How is adenomyosis managed when contraception is unwanted?
- tranexamic acid if no pain
- mefenamic acid with pain
168
How is adenomyosis managed when contraception is an option?
- mirena
- cocp
- cyclical oral progestogens
169
What are specialist options for adenomyosis?
- GnRH analogues
- endometrial ablation
- uterine artery embolisation
- hysterectomy
170
What complications are associated with adenomyosis in pregnancy?
- infertility
- miscarriage
- preterm
- SGA
- preterm PROM
- malpresentation
- PPH
- C-section
171
What is ovarian torsion?
- ovary twists in relation to surrounding connective tissue, fallopian tube and blood supply
172
What causes ovarian torsion?
- ovarian mass >5cm e.g. cyst or tumour
- more likely to occur with benign tumour
- long infundibulopelvic ligaments in pre-menarchal girls
173
How does ovarian torsion present?
- sudden onset, severe unilateral pelvic pain
- constant pain getting progressively worse
- nausea and vomiting
174
What is found on examination for ovarian torsion?
- localised tenderness
- possible palpable mass in pelvis
175
How is ovarian torsion diagnosed?
- transvaginal USS
- whirlpool sign
- free fluid in pelvis
- ovarian oedema
- GOLD: laparoscopic surgery
176
How is ovarian torsion managed?
- emergency admission
- detorsion and possible oophorectomy
- laparotomy if large ovarian mass suspected
177
What are possible complications of ovarian torsion?
- loss of function due to ischaemia
- dependent on if there's another functioning ovary
- infection, abscess, sepsis
- rupture, peritonitis, adhesions
178
What is atrophic vaginitis?
- dryness and atrophy
- due to lack of oestrogen
179
How does lack of oestrogen affect the vagina?
- epithelial lining becomes thinner, less elastic and more dry
- tissue more prone to inflammation
- changes in vaginal pH and microbial flora
180
How does atrophic vaginitis present?
- itching
- dryness
- dyspareunia
- bleeding
- recurrent UTIs/stress incontinence
181
What does examination show in atrophic vaginitis?
- pale mucosa
- thin skin and reduced folds
- erythema
- dryness
- sparse pubic hair
182
How is atrophic vaginitis managed?
- estriol cream/pessaries
- estradiol tablets/ring
183
What contraindications are there for topical oestrogen?
- breast cancer
- angina
- VTE
184
What are the most common types of cervical cancer?
- squamous cell carcinoma (80%)
- adenocarcinoma
185
What is the most common cause of cervical cancer?
- HPV (STI)
- type 16 and 18
- produces proteins E6 and E7 which inhibit p53 and pRb (tumour suppressor genes)
186
What increases risk of catching HPV (therefore inc cervical cancer risk)?
- early sexual activity
- inc no of partners
- sexual partners who have had more partners
- not using condoms
187
What are other risk factors for cervical cancer?
- non-engagement with screening
- smoking
- HIV
- cocp
- inc. no of full term pregnancies
- family history
188
With which presenting symptoms should you consider cervical cancer?
- abnormal vaginal bleeding (IM, PC, PMB)
- vaginal discharge
- pelvic pain
- dyspareunia
189
What abnormal appearances of the cervix suggest cervical cancer?
- ulceration
- inflammation
- bleeding
- visible tumour
190
How is cervical intraepithelial neoplasia (CIN) graded?
- CIN I: mild dysplasia, affecting 1/3 thickness - likely to return to normal w/out treatment
- CIN II: moderate, affects 2/3, likely to progress to cancer
- CIN III: severe, very likely to progress
191
How is cervical cancer staged?
1: confined to cervix
2: invades uterus or upper 2/3 of vagina
3: pelvic wall or lower 1/3 of vagina
4: bladder, rectum or beyond pelvis
192
What are the differences between stages 1a and 1b in cervical cancer?
1a: only visible by microscopy or<7mm wide
1b: clinically visible or >7mm
193
How does a smear test work?
- collection of cells from cervix using brush
- deposited into preservation fluid
- liquid based cytology
194
What is being looked for in a smear test?
- precancerous changes: dyskaryosis
- high risk HPV
195
How often is smear testing done?
- every 3yrs for 25-49
- every 5yrs for 50-64
196
What are possible cytology results from smear testing?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Poss invasive squamous cell carcinoma
- Poss glandular neoplasia
197
What are the possible management options based on smear results?
- inadequate sample – repeat the smear after at least 3mo
- HPV -ve – continue routine screening
- HPV +ve w/ normal cytology – repeat the HPV test after 12 months
- HPV +ve w/ abnormal cytology – refer for colposcopy
198
How does colposcopy work?
- inserting speculum and using colposcope
- epithelial lining examined in detail
- stains to differentiate abnormal areas
199
Which stains are used in colposcopy and what colours do they appear?
- acetic acid: white
- iodine: brown
200
What is large loop excision of the transformation zone (LLETZ)?
- loop biopsy
- diathermy to remove abnormal epithelial tissue
- current cauterises tissue and stops bleeding
201
What is cone biopsy?
- treatment for CIN + v early stage cancer
- removes cone-shaped piece of cervix
- sent for histology to assess for malignancy
202
What are the main risks of cone biopsy?
- pain
- bleeding
- infection
- scar formation with stenosis
- inc risk of miscarriage and prem labour
203
Which strains of HPV does the vaccine prevent against?
- given to girls and boys
- strains 6 and 11 (genital warts)
- strains 16 and 18 (cervical cancer)
204
What is pelvic exenteration?
- removing most or all pelvic organs
- vagina, cervix, uterus, tubes, ovaries, bladder, rectum
205
What is the management for CIN or early stage 1a cervical cancer?
- LLETZ
- cone biopsy
206
What is the management for stage 1b-2a cervical cancer?
- radical hysterectomy
- removal of local lymph nodes
- chemotherapy and radiotherapy
207
What is the management for stage 2b-4a cervical cancer?
- chemotherapy and radiotherapy
208
What is the management of stage 4b cervical cancer?
- surgery
- radiotherapy
- chemotherapy
- palliative care
209
Which monoclonal antibody can be used in cervical cancer?
- bevacizumab
- metastatic or recurrent cancer
- targets vascular endothelial growth factor A
- stops development of new blood vessels
210
What are risk factors for vulval cancer?
- age (>75)
- immunosuppression
- HPV
- lichen sclerosus
211
How does vulval cancer present?
- lump
- ulceration
- bleeding
- pain
- itching
- lymphadenopathy
212
What is seen on the labia majora in vulval cancer?
- irregular mass
- fungating lesion
- ulceration
- bleeding
213
How is vulval cancer diagnosed?
- 2ww pathway
- (sentinel node) biopsy
- imaging for staging
214
How is vulval cancer managed?
- wide local excision
- groin lymph node dissection
- chemo and radiotherapy
215
What is the most common type of vulval cancer?
- 90% squamous cell carcinoma
216
What is vulval intraepithelial neoplasia?
- premalignant condition
- affects squamous epithelium
217
What are the types of VIN?
- high grade squamous intraepithelial lesion: associated with HPV in women aged 35-50
- differentiated VIN: associated with lichen sclerosus in women aged 50-60
218
How is VIN treated?
- watch and wait
- wide local excision
- imiquimod cream
- laser ablation
219
Describe the most common types of endometrial cancer
- 80% adenocarcinoma
- oestrogen dependent
220
What is endometrial hyperplasia?
- precancerous thickening of endometrium
- with or without atypia
221
How is endometrial hyperplasia treated?
- IUS e.g. mirena
- continuous oral progestogens
222
What are risk factors for endometrial cancer?
- increased age
- earlier onset of menstruation
- late menopause
- oestrogen only HRT
- obesity
- no pregnancy
- PCOS
- tamoxifen
223
Why is obesity a risk factor for endometrial cancer?
- adipose tissue is an oestrogen source
- contains aromatase which converts androgens to oestrogen
- more unopposed oestrogen
224
What are protective factors against endometrial cancer?
- COCP
- mirena
- inc pregnancies
- smoking
225
How does endometrial cancer present?
- post coital bleeding
- intermenstrual bleeding
- heavy menstrual bleeding
- abnormal discharge
- haematuria
- anaemia
226
What is the 2ww referral criteria for endometrial cancer?
- post menopausal bleeding
- >12 mo after last menstrual period
227
Under what circumstances should women over 55 be referred for a transvaginal ultrasound?
- unexplained vaginal discharge
- visible haematuria + inc platelets, anaemia or inc glucose levels
228
What are the investigations for endometrial cancer?
- transvaginal ultrasound: endometrial thickness <4mm
- pipelle biopsy
- hysteroscopy w/ biopsy
229
What are the stages of endometrial cancer?
1. confined to uterus
2. invades cervix
3. invades ovaries fallopian tubes, vagina or lymph nodes
4. invades bladder, rectum or beyond pelvis
230
What is the management of endometrial cancer?
- TAH w/ BSO
- radio/chemotherapy
- progesterone to slow progression
231
What is cervical ectropion?
- eversion of endocervix
- due to high oestrogen
232
What are the symptoms of ectropion?
- PCB, IMB, discharge
- reddish appearance around os
233
What is the pathophysiology of ectropion?
- mucus secreting glands > inc discharge
- fine blood vessels > PCB
234
What is the treatment for ectropion?
- ablation
- stop COCP
- silver nitrate
235
After how long can a couple be referred for infertility?
- TTC for >12 months
- 6 months if over 35
236
Give lifestyle advice for a couple TTC
- 400mcg folic acid daily
- healthy BMI
- avoid smoking, alcohol, stress
- intercourse every 2-3 days
237
What is involved in female hormone infertility testing?
- serum LH and FSH on day 2-5
- AMH
- TFT
- prolactin
- serum progesterone 7d before period
238
What is AMH?
- anti-mullerian hormone
- ovarian reserve marker
- released by granulosa cells
239
What does high FSH indicate?
- poor ovarian reserve
- pituitary producing extra FSH to attempt to stimulate follicular development
240
What investigations are performed in secondary care infertility?
- USS pelvis
- hysterosalpingogram
- laparoscopy and dye test
241
How is anovulation managed?
- weight loss
- clomifene: stimulates ovulation
- letrozole
- gonadotropins
242
What methods can be used to manage sperm problems in infertility?
- surgical retrieval
- IUI: collecting and separating high quality sperm
- ICSI: injecting sperm into cytoplasm of egg
- donor sperm
243
What methods can be used to manage tubal problems in infertility?
- tubal cannulation
- laparoscopy
- IVF
