Gynaecology Flashcards
(94 cards)
1
Q
A
2
Q
What are the 5 Fs that contribute to abdominal distension differentials?
A
- fat
- fluid
- flatus
- fetus
- faeces
3
Q
What are some compressive symptoms associated with abdominal masses?
A
- urinary frequency
- urinary retention
- constipation
- leg swelling
4
Q
What blood tests are typically conducted for abdominal masses?
A
- FBC
- RP
- LFT
- CRP
- germ cell tumor markers (AFP, LDH, HCG)
- CA125, CEA, CA19-9
5
Q
What is the significance of CA125 in abdominal mass evaluation?
A
CA125 is sensitive but not specific and is used for surveillance but not for diagnosis.
Malignant: ovarian, endometrial, lung, colon, breast cancers etc.
6
Q
What are some benign conditions that can elevate CA125 levels?
A
- pregnancy
- menstruation
- fibroids
- pelvic inflammatory disease
- ovarian cysts
- endometriosis
7
Q
True or False: Ovarian cancer is the 5th most common cancer in Singaporean women.
A
True
2nd most common gynae cancer
8
Q
What are the main types of ovarian cancer?
A
- Epithelial (serous, endometrioid, mucinous, clear cell, transitional cell)
- Germ cell (immature teratoma, dysgerminoma, endodermal sinus tumor, choriocarcinoma)
- Sex cord/stroma (granulosa cell, sertoli, leydig, fibroma, thecoma)
9
Q
What is the most common presentation of ovarian cancer in postmenopausal women?
A
Abdominopelvic mass
10
Q
What are the risk factors for ovarian cancer?
A
- incessant ovulation (early menarche, late menopause, no children)
- age (postmenopausal)
- smoking
- PCOS
- endometriosis
- infertility
- estrogen replacement therapy
- genetics (BRCA1, BRCA2, Lynch syndrome)
11
Q
What are protective factors against ovarian cancer?
A
- combined oral contraceptive pills (COCPs)
- tubal ligation
- previous pregnancy
- breastfeeding
12
Q
What does FIGO staging involve for ovarian cancer?
A
- surgical exploration to assess tumor spread
- removal of uterus, tubes, omentum, para-arotic LN, pelvic LN
- pathological testing of removed tissue
surgico-pathological staging required
13
Q
What is the first-line treatment for ovarian cancer?
A
Surgical debulking followed by adjuvant chemotherapy
14
Q
What is the neoadjuvant indication for chemotherapy in ovarian cancer?
A
Chemotherapy followed by interval debulking surgery followed by more chemotherapy for disease that cannot be completely resected.
15
Q
What is the transformation zone?
A
Region bound by original and new squamocolumnar junction
Main site for cervical cancer
16
Q
Which HPV types are most related to cervical cancer?
A
HPV 16 and 18
Makes up 70% of all cervical cancer
17
Q
What is the significance of persistent HPV infection?
A
Only persistent infection increases the risk of cervical cancer
18
Q
What are the risk factors for persistent HPV infection?
A
- Increased exposure to HPV infection (multiple partners, unprotected sex)
- Reduced ability to eradicate HPV infection (STD infection, immunosuppression, smoking)
19
Q
What are causes of post-coital bleeding?
A
- Atrophic vaginitis
- Cervical ectropion
- Cervical growths (benign and malignant)
20
Q
What is the most common type of cervical cancer?
A
Squamous cell carcinoma
21
Q
What is the first-line screening method for cervical cancer?
A
PAP smear/HPV testing
22
Q
What is the recommended screening interval for women aged 25-29?
A
Every 3 years
23
Q
What should be done if a PAP smear is abnormal?
A
Refer for colposcopy except for ASCUS
ASCUS → repeat in 6 months, if >2 ASCUS → colposcopy or HPV
24
Q
What is a colposcopy?
A
Examination of the cervix with low power microscopy and bright illumination
25
What is the purpose of acetic acid and iodine in colposcopy?
Acetic acid: Denatures protein, making abnormal cells turn white
Lugol's iodine: stains glycogen, making normal cells turn brown
26
What does a punch biopsy do?
Confirms diagnosis of cervical lesions - CIN grading, or invasive cancer
## Footnote
Done even if no obvious lesions are seen
27
What is the FIGO staging for cervical cancer based on?
Size of tumor, vaginal involvement, parametrial involvement, rectal mucosal involvement
28
What is CIN I and its management?
No need to treat, follow up with regular colposcopy in 6 months
29
What is the management for CIN III?
Treat with excision
Cannot be seen: cone biopsy under GA
Can be seen: LEEP under LA in clinic
## Footnote
Loop electrosurgical excision procedure (LEEP) can be done in clinic
30
What are common symptoms of advanced cervical cancer?
* Pelvic pain
* DVT
* Obstructive uropathy symptoms
31
What are the two types of cervical cancer?
* Squamous cell carcinoma
* Adenocarcinoma
32
True or False: Cervical cancer is the second most common cancer in women.
True
33
What are the screening recommendations for immunosuppressed women aged 25-29?
CYTOLOGY yearly
34
What are the screening recommendations for women aged 30-69?
5 yearly HPV DNA primary screening
35
Investigations used to assess tumor extent in invasive cervical cancer?
MRI
CT and PET CT - assess nodes, urinary tract
36
What staging system is used for cervical cancer?
FIGO staging
37
What therapies are included in the management of cervical cancer?
Chemo-Radiation for all stages
38
What is a significant risk of radiation therapy in fertile patients?
Ovaries will die, leading to loss of fertility
39
When is surgery used in cervical cancer?
Early disease, stage 1-2
40
What to do if HPV DNA positive?
HPV 16/18 - straight to colposcopy
HPV non16/18 - reflex cytology -> pap positive -> colposcopy
41
What is the most common cause of postmenopausal bleeding?
Endometrial atrophy
BUTTT All postmenopausal bleeding is considered endometrial CANCER until proven otherwise.
42
What are some risk factors for endometrial cancer
* Unopposed estrogen (HRT, estrogen-secreting tumors, chronic anovulation)
* Fertility treatments
* Nulligravidity
* Metabolic syndrome
* Tamoxifen
* Strong family history of breast, colon, ovary, or endometrial cancer, or Lynch syndrome
## Footnote
Tamoxifen is a selective estrogen receptor modulator that acts as an antagonist in the breast and an agonist in the endometrium.
43
What specific examination is performed during the physical examination for postmenopausal bleeding?
* SCN
* Breast examination
* Abdominal examination (including access to the pouch of Douglas via rectal wall)
* Vulva and vagina examination
* Bimanual and rectovaginal exam
44
What kind of imaging is only applicable for postmenopausal women?
Ultrasound (US)
45
What type of staging is required for postmenopausal bleeding?
Surgicopathological staging
## Footnote
This may include total hysterectomy with bilateral salpingo-oophorectomy (THBSO) and lymphadenectomy.
46
What is the treatment for endometrial cancer
* Total hysterectomy with bilateral salpingo-oophorectomy (THBSO)
* Hormonal therapy if surgically unfit or to preserve fertility
* Adjuvant chemotherapy and radiation for systemic involvement
## Footnote
Hormonal therapy is a temporary measure, and patients need to undergo THBSO once they are done having children.
47
What thickness of endometrium warrants further investigation in postmenopausal women?
5mm or more
will require endometrial sampling with pipette or dilatation & curettage
48
How long can it take to diagnose endometriosis?
7-10 years
## Footnote
This delay is often due to nonspecific symptoms, lack of specific biomarkers, and stigma.
49
What is the primary pathology of endometriosis?
Ectopic endometrial-like tissue outside the uterine cavity
## Footnote
This tissue can be found in various organs except the spleen.
50
What are common areas where endometriosis can occur?
* Uterus
* Tubes
* Ovary
* Bowel
* Ureter
* Diaphragm
* Lung
* Previous scars
51
What are the main symptoms of endometriosis?
* Chronic pelvic pain
* Cyclic dysmenorrhea
* Dyspareunia
* Dysuria
* Infertility
* Pelvic inflammatory disease
52
What can cause chronic pelvic pain in endometriosis?
* Excessive prostaglandin
* Direct invasion of endometrial tissue into nerves
* Inflammation in peritoneal fluid
* Central sensitization
53
What factors are considered in the management of endometriosis?
* Age
* Symptom severity
* Patient desire for fertility
* Ultrasound scan findings
* Previous treatments
54
What is the first-line treatment for endometriosis?
Progestin-based therapy (dienogest, COC)
## Footnote
This treatment induces decidualization and endometrial atrophy.
55
What is a potential side effect of GnRH agonists used in endometriosis treatment?
Bone mineral density (BMD) depletion
## Footnote
They can also cause menopausal side effects.
56
What is adenomyosis?
Infiltration of the endometrium in the uterus.
57
What is the standard treatment approach for adenomyosis?
* Medical treatment similar to endometriosis
* Minimally invasive techniques
* Surgery if fertility is not desired
58
What are red flag symptoms associated with chronic pelvic pain?
* Irregular bleeding >40 years old
* New bowel mass >50 years old
* Foul vaginal discharge
* Postcoital bleeding
* Rectal bleeding
* Pelvic mass
59
What initial investigations should be conducted for chronic pelvic pain?
* Urine pregnancy test (UPT)
* Urinalysis
* STI screening
* Transvaginal ultrasound (TV US)
* Endometrial biopsy
60
What is a common imaging technique used to diagnose endometriosis?
Pelvic ultrasound
* endometriosis mapping ultrasound scan
* MRI can also be used
## Footnote
This can show cystic structures and ground glass echogenicity.
61
True or False: Normal physical examination rules out endometriosis.
False
62
What hormone stimulates the maturation of oocytes during the follicular phase?
FSH (Follicle-Stimulating Hormone)
## Footnote
FSH increase leads to the development of follicles.
63
What is the effect of estrogen on FSH during the follicular phase?
Provides negative feedback, decreasing FSH levels
## Footnote
This prevents multifollicular recruitment and allows only the follicle with maximum FSH receptors to develop.
64
What triggers ovulation?
LH surge
## Footnote
The LH surge stimulates the release of the oocyte from the follicle.
65
What does the corpus luteum secrete?
Progesterone
## Footnote
The corpus luteum forms from granulosa cells and is essential for maintaining the endometrium.
66
What happens to the corpus luteum if there is no pregnancy?
It degenerates
## Footnote
This leads to a decline in estrogen and progesterone, resulting in menstruation.
67
Define hypomenorrhea.
Periods < 3 days with scanty bleeding
## Footnote
This condition indicates a shorter duration of menstruation.
68
What is menorrhagia?
Periods > 7 days and/or >80mL blood loss
## Footnote
Menorrhagia is characterized by excessive menstrual bleeding.
69
What are common causes of heavy menstrual bleeding?
Structural (PALM) and Systemic (COEIN)
PALM includes Polyp, Adenomyosis, Leiomyoma, and Malignancy;
COEIN includes Coagulopathy, Ovulatory dysfunction, Endometrial issues, Iatrogenic causes, and Not otherwise classified.
70
What is adenomyosis?
Endometrial tissue grows into the myometrium
## Footnote
This benign condition results in heavy regular bleeding and dysmenorrhea.
71
How is endometrial hyperplasia classified?
With atypia (precancerous) and without atypia (benign)
## Footnote
Hyperplasia without atypia has a risk of malignancy <5%, while with atypia has a risk ~20%.
72
What is primary amenorrhea?
Failure of menarche to occur before 16 years of age
## Footnote
It can be due to delayed menarche, outflow tract abnormalities, or chromosomal issues.
73
What is the first step in diagnosing secondary amenorrhea?
Exclude pregnancy
## Footnote
This is crucial before investigating other causes of menstrual cessation.
74
What are the Rotterdam criteria for diagnosing PCOS?
2 out of 3 of the following: oligomenorrhea/amenorrhea, polycystic ovarian morphology, hyperandrogenism
## Footnote
These criteria must exclude other etiologies such as CAH and androgen-secreting tumors.
75
What is the management approach for PCOS?
Lifestyle management and hormonal treatment
## Footnote
Lifestyle changes include weight loss and diet control; hormonal treatments include oral contraceptive pills.
76
What is the definition of oligomenorrhea?
Infrequent menstruation, fewer than 8 menstrual cycles/year
## Footnote
It is often associated with conditions like PCOS.
77
What defines polycystic ovarian morphology in polycystic ovary syndrome (PCOS)?
Presence of 12 or more follicles measuring 2-9mm in diameter or increased ovarian volume >10ml
78
What are the components of hyperandrogenism in PCOS?
Hirsutism and raised serum androgen levels
## Footnote
Clinical assessment using Ferriman Gallwey score and biochemical measurement of total testosterone
79
What is the first-line management for lifestyle in PCOS?
Weight loss and diet control to reduce sugar intake
80
What is the purpose of inducing menses in PCOS management?
To reduce the risk of endometrial hyperplasia and infrequent menstruation
81
What STI screenings should be conducted if there is post-coital bleeding?
High vaginal swab for trichomonas and endocervical swab for chlamydia and gonorrhea
82
What blood tests are recommended for evaluating irregular bleeding?
FBC, hormonal profile (FSH, LH, E, testosterone), prolactin, TFT
83
What imaging technique is used to check for cysts and polyps in cases of irregular bleeding?
Pelvic ultrasound
84
What is the indication for an endometrial biopsy?
Women >40 y/o, persistent intermenstrual bleeding, post-menopausal bleeding, high-risk profiles
85
What defines dysfunctional uterine bleeding (DUB)?
Abnormal uterine bleeding in the absence of organic disease
diagnosis of exclusion
86
What are the two types of dysfunctional uterine bleeding?
Anovulatory and ovulatory
87
What is anovulatory bleeding characterized by?
Absence of ovulation leading to uncontrolled proliferation of endometrium until blood supply cannot keep up -> start shedding
88
What can cause anovulatory bleeding in women under 20?
Immature hypothalamic-pituitary-ovarian (HPO) axis
89
What usually causes ovulatory bleeding?
Early degeneration of the corpus luteum or prolonged function of the corpus luteum
90
What is the difference between primary and secondary dysmenorrhea?
Primary: painful periods with no cause; Secondary: painful periods due to an organic cause
91
What are common causes of secondary dysmenorrhea?
Pelvic inflammatory disease, endometriosis, fibroids, cervical stenosis
92
What is the first-line treatment for primary dysmenorrhea?
Analgesia
93
What hormonal treatments can be used for primary dysmenorrhea?
Combined oral contraceptive pills (COCPs) and progesterone
94
What surgical options are available for endometriosis treatment?
Endometriotic cystectomy and salpingo-oophorectomy
