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Flashcards in Gynaecology 2 Deck (170):
1

One of the VIN types is associated with older women, lichen sclerosus and greater risk of malignant progression. Which is it?

Differentiated type VIN

2

2 common symptoms of VIN?

Pain
Pruritis vulvae

3

What histological type are most vulval cancers?

SCC

4

What features of vulval cancer are more suggestive of malignancy than of VIN?

Pruritis
Bleeding (older women PMB), PCB
Discharge

5

Is most vaginal malignancy primary or secondary?

Secondary from endometrium, cervix or vulva

6

Vaginal cancer that is more common in teenagers and associated with maternal DES in pregnancy?

Clear cell adenocarcinoma

7

3 broad types of prolapse?

Anterior wall
Apical
Posterior wall

8

Subdivisions of anterior wall prolapse?

Cystocoele
Urethrocoele
Cystourethrocoele

9

Subdivisions of apical prolapse?

Uterine
Cervical
Upper vaginal

10

Subdivisions of posterior wall prolapse?

Rectocoele
Enterocoele (pouch of Douglas) - often has bowel in

11

RFs for prolapse?

Parity - vaginal delivery, instrumental, long second stage, big babies
Age and menopause (low oestrogen so low collagen)
Connective tissue disorders e.g. Ehlers danlos
Spins bifida occulta
Raised IAP - obesity, chronic cough, heavy lifting
Iatrogenic mostly surgical - hysterectomy

12

What is procidentia?

Complete prolapse and vaginal eversion

13

What is the word for complete prolapse?

Procidentia

14

Stage 0-4 of Pelvic Organ Prolapse Quantification grading? Based upon position of distal portion on straining.

Stage 0 = normal
Stage 1 = >1cm above hymen
Stage 2 = less than 1cm either side of hymen
Stage 3 = >1cm below hymen
Stage 4 = fully everted (procidentia)

15

Management of prolapses?

Conservative - lose weight, quit smoking/stop cough etc
Medical - ring pessaries/shelf pessary
Surgical - sacrocolpopexy, uterine sling etc

16

With which form of incontinence is prolapse often coexistent but not necessarily related?

Stress incontinence

17

What is the pathophysiology behind stress incontinence?

Increased intra abdominal pressure with a weakened pelvic floor so bladder pressure > upper urethral pressure and sphincter leaks

18

How is stress incontinence diagnosed?

UTI to rule out infection + urodynamics to rule out overactivity (urge) incontinence

19

Management of stress incontinence?

Physiotherapy - pelvic floor training exercises for > 3m
Medical - SSRI (duloxetine) for mod-severe
Surgery if the above fail and significantly affecting QoL (TVT)

20

How does urge/overactivity incontinence tend to present?

Urgency usually with frequency and nocturia
In the absence of proven infection

21

How is urge/overactivity incontinence diagnosed?

Via cystometry Urodynamics - needs confirmed detrusor overactivity

22

What are common causes of urge/overactivity incontinence?

Normally idiopathic - can be nervous system dysfunction

23

Which type of incontinence can be associated with UTIs, medications and caffeine/alcohol?

Urge/overactivity

24

What is mixed incontinence a combination of?

Stress and urge

25

Management of overactivity/urge incontinence?

Conservative - avoid triggers, caffeine etc and keep bladder diary
Bladder training + Anticholinergics e.g. Oxybutinin, tolterodine to suppress Detrusor activity
Topical oestrogens
Injected Botulinum toxin A (BTX) to paralyse Detrusor

26

What type of incontinence is associated with chronic retention or detrusor underactivity?

Overflow

27

What type of incontinence can have heavy and constant flow?

Chronic retention/overflow -> total

28

Causes of overflow incontinence?

Bladder cancer
Prostate increased size
Constipation
Detrusor underactivity - DM or neuropathies

29

What are the 2 types of VIN and which is most common? Which is associated with lichen sclerosus?

Usual type (most common)
Differentiated type (associated with lichen sclerosus)

30

In whom is endometriosis most common?

Nulliparous women closer to the menopause

31

What hormones does endometriosis growth depend on?

Oestrogen +/- progesterone

32

What are chocolate cysts?

Blood-filled endometriosis pockets

33

How does a frozen pelvis form from endometriosis?

Inflammation -> fibrosis and scarring -> adhesions

34

Key symptoms of endometriosis?

Cyclical chronic pelvic pain - just before menstruation (secondary dysmenorrhea)
Subfertility
Deep dyspareunia
Dyschezia and dysuria during menses

35

What Bimanual examination finding is suggestive of severe endometriosis with adhesions?

Retroverted immobile uterus + tenderness

36

What investigation differentiates between active lesions and chronic ones for endometriosis?

Laparascopy
Active lesions = red vesicles/petechial marks
-> white brown when less active

37

What investigation is best for adenomyosis?

MRI

38

What is an endometrioma?

Endometriotic ovarian lesion - risk of cancerous progression

39

Medical treatment for endometriosis if symptomatic?

Hormonal - COCP/cyclic Progestogens
GnRH analogues -> add back HRT
IUS will reduce menstrual symptoms

40

What is chronic pelvic pain?

Pain lasting over 6 months and not exclusively related to menstruation or sex

41

Differentials for chronic pelvic pain: cyclical vs non-cyclical?

Cyclical: endometriosis, adenomyosis
Non-cyclical: IBS, interstitial cystitis, chronic PID, pelvic mass

42

Appropriate management of chronic pelvic pain?

Analgesia
COCP if cyclical and fertility not desired
Laparoscopy to investigate

43

Why are prepubescent and postmenopausal women more susceptible to UTI and genital tract infection?

Lower oestrogen so thinner atrophic vaginal epithelium and increased vaginal pH (so lactobacilli aren't as efficient vs infection)

44

Common causes of endometritis?

Instrumentation of uterus
Complication of pregnancy e.g. PPROM, post CS, miscarriage, ToP

45

Presentation of endometritis?

Persistent, heavy, painful vaginal bleeding
Tender uterus, often open os
Fever, sepsis

46

What is acute PID/salpingitis?

Ascending pelvic infection, often sexual although occasionally descendant from appendix

47

What infection often precedes or coexists with salpingitis?

Endometritis

48

What is heavily protective against salpingitis to the extent that it almost never occurs during this?

A viable intrauterine pregnancy
Less protective are COCP and IUS

49

Under what circumstances may acute PID go unnoticed?

Particularly gonococcal infection
If no coexistent endometritis

50

Symptoms of acute PID/salpingitis (particularly gonococcal)?

Bilateral lower abdominal/pelvic pain
Deep dyspareunia
Discharge
O/E cervical excitation, lower abdo rebound tenderness and adnexal tenderness

51

What is the role of pelvic US in acute PID?

Looking for abscess formation or ovarian cysts

52

What infection is associated strongly with Fitz Hugh Curtis syndrome?

Chlamydia

53

In whom is chlamydia more commonly symptomatic?

Men - 50% symptomatic, only 20% of women

54

What complication of chronic PID can result in subfertility?

Hydro/pyosalpinx due to Fallopian tube adhesions

55

Definition of subfertility?

Failure to conceive after 1 year of regular unprotected sex
Affects 15% of couples

56

Primary vs secondary failure to conceive?

Primary = never conceived
Secondary = previously conceived (even if not delivered)

57

4 broad areas of causes of subfertility?

Egg production
Male factor
Fertilisation incl tubal factor and sexual problems
Idiopathic

58

What are the most common causes of subfertility?

Ovarian dysfunction or idiopathic

59

Physiological subfertility in terms of egg production?

Egg genetic quality decreases with age so natural reduction in fertility as women get closer to the menopause (declines from roughly age 30)

60

What is mittelschmerz?

Pain +/- discharge and spotting around time of ovulation (day 13-14)

61

When is body temperature lowest in the ovarian cycle?

Just pre-ovulation, before rising in luteal phase

62

3 tests for ovulation (apart from proof I.e. Conception)?

Mid-luteal phase serum progesterone (elevated = ovulated)
USS (time consuming)
OTC wee sticks for LH to predict surge

63

5 broad areas of causes of anovulation?

Thyroid - Hypothalamic hypogonadism
Pituitary - hyperprolactinaemia
Ovarian - PCOS, Premature ovarian failure, gonadal dysgenesis
Other e.g. Thyroid or androgen secreting tumours

64

What is the mechanism behind hypothalamic hypogonadism?

Reduced GnRH production -> reduced LH, FSH and oestrogen
-> anovulation

65

What is Kallmann's syndrome?

Non-development of GnRH secreting neurones

66

What medication can be given to induce ovulation in PCOS? Caveats?

Clomifene citrate
Weight and lifestyle should be controlled first

67

What is ovarian hyperstimulation syndrome?

Side effect of IVF/GnRH agonists -> overstimulation of follicles which become large and painful and produce mega oestrogen
Can be fatal via hypovolaemia, electrolyte imbalance, ascites, VTE, pulmonary oedema

68

What condition is a major risk factor for OHSS particularly following clomifine use?

PCOS

69

What age of women are more susceptible to OHSS and why?

Younger women with higher follicular reserve

70

Typical presentations of OHSS?

4-5 days following egg harvest; abdo pain and distension due to fluid ascites, nausea and vomiting, pleural effusions (SOB), hypovolaemia -> VTE, reduced UO

71

What 2 things does spermatogenesis depend on?

LH -> testosterone production in Leydig cells
FSH -> + testosterone make Sertoli cells produce and transport sperm

72

What is asthenospermia?

Poor sperm motility

73

5 common causes of abnormal semenalysis?

Idiopathic oligo/asthenozoospermia
Drugs, chemicals, smoking, alcohol
Varicocoele
Antisperm antibodies - common post-vasectomy reversal
Infection - mumps orchitis, epididymitis

74

What is another name for Kallmann's syndrome?

Hypogonadotrophic hypogonadism

75

Genetic causes of sperm abnormalities?

Klinefelters XXY
CF

76

3 common causes of tubal dysfunction?

Infection - PID
Endometriosis
Surgery/adhesions

77

What are the 2 main methods for investigating tubal damage?

Lap and Dye
Hysterosalpingogram - less invasive and safer but may not show endometriosis or adhesions

78

2 methods for intrauterine insemination?

In line with cycle (LH)
GnRH ovulation induction (stimulated IUI)

79

What are the requirements for IUI?

Patent tubes and no ovarian problems

80

What does ICSI stand for and what assisted contraception method is it used in conjunction with?

Intracyctoplasmic Sperm Injection, oft used with IVF when indication is male factor infertility

81

What is the primary indication for IVF?

Tubal or idiopathic with confirmed ovulatory reserve via FSH/AMH

82

What are 3 methods of assessing ovarian reserve?

FSH (high = low reserve)
AMH (high = high reserve)
TVUS of ovaries to measure antral follicle count AFC

83

What technique associated with IVF may be useful for older women or those at higher risk of chromosomal abnormalities e.g. CF?

Preimplantation Genetic Diagnosis PGD

84

What are the best methods of contraception for use in adolescents?

Pill and condoms for STI protection
Depo-provera (risk of reduced bone density)
Emergency contraception

85

What long term risk does depo-provera carry, particularly in younger people?

Osteoporosis

86

What methods of contraception are recommended for those with IBD or other malabsorbative disorders?

Oral contraception use limited due to reduced absorption so alternatives e.g. Patch, injection, implants
Increased risk of osteoporosis anyway so avoid Depo-provera

87

Contraception suitable for those breastfeeding?

In theory breastfeeding is contraceptive in itself as it inhibits ovulation
However if using added contraception: avoid COCP but POP is fine
IUD fine from 4 weeks postpartum

88

Rules for contraception for women around the time of menopause?

Women under 50 should use contraception for > 2years post LMP
Women over 50 should use contraception for > 1 year post LMP
IUS can be particularly useful for those with excessive menstrual loss

89

How do combined oestrogen and progesterone contraceptives work?

Negative feedback loop - suppress LH and FSH via GnRH and thus inhibit ovulation
Also thin endometrium and thickens cervical mucus (progesterone)

90

What is the normal regime for COCP?

3 weeks on -> bleed due to prog withdrawal -> 1 week off

91

Major contraindications to COCP?

VTE, CV Hx
Migraine with aura
Active breast or endometrial cancer
Thrombophilias + liver disease
Pregnancy
Most smokers
Really high BMI

92

Apart from contraceptive use, what is the COCP useful for?

Cycle control - menorrhagia, dysmenorrhea, irregular periods
Acne and hirsutism
Simple ovarian cysts

93

What 3 conditions can the COCP be used to suppress?

Fibroids
Endometriosis
PID/ovarian cysts

94

What are some considerations to make when considering COCP usage?

Compliance/missed pill
Reduced absorption
Liver enzyme inducers e.g. Anticonvulsants
Major surgery (stop 4 weeks before)
STI risk (concurrent condom use in teens and young adults)

95

4 major side effects of the COCP?

Nausea
Headache
Breast pain
Weight gain

96

How does the POP work?

By inhibition of cervical mucus and preventing uterine proliferation - inhibit ovulation in 50%

97

4 progestogenic side effects?

Vaginal spotting (breakthrough bleeds)
Pre-menstrual syndrome
Weight gain
Breast pain

98

What can the POP cause if it doesn't result in anovulation (as in 50%)?

Functional ovarian cysts (follicular or luteal)

99

In whom is the POP>COCP?

In older women
In those who the COCP is contraindicated

100

2 types of Long Acting Reversible Contraceptives LARCs?

Depo provera - progesterone injection
Progestogen implant rod

101

How do the LARCs work and what do they therefore protect against?

Work by preventing ovulation and so protect against functional ovarian cysts and ectopics

102

Why is the progestogen rod implant a better choice than depo for teenagers and those with IBD?

Doesn't cause a reduction in bone density so no risk osteoporosis

103

2 options for emergency contraception?

Morning after pill or IUD

104

What 2 morning after pill options are there?

Levonelle - up to 3 days after sex
Ulipristal (ellaOne) - up to 5 days after sex

105

When can an IUD be fitted after unprotected sex as emergency contraception?

Up to 5 days after sex or 5 days after expected date of ovulation

106

Potential complications of IUD/IUS insertion?

Pain/cervical shock due to increased vagal tone after insertion
Threads disappearing
IUD may worsen dysmenorrhea/menorrhagia
Infection and PID
Ectopic pregnancy

107

Which type of IUD can worsen menstrual symptoms?

Copper coil IUD

108

What are 2 causes of threads disappearing from IUD/IUS insertion?

Expulsion
Perforation of uterine wall

109

Average age of menopause?

51

110

When is the menopause officially recognised?

12 months after LMP

111

Define the perimenopause?

From onset of symptoms to 1 year after LMP

112

What is premature menopause? What does it require?

Ovarian failure before age of 40
Requires HRT until at least age of 50

113

What is PMB defined as?

Bleeding occurring >1 year after LMP

114

What are 3 important causes of PMB to rule out?

Endometrial cancer/hyperplasia with atypia
Intrauterine polyps
Cervical cancer

115

4 other potential causes of PMB?

Withdrawal bleeds with sequential HRT
Atrophic vaginitis
Cervicitis or cervical polyps
Ovarian carcinoma

116

What must purulent blood stained discharge be assumed to be until proven otherwise?

Endometrial carcinoma

117

Appropriate line of investigations for PMB?

Physical examination + smear test
TVUS -> endometrial pipelle biopsy -> hysteroscopy

118

5 areas of symptoms of the menopause?

Cardiovascular - stroke and MI risk
Vasomotor - hot flushes, night sweats (-> sleep disturbance)
Urogenital - vaginal atrophy, dyspareunia, itching burning dysuria, urinary frequency, urgency, Nocturia, incontinence and infection
Sexual and psychological - loss of interest and arousal, dyspareunia, irritability, mood changes, depression, sleep disturbance
Osteoporosis

119

Lines of investigation for the menopause?

FSH
AMH
T4/TSH, LH, oestrogen, progesterone

120

When investigating anovulation, what low level of hormone indicates anovulation?

Low progesterone

121

General rules for types of HRT requirement?

Oestrogen only if no uterus
Oestrogen and progesterone for uterus

122

Combined HRT regimes?

Quarterly or monthly bleeds (prog given sequentially)
No bleeds (prog given continuously e.g. IUS)

123

Which HRT method is the best for protecting vs endometrial cancer?

Continuous ie no bleed, as it induces endometrial atrophy

124

3 benefits of HRT?

Reducing troublesome symptoms
Reducing osteoporosis risk
Reducing colorectal cancer risk

125

4 potential risks of HRT?

Increased risk of endometrial cancer if oestrogen only and uterus present
Increased risk of breast cancer if combined
Increased risk of VTE particularly for oral (during 1st year)
Increased risk of gallbladder disease

126

What medications might be useful for perimenopausal symptoms for those wanting to avoid oestrogen (e.g. Breast ca risk)?

Progestogens
SSRIs for vasomotor

127

What is a miscarriage and when do most occur?

Fetus dies or delivered dead before 24 weeks
Most occur before 12 weeks

128

6 types of miscarriage?

Threatened
Inevitable
Complete
Incomplete
Septic
Missed

129

What indicates a threatened miscarriage?

Bleeding PV, closed cervical os. Fetus is still alive and correct size for dates

130

What fraction of people with threatened miscarriage go on to miscarry?

1/4

131

What indicates an inevitable miscarriage?

Heavier PV bleeding and open cervical os

132

What indicates an incompletely miscarriage?

Some but not all of fetal parts are passed; cervical os still open

133

What indicates a complete miscarriage?

All fetal parts have been passed and the cervical os is closed

134

What indicates septic miscarriage?

Uterine contents infected -> endometritis. Patient will have offensive vaginal loss with a tender uterus +/- systemic infection

135

What indicates a missed miscarriage?

Fetur not developed/died in utero but not recognised until bleeding or US
Small for dates fetus and closed os

136

What types of miscarriage present with an open os?

Incomplete
Inevitable

137

What types of miscarriage present with a closed os?

Threatened
Complete
Missed

138

What are sporadic miscarriages usually caused by?

Isolated chromosomal or genetic abnormalities

139

What are 'recurrent miscarriages' and why do they most commonly occur?

3 or more miscarriages in succession
Antiphospholipid Abs (thrombosis in placental circulation)
Parental chromosomal defects
Anatomical factors

140

Appropriate investigations for possible miscarriage (bleeding PV)?

US to observe viable IUP or retained fetal products
HCG levels
FBC and rhesus

141

What hCG levels are indicative of viable IUP or miscarriage?

Increase of >66% in 48 hours is indicative of viable IUP
Plateauing or decreasing suggests viable IUP

142

What investigations are combined to assess possibility of ectopic pregnancy?

HCG - if rise of >66% in 48 hours but no visible IUP suggests ectopic
Visualisation of IUP normally rules out ectopic

143

What is a heterotopic pregnancy?

IUP + ectopic pregnancy together

144

Under what circumstances does anti-D need to be given for miscarriage?

For bleeding > 12 weeks or surgically/medically managed in rhesus negative women

145

Management methods for non-viable IUP?

Expectant - for incomplete or inevitable miscarriage and no signs of infection
Medical - prostaglandins possibly with preceding mifepristone
Surgical - ERPC for infection, heavy bleeding or maternal choice

146

What is Asherman's syndrome?

A rare complication of ERPC and some uterine surgical procedures resulting in amenorrhea due to outflow blockage

147

When do rhesus negative women need to be given anti-D for ToP?

Within 72 hours of ToP

148

When is medical ToP most appropriate?

Less than 7-9 weeks
From 13-24 weeks

149

When is surgical ToP most appropriate?

7-13 weeks

150

What is the most common area for ectopic pregnancy?

Fallopian tubes
Occasionally Cornu, cervix, ovary, intra-abdo

151

RFs for ectopic pregnancy?

Previous ectopic
Tubal - PID, surgical adhesions
Increasing maternal age
Smoker

152

What should a patient who conceives despite IUD in situ be assumed to have until proven otherwise?

Ectopic pregnancy

153

Presentation for ectopic pregnancy?

Lower abdo pain - colicky then chronic
Scanty dark vaginal bleeding
Abdo/rebound tenderness
Adnexal tenderness, cervical excitation
Small uterus for dates, closed os

154

What should all women of reproductive age who present with bleeding, pain or collapse have done?

Pregnancy test

155

Medical management of ectopic pregnancy?

If unruptured, stable patient and hCG

156

Surgical management of ectopic pregnancy?

Laparoscopy and salpingectomy/salpingostomy if subacute
Laparotomy and salpingectomy if acute

157

What is hyperemesis gravidarum?

Nausea and vomiting in early pregnancy so severe as to cause dehydration, weight loss or electrolyte disturbance

158

In whom is hyperemesis more common?

Older, multiparous women
UTI
Molar pregnancy

159

When does hyperemesis normally resolve by?

12-14 weeks

160

Management of hyperemesis?

IVT +/- antiemetics e.g. Cyclizine, metoclopramide, ondansetron

161

What vitamin needs to be given in hyperemesis?

B particularly thiamine to prevent wernicke-korsakoff

162

What is gestational trophoblastic disease GTD?

Trophoblastic tissue which normally invades the endometrium proliferates more aggressively than normal -> mega hCG levels

163

What is local, non-invasive trophoblastic overproliferation called?

Molar pregnancy - hyatidiform mole

164

2 types of hyatidiform mole?

Complete (no fetus, entirely paternal)
Partial (+/- fetus, usually triploid)

165

What is a locally invasive GTD called and what does it have the potential to do?

Invasive mole
Can metastasise and become a choriocarcinoma

166

What is persistently elevated hCG in the context of GTD called?

Gestational trophoblastic neoplasia GTN

167

In whom is GTD more common?

Asian women at extremes of reproductive age

168

How does GTD present?

Large uterus, possible heavy vaginal bleeding
Early pre-eclampsia and hyperthyroidism
Hyperemesis

169

What does a 'snowstorm' uterus on US indicate?

Complete moles

170

Management of GTD?

ERPC + histological diagnosis
Serum or urine hCG follow up to rule out malignancy