Gynaecology Flashcards
(136 cards)
1
Q
2 systemic disorders causing Menorrhagia
A
Hypothyroidism
Clotting disorders
2
Q
Local pathology causing menorrhagia
A
Fibroids Polyps Endometrial carcinoma Endometriosis Pelvic inflammatory disease Dysfunctional uterine bleeding (diagnosis of exclusion)
3
Q
Iatrogenic cause of menorrhagia
A
Copper IUD
4
Q
Important red flag questions in menorrhagia
A
Intermenstrual bleeding
Post coital bleeding
5
Q
How to subjectively assess abnormal uterine bleeding?
A
clots noctural soiling flooding wearing double sanitary protection interfear with work / social events
6
Q
With AUB what condition to check they’re not suffering from as a result?
A
Anaemia - lethargy / breathlessness
7
Q
Premenstrual dysmenorrhoea indicates?
A
endometriosis
8
Q
How does PID present?
A
Fever
Pelvic pain
Dyspareunia
Vaginal discharge
9
Q
What in the PMH could cause AUB?
A
PCOS
Thyroid disease
Clotting disorders
Contraceptive hx
10
Q
What test should be performed in AUB in all women 45+
A
endometrial biospy
11
Q
Two types of medical treatment for menorrhagia
A
Antifibrinolytics / haemostatics
Hormone therapy
12
Q
Antifibrinolytic used in menorrhagia
A
Tranexamic acid
13
Q
What is the risk with tranexamic acid?
A
Thrombosis
14
Q
Other non hormone therapy used in menorrhagia
A
NSAIDS
Aspirin - prostaglandin inhibitor
15
Q
What hormonal therapy is most useful for anovulatory menorrhagia?
A
Progestrogens
16
Q
Hormonal therapies for menorrhagia
A
Porgestogens
IUS
COCP
17
Q
Surgical treatments for menorrhagia
A
Hysterscopic ressection of interuterine pathology e.g. fibroids / endometrial polyps
Open myomectomy - fibroids
Endometrial ablation
Hysterectomy
18
Q
Who is endometrial ablation not appropriate for?
A
women wishing to conceive
19
Q
Complications of endometrial ablation
A
Uterine perforations
Fluid overload - non electrolyte sol. used in electrosurgery
Haemorrhage
Infection
20
Q
Uterine fibroids are
A
benign tumour of the myometrium
21
Q
What situation can cause fibroids to
- grow
- shrink
A
- pregnancy - hyperoestrogenic state
- menopause - hypo-oestrogenic state
22
Q
what 3 things cause pain in women with fibroids?
A
degeneration of fibrois
associated pelvic varicosities
stretching of uterine ligaments
23
Q
How can fibroids cause subfertility?
A
press on the cornual region of the fallopian tube
submucosal fibroids are hormonally active - may affect implantation and cause miscarriage
24
Q
where may fibroids put pressure on
A
bladder - urinary symptoms
rectum - abdo bloating
25
4 types of fibroid
submucous
intramural
subserous
pedunculated
26
Risk factors for fibroids
Afro-caribbean women
Increasing age
Nulligravidity
Obesity
27
Protective factors from fibroids?
Smoking
Use of COCP
Full term pregnancy
28
Gynaecological complications of fibroids?
Degeneration
Torsion if pedunculated
Malignancy - v small risk of leimyosarcoma
29
How can fibroids effect pregnancy?
Infertility
Obstructed labour
Risk of PPH
30
First line imaging investigation for fibroids?
USS
31
Gold standard imaging for fibroids?
MR
32
3 indications for treating fibroids?
Symptomatic
Rapidly enlarging
Cause infertility
33
Adjunct to surgery for fibroids?
GnRH analogues - reversible, temporary, chemical menopause
34
Surgical options for fibroids
Transcervical resection - hysteroscopy - submucous fibroids
Myomectomy - open / closed
Hysterectomy
35
New treatment option for fibroids?
Uterine artery embolism
- less invasive than surgery
- radiological embolisation of fibroids
- catheter inserted into femoral artery
- inject microbeads into arteries supplying fibroids (thrombosis and fibroid infarction)
- complications - infection, pain, failed treatment, does not preserve fertility
36
4 important aspects of an early pregnancy complication hx?
LMP
Last cervical smear
Bleeding / discharge
Pain
37
Risk factors for ectopic pregnancy?
```
PID
Tubal surgery
Peritonitis / pelvic surgery
Endometriosis
IUCD in situ
IVF pregnancy
```
38
What is cervical shock?
| How does it present?
vagal response to dilation caused by products of conception distending the cervical canal
Pulse and BP would both be low
39
Signs of haemorrhage due to ectopic
Pulse weak and tachycardic
Reduced BP
Pt pale, sweaty, unwell and may collapse
40
Miscarriage abdo exam
Abdo soft and >12 weeks then uterus may be palpable
41
Ectopic pregnancy abdo exam
Uterus not palpable
Tenderness on the affected side
May be some guarding and rebound tenderness
42
ruptured ectopic pregnancy abdo exam
Entire abdomen tense, tender with guarding and rebound tenderness
43
What is an ectropian?
Columnar epithelium present in the vaginal portion of the cervix
Not pathological
Bleeds easily
Common in pregnancy due to oestrogen changes
Bleeds more if irritated e.g. due to infection
take swabs and treat infection
44
Threatened miscarriage =
bleeding occurring before 24 weeks
| cervix closed on examination
45
Inevitable miscarriage =
bleeding before 24 weeks
| cervix is OPEN on examination
46
Missed / delayed / silent miscarriage =
scan shows no viable fetus / empty intrauterine sac
Cervix closed on exam
Patient may not have any bleeding
47
Complete miscarriage =
no products of conception on scan
patient has had bleeding
cervix closed on exam
48
Incomplete miscarriage =
scan shows products of conception left in the uterus
patient has had bleeding
cervix is open on exam
49
Contributing factors to miscarriage
```
Fetal abnormality
Infection
Maternal age
Abnormal uterine cavity
Maternal illness
Intervention e.g. amniocentesis and CVS
```
50
Surgical management of miscarriage -
Evacuation of retained products of conception
51
Complication of ERPC
Endometritis
52
Endometritis presentation =
fever, malaise, lower abdo pain, change in vaginal bleeding
53
Up to what week can watch and wait management be given for miscarriage
13
54
```
If it's not clear whether a patient had an ectopic pregnancy what test should be done?
What results would be expected
- viable pregnancy
- miscarriage
- ectopic
```
Beta HCG test 48hrs apart
- doubled
- significantly reduced
- increased or stayed the same but not doubled
55
Two surgical options for ectopic pregnancy
Salpingectomy - especially if ruptured
| Salpingotomy
56
Medical treatment for tubal ectopic
Methotrexate, IM 50mg/m2
57
What needs to be discussed with the mother who has an ectopic pregnancy ?
respectful disposal of fetal tissue
58
Criteria for expectant management of ectopic preg
minimal symptoms
patient stable
low / falling hCG
Mass <4cm on USS
59
Criteria for medical management ectopic preg
static / rising hCG
| No contraindications to methotrexate
60
Advice about methotrexate
can't get pregnant for 3m after
61
criteria for surgical management of ectopic pregnancy
```
patient clinically unstable
hCG <5000
US mass >4cm
failed medical treatment
previous IVF/ ectopic
```
62
STI causes of vaginal discharge
Chlamydia
Trichomas vaginalis
Neisseria gonorrhoea
63
Non STI causes of vaginal discharge
Candida albicans
| Bacterial vaginosis
64
inflammatory causes of vaginal discharge
atrophic changes
allergic reaction
post op granulation tissue
65
Malignant causes of vaginal discharge
Vulval carcinoma
Cervical carcinoma
Uterine carcinoma
66
Other causes of vaginal discharge
Foreign body
| Fistula
67
Investigations if suspect infectious cause of vaginal discharge
microbiology swabs
MSU
Laprascopy - PID
68
Suspect malignant cause of vaginal discharge - investigations to carry out..
```
vulval biopsy
cervical smear / biopsy
pelvic uss
endometrial sampling
hysteroscopy
```
69
Endometriosis =
growth of endometrial tissue outside of the uterine cavity
70
clinical features of endometriosis
chronic pelvic pain
dysmenorrhoea
Deep dyspareunia
Subfertility
71
gold standard investigation for endometriosis
laparascopy
72
Medical management of endometriosis
What does it not achieve
```
NSAIDs
Progestrogens
COOP
GnRH analouges
Mirena coil
```
They do not improve subfertility
73
surgical options for endometriosis
Laporoscopic excision
| Laser treatment of endometriotic ovarina cysts
74
When can a diagnosis of menopause be made
Women >50 y/o
Woemn < 50 y/o
12 m after LMP
| 24m after LMP
75
Contraindications to HRT
```
Undiagnosed PV bleeding
Pregnancy
Oestrogen dependent cancer
Acute liver disease
Uncontrolled HTN
```
History of breast cancer
VTE
Recent stroke / MI / angina
76
Long term benefits of HRT
reduced osteoporosis
| reduce risk of coronary artery disease
77
Risks of HRT
```
VTN
Stroke
ovarian cancer if used 5+ yrs
breast cancer
endometrial cancer
```
78
Bacterial vaginosis treatment
oral metronidazole 5-7 days
79
Presentation of trichomonas vaginalis
frothy yellow / green discharge
offensive
vulvovaginitis
strawberry cervix
80
treatment for trichomonas vaginalis
metronidazole
81
presentation of candida infection
```
cottage cheese discharge
vulvitis
burning with urination
pain with sex
redness round the vagina
```
82
Risk factors for cervical cancer
```
HPV infection
Early age of first intercourse
high number of sexual partners
lower socioeconomic group
smoking
partner with protatic / penile cancer
```
83
Symptomatic presentations of cervical cancer
intermenstrual bleeding
post coital bleeding
persistant vaginal discharge
post menopausal bleeding
84
Management of cervical smear with borderline changes / low grade dyskaryosis
Reflext HPV test
+ve - refer for colposcopy in 6 weeks
-ve - return to routine screening
85
High grade dyskaryosis / suspected cancer management t
refer to colposcopy within 2 weeks
86
treatment of cervical intraepithelial neoplasia
large loop excision
needle excision
core biopsy
87
ovarian hyperstimulation syndrome pathology
high oestrogen levels
vascular permeability
build up of fluid in the 3rd space
leads to intravascular fluid depletion
88
ovarian hyperstimulation syndrome severe presentation
N&V
Painful abdominal distension
fluid shift - ascites and pleural effusions
89
Risks with ovarian hyperstimulation syndrome
Hepatorenal failure
ARDS
increased risk of VTE
90
What is associated with PCOS
insulin resistance
metabolic syndrome
increased risk of T2D
91
Common features of PCOS
```
Hirsutism
Acne
Irregular / infrequent periods
Weight gain
Infertility
Scalp hair loss
```
92
What can be found on examination with PCOS
Hirsutism
Sweating / oily skin
Acne
Acanthosis nigricans
93
Risk factors for endometrial cancer
Obesity
Tamoxifen
Early menarche / late menopause
Lynch syndrome
94
Most common feature of endometrial cancer presentation?
post menopausal bleeding
95
Ovarian cancer presentation
```
bloating
abdo pain
early satiety
loss of appetite
(>12 times in a month)
```
96
Main blood test in ovarian cancer?
Ca125
97
Imaging in ovarian cancer?
USS firstly
then MR/CT to stage
98
US - "snowstorm" description likely to be?
molar preg
99
How may vulval and vaginal carcinomas present?
itching / bleeding
lesions on that area
100
What drug is a risk factor for endometrial hyperplasia
tamoxifen
101
Most common cause of PID
Chlamydia
102
4 parts of a gynae history
Periods
Urology
Sexual hx
103
Questions about periods
```
Length
Regular
How much ? heavy
Pain - when
Bleed after sex
Intermenstrual bleeding
Smear hx
```
104
Urology questions in gynae
UTIs
| Incontinence
105
Obstetric hx
```
How many children
Types of deliveries
Traumatic deliveries
HTN
Diabetes
Terminations
Miscarriages
Ectopics
```
106
Sexual
```
CONTRACEPTION
Pain
Bleeding
How many partners
Any STIs
```
107
Medical hx in gynae
Clotting
Thyroid
PCOS
108
Red flag for endometrial cancer
Post menopausal bleeding
109
Cervical cancer red flag
Looks abnormal
110
1st line for menorrhagia
progesterone coil
111
HRT if no oestrogen
continuous oestrogen-only therapy is given
112
HRT if <1 yr since LMP and uterus
cyclical combined HRTW
113
When is continuous HRT used?
taken cyclical combined for at least 1 year or
it has been at least 1 year since their LMP or
it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)
114
Menopause definition
Absence of menses for 12 months
115
Menopause symptoms
```
Amenorrhoea / irregular cycles
Hot flushes
Night sweats
Vaginal symptoms
Mood changes
Sleep disturbance
```
116
Tests when suspect menopause
Pregnancy test
FSH
Serum estradiol
117
Initial treatment of menopause
Lifestyle changes
- loose weight
- exercise more
- avoid caffeine / alcohol
118
Treatment of menopause symptoms in women with uterus
Amenorrhoea >12 m
Continuous combined regimen - oestrogen & progestin
oral / patch
119
In women with high thrombotic risk, which type of oestrogen is preferred to treat menopause?
Transdermal
120
1st line Treatment of menopause symptoms in women without a uterus / progesterone coil inserted in last 5 years
Oestrogen alone
121
Treatment of menopause symptoms in women with uterus with menstural irregularity and periods of irregularity
Sequential regimen
122
2nd line Treatment of menopause symptoms in women without a uterus / progesterone coil inserted in last 5 years
SSRI
123
Treatment of reduced libido
Oestrogen and androgen combined
124
Treatment for urogenital atrophy only
Vaginal oestrogen +/- vaginal moisturiser
125
Classification of dysmenorrhoea
Primary - absence of pelvic pathology
Secondary
126
Common causes of secondary dysmenorrhoea
Endometriosis
Chronic PID
Fibroids
Polyps
127
When does primary dysmenorrhoea usually start
6-12m after onset
128
Investigations in dysmenorrhoea
Preg test
Swabs
Clotting, FBC, CRP
Ultrasound (usually TV)
129
Menorrhagia definition
excess volume and or duration of menstrual bleeding
130
People with which condition need annual cervical smear screening?
HIV +ve
131
menopause treatment - 3 categories
life style
hormone replacement
non hormone replacement
132
lifestyle modifications in menopause
Hot flushes
regular exercise, weight loss and reduce stress
Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene
Mood
sleep, regular exercise and relaxation
Cognitive symptoms
regular exercise and good sleep hygiene
133
contraindications to HRT
```
Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
```
134
How long do the symptoms of menopause usually last?
2-5 years
135
Risks with HRT
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined
HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.
136
Management without HRT in menopause
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
