Gynaecology Flashcards
(211 cards)
1
Q
what are the 4 causes of ovarian cancer?
A
- epithelial ovarian tumours
- germ cell tumours
- sex cord-stromal tumours
- metastatic tumours
2
Q
which is the most common type of ovarian cancer?
A
epithelial ovarian (85-90%)
3
Q
features of an ovarian germ cell tumour
A
- common in younger women (<35)
- high survival rate
- presents as a rapidly enlarging abdominal mass, can rupture or undergo torsion
4
Q
where may tumours metastasise from to cause ovarian cancer?
A
breast, GI tract, haemopoietic system, uterus, cervix
5
Q
risk factors of ovarian cancerr
A
- increased age
- lifestyle
- talcum powder use pre-1975
- history of infertility / use of fertility drugs (clomifene)
- nulliparous women (never given birth)
- early menarche/ late menopause
- FH
- HRT
- endometriosis
6
Q
where is the gene mutation located in patients with familial ovarian cancer?
A
BRCA 1 and 2
7
Q
epidemiology of ovarian cancer
A
1/5 most common cancer in women
incidence rate increases with age, peaks around 70-80
8
Q
clinical presentation of ovarian cancer
A
- majority present late (stage III or IV)
- insidious onset
- IBS- like symptoms
- abdominal discomfort, distention, bloating
- urinary frequency
- dyspepsia
- fatigue
- weight loss
- pelvic or abdominal mass associated pain
- abnormal uterine bleeding
- ascites
9
Q
differential diagnosis of ovarian cancer
A
- benign ovarian tumour/ cyst
- uterine or tubal mass
- endometriosis
- bowel mass
- primary peritoneal carcinoma
- secondary carcinoma
10
Q
diagnostic tests and results in ovarian cancer
A
- clinically- symptoms+age= likely
- Ca125- tumour marker
- USS + CT pelvis and abdo
- CXR- pleural effusion/ lung mets
11
Q
staging of ovarian cancer
A
1- limited to ovaries
2- involves one or both ovaries with pelvic extension and/or implants
3- involves one or both ovaries with microscopically confirmed peritoneal implants outside pelvis
4- one or both ovaries with distant mets
12
Q
treatment of ovarian cancer
A
- total abdominal hysterectomy and bilateral salpingo-oopherectomy (lymphadenectomy may be required also)
- chemotherapy for III/IV after surgery
- radiotherapy can be used in early disease
13
Q
what is endometrial cancer?
A
cancer of the endometrium that arises from the lining of the uterus and is an oestrogen dependent tumour
14
Q
risk factors for endometrial cancer
A
- prolonged exposure to unopposed oestrogen
- nulliparous
- late menopause
- obesity
- endometrial hyperplasia
- HNPCC
- PCOS
- diabetes
- tamoxifen
15
Q
what are the 2 types of andenocarcinoma’s seen in endometrial cancer?
A
type 1- oestrogen- dependent endometioid
type 2- oestrogen- independent non-endometrioid
16
Q
epidemiology of endometrial cancer
A
90% of women are over 50 %
17
Q
clinical presentation of endometrial cancer
A
- early sign- post menopausal/ abnormal uterine bleeding
- heavy/ irregular periods in pre-menopausal women
18
Q
diagnosis of endometrial cancer
A
- clinical examination usually normal
- Transvaginal US scan (looking for endometrial thickness >4mm)
- endometrial pippelle biopsy if thickness >4mm
- hysteroscopy
19
Q
treatment of endometrial cancer
A
total abdominal/ laparoscopic hysterectomy with bilateral salpingo-oopherectomy (with possible lymphadenopathy depending on stage)
- post op chemo
20
Q
what causes cervical cancer?
A
persistent infection with human papillomavirus (HPV)
21
Q
in cervical cancer, what is CIN?
A
CIN= Cervical Intraepithelial Neoplasia (also known as cervical dysplasia)
abnormal growth of cells on the surface of the cervix that could lead to cervical cancer
22
Q
what are the 3 grades of CIN?
A
CIN I= lower basal 1/3 of cervical epithelium
CIN II= affects <2/3 of cervical epithelium
CIN III= affects >2/3 of full thickness of epithelium
23
Q
who is screened for cervical cancer?
A
25-49- every 3 years
50-65- every 5 years
24
Q
what is dyskaryosis?
A
dyskaryosis= abnormal nucleus and refers to the abnormal epithelial cell which may be found in cervical sample.
graded from low to high based on degree of abnormality
25
what tests and management plan are used for a borderline/ mild dyskaryosis?
test for HPV
negative= back to routine
positive= colposcopy
26
what tests and management plan are used for a moderate dyskaryosis?
urgent colposcopy within 2 weeks
consistent with CIN grade ii
27
what tests and management plan are used for a severe dyskaryosis or a suspected invasive cancer?
urgent colposcopy within 2 weeks, consistent with CIN III
28
what is the management plan if an inadequate cervical smear is provided?
repeat smear
if consistently inadequate, then colposcopy
29
risk factors for cervical cancer
- persistence of HPV (high risk- HPV 16 and 18)
- early intercourse (under 16)
- multiple sexual partners
- smoking
- lower social class
- immunosuppression (HIV, post-transplant)
- COCP (combined oral contraceptive)
30
what are the 3 most common primary tumours seen in cervical cancer?
- bulky, ectocervical tumour (fills upper vagina)
- invasive, bulky tumour that can fill lower pelvis
- destructive, invasive tumour that erodes tissues, causing ulceration and excavation with infected, necrotic cavities
70%= squamous cell
31
most common ages cervical cancer is seen in
25-34
32
clinical presentation of cervical cancer
- abnormal vaginal bleeding (post coital)
- vaginal discharge
- post-micturition bleeding
- vaginal discomfort/ urinary symptoms
- haematuria
- polyuria
33
differential diagnosis of cervical cancer
- cervicitis
- dysfunctional uterine bleeding
- PID
- endometrial cancer
34
diagnosis of cervical cancer
- colposcopy/ cystoscopy- looking for irregular cervical surface
- punch biopsy
- bimanual examination
PET for staging
35
how is cervical cancer treated?
surgery- local excision (in a mild disease presentation) or full hysterectomy
chemotherapy- cisplatin
36
how is cervical cancer managed in pregnant women?
treatment delayed until a viable fetus can be delivered
in serious cases, therapeutic abortion may be necessary
37
aetiology of vulval cancer
- Vulval intreepithelial neoplasia (HPV)
- lichen sclerosis
- squamous (90%)
38
symptoms of vulval cancer
- vulvar itching
- persistent 'lump'
- post-menopausal bleeding
- pain passing urine
- past history of VIN
39
diagnosis of vulval cancer
USS
40
treatment of vulval cancer
surgery and radiotherapy
41
what causes vaginal cancer?
- HPV related
- metastatic spread- cervical, uterine, vulval
- pelvic radiotherapy
- long term vaginal inflammation from pessaries
commonly squamous
42
presentation, treatment and prognosis of vaginal cancer
bleeding
radiotherapy
poor prognosis 58% 5 year survival
43
what can cause atrophic vaginitis?
caused by falling oestrogen levels
- menopause
- oohrectomy
- anti-oestrogenic treatment- tamoxifen, aromatise inhibitors
- radio/chemotherapy
- post-partum
44
what changes of the mucosa and the vagina are seen in atrophic vaginitis?
- thinner, drier, less elastic, fragile mucosa
- inflamed vaginal epithelium
- change in vaginal pH (can result in UTI's)
- pelvic laxity and STRESS INCONTINENCE
45
symptoms of atrophic vaginitis
- vaginal dryness
- burning/ itching of the vagina
- dysparaeunia
- vaginal discharge
- post-coital and post-menopausal bleeding
- urinary symptoms- polyuria, nocturia, dysuria, UTI's, stress incontinence
46
clinical signs of atrophic vaginitis
- reduced pubic hair
- painful vaginal examination
- lack of vaginal folds
47
differential diagnosis of atrophic vaginitis
- genital infections
- uncontrolled diabetes
- local irritation due to soap etc
48
how is atrophic vaginitis diagnosed ?
- diagnosis of exclusion
| - TVS- transvaginal ultrasound to rule out pathology
49
treatment of atrophic vaginitis
- vaginal lubricants
- vaginal oestrogen
- HRT
50
definition of atrophic vaginitis
thinning, drying and inflammation of the vaginal mucosa and epithelium that occurs due to a decrease in oestrogen
51
what are fibroids?
common benign tumours of the smooth muscle cells of the uterine myometrium
- stimulated by oestrogen and progestogens
52
how are fibroids classified?
according to position in uterine wall
- intramural- within endometrium
- submucosal- growing into the uterine cavity
- subserosal- growing outwards from uterus (can be uterine, cervical, intraligamentous, pedunculated subserous)
53
aetiology of fibroids
genetic
54
risk factors for fibroids
- obesity
- early menarche
- afro-carribean
- age 30-40
- first degree relatives who had fibroids
- COCP
- pregnancy
55
clinical presentation of fibroids
- 50% asymptomatic
- prolonged, heavy periods
- pelvic pain
- recurrent miscarriage
- sub-fertility
56
differential diagnosis of fibroids
- dysfunctional uterine bleeding
- endometrial polyps
- pelvic inflammatory disease
- ovarian tumour
- pregnancy
57
diagnosis of fibroids
- pregnancy tests
- FBC- anaemia
- TVUS
- MRI
58
treatment of fibroids
- tranexamic acid (antifibrinolytic agent)
- GnRH agonists (goserelin)- shrinks fibroids
- ulipristal acetate- progesterone receptor modulator
- surgical- myomectomy
- uterine artery embolisation
- hysterectomy
59
what are the 3 types of ovarian cyst and which is most common?
- functional (24%)
- benign (70%)
- malignant (6%)
60
what are 3 benign neoplastic causes of ovarian cysts?
- benign epithelial neoplastic cysts
- benign neoplastic cystic tumours of germ cell origin
- benign neoplastic solid tumours
61
what are 3 benign fibrous causes of ovarian cysts?
- adenofibroma
- teratoma
- brenner tumour
62
what is a brenner tumour?
- rare ovarian tumour which displays in either a benign, borderline, proliferative or malignant variant
63
risk factors of ovarian cysts
- obesity
- tamoxifen therapy
- early menarche
- infertility
- dermoid cysts- teratoma
64
when are ovarian cysts most commonly seen (epidemiology)
pre-menopausal women
65
clinical presentation of ovarian cysts
- pain- dull ache, lower back pain, pain in lower abdo
- irregular vaginal bleeding
- swollen abdomen with palpable mass, dull to percussion
- torsion, infarction or haemorrhage- severe pain
- irregular vaginal bleeding
66
what findings on clinical examination would indicate the presence of an ovarian cyst?
- swollen abdomen with palpable mass that is dull to percussion
- ascites- malignancy
67
ovarian cysts- what can a hormone-secreting tumour cause?
- virilisation
- menstrual irregularities
- post-menopausal bleeding
68
differential diagnosis of ovarian cysts
- non-neoplastic functional cysts
- PCOS
- endometrioma
- ovarial malignant tumour
- bowel problems
- PID
69
diagnostic tests and results in ovarian cysts
- pregnancy test
FBC (infection, haemorrhage)
- TVS
- diagnostic laparoscopy
- CA125- ovarian cancer tumour marker
70
what is the risk of malignancy index (RMI) used for and how is it scored?
RMI= suspected ovarian cancer
is a product of the USS score (below), menopausal status and serum Ca125 levels
USS score (1 point for each)
- multi-ocular cysts
- solid areas
- metastases
- ascites
- bilateral lesions
71
what is a Rokitansky's Protuberance and what does it indicate?
a solid protuberance from a mature dermoid cysts- indicates a teratoma
72
management of a small, medium and large ovarian cyst
small (<50mm) does not require follow up
medium (50-70mm) yearly US follow up
larger= MRI
73
what surgery is required in the treatment of ovarian cysts?
cystectomy
oopherectomy
74
how does ovarian torsion present?
- sudden onset deep seated colicky pain
- iliac fossa pain radiating to loin, groin or back
- low grade fever
- pain may start to improve after 24h- ovary dies at this point
- vomiting and distress
75
what would an US show in a patient with ovarian torsion?
free fluid (oedema)- due to a cut off of venous supply
- whirlpool sign- wrapping of vessels around a central axis
- potential volvulus
76
how is ovarian torsion diagnosed and managed?
laparoscopy
77
what is Mittelschmerz?
- mid cycle pain associated with ovulation
- sharp onset
- settles over 24-48 hours
78
what is endometriosis?
chronic, oestrogen dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity
79
where is endometriosis most common?
- pelvic cavity
- uterosacral ligaments
- pouch of Douglas
- rectosigmoid colon
- bladder
- distal ureter
80
what is adenomyosis?
invasion of the endometrial tissue intro myometrium
81
aetiology of endometriosis
- retrograde menstruation
| - impaired immunity
82
risk factors for endometriosis
- early menarche
- late menopause
- delayed childbearing
- short menstrual cycles
- obstruction to vaginal outflow
- defects of uterus or fallopian tubes
- genetic predisposition
83
give 2 protective factors for endometriosis
- multiparity
| - COCP
84
what is the triad of symptoms classically seen in endometriosis?
- dysmenorrheoa
- deep dyspareunia
- cyclic/ chronic pelvic pain
85
other symptoms (other than the triad) in endometriosis
- subfertility
- dysuria
- bloating
- lethargy
- constipation
- lower back pain
86
differential diagnosis of endometriosis
- PID
- ectopic pregnancy
- torsion of ovarian cyst
- appendicitis
- primary dysmenorrhoea
- IBS
- uterine fibroids
87
diagnostic test and results in endometriosis
- laparoscopy w/ biopsy- gold standard
- bimanual examination- finds a fixed, retroverted uterus
- transvaginal ultrasound
- MRI
88
treatment of endometriosis
- pain- NSAID's
- suppression of ovarian function for 6 months- COCP, medroxyprogesterone acetate, Goserelin (GnRH agonist)
- surgery- laparoscopic excision or ablation, hysterectomy with salpingo-oopherectomy
89
what is polycystic ovarian syndrome (PCOS)?
a syndrome of polycystic ovaries in association with systemic symptoms causing reproductive, metabolic and psychological disturbances
90
what is the basic pathophysiology of PCOS?
excess androgens produced by theca cells of the ovaries due to:
- hyperinsulinaemia
- increased LH levels
91
in PCOS, how are excess androgens caused by hyperinsulinaemia?
- insulin resistance, weight gain leads to further insulin resistance
- this leads to increased androgen production and reduced production of sex hormone-binding globulin (SHBG) in the liver
- free testosterone is therefore raised
92
clinical presentation of PCOS
- oligomenorrheoa (<9 periods per year) and amenorrhoea
- infertility and subfertility
- signs of androgen production- acne, hirsutism, deepening voice, alopecia, male pattern balding, reduced breast size
- obesity/ difficulty losing weight
- psychological- mood swings, depression, anxiety, poor self esteem
- sleep apnoea
- acanthosis nigricans (due to insulin resistance)
93
differential diagnosis of PCOS
- thyroid disorder
- hyperprolactinaemia
- cushings syndrome
- acromegaly
- SE of medication
94
what triad of clinical signs and symptoms must be seen to diagnose PCOS?
- signs of excess androgen production
- oligomenorrhoea/ amenorrhoea
- cystic ovaries on US (12 or more on one ovary)
95
other than the triad, what other tests and results are seen in PCOS?
- testosterone normal/ raised
- SHBD- low
- LH levels- elevated
- insulin resistance (impaired glucose tolerance)
- normal prolactin
96
what is the Rotterdam criteria in PCOS?
SHOP
- string of pearls (cystic ovaries)
- hyperandrogenism
- oligomenorrhoea
- prolactin normal
97
treatment of PCOS
treat symptoms:
- hirsutism and acne- co-cyprindol
- menstrual irregularity- COCP
- insulin resistance= metformin
- fertility- clomifene, metformin
98
features of early menopause
- irregular periods
- vasomotor
- vaginal dryness
- poor concentration and fatigue
- headaches
- reduced libido
- joint pain
99
features of ongoing menoapuse
- GU- frequency, urgency, nocturia, UTI;s
- atrophic vaginitis
- post-menopausal bleeding (PMB)
100
features of late menopause
- osteoporosis
- dementia
- cvd
101
what is menopause?
permanent cessation of menstruation from loss of follicular activity
102
symptoms and consequences of menopause
- CV disease
- vasomotor symptoms- hot flushes, night sweats, palpitations
- urogenital problems- dysparaeunia, female sexual dysfunction, dryness, frequency, urgency, incontinence
- osteoporosis
103
what hormones are assessed in a patient with suspected menopause?
- increased FSH
| - anti-Mullerian hormone (direct measurement of ovarian reserve)
104
treatment of menopause
HRT
- treatment of hot flushes and night sweats- progesterone, clonidine, SSRI's
- osteoporosis- bisphosphonates, denossumab
105
benefits of HRT
- symptom management
- osteoporosis prevention
- colorectal cancer prevention
106
risks of HRT
- breast Ca if combined
- endometrial cancer if oestrogen only
- gallbladder disease
107
differential diagnosis of bleeding
- pregnancy- related- ectopic, hydatiform molar pregnancy, miscarriage
- infection- chlamydia
- vaginitis
- fibroids
- cervical ectropian
- endometritis
- cervical/ endometrial cancer
- iatrogenic- tamoxifen, missed dose of OCP, post- smear
108
postcoital bleeding differential diagnosis
- infection
- cervical/ endometrial polyps or cancer
- cervical ectropion
- trauma
109
differential diagnosis of pelvic pain
- ectopic
- miscarriage
- endometriosis
- UTI
PID
- ovarian cyst rupture
110
typical presentation of an ectopic pregnancy
female with a 6-8 wk amenorrhoea who presents with lower abdo pain, later develops vaginal bleeding
shoulder tip pain and cervical excitation may be seen
111
typical presentation of pelvic inflammatory disease
- pelvic pain
- fever
- deep dyspareunia
- vaginal discharge
- dysuria
- menstrual irregularities
- cervical excitation seen on examination
112
typical presentation of ovarian torsion
sudden onset unilateral lower abdominal pain.
nausea, vomiting, unilateral tender adexal mass on examination
113
typical presentation of miscarriage
vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
114
classic presentation of endometriosis
chronic pelvic pain
dysmenorrhoea
deep dyspareunia
subfertility
115
classic presentation of an ovarian cyst
unilateral dull ache
torsion or rupture leads to severe abdo pain
large cyst- swelling or pressure effects on bladder
116
classic presentation of a urogenital prolapse
seen in older women
sensation of pressure, heaviness and 'bearing down'
urinary symptoms- incontinence, frequency, urgency
117
what is the hypothalamic-pituitary axis?
GnRH- FSH- LH- oestrogen from ovaries
118
describe the normal menstrual cycle
1-4- menstruation
5-13- proliferative phase
14-28- luteal/ secretory phase
119
describe what happens between days 1-4 (menstruation) in the menstrual cycle
- hormone support withdrawn
- endometrial shed (<80ml blood loss)
- some myometrial contractions can be painful
120
describe what happens between days 5-13 (proliferative phase) in the menstrual cycle
- GnRH stimulates FSH and LH
- LH induces follicular growth- produces oestradiol and inhibin. this inhibits FSH with negative feedback
- oestradiol continues to increase- endometrium thickens and reforms
- positive feedback of LH causes ovulation
121
describe what happens between days 14-28 (luteal/ secretory phase) in the menstrual cycle
- follicle becomes the corpus luteum- produces more progesterone than oestradiol
- results in increasing blood supply and enlargement of cells in endometrium
- corpus luteum collapses near end if not fertilised. Oestrogen and progesterone levels fall
122
what is premenstrual syndrome and what are the symptoms and management of it?
the emotional and physical symptoms that women experience prior to menstruation (in luteal phase)
- symptoms- anxiety, stress, fatigue, mood swings
- management- lifestyle, COCP and SSRI's if severe
123
what is the definition of menorrhagia?
excessive menstrual blood loss (>80ml) within a normal menstrual cycle, interfering with the womans physical, emotional and social quality of life
124
causes of menorrhagia
- majority have no pathology
- 30% uterine fibroids
- 10% polyps
- PID, ovarian tumours, endometrial/ cervical malignancy
- hypothyroidism
- coagulation defects- Von-Willebrand or ITP
125
how is menorrhagia assessed?
- FBC, TSH, coag
- transvaginal ultrasound- assesses endometrium for masses
- if pt if >40 and the mass is >10mm, endometrial biopsy with hysteroscopy
126
management of menorrhagia
medical
1st- IUS (mirena)
2nd- tranexamic acid, NSAID, COCP
3rd- progestogen
surgical:
- endometrial ablation
- resection of fibroids/ polyp
- uterine artery embolisation
127
what is intermenstrual bleeding?
vaginal bleeding at any times during the menstrual cycle other than during normal menstruation
128
causes of intermenstrual bleeding
- anovulatory cycles
- fibrouds, polyps etc
- if older woman, consider malignancy
129
causes of post-coital bleeding
- infection
| - cervical ectropion, polyps or carcinoma
130
what is amenorrhoea?
abscence of menstruation
131
caues of amenorrhoea
- primary- Turner's syndrome, andorgen insensitivity syndrome, congenital malformations of genital tract, congential adrenal hyperplasia
- secondary- is when previously normal mensturation ceases for >6 months
132
what is oligomenorrhoea?
menstruation occurring every 35d- 6 months
133
causes of oligomenorrhoea
- physiological- pregnancy, menopause, lactation
- hypothalamic hypogonadism
- hyperprolactinaemia due to hypothyroidism
- ovarian causes- PCOD, ovarian insufficiency, tumours
134
investigations in Amenorrhoea
- BhCG (pregnancy)
- FSH/LH
- Prolactin
- TFT
- Testosterone
135
in amenorrhoea, what would a low FSH/ LH indicate?
hypothalamic pituitary ovarian axis problem
136
in amenorrhoea, what would a high FSH/ LH indicate?
premature ovarian failure
137
treatment of premature ovarian failure in amenorrhoea
- cannot be reversed
| - HRT to prevent oestrogen deficiency and therefore prevent osteoporosis
138
in amenorrhoea, how is a malformation of the hypothalamic pituitary axis treated?
- if mild- sufficient activity to stimulate enough oestrogen to produce an endometrium
- severe- GnRH analogues
139
if a woman who has amenorrhoea is asking for fertility, what would be provided?
clomifene
140
what is Lichen Sclerosis?
chronic inflammatory dermatosis that affects the skin of the anogenital region in women or the glans penis and foreskin in men
141
aetiology of Lichen Sclerosis
autoimmune induced
142
clinical presentation of Lichen Sclerosis (in males and females)
- white thickened patches which may have ecchymosis, hyperkeratosis or bullae
- females- itchy, pain, perianal lesions, white lesions (figure 8 around vulvula and anus), shrinking of labia
- men- soreness, painful erections, dysuria
143
differential diagnosis of Lichen Sclerosis
- child sexual abuse
- vitiligo
- scleroderma
- lichen planus
144
treatment of lichen sclerosis
topical steroids- clobetasol propionate
145
what is an ectopic pregnancy and where do they commonly occur?
a pregnancy that occurs anywhere outside the uterus
- 97% in fallopian tubes
- 2-3% occur as interstitial ectopic pregnancies
146
risk factors of an ectopic pregnancy
IVF, age, PID, previous ectopic, smoking, adhesions from infection, inflammation from endometriosis, previous tubal surgery
147
clinical presentation of an ectopic pregnancy
```
abdominal/ pelvic pain
amenorrhoea (6-8 weeks)
vaginal bleed
pelvic tenderness
dizziness, fainting, syncope
rebound tenderness
```
SHOULDER TIP PAIN
148
differential diagnosis of an ectopic pregnancy
- threatened miscarriage
- appendicitis
- bowel ischaemia
149
diagnosis of an ectopic pregnancy
- pregnancy test- no rapid decline of BhCG
- transvaginal USS
- empty uterus w/ positive pregnancy test
- cervical excitation on pelvic exam
150
treatment of an ectopic pregnancy
- initial- FC, crossmatch, IV fluids
| - if foetal heartbeat- salpingectomy/ salpingotomy
151
what is pelvic inflammatory disease?
- general term for infection of the upper female genital tract
152
causes of PID
- gonorrhoea + chlamydia
- vaginal anaerobes
- sti
- pregnancy
- miscarriage
- uterine instrumentation
153
risk factors for developing PID
- young
- new sexual partner/ multiple sexual partners
- lack of barrier contraception
- lower socio-economic group
- IUD present
154
clinical presentation of PID
- bilateral lower abdominal pain
- deep dyspareunia
- abnormal vaginal bleeding
- vaginal or cervical purulent discharge
- abdo tenderness
- fever
155
presentation of acute salpingitis/ PID
- fever, tachycardia
- lower abdo tenderness
- cervicitis
156
differential diagnosis of PID
- appendicitis
| - ectopic pregnancy
157
diagnosis of PID
- pregnancy test
- cervical swab
- raised ESR and CRP
- biopsy
- USS
158
treatment of clinically severe PID
- ceftriaxone 500mg
- doxycycline
- metronidazole
159
what is dysmenorrhoea?
Dysmennorhoea is associated with high levels of what?
painful menstruation associated with high prostaglandin levels in the endometrium due to contraction and uterine ischaemia
160
primary and secondary causes of dysmenorrhoea?
primary- no organic cause
secondary- pelvic pathology- fibroids, adenomyosis, endometriosis, PID
161
treatment of primary dysmenorrhoea
NSAIDS and COCP
162
What is a genitourinary prolapse?
descent of one or more of the pelvic organs including the uterus, bladder, rectum small/ large bowel or vaginal vault
resulting in protrusion of the vaginal walls
163
risk factors of genitourinary prolapse
```
increasing age
vaginal delivery
increasing parity
high BMI
spina bifida
pelvic mass
menopause
```
164
pathophysiology of GU prolapse
occurs when support structure (levator ani muscles and endopalvic fascia) is damaged- trauma etc
165
clinical presentation of an anterior compartment GU collapse
urethrocele- prolapse of urethra into vagina
cystocele- prolapse of bladder into vagina
cystourethrocele- both of the above
166
clinical presentation of a middle compartment GU collapse
- uterine prolapse- descent of uterus into vagina
- vaginal vault prolapse- descent of the vaginal vault post-hysterectomy
- enterocele- herniation of pouch of Douglas into the vagina
167
clinical presentation of a posterior compartment GU collapse
rectocele- prolapse of the rectum into the vagina
168
stages of a genitourinary prolapse
0- no prolapse
1- more than 1cm above hymen
2- within 1cm proximal or distal to the plane of the hyman
3- more than 1cm below the plane of the hymen but protrudes no further than 2cm less than the total length of vagina
4- complete eversion of the vagina
169
features of asymptomatic genitourinary prolapse
sensation of dragging down, pressure, fullness or heaviness
sensation of bulge
discomfort
spotting
IF ANTERIOR- incontinence, urgency, frequency
170
diagnostic tests and results in a GU prolapse
- history and examination- sims speculum
171
treatment of a GU prolapse
- conservative- aims to reduce intrabdominal pressure (lose weight, stop smoking, treat cough, stop constipation, pelvic floor exercises)
- vaginal pessary insertion
- surgery- hysterectomy, colporrhaphy
172
what are the 2 types of incontinence?
urgency- overactive bladder (involuntary detrusor muscle bladder contractions)
stress- sphincter weakness (detrusor pressure > closing pressure of urethra)
173
symptoms of an overactive bladder
```
urgency
frequency
nocturia
'key in door'
ensuresis
```
174
symptoms of stress incontinence (what brings it on?)
cough, laughing, lifting, exercise, movement
175
causes of stress incontinence
- menopause- low oestrogen results in weakening pelvic support
- radiotherapy, congenital weakness, pelvic surgery
176
'simple assessments' of incontinence
- Dipstick/urinalysis – UTI check
- MSU (Midstream urine sample for urinalysis below)
```
-FVC (frequency volume chart) (urine diary)
▪ Frequency and quantity of urination
▪ Frequency and quantity of leakage
▪ Fluid intake
▪ Diurnal variation
```
- RU (residual urine measurement)
▪ In and out catheter
▪ USS
177
what is the ePAQ questionarre?
determines impact on life of variety of issues to determine management plan (of incontinence)
- Urinary- pain / voiding / overactive bladder / stress
incontinence / QoL
- Vaginal- Pain / capacity / prolapse / QoL
- Bowel- IBS / constipation/ continence / QoL
- Sexual- Urinary / bowel / vaginal / dyspareunia / overall
sex life
178
what are the treatment options of incontinence?
- lifestyle- reduce caffiene, weight loss, smoking cessation
| - containment- bladder bypass (catheters), vaginal support devices
179
treatment of stress incontinence
- pelvic floor training
- SNRI- duloxetine
- surgery
180
treatment of an overactive bladder
- bladder drills
- anticholinergics
- antimuscarinics- solifenacin, oxybutynin
- adrenergic agonist- mirabegron
- botox
181
what is a rectocele?
prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
182
symptoms of a rectocele
- constipation
| - difficulty with defecation
183
how is a rectocele managed?
posterior repair
184
what is a cystocele?
prolapse fo the anterior vaginal wall, involving the bladder
- usually associated with prolapse of the urethra, in this case it is referred to as a cysto-urethrocele prolapse
185
how does a cystocele/ cysto-urethrocele present clinically?
- urinary urgency and frequency
- incomplete bladder emptying
- urinary retention/ reduced flow
186
how is a cystocele managed?
anterior repair
187
what is a vesicovaginal fistula?
opening from the vaginal tract into the urinary tract
188
aetiology of a vesicovaginal fistula
- trauma
- abdo hysterectomy
- vaginal hysterectomy
- vaginal/ bladder biopsy
- radiation therapy
189
how does a vesicovaginal fistula present clinically?
continuous incontience presenting after recent pelvic trauma/ surgery
190
what is a hydatidiform mole?
growth of an abnormal fertilised egg
191
how does a hydatidiform mole present clinically?
- irregular 1st trimester vaginal bleeding
- large uterus for dates
- exaggerated pregnancy symptoms- hyperemesis, hyperthyroidism, pre-eclampsia
192
how does a complete hydatidiform mole present on an USS?
'snowstorm appearance'
193
how is a hydatidiform mole managed (complete and partial)?
complete- surgical evacuation, give oxytocin to reduce haemorrhage risk
partial- medical evacuation if small enough
194
what is Adenomyosis?
presence of endometrial glands and stroma within the myometrium
195
what symptoms would a patient with adenomyosis present with clinically and how would this present on examination?
symptoms- dysmennorhoea, menorrhagia, dyspareunia, cyclical pelvic pain
usually presents after pregnancy
O/E- enlarged 'boggy' uterus
196
how is adenomyosis diagnosed?
histopathology
197
how is a patient with adenomyosis managed?
continuous OCP's- for symptoms
- only curative Tx is a hysterectomy
198
what is androgen insensitivity syndrome?
mutation in androgen receptor gene results in resistance to androgens in target tissues- so body does not respond to male sex hormones
- X linked recessive pattern-
- patient is 46XY but appears female
199
in a patient with complete androgen insensitivity syndrome, how do their genitalia present?
- female external genitalia
- short blind-ending vagina
- absent uterus and fallopian tubes
- normal breast development
- sparse pubic and axillary hair
- undescended testes
200
how does a patient with partial androgen insensitivity syndrome present clinically?
'under-masculinisation'
ambiguous genitalia
201
when and how does mild androgen insensitivity syndrome present?
will not present until puberty
high pitched voice and gynaecomastia
202
how is androgen insensitivity syndrome managed
gonadectomy and HRT
203
what is dysfunctional (abnormal) uterine bleeding?
irregular uterine bleeding that occurs in the absence of recognisable pelvic pathology or pregnancy
204
aetiology of dysfunctional uterine bleeding
- PCOS
- endometriosis
- polyps/ fibroids
- STD
- Warfarin, spironolactone, OCP
205
what is an endometrial polyp and what % of these are malignant?
focal overgrowth of the endometrium
1% are malignant
206
how are endometrial polyps treated?
resection during hysteroscopy
send for histological assessment
207
what is a prolactinoma and how are they classified?
commonest pituitary tumour seen in pregnancy
macroprolactinoma= >1cm
microprolactinoma= <1cm
208
outside of pregnancy, diagnosis of a prolactinoma is based on serum prolactin level, why is this not the case in pregnancy?
how are they diagnosed in pregnancy instead?
during pregnancy, serum prolactin levels rise significantly anyways so this is not useful
imaging- CT etc
209
clinical features of a prolactinoma?
- amenorrhoea
- galactorrhoea
- headache
- visual field defects- bitemporal hemianopia
- diabetes insipidus
210
what medications that are normally used to manage a proclactinoma should be stopped in a pregnant lady?
dopamine receptor agonists- cabergoline and bromocriptine (bromocriptine can be restarted if there is a fear the tumour is expanding)
211
how are prolactinomas in pregnancy managed?
surgery- but delay until after delivery unless critical
