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Women's health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is the first system used for testing for cervical cancer screening

A

HPV first system

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2
Q

Negative hrHPV results: how to manage- the steps

A

the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells

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3
Q

Positive hrHPV - cytology is abnormal- what to do

A

Colposcopy

this includes the following results:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
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4
Q

Positive hrHPV, cytology is normal

A

(i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy

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5
Q

What to do is HPV sample is inadequate

A

Repeat the sample within 3 months

- If two consecutive inadequate samples then- colposcopy

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6
Q

Risk factors for urinary incontinence

A 
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
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7
Q

Classification for urinary incontinence

A

Overactive bladder (OAB)/urge incontinence: due to destrusor overactivity
- Stress incontinence: leaking small amounts when coughing or laughing
Mixed incontinence: both urge and stress
Overflow incontinence: due to bladder outlet obstruction: due to prostate enlargement

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8
Q

Initial investigation of urinary incontinence

A
  • Bladder diaries should be completed for a minimum of 3 days
    Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercises)
    Urine dipstick and culture
    Urodynamic studies
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9
Q

Management of Urinary continence if urge incontinence is predominant

A

Bladder retraining - minimum of 6 weeks
Bladder stabilising drugs- antimuscarinics first-line
NICE recommend- oxybutynin- imediate release, tolterodine (immediate release) or darifenacin (once daily)
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

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10
Q

Management of urinary incontinence is stress incontinence is predominant

A

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction

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11
Q

Risk factors for endometrial cancer

A 
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal carcinoma
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12
Q

Features of endometrial cancer

A

postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features

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13
Q

Investigation of endometrial cancer

A

women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy

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14
Q

Management of endometrial cancer

A

Localised diseas is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
High-risk disease have post-operative radiotherapy
Progestogen therapy used in frail elderly women not suitable for surgery

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15
Q

Side effects of hormone replacement therapy: adverse effects

A
  • Nausea
  • Breast tenderness
  • Fluid retention and weight gain
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16
Q

Potential complications of HRT - increased risk of breast cancer

A

Increased risk of breast cancer
Increased by addition of a progestogen
Increased risk of cancer related to the duration of use
Risk of breast cancers begins to decline when HRT is stopped and by 5 years it reaches same level as women never taken HRT

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17
Q

HRT: increased risk of endometrial cancer

A

oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously

18
Q

HRT: increased risk of VTE: how?

A

Increased by the addition of a prostetogen
Transdermal HRT does not appear to increase the risk of VE
Increased risk fo stroke
Increased risk of ischaemic heart disease if taken more than 10 years after menopause

19
Q

Gold standard investigation of endometriosis

A

Laparoscopy

20
Q

Management of the clinical features

A

NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried

21
Q

Secondary treatments of endometriosis

A

GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

22
Q

Pathophysiology of ovarian cancer

A

around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers

23
Q

Risk factors of ovarian cancer

A

family history: mutations of the BRCA1 or the BRCA2 gene

many ovulations*: early menarche, late menopause, nulliparity

24
Q

Clinical features of ovarian cancer

A 
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
25
Q

Investigations

A

CA125
NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
a CA125 should not be used for screening for ovarian cancer in asymptomatic women
ultrasound

26
Q

Management of ovarian cancer

A

usually a combination of surgery and platinum-based chemotherapy

27
Q

Prognosis of ovarian

A

80% of women have advanced disease at presentation

the all stage 5-year survival is 46%

28
Q

Hyperemesis gravidarum- incidence in pregnancy

A

Most common between 8 to 12 weeks but may persist up to 20 weeks

29
Q

Associations of Hyperemesis gravidarum

A 
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
30
Q

Complications of hyperemesis gravidarum

A 
Wernicke's encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
fetal: small for gestational age, pre-term birth
31
Q

Management

A

antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
ondansetron and metoclopramide may be used second-line
metoclopramide may cause extrapyramidal side effects
ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration

32
Q

Complications

A 
Wernicke's encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
fetal: small for gestational age, pre-term birth
33
Q

What is an ectopic pregnancy

A

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

34
Q

Presentation of ectopic pregnancy

A

Female with a history of 6-8 weeks amenorrhoea presents with lower abdominal pain and later develops vaginal bleeding

35
Q

Symptoms of ectopic pregnancy

A

lower abdominal pain
due to tubal spasm
typically the first symptom
pain is usually constant and may be unilateral.
vaginal bleeding
usually less than a normal period
may be dark brown in colour
history of recent amenorrhoea
typically 6-8 weeks from the start of last period
if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
dizziness, fainting or syncope may be seen
symptoms of pregnancy such as breast tenderness may also be reported

36
Q

Examination findings of ectopic pregnancy

A 
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
37
Q

Investigation for ectopic pregnancy

A

Transvaginal ultrasound

38
Q

Investigations of heavy menstrual bleeding

A

FBC

Transvaginal Ultrasound scan if symptoms

39
Q

Treatment for heavy menstrual bleeding not requiring contraception

A

Either mefanamic acid 500mg tds or tranexamic acid 1g tds

40
Q

Treatment for heavy menstrual bleeding requiring contraception

A

Intrauterine system (Mirena) should be considered first-line
Combined oral contraceptive pill
Long-acting progestogens

Women's health (2 decks)

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