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Gynaecology conditions Flashcards

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1
Q

What is a fibroid?

Who are they more commonly seen in?

A

Benign smooth muscle tumour of uterus

More common in afro-caribbeans

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2
Q

What is the pathogenesis of fibroids?

A

Poorly understood but growth thought to be stimulated by oestrogen

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3
Q

What are the types of fibroids?

A

Subserosal - protrude into serial surface of uterus, can be pedunculated

Intramural - most common, confined to myemetrium

Submucosal - Develop immediately beneath endometrium and protrude into uterine cavity

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4
Q

How do fibroids present?

A

Often asymptomatic

Menorrhagia
Pelvic pain
Bloating/distention
Pressure –> constipation, urinary frequency and urgency
Fertility problems
!!Polycythaemia - due to the fibroids producing erythropoietin!!

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5
Q

How would fibroids present on examination?

A

Solid mass

Enlarged NON-TENDER uterus may be palpated

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6
Q

How are fibroids investigated?

A

Transvaginal USS

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7
Q

What are the medical options for fibroid management?

A

Symptom control:
IUS (mirena), NSAIDs, TXA, COCP

GnRH agonist (goserelin) - pre-op to reduce size
Ulipristal (selective progesterone receptor modulator) - reduce fibroid size and help with menorrhagia
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8
Q

What surgical options are there for fibroid management?

A

Myemectomy - if want to preserve uterus
Hysterectomy
Uterine artery embolisation

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9
Q

What normally happens to fibroids in menopause?

A

Regress

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10
Q

What complications are associated with fibroids?

A

Infertility

In pregnancy - miscarriage, fetal malpresentation, IUGR

Red degeneration - haemorrhage into fibroid

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11
Q

How does red degeneration (complication of fibroids) present?

A

Fever, pain and vomiting

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12
Q

What is endometriosis?

A

Endometrial tissue located at sites other than the uterine cavity

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13
Q

What are the most common sites for endometriosis to affect?

A

Lining of pelvis
Uterosacral ligament
Bladder
Ovary

Others include: intestines, Fallopian tubes, ureter, cervix etc.
Can go as far as lungs

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14
Q

What is the pathophysiology of endometriosis?

A

Retrograde menstruation - endometrial cells travel backwards from the uterus via the fallopian tubes to pelvic organs

Tissue sensitive to oestrogen so bleed during menstruation

Repeated inflammation and scarring lead to adhesions

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15
Q

What is the mean age of endometriosis diagnosis?

A

25-40yo

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16
Q

How does endometriosis present?

A

Cyclical pelvic pain beginning the day before menstruation

Dysmenorrhoea + dyspareunia + dysuria + dyschezia (painful bowel motions)

May be subfertility

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17
Q

What are the main risk factors for endometriosis?

A 
Early menarche
Short cycle
Long bleed time
Heavy bleeding
Family history
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18
Q

What can be seen on examination in endometriosis?

A

Fixed retroverted uterus
Uterosacral ligament nodules
General tenderness especially in the posterior vaginal fornix

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19
Q

How is endometriosis investigated? What are the results of these?

A

Laparoscopy

  • Chocolate cysts
  • Adhesions
  • Peritoneal deposits

Pelvis USS - kissing ovaries can be seen (adhesions)

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20
Q

What are the key differentials for endometriosis?

A

PID
Ectopic
Fibroids
IBS

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21
Q

How is endometriosis managed?

A
  1. NSAIDs +/- paracetamol
  2. COCP or progesterone’s (POP, injected or IUD)
  3. GnRH analogues, laser ablation or excision.
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22
Q

What is adenomyosis?

A

Functional endometrial tissue within myometrium of uterus

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23
Q

How does adenomyosis present?

A

Menorrhagia
Dysmenorrhoea - progress from cyclical to daily
Deep dyspareunia
Irregular bleeding

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24
Q

Who does adenomyosis affect?

A

Multiparous women at end of their reproductive life

Associated with fibroids

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25
What is the pathophysiology of adenomyosis?
Thought to occur when endometrial connective and supportive tissue allowed to interact with myometrium after damage (childbirth, c-section, surgery) Can occur anywhere but most often posterior uterine wall Tissue responsive to hormones
26
How is adenomyosis diagnosed?
Histological diagnosis after hysterectomy
27
How is adenomyosis investigated? What do they show?
Transvaginal USS - globular uterine configuration - Poorly defined endometrial-myometrial interface - anterior-posterior myometrium asymmetry Hysteroscopic biopsy MRI - thickening of endo-myometrial junction zone
28
What is observed on examination of a lady with adenomyosis?
Enlarged, tender, boggy uterus
29
How is adenomyosis managed curatively?
Hysterectomy
30
What is the medical management for adenomyosis?
Similar to endometriosis - NSAIDs - COCP - Progesterone - oral, IUS, depot - GnRH agonist - Aromatase inhibitors
31
What surgical option is there for adenomyosis apart from hysterectomy?
Uterine artery embolisation - stop blood supply to adenomyosis causing it to shrink
32
What is a cervical polyp?
Benign growths due to hyperplasia of the endocervical epithelium They arise from the inner surface of the cervix
33
What age is peak incidence of cervical polyps?
50-60 years old
34
How do cervical polyps present?
Generally asymptomatic and picked up on cervical screening Can cause abnormal vaginal bleeding: - Menorrhagia - Post-coital - Intermenstrual - Post-menopausal
35
How are cervical polyps diagnosed?
``` Histological examination after removal May also do: - Swab for infection - Cervical smear - CIN - USS if symptoms persist after removal ?endometrial polyp ```
36
How are cervical polyps managed?
Removal - small risk of malignant transformation Can be done in primary care - twist polypectomy forceps Larger/hard to access need diathermy in colposcopy clinic
37
What is cervical ectropion? | Who it is common in?
Eversion of the endocervix - metaplasia of stratified squamous (ectocervix) to glandular simple columnar (endocervix) Common in teenagers, pregnancy and those on COCP
38
What causes the metaplasia seen in ectropion?
High oestrogen levels
39
How does cervical ectropion present?
Commonly asymptomatic Discharge - increased glandular tissue Post-coital bleeding - fine blood vessels in epithelium
40
How is cervical ectropion investigated?
Rule out more sinister diagnosis: - Swabs - infection - Smear - CIN - Biopsy - if lesions seen
41
How does a cervical ectropion appear on examination?
Ring of reddish tissue around external os
42
How are cervical ectropion's managed?
Stop any oestrogen containing medication | Cryotherapy can be used
43
What happens in PCOS?
Excess androgen production and multiple immature follicles (cysts) in the ovaries
44
What happens to the hormones in PCOS?
Increased frequency of GnRH pulses = increased LH = ovarian production of androgens Insulin resistance means increased insulin secretion = suppression of sex hormone binding globulin = more free circulating androgens Free circulating androgens suppress LH surge so follicles develop in ovaries but maturation arrest at early stage so remain visible as cysts in ovaries
45
How does PCOS present?
``` Oligo/amenorrhoea Infertility Chronic pelvic pain Acne Male pattern baldness Hirsutism Obesity Depression Acanthosis nigricans ```
46
What are the main risk factors for PCOS?
Diabetes | Family history
47
What are the main differentials for PCOS?
Hypothyroidism Hyperprolactinaemia Cushing's
48
What is the Rotterdam criteria for PCOS?
Need 2/3 for diagnosis: >=12 cysts or ovarian volume >10cm3 Oligo/anovulation Clinical or biochemical signs of hyperandrogenism
49
What hormones would be raised in PCOS?
Testosterone LH LH:FSH
50
What hormones would be low in PCOS?
Sex Hormone Binding Globulin | Progesterone
51
How is amenorrhoea in PCOS managed? Why is this done?
COCP to induce at least 3 bleeds per year Anovulatory cycles due to unopposed oestrogen lead to endometrial hyperplasia which can become malignant so bleeding must be induced
52
How is weight controlled in PCOS?
Orlistate - can improve insulin resistance
53
How is hirsutism in PCOS managed?
1. COCP or co-cyprindiol 2. Eflornithine topical cream 3. Antiandrogens - spironolactone, finasteride
54
How is infertility in PCOS managed? (2 drugs) | What are the risks of on of these drugs?
Clomifene - associated with multiple pregnancy, ovarian hyper stimulation syndrome and ovarian cancer Metformin - particularly good in obese patients
55
Where are the bartholin's glands located?
Deep to posterior aspect of labia majora Also called greater vestibular glands
56
Where do the bartholin's glands open?
Either side of vaginal orifice Within vestibule - 4 o clock and 8 o clock Just below hymenal ring
57
What is the function of the bartholin's glands?
Secrete mucus to lubricate vagina
58
What is the pathophysiology of a bartholin's cyst?
Build up of mucus secretions can cause duct of gland to become blocked - cyst develop Cyst can become infected and if untreated develop into abscess
59
What organisms can infect a bartholin's cyst?
Usually aerobic E.Coli, MRSA and STI's most common
60
Who gets bartholin's cysts?
Nulliparous women of reproductive age
61
How do bartholin's cysts present?
Often asymptomatic Vulval pain on sitting or walking Superficial dyspareunia Soft fluctuant and non tender mass
62
How do bartholin's abscesses present?
Acute onset of pain Difficulty passing urine Hard mass and surrounding cellulitis
63
How are bartholin's cysts diagnosed?
Clinical diagnosis If >40yo a biopsy should be done - exclude vulval malignancy If signs of STI - swab
64
How are bartholin's cysts managed?
Warm bath - aid spontaneous rupture in small asymptomatic cysts NO SIMPLE INCISION AND DRAINAGE - reaccumulate Either word catheter or marsupialisation
65
Describe the use of word catheters for bartholin's cysts
Catheter inserted into cyst and left in place for 4-6 weeks Done under local anaesthetic Risks - recurrence, dyspareunia, scarring
66
Describe how marsupialisation is used for bartholin's cysts
Incision into cyst allow drainage. Cyst wall everted and sutured to vaginal mucosa General anaesthesia Risks - hameatoma, dyspareunia
67
What is lichen sclerosis?
Chronic inflammatory skin disease which has the potential to progress to squamous cell carcinoma
68
What is the epidemiology of lichen sclerosis?
Bimodal incidence - prepubescent girls and post-menopausal women
69
What is the pathophysiology of lichen sclerosis?
Atrophy of the epidermis - thin stratified squamous epithelium Band-like infiltrate of chronic inflammatory cells beneath epithelial layer
70
How would you investigate lichen sclerosis?
Biopsy Only needed if suspicious of vulval cancer or not responding to treatment
71
How does lichen sclerosis present?
White atrophic patches on skin - anogenital region !!Itching!! Skin may fissure/erode - pain Dyspareunia
72
What would be seen on examination of a woman with lichen sclerosis?
``` White well defined lesions Evidence of adhesions and/or scarring: - clitoral hood fusion - fusion of labia minora to labia majora - posterior fusion - loss of vaginal opening ```
73
What are the main differentials for lichen sclerosis?
Vitiligo Vulval cancer Candida
74
How would you manage lichen sclerosis?
Topical steroids and emollients- clobetasol propionate
75
Why is follow up important for lichen sclerosis?
Risk of developing squamous cell carcinoma (2-5% lifetime risk)
76
What are the types of ovarian cyst?
Simple - fluid only | Complex - can vary but may be irregular, solid, have septations or a vascular supply
77
What is a dermoid cyst?
Also called mature teratoma or benign germ cell Lined with epithelial tissue - hair, teeth, fat etc. Most likely to torsion
78
What is an endometrioma?
"chocolate cysts" seen in patients with endometriosis Blood in cyst
79
What type of cyst is a follicular cyst? What causes it?
Commonest type of functional cyst/physiological Non-rupture of dominant follicle or failure of atresia of non-dominant follicle
80
What type of cyst is a corpus luteal cyst? What causes it? What complication can it lead to?
Functional cyst/physiological Corpus luteum doesn't break down, can fill with blood or fluid and become cyst Can cause intra-peritoneal bleeding
81
What are the types of benign epithelial cyst? Which is most common? Describe them?
Either mucinous cystadenoma or serous cystadenoma Serous is most common Mucinous - very large, can rupture and cause rare type of peritoneal cancer, common 20-40yo Serous - bear resemblance to serous carcinoma, common 40-50yo
82
How do ovarian cysts present?
Asymptomatic mostly - found incidentally Dull ache in lower abdomen + back ache Dyspareunia Pressure effects on bladder Acute events - torsion or rupture
83
How do ovarian cysts present acutely?
Torsion - severe abdominal pain and fever | Rupture - peritonitis and shock
84
What are the risk factors for ovarian cysts?
Obesity Tamoxifen Early menarche
85
What investigations are requested for an ovarian cyst?
Transvaginal USS 1. Biopsy 2. Fine needle aspiration (second line as risk of spillage and malignancy spread) CA125 not needed in premenopausal women LDH, AFP, Beta HCG should be measured if <40yo
86
What complications are associated with ovarian cysts?
Torsion Rupture Haemorrhage Infertility - surgical management
87
How are simple cysts in pre-menopausal women managed?
Malignancy unlikely - watchful waiting | Most disappear within 3 menstrual cycles
88
How are larger cysts in pre-menopausal women managed?
>5cm, complex or concern for malignancy Surgical removal - cystectomy or oophorectomy
89
How are cysts managed in post menopausal women?
Risk of malignancy index (RMI) based RMI <25 - 1yr follow up USS and CA125 (<5cm) RMI 25-250 - bilateral oophorectomy and if malignancy found then staging req. (with completion of surgery) RMI > 250 - Referral for staging laparotomy
90
How would an ovarian torsion present?
Often acute onset pain with exercise | N&V
91
What would an USS of a tortioned ovary show?
``` whirpool sign free fluid (due to venous/lymph obstruction leading to transudate from the ovary leaking out) ```
92
What constitutes a complex cyst?
solid mass within cyst | multi-loculated

Obstetrics and Gynaecology (21 decks)

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