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Gynaecology step 2 Flashcards

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1
Q

estradiol, FSH and LH in central vs peripheral precocious puberty

A

central causes elevated estradiol, FSH and LH

peripheral causes increased estradiol but low FSH and LH

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2
Q

describe the 2 different investigations carried out if precoocious puberty is suspected

A

bone age
- within 1 yr of chronological age = puberty hasnt started/about to start
- >2 years of chronological age = puberty recently started with rapid progression or started > 1 year ago

GnRH agonist (leuprolide) stimulation test
- elevated LH = central
- no change in LH = peripheral

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3
Q

what investigation is used to determine whether central or peripheral precocious puberty

A

GnRH agonist (leuprolide) stimulation test
- if elevated LH = central
- if no change in LH = peripheral

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4
Q

1st line therapy for central precocious puberty

A

GnRH agonist - Leuprolide

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5
Q

treatment for McCune Albright syndrome

A

causes peripheral preococious puberty
estrogen blockers (tamoxifen), drugs that decrease estrogen synthesis (aromatase inhibitors) or synthesis blockers (ketaconazole)

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6
Q

1st line investigation for primary or secondary amenorrhoea

A

pregnancy test

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7
Q

what test is used to investigate the cause of secondary amenorrhoea and describe the results of the test

A

progestin challenge (10 day progestin)

positive (withdrawal bleed) = noncyclic gonadotrophin secretion i.e. PCOS

negative (no withdrawal bleed) = uterine abnormality or low estrogen

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8
Q

what are the indications for endometrial biopsy for menorrhagia

A

if endometrial thickness 4mm or more and is menopausal or > 45 years old
if > 35yrs with risk factors such as diabetes or obesity

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9
Q

treatment for acute uterine bleeding

A

IV estrogen
consider surgical D&C if > 45yrs and have high cardiovascular risk and/or endometrial sampling is indicated

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10
Q

endometrial biopsy shows hyperplasia without atypia. what is the next step?

A

treat heavy uterine bleeding with medroxyprogesterone acetate or IUD
repeat biopsy in 3-6 months

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11
Q

gonadotrophin levels found in PCOS

A

LH:FSH > 2:1

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12
Q

female patient with vaginal discharge and saline smear shows many WBC but no organisms. what should you suspect?

A

chlamydia

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13
Q

what level should you test in suspected menopause ?

A

FSH (elevated in menopause)

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14
Q

presentation of cervicitis vs PID

A

cervicitis causes mucopurulent discharge and cervical motion tenderness without any other symptoms/signs PID

PID diagnostic criteria is lower abdominal/pelvic pain plus 1 of the following: cervical motion, adnexal or uterine tenderness

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15
Q

best initial investigation for PID

A

NAAT

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16
Q

after NAAT and initiation of abx in PID, what investigation would you carry out next

A

pelvic USS to look for tubo-ovarian abscess
(may also show thickening of fallopian tubes, fluid in cul-de-sac and multicystic ovary)

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17
Q

patient with vaginal discharge. PH > 4.5 but KOH negative. ?diagnosis

A

trichomoniasis
if KOH was positive then bacterial vaginosis

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18
Q

vaginal discharge shows presence of flagellated organisms slightly larger than WBC. ?diagnosis

A

trichonomiasis

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19
Q

what are the 2 abx regimens for outpatient treatment for PID

A
  1. IM ceftriaxone for 1 dose then oral doxycyline for 14 days +/- metronidazole for 14 days (anaerobic cover)
  2. ofloxacin or levofloxacin for 14 days +/- metronidazole for 14 days
    (regiment 2 is only used in special circumstances as there is risk of quinolone resistant gonorrhoea)
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20
Q

what are the x2 inpatient abx regiments for inpatient treatment of pid

A

cefoxitin or cefotetan plus doxycyline for 14 days

clindamycin + gentamicin for 14 days

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21
Q

patient with history of PID presents with RUQ abdominal pain, derranged LFT’s and right shoulder pain. ?diagnosis

A

fitz-hugh-curtis syndrome

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22
Q

at what period during pregnancy is the risk ovarian torsion higher and why

A

around 18 weeks when the uterus is rising over the pelvic brim or immediately post partum
this is because of uterine involution
increased motion of the uterus at these times increases risk of torsion

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23
Q

most common cause of vaginal discharge in paediatrics

A

foreign body

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24
Q

lesion that resembles /bunch of grapes’ within the vagina

A

sarcoma botryoides (rhabdomyosarcoma)
presents in paediatric patients with vaginal discharge

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25
in toxic shock syndrome, why will blood cultures be negative
because TSS is caused by preformed toxin and not invasive properties of the organism
26
presentation of toxic shock syndrome
patient during menses with prolonged tampon use or non-menstrual with recent surgery or burns hypotension, fever, non-purulent conjunctivitis, desquamination of hands and soles of feet, involving 3 or more organs
27
1st line management for TSS
IV rehydration and look for and remove foreign objects i.e. tampons
28
antibiotic regimen for TSS
clindamycin + vancomycin
29
causes of death with TSS
cardiac arrythmia cardiomyopathy ARDS coagulation defect (DIC)
30
breast biopsy reveals coarse calcifications and foamy macrophages. ?diagnosis
fat necrosis
31
breast biopsy reveals micro calcifications. ? diagnosis
cancer
32
most common cause of bloody nipple discharge in women
intraductal papiloma papillary tumour affecting a single lactiferous duct
33
treatment for intraductal papiloma
excision
34
investigations if you suspect intraductal pappiloma
1st USS or mammography (depending on age of patient) then surgical duct excision
35
what is atypical hyperplasia of the breast and how is it managed
atypical hyperplasia is overgrowth of either a duct or lobule but not filling it completely. has a risk of malignant transformation . managed with risk reduction including yearly mammograms and tamoxifen or aromatase inhibitor
36
safest option of contraception in a patient with breast cancer
copper IUD
37
at what stage does breast cancer with associated ipsilateral supraclavicular or infraclavicular lymphadenopathy indicate
stage IV
38
at what stage does breast cancer with axillary lymph nodes mattered or sttached to the skin indicate
stage III
39
women with what risk factors are recommended to undertake annual MRI breast screening
known BRCA mutation first degree relative who is BRCA carrier lifetime risk for breast cancer 20-25% or greater
40
whats the pros and cons of FNA vs core needle biopsy for suspected breast cancer?
FNA: good initial biopsy, only reaches lumps closer to the skin. small sample with high false negative rate. good for follow up for treatment progression. core needle biopsy: larger sample that allows testing for receptor status
41
tumour markers associated with breast cancer
CA 15-3 CA 27-29 CEA used for monitoring metastatic disease response to treatment
42
what is the action of tamoxifen and why is it protective for the breast but causes increased risk of endometrial cancer
tamoxifen is estrogen receptor antagonist at breast and agonist at endometrium therefore is favourable at the breast but with agonistic activity on endometrium increases risk for hyerplasia/dysplasia
43
contraindications to lumpectomy for breast cancer
large tumour size close to areola/nipple multifocal tumours fixation ot chest wall previous radiation to the breast/chest axillary nodal or overlying skin involvement
44
what is a common complication found in patients metastatic breast cancer
pleural effusion
45
sign on pelvic examination suggestive of fibroids
firm, mobile, nontender, irregular, enlarged ('lumpy bumpy') or cobblestone uterus
46
what is a luteoma
benign ovarian ovarian mass associated with pregnancy, maternal hirutism/virulization
47
type I vs II vs III endometrial cancers
type I endometrioid adenocarcinoma derived from endometrial hyerplasia. most common and best prognosis. unopposed estrogen stimulation. type II derived from serous or clear cell. unrelated to estrogen stimulation. P53 mutation found in 90% cases. type III most aggressive
48
treatment for endometrial cancer in patients who want to preserve fertility
high dose progestins
49
what HPV is most associated with adenocarcinoma of the cervix
HPV 18
50
what HPV is most associated with squamous carcinoma of the cervix
HPV 16
51
describe the screening for HPV in females
21-29 every 3 years 30-65 every 3 years or dual testing (pap smear + HPV testing) every 5 years or HPV test alone every 5 years >65 stop screening
52
PAP smear shows low grade squamous intraepithelial lesion. what is the next step?
repeat PAP smear in 12 months. if x2 negative results then return to normal screening.
53
PAP smear shows high grade intraepithelial lesion. what is the next step?
colposcopy
54
describe the 4 stages of cervical cancer
stage 0: CIN stage 1: confined to cervix stage 2: spreads to uterus but not pelvic wall stage 3: spreads to pelvic wall or lower 1/3 vagina stage 4: invades bladder, rectum or distant mets
55
treatment options for vulvar intraepithelial neoplasia
topical chemotherapy laser ablation wide local excision skinnning or simple valvectomy
56
histological origins of vaginal cancer
postmenopausal usually squamous cell pre menopausal usually other such as adenocarcinoma, clear cell
57
what is the correlation between OCP and ovarian cancer risk
use of COCP for > 5 years decreases ovarian cancer risk of 29%
58
what BRCA mutation has greatest increase for ovarian cancer
BRCA 1
59
what genetics are associated with ovarian cancer
BRCA 1 & 2 HNPCC (lynch syndrome, associated with ovarian, endometrial, breast and colon cancer)
60
at what size is an adnexal mass concerning for malignancy
> 8cm (solid or cystic/solid, fixed, multilocular, nodular, bilateral are other concerning features)
61
most common femal genital tract cancer and highest mortality
most common: endometrial > ovarian > cervical mortality: ovarian > endoemtrial > cervical
62
what histological type of ovarian cancer is CA-125 associated with
epithelial cancer
63
cause of elevated ca-125 in pre and post menoapusal women
premenopausal most likely tubu-ovarian asbcess or endometriosis post menopausal most likley malignancy
64
ovarian tumour with tumour marker inhibin
granulosa cell (stromal) ovarian tumour associated with post menopausal bleeding due to high estrogen/progestin levels call-exner bodies on histology (give granny a call)
65
ovarian tumour that can develop during or after pregnancy
choriocarcinoma elevated HCG can also occur after molar pregnancy spreads haematogenously
66
ovarian tumour associated with precocious puberty
embryonal carcinoma very rare presents in adolescents with precocious puberty and uterine bleeding elevated AFP and bHCG
67
ovarian tumour with elevated AFP but normal hcg
endodermal sinus (yolk sac) tumour yellow friable mass on histology aggressive found in adolescents
68
ovarian tumour with associated hirutism and virulization
sertoli-leydig tumour
69
what investigation should be carried out if abnormal mammogram findings but no palpable lump in the breast
steroetactic core biopsy (FNA is for palpable lumps)
70
1st line treatment for vaginal candidiasis
oral fluconazole
71
in what patients would you give topical antifungal instead of oral antifungal for candidiasis
patients with seizure disorder on antiepleptics such as phenytoin azoles such as fluconazole inhibit p450 so would alter anti seizure medication levels
72
whats the association between HRT and ovarian cancer
no increased risk HRT is the similar OCP in that it may decrease risk
73
secondary amenorrhoea with ihstory of dilatation and curettage
asherman syndrome perform operative hysteroscopy to remove adhesions
74
a patient with uterine prolapse has a gaping interotius and large pessaries are causing urinary retension and recurrent uTI's. what is the next best step in management?
surgical perineoplasty to reduce size of the vaginal opening so that a smaller pessary can be used
75
what is the prodrug of aciclovir
valacyclovir
76
treatment for acute intrauterine bleeding if IV estrogen fails
intrauterine tamponade with dilatation and curettage
77
treatment for tubo-ovarian abscess
if < 7cm - antibiotics if > 7cm - antibiotics + CT guided aspiration
78
patient presents with signs of thyrotoxicosis. Thyroid is non-tender and not enlarged. radio-iodine uptake scan shows no uptake. TSH low and T3 + T4 elevated. ?differentials
unlikely primary due to low uptake on scan and normal thyroid on examination. unlikely secondary due to low TSH therefore likely ectopic thyroid tissue i.e. ovarian tumour (struma ovarii)
79
cervical biopsy shows malignant cells with clear cytoplasm ?histological type ?risk factor
clear cell adenocarcinoma only risk factor associated with this cancer is in utero exposure to diethylstilbestrol (not caused by HPV)
80
what underlying pathology could be present with the visualization of theca lutean cysts on USS
molar pregnancy

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