Post-Menopausal Health Flashcards
(172 cards)
1
Q
Where do the majority of the arteries supplying the lateral pelvic wall arise from?
A
Internal iliac artery
2
Q
Where do the gonadal arteries arise?
A
L2 abdominal aorta
3
Q
Where does the superior rectal artery arise?
A
Continuation of inferior mesenteric
4
Q
What is the medial umbilical ligament?
A
Remnant of the umbilical artery
5
Q
What does the lateral umbilical fold contain?
A
Inferior epigastric vessels
6
Q
What is the median umbilical ligament?
A
Remnant of the urachus
7
Q
What does the internal pudendal artery terminate as in males?
A
Dorsal artery
Deep artery of penis
8
Q
What arteries branch off from the pudendal artery in the male perineum?
A
Perineal
Posterior scrotal
9
Q
Where does the anterior scrotal artery arise from?
A
Common iliac
10
Q
Where do most of the veins draining the lateral pelvic wall drain to?
A
Internal iliac vein
11
Q
Veins of the lateral pelvic wall that drain via the superior rectal vein empty where?
A
Hepatic portal system
12
Q
Veins of the lateral pelvic wall that drain via the lateral scrotal vein empty where?
A
Internal vertebral venous plexuses
13
Q
Why is the left ureter more likely to be damaged than the right?
A
Right is constant and usually crosses external iliac
Left is more medial and crosses common iliac
14
Q
Where does lymph from the superficial pelvic viscera drain to?
A
External iliac nodes:
- Common iliac
- Aortic
- Thoracic duct
- Venous system
15
Q
Where does lymph from the inferior pelvis viscera drain to?
A
Deep perineum:
- Internal iliac nodes
- Common iliac
- Aortic
- Thoracic duct
- Venous system
16
Q
Where does lymph from the superficial perineum drain to?
A
Superficial inguinal nodes
17
Q
What is the average age of menopause?
A
51 years
18
Q
When is early menopause defined?
A
<45 years
19
Q
When is premature menopause defined?
A
<40 years
20
Q
When is late menopause defined?
A
> 54 years
21
Q
What results in raised FSH and LH?
A
Stopping: - COC - Depot Breastfeeding SSRIs
22
Q
How long does a typical hot flush in menopause last?
A
3-5 minutes
23
Q
How long do hot flushes persist for?
A
2yrs usually
24
Q
How can menorrhagia in menopause be treated?
A
Mefanamic or Tranexamic acid Progesterones IUS Endometrial ablation Hysterectomy
25
What protective features does HRT have?
Reduces osteoporotic fractures
Reduces bowel cancer
?Alzheimer's and Parkinson's protection
26
What are the risks of HRT?
VTE
CVA
Breast cancer
Gallbladder disease
27
When do endometrial polyps tend to occur in relation to menopause?
Around/After menopause
28
What may be a possible cause of endometrial hyperplasia?
Persistent oestrogen stimulation
29
What is the distribution of the three kinds of endometrial hyperplasia?
```
Simple:
- General
Complex:
- Focal
Atypical:
- Focal
```
30
What are the components of the three kinds of endometrial hyperplasia?
```
Simple:
- Glands and stroma
Complex:
- Glands
Atypical:
- Glands
```
31
What is the appearance of the glands in the three kinds of endometrial hyperplasia?
```
Simple:
- Dilated
Complex:
- Crowded
Atypical:
- Crowded
```
32
What is the cytology of the three kinds of endometrial hyperplasia?
```
Simple:
- Normal
Complex:
- Normal
Atypical:
- Atypical
```
33
When is the peak incidence for endometrial cancer?
50-60 years
34
What should be considered if endometrial cancer presents in a younger patient?
PCOS
| Lynch Syndrome
35
What is the usual precursor of endometrial carcinoma?
Atypical hyperplasia
36
What is the usual precursor of an endometrial serous carcinoma?
Serous intraepithelial
37
How does endometrial carcinoma generally present?
Abnormal bleeding
38
How does an endometrial cancer appear macroscopically?
Large uterus
| Polypoid
39
How does an endometrial cancer appear microscopically?
Most are adenocarcinomas
| Most are well differentiated
40
How can endometrial cancers spread?
```
Directly into:
- Myometrium
- Cervix
Lymphatic
Haematogenous
```
41
What are Type 1 endometrial carcinomas?
Endometroid (and mucinous)
42
What are Type 1 endometrial carcinomas related to and associated with?
Related to unopposed oestrogen
| Associated with atypical hyperplasia
43
What percentage of endometrial carcinomas are type 1?
80%
44
What are Type 2 endometrial carcinomas?
Serous (and clear cell)
45
What are Type 2 endometrial carcinomas related to and associated with?
Not oestrogen associated
Associated with elderly postmenopausal women
TP53 often mutated
46
What mutations may be seen in Type 1 endometrial carcinomas?
PTEN
KRAS
PIK3CA
47
How is obesity linked to an increased risk of endometrial cancer?
Endocrine and inflammatory effects of adipose tissue
48
What do adipocytes contain that results in endometrial proliferation?
Aromatase:
| - Converts ovarian androgens to oestrogens
49
How does obesity affect sex hormone binding globulins and what effect does this have?
Reduced levels:
| - Increased levels of unbound, biologically active hormones
50
How does obesity affect insulin binding globulin levels and what effect does this have?
Reduced levels:
- Increased free insulin levels
- Proliferative effect on endometrium
51
What cancers does Lynch Syndrome predispose to?
Colorectal cancer
Endometrial cancer
Ovarian cancer
52
How is Lynch Syndrome inherited?
Autosomal dominant
53
How can Lynch Syndrome tumours be identified?
Immunohistochemistry staining
54
What is the instability found in Lynch Syndrome called?
Microsatellite instability
55
What are the precursor lesions to Type 2 endometrial tumours?
Serous endometrial intraepithelial carcinoma
56
How do Type 2 endometrial tumours spread?
Fallopian tube mucosa
| Peritoneal surfaces
57
What endometrial tumours are more aggressive - Type 1 or Type 2?
Type 2
58
What is the structures of a serous endometrial carcinoma?
Complex papillary +/or glandular structure
| Diffuse, marked nuclear polymorphism
59
How is a Grade 1 endometrial carcinoma defined?
=<5% solid growth
60
How is a Grade 2 endometrial carcinoma defined?
6-50% solid growth
61
How is a Grade 3 endometrial carcinoma defined?
>50% solid growth
62
What types of endometrial carcinomas are not routinely graded?
Serous
| Clear cell
63
What is Stage 1 of endometrial carcinoma?
Confined to uterus:
- 1A = No/<50% myometrial invasion
- 1B = >50% myometrial invasion
64
What is Stage 2 of endometrial carcinoma?
Tumour invades cervical strome
65
What is Stage 3 of endometrial carcinoma?
Local +/or regional tumour spread:
- IIIA = Tumour invades serosa of uterus +/or adnexae
- IIIB = Vaginal +/or parametrial involvement
- IIIC = Mets. to pelvic +/or para-aortic nodes
66
What is Stage 4 of endometrial carcinoma?
Tumour invades:
- Bladder +/or
- Bowel mucosa (IVA) +/or
- Distant metastases
67
How do endometrial stromal sarcomas spread?
Infiltrate myometrium and often lymphovascular spaces
68
What is the most important prognostic factor in endometrial stromal sarcomas?
Stage
69
What is an endometrial carcinosarcoma?
Mixed tumour:
- Epithelial (carcinomatous) elements
- Stromal (sarcomatous) elements
70
What is the alternative name for endometrial carcinosarcoma?
Malignant Mixed Mullerian Tumour
71
What are the heterologous elements that can appear in 50% of endometrial carcinosarcoma cases?
Rhabdomyosarcoma (worst prognosis)
Chondrosarcoma
Osteosarcoma
72
How does an endometrial carcinosarcoma appear macroscopically?
Large bulky tumours
Filling cavity
Often protruded through cervical canal
73
What symptoms are myometrial leiomyomas associated with?
Menorrhagia
| Infertility
74
What sort of morphology do leiomyosarcomas typically have?
Spindel cell
75
In what women are leiomyosarcomas most common?
>50 years
76
What are the common symptoms of leiomyosarcomas?
Abnormal vaginal bleeding
Palpable pelvic mass
Pelvic pain
77
What is the overall 5yr survival for endometrial leiomyosarcoma?
15-25%
78
What is the strongest prognostic factor in leiomyosarcoma?
Stage
79
What are uterine fibroids?
Leiomyomas
80
In what age group are fibroids most common?
>40 years
81
How do uterine fibroids typically present?
Menorrhagia
Pelvic mass
Slight pain/tenderness
'Pressure' symptoms
82
When might a fibroid be disproportionately painful or tender?
If 'red degeneration':
- Pregnancy
- Menopause
83
In what populations are fibroids most common?
Afro-Caribbean
84
How can fibroids be investigated?
Hb if high bleeding
USS is usually diagnostic
MRI for precise localisation
85
How do fibroids appear on USS?
Smooth
Echogenic mass
(Often multiple)
86
What can be used pre-op to shrink the size of a fibroid?
GnRH agonists:
| - Mifepristone
87
If a woman's family is complete, what operation can be offered for fibroids?
Hysterectomy
88
If a woman wishes to maintain her fertility, what operations can be offered for fibroids?
Myomectomy
Uterine artery embolisation
Hysteroscopic resection
89
How does a hydrosalpinx present?
Longstanding tubal swelling - +/- pain
| Usually incidental USS finding
90
How does a pyosalpinx present?
Acute inflammation
| Acute PID
91
What are functional ovarian cysts related to?
Ovulation:
- Follicular cysts
- Luteal cysts
92
What symptoms can functional cysts cause?
Menstrual disturbance
Bleed/rupture and pain:
- Mid cycle pain (Mittelschmerz)
(Often asymptomatic)
93
What are endometriomas and how do they appear?
Blood-filled endometriotic cysts:
| - 'Chocolate' cysts
94
What are the signs and symptoms of endometriomas?
```
Severe dysmenorrhoea
Premenstrual pain
Dyspareunia
Subfertility
Tender mass with 'nodularity' and tenderness behind uterus
```
95
What is a dermoid cyst?
Benign ovarian cystic teratoma
96
What are the types of primary ovarian tumours arising the the surface epithelium?
```
Serous
Mucinous
Endometrioid
Clear cell
Brenner
```
97
If a primary ovarian tumour arises from stromal granulosa cells, what may it secrete?
Oestrogens
98
If a primary ovarian tumour arises from stromal theca/leydig cells, what may it secrete?
Androgens
99
What syndrome are ovarian fibromas linked to?
Meig's Syndrome
100
What can a malignant germ cell tumour produce and how may this present?
hCG:
- False pregnancy test
AFP
101
If a dermoid cyst differentiates into thyroid tissue, what can occur?
Thyrotoxicosis
102
What does a dermoid cyst usually secrete?
AFP
| no hCG if pure
103
How does a dermoid cysts appear on a plain x-ray?
Rim calcification
104
How can ovarian granulosa cell tumours present?
Precocious puberty
| Postmenstrual bleeding
105
How can ovarian thecal tumours present?
Hirsutism
| Virilisation
106
How does Meig's Syndrome present?
Benign fibromas
Pleural effusion
Ascites
107
What primary tumours can commonly metastasise to the ovaries?
Breast
Pancreas
Stomach
GI
108
What sort of spread do malignant ovarian tumours display?
Early transperitoneal spreads (trans-coelomic):
- Deposits on all peritoneal surfaces
- Omental disease/infiltration
- Malignant ascites with protein exudate
109
What gene is linked to ovarian cancer?
HNPCC
110
What are the risk factors for ovarian cancer?
Increasing age
Nulliparity
Family history
111
What effect does COC (oestrogen) have on ovarian cancer?
Protective
112
What tumour markers must be tested for in suspected ovarian cancer?
CA-125
| Carcino-embryonic antigen
113
When is CT used in the investigation of a suspected ovarian cancer?
Assessing:
- Omental disease
- Peritoneal disease
- Lymph nodes
114
In what proportion of ovarian cancers is CA-125 raised in?
80%
115
What ovarian tumours raise carcinoembryonic antigen the most?
Mucinous tumours
116
What is the main use of carcinoembryonic antigen?
Exclusion of metastases from GI primary
117
What is the 'risk of malignancy' index?
Menopausal status x Serum CA-125 x US score
118
How is a benign ovarian tumour treated?
Removal or drainage
119
How is a malignant ovarian tumour treated?
Oophorectomy and hysterectomy
With removal/debulking of omentum
Tumour 'debulking'
120
How does cervical cancer present?
Screening
Post-coital bleeding/IMB/PMB
Acute renal failure
121
What surgical treatments are available for cervical cancer?
Large Loop Excision of the Transitional Zone
Fertility sparing
Wertheim
122
What chemotherapy agents can be used in cervical cancer?
Cisplatin:
- 40mg/m^2 weekly
Carboplatin/Paclitaxol
123
What are the risk factors for ovarian cancer
```
>50 years
Nulliparity (or low parity)
Delayed pregnancy
FHx of breast or ovarian cancer
BRCA1 and BRCA2
```
124
What are the USS scores for calculating RMI?
```
Features:
- Multilocular cysts
- Solid areas
- Bilateral lesions
- Ascites
- Intra-abdominal
0 = No features
1 = One abnormality
3 = Two or more abnormalities
```
125
What are the menopausal scores for calculating RMI?
```
Premenopausal = 1 point
Postmenopausal = 3 points
```
126
What is the CA-125 score measured in for calculating RMI?
U/ml
127
If there is an RMI score >200, what should be done?
Refer to gynaecology-oncology MDT
| CT abdomen and pelvis
128
What staging is used for ovarian cancer?
FIGO staging
129
Where does ovarian cancer spread to haematogenously?
Liver
Lungs
Brain (2%)
130
What are the first line chemotherapy agents in epithelial ovarian cancer?
Carboplatin +/- Paclitaxel (80mg/m^2)
131
What other cytotoxic agents can be added if paclitaxel is not tolerated?
Doxorubicin
OR
Gemcitabine
132
When is intraperitoneal chemotherapy considered?
Epithelial ovarian cancer and residual disease =<1cm after primary surgery
133
If ovarian cancer relapses, what chemo regimen should be used?
If platinum sensitive, use cisplatin in combo with:
- Paclitaxel or
- PLDH or
- Gemcitabine
134
If ovarian cancer relapses and it is not platinum sensitive or the patient wants to avoid further chemo, how can it be treated
Tamoxifen
| Aromatase inhibitor
135
What tumours does Letrozole have an effect on and how long is it given for?
ER+ tumours
| Maintained for >6 months
136
What can cause impaired gastric emptying in gynaecological malignancy?
Locally advanced
Drugs (Opioids and anticholinergics)
Damage to gut
Autonomic neuropathy
137
How does impaired gastric emptying in gynaecological malignancy present?
Not usually nauseated
Then very nauseated:
- Large volume vomits
- Feels better
138
What causes regurgitation in gynaecological malignancy?
Obstruction/Compression of oesophagus
139
How does regurgitation in gynaecological malignancy present?
Dysphagia
Pain
Coughing/Stridor
140
What chemical or metabolic influences can result in vomiting in gynaecological malignancy?
```
Medications (opioids and ABx)
Advanced cancer (esp. liver metastases)
Sepsis
Kidney/Liver impairment
Biochemical
```
141
How do chemical or metabolic changes result in vomiting?
Hypercalcaemia
Hyponatraemia
Hypermagnesaemia
Uraemia
142
How does chemical or metabolic vomiting present?
Persistent nausea
| Little relief from vomiting
143
How does bowel obstruction present?
Intermittent large volume vomits
| Colic
144
How does cerebral disease result in vomiting?
Compression/Irritation by tumour
Increased ICP
Anxiety
145
How does vomiting induced by cerebral disease present?
Worse in the morning
| Headache
146
How does vestibular disease result in vomiting?
Base of skull/Brainstem disease
Ear infections
Motion sickness
147
How does vomiting induced by vestibular disease present?
Worse on movement
Vertigo
Tinnitus
148
What effects do steroids have in palliative care?
Anti-emetic
| Anti-inflammatory (reduce peri-tumour oedema)
149
What steroid can be prescribed in palliative care?
8-16mg CSCI/24 hours
150
When is Hyoscine Butylbromide used?
Colic:
- 20mg S/C bolus PRN
- 60-120mg/24hrs CSCI
151
When can anti-emetics be used in mechanical bowel obstruction?
If incomplete MBO and no colic
152
What anti-emetic is used in mechanical bowel obstruction?
Metoclopramide:
| - 30-100mg CSCI/24 hours
153
What type of drug is Hyoscine hydrobromide? What dose is given?
Anti-secretory agent
| 0.4-2.4mg/24 hours CSCI
154
What examination must be done before prescribing laxatives?
Faecal impaction on examination and AXR
155
If there is partial obstruction, what can be prescribed as a laxative?
Sodium docusate
| Movicol
156
When is methylnaltrexone prescribed as a laxative?
In opioid-induced constipation
157
What happens when follicular cysts form when ovulation doesn't occur?
Polycystic ovaries
158
What are the thin walls of a follicular cyst lined by?
Granulosa cells
159
What are high grade malignant serous carcinomas known as?
Serous tubal intraepithelial carcinoma
160
What are low grade malignant serous carcinomas known as?
Serous borderline tumour
161
What ovarian tumours have a strong association with ovarian endometriosis?
Endometrioid
| Clear cell
162
What is a Brenner ovarian tumour?
A tumour of transitional-type epithelium
| Usually benign
163
What is ovarian cancer - FIGO Stage 1?
```
1A = Limited to one ovary
1B = Limited to both ovaries
1C = Involving ovarian surface/rupture/surgical spill/tumour in washings
```
164
What is ovarian cancer - FIGO Stage 2?
```
2A = Extension or implants on uterus/fallopian tube
2B = Extension to other pelvic organ (bowel, bladder)
```
165
What is ovarian cancer - FIGO Stage 3?
```
3A = Retroperitoneal LN mets. or microscopic extrapelvic peritoneal involvement
3B = Macroscopic peritoneal mets beyond pelvis up to 2cm
3C = 3B but >2cm
```
166
What is ovarian cancer - FIGO Stage 4?
Distant metastases
167
When is a transabdominal USS used?
Established thick endometrium in PMP
Ensure no hydronephrosis
Detect early ascites
Ensure pelvic abnormality isn't secondary to upper. abdo. pathology
168
Why must a patient have a full bladder for transabdominal USS?
Acts as an 'acoustic window'
Displaces gas filled bowel out of pelvis:
- Improves image quality
169
When is CT used for gynaecological disease?
```
2nd line for acute abdomen
Assess post-surgical complications:
- Small bowel obstruction due to adhesions
- Collections/Abscesses
Cancer staging
Assessing chemo/radiotherapy response
```
170
When is MRI used for gynaecological disease?
Cancer staging (esp. cervical)
Characterising adnexal and uterine masses
Evaluating sub-fertility
Pituitary MR if prolactinoma
171
What does hysterosalpingography used?
To assess tubal patency in infertility
| Can assess outline of uterine cavity
172
How long does a hysterosalpingogram take?
3-5 minutes
