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Reproduction/Sexual Health > Week 1 > Flashcards

Week 1 Flashcards

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1
Q

What is the Graafian follicle?

A

The dominant of two follicles released each month
- the one which may be fertilised

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2
Q

What are progesterone and oestrogen secreted from?

A

Progesterone - corpus luteum
Oestrogen - granulosa cells

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3
Q

What s corpus albicans?

A

Degenerative corpus luteum

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4
Q

Effect of HCG on endometrium

A

Decidualisation
- endo getting stronger for pregnancy
- maintained by progesterone as well

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5
Q

Features of proliferative phase under microscope

A

Donut looking proliferations
Mitotically active cells

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6
Q

Features of secretory cells under microscope

A

Increasing tortuosity of glands and lumenal secretions

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7
Q

Features of menstrual phase under microscope

A

Endometrial stromal breakdown
Dense round clsters of stomal cells surrounded by inflam cells and blood

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8
Q

Features of decidual change udner microscope

A

Abundant eosinophilic cytoplasm of stroma

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9
Q

Features of endo atrophy on microscope

A

INactive low CC cells
Glands detach from stroma to form “hairpin” structures
May be caused by trauma of biopsy

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10
Q

Indications for endo sampling

A

Abnormal uterine bleeding (e.g. post-menopausal)

Investigation for infertility

Spontaneous and therapeutic abortion

Assessment of response to hormonal therapy

Endometrial ablation

Work up prior to hysterectomy for benign indications

Incidental finding of thickened endometrium on scan

Endometrial cancer screening in high risk patients (e.g. Lynch syndrome)

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11
Q

Causes of abnormal uterine bleding in early repro life/adolescence

A

DUB usually due to anovulatory cycles

Pregnancy/miscarriage

Endometritis

Bleeding disorders

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12
Q

Causes of AUB in reproductive life

A

Ado causes PLUS

Cancers (cervical/endometrial)
Endometriosis in myo layer
Exogenous hormone effects
Bleeding disorders
Hyperplasia

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13
Q

Causes of AUB post-meopause

A

Atrophy
Endometrial polyp
Exogenous hormones: HRT, tamoxifen
Endometritis
Bleeding disorders
Hyperplasia
Carcinoma/sarcoma

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14
Q

How is endometrium sampled?

A

Hysteroscopy
Endo pipelle
Dilatation and curretage

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15
Q

History aspects path needs for diagnostic sampling

A

Age
Date of LMP and length of cycle
Pattern of bleeding
Hormones
Recent pregnancy

Do not need to know number of pregnancies, drugs without hormonal influences etc.

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16
Q

Define dysfunctional uterine bleeding

A

irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining (no organic cause for bleeding)

most commonly due to anovulatory cycles, either end of repro life

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17
Q

Describe endometritis

A

abnormal pattern of inflammatory cells in endometrium (has oenetrated cervical mucus plug)

caused by e.g. actinomyes, neiserria, HSV, IUDs, post-partum, post-abortion, granulomatous, polyps

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18
Q

PLasma cells in endometrium means?

A

Chronic plasmacytic endometritis
- Infectious unless proved otherwise
- Associated with PID

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19
Q

Describe complete mole pregnancy

A

Complete
- Single or two sperm combining with egg that has lost its DNA, sperm reduplicates to form “complete” 46chrom set, only paternal DNA present
- Incr choriocrcnoma risk

Partial
- Egg fertilised by two sperm or one sperm which reduplicates itself causing triploid genotype 69XXY

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20
Q

Describe fibroid/leiomyoma

A

Benign smooth muscle tumour forming from myoetrium

Growth oestrogen dependent
Interlacing SM cells
Presents w haemorrhagia, infertility, mass effect

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21
Q

Describe features of folicular cysts

A

Physiological cyst
Form when ovulation doesn’t occur
(polycystic ovaries)
Follicle doesn’t rupture but grows until it becomes a cyst
Several cm, resolve over months
Thin walled, granulosa lining

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22
Q

Describe endometriosis and its presentation

A

Endometrial glands and stroma outside the uterine body, cycle in the same way as uterine tissue

Presenst with:
- pelvic inflam
- infertility (scarring and obstruction of uterine tube)
- pain

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23
Q

Where do endometrioma form?

A

– Ovary (‘chocolate’ cyst)
– Pouch of Douglas
– Peritoneal surfaces, including uterus
– Cervix, vulva, vagina
– Bladder, bowel etc

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24
Q

Macro and microscopic features of endo

A

Macroscopic
Peritoneal spots or nodules
Fibrous adhesions
Chocolate cysts

Microscopic
Endometrial glands and stroma
Haemorrhage, inflammation, fibrosis

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25
Malignancy linked to endometriosis
Endometrioid carcinoma - can be found outwith uterus
26
Types of epithelial ovarian tumour
Serous (lines tubes) Mucinous (epi cells with mucin) Endometrioid Clear cell Brenner (transitional epi, from bladder) Undifferentiated carcinoma Can be benign, borderline, malignant
27
Describe serous carcinoma of ovary
Most common, linked with BRACA mutation Most originate in tubes 90% high grade, 5% low grade/borderline (with different path)
28
Describe endometrioid and clear cell carcinoma of ovary
Assoc with ovarian endometriosis and Lynch syndrome Graded same way as uterine tumurs Mostly low grade/early stage Primary diag most often made on ascitic fluid
29
What key feature makes a neoplasm malignant?
Stromal invasion - cells break through the basement membrane
30
Describe Brenner tumour of ovary
A tumour of transitional type epithelium, usually benign, borderline and malignant variants are rare Really solid tumour Round nests of transitional cells
31
Describe germ cell tumours of ovary
Mostly benign mature cystic teratoma - containing sebum, teeth, hair, tragus - rarely malignant, but could get malignancy from tissue within teratoma e.g. SCC skin, thryroid ca Rarely immature teratoma - 8 week foetal tissue, really malignant Others e.g. dysgerminoma (like testis seminoma), yolk sac, choriocarcinoma, mixed
32
Describe types of sex cord/stromal tumours
Fibroma/Thecoma - Benign - May produce oestrogen causing uterine bleeding Granulosa cell tumour - All are potentially malignant - May be associated with oestrogenic manifestations Sertoli-Leydig cell tumours - Rare, may produce androgens
33
Figo staging of ovarian cancer
1A tumour limited to one ovaries 1B tumour limited to both ovaries 1C Cancer involving ovarian surface/ rupture/surgical spill/tumour in washings 2A Extension or implants on uterus/fallopian tube 2B Extension to other pelvic intraperitoneal 3A Retroperitoneal lymph node Metastasis or microscopic extrapelvic peritoneal involvement 3B Macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension 3C Macroscopic peritoneal metastasis >2cm in dimension 4 Distant metastasis
34
Why is Hb low in ovarian cancer?
Ovarian cancer cells hoard iron causing rest of body anaemia
35
CRP vs ESR
CRP - acute inflam ESR - chronic inflam
36
Apperance of molar pregnancy on US
Snowstorm appearance
37
3 main abnormal pregnancy types
Miscarriage (normal, in uterus) Ectopic (outwith uterus) Molar (abnormal, in uterus)
38
Causes of early pregnancy bleeding
Implantation bleeding Sub-chorionic haematoma Cervical/vaginal causes: Infection Malignancy ( important to take a cervical smear history) Cervical polyp
39
Types of miscarriage
Threatened Miscarriage (risk to pregnancy) Inevitable Miscarriage (pregnancy can’t be saved) Incomplete Miscarriage (part of pregnancy is already expelled) Complete Miscarriage (all of pregnancy is expelled, uterus empty) Early Fetal Demise/Non continuing pregnancy NCP (pregnancy in-situ, no heartbeat, >25 sac diameter, >7 fetal pole) Anembryonic Pregnancy (no fetus, empty sac)
40
Presentation of miscarriage
Pos preg test Amennhoroea Bleeding Period type cramps
41
Presentation of cervical shock
Acute clin emergency Cramps Nausea, vomting Sweating, fainting Remove preg poriducts from cerviz!!!! Resus with IVI and uterotonics
42
Causes of miscarriage
Embryonic abnormality : Chromosomal. Immune cause : APS/Lupus Infections : CMV, Rubella, etc Severe emotional upsets, extreme physical stress. Iatrogenic loss (after CVS) “Associations”: heavy smoking, cocaine, alcohol misuse. Uncontrolled Diabetes. Cervical incompetence and shortened cervix. Vaginal (bacterial) infections.
43
Management of miscarriage
Ensure HD stability FBC, group save, hCG, US< histology Conservative Medical - misoprostol Surgical/MVA Anti-D, emotional support
44
Management of threatened miscarriage
Micronised Progesterone 400 mg PV b.d. till 16 weeks (if viable IU preg on scan)
45
When to refer about recurrent miscarriage
3 or more preg losses or if 2 or more losses >35years
46
Presentation of ectopic preg
Presentation: Pain > bleeding, dizziness / collapse / shoulder tip pain, short on breath, rare presentation diarrhoea. Findings: Pallor, hemodynamic instability, signs of peritonism, guarding & tenderness.
47
Red flag signs in ectopic pregnancy
Repeated pres of abdo/pelvic pain Pain requiring opiates in a known pregnant person
48
Investigation of ectopic pregnancy
Investigation: FBC, G&S, ẞhCG, Ultrasound Trans-vaginal scan (TVS) is gold standard: - empty uterus - pseudosac - free fluid pouch of Douglas - mass in adenexa Serum hCG - 48h apart to assess doubling
49
Manegment of ectopic
Surgical - laparoscopic salpingectomy - conservative salpingotomy to preserve tube Medical - stable pts with low hCG and small/unruptured ectopic - methotrexate 1 or 2 doses Conservative - supportive management, not v common
50
Describe pres and management of PUL
Amenorrhoea, abdominal pain. Level of hCG confirming a pregnancy circumstance. NO PREG IN UTERUS/TUBES/CERVIX ON SCAN Manage conservatively with M6 model
51
Describe the M6 management of PUL
Principle: level of Progesterone which guides the progress or regression of a pregnancy is used to add value to the pathway of follow up. Outcome of follow up: may eventually evidence as an intrauterine pregnancy or an ectopic pregnancy on scan Management : Medically with Methotrexate if no clinical deterioration.
52
Describe molar pregnancy
Gestational Trophoblastic Disease Outcome of a non-viable fertilised egg Complete vs Partial Complete has 2.5% risk of developing into choriocarcinoma
53
Complete mole
Egg without DNA 1 or 2 sperms fertilise, result in diploid ( paternal contribution only) No fetus overgrowth of placental tissue
54
Partial mole
Haploid egg 1 sperm ( reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy May have fetus Overgrowth of placental tissue
55
Presentation of molar pregnancy
Hyperemesis, hyperthyroidism, early onset pre-ecclampsia Varied bleeding and occasional history of passage of “grapelike tissue” Fundus > dates on abdominal palpation. Snowstorm on USS (with potential foetus, theca lutein cyst) Rarely SoB or seizures from embo/mets
56
Management of molar pregnancy
Surgical evacuation and histological tissue typing Medical management in higher gestation with partial mole Follow up with molar preg services
57
Describe implantation bleeding
when the fertilised egg implants in the endometrial lining. Timing is about 10 days post-ovulation. Bleeding is light/brownish and self limiting, mistaken as period Prgnancy signs emerge soon after
58
Describe subchorionic haematoma
Pooling of blood between endometrium and the embryo due to separation : sub-chorionic haematoma Bleeding, cramping, threatened miscarriage Large haematomas can cause infection/irritability/cramping and miscarrige
59
Cervical causes of early pregnancy bleeding
Ectopy/ectropion. Infections: Chlamydia, Gonococcus or bacterial. Polyp. Malignancy
60
Vaginal causes of early pregnancy bleeding
Infections: - Trichomoniasis ( strawberry vagina) - Bacterial vaginosis - Chlamydia Malignancy: - Ulcers - Rare cause of bleeding in repro ages Forgotten tampon
61
Managing infections in pregnancy
BV - metronidazole 400mg bd 7 days - vaginal gel, no alcohol Chlamydia - erthyromycin/amoxicillin - test of cure at 3 weks - contact tracing
62
Causes of pain in pregnancy
Miscarriage (bleeding>pain) Ectopic (main symptom, dull->sharp, peritonism) Torsion of ovarian cyst (when uterus moves into abdo) Cyst acident (IA bleeding) Unrelated (UTI, appenidicitis) Vaginal infections
63
When is anti-D advised?
Surgical management of surgical removal of ectopic or molar pregnancy 500 IU given IM
64
Presentation of hyperemesis gravidarum
Excessive and protracted N/V Starts at first missed period, continues beyond 1st trimester Severe impact on quality of life Presents with: - dehydration, keotsis, elec/nutrional abnormalities - WL, altered liver function - malnutrition - mental health issues
65
Management of HG
PUQE score for severity Inpatient - IV, NG< TPN - parenteral antiemetics - manage electrolytes, thyroid - thromboprophylaxis - sometimes termination
66
Definition of infertility
inability to conceive after 12 months regular intercourse without contraception Primary - no previous pregnancy Secondary - to miscarriage, prev child etc
67
What hormone does OTC fertility tests assess?
LH surge just before day 14 Not always reliable
68
Assessing ovulation in clinic
Midluteal serum progresterone on day 21 (week before period) - look for value >30nmol/L
69
Define azoospermia
No sperm in ejaculate
70
Define asthenozoospermia
% progressive motile sperm below reference limit
71
Define oligozoospermia
Total number / concentration of sperm below reference limit
72
Define teratozoospermia
% morphologically normal sperm below reference limit
73
Structural abnormalities causing infertility
Congenital uterine abnormalities Fibroids Endometrial polyp Hydrosalpinx Tubal patency issues PCOS Ovarian cyst
74
Tubal patency testing
Hysterosalpingogram (HSG) - XR with radioopaque dye - no risk factors/pelvic pathology Diag laparoscopy, hydrotubation (HTB) - possible tubal disease, pelvic pain, prev abnormal HSG
75
Role pf hysteroscopy in infertility
Cases with suspected/known endo pathology e.g. uterine septum, adhesions, polyps
76
Rotterdam criteria for PCOS
2 of: 1. oligo/amennhorhoea 2. polycystic ovaries on scan 3. clinical/biochem signs of hyperandrogenism
77
How is ovulation induced?
Clomefine citrate or tamoxifen tablets - first line - days 2-6 Gonadotrophin injections - recombinant FSH, risk of overstimulation and multiple pregnancy - close monitoring Lap ovarian diathermy - needle heat treatment to ovary - mainly singleton pregnancy
78
How to manage clomifene resistance?
Weight loss Adjuvant metformin: improves insulin resistance and reduces androgen production Helps to improve sensitivity to meds and restore menstruation
79
Investigatons of male infertility
Examination of male and testes volume Check LH, FSH, testosterone, prolactin Karyotype, CF mutation, Y microdeletions Check meds or hormonal conditions
80
Management of male infetrility
Intrauterine insemination (IUI) In vitro fertilisation (IVF) Intracytoplasmic sperm injection (ICSI)
81
Standard IVF protocol
1st period Decapeptyl IM day 21 2nd period Basseline scan at 2 weeks FSH injections daily Action scan at 2 weeks Ovitrielle hCG SC Egg collection at 2 days Progesterone PV daily Embryo transfer at day 5 Continue progesterone next few weeks Pregnancy test!!!!
82
Effect on ovaries and uterus in menstrual phase
Ovary - FSH causes primary follicles -> secondary follicles Uterus - decr oestogren and progesterone releases prostaglandins - arterioles constrict - stratum fucntionalis of endo sloughs off - 50-150ml of blood/tissue etc shed through cervix and vagina
83
Effect on ovaries and uterus in preovulatory phase
Ovary - secondary follicles secrete oestogren - one follicle becomes dominant graafian follicle Uterus - oestrogen stimulates growth of endo - stratum basilis undergoes mitosis = new stratum fucntionalis - endo thickness doubles to 4-10mm
84
Effect on ovaries and uterus in ovulatory phase
Ovary - oestrogen stimulates more GnRH release - LH surges causes rupture of Graafian and explosion of secondary oocyte Uterus - prog/oestro continue to stimulate proliferation of endo
85
Effect on ovaries and uterus in postovulatory phase
Ovaries - collapsed follicle bceomes corpus luteum due to LH - CL secretes prog/oestro/relaxin/inhibin - decr agyer 2 weeks if no fertilisation Uterus - prog/oestro cause growth/coiling of endo glands, vascularisation, thickening of endo - endo glands secrete glycogen
86
Management of PMD in terms of Ovulation suppression
- yasmin and eloine COC 1st line - GnRH agonisys - anazol (lots of SEs) - oestrogen (if incr chance of endo hyperplasia) - bilateral oopherectomy and hysterectomy with only oestrogen treatement
87
Other management of PMD
SSRIs - continuously or just luteal phase Diuretics for physical symptoms CBT for mental health symptoms Supplements and vitamins
88
Management of heavy menstrual bleeding
1st line mirena coil 2nd line tranexamic acid/COC 3rd line norethisterone/DMPA 4th line surgery/ref to gynae
89
Causes of heavy menstrual bleeding
Fibroids Polyps Adenomyosis assoc with Hx preg, curettage Coagulopathy e.g. von Willebrand's Malignancy
90
Surgical management of heavy menstrual bleeding
Polypectomy Endometrial ablation Uterine artery embolization Myomectomy Hysterectomy
91
What is a heterotopic pregnancy?
Twins where one fertilised egg implants in uterus and other implants in tube
92
Why is methotrexate used in ectopics?
Helps to stop rapidly dividing cells
93
Menstrual causes of acute bleeding
Anovulatory e.g. PCOS Fibroids (more SA to bleed from) Anticoagulant Von Willebrand’s disease
94
Non-menstrual causes of acute bleeding
Miscarriage Cervical cancer Endometrial cancer Vaginal trauma
95
Management of acute bleeding in gynaecology
Resuscitation Tranexamic acid Mefenamic acid Norethisterone IUS COCP GnRH analogues
96
Effect of GnRH analogues on FSH and LH
Downregulation of LH and FSH Causes mini pseudomenopause
97
Describe pres and management of HSV infection of vulva
Pres - pain, ulcers, discharge, dysuria, urinary retention Inv - HSV1&2, inguinal lymphadenopathy, viral swab Manage - aciclovir, bladder cath, local anaestehtic gel
98
Describe pres and management of Bartholin's abscess
Pres - blocked duct at 5 and 7 oclock, infection, swelling pain Inv - swabs for micro Manage - conservative, broad spectrum antibiotics, word catheter, marsupialisation
99

Reproduction/Sexual Health (9 decks)

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