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Flashcards in Week 7 Deck (231):
1

What are the muscles of the Lateral pelvic wall

Obturator internus
Levator Ani
Piriformis
Coccygeus

2

Which arteries of pelvis and perineum does not arise from internal iliac artery

Gonadal artery
Superior rectal artery

3

Which artery supply majority of the perineum

Internal Pudendal artery

4

What is the median umbilical ligament

Remnant of the umbilical artery which connected the internal iliac to the placaenta

5

Which pelvic and perineum arteries exist in men only, equivalent in females

Inferior Vescial
Replaced by vaginal artery

6

Blood supply to penis, from which artery

Dorsal artery of penis AND
Deep artery FROM
Internal pudendal artery

7

Blood supply to scrotum, from which artery

Anterior scrotal artery FROM External iliac AND
Posterior scrotal artery FROM Internal pudendal nerve

8

Which artery gives of branches to the inferior bladder in females

Vaginal artery

9

Which two anastomosis occurs in females pelvis/perineum

Between the Uterine artery and the Ovarian artery
Between the Uterine artery and the Vaginal artery

10

Describe the blood supply to female perineum

Common Iliac --> Internal Iliac --> Internal pudendal artery --> into Inferior rectal artery AND Dorsal artery of clitoris AND Perineal artery -->Labial arteries

11

Venous drainage of pelvis and perineum drains into

Mainly internal iliac OR
Superior rectal -->Hepatic portal system OR
Lateral sacral veins --> Internal vertebral venous plexus

12

Superior Pelvic Viscera drains into which lymphatic nodes

External iliac nodes -->
Common Iliac nodes -->Aortic --> Thoracic duct --> Venous system

13

Inferior Pelvic Viscera drains into which lymphatic nodes

Deep Perineum AND
Internal Iliac nodes --> Common Iliac nodes --> aortic --> Thoracic duct --> venous system

14

Superficial perineum drains into which lymphatic nodes

Superficial inguinal nodes

15

Where does the gonadal arteries arise

From abdominal aorta

16

Which nerve supply the perineum

Pudendal nerve

17

What imaging methods are used in Gynecology

Ultrasound
CT
MRI
X-ray screening fluoroscopy
Funtional imaging

18

Gynecology imaging: What does HSG stand for and what is it

Hysterosalpingogram --
X-ray test that looks at the uterus and fallopain tube using dye

19

Gynecology imaging: What two main ultrasound techniques are used

Transabdominal
Transvaginal

20

Why should an upper abdominal examination be done prior to USS of pelvis

Ensure there is no hydronephrosis
Detect early ascites
Exclude pelvic abnormality due to primary upper abdominal pathology

21

Should the patient have empty or full bladder prior to Transabdominal USS of pelvis

Full bladder

22

Why should patient's bladder be full prior to USS of pelvis

Distended bladder displaces gas-filled bowel loops out of the pelvis

23

Disadvantages of Transabdominal USS of pelvis

Difficult in obese and gaseous patients
Operator dependent
Difficult to produce identical images (angles) which mean it is hard to follow up treatment progression

24

Benefit of higher frequency ultrasound

Shorter wavelength so better resolution

25

Disadvantages of higher frequency ultrasound

More likely to be scattered so transducer needs to be closer to target

26

Should a bladder be full or empty prior to Transvaginal USS scan

Empty
(A full bladder can make the examination uncomfortable)

27

Second line investigation after Ultrasound in patients presenting with acute abdominal pain

CT scanning

28

Disadvantage of CT scanning

High radiation dose

29

MRI is used in Cancer staging, especially of ____ cancer

Cervical

30

When can a MRI of the head be done in a gynecology setting

Of pituitary gland in patients with suspected prolactinoma

31

What does endometriosis deposits contain

Altered blood and hemoglobin degradation products

32

How can endometriosis be diagnosed

History
MRI
Diagnostic laparoscopy

33

What is another name for Ovarian teratomas

Dermoid cysts

34

What investigation looks at tubal patency in patients with infertility

Hysterosalpingography (HSG)

35

How does Ovarian cancer Disseminate

By peritoneal spread

36

Lymph node, lung and hepatic metastases are common in Ovarian cancer. T/F?

False.
More commonly seen in patients with BRCA1 mutations

37

What is the investigation for staging of Ovarian cancer

CT scan

38

What is the investigation for staging of Cervical cancer

MRI is better at local disease but CT is often used to determine wheter or not htere are distant metastases

39

Cervical cancer spread to

Parametrium, Vagina, Infiltration of adjacent organs (rectum, ureters, urinary bladder)
Metastases to regional lymph nodes (internal iliac and obturator)

40

What can happen if Cervical cancer obstruct the cervical canal

Hydrometra

41

What is the parametrium

Fibrous tissue that separates the supravaginal portion of the cervix from the urinary bladder

42

Investigation for abnormal thickened endometrium

Transvaginal ultrasound

43

What are the indications for Transvaginal ultrasound to look for abnormally thickened endometrium

Post-menopausal patient with post-menopause bleed (PMB)

44

Investigation to assess the degree of myometrial invasion of Endometrial cancer

MRI scan

45

Investigation to look for distant nodal metastases and pulmonary metastases in Endometrial caner

CT scan

46

What is the Menopause

The last menstrual period

47

When is menopause diagnosed

1 year after amenorrhea

48

Average age of menopause

52 years

49

What is the phase encompassing the menopause

Perimenopause
Climateric

50

When is FSH and LH secreted

With pulsatile secretion of GnRH from hypothalmus

51

What is the relation between Serum FSH levels and menopause

Increase and peaks around menopause.
Measured levels >30 IU/L on 2 separate occasions =ovarian failure

52

What are the three important estrogens in women

Estradiol (E2)
Estriol
Estrone (E1)

53

Which Estrogen is predominant in premenopausal women

Estradiol (E2)

54

Which Estrogen is predominant in postmenopausal women

Estrone (E1)

55

Where is Estradiol produced

Produced by the ovaries

56

Where is Estrone produced

Produced by peripheral conversion of androgens in the adipose tissue

57

Which Estrogen is biologically most active, E1 o E2? (full name

E2 (Estradiol) is most active

58

Categorise of Acute symptoms of Menopause

Vasomotor
General
Psychological
Reduced Libido

59

Vasomotor acute symptoms of Menopause

Hot flushes
Night sweats

60

General acute symptoms of Menopause

Headache
Fatigue
Insomnia
Arthralgia
Dizziness

61

Psychological acute symptoms of Menopause

Poor memory
Loss of concentration
Irritability
Low mood
Anxiety

62

Which is the most common symptoms of menopause

Vasomotor (Hot flushes and night sweats)
Predates LMP and most frequent in 1st year post LMP

63

Categories of Medium term effect of menopause

Vaginal
General
Urinary tract

64

Vaginal medium term effect of menopause

Dryness/Itch/burning
Dyspareunia
Sexual dysfunction
Prolapse

65

General medium term effect of menopause

Dry skin
Hair thinning

66

Urinary tract medium effect of menopause

Urinary frequency/nocturia
Urgency
Stress/urge incontinence
Recurrent UTI

67

Long term consequences of menopause

Cardiovascular Disease
Cerebrovascular disease
Osteoperosis

68

Estrogens effect on cholesterol

Reduced LDL
Increases HDL

69

What form can Estrogen be taken in

Tablet
Patch
Gel
Implant

70

What form can comined HRT be taken

Tablets
Patch

71

What hormones are in combined HRT

Estrogen
Progestogen

72

What are the two types of regimes of Combined HRT

Sequential
Continuous

73

Who need combined HRT over Estrogen only HRT, why

Women with uterus requires combined for endometrial protection

74

Difference between hormones in OCP and HRT

OCP contains synthetic estrogens in higher dosage

75

Estrogen only HRT should only be used in what patients

Women with total hysterectomy

76

Patient with subtotal hysterectomy needs HRT, combined or estrogen only and why?

Combined because some endometrium may remain

77

What is the regime of Sequential combined HRT

Estrogen continuous for 28days and Progesterone for the last 10-14 days. Mimics menstrual cycle

78

Who is given sequential combined HRT

Peri-menopausal women with uterus

79

What is the regime of Continuous combined HRT

Estrogen and progesterone continuously for 28days

80

When should continous combined HRT be started

Not until 1 year after LMP or after age 54
After 2years of sequential therapy, switch to continuous

81

What is the benefit of continuous combined HRT

No monthly bleed

82

Continuous or Sequential HRT prescription algorithm

Over 54 or LMP >1y - start CC HRT
Under 54 - Sq HRT for 2y then switch to CC HRT

83

What is an alternative to HRT

Tibolone (for CC HRT)
Testosterone

84

What is Tibolone

Synthetic steroid --> Weak estrogenic, progestongenic and androgenic properties

85

Riks factor of Tibolone in over 60y old patients

Increased risk of stroke

86

Alternative to systemic HRT for vaginal and bladder symptoms

Local estrogen creams/tablets/rings

87

Is additional progestogen needed for Local estrogen preparations

No. Low systemc absorption of estrogen so additional endometrial protection is not required

88

Screening program for women on HRT

Cervix smear every 3y until 60
Mammography every 3y between 50-64
Annual BP checks

89

Estrogen HRT reduces the risk of ____ cancer

Colorectal

90

HRT effect on Osteoperosis

Beneficial, reduced risk of osteoperotic fractures.
Not first line though

91

First line treatment for Osteoperosis

Bisphosphonates

92

Which type of HRT increases risk of breast cancer

Combined HRT

93

Risk of breast cancer and HRT correlation

Increases with duration of use and returns to normal risk within 5 years of stopping HRT

94

HRT and DVT correlation

Oral increase risk, transdermal does not.
More common in first year of use
Combined higher risk than estrogen only HRT

95

HRT and Endometrial cancer risk

Dose and duration dependent
Substantial increase in risk with estrogen only HRT in women with uterus

96

HRT and Ovarian cancer correlation

Long term use may be associated with small increased risk

97

Who has increased risk of CVD with HRT

Women who started combined HRT more than 10y post menopause

98

What is the dosage reccomendations for HRT

Lowest possible dose to control symptoms for the shortest possible time

99

What types of drugs are used against hot flushes but wtih limited evidence

Clonidine
SSRIs
SNRIs
Gabapentin

100

Dietary control of menopasue

Eat phytoestrogens.
Isoflavones and Lingnans which can be found in red clover, soy beans and products, legumes, whole cereals, oilseeds, berries

101

Definition of premature ovarian failure

Cessation of menses and complete/partial loss of ovarian activity before the age of 45

102

Primary causes of Premature ovarian failure

Chromosome abnormalities (Turners syndrome)
Enzyme deficiencies
Autominmmune disorders

103

Secondary causes of Premature ovarian failure

Chemo or Radio therapy
Surgery
Infection

104

Treatment of Premature ovarian failure

HRT in higher dose

105

When does Endometrial polyps occur

Around/after menopause

106

Types of Endometrial hyperplasia

Simple
Complex
Atypical (precursor to carcinoma)

107

How does Endometrial hyperplasia present

Abnormal bleeding (Dysfunctinonal Uterine bleeding or Postmenopausal bleeding)

108

What is the distribution of the types of Endometrial hyperplasia

Simple - General
Complex - Focal
Atypical - Focal

109

What is the component of the types of Endometrial hyperplasia

Simple - Glands and stroma
Complex - Glands
Atypical - glands

110

What is the cytology of the types of Endometrial hyperplasia

Simple - normal
Complex - Normal
Atypical - Atypical

111

When does Endometrial carcinoma occur

Peak incidence 50-60y
Uncommon under 40

112

Underlying predisposition for Endometrial carcinoma

Polycystic ovary syndrome
Lynch syndrome

113

What are the groups of endometrial carincoma

Endometrioid carcinoma
Serous carcinoma

114

What is the precursor lesion of Endometrioid carcinoma

Atypical hyperplasia

115

What is the precursor lesion of Serous carcinoma

Serous intraepithelial carcinoma

116

Endometrial carcinomas microscopic features

Most are adenocarcinoma
Most are well differentiated

117

Endometiral carcinoma macropscopic features

Large uterus
Polypoid

118

Spread of endometiral carcinoma

Local invasion into myometrium and cervix
Lymphatic and hematogenous spread

119

Most common mutation in Endometrial Serous carcinoma

TP53

120

Most common type of Endometrial carcinoma

Endometrioid - 80%

121

What cancers are type 2 endometrial carcinomas

Serous
Clear cell

122

What cancers are type 1 endometrial carcinomas

Endometrioid adenocarcinoma
Mucinous

123

Which mutations are associated with Type 1 endometrial carcinomas

PTEN
KRAS
PIK3CA

124

What is the precursor lesion in type 1 endometrial carcinomas

Atypical hyperplasia

125

What is Lynch syndrome

Genetic DNA mismatch repair with high risk of cancer (Type 1 endometrial cancer)

126

Why is obesity associated with increased risk of Endometrial cancer

Adipocytes express aromatase that converts ovarian androgens to estrogen which induce proliferation
Sex hormone-binding globulin levels are low in obestiy, higher unbound levels of active hormone
Insulin is unbound in obesity which increase proliferative effect on endometrium

127

Lynch syndrome is associated with what types of cancer

Colorectal cancer
Endometrial cancer

128

Inheritance of Lynch syndrome

Autosomal dominant inheritance

129

Which mutation is associated with Type 2 endometiral carcinomas

TP53

130

What is the spread of type 2 endometrial carcinoma

Along fallopan tube mucosa and peritoneal surfaces so can present with extrauterine disease

131

Which is the most aggressive type of Endometrial carcinoma

Type 2

132

Characteristics of Serous carcinoma

Complex papillary and/or glandular archietecture with diffuse, marked nuclear pleomorphism

133

Prognosis of endometrioid carcinoma

Normally good as it usually is confined to uterus at presentation

134

Treatment of Endometrial carcinoma

Hysterectomy
Chemo/radiotherapy

135

Grades or Endometrioid carcinoma

Grade 1 - 5% or less solid growth
Grade 2 - 6-50% solid growth
Grade 3 - >50% solid growth

136

Staging endometrial cancer: Stage 1

1A - no or 50% or myometrium

137

Staging endometrial cancer: Stage 2

Tumor invades cervical stroma

138

Staging endometrial cancer: Stage 3

3 - Local +/- regional tumor spread
3A - Serosa of uterus +/- adnexae
3B - Vaginal +/- parametrial
3C - Metastases to pelvic +/- para-aortic lymph nodes

139

Staging endometrial cancer: Stage 4

Tumor invades bladder +/- bowel mucosa (4A) +/- distant metastases (4B)

140

Other endometrial tumors than carcinomas

Endometrial stromal sarcoma
Carcinosarcoma

141

How is Endometrial stromal sarcoma classified

Low or High grade

142

How is endometrial stromal sarcoma present

Typically with Abnormal uterine bleeding but may present with metastasis (ovary or lung)

143

Leiomyosarcoma is sarcoma of

smooth muscles

144

Rhabdomyosarcoma is sarcoma of

Skeletal muscles

145

How common is Carcinosarcoma

Rare

146

Staging system of Carcinosarcoma

Same as endometrial cancers

147

What is Leiomyoma of myometrium and what is it assoicated with

Smooth muscle tumor of myometrium
Associated with menorrhagia and infertility

148

What is another name of Leiomyoma of myometrium

Fibroids

149

Symptoms of Leiomyosarcoma

Abnormal vaginal bleeding
Palbable pelvic mass
Pelvic pain

150

Prognosis of Leiomyosarcoma

Poor prognosis even if confined to uterus at time of diagnosis

151

Most common causes of Uterine mass

Pregnacy
Fibroids

152

Why is Endometrial and cervical cancer not common causes of Uterine mass

Usually presents early with abnormal bleed

153

When is Uterine fibroids more common

>40y

154

How big are Uterine fibroids

Usually a few cm, may be bigger and multiple

155

Types of uterine fibriods

Intramural
Submucous
Subserous
Intracavitary
Pedunculated

156

How may uterine fibroids present

incidential
Menhorrhagia
Pelvic mass
Pain/tenderness
Pressure symtomps

157

What ethnic group more commonly gets uterine fibroids

Afro Carribean population

158

Investigation of suspected fibroids

Hemoglobing (if heavy bleed)
Ultrasound
MRI

159

Where does Subserous fibroids grow

Outside of the uterus

160

Treatment of Uterine fibroids

Hysterectomy if family complete
Myomectomy
Uterine artery embolisation
Hysterocopic resection
Nothing if asymptomatic

161

Cause of fallopian tube swelling

Ectopic pregnancy
Hydrosalpinx
Pyosalpinx
Paratubal cysts

162

What is Pyosalpinx

Fallopian tube filled with pus
Caused by inflammation

163

What are chocolate cysts

Endometriomas

164

What is Endometriomas associated with

Severe dysmenhorrhea
Premenstrual bleed
Dyspareunia
Subfertility

165

Common presentation of Endometrial cancer

Post-menopausal bleeding
Rarely present with pelvic mass

166

What are uterine fibroids also called

Leiomyomas of the uterus smooth muscle

167

Who gets uterine fibroids

Common
Women over 40

168

Most common type of Uterine fibroids

Intramural,
Within the wall of the uterus

169

Which uterine fibroids is located deepest, submucous or subserous

Submucous

170

What is myomectomy

Surgical removal of just the uterine fibroid, leaving the uterus intact

171

Most common type of Tubal swelling

Ectopic pregnancy

172

Treatment of Ectopic pregnancy

Cut it out
Methotrexate is used to medically remove the ectopic pregnancy

173

What is a functional ovarian cyst

Sac that is formed when the egg is maturing becomes a cyst when it gets fluid filled. Sac is normal but cyst is pathological

174

What are the two types of functional ovarian cyst

Follicular cyst
Luteal cyst

175

What is follicular cyst

Functional ovarian cyst
Sac does not release egg but is filled with fluid to form the cyst

176

What is a Luteal cyst

Functinonal ovarian cyst
Sac release egg but then closes and fills with water to form a cyst

177

Treatment for functional ovarian cyst

Usually resolve spontaneously, wait and see

178

What is endometriosis

Endometrium in wrong place

179

Endometriotic cysts are associated with what symptoms

Dysmenhorrhea
Premenstrual pain
Dyspareunia
Subfertility

180

Why are Endometriotic cysts called chocolate cysts

Because they are blood filled and look like chocolate

181

What type of precursor area can primary ovarian tumors arise

Surface epithelium
Germ cells
Stroma

182

What Ovarian tumors arise from the surface epithelium

Serous -- Mucinous -- Endometrioid -- Clear cell -- Brenner

183

What Ovarian tumors arise from the Germ cells

Benign cystic Teratoma
Malignant germ cell tumors

184

What Ovarian tumors arise from the Stroma

Granulosa cell
Theca/Leydig cell
Fibroma

185

What is Meig's syndrome

Triad of Ascites, pleural effusion (more on right) and an Ovarian tumor (most commonly Fibroma)

186

Granulosa cell ovarian tumor may secrete

Estrogen

187

A patient has abnormal levels of androgens, what type of Ovarian tumor may be responsible

Theca or Leydig cell tumor

188

Dermoid cyst may cause which endocrinology disorder

Thyrotoxicosis if it contains thyroid tissue

189

Increased levels of HCG may be due to which ovarian tumor

Malignant germ cell tumors

190

Which ovarian tumor may present with hirsutism and virilisation

Thecal tumors

191

What type of cancers metastasize to Ovaries

Breast
Pancreas
Stomach
GI

192

How is Ovarian cancer presented

May be mass, swelling or mass symptoms
More commonly found due to spread due to early transperitoneal spread

193

Symptoms of ovarian cancers

Varied: Hearthburn - early satiety - Weight loss - Bloating - Pressure symptoms - Bowel habit change - SOB/Pleural effusion - Leg edema or DVT

194

Which genes pre disposes for Ovarian cancer

BRCA 1 and 2
HNPCC (Hereditary nonpolyposis colorectal cancer)

195

HNPCC is also called

Lynch syndrome

196

Lynch syndrome/HNPCC causes

Bowel cancer
Endometrial cancer
Ovarian cancer
Many other cancers

197

Risk factors for Ovarian cancers

Increasing age
Nulliparity
Family history

198

What is protective for Ovarian cancer

Oral contraceptive pill

199

What tumor markers are raised in Ovarian cancer

CA 125
Carcino-embryonic antigen CEA

200

Why is CA 125 not a great marker for cancer

Because it can be raised in alot of things, ie fibroids. And normal levels does not exclude cancer

201

Why is Carcino embryonic antigen not great marker for cancer

Can be raised in heavy smokers

202

What is the main function of CEA in ovarian cancers

Exclude that it's mets from primary colorectal cancer

203

What is the formula of ovarian cancer Risk of Malignancy Index

RMI= Menopausal status x Serum CA125 x Ultrasound score

204

What is looked at in the Ultrasound score for the RMI

1 point for each of: Multilocular cysts, solid areas, metastases, ascites and bilateral lesions. No point is 0, 1 point is 1, >2 is 3.

205

What is menopausal scoring for RMI

1= perimenopausal
3= post-menopausal

206

Treatment of Ovarian cyst if benign

Removal or drainage

207

Treatment of Ovarian mass if malignant

Removal +remove peritoneum and more
Chemotherapy before or after

208

How likely is cure of Ovarian cancer

Unlikely unless confined to ovary only at presentation

209

How is a mass described

Size -- Consistency -- Surface -- Tenderness -- Mobility -- Relation to uterus -- Pouch of Douglas

210

What are Follicular cysts lined by

Granulosa cells

211

How is Malignant serous carcinomas typed

Low grade
High grade

212

An Epithelial Ovarian Tumor that is categorized as Benign has what features

No cytological abnormalities, proliferative activity absent o scant
no stromal invasien

213

An Epithelial Ovarian Tumor that is categorized as Borderline has what features

Cytological abnormalities, proliferative
No stromal invasion

214

An Epithelial Ovarian Tumor that is categorized as Malignant has what features

Cytological abnormalities, proliferative
Stromal invasion

215

High Grade serous carcinoma is also called

Serous tubal intraepithelial carcinoma (STIC)

216

Brenner tumor is of what cell, benign or malignant?

Tumor of transitional type epithelium
Usually bening but borderline and malignant are rare

217

What germ cells layer is in a Teratoma

All
Ectoderm, mesoderm, endoderm

218

What type of tumor is Choriocarcinoma? associated with what

Germ cell tumor
Molar pregnancies

219

Most common type of malignant germ cell tumor

Dysgerminoma

220

Figo staging of Ovarian cancer, 1A

Cancer Tumor limited to one ovary

221

Figo staging of Ovarian cancer, 1B

Cancer Tumor of both ovaries

222

Figo staging of Ovarian cancer, 1C

Cancer in ovary and or the surface of one ovary

223

Figo staging of Ovarian cancer, 2A

Cancer in ovary extending or implanting onto uterus/fallopian tube

224

Figo staging of Ovarian cancer, 2B

Cancer has spread to the bowel or bladder

225

Figo staging of Ovarian cancer, 3A

Retroperitoneal lymphnode spread
Metastasis or microscopic extrapelvic peritoneal involvement

226

Figo staging of Ovarian cancer, 3B

Macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension

227

Figo staging of Ovarian cancer, 3C

Macroscopic peritoneal metastasis >2cm in dimension

228

Figo staging of Ovarian cancer, 4

Distant metastasis

229

Female of reproductive age with amenorrhea and acute hypotension, always think

Ectopic pregnancy rupture

230

Female of reproductive age with amenorrhea and an acute abdomen, always think

Ectopic pregnancy

231

Done week 7

Yes