Women's health - gynaecology Flashcards
(294 cards)
1
Q
What is considered in the field of gynaecology?
A
- Female organ problems
- Pregnancy before 13 weeks
2
Q
How long is a normal menstrual cycle?
A
21-35 days
3
Q
What are the stages of the ovarian menstrual cycle and how long do they last?
A
- Follicular (d1-13)
- Ovulation (d14)
- Luteal (d14-28)
4
Q
What are the stages of the uterine menstrual cycle and how long do they last?
A
- Menses (d1-5)
- Proliferative (d6-14)
- Secretory (d15-28)
5
Q
What is considered the first day of the menstrual cycle?
A
The first day of the menstruation
6
Q
When is the fertile window in the menstrual cycle?
A
5 days before ovulation until the day after ovulation (so d9-15)
7
Q
Draw out the menstrual cycle - phases of cycle, thickness of the endometrium and levels of oestrogen and progesterone.
A
Follow link, scroll to bottom of page
https://zerotofinals.com/obgyn/reproductivesystem/menstrualcycle/
8
Q
What stimulates LH and FSH production?
A
Gonadotrophin releasing hormone
9
Q
Where are LH and FSH released from?
A
Anterior pituitary
10
Q
Where is oestrogen released from?
A
Theca and granulose cells in ovaries
11
Q
What causes the release of oestrogen?
A
LH + FSH
12
Q
What are the effects of oestrogen (4)?
A
- Growth + development of breast + female reproductive organs
- Increase BMD
- Growth of endometrium
- Development of blood vessels in uterus
13
Q
Where is progesterone released from?
A
Corpus luteum
14
Q
What are the functions of progesterone (3)?
A
- Maintain endometrial thickness
- Thicken cervical mucous
- Increase body temp
15
Q
What does FSH act on and what does it do?
A
Granulose cells –> stimulates folliculogenesis
16
Q
What effect does oestrogen alone have on LH and FSH?
A
Increases LH levels and FSH
17
Q
What effect does high oestrogen and progesterone have on LH and FSH?
A
Negative feedback
18
Q
What are the main presenting complaints in gynaecology (9)?
A
- Amenorrhoea (no periods)
- Irregular menstruation
- Intermenstrual bleeding
- Dysmenorrhoea (painful periods)
- Menorrhagia (heavy periods)
- Postcoital bleeding
- Pelvic pain
- Vaginal discharge
- Pruitis vulvae (itchy vagina)
19
Q
When does puberty in girls typically begin?
A
8 to 13 years
menarche 2 years after this
20
Q
What are the two types of amenorrhoea?
A
- Primary - never started periods
- Secondary - > 3 months no period (in normally regularly menstruating woman)
21
Q
What is primary amenorrhoea defined as (2)?
A
- No periods + no evidence of puberty at 13 years
- All 15 year olds without periods
or 3 years after starting breast development
22
Q
What is the first sign and stages of puberty in females (3)?
A
- 1st = breast buds
- 2nd = pubic hair
- 3rd = menstruation
23
Q
What are the two fundamental causes of primary amenorrhoea?
A
- Hypogonadotrophic hypogonadism
- Hypergonadotrophic hypogonadism
24
Q
What are some causes of hypogonadotrophic hypogonadism (5)?
A
- Hypopituitarism
- Delayed growth + development (but otherwise normal)
- Excessive exercise/ dieting/ failure to thrive
- Endocrine disorders e.g. hypothyroidism/ growth hormone deficiency
- Kallman syndrome
25
What are some causes of hypergonadotrophic hypogonadism (relating to primary amenorrhoea) (4)?
* Turners syndrome
* Damage to ovaries e.g. cancer, torsion, infection
* Absence of ovaries
* Androgen insensitivity syndrome (although high levels of sex hormones this is still hypogonadism as the function is decreased)
26
What other condition may cause primary amenorrhoea?
Congenital adrenal hyperplasia (this often causes high levels of androgens, but lack of periods)
27
How is primary amenorrhoea typically investigated (6)?
* Standard bloods - coeliac screen, U&E for CKD, anaemia
* FSH, LH levels
* TFTs
* ILGF-1
* Genetic testing
* USS + other imaging
28
What are some causes of secondary amenorrhoea (8)?
* Pregnancy
* Menopause
* **PCOS**
* Hyperprolactinaemia
* Psychological/ physiological stress (weight loss/ extreme exercise)
* Ashermans syndrome
* Sheehans syndrome (damage to pituitary gland - typically after birth due to shock)
* Hyperthyroidism
29
Why does hyperprolactinaemia cause amenorrhoea?
Prolactin acts on hypothalamus to prevent GnRH release --> low LH + FSH --> no periods
30
How is secondary amenorrhoea investigated (3)?
* Hormone bloods
* USS
* Urine bHCG
31
What is included in the hormone blood tests for secondary amenorrhoea?
* FSH +LH
* Prolactin
* TSH
* Testosterone
32
What are some congenital structural abnormalities that occur in females (4)?
* Bicornuate uterus
* Imperforate hymen
* Transverse vaginal septum
* Vaginal hypoplasia and agenesis
33
What is a bicornuate uterus?
Uterus with two horns (heart shaped appearance)
34
What are some complications of bicornuate uterus (3)?
* Miscarriage
* Premature birth
* Malpresentation
35
How does an imperforate hymen present?
When girls start to menstruate they will get 'period cramps' but without any bleeding
36
What is a transverse vaginal septum?
Septum forms transversely across the vagina - can be imperforate or perforate (with a hole)
*presents similarly to imperforate hymen*
37
What is vaginal hypoplasia and agenesis?
Abnormally small or non-existent vagina
38
What causes vaginal hypoplasia and agenesis?
Failure of mullerian ducts to properly develop
39
What is the typical amount of blood lost during menstruation?
40 ml
40
What is considered menorrhagia in terms of blood loss?
> 80ml
*rarely measured in practice - rely on history*
41
What causes menorrhagia (2 big ones, 6 others)?
* **Dysfunctional uterine bleeding**
* **Fibroids**
* IUD
* Hypothyroidism
* Bleeding disorders
* Endometriosis + adenomyosis
* PCOS
* Cancers
42
How is menorrhagia investigated (3)?
* FBC, clotting, ferritin, TFTs
* USS
* Hysteroscopy
43
What is dysfunctional uterine bleeding?
No identifiable cause for the menorrhagia
44
How is dysfunctional uterine bleeding managed symptomatically (2)?
* Transexamic acid (reduces bleeding)
* Mefanamic acid (when there is associated pain - reduces bleeding and pain, type of NSAID)
45
How is dysfunctional uterine bleeding typically treated (3)?
1. Mirena coil
2. COCP
3. Cyclical oral progesterones
46
What is a fibroid also known as and what are they?
Uterine leiomyomas - benign tumours of the smooth muscle
47
What age are fibroids most common?
Child bearing age 30-50 years old
48
What percent of females have fibroids of child bearing age?
1/3rd
49
What tends to happen to fibroids after menopause?
Shrink as oestrogen sensitive
50
What are the types of fibroids (4)?
* **Subserosal** = just below the outer layer of uterus - can grow to fill abdomen
* **Intramural** = within the myometrium
* **Submucosal** = just below the lining of uterus (endometrium)
* **Pedunculated** = on a stalk
51
What are some risk factors for fibroids (4)?
* Nulliparous
* Black
* Early menarche/ late menopause
* Obesity
52
What are the signs/ symptoms of fibroids?
* **Menorrhagia**
* Prolonged periods (> 7 days)
* Abdo pain
* Deep dyspareunia
* Reduced fertility
* Bowel/ urinary Sx/ bloating
53
How are fibroids investigated (3)?
* Bimanual exam = large, irregular, non tender uterus
* TV USS
* Hysteroscopy
54
How are fibroids managed medically (3)?
Same as dysfunctional endometrial bleeding:
* Mirena coil
* COCP
* Symptomatic management = transexamic acid
55
How can fibroids be managed surgically (4)?
* Uterine artery embolisation
* Hysteroscopic endometrial ablation/ resection
* Myomectomy
* Hysterectomy
56
What size should fibroids be referred?
Larger than 3 cm
57
What is uterine artery embolisation?
Radiologically guided catheter insertion --> particles injected to block artery to fibroid
58
What is myomectomy?
Laparoscopic procedure to remove fibroid
59
What is a big advantage of myomectomy?
Can improve fertility in women of child bearing age
60
What are some complications of fibroids (6)?
* **Red degeneration**
* Reduced fertility
* Pregnancy complications
* Malignant change (very rare)
* IDA
* Torsion (usually affecting pedunculated fibroids)
61
What is red degeneration?
Ischemia, infarction, necrosis of fibroid due to interruption of blood supply
62
When does red degeneration often present?
During pregnancy - often in 2nd + 3rd trimester due to changing shape of uterus interrupting the blood supply
63
How does red degeneration present (4)?
* Mild fever
* Tachycardia
* Vomiting
* Pain
64
How is red degeneration managed?
Supportive
65
What is a differential for a fibroid (2)?
* **Endometrial polyps**
* Malignant tumours
66
What is dysmenorrhoea?
Painful periods
67
What are some causes of painful periods (6)?
* Primary dysmenorrhoea (no underlying cause)
* **Endometriosis**
* **Adenomyosis**
* Fibroids
* PID
* IUD
68
What are the features of primary dysmenorrhoea (2)?
* Present from menarche (or within 1-2 years)
* Just before or after start of period (not days before)
69
How is primary dysmenorrhoea managed (2)?
1. NSAIDs e.g. mefenamic acid
2. COCP
70
What is endometriosis?
Ectopic endometrial tissue (outside the uterus)
71
What age does endometriosis most commonly occur?
20-40 year old
72
What percentage of females have endometriosis in uk?
10%
73
Where does endometrial tissue sometimes form (4)?
* Urinary tract
* Bowel
* Abdomen (especially ovaries)
* Thorax (may present with cyclical haemoptysis)
74
What are some theories for the cause of endometriosis (4)?
* **Retrograde menstruation**
* Embryonic cells destined to become endometrial tissue remained outside uterus during development
* Spread via lymphatic system
* Cells change via metaplasia
75
What are some risk factors for endometriosis (5)?
* Nulliparous
* Early menarche/ late menopause
* Vaginal outflow obstruction
* Autoimmune disease
* Family history
76
What are the signs/ symptoms of endometriosis (5)?
* Cyclical abdo/ pelvic pain
* Dysmenorrhoea
* Deep dyspareunia
* Infertility
* Cyclical bleeding (in GI or uriniary or resp tract)
77
How is endometriosis investigated (3)?
* Bimanual vaginal exam + abdo exam (adnexal motion tenderness + fixed retroverted uterus)
* **TV USS** = first line
* **Laparoscopic surgery** = gold standard
78
What is a staging system that can be used for endometriosis?
ASRM (stages 1-4)
*american society of reproductive medicine*
79
How is endometriosis managed (5)?
* NSAIDs
* COCP
* GnRH analogue
* Laparoscopic ablation/ excision
* Hysterectomy
80
What does a GnRH analogue do?
Prevents the anterior pituitary producing LH and FSH
81
What is an example of a GnRH analogue?
Goserelin
82
What is endometrial tissue in the ovaries known as?
Chocolate cyst
83
What is a side effect of GnRH analogues?
OSTEOPOROSIS (no oestrogen)
84
What are the different types of hysterectomy (4)?
* Partial hysterectomy = ONLY uterus
* Total hysterectomy = uterus + cervix
* Radical hysterectomy = uterus + cervix + part of vagina/ soft tissues
* Hysterectomy with bilateral salpingo-oophrectomy = uterus + cervix + fallopian tubes + ovaries
85
What is a major differential/ sister condition of endometriosis?
Adenomyosis
86
What is adenomyosis?
Endometrial tissue in myometrium
87
What are some risk factors for adenomyosis (2)?
* Multiparous
* Uterine surgery/ trauma
*
88
What age does adenomyosis typically occur?
Later in reproductive age (35-45)
*resolves with menopause*
89
What percentage of women are affected by adenomyosis?
10%
90
What are the signs/ symptoms of adenomyosis (4)?
* Dysmenorrhoea/ cyclical pain
* Menorrhagia
* Deep dyspareunia
* Subfertile
91
How is adenomyosis investigated (3)?
* Bimanual exam
* TV USS
* Excision + biopsy (post hysterectomy)
92
What is the classic finding on a bimanual exam for adenomyosis?
BOGGY uterus
93
How is adenomyosis managed (6)?
* Symptomatic = transexamic/ mefenamic acid
* Mirena coil = first
* COCP
* Cyclical oral progesterones
* GnRH analogues
* Surgery (hysterectomy, myomectomy, uterine artery embolisation)
+ REFER
94
What are some complications on pregnancy of adenomyosis (7)?
* Miscarriage
* Infertility
* Preterm
* Small for gestational age
* Malpresentation
* PPH
* C-section (increased likelihood)
95
What is polycystic ovarian syndrome?
A metabolic and reproductive condition causing multiple cysts (immature follicles) on the ovaries
96
What criteria are used to diagnose PCOS?
Rotterdam criteria
97
What are the Rotterdam criteria to diagnose PCOS (3)?
* Oligo/anovulation (irregular/ absent periods)
* Hyperandrogenism (hirtuism + acne)
* Polycystic ovaries/ ovaries over 10cm^3 on USS
98
How many Rotterdam criteria are needed for a diagnosis of PCOS?
2 out of 3
99
What are the signs/ symptoms of PCOS (8)?
* Oligo/anovulation (or oligo/amenorrhoea)
* Infertility
* Obesity (up to 70% of people with PCOS)
* Hirsutism
* Acne
* Male pattern hair loss
* Mood swings
* Acanthosis nigricans
100
What are some complications of PCOS (5)?
* Insulin resistance/ diabetes
* Infertility
* **Endometrial hyperplasia + cancer**
* OSA
* Metabolic syndrome
101
What is metabolic syndrome?
At least 3 of the 5 medical conditions:
* Abdo obesity
* High blood pressure
* High blood sugar
* High serum triglycerides
* Low HDL
102
What are the effects of insulin resistance on PCOS (3)?
* Insulin increases production of androgens (e.g. testosterone)
* Insulin surpreses sex hormone binding globulin (SHBG) --> more testosterone free in blood --> hirsutism
* Insulin further halts the development of follicles in ovaries --> anovulation
103
Other than PCOS what are some other causes of hirsutism (3)?
* Medications (e.g. steroids, phenytoin - anticonvulsant)
* Cushings
* Congenital adrenal hyperplasia
104
How is PCOS investigated (3)?
* Bloods
* TV USS
* OGTT (check for diabetes - not HbA1C)
105
What blood are done on those with PCOS (5)?
* Testosterone
* LH + FSH
* SHBG
* Prolactin
* TSH
106
What would the blood test results typically show for those with PCOS?
* **Raised LH**
* **Raised LH:FSH ratio**
* Raised testosterone
107
What finding on ultrasound would satisfy one of the Rotterdam criteria (2)?
either:
* Ovary more than 10cm^3
* 12 or more developing follicles in one ovary
*"beads on string" appearance*
108
How is PCOS managed?
* **Lifestyle advice**
109
What are some examples of lifestyle advice for those with PCOS?
* Weight loss
* Stop smoking
* Exercise
110
How can increased risk of endometrial cancer be managed for those with PCOS?
Mirena coil
111
How can reduced fertility be managed in those with PCOS (3)?
* Clomifene (induces OVULATION)
* Metformin
* IVF
112
How can hirsutism be managed in those with PCOS (4)?
* COCP
* Topical eflornifine
* Spironolactone (reduces androgens)
* Laser hair removal
113
How is acne managed in those with PCOS?
COCP
114
What are the important gynaecological cancers to know about (4)?
* Endometrial cancer
* Cervical
* Ovarian cancer
* Vulval cancer
115
How are all gynaecological cancers staged?
Using FIGO staging criteria
*International Federation of Gynaecology and Obstetrics*
116
What is the most common gynaecological cancer worldwide?
Cervical
*endometrial in UK - due to HPV vaccine*
117
When should endometrial and cervical cancer be suspected?
* Endometrial = post menopausal bleeding (until proven otherwise)
* Cervical = intermenstrual
118
What is the most common type of endometrial cancer?
Adenocarcinoma (80%)
*starts in glandular tissue*
119
What is a key feature of endometrial cancer in terms of its pathophysiology?
It is oestrogen sensitive
120
What are the two types of endometrial cancer?
* Type 1 = oestrogen sensitive (often remain within uterus)
* Type 2 = rarer, faster growing, spread outside uterus, may resemble ovarian tumours
121
What is the histology of type 2 endometrial cancers (2)?
* Clear cell carcinoma
* Serous carcinoma
122
What are the two main categories of risk factors for endometrial cancer?
* Unopposed oestrogen
* Family history / genetics
123
What causes increased exposure to unopposed oestrogen (8)?
* Nulliparous
* Obesity (adipocytes produce oestrogen)
* Early menarche
* Late menopause
* PCOS
* Oestrogen only HRT
* TAMOXIFEN
* Increased age
* T2DM
124
What are two genes responsible for endometrial cancer (2)?
* HNPCC (hereditary non-polyposis colorectal cancer/ Lynch syndrome)
* PTEN
*Lynch is the most common inherited type of endometrial cancer (autosomal dominant)*
125
What is protective against endometrial cancer (5)?
* COCP
* IUS
* Breastfeeding
* Multiparity
* SMOKING
126
What are the signs/ symptoms of endometrial cancer (7)?
* **Postmenopausal bleeding**
* Postcoital bleeding
* Intermenstrual bleeding
* Dyspareunia
* Pelvic mass
* Anaemia
* Abnormal vaginal discharge
127
How should all postmenopausal bleeding be managed?
2 week wait referral
*if > 12 months after last period*
128
What would endometrial cancer feel like on bimanual exam?
Large irregular uterus
129
How is endometrial cancer investigated (2)?
* TV USS = 1st
* Hysteroscopy + **biopsy** (or pipelle biopsy) = gold standard
130
What would a USS show for those with endometrial cancer?
Increased endometrial thickness > 5mm
131
How is endometrial cancer staged?
1. Confined to uterus
2. + cervix
3. + pelvis e.g. LN, ovaries, vagina
4. Extrapelvic e.g. bladder, rectum
132
How is endometrial cancer managed (2)?
* Stages 1 + 2 = total abdominal hysterectomy + bilateral salpingo-oophorectomy
* Stages 3/4 = radical hysterectomy + chemo/ radiotherapy
133
What are the most common types of cervical cancer (2)?
* **Squamous cell carcinoma** (80%)
* Adenocarcinoma (10%)
134
Who is the typical patient with cervical cancer?
Sexually active 30-45 y/o female
135
What is the main risk factor for cervical cancer?
**HPV**!!!!!
*human papilloma virus*
136
What are the types of HPV most commonly responsible for cervical cancer?
16 and 18
137
How does HPV increase the risk of cervical cancer?
Inhibits two tumour suppressor genes P53 and pRb
138
Other than HPV infection what are some risk factors for cervical cancer (8)?
* Unprotected sex
* Lots of sexual partners
* Early sexual activity
* Not participating in screening
* Not vaccinated
* COCP (for more than 5 years)
* Smoking
* HIV/ immunosuppressed
139
When are HPV vaccines given?
12/13 year old
140
What are the signs/ symptoms of cervical cancer (4)?
* **Intermenstrual bleeding**
* **Post coital bleeding**
* Vaginal discharge
* Deep dyspareunia
141
How is cervical cancer investigated (2)?
* Speculum = masses/ ulcerations
* Colposcopy + biopsy
*smear not performed for suspected cervical cancer*
142
How is cervical cancer frequently identified?
Cervical smear test
143
When are women screened for cervical cancer?
* Every 3 years from 25-49
* Every 5 years from 50-64
144
What are some exceptions to the cervical screening programme (3)?
* Pregnant women should wait until 12 weeks post party
* HIV +ve patients have yearly screens
* Women menstruating should wait until it is over
145
How are smear tests analysed (2)?
1. High risk HPV identified
if high risk found...
2. Cells examined
146
How is an inadequate sample smear managed?
1. Repeat smear again in 3 months
2. Refer for colposcopy
147
How is a HPV +ve smear managed?
1. Repeat smear in 12 months
2. Repeat smear in 12 months
3. Refer for colposcopy
148
What are premalignant changes in cervical cells known as?
Cervical intraepithelial neoplasia (CIN)
149
What are the 3 types of CIN?
* CIN 1 = mild dysplasia
* CIN 2 = moderate dysplasia
* CIN 3 = severe dysplasia (carcinoma in situ) - likely to progress to cancer
150
How is CIN and cervical cancer distinguished between?
Cervical biopsy during colposcopy
151
What are the two types of biopsy that can be done after an abnormal cervical screen result?
* LLETZ (large loop excision of the transformation zone) - smaller number of cells removed
* Cone biopsy - larger number of cells removed
152
How is cervical cancer staged?
1. = confined to cervix (A=microscopic; B=visible)
2. = upper 2/3rds vagina or uterus
3. = lower 1/3rd vagina or pelvic wall
4. = bladder/ rectum/ extrapelvic
153
How is cervical cancer and CIN managed (3)?
* CIN = LLETZ/ cone biopsy
* Stage 1-2A = radical hysterectomy + LN clearance (+/- chemo/radio) or radical trachelectomy
* Stage 2B + = chemo (cisplastin)/ radio/ palliative care
154
How is CIN 1 managed?
Usually just monitored as most regress
155
What are the most common types of ovarian tumours (3)?
1. Epithelial cell tumours
2. Germ cell tumours
3. Sex-cord stromal tumours
156
What is the most common epithelial cell tumour in the ovaries?
Serous tumour
157
What are the most common germ cell tumours in the ovary (2)?
* Mature teratoma (dermoid cyst - benign, contain teeth/ hair)
* Dysgerminoma = most common malignant
158
What are two types of sex-cord stroll tumours in the ovaries?
* Sertoli-leydig
* Granulosa
159
Is the prognosis good or bad for ovarian cancer?
Pretty bad
*in 70% of women the cancer has spread beyond the pelvis*
160
What is a metastisy in the ovary known as?
Krukenberg tumour
*usually from the GI tract*
161
What are some risk factors for ovarian cancer (5)?
* Age (peaks at 60 y/o)
* Smoking
* Unopposed oestrogen (obesity, early periods, late menopause, etc.)
* Family history/ genetics
* Recurrent use of clomifene
*factors that increase number of ovulations*
162
What is clomifene?
Fertility medication
163
What genes increase the risk of ovarian cancer?
BRCA 1 and 2
164
What are some protective factors for ovarian cancer (3)?
* COCP
* Breastfeeding
* Pregnancy
*factors that reduce number of ovulations*
165
What are the signs/ symptoms of ovarian cancer (8)?
* **Any new IBS-like symptoms**
* Abdo bloating
* Early satiety/ loss of appetite
* Weight loss
* Pelvic pain
* Urinary Sx (e.g. frequency/ urgency)
* Abdo/ pelvic mass
* Ascites
166
What ovarian cancer symptoms should be referred under 2 week wait (3)?
* Pelvic mass
* Abdo mass
* Ascites
167
How is ovarian cancer investigated (3)?
* 1st = CA-125 + TVUSS
* Gold = pipelle biopsy
* Staging = CT
168
What extra investigations should be done for ovarian cancer in women under 40 (i.e. germ cell tumour suspected) (2)?
* AFP (alpha-fetoprotein)
* HCG (human chorionic gonadotropin)
169
How is the risk of malignancy assessed in those with suspected ovarian cancer (3)?
* CA-125
* Postmenopausal
* USS findings
170
Other than ovarian cancer, what can cause a raised CA-125 (4)?
* Endometriosis/ adenomyosis
* Fibroids
* Pelvic infection
* Pregnancy
171
How is ovarian cancer staged?
1. Ovaries
2. + pelvis
3. + abdomen
4. = distant mets
*FIGO criteria*
172
How is ovarian cancer managed (3)?
* MDT with gynae-oncology
* Hysterectomy + bilateral salpingo-oophrectomy
* Chemo/ radio
173
What bloods should be done pre surgery (for something like a hysterectomy + bilateral salpingo-oophrxectomy for ovarian cancer) (3)?
* FBC = anaemic?
* Group + save = for transfusion
* Clotting screen = bleeding risk
174
What are the most common types of vulval cancer (2)?
* Squamous cell carcinoma (90%)
* Melanoma (10%)
175
Which part of the vulva is most commonly affected by cancer?
Labia majora
176
What are the two types of person vulval cancer typically might affect?
* Older woman (75+) with **lichen sclerosis**
* Younger woman (35-45) with HPV infection
177
What are the signs/ symptoms of vulval cancer (6)?
* Vulvodynia (vulval pain)
* Superficial dyspareunia
* Ulcers
* Bleeding
* Itching
* Lymphadenopathy (in region)
178
What does vulval cancer typically look like?
Irregular, fungating lesion
179
How is vulval cancer investigated (4)?
* 2WW referral for suspected vulval cancer
* Biopsy of lesion
* Sentinel node biopsy
* Further imaging (e.g. CT)
180
How is vulval cancer managed (3)?
* Wide local excision
* LN removal
* Chemo/ radio
181
What is a precancerous lesion of the vulva associated with HPV infection?
Vulval intraepithelial neoplasia
182
What is the cause of the majority of vaginal cancers?
Secondary to vulval cancer
183
Who do ovarian cysts most commonly affect?
Premenopausal women
184
Ovarian cysts signs/ symptoms (4)?
* Pelvic pain
* Bloating
* Fullness
* Pelvic mass
185
How can ovarian cysts be categorised (3)?
* Functional (from normal processes)
* Neoplastic (overgrowth of abnormal cells e.g. endometriosis and ovarian cancers)
* Non-functional (PCOS)
186
What are the two types of functional cysts?
* Follicular cyst
* Corpus luteum cyst
187
What are some complications of ovarian cysts (4)?
* Cyst rupture
* Cyst haemorrhage
* Ovarian torsion
* Meigs syndrome
188
How do ovarian cyst rupture, haemorrhage and ovarian torsion present?
Severe acute pain
189
What is Meig syndrome (3)?
* Ovarian fibroma (benign ovarian tumour)
* Pleural effusion
* Ascites
*resolves after tumour removal*
190
What is ovarian torsion?
When the ovary twists in relation to the surrounding Fallopian tube and blood supply
191
What age is ovarian torsion most common?
15 - 45 year old
192
What are some risk factors for ovarian torsion (3)?
* Ovarian cysts
* Pelvic surgery
* Pregnancy
193
What are the signs/ symptoms of ovarian torsion (4)?
* **Sudden severe unilateral pelvic pain**
* N+V
* Localised tenderness
* Palpable mass
194
How is ovarian torsion investigated (3)?
* B-hCG
* TV USS
* Laparoscopic surgery = definitive
195
What are the ultrasound finding of those with ovarian torsion (3)?
* **"Whirlpool sign"**
* Free fluid in pelvis
* Ovary oedema
196
How is ovarian torsion managed (2)?
* Surgical detorsion
* Oophrectomy (if dead)
197
What are some complications of ovarian torsion (3)?
* Infection --> abscess --> sepsis
* Rupture
* Peritonitis
198
What are 3 key differential diagnoses for ovarian torsion?
* Ectopic pregnancy
* Appendicitis
* Cyst rupture/ haemorrhage
199
What is cervical ectropion?
Collumnar epithelium of the ednocervix extends into exocervix
200
What is the transformation zone?
Border between columnar epithelium of the endocervix and stratified squamous epithelium of the exocervix
201
What are some risk factors for cervical ectropion (3)?
* Younger women
* Pregnancy
* COCP
*associated with high oestrogen levels*
202
What are the signs/ symptoms of cervical ectropion (3)?
* Increased vaginal discharge
* Post coital bleeding
* Deep dyspareunia
203
How is ectropion managed (3)?
* Reassurance
* Stop COCP --> POP
* Surgical ablation
204
What is pelvic organ prolapse?
Decent of the pelvic organs into the vagina
205
What causes pelvic organ prolapse (3)?
* Weakness/ lengthening of the ligaments/ muscles surrounding the bladder/ rectum/ uterus
* Weakness of the vaginal wall (muscle)
* Increased intrabdominal pressure
206
What is the most common type of pelvic organ prolapse?
Cystocele (prolapse of bladder)
207
What are the types of pelvic organ prolapse (5)?
* Cystocele = MC
* Uterine prolapse
* Vault prolapse
* Rectocele
* Urethrocele (cystourethrocele)
208
Which part of the vagina wall does each pelvic organ prolapse come through (3)?
* Cystocele + urethrocele = anterior wall
* Uterine prolapse + vault = apical prolapse (apex of vagina)
* Rectocele = posterior vaginal wall
209
What is a vault prolapse?
Women with a hysterectomy whose top of vagina descends into the vagina
210
What are some risk factors for pelvic organ prolapse (6)?
* Older age (50+)
* Multiparity
* Traumatic delivery
* Obesity
* Chronic cough
* Chronic constipation
211
What are the signs/ symptoms of pelvic organ prolapse (5)?
* Feeling of 'something coming down'
* Dragging/ heavy sensation in vagina
* Urinary Sx (incontinence, urgency, frequency, weak stream)
* Bowel Sx (constipation, incontinence, urgency)
* Sexual dysfunction (pain, reduced enjoyment)
212
How is pelvic organ prolapse examined?
**Sims speculum** is used to hold wall of vagina out the way whilst prolapse is examined
213
What are women often asked to do during examination of a pelvic organ prolapse?
Cough/ bear down
214
How is the extent of a pelvic organ prolapse graded (4)?
1. > 1 cm above the introitus
2. 1 cm above or below introitus
3. > 1 cm below the introitus
4. Full decent with eversion of vagina
215
What is the introitus?
Opening to the vagina
216
What can a prolapse extending beyond the introitus be referred to as?
Uterine procidentia
217
What are the 3 overarching ways to manage pelvic organ prolapse?
* Conservatively
* Pessary
* Surgically
218
What is the conservative management for pelvic organ prolapse (4)?
* Physio (pelvic floor exercises)
* Weight loss
* Lifestyle changes for incontinence (e.g. less caffeine)
* Treat associated symptoms e.g. constipation/ chronic cough
219
What are the two main types of pessary?
* **Ring**
* **Shelf/ Gellhorn** - flat disc with stem coming down
*can't have sex with shelf*
220
What is often inserted with a pessary?
Oestrogen cream to stop vagina drying out
221
How often should a pessary be changed?
Every 4-6 months
222
What are the surgical treatment options for pelvic organ prolapse?
Many including hysterectomy, pelvic floor repair
223
What are some complications of pelvic organ prolapse surgery (4)?
* Pain/ bleeding/ infection
* Damage to bowel/ urinary tract
* Recurrence of prolapse
* Altered sensation of sex
224
What is an outdated surgical technique that was used for pelvic organ prolapse, but now no longer recommended by NICE?
**Mesh repair** - refer patients for specialist management
*caused chronic pain, urinary/ bowel Sx, dyspareunia, etc*
225
What is premenstrual syndrome (PMS)?
The psychological, behavioural and physical symptoms in the luteal phase of menstruation particularly in the days prior to menstruation
226
What causes premenstrual syndrome?
Fluctuations in hormones during the menstrual cycle and the interaction with neurotransmitters serotonin and GABA (the exact cause is not known however)
227
What are the signs/ symptoms of premenstrual syndrome (10)?
* Low mood
* Anxiety
* Mood swings
* Irritability
* Bloating
* Fatigue
* Headaches
* Breast pain
* Reduced confidence
* Lack of libido
228
What is important to establish when taking a history of someone with premenstrual syndrome?
No symptoms before menarche, during pregnancy or after menopause
229
How is premenstrual syndrome investigated (2)?
* **Symptom diary** - must be present before menstruation for at least 2 cycles
* **GnRH analogues** - temporarily induce menopause, Sx stop = definitive diagnosis
230
How is premenstrual syndrome managed (4)?
* Mild = lifestyle changes
* COCP
* SSRI + CBT
* NSAIDs (for pain)
231
What lifestyle modifications are recommended for those with premenstrual syndrome (3)?
* Exercise
* Good sleep hygiene
* **Regular small meals with complex carbohydrates**
232
Which COCP is recommended for those with premenstrual syndrome?
New generation e.g. drospirenone
233
What is a severe form of premenstrual syndrome?
**Premenstrual dysphoric disorder**
*can present with Sx such as psychosis*
234
What is the menopause?
Permanent end to menstruation
235
When can a diagnosis of menopause be made?
When it has been at least 12 months since the last period
*or 2 years if under 50*
236
What is the average age of the menopause?
51 years old
*usually between 45-55 years*
237
What may cause women to go through the menopause prematurely (2)?
* Any operation that removes both ovaries
* Sheehans syndrome
238
What is defined as premature menopause?
Menopause before 40
*due to primary ovarian insufficiency*
239
What is defined as early menopause?
40-45 year olds
240
What is the perimenopause?
12 months after menstruations finish in woman with vasomotor symptoms
241
What is the physiology of the menopause?
Decreased functioning of the ovaries --> less oestrogen --> more LH+FSH --> low oestrogen causes the menopause symptoms
242
What are the signs/ symptoms of the perimenopause (9)?
* Hot flushes
* Emotional fluctuations
* Low mood
* Night sweats
* Irregular periods
* Vaginal dryness/ atrophy
* Reduced libido
* Brain fog
* Fatigue
243
Which symptoms are vasomotor symptoms of the menopause (2)?
* Hot flushes
* Night sweats
244
How is menopause investigated (2)?
* Clinical retrospective diagnosis (no menstruation for 12 months and over 45 years)
* Measure FSH > 30 (if woman under 45/ any doubt)
245
How are menopausal symptoms managed (5)?
* No treatment (if not wanted)
* Lifestyle (e.g. regular exercise, sleep hygiene, weight loss)
* HRT
* Vaginal oestrogen cream
* SSRI - fluoxetine (for vasomotor Sx)
246
What are the HRT options available to treat the menopause (2)?
* Oestrogen + progesterone transdermal patch
* Oestrogen only (if hysterectomy as low chance of endometrial cancer)
247
What are some contraindications to HRT (2)?
* Breast cancer past or present
* High VTE risk
248
What are the risks associated with HRT (4)?
* Increased VTE risk
* Increased stroke + CVD risk
* Increased breast
* Ovarian cancer risk
*risk of dying from breast cancer however, not raised*
249
What are some risk factors for primary ovarian insufficiency (5)?
* Cancer
* Infection
* Chemo
* PCOS
* Family history + fragile X syndrome
250
What is a health benefit of taking HRT?
Decreased risk of osteoporosis
251
What is the most common cause of post menopausal bleeding?
Atrophic vagina
*don't forget endometrial cancer*
252
How is atrophic vaginits managed (2)?
1. Moisturisers/ lubricants
2. Topical oestrogen
253
What is the most common cause of postcoital bleeding (2)?
* Cervical ectropion (young)
* Atrophic vagina (older)
254
What are the most common causes of superficial dyspareunia (4)?
* Vulvodynia (pain in vulval area without an identifiable cause)
* Vulval cancer
* Lichen sclerosis
* Atrophic vagina
255
What are the most common causes of deep dyspareunia?
* Endometriosis
* Adenomyosis
* Pelvic inflammatory disease
* Cervical cancer
256
What are the 5 types of incontinence?
* Stress = MC
* Urge/ overactive bladder = 2nd MC
* Mixed
* Overflow
* Functional
257
What is urge incontinence?
Overactivity of the detrusor muscle
258
What is the presentation of someone with urge incontinence?
Sudden feeling of needing to urinate "key in door syndrome", sometimes have nocturnal enuresis
259
What is the typical patient affected by urge incontinence?
Younger female with UTI/ DM during pregnancy/ constipation
260
What causes stress incontinence?
Weakness of the pelvic floor and sphincter muscles allowing urine to leak at times
261
What is the presentation of stress incontinence?
Urine leakage when laughing/ coughing
262
What are some risk factors for stress incontinence (4)?
* Older age
* Surgery
* Multiple births
* Obese
263
What is mixed incontinence?
Symptoms of both urge and stress incontinence
*must work out which are having the largest affect on the patients life*
264
What causes overflow incontinence?
Chronic urinary retention due to an obstruction to the outflow
*more common in med due to enlarged prostates*
265
What are the signs/ symptoms of overflow incontinence (3)?
* Poor stream
* Incomplete emptying
* Nocturnal Sx
266
What are some risk factors/ causes for overflow incontinence (3)?
* Traumatic surgery
* Neurological condition e.g. MS
* Tumours
267
What is functional incontinence?
Lack of mobility means patient is unable to get to the toilet in time
268
How should incontinence be investigated (4)?
* Urinary diary
* Vaginal examination (tone + prolapse)
* Urine dip + MC&S
* Urodynamics
269
How is urge incontinence managed (3)?
* Bladder retraining (minimum 6 weeks)
* Antimuscarinics (M3 receptors) e.g. oxybutynin
* Cystoplasty (bladder enlargement)/ botox injection
270
How is stress incontinence managed (3)?
* Pelvic floor 'kegal' exercises for **3 months**
* Surgery (mid urethral tape)
* Duloxetine
271
How is overflow incontinence managed?
Self catheterisation
272
What is lichen sclerosus?
Chronic inflammation + fibrosis of superficial dermis --> scar tissue + white plaques
273
How is typically affected by lichen sclerosus?
Elderly females
*although males can get it too!!!*
274
Where does lichen sclerosus typically affect?
Genitalia
275
What are the signs/ symptoms of lichen sclerosus (3)?
* White patches that may scar
* Itchy
* Pain during sex
276
How is lichen sclerosus investigated?
* Clinically
* Biopsy can be taken if doubt
277
How is lichen sclerosus managed?
Potent topical steroids - clobetasol propionate (+emollients)
278
What is a compilation of lichen sclerosus?
Squamous cell carcinoma (of the vulva)
279
What is a similar condition to lichen sclerosus?
Lichen planus
280
How can lichen planus be differentiated from lichen sclerosus (2)?
* Appears purple not white
* Lesions on mucous membrane of mouth found in lichen planus
281
What is Ashermans syndrome?
Where adhesions form in the uterus for various reasons
282
What can cause ashermans syndrome (2)?
* Surgery (dilatation and curettage + c-section)
* Repeated infections (endometritis/ PID)
283
What are the signs/ symptoms of ashermans syndrome (4)?
* Secondary amenorrhoea
* Dysmenorrhoea
* Lighter periods
* Infertility
284
How is ashermans syndrome investigated?
Hysteroscopy = gold standard
285
How is ashermans syndrome managed?
Cut the adhesions during hysteroscopy
286
What is bartholins cyst?
Blockage of bartholins gland resulting in collection of mucous + secretions at inside of labia majora
287
What is a complication of bartholins cyst?
Bartholins abscess
288
What organisms are most commonly found in bartholins abscess (3)?
* E. coli
* STIs (chlamydia, gonorrhoea)
* Staph aureus
289
How is bartholins cyst managed?
Good hygiene
*can do surgical drainage if persisting*
290
What tumour in the head can cause a number of gynaecological symptoms?
Prolactinoma
291
What are the signs/ symptoms of a prolactinoma in women (6)?
* Amenorrhoea
* Infertility
* Galactorrhoea (breast milk production)
* Osteoporosis
* Headache
* Bilateral hemianopia
292
What is a genital tract fistula?
An abnormal connection between the vagina and adjacent organs such as the bladder and rectum
293
What are the causes of genital tract fistula (4)?
* (Obstetric) trauma
* Pelvic surgeries
* PID
* Cancers
294
What is the presentation of someone with a genital tract fistula?
Leakage of urine/ faeces into the vagina
