Card Set Information
List 5 signs/symptoms of PID.
Abnormal vaginal discharge
Abnormal vaginal bleeding
Lower abdominal pain
Cervical motion tenderness
How would you diagnose PID?
Laparoscopy = gold standard
Adnexal tenderness (not v specific)
Cervical motion tenderness + lower abdominal pain (not v sensitive)
List 5 RFs for PID.
Management of PID in sexually active female with no other RFs .
- Azithromycin 1g stat
- Ceftriaxone 250mg IM stat or ciprofloxacin 500mg PO stat
- Doxycycline 100mg bds 14d
- Metronidazole 400mg bds 14d
Prevent future cases - barrier contraception & screening
Investigations in PID?
- Serology hep, HIV, syphillis if high risk
First catch PCR for chlamydia
PCR for chlamydia or gonorrhea
- BV & trichomonas
adnexal mass or tubal oedema
= gold standard (adhesions, erythema, oedema, pus, abscess)
Diagnostic criteria for PCOS
Rotterdam - 2/3 of:-
- Hyperandrogenism (clinical or biochemical - inc free T, inc FAI, dec SHBG)
- TV USS evidence of polycystic ovaries
What are the immediate repercussions of PCOS and how would you manage it?
Irregular periods - COC
Infertility - Wt loss, test ovulation, IVF
Hirsutism - COC with cyproterone, cyproterone, spironolactone
What are the long term repercussions of PCOS?
How do you classify endometrial hyperplasia, and what is the risk of each subtype progressing to uterine Ca?
Simple wuth no atypia - <1%
Complex with no atypia - 3%
Simple with atypia - 8-9%
Complex with atypia - 28-30% (20% already have concomitant uterine Ca)
Compare & contrast the two pathogenetic groups of endometrial carcinomas.
Type I (80%)
- Endometrioid (majority adenoCa)
- Oestrogen-related (unopp E, tamoxifen)
- Pre/perimenopausal onset
- Protective factors
: COC, smoking, P
- Presentation - abnormal bleeding, thickened endometrium
- Good prognosis
- Non-endometrioid (papillary serous, clear cell)
- Not associated with E exposure
- Endometrium not thickened
- Poorer prognosis
Investigations for suspected endometrial cancer?
Hysteroscopy D&C = gold standard
Pipelle endometrial sample (low sensitivity)
--> grading of sample
List 6 DDx for a young woman presenting with sudden onset, severe lower abdominal pain.
- GIT - appendicitis, mesenteric adenitisi
- GUT - UTI, renal calclui
- Gynae - ovarian cyst accident, bleeding, torsion, PID
- Endocrine - DM
What is the definition of postmenopausal bleeding?
: Bleeding after 1 year of amenorrhea
Cts E & P HRT
: bleeding that persists after the 1st 6/12 of Tx
Cyclical P HRT
: irregular bleeding (regular cyclical withdrawal bleed is normal)
List 5 causes of postmenopausal bleeding.
Vaginal/uterine atrophy (60-80%)
Uterine/cervical polyps )2-12%)
Endometrial hyperplasia (5-10%)
Cancer - vaginal, cervical or uterine
Definitive investigations for cause of postmenopausal bleeding?
D & C
Endometrial biopsy (with anti-prostaglandin administration 1h before)
Hysteroscopy (if cervical stenosis/discomfort/persistent bleeding/inadequate specimen)
Management of endometrial hyperplasia.
Simple, no atypia --> mirena
Simple with atypia --> hysterectomy
Complex without atypia --> mirena/high dose P/hysterectomy
Complex with atypia --> TAH BSO
How would you treat endometrial Ca?
Depends on stage (1-4)
TAH BSO, peritoneal washings
R/v 3/12ly for 2 years (80%) - vault/lower 1/3 of vagina
Clinical appearance & Mx of candidiasis?
White-green caseous discharge, fullness in adnexae, vulval pruritis
HVS shows hyphi
: topical ketoconazole/nystatin, PO fluconazole (single dose)
NB. mild candidiasis is
List 5 predisposing factors for candidasis
Premenstrual point in cycle
Clinical appearance & Mx of gardnerella vaginalis (BV)?
Grey, frothy, fishy PV DC & pruritis
Dx whiff test, pH change, HVS (clue cells)
Metronidazole (2g stat dose)
How common is bacterial vaginosis?
Clinical appearance & Mx of Trichomonas vaginalis?
Green, frothy, fishy PV DC; strawberry cervix; pruritis
Dx - whiff test, HVS (flagellae)
Metronidazole (2g stat, treat partner)
Clinical appearance & Mx of Chlamydia trachomatis?
70% asymptomatic, present later with complications (infertility, PID)
Thin, white, anodorous PV DC
Endocervical (obligate intracellular)/1st catch PCR
Azithromycin 1g stat & doxycycline 100mg bds 14d
Clinical appearance & Mx of Neisseria gonorrhea?
Thick green DC
Endocervical/1st catch PCR
Ceftriaxone 250mg IM stat or ciprofloxacin 500mg PO stat
What is the recommended schedule of Pap smears for women with no Hx of abnormal bleeding or abnormal cervical cytology?
Every 2 years
First smear within 2 years of 1st sexual intercourse or 18-20
Cease at 70 if two normal smears in past 5 years
When is the best time to perform cervical cytology?
What is the benefit of cervical cytology screening?
Ca reduced by 92.5% with two-yearly screens.
How do you manage an abnormal Pap smear?
LSIL (HPV & CIN1)
: repeat in 12m then 24m if normal result; if persistently LSIL, annual smears until 2+ are negative
Possible/actual HSIL (CIN2 & 3)
: refer for colpopscopy & biopsy
What are the different grades of cervical intraepithelial neoplasia?
: >2/3 of upper epithelium showing good differentiation
: maturation/differentiation in upper half of epithelium with mitotic figures in basal half
: <1/3 of upper epithelium showing differentiation
How likely is CIN1 to progress to higher CIN lesions?
16-25% in 2-4 years
How likely is CIN3 to progress to invasive cancer?
18-35% in 1-23y
Visualise transformation zone
Acetic acid --> abnormal epithelium whitens
Iodine (Schiller's test) --> columnar/abnormal squamous epithelium does
: punctation, mosaic, atypical vessels irregular in size, shape and course
Options for definitive Mx of high grade CIN
Cryosurgery (CIN2 only)
Excision - large-loop excision of the transformation zone (LLETZ)
Cone biopsy (suspected adenoCa in situ, poorly visualised, -ve colposcopy, early invasive disease expected)
: colposcopy & pap smear at 6m, repeat Pap & HPV typing at 12m, than annually until 2 consecutive negatives
Mx of CIN in pregnancy
Perform colposcopy to exclude invasive cancer
If CIN, defer Tx to postpartum
If invasive --> cone biopsy (5% foetal loss)
List 3 RFs associated with cervical cancer
HPV 16, 18, 33, & 35
No pap smear
Abnormal pap smears
Early age of sexual activity
Multiple sexual partners
Partner with previous partner with cervical cancer
Age bimodal - 35-39 & 60-64
What is AIS?
Adenocarcinoma in situ - coexists with CIN in 70% of patients, usually at the squamocolumnar junction
Mx of AIS?
Cone biopsy (30% risk skip lesion)
Hysterectomy recommneded if fertility not an issue
What is AGUS?
Atypical glandular cells of undetermined significance (morphological changes in glandular cells beyond benign reactive process but insufficient for AIS)
The majority of cervical cancers are...
Squamous cell Ca (85%), the remainder are adenoCa
The development of cervical cancer is...
Squamous epithelium or endocervix (most squamous Ca arise in transformation zone)
How does cervical cancer present clinically?
Abnormal vaginal bleeding - menorrhagia, postcoital, irregular, postmenopausal
Ix for cervical Ca?
CXR, abdominopelvic CT, MRI of pelvis (PET good)
Staging clinically under anaesthesia (FIGO) - vaginal/pelvic and rectal examination, cervical biopsy, cystoscopy +/- D & C and sigmoidoscopy
List 4 types of uterine neoplasia
Cancer (adenoCa, adenosquamous, papillary serous, clear cell, sarcoma)
How can leiomyomas present?
Pressure effecgts --> bladder/veins (oedema, DVT)
Mx of fibroids?
: P & GnRH analogues (regrowth 3/12 after cessation)
: hysteroscopic resection, myomectomy, hysterectomy (+/- pretreatment with GnRH)
Effect of fibroids on pregnancy?
Red degeneration during pregnancy with torsion (pain & temp)
Risk of abortion
Post-myomectomy rupture is
What features make an ovarian neoplasm more likely to be malignant?
Solid, nodular or irregular consistgency
Evidence of metastases
List 5 RFs associated with ovarian cancer
Early menarche or late menopause
FHx (BRCA1 & 2 mutations)
Previous breast/endometrial cancer
Presentation of ovarian cancer?
Asymptomatic in early disease
Mass effects later on:
- abdo pain
- pelvic pressure
- back pain
- urinary frequency
Ix for ovarian mass?
Tumour markers (CA125 - epithelial, CA19.9 - mucinous, CEA - bowel mets)
hCG, AFT, inhibin, LDH if non-epithelial suspected
Abdominopelvic USS & CT
RFs associated with vulval intraepithelial neoplasia
CIN & vaginal intraepithelial neoplasia
Mx of VIN?
: preferred - wide local excision, skinning vulvectomy, laser ablation
: imiquimod or 5-FU cream (only 75% response)
Long term follow up
: 30% recur!
Vulval cancers are usually (histopathologically)...
Squamous cell carcinomas >> melanoma > bartholin's gland
What are the principle supports of the uterus?
Transverse cervical (cardinal) ligaments
(round ligaments --> labia majora, but minimal support)
(pubocervical ligament attaches Cx to pubic symphysis)
How are the ovaries attached to the uterus?
Infundibular ligaments (to posterolateral wall)
List 5 RFs for genital prolapse.
prolonged 2nd stage
What are the different grades of uterine prolapse?
1st deg - Cx does not reach introitus
2nd deg - Cx reaches introitus
3rd deg - Cx & uterus protrude
Procidentia - Cx, uterus & vagina completely prolapsed through introitus
What are the anatomical supports of the pelvic floor?
Fascia & associated ligaments:
transverse cervical (cardinal)
levator ani -> iliococcygeus; pubococcygeus; puborectalis
Prolapse of lower anterior vaginal wall involving urethra
Prolapse of upper anterior vaginal wall, involving bladder
Prolapse of bladder & urethra into anterior vaginal wall.
Define apical prolapse
Prolapse of uterus (or vault), cervix & upper vagina
Prolapse of upper posterior wall of vagina (small bowel loops)
Prolapse of lower posterior wall of vagina, involving the anterior wall of rectum
List 7 DDx for menorrhagia.
Dysfunctional uterine bleeding:
- anovulatory (PCOS, obesity)
- ovulatory - defective regulation of blood loss
- coagualopathy (VWD, platelet dysfunction)
- chronic PID
- uterine tumours (fibroids, polyps, Ca)
- ovarian tumours
Medical Mx of menorrhagia?
: PGEi - commence 5-7/7 before menses - 20-50% decr bleed, decr dysmenorrhea; SE. gastric irritation
: antifibrinolytic - take on heavy days; SE abdo bloating
: 95% decrease, lasts 5 years, daily spotting in first 6/12
Surgical Mx of menorrhagia?
Hysteroscopic removal of polyps/fibroids
Endometrial ablation (DUB)
How common are spontaneous abortions?
15-20% of Dx pregnancies
50-75% of all pregnancies
List 8 causes of spontaneous abortion.
Blighted ovum (1/3 of <k8)
Foetal chromosomal abnormalities (50-60% of T1)
Infection (TORCH, chlamydia, gonorrhea, listeria)
Drugs - chemotherapy, heavy metals
Parental chromosomal abnormality
Luteal phase defect
What are important pregnancy dates in USS?
- k5 gestational sac & yolk sac
- k6 foetus & FH
- k6 gestational sac
- k7 foetus & FH
How does bHCG levels vary throughout pregnancy?
Detectable 10/7 post-fertilisation
Doubles every 48h
Peaks at 100,000 @k9
Remains at 10,000-20,000 for remainder of pregnancy
What should you advise a woman experiencing bleeding <k20 with a closed os?
Bleeding is very common (20-30%) (but 50% progress to spontaneous abortion)
Avoid strenuous activity or sex
Return if incr bleeding/cramp/pain
What is the most common site of ectopic pregnancies?
Ampullary portion of the fallopian tube (93%)
List 7 RFs for ectopic pregnancy.
PID (esp chlamydia)
Tubal reconstructive surgery
Reversal of tubal sterilisation
Hx of infertility
Previous ectopic pregnancy
In utero exp to DES
Mx of ectopic pregnancy?
linear salpingostomy (with serial bHCG until -ve)
Medical (select pts):
single dose methotrexate
multidose methotrexate + folic acid (more effective, but more SEs)
Clinical presentation of ruptured ectopic?
Vitals - shock - tachycardic & hypotensive
Lower abdominal distention
Shoulder tip tenderness
What criteria must be satisfied before medical Mx (methotrexate) of ectopic can be conducted?
Haemodynamically stable pt w/o active bleed
No FH on US
Ectopic mass <3.5cm
Mx of molar pregnancy
D & C
Follow up - 2 -ve BhCG, then monthly for 6/12, 2-monthly for 6/12
Contraception for >12/12
What are the long term (systemic) problems associated with PCOS?
Possible incr breast Ca
What are the SEs/risks associated with COCP?
Malignancy (slight increase in breast Ca & cervical Ca)
HTN & stroke in high dose formulations
List 5 contraindications of COCP use.
List 3 forms of emergency contraception & the window in which they are effective.
Levonorgestrel - single dose 1.5mg - 3-4d
Yuzpe (2 doses of 4 tablets of E & levonorgestrel) - less effective, more N&V - 3d
Copper IUD - 5d
What 3 factors make up the risk malignancy index for ovarian cancer?