A: Finals: Women's problems
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What main questions about a gynaecological feature should be asked?
- Previous occurrence
- Associated symptoms
- Then: menstrual/gyne/obs history
When do women receive cervical screening?
- Between ages 20 and 64
- 20+ is every 3 years
- 50+ is every 5 years
What management is required with the various findings of a cervical smear?
- Borderline->Mild dyskaryosis: Consistent with CIN1. Repeat in 6 months and if still present refer for colposcopy
- Moderate-severe dyskaryosis: Colposcopy
What features are suggestive of cervical cancer?
- Age 40+
- No intermenstrual bleeding
Give 6 risk factors for cervical cancer
- High parity
- HPV infection risks (age of first intercourse, sexual partners, inadequate protection_
- Family history
What management options are available for CIN and cervical cancer
- Large loop excision of transformation zone via colposcopy (most common)
- Laser ablation/diathermy/cryotherapy
- Total abdominal hysterectomy
Give 5 causes of post-menopausal bleeding
- Atrophy - vaginitis or endometrial
- Cervical/endometrial polyps
- Neoplasia of vulva/vagina/cervix/endometrium
What investigations are available for PMB?
- Endometrial biopsy
When is the HPV vaccination received and what does it prevent?
- Ages 12-13
- 3 doses over 6 month period
- 6, 11, 16, 18 HPV types
- Carcinogenic + wart types
Give a brief outline of the menstrual cycle until ovulation
- GnRH pulses stimulate LH and FSH release
- LH promotes androgen production by thecal cells
- FSH causes follicle development and androgen/oestrogen conversion by ovaries
- Low dose oestrogen causes uterine proliferation
- Eventual high dose oestrogen causes LH sensitivity to GnRH and positive feedback
- LH surge causes ovum release
Describe the processes which occur after ovulation
- After ovulation, follicle become corpus luteum
- Secretion of progesterone begins
- If implantation occurs:
- - hcG produced by trophoblast maintains C.L
- - Progesterone maintains endometrium
- - Eventually placenta develops oestrogen/progesterone
- If implantation does NOT occur:
- - Luteum regresses and oestrogen/progesterone levels fall
- - Constriction of spiral arteries and endometrial death
- - Dilation of arteries causes flushing of uterus
- - Negative feedback of GnRH and FSH stop, beginning cycle
What features are suggestive of endometriosis?
- Recurring pelvic pain, typically around menstruation
- "Tugging" if adhesions present
Give 5 complications of endometriosis
- Ectopic pregnancy
- Bowel obstruction
- Ureter obstruction
What management options are available for endometriosis?
Conservative: Pain management (NSAIDS) and wait till menopause
- - Progesterone prevents menstruation/pain and inhibits oetrogen/endometrial growth (POP, depot, mirena, implant)
- - COC: Prevents menstruation
- - Laparoscopic diagnosis, with ablation and adhesion devision if required
- - Hysterectomy (not curative)
Give a brief description of the following drugs:
- Dianette: Cyproterone acetate + ethinylestradiol. Acne/Hirsutism
- Danazol: Progestogen. Endometriosis
- Tibolone: Oestrogen agonist. HRT + endometriosis
- Clomiphene: Prevents oestrogen -ve feedback of GnRH. Induces ovulation
- Tolterodine: Antimuscarinic. Urinary incontinence
What is adenomyosis?
- Uterine thickening when endometrium moves into outer muscular walls of uterus
- Due to uterine trauma breaking the endo/myo barrier
- Childbirth, termination, C-Section
What features suggest adenomyosis?
- Intense pain, particularly on menstruation
- Pressure on bladder
- Large blood clots in menstruation
- Prolonged bleeding
How do fibroids typically present?
- Usually asymptomatic
- Abnormal bleeding with bloating
- Heavy/painful periods
- Urinary changes
- Sometimes dysparaenia
What features suggest an endometrial polyps?
- Continued bleeding after menopauseIntermenstrual bleeding
How is a diagnosis of endometrial polyps confirmed and how are they managed?
- Hysteroscopy with curettage
- Biopsy/pathology performed
- Hysterectomy an option if cancerous cells detected
Outline 6 risk factors for endometrial adenocarcinoma
- Diabetes Mellitus
- History of polyps/breast/ovarian cancer
- High oestrogen exposure (nulliparity, PCOS, early menarche, late menopause)
Outline the staging of endometrial adenocarcinoma
- 1A: +/-Inner myometrium involvement
- 1B: Outer myometrium involvement
2: Stromal involvement
- 3a: Serosa
- 3b: Vagina
- 3c: Pelvic/para-aortic lymph nodes
4: Bladder/bowel mucosa or distant metastases
What main points should be given when describing a hysteroscopy to a patient?
- Performed in clinic, not surgery
- Best performed after menstruation for thinner endometrium
- Lidocaine injection into cervix
- Misoprostol may be required
- Endoscope inserted via vagina into uterus
- Distended with gas/fluid
- Ablation/fibroid/polyps resection also an option
- Sent for pathology
- Complications; bleeding, perforation, infection
- Cramping/spotting for 1-2 weeks normal
- Follow up at 2-4 weeks
What are the main points of a endometrial biopsy when informing a patient?
- Performed in outpatient clinic
- Diagnoses and assesses infertility, endometrial hyperplasia and adenocarcinoma
- Speculum inserted and cervix cleaned, similar to smear
- Local anaesthesia (lidocaine injection)
- Forceps holds cervix
- Biopsy curette inserted into uterus and fundus scraped
- Bleeding/cramping for 1-2 weeks is normal
Give 6 risk factors for pelvic organ prolapse
- Increasing parrity
- Long-term constipation
- Surgery; hysterectomy
- Connective tissue disease
What forms of prolapse exist and what organs are involved?
- Anterior prolapse: Cystocoele
- Vault prolapse: Cervix/uterus drops
- Posterior prolapse: Rectocoele/enterocoele
Give 5 management options available for a vaginal prolapse
- Lifestyle advice: Obesity/occupation
- Physiotherapy: Kegel exercises
- Pessaries: Shelf/ring
- Surgery: Sacropexy, hysterectomy
- HRT: Symptom control, e.g. dryness
What are the main urodynamic studies and what do they determine?
- Post-void residual volume: High = UTI, overflow incontinence
- Uroflowmetry: Bladder muscle weakness, obstruction
What are the characteristics of an overactive bladder?
- Urgency (sudden necessity to urinate)
- Urge incontinence
- Urinary frequency (>8)
- Nocturia (>2)
Give 4 management strategies for OAB
- Lifestyle: Fluid restriction/caffeine avoidance
- Physiotherapy: Bladder re-training
- Medical: Antimuscarinics, alpha-adrenergic blockers
- Surgical: Botulinum injection
What is stress incontinence?
- Incontinence when intra-abdominal pressure increases
- Coughing, sneezing, exercise
- Caused by weak pelvic floor (or possibly sphinctre)
Give 5 management strategies for Stress incontinence
- Lifestyle: Weight loss
- Exercise: Kegel
- Supportive: Incontinence pads
- Pessary: Especially if prolapse present
- Surgery: Urethropexy (vaginal tape)
What features are suggestive of ovarian cancer?
- Pressure in abdomen, causing pain
- Abdominal swelling/bloating
- GI symptoms with no other cause
- Ascites (poor prognosis)
- Typically late presentation (70% present >3 staging)
Describe the pathogenesis of PCOS
- Multiple small ovarian cysts with excess androgen production
- Closely related to the metabolic syndrome
- Precise link is unknown
What is the metabolic syndrome?
- 3/5 of:
- - Central obesity
- - Hypertension
- - Elevated fasting glucose
- - High triglycerides
- - Low HDL levels
Give 4 causes of virilisation
- Ovarian hyperthecosis (perimenstrual)
Give 5 clinical features of PCOS
- Virilisation (clitoromegaly, balding, male phenotype)
What investigations are of use in suspected PCOS?
- Serum testosterone: Elevated but non-specific vs other virilising tumours
- Gonadotrophin levels: LH hypersecretion
- Ultrasound: Multiple small cysts and hyperechogenic stroma
How is PCOS managed?
- Supportive: Hair removal/electrolysis
- Dianette: Non-adrogenergic progesterone/oestrogen
- Metformin: Hyperinsulinaemia
Give 6 clinical features of PID
- Lower abdominal pain
- Discharge (offensive)
- Irregular bleeding
- Cervical tenderness
What are the 3 most common causes of PID?
Give 5 of the most worrying complications of PID
- Abscess formation
- Chronic pelvic pain
- Ectopic pregnancy
Describe why fibrocystic changes occur in the breast
- Menstrual hormones cause cyclical hypertrophy and hyperplasia
- Numerous small, fibrous or cystic areas are created due to dysplasia
- These cells have a greater likelihood of becoming atypical
What is a phyllodes tumour?
- A large, fast growing mass composed of periductal stromal cells.
- Has a high likelihood of becoming malignant
What is a fibroadenoma?
- A discrete, mobile lump of both stromal and epithelial tissue
- Normally found in young women
Outline the pathological changes in duct ectasia and give 4 features seen on examination
- Secretory stasis causes dilation of a lactiferous duct
- Squamous metaplasia and fibrosis results
- Nipple retraction
- Bloody discharge
Describe the index used to determine breast cancer prognosis
- Nottingham prognostic index
- Grade (1-3) + Stage (0 or 3) + 0.2 x cm
- <3.4 = 85% at 5 years
- <5.4 = 70%
- >5.4 = 50%
What is the cause of periductal mastitis, and what are its clinical features? Give 4
Lactiferous duct inflammation due to bacteria, e.g. S. Aureus
- - Tenderness
- - Discharge
- - Nipple retraction
- - Abscess on palpation
What is an intraductal papilloma and how does it present?
- Benign epithelial tumour caused by hyperplasia
- Not palpated
- Can cause bloody discharge
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