A: Finals: Women's problems

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Mike2556
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259151
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A: Finals: Women's problems
Updated:
2014-02-04 19:45:41
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breast uterine ovarian vaginal
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Breast, uterine, ovarian and vaginal disease
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  1. What main questions about a gynaecological feature should be asked?
    • Previous occurrence
    • Progression
    • Associated symptoms
    • Cyclical
    • Exacerbating/relieving
    • Duration
    • Then: menstrual/gyne/obs history
  2. When do women receive cervical screening?
    • Between ages 20 and 64
    • 20+ is every 3 years
    • 50+ is every 5 years
  3. 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
  4. What features are suggestive of cervical cancer?
    • Age 40+
    • Bleeding
    • Discharge
    • Dysparaenuia
    • No intermenstrual bleeding
  5. Give 6 risk factors for cervical cancer
    • High parity
    • Smoking
    • HPV infection risks (age of first intercourse, sexual partners, inadequate protection_
    • Family history
  6. 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
  7. Give 5 causes of post-menopausal bleeding
    • Atrophy - vaginitis or endometrial
    • Trauma
    • Cervical/endometrial polyps
    • Candidiasis
    • Neoplasia of vulva/vagina/cervix/endometrium
  8. What investigations are available for PMB?
    • US
    • Endometrial biopsy
    • Hysteroscopy
  9. 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
  10. 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
  11. 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
  12. What features are suggestive of endometriosis?
    • Recurring pelvic pain, typically around menstruation
    • Dysmenorrhoea
    • Dyspareunia
    • "Tugging" if adhesions present
    • Infertility
  13. Give 5 complications of endometriosis
    • Fibrosis
    • Infertility
    • Ectopic pregnancy
    • Bowel obstruction
    • Ureter obstruction
  14. What management options are available for endometriosis?
    Conservative: Pain management (NSAIDS) and wait till menopause

    • Medical:
    • - Progesterone prevents menstruation/pain and inhibits oetrogen/endometrial growth (POP, depot, mirena, implant)
    • - COC: Prevents menstruation

    • Surgical:
    • - Laparoscopic diagnosis, with ablation and adhesion devision if required
    • - Hysterectomy (not curative)
  15. Give a brief description of the following drugs:
    - Dianette
    - Danazol
    - Tibolone
    - Clomiphene
    - Tolterodine
    • 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
  16. 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
  17. What features suggest adenomyosis?
    • Intense pain, particularly on menstruation
    • 'Tugging'
    • Pressure on bladder
    • Large blood clots in menstruation
    • Prolonged bleeding
  18. How do fibroids typically present?
    • Usually asymptomatic
    • Abnormal bleeding with bloating
    • Heavy/painful periods
    • Urinary changes
    • Sometimes dysparaenia
  19. What features suggest an endometrial polyps?
    • Continued bleeding after menopause
    • Intermenstrual bleeding
    • Menorrhagia
  20. How is a diagnosis of endometrial polyps confirmed and how are they managed?
    • US
    • Hysteroscopy with curettage
    • Biopsy/pathology performed
    • Hysterectomy an option if cancerous cells detected
  21. Outline 6 risk factors for endometrial adenocarcinoma
    • Obesity
    • Hypertension
    • Diabetes Mellitus
    • History of polyps/breast/ovarian cancer
    • High oestrogen exposure (nulliparity, PCOS, early menarche, late menopause)
  22. 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
  23. 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
  24. 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
  25. Give 6 risk factors for pelvic organ prolapse
    • Increasing parrity
    • Obesity
    • Menopause
    • Long-term constipation
    • Surgery; hysterectomy
    • Connective tissue disease
  26. What forms of prolapse exist and what organs are involved?
    • Anterior prolapse: Cystocoele
    • Vault prolapse: Cervix/uterus drops
    • Posterior prolapse: Rectocoele/enterocoele
  27. 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
  28. What are the main urodynamic studies and what do they determine?
    • Post-void residual volume: High = UTI, overflow incontinence
    • Uroflowmetry: Bladder muscle weakness, obstruction
    • Fluoroscopy
  29. What are the characteristics of an overactive bladder?
    • Urgency (sudden necessity to urinate)
    • Urge incontinence
    • Urinary frequency (>8)
    • Nocturia (>2)
  30. Give 4 management strategies for OAB
    • Lifestyle: Fluid restriction/caffeine avoidance
    • Physiotherapy: Bladder re-training
    • Medical: Antimuscarinics, alpha-adrenergic blockers
    • Surgical: Botulinum injection
  31. What is stress incontinence?
    • Incontinence when intra-abdominal pressure increases
    • Coughing, sneezing, exercise
    • Caused by weak pelvic floor (or possibly sphinctre)
  32. Give 5 management strategies for Stress incontinence
    • Lifestyle: Weight loss
    • Exercise: Kegel
    • Supportive: Incontinence pads
    • Pessary: Especially if prolapse present
    • Surgery: Urethropexy (vaginal tape)
  33. 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)
  34. Describe the pathogenesis of PCOS
    • Multiple small ovarian cysts with excess androgen production
    • Closely related to the metabolic syndrome
    • Precise link is unknown
  35. What is the metabolic syndrome?
    • 3/5 of:
    • - Central obesity
    • - Hypertension
    • - Elevated fasting glucose
    • - High triglycerides
    • - Low HDL levels
  36. Give 4 causes of virilisation
    • PCOS
    • CAH
    • Cushing's
    • Ovarian hyperthecosis (perimenstrual)
  37. Give 5 clinical features of PCOS
    • Amenorrhoea/oligmoenorrhoea
    • Hirsutism
    • Acne
    • Virilisation (clitoromegaly, balding, male phenotype)
  38. 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
  39. How is PCOS managed?
    • Supportive: Hair removal/electrolysis
    • Dianette: Non-adrogenergic progesterone/oestrogen
    • Metformin: Hyperinsulinaemia
  40. Give 6 clinical features of PID
    • Fever
    • Lower abdominal pain
    • Discharge (offensive)
    • Dyspaerunia
    • Irregular bleeding
    • Cervical tenderness
  41. What are the 3 most common causes of PID?
    • Gonorrhoea
    • Chlamydia
  42. Give 5 of the most worrying complications of PID
    • Abscess formation
    • Chronic pelvic pain
    • Infertility
    • Ectopic pregnancy
    • Peritonitis
  43. 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
  44. What is a phyllodes tumour?
    • A large, fast growing mass composed of periductal stromal cells.
    • Has a high likelihood of becoming malignant
  45. What is a fibroadenoma?
    • A discrete, mobile lump of both stromal and epithelial tissue
    • Normally found in young women
  46. 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
    • Inversion
    • Pain
    • Bloody discharge
  47. 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%
  48. 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
  49. 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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