Please enable JavaScript.

Coggle requires JavaScript to display documents.

FRS - Gynaecology, Cancer, Continence - Coggle Diagram

- - - - Anterior
        
        Thyrotroph - TSH
        Lactotroph - prolactin
        Somatotroph - GH
        Gonadotroph - GnRH
        Corticotroph - ACTH
        
        Gonadal axis - TRH stimulates prolaction, stimulates dopamine release, inhibits GnRH, limits gonadotropin levels
      - Posterior
        
        ADH
        Oxytocin - uterine contraction
    - - Outer theca - produces androgens -> oestrogens
        Inner granulosa - convert androgens to oestrogen
        Antrum - fwcondary follicles grow under FSH
        Oocyte - surrounded by granulosa layers
    - - Stimulate breast development
        Bone and growth
        Increases HDL, decreases LDL
    - - Thickens cervical mucus to prevent sperm penetration
        Prevents uterine contractions
        Secretory changes of endometrium
  - - - 21-hydroxylase deficiency - affects steroid biosynthesis - precocious puberty
      - McCune Albright Syndrome - unregulated production of sex steroids by gonads (mutation of G protein complex) - precocious
        Triad of cafe au lait spots, bifrous dysplasia of bone, endocrine hyperfunction
      - Turner syndrome - ovarian dysgenesis, short stature, neck webbing, aortic coarctation, autoimmune thyroid disease
- - - - Structural (PALM)
        
        Polyps
        Adenomyosis
        Leiomyoma (fibroids)
        Malignancies/hyperplasia
      - Non-structural (COEIN)
        
        Coagulopathy
        Ovulatory dysfunction
        Endometrial
        Iatrogenic
        Not yet classified
    - - Anovulatory - PCOS
        Mo formation of corpus luteum - insufficienct effects of progesterones on endometrium - abnormal production - unopposed oestrogen effects - persistently proliferating endometrium
    - - Primary
        
        Uterine contractions
        Higher levels of prostaglandin F2a and E2 - vasoconstriction
        Oncreased leukotrienes
        Increased vasopressin
      - Secondary
        
        Endometriosis
        Adenomyosis
        Pelvic inflammatory disease - upper genital tract infection
        Pelvic venous congestion - enlrged varicose veins
        cervical stenosis
    - - Hypothalamic
        
        Kallmann - failure of GnRH neurons
        Hyposmia, colour blindness, renal agenesis
      - Pituitary
        
        Pituitary adenoma - hyperprolactinemia - dopamine release (lack of inhibition) - reduced GnRH - reduced FSH/LH secretion
        
        Sheehan's synfrome - pituitary gland necrosis - massive blood loss and hypovolemic shock
      - Ovarian
        
        Ovarian dysgenesis - Turner's, gonadal dysgenesis
        Turner's
        PCOS
        POF
      - Structural
        
        Absence of uterus
        Transverse vaginal septum/imperforate hymen
        Asherman's syndrome - trauma to basal layer of endometrium due to evacuation of uterus - intrauterine scars - adhesions can obliterate uterine cavity
- - - - Inhibin B - normally produced by ovarian granulosa cells - first to decline
        AMH (anti-mullerian hormone) - produced by antral (secondary) follicles - high during menarche, decreases with age
        FSH - normally inhibited by inhibin B - persistently elevated post menopause
        Oestradiol - normally produced by ovarian granulosa cells - persistently declining
        Progesterone - corpus luteum - falls steadily throughout menopause
      - Testosterone - premenopause produced via peripheral conversion of androstenedione, decline during menopause
        Androstenedione - main premenopausal androgens - largely unchanged (compensated by increased adrenal synthesis)
        DHEA-S - Produced almost exclusively by adrenal cortex - largely unchanged - precursor to sex hormones
    - - Loss of bone density, adverse lipid profile - increase in LDL, decrease in HDL
        Increased risk of cardiovascular disease
      - Hot flushes - decline in oestradiol - dysfunction of brainstem thermoregulatory nucleus
        Urogenital - vaginal dryness, burning, irritation, urgency, recurrent UTIs
  - - - Combined - all women
        Oestrogen only - women who had hysterectomy
  - - - Oestradiol levels - usually undetectably low
        Karyotyping - exclude Turner's syndrome
        Autoantibody screening - against ovaries and thyroid
        Transvaginal ultrasound - low antral follicle count, low ovarian volume
        Baseline bone density scan
- - - - Temperature rises in response to progesterone after ovulation
      - Changes in cervial secretions
        White and sticky in follicular phase
        Clear, wet and slippery during ovulation
        White and thick during luteal phase
    - - Condoms
      - Diaphragms and Caps
    - - Suppress ovulation - negative effect on hypothalamic GnRH release - reduce FSH and LH, prevent LH surge
        Thicken cervical mucua
        Endometrial atrophy
      - Risks
        
        VTE
        Ischemic stroke
        Breast cancer
        Cervical cancer
        Liver cancer
      - Contraindications
        
        Hypertension, history of VTE, smokers
        Impaired liver function
        Breast cancer
        Abnormal vaginal bleeding
      - Methods
        
        Compined Oral Contraceptive Pill (COCP)
        Transfermal contraceptive patch
        Hormonal vaginal ring
        
        Treatment of HPPE - hirsutism, PCOS, premenstrual syndrome, endometriosis
      - Progesterone-only pill
    - - Progesterone-only subdermal implant
        
        Implanon - inserted into inner side of non-dominant upper arm
        Inserted between day 1-5 of menstrual cycle, effective up to 3 years
      - Progesterone-only injectable
        
        Deoi-Provera - suppress ovulation, thin endometrium, thicken cervical mucus
        Administer IM every 3 monthsl day 1-5
      - Intrauterine system
        
        Progesterone-only IUS
        
        progesterone releasing rod - thicken cervical mucus, prevents endometrial proliferation
        
        Copper IUD
        
        T-shaped device covered in copper wire - physically interferes with sperm transfer, cirect toxic effect of Cu to sperma nd egg
  - - - Filshie clip applied around each fallopian tube
    - - Permanently block vas deferens, then section of each tied and cut
        Take up to 12 weeks until ejaculate is free of sperm
- - - - Anencephaly
        Multiple foetal anomalies
    - - Mother with Eisenmenger syndrome
        Maternal rubella infection - 1st trimester - triad - sensorineural deafness, eye abnormalities, congenital heart disease
        Teratogenic medications
- - - - Hypothalamic causes - no GnRH
        
        Immature HPG acis
        Kallmann syndrome - lack of hypothalamic GnRH secretion
      - Pituitary causes - no FSH/LH
        
        Hyperprolactineia
        External damage
        Sheehan's syndrome
        Pituitary apoplexy - sudden haemorrhage/imapired blood supply into pituitary gland due to pituitary adenoma
    - - Excess androgens - excessive LHrelease and hyperinsulinemia
        Early develioment of small pre-ovulatory follicles - premature luteinisation , maturation arrest at large antral follicular stage, follicules do not ovulate
      - Oolycystic appearance
        Oligomenorrhea
        Abnormal secondary secual characteristics (hyoerandrogenism)
      - Always test hCG, exclude other hyperandrogenic causes
  - - - Lower abdominal pain, abnormal vaginal discharge (purulent), abnormal vaginal bleeding, burning with urination, dyspareunia
      - Complications - perihepatitis - inflammation or peritoneal coating of liver, adhesions - acute RUQ pain, tenderness, hydrosalpinx
        Chronic infection and fibrosis of fallopian tubes - subfertility, ectopic pregnancy
    - - Proximal blockage - tubal cannulation
        Distal blockage - neosalpingostomy
        Hydrosalpinx - salpingectomy - remove fallopian tubes
  - - - Uterine fibroids
        Endometrial polyps
        Endometrial adhesions - Asherman's syndrome
  - - - Uterus didelphys - double uterus with 2 separate cervices, 2 separate vaginas
        Septate uterus (commonest) - midline uterine septum
        Bicornuate uterus - separation of horns only
    - - Vaginal septum - vaginal septum
        Cervical agenesis, dysgenesis
- - - - Signs - vaginal dischargem strawberry cervix
        Treatment - metronidazole
    - - Treat with metronidazole
        Amsel's criteria - vaginal dischargem clue cells (vaginal epithelial cells heavily covered with bactria - cell margins fuzzy), ph >4.5, positive whiff test (fishy odour)
    - - Treat with oral fluconazole, topical antifungal agents
    - - Gonorrhoea - gram -ve diplococcus
        Treat with IM ceftriazone (or azithromycin, doxycyline)
      - Chlamydia - intracellular gram -ve bacteria
        Treat with zaithromycin.doxycycline
- - - - CIN1/LSIL - mildly atypical cells - lowe 1/3 of epithelium
        CIN2/HSIL - atypical cells affecting basal 2/3 of epithelium
        CIN/HSIL - cellular changes more than 2/3 of epithelium - high risk to transform into cancer
      - HSIL has high risk of progression to carcinoma
    - - Squamous cell carcinoma most common
      - Morphology - develop in transformation zone, stromal invasion to grossly conspicuous exophytic tumours
        Microscopy - tongues and nests of squamous cells producing desmoplastic stromal response - squamous differentiation
  - - - Epithelial ovarian cancers - most common - serous
        Germ cell
        Sex-cord stromal
        Sarcomas
    - - Inccessant ovulation - rupture of follicle, physical trauma - repeated damage and repair - dedifferentiation of epithelium
        OSE-CIC model - ovarian surface invaginates into cortical stroma with age - tumour
        STIC - fallopian tube epithelium serves as site of origin - STIC - ovarian cancer
    - - Direct spread - capsular invasion and peirtoneal seeding
        Lymphatic infiltration - para-aortic nodal tissue, pelvic nodes
        Hematogenous spread - liver parenchyma, lungs, bones
- - - - Endometrioid - type 1
        
        Endometrioid adenocarcinoma
        Oestrogen-related, background of endometrial hyperplasia - unopposed oestrogen-mediated proliferative phase on menstrual cycle
        HNPCC/Lynch syndrome
        Younger age group
        
        Histology
        Grade 1 - glandular pattern
        Grade 3 - predominantly soid growth pattern
      - Serous carcinoma - type 2
        
        Seroous/clear cell
        Non-oestrogen related - atrophic oestrogen-deficient endometrium, develop from SEIC
        p53 mutations
        Older age group
        
        Histology - marked cytologic atypia, TP53 mutation
- - - - Levator ani - tonic contraction pulls vagina forwar, squeeze urethra shut
        Urethral muscles - smooth muscle (resting tone), contraction (rise in intra-abdominal pressure)
        Pudendal nerve 0 supplies external urethral sphincter
    - - Afferent sympathetic pathways in hypogastric nerves
        Inhibition of detrusor muscels
        Contraction of striated urethral spincter muscle (pudendal nerve) and internal urethral spincter (sympathetic)
    - - Bladder afferents activate spinal reflex pathway (pontine micturition centre), increase parasympathetic efferents to bladder
        Stimulation of detrusor muscles (pelvic splanchnic nerves)
        Urethral relaxation
  - - - Stress
        
        Cause - sphincter insufficiency
        Raised intra-abdominal pressure
        Small volume of urine leak, no bed wetting
      - Urge
        
        Cause - detrusor instability, menopause
        Large volume of urine leak, bed wetting
      - Mixed
        
        Stress + urge
      - Overflow
        
        Cause - bladder outlet obstruction, hypotonic detrusor
        Associated with incomplete bladder emptying
        Small volume of urine leak, bed wetting
      - Continuous
        
        Contious involuntary loss of urine
        Usually related to urinary fistula or congenital defects
  - - - Cystocele - prolapse of bladder into anterior vaginal wall
    - - Rectocele - prolapse of rectum into posterior vaginal wall
        Enterocele - intestinal herniation through vaginal wall
    - - Uterine prolapse - prolapse of uterus into medial compartment of vagina - failure of pelvic diaphragm and ligaments
        Vaginal vault prolapse - post-hysterectomy