16. Pathology of the Female Reproductive Tract

Question 1

Presenting Complaints

Answer 1

Vaginal Bleeding:
post-coital, inter-menstrual, post-menopausal, heavy periods, irregular periods

Pain:
pelvic, abdominal, painful sex, painful periods

Discharge:
heavy, bloody, offensive, itchy.

Infertility:
primary, secondary

Question 2

Cervical Pathology

Answer 2

Cervical Screening – Smear Test
Cervical Intra-epithelial Neoplasia (CIN)
Cervical Carcinoma
Endocervical Polyps

Question 3

Cervical Screening-Smear Test

Answer 3

View cervix and take sample of cells

Every 3 years from age 25 to 49 years.

Every 5 years from age 49 to 64.

After age 64, screening only if no previous smears or abnormal smears.

Aims to detect early disease stages before becomes invasive.

Question 4

Human Papilloma Virus

Answer 4

Transmitted by sexual contact
Risk increases with increased numbers of sexual partners
No symptoms
Thought to be main cause of CIN and therefore cervical cancer

Question 5

HPV

Answer 5

Many different types

Low risk types- wart/verrucas

High risk types- cervical cancer

Girls aged 12 -13 offered HPV vaccination
offers protection against infection for strains associated with 70% of cervical cancers

Question 6

Screening programme

Answer 6

Cervical cancer screening programme

“Smear” test carried out in GP surgery

Question 7

Cytology Screening

Answer 7

Normal- routine 3/5 year re-smear

Abnormal- referred to colposcopy

May have biopsies taken

Question 8

Cervical Cancer

Answer 8

2nd most common female malignancy
Risk factors
HPV, smoking, non attendance to CSP
Symptoms
Abnormal discharge and bleeding
On examination the cervix appears abnormal

Question 9

Cervical Carcinoma

Answer 9

Abnormal cells and invasion

Can present with inter-menstrual or post-coital bleeding

Question 10

Treatment

Answer 10

Depends on stage either local excision or radical hysterectomy +/- chemoradiotherapy

Question 11

Endocervical Polyps

Answer 11

Usually present with irregular vaginal bleeding ‘spotting’
Benign lesions
Can remove at hysteroscopy

Question 12

Uterine Pathology

Answer 12

Menorrhagia
Fibroids
Endometritis and Pelvic Inflammatory Disease
Endometriosis
Endometrial Polyps
Endometrial Cancer

Question 13

Menorrhagia

Answer 13

“Heavy periods” >80ml blood loss
Very common
1 in 20 women consult their GP a year
Costing the NHS £7 million in prescriptions
Causes
DUB in 50%
Fibroids, endometriosis, polyps......

Question 14

Treatment

Answer 14

Mirena coil 
Mefanamic and tranexamic acid
COCP
Depo provera
Endometrial ablation
Hysterectomy

Question 15

Fibroids (Leiomyomas)

Answer 15

Very common benign tumours
Arise from myometrium (uterine muscular wall)
Can present with heavy or painful periods, pelvic pain or distension
Treatment depends on symptoms and wishes for pregnancy

Question 16

Endometritis and Pelvic Inflammatory Disease

Answer 16

Caused by Infections, usually sexually transmitted.
Can present with abnormal discharge, pain or bleeding.
Can be asymptomatic
Major cause of infertility

Question 17

Endometriosis

Answer 17

Endometrial tissue in the wrong location i.e outside the endometrium
Very common benign condition
Can present with heavy or painful periods, pelvic pain, painful sex
Treatment depends on symptoms and often difficult

Question 18

Endometriosis Treatment

Answer 18

COCP
Mirena
Zoladex
Surgery

Question 19

Endometrial Polyps

Answer 19

Benign growths from endometrial cavity

Can be removed at hysteroscopy

Question 20

Endometrial Cancer

Answer 20

Cancer of the lining of the uterus
Often presents as post menopausal bleeding and so is detected early
Risk factors are nulliparity, high BMI, HRT and late menopause
Diagnosed on biopsy
Either pipelle or hysteroscopy
Usually undergo TAH and BSO
Overall 20 year survival rate is 80%

Question 21

Endometrial Carcinoma

Answer 21

Usually presents as post-menopausal bleeding- early stage
Risk factors include obesity and oestrogen exposure
Diagnosed by endometrial biopsy (pipelle or hysteroscopy)
Treatment usually hysterectomy

Question 22

Ovarian Cysts

Answer 22

Follicular cysts
Benign, very common
Usually less than 6cm
Often asymptomatic, no treatment needed

Cystadenomas
Can be very large fluid filled cysts
Symptoms caused by pressure effect

Benign Mature Teratomas
Large cysts filled with solid substance

Question 23

Polycystic Ovarian Syndrome (1)

Answer 23

Common condition
Multiple cysts on ovaries
Usually presents as irregular periods, no periods, infertility, other symptoms
Major cause of infertility

Question 24

Polycystic Ovarian Syndrome (2)

Answer 24

Treatments
COCP
Metformin
Clomifene

Complications
Increased CV risk
Increased risk of T2DM
Increased problems in pregnancy

Question 25

Ovarian Cysts

Answer 25

Can be benign or malignant
Can be HUGE!!!
Can occur in young women- usually benign (20-45)
Can occur in older women- usually malignant (>45)
Usually need ovary to be removed with the cyst if large

Question 26

Ovarian cancer

Answer 26

Often asymptomatic especially if small
Usually present late when already spread
Poorer prognosis than endometrial cancer

Question 27

Pregnancy Associated Diseases

Answer 27

Miscarriage
Ectopic Pregnancies
Gestational Trophoblastic disease

Question 28

Miscarriage

Answer 28

Loss of pregnancy before 24 weeks
Occurs in approx 15% of pregnancies
Usually first trimester
Classification
Threatened, Inevitable, Incomplete and Missed
Often no cause found
Risk factors
Increasing age, multiple pregnancies, smoking, alcohol, connective tissue disorders in mother and diabetes
Presentation is usually with pv bleeding

Question 29

Treatment options

Answer 29

Conservative
Medical with misoprostol
Surgical usually by vacuum suction under GA

Question 30

Ectopic Pregnancy (1)

Answer 30

Think about in any ‘young woman’ with abdominal or pelvic pain- always test!!!!!
Risk factors are PID, coil, IVF, previous ectopic, pelvic surgery.

Question 31

Ectopic pregnancy (2)

Answer 31

An extra uterine pregnancy usually occurring in the Fallopian tubes
Occurs in 1% of pregnancies
Can occur very early before a period has been missed
Can be a gynaecological emergency as rupture of the pregnancy carries a high mortality
Risk factors for ectopics
Fertility treatments, PID, previous ectopics, smokers
Presentation pain and unilateral lower abdominal pain

Question 32

Ectopic pregnancy (3)

Answer 32

Raised beta-HCG levels on blood testing

Treatment almost always surgical