17 Pathology of the Female Reproductive Tract

Question 1

Aims

Answer 1

Basic anatomy 
Common presentations of gynaecological pathology. 
Pathology of the:
Cervix
Uterus and Endometrium
Ovaries
Pregnancy related disorders

Question 2

Presenting Complaints

Answer 2

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 3

Cervical Pathology

Answer 3

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

Question 4

Cervical Screening-Smear Test

Answer 4

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 5

Human Papilloma Virus

Answer 5

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 6

HPV

Answer 6

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 7

Screening programme

Answer 7

Cervical cancer screening programme

“Smear” test carried out in GP surgery

Question 8

Cytology Screening

Answer 8

Normal- routine 3/5 year re-smear

Abnormal- referred to colposcopy

May have biopsies taken

Question 9

Cervical Intra-epithelial Neoplasia CIN

Answer 9

CIN is a microscopic lesion in that affects the cervix that could potentially develop into cervical cancer if left untreated

Question 10

Cervical Cancer

Answer 10

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 11

Cervical Carcinoma

Answer 11

Abnormal cells and invasion

Can present with inter-menstrual or post-coital bleeding

Question 12

Treatment:

Answer 12

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

Question 13

Endocervical Polyps

Answer 13

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

Question 14

Uterine Pathology

Answer 14

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

Question 15

Menorrhagia

Answer 15

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 16

Menorrhagia

Answer 16

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

Question 17

Fibroids (Leiomyomas)

Answer 17

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 18

Endometritis and Pelvic Inflammatory Disease

Answer 18

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

Question 19

Endometriosis

Answer 19

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 20

Endometriosis

Answer 20

Treatment
COCP
Mirena
Zoladex
Surgery

Question 21

Endometrial Polyps

Answer 21

Benign growths from endometrial cavity

Can be removed at hysteroscopy

Question 22

Endometrial Cancer

Answer 22

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 23

Endometrial Carcinoma

Answer 23

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 24

Ovarian Cysts

Answer 24

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 25

Polycystic Ovarian Syndrome

Answer 25

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

Question 26

Polycystic Ovarian Syndrome

Answer 26

Treatments
COCP
Metformin
Clomifene

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

Question 27

Ovarian Cysts

Answer 27

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 28

Ovarian cancer

Answer 28

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

Question 29

Pregnancy Associated Diseases

Answer 29

Miscarriage
Ectopic Pregnancies
Gestational Trophoblastic disease

Question 30

Miscarriage

Answer 30

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

Treatment options
Conservative
Medical with misoprostol
Surgical usually by vacuum suction under GA

Question 31

Ectopic Pregnancy

Answer 31

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

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

Raised beta-HCG levels on blood testing

Treatment almost always surgical