8 - Cervical and Ovarian Disorders Flashcards
What are cervical polyps and why do they occur?
Focal hyperplasia of columnar epithelium of endocervix
- Chronic inflammation
- Abnormal response to oestrogen (cervical polyps associated with endometrial hyperplasia)
- Localised congestion of cervical vasculature
Who do cervical polyps tend to occur in?
- Multigravidae
- 50 to 60 year olds
Risk of malignancy
What are the clinical features of cervical polyps?
Often asymptomatic and found incidentally on cervical screening
- Abnormal vaginal bleeding: IMB, PCB, PMB
- Increased vaginal discharge
- Infertility if large enough to block cervix
What are some differential diagnoses for cervical polyps?
ALWAYS NEED TO EXCLUDE ENDOMETRIAL CANCER IF POST MENOPAUSAL
- Endometrial polyp projecting through cervix
- Cervical ectropion
- STI
- Fibroids
- Endometriosis
What investigations are done for cervical polyps?
- Histology after removal
- Cervical smear to rule out CIN
- Triple swabs (endocervical and high vaginal)
How are cervical polyps managed?
- Polypectomy Forceps: can be done in primary care if small, twist and pull. If any bleeding cauterise with silver nitrate
- Diathermy Loop excision: if large need to refer to colposcopy clinic
Need to send for histological exam. High recurrence rate. If still bleeding after removal do TVUS of endometrium as could be endometrial polyp
What are some complications of polyp removal?
What is cervical ectropion?
Eversion of endocervix (columnar epithelium) to the ectocervix (stratified squamous). Metaplasia of stratified squamous cells
It is benign and not linked to cervical cancer!!!
What is the aetiology of cervical ectropion?
Induced by high levels of oestrogen so
- COCP
- Younger women
- Pregnancy
Cells of endocervix are more fragile so prone to trauma and bleeding so common to have post-coital bleeding
What is the transformation zone?
Border between columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
When located on the ectocervix, it is visible during speculum examination as a border
How may cervical ectropion present?
Often asymptomatic and found incidentally
Post coital bleeding
Excessive discharge as columnar cells have mucus secreting glands
Dysparaunia
How does cervical ectropion appear on speculum examination?
Well-demarcated border between redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the endocervix
What is the management for cervical ectropion?
No need to treat unless symptomatic
If symptomatic:
- Stop oestrogen drugs e.g COCP
- Cauterise with silver nitrate or cold coagulation
- Boric Acid pessary
What investigations should you do for cervical ectropion ?
Exclude other causes:
- Pregnancy test
- Triple swabs for STIs
- Cervical smear for CIN
What is a Nabothian cyst?
Fluid filled cyst on the surface of the cervix
Columnar epithelium of the endocervix produces cervical mucus. When squamous epithelium of ectocervix covers the mucus-secreting columnar epithelium, mucus becomes trapped and forms a cyst.
Causes: childbirth, minor trauma to the cervix or cervicitis secondary to infection.
How may Nabothian cysts present?
Found incidentally on speculum exam
Usually white or yellow colour
Asymptomatic but if large enough can cause pelvic fullness
How are Nabothian cysts managed?
If diagnosis is clear can be reassured and no treatment needed as often resolve spontaneously
If doubts then do colposcopy for excision and biopsy
What is PCOS and the pathophysiology of this? (two main hormone
Endocrine condition characterised by menstrual irregularity (oligo/amenorrhoea), hyperandrogenism (e.g acne, hirsutism) and anovulatory infertility
- Genetics: strong
- Increased LH: Serum levels are elevated and its pulse frequency and amplitude can be increased. In addition increased expression of LH receptors may be seen in the thecal and granulosa cells of the ovary. These changes result in an increased LH to FSH ratio which leads to excess androgens production by theca cells (in the ovary). Although high LH
- Insulin resistance: Results in hyperinsulinaemia, due to increased pancreatic production of insulin to compensate for the resistance. This stimulates theca cells, causing secretion of more androgens and a reduction in sex hormone-binding globulin (SHBG), leading to increased biologically active free androgens.
What are the characteristics of PCOS?
- multiple ovarian cysts
- Infertility
- Oligomenorrhea
- Hyperandrogenism
- Insulin resistance.
What are some signs and symptoms of PCOS?
Symptoms
- Oligo/amenorrhoea
- Infertility/sub-fertility
- Acne
- Hirsutism
- Obesity
- Sleep apnea
Signs
- Hirsutism
- Obesity
- Male pattern baldness
- Acanthosis nigricans
- Anxiety/depression
What are some pregnancy related complications with PCOS?
- High spontaneous abortion rate
- Pre-term labour
- Gestational diabetes
What are some other conditions related to PCOS?
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
What are some differential diagnoses for the presenting symptoms of PCOS and how can you test to rule these differentials out?
- Medications: phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours: that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
- Thyroid dysfunction
- Hyperprolactinaemia
- Premature ovarian insufficiency
What investigations are done for suspected PCOS and what will they show in PCOS?
Bloods
- Total testosterone: normal or moderately elevated in PCOS
- Sex hormone-binding globulin (SHBG): tends to be normal or low in patients with PCOS. Low levels mean increase in free testosterone and more severe disease
- LH/FSH: LH is elevated, resulting in an increased LH/FSH ratio. FSH is elevated in those affected by premature ovarian failure
- Prolactin: hyperprolactinaemia can cause oligomenorrhoea, can be raised in PCOS
- Thyroid profile
- 17-hydroxyprogesterone: morning levels elevated in non-classic congenital adrenal hyperplasia
Transvaginal US (Gold standard)
- Usually transvaginal
- Over 12 or more follicles in one ovary (string of pearls)
- Increased ovarian volume >10cm3 without cysts
- Not valid in adolescents
Diabetes must be screened for in PCOS. How is this done?
2-hour 75g oral glucose tolerance test (OGTT).
In the morning before breakfast take baseline fasting plasma glucose, give a 75g glucose drink and then measuring plasma glucose 2 hours later
- Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l
- Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
- Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
How is the diagnosis of PCOS made?
Rotterdam Criteria
Need 2 out of 3 of the following:
- Polycystic ovaries (12 or more follicles (2-9mm) on one ovary OR increased ovarian volume (>10cm3))
- Oligo-anovulation or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have PCOS
How is PCOS managed generally?
Crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease
- Weight loss
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
What is the most significant management of PCOS?
Weight loss
Orlistat for weight loss in women with BMI>30. It is a lipase inhibitor that stops absorption of fat
Reduces CVD risk, can improve chances of ovulation, can lower insulin resistance and hirsutism
Women with PCOS are at an increased risk of endometrial cancer. Why is this and how is this risk managed?
As women do not ovulate, they do not produce a corpus luteum so lack of progesterone so unopposed oestrogen so endometrial hyperplasia
Mx
- If more than 3/12 between periods or abnormal bleeding need pelvic US to assess endometrial thickness. Give cyclical progestogens to induce a period prior to scan. If endometrial thickness >10mm, refer for biopsy to exclude endometrial hyperplasia or cancer
- Mirena coil for continuous endometrial protection
-
Inducing a withdrawal bleed at least every 3 – 4 months with:
- Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) OR
- COCP
How is infertility managed in PCOS?
- Weight loss (1st line)
- Clomifene: SERM
- Letrozole: aromatase inhibitor, stops androgen conversion to oestrogen
- Metformin
- Laparoscopic ovarian drilling: diathermy or laser therapy in ovaries, improves hormone profile
- IVF
When a women with PCOS becomes pregnant, what needs to be screened for?
Gestational Diabetes
Do OGTT before 24-28 weeks
Hyperandrogenism in PCOS can cause acne and Hirsutism. How can Hirsutism be managed?
- Weight loss
- Cosmetic treatments e.g shaving/waxing
- Co-cyprindiol (Dianette): anti-androgenic COCP, is a contraceptive and will also regulate periods. Increased risk of VTE so can only use for 3/12
- Topical eflornithine: for facial hirsutism, takes 6 – 8 weeks to see improvement and will return within two months of stopping
How can acne be managed in PCOS?
1st Line: COCP (usually Co-cyprindiol but high risk of VTE)
What is the difference in management for women with PCOS who are planning pregnancy and for those who are not planning pregnancy?
How are metabolic complications reduced in PCOS?
- Exercise and Diet Advice
- Smoking cessation advice
- Screen for T2DM, HTN and Dyslipidaemia on diagnosis
What is metformin used for in PCOS?
Induce ovulation and reduce circulating androgens by improving insulin sensitivity
Research has design flaws, small groups and lack of placebo group so not routinely used anymore
What are some psychological issues in PCOS and where can you signpost them to?
VERITY
- Anxiety and Depression
- Eating disorders
- Psychosexual issues
What is premature ovarian insufficiency and what are the symptoms of this?
Menopause before the age of 40
Typical menopause symptoms e.g irregular menstrual periods, amenorrhea, hot flushes, night sweats, vaginal dryness
Symptoms due to low oestrogen
What are some of the causes of premature ovarian insufficiency?
- Idiopathic
- Iatrogenic: e.g chem, radio, oophorectomy
- Autoimmune: coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
- Genetic: family history, Turner’s syndrome
- Infections: mumps, TB, cytomegalovirus
How is premature menopause diagnosed?
Younger than 40 with typical menopausal symptoms plus elevated FSH.
FSH level: needs to persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. Difficult to interpret if taking hormonal contraception
What are women with premature menopause at increased risk of?
Due to lack of oestrogen:
- Cardiovascular disease
- Stroke
- Osteoporosis
- Cognitive impairment
- Dementia
- Parkinsonism
How is premature menopause managed?
HRT until at least the age at which women typically go through menopause to reduce cardiovascular risk, osteoporosis.
Need contraception as still small chance of pregnancy
What HRT options are available for women with premature menopause and how do you choose which one to have?
Traditional HRT or COCP
- Traditional HRT lower blood pressure
- COCP has less stigma for younger women and acts as contraception
- HRT before the age of 50 does NOT increase risk of breast cancer. However increased risk of VTE, can lower this by using transdermal methods
What are some causes of ovarian cysts?
Pre-menopausal: Benign in response to hormone fluctuations
Post-menopausal: Malignancy
PCOS: string of pearls
How may ovarian cysts present?
Often asymptomatic and found incidentally on imaging
- Pelvic pain
- Bloating
- Fullness in the abdomen
- A palpable pelvic mass (large cysts such as mucinous cystadenomas)
Acute pelvic pain if ovarian torsion, haemorrhage or rupture of the cyst
What are some different types of ovarian cysts?
- Follicular cysts (Most common): developing follicle that can fail to rupture and release the egg. Disappear after a few menstrual cycles. Thin walls and no internal structures on US
- Corpus luteum cysts: corpus luteum fails to break down and instead fills with fluid. Cause pelvic discomfort, pain or delayed menstruation. Often seen in early pregnancy
- Serous Cystadenoma
- Mucinous Cystadenoma: can become huge, taking up lots of space in the pelvis and abdomen.
- Endometrioma: occurring in patients with endometriosis, can cause pain and disrupt ovulation.
- Dermoid Cysts / Germ Cell Tumours: may contain various tissue types, such as skin, teeth, hair and bone. Associated with ovarian torsion.
- Sex Cord-Stromal Tumours: these are rare tumours, that can be benign or malignant
How can you assess via the history whether an ovarian cyst is benign or malignant?
Ask about the following symptoms:
- Abdominal bloating
- Reduce appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
What are some investigations you can do for an ovarian cyst?
- Pelvic US: if premenopausal and <5cm then no further investigation
- CA125
- Germ cell tumour markers: LDH, HCG, AFP
What are some causes of a raised CA125?
Non-specific:
- Epithelial cell ovarian malignancy
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
What is the risk of malignancy index?
Estimates risk of an ovarian mass being malignant:
- Menopausal status
- Ultrasound findings
- CA125 level
How are ovarian cysts managed?
- Possible ovarian cancer (complex cysts or raised CA125): two-week wait
- Possible dermoid cysts: refer to gynaecologist
- Simple ovarian cysts in premenopausal women: <5cm cysts will almost always resolve within three cycles, 5cm to 7cm: routine referral to gynaecology and yearly ultrasound monitoring, >7cm: Consider MRI scan or surgical evaluation
- Cysts in postmenopausal women : raised CA125, two-week wait. If <5cm with normal CA125 monitor with US every 4 – 6 months.
- Persistent or enlarging: surgical intervention ovarian cystectomy possibly along with the affected ovary (oophorectomy).
What are some complications of ovarian cysts?
Will have acute onset pain
- Torsion
- Haemorrhage into the cyst
- Rupture, with bleeding into the peritoneum
What is Meig’s syndrome?
Triad of:
- Ovarian fibroma (a type of benign ovarian tumour)
- Pleural effusion
- Ascites
Removal of the tumour results in complete resolution of the effusion and ascites.
How may an ovarian cyst rupture present and what are some differentials for this?
- Asymptomatic
- Acute unilateral pain
- Intraperitoneal haemorrhage with haemodynamic compromise
Differentials: ectopic pregnancy, ovarian torsion, appendicitis
What investigations should you do for an ovarian cyst rupture?
- Pregnancy to exclude ectopic
- Laparoscopic exploration for unstable patient
What are some causes of ovarian torsion?
- Tumour larger than 5cm (usually benign)
- Pregnancy
- Before menarche (when girls have longer infundibulopelvic ligaments so easily twists)
EMERGENCY PRESENTATION AS ISCHAEMIA AND NECROSIS
How does ovarian torsion present?
- Sudden onset severe unilateral pelvic pain
- Pain is constant and gets worse
- Nausea nad vomiting.
- Localised tenderness
- May be a palpable mass in the pelvis
How is ovarian torsion diagnosed?
First Line:
- Pelvic US: Preferably transvaginal. May show “whirlpool sign”, free fluid in pelvis and oedema of the ovary.
- Doppler studies: for lack of blood flow
Diagnostic:
- Laparoscopic surgery
How is ovarian torsion managed?
Laparoscopy and either:
- Un-twist the ovary and fix it in place (detorsion) OR
- Remove the affected ovary (oophorectomy)
What are some complications with ovarian torsion?
- If necrotic may develop an infection, form an abscess and become septic
- May rupture and chase peritonitis and adhesions
- Lack of fertility
Fibroid embolisation
