Atrophic vaginitis; Bartholin's abscess; Fibroids

Question 1

Describe the pathophysiology of atrophic vaginitis [2]

Answer 1

Reduction in levels of oestrogen in the body:
- The vaginal mucosa becomes drier, thinner and more easily broken, which can lead to epithelial irritation and inflammation
- levels of glycogen production in the vagina fall, leading to a decrease in the numbers of lactobacilli which normally maintain the acidic environment of the vagina. Their absence allows an increasingly alkaline environment in which infection is more likely to develop

Question 2

Describe the clinical presentation of atrophic vaginitis [5]

Answer 2

1. Dryness of the vagina (57% of patients)
2. Local irritation
3. Painful intercourse
4. Vaginal bleeding, particularly post-coital bleeding or haematuria
5. Vaginal discharge
   * Usually white or yellow and occasionally malodorous

Question 3

Describe the internal [4] and external [4] examination findings of atrophic vaginitis

Answer 3

External examination
* Reduced pubic hair
* Loss of labial fat pad
* Narrowing of vaginal introitus
* Thinning of labia minora

Internal examination
* Smooth, shiny vaginal mucosa with loss of skin folds
* Dryness of mucosa
* Loss of vaginal muscle tone
* Erythema or bleeding

Question 4

Atrophic vaginitis can cause post-menopausal bleeding.

What is an important differential? [1]
How would you differentiate between them? [1]

Answer 4

endometrial cancer:
- Perform TVUS - atrophic vaginitis should be nromal
- If it is abnormal (>4mm), then endometrial biopsy would be done. Laparoscopy would not help.

Question 5

Describe how you treat atrophic vaginitis [3]

Answer 5

Vaginal lubricants and moisturisers

Topical oestrogens
* Treatments will take around 3 weeks to have any effect, with maximal effect noticeable within 3 months of starting
* Long-term topical oestrogens are considered safe, with no effect on endometrial proliferation

Systemic HRT
* Can be used in patients with other post-menopausal symptoms
* Up to 25% of patients taking systemic HRT will also experience vaginal dryness, so may require topical oestrogens in addition.

Question 6

How do you dx AV? [1]

Answer 6

Atrophic vaginitis is a diagnosis of exclusion, and can only be made after ruling out other pathology

Question 7

Describe what is meant by a Bartholin’s absess [1]

Answer 7

A common gynaecological condition that affects women of reproductive age.

It occurs when the Bartholin’s gland, located on either side of the vaginal opening, becomes blocked and infected

Question 8

What is the role of the Bartholin’s glands? [1]

Answer 8

The Bartholin’s glands, located bilaterally at the posterior introitus, serve to secrete mucus for vaginal lubrication

Question 9

Describe the pathophysiology of a Bartholin’s cyst and then abscess

Answer 9

A Batholin gland cyst:
- A duct of one of the Bartholin glands becomes obstructed due to trauma, inflammation or infection
- An accumulation of secretions within the gland leading to cyst formation. This is known as a Bartholin’s cyst.

A Batholin gland abscess:
* Bacteria then infect the cyst; include Escherichia coli, Staphylococcus aureus, and sexually transmitted infections such as Neisseria gonorrhoeae and Chlamydia trachomatis.
* If not drained or treated promptly, pus accumulates leading to abscess formation.

Question 10

Describe the clinical features of Bartholin’s abscess

Answer 10

Swelling:
* Patients often present with a unilateral, tender swelling at the lower vestibule near the vaginal opening. The size of the swelling may vary from a small nodule to a large mass occupying a significant portion of the labium majus.

Pain:
* The affected area typically exhibits localized pain that may be exacerbated by walking, sitting, or engaging in sexual activity.
* In some cases, patients may report dyspareunia due to increased pressure on the abscess during intercourse.

Erythema and warmth:

Fluctuance:
* Upon palpation, a fluctuant mass may be appreciated, indicating pus accumulation within the abscess cavity.

Pus discharge:
* Spontaneous rupture or incision and drainage of the abscess can lead to purulent discharge from the external opening.

NB: fever and malaise alsoo occur

Question 11

How do you differentiate a Bartholin abscess to a Bartholin gland cyst [2]

Answer 11

1. not associated with signs of infection
2. A gland cyst typically presents as a painless, unilateral swelling at the posterior introitus. Its size can vary from small and barely noticeable to large and uncomfortable.

Question 12

What is an important differential diagnosis for Bartholin’s abscess? [1]

How do you differentiate between them? [4]

Answer 12

Vulvar or vaginal malignancies can present as a mass mimicking a Bartholin’s abscess: Typically present as:
- persistent lesions despite treatment
- irregular or bleeding ulcers
- weight loss or other systemic symptoms
- NOT typically associated with acute onset pain or signs of infection unless secondarily infected.

Question 13

The management depends on the size of the cyst and presence or absence of an abscess.

Describe the management of small (< 3cm) [1] and large (> 3cm) [3] large cysts

Answer 13

Small cysts (< 3 cm):
- No specific management is required for small asymptomatic cysts
- Symptomatic cysts may be managed with warm compresses or bath

Large cysts (≥3 cm) or abscess:
- Marsupialisation: incision into the cyst or abscess and suturing the edges of the skin to create a permanent opening; The stitches should dissolve over four weeks.
- Word Catheter Placement: placement of a small plastic tube with an inflatable balloon; done under local anaesthetic and usually remains for 4 weeks and then removed

Antibiotics are generally reserved for patients with recurrent abscess, systemic features (e.g. fever, rigors), complicated infection (e.g. immunosuppressed, extensive cellulitis), or resistant organisms (e.g. MRSA).

NB: Gland Excision: Reserved for recurrent cases that do not respond to other treatments, this procedure involves complete removal of the Bartholin’s gland. However, due to significant postoperative morbidity associated with this procedure, it is typically considered as a last resort.

Question 14

What are complications of Bartholin’s abscess [4]

Answer 14

Recurrent Bartholin gland abscesses

Fistula formation: Chronic inflammation and recurrent infections may lead to fistula formation between the abscess cavity and the skin or vaginal mucosa.

Cellulitis

Abscess extension: In severe cases, the abscess can extend to adjacent structures such as the perineum, buttock, or anterior abdominal wall.

Question 15

Define what is meant by a uterine fibroid (leiomyomas) [1]
What are the three types? [3]

Answer 15

Uterine fibroids (leiomyomas) are benign tumours that arise from the muscle layer of the uterus termed the myometrium
- Depending on the location of fibroids, they may be classified as subserosal, intramural or submucosal.

Question 16

Name a factor that decreases the chance of fibroids [1]

Answer 16

The risk of developing fibroids is decreased by pregnancy.

Question 17

There are several risk factors that increase the chances of a female developing fibroids.

Name 4 [4]

Answer 17

Early age of puberty
Increasing age
Obesity
Ethnicity (e.g. black females)

Question 18

Describe the signs and symptoms of fibroids [6]

Answer 18

Menorrhagia (most common) and dysmenorrhoea

Sub/Infertility, if the fibroid is large enough to distort the uterine cavity

Deep dyspareunia (pain during intercourse)

Bloating or feeling full in the abdomen

Abdominal pain, worse during menstruation

Urinary frequency if large enough and putting pressure on the bladder

NB: Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

Question 20

Describe the management of fibroids [+]

Answer 20

Menorrhagia is the most common problem associated with fibroids and thus management focuses on the treatment of heavy periods:
- Levonorgestrel-releasing intrauterine system (Mirena) - 1st line
- COCP
- NSAIDS
- TXA

Surgical intervention:
- Endometrial ablation
- Myomectomy or hysterectomy
- Uterine artery embolisation (for large fiboids)

Question 21

For fibroids more than [] cm, women need referral to gynaecology for investigation and management.

Answer 21

For fibroids more than 3 cm, women need referral to gynaecology for investigation and management.

Question 22

Describe the initial investigation for submucosal fibroids that present with heavy menstrual bleeding [1]

Describe the investigation for larger fibroids [1]

What investigation do you perform prior to surgery? [1]

Answer 22

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.

Pelvic ultrasound is the investigation of choice for larger fibroids.

MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Question 23

Which medications can be used to reduce the size of fibroids prior to surgery? [2]

Answer 23

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)
- They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Question 24

[] is the only treatment known to potentially improve fertility in patients with fibroids.

Answer 24

Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.

Question 25

TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be []

Answer 25

TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.

Question 26

Endometrial ablation can be used to destroy the endometrium.

Name a type of endometrial ablation that is most commonly used? [1]

Answer 26

Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation
- This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.

Question 27

Describe what is meant by ‘red’ degeneration of fibroids [1]

Answer 27

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

Question 28

Describe which type of fibroids typically undergo ‘red’ degeneration [1]

Describe why this occurs

Answer 28

Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy
- Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
- It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.

NB: most commonly occurs in the 12th - 22nd week of pregnancy

Question 29

Describe the typical presentation of fibroid degeneration / red degeneration [+]

Answer 29

Acute abdominal pain during pregnancy
- Constant abdominal pain localising to the area of the fibroid
- Area tender to palpation
- Rebound tenderness
- Fibroid likely palpable as it enlarges

A low-grade fever commonly accompanies fibroid degeneration

There should be no haemodynamic compromise or increased oxygen requirement in simple acute fibroid degeneration

Vaginal bleeding is NOT a common feature of degeneration and should prompt suspicion of other conditions such as placental abruption.

Question 30

Describe the management of fibroid degeneration

Answer 30

The mainstay of treatment is conservative management. The patient will need to be assessed at a centre with obstetrics care

Patients should be reassured that fibroids usually regress during the puerperium owing to hormonal withdrawal.

Analgesia
- Acute painful episode usually resolves in 4-7 days
- Paracetamol
- NSAIDS should be used with caution to avoid fetal complications such as premature closure of the ductus arteriosus

In very rare cases, the decision may be made to remove fibroids in the first or second trimester of pregnancy:
- Fibroids causing intractable pain or a torted pedunculated fibroid are rare indications

Question 31

Why do GnRH agonists shrink fibroids?

Answer 31