benign gynae Flashcards
10yr survivals of repro cancers
endometrial 72%
cervical 51%
vulval 67%
ovarian 35%
side effects of radiotherapy in repro cancers
- Vaginal discharge/dryness
- Vaginal stenosis
- Rectal stenosis
- Radiation cystitis
fatigue N+V+D
indications for radical radiotherapy as primary curative treatment
cervical cancer
- stage I is medically unfit for surgery
- stage II, III, IV
endometrial cancer if medically inoperable
some vulval cancers
adjuvant radiotherapy, indications?
following surgery to treat microscopic disease + reduce the risk of disease recurrence
indications
- cervical - large tumour diameter, positive margins on resection, positive lymph nodes
- endometrial - grade III, IV, grade II depending on histology
- vulval - depending on histology
palliative radiotherapy indications
pain
bleeding
spinal cord compression from metastases
skin mets
most commonly used chemo in ovarian cancer
carboplatin +/- paclitaxel
usually 6 cycles - may have debulking after 3
treatment depends on stage/grade of cancer
what origin is the symptom of bleeding usually from? what would bimanual examination show?
uterine
midline, lobulated mass
moves with cervical motion
NONtender
what origin is the symptom of pain usually from? what would bimanual examination show?
ovarian
lateral, occupying fornices
NO movement with cervical motion
can be TENDER
what origin pressure symptoms usually from?
uterine or ovarian
how do benign vs malignant present differently?
benign
- long term symptoms
- smooth mass, MOBILE
malignant
- short term
- cachexia (wasting of body)
- ascities
- craggy mass
- NOT mobile
investigating premenopausal vs postmenopausal ovarian masses
pre - MRI, tumour markers (AFP, HCG, LDH)
post - CT + CA125
nonmalignant causes of a raised Ca125
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy
tumour markers
alphafetoprotein (AFP) - embryonal carcinoma
human chorionic gonadotrophin (HCG) - choriocarcinoma
LDH - dysgerminoma
women under 40 with a complex ovarian mass require tumour markers for a possible germ cell tumour
risk of malignancy index
estimates risk of an ovarian mass being malignany
takes into account 3 things -
- menopausal status
- ultrasound findings
- CA125 level
how to calculate risk of malignancy index
A = menopausal status
- pre = 1
- post = 3
B =ultrasound features (no =0, one feature = 1, >1=3)
- multioculated
- solid areas
- bilaterality
- ascities
- metastasis
C=serum Ca125
RMI = A x B x C
RMI value meanings
RMI <30 -> 3% risk of ovarian cancer
RMI 30-200 -> 10%
RMMI >200 -> 75%
functional ovarian cysts
- Related to ovulation
- Common in premenopausal – postmenopausal may need further Ix
- Rarely >5cm
- Usually resolve spontaneously after a few cycles
- May cause menstrual disturbance
- Consider as differential in acute abdomen as may bleed or rupture
- Often asymptomatic/incidental finding
follicular or corpus luteum cyst
endometriotic cysts
presents with
o Severe dysmenorrhea/premenstrual pain
o Dyspareunia
o Assoc with sub fertility
o Occasionally asymptomatic
o Acute abdomen if ruptures
Examination
o Tender mass with modularity
o Tenderness behind uterus
dermoid cysts
Totipotential
o Teeth
o Sebaceous material
o Hair
o Thyroid tissue
Assoc with ovarian torsion
Commonest benign tumour in women under30
ovarian mass investigation
- ultrasound
- Premenopausal simple ovarian cyst <5cm on US don’t need further investigation
- Ca125
- Women under 40 with complex ovarian mass require tumour markers for a possible germ cell tumour
o Lactate dehydrogenase (LDH)
o AFP
o HCG
management of benign ovarian tumours
monitoring, if >7cm MRI
medical - GNRH analogues, OCP
surgical - laparoscopic/laparotomy
- ovarian cystectomy
- uni/bilateral oophrectomy
- pelvic clearance
borderline ovarian tumours
- Growth much more controlled than cancer
- Unlikely to spread
- Even if spread – as implant rather than deeply invasive
- Usually a better prognosis compared to ovarian cancer
- Young women – unilateral cystectomy/oophorectomy with close follow up
- Postmenopausal women – pelvic clearance
fibroids
smooth muscle cell tumour - usually benign
v common 40-60% of women in later reproductive years
**oestrogen sensitive - grows in response
types of fibroids
subserosal - just below outer layers of uterus, grow outwards + can become v large filling abdominal cavity, PAIN
intramural - within myometrium, can distort uterus, BLEEDING
submucosal - just below lining of uterus, PAIN + BLEEDING
pedunculated - on stalk
fibroids presentation
heavy menstrual bleeding + prolonged
reduced fertility
post coital bleeding
lower abdo pain - worse during period
deep dyspareunia
urinary/bowel symptoms - due to pelvic pressure
fibroids investigations
abdo + bimanual exam
- palpable pelvic mass
- enlarged firm non-tender uterus
diagnosis = transvaginal US
management of fibroids
asymptomatc = nothing, monitor
medical
- wants kids -> tranexamic acid
- for fibroids <3cm, Mx same as HMB
–> mirena coil = 1st line
- GnRH agonists (goserline) - reduce size
–> induce menopause like state, reduce oestrogen but SE = hot flushes, dry vaj, loss of bone min density
surgical
- endometrial ablation(<3cm), myomectomy, hysterectomy
- uterine artery embolisation (starves fibroid of O2)
endometriosis
presence of endometrial glands + stroma outside of uterine cavity
- endometrioma
- adenomyosis = endometrial tissue within myometrium of uterus
20-30% of infertile women
causes of endometriosis
retrograde menstruation = blood flows backwards into fallopain tubes and implants in pelvis
abnormal development as fetus
spread through lymphatics - altered immune function
metaplasia
altered cellular adhesion
IDK
presentation of endometriosis
dysmenorrhoea - pain before menstruation
dysparenunia
menorrhagia
painful defaecation
chronic pelvis pain
infertility
bleeding from other sites - haematuria
chocolate cysts
gunpowder appearance on laparoscopy
endometrial tissue in poterior fornix
tenderness in vagina, cervix + adnexa
endometriosis investigation
lapaoscopy = gold standard
–> definitive diagnosis - biopsy lesion
pelvic US may reveal large endoetriomas + chocolate cysts
endometriosis management
initial mx - NSAIDs / paracetamol
hormonal mx - COCP or POP
– still want kids -> GnRH analogues (pseudomenopause to reduce oestrogens)
surgical Mx
- laparoscopic surgery to excise or ablate endometrial tissue + adhesions
- hysterectomy - stop response to menstrual cycle
surgery may improve fertility, hormonal therapies may improve symptoms not fertility
endometriosis complications
infertility
adhesions
ectopic pregnancy
malignancy - endometriod carcinoma
