Benign gynaecological conditions

Question 1

What is the presentation of Bartholin abscess and cyst?

Answer 1

Abscess - acute infection of bartholin gland by duct. Very painful swollen area.
Cyst - chronic swelling after previous acute infection. Painless.
Management: Antibiotics, marsuplisation with GA (drainage and inversion) or word catheter with LA.

Question 2

Describe features of lichen sclerosis

Answer 2

Autoimmune condition which presents with itching and excoriation, pain and dyspareunia.
O/e - whitening vulval skin, loss of labial and clitoral contours and narrowing of vagina.
Diagnosis - Typically clinical but can do biopsy
Treatment - potent steroids eg, clobetasol (dermovate)

Question 3

Describe features of genital herpes

Answer 3

HSV2. Usually presents with painful vesicular rash, dysuria and dyspareunia.
Management - Oral aciclovir 400mg TDS for 5-10 days and self care measures (oral analgesia, salt water baths and increase fluid intake to dilute urine)

Question 4

Describe features of cervical ectropion

Answer 4

Columnar cells from canal everted to cervix.
Usually asymptomatic but can present with chronic discharfe/post coital bleeding.
Ix - speculum exam showing typical appearence.
Rx - Cautery or cryotherapy only if symptomatic

Question 5

Describe features of Cervical polpys

Answer 5

Usually asymptomatic but can present with PCB or PMB.
Diagnosis via typical appearance.
Treat only if symptomatic with avulsion.

Question 6

Describe features of fibroids (leiomyomas)

Answer 6

Benign tumours of myometrium which are very common. Most common in afro-caribbean women.
Oestrogen dependent so grow during pregnancy and shrink after menopause.

Question 7

What are the symptoms of fibroids?

Answer 7

Heavy menstrual periods, abdominal swelling, pressure symptoms (ureteric obstruction and hydronephrosis), subfertility, difficulties in pregnancy, pain (torsion or degeneration).
Signs - Abdominal or pelvic mass

Question 8

What is the diagnosis and management of fibroids?

Answer 8

Diagnosis: Clinical suspicion, confirmed by US and MRI to plan management.
Conservative management - Mirena coil, mefenamic acid, TXA, POP.
Medical management: GnRH analogues (artificial menopause), ulipristal acetate (do LFTs every month).
Surgical management: Hysterectomy or myomectomy (if to preserve fertility)
Uterine artery embolization: Minimally invasive IR procedure.

Question 9

What are the symptoms and diagnosis of an endometrial polyp?

Answer 9

Symptoms: PMB, IMB and HMB.
Diagnosis - TVU, hysteroscopy and histology.
Management - Hysteroscopy and polypectomy

Question 10

Describe features of PID

Answer 10

Ascending infection from cervix. Can also be caused by anaerobes, not always STIs. Increases the risk of infertility, ectopic pregnany and chronic pelvic pain.

Question 11

What are the signs and symptoms of PID?

Answer 11

Symptoms - Anorexia, malaise, lower abdominal pain, deep dyspareunia, purulent discharge, PCB or IMB.

Signs - Pyrexia, abdominal distention, tenderness, Fitz-Hugh-Curtis syndrome, tender on vaginal exam, discharge on speculum examination.

Question 12

What are the investigations for PID?

Answer 12

Urinary pregnancy test,
FBC and CRP,
Urine dip and culture,
Swabs for chlamydia, gonorrhoea and anaerobes,
Transvaginal ultrasound,
Laparoscopy if diagnostic uncertainty

Question 13

What is the management of PID?

Answer 13

Empirical antibiotics - Ceftriaxone 500mg IM stat followed by oral doxycycline 1mg BD AND metronidazole 400mg BD for 10 days.
Give analgesia with ibuprofen or paracetamol
Refer to GUM.

Question 14

Describe features of hydrosalpinx

Answer 14

It is fluid collection in fallopian tube. Typically asymptomatic following infective phase. May have pelvic pain and infertility.
Diagnosis via laparoscopy or hysterosalpingogram.
Treatment - Conservative if asymptomatic, bilateral salpingectomy if pain and IVF if infertile.

Question 15

What are some different types of ovarian cysts?

Answer 15

Functional cysts,
Dermoid cysts,
Epithelial cysts,
Endometrial cysts.

Question 16

What are the clinical features of ovarian cysts?

Answer 16

Often asymptomatic but can have pain, abdo or pelvic swelling.
Diagnosis - Ultrasound, CT or MRI. MUST do CA125, CEA, AFP, hCG and LDH.
Management: If symptom free and < 6cm then conservative (consider doing CA125). Surgical removal if > 6cm or symptomatic. (if undergoing fertility treatment then drain if >3cm).

Question 17

Describe features of functional cysts

Answer 17

Either follicular or luteal. Both are related to menstrual cycle and usually resolve within 6-12 weeks.
These are very common and often incidental.

Question 18

Describe features of dermoid cycts

Answer 18

Variable size which can often contain hair, bone, teeth.
Diagnosed via ultrasound +/- CT.
Management - Open ovarian cystectomy or oophorectomy.

Question 19

Describe features of epthelial ovarian cysts

Answer 19

Serous or mucinous cystadenomas which will not resolve spontaneously. May present with abdo swelling and pain (torsion).
Ix - US, CT/MRI and do tumour markers especially CA125.
Management - Surgical removal. Open surgery.

Question 20

Features of cyst accidents (complications)

Answer 20

Mainly torsion but can be ruptured cysts, haemorrhage or infection
Presents with unilateral lower abdo pain and PV tenderness.
Ix - Pregnancy test, MSU, swabs, CA125, TVU.
Management - laparoscopy.

Question 21

Describe features of endometriosis

Answer 21

Oestrogen dependent benign inflammatory disease characterized by ectopic endometrium.
Three types: superficial peritoneal lesions (mild), deep infiltrating lesions and ovarian cysts (endometriomas)

Question 22

What are the clinical features and Ix for endometriosis?

Answer 22

Symptoms - Dysmenorrhoea, dysparunia, pelvic pain, subfertility.
Signs - Fixed tender retroverted uterus.
Investigations: History and vaginal exam. Transvaginal ultrasound, raised CA 125 (36-100), laparoscopy and biopsy is gold standard.

Question 23

What is the management of endometriosis?

Answer 23

Conservative management if symptom free.
Symptoms relief: NSAIDs, progestogens, mirena, COCP,
Definitive treatment is surgery - cautery if mild an ovarian cystectomy if endometrioma

Question 24

Describe features of dysmenorrhoea

Answer 24

Pain which coincides with menses - cramping lower abdo pain which can radiate to lower back and legs.
Primary - idiopathic, onset soon after start of periods.
Secondary - onset occurs years after menarche and is more likely due to pathology.

Question 25

Describe features of vulvodynia

Answer 25

Sensation of burning and soreness but with no obvious skin problem.
Causes by hypersensitivity of vulval nerve fibers.
Management - Low dose tricyclic antidepressants, lubricants and vulval care advice.

Question 26

Describe features of chronic pelvic pain syndrome?

Answer 26

Intermittent or constant lower abdominal pain which has gone on for over six months with no obvious cause.
It is often multifactorial - always discuss abuse

Question 27

What is the assessment/managment for chronic pelvic pain syndrome?

Answer 27

Allow time for discussion,
Rule out gynaecological pathology - imaging and laparoscopy.
Consider - IBS, intersitital cystitis, psychological and social issues
Management - analagesia, MDT meeting