Day 3 Gynaecology Flashcards
A 21-year-old woman presents for her dating scan after discovering she was pregnant 6 weeks ago, following a urinary pregnancy test.
Her ultrasound shows the pregnancy is extra-uterine and is located in her left fallopian tube. It is 20mm in size, is unruptured and has no cardiac activity.
She is currently reporting no symptoms, including no bleeding, cramping, vomiting or systemic symptoms her vitals are normal.
Her blood test results are as follows:
- β-hCG Today 740 IU/L
- β-hCG 1 week ago (Booking Appointment) 940 IU/L
There is no past medical history of note.
What is the most appropriate management to offer her?
Give safety netting advice and ask to return in 48 hours for serum β-hCG levels
Expectant management of an ectopic pregnancy can only be performed for
- An unruptured embryo
- <35mm in size
- Have no heartbeat
- Be asymptomatic
- Have a B-hCG level of <1,000IU/L and declining
You are working in general practice, a 53-year-old female presents with 2 months of per-vaginal (PV) bleeding.
She passed through the menopause at 49-years-old, her body mass index (BMI) is 34kg/m² and she drinks 18-units of alcohol a week.
She has only had one sexual partner her whole life.
She has no pain during sex or post-coital bleeding.
Which diagnosis is most likely?
Endometrial hyperplasia may present with :
intermenstrual bleeding
post-menopausal bleeding
menorrhagia
irregular bleeding
Types fo endometrial hyperplasia
(4)
simple
complex
simple atypical
complex atypical
Feature of endometrial hyperplasia
abnormal vaginal bleeding e.g. intermenstrual
Management of endometrial hyperplasia
(3)
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months.
The levonorgestrel intrauterine system may be used
atypia: hysterectomy is usually advised
A 30-year-old woman presents with ongoing, cyclical pain around the time of her periods. The pain starts several days before the period itself and can last until several days after. She also experiences pain during sexual intercourse, particularly with deep penetration.
Examination demonstrated tender nodularity in the posterior fornix.
The patient has already tried paracetamol and ibuprofen, but these are no longer effective.
What is the likely diagnosis?
What is the next most appropriate step?
If analgesia doesn’t help endometriosis then the
combined oral contraceptive pill or a progestogen should be tried
What is Clomifene used for in gynaecological medicine?
Clomifene is used to induce ovulation in a number of conditions.
What is Elagolix used for?
Elagolix is a relatively new gonadotropin-releasing hormone antagonist. It is licensed in the USA for endometriosis-related pain.
It is not widely used in the UK currently and so the next most appropriate option remains the combined contraceptive pill.
What is Leuprorelin?
Leuprorelin is a gonadotropin-releasing hormone agonist.
Whilst effective for the control of endometriosis-related pain, it is prescribed by specialists and would not be the next step after simple analgesia.
Endometriosis Clinical features
(7)
- chronic pelvic pain
- secondary dysmenorrhoea
- pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
Endometriosis pelvic examination findings
(3)
reduced organ mobility
tender nodularity in the posterior vaginal fornix
visible vaginal endometriotic lesions
Investigations for endometriosis
(2)
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Primarry treatments/management of endometriosis
(2)
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
Secondary treatments of endometriosis:
(2)
If analgesia/hormonal treatment does not improve symptoms, patient should be referred to secondary care.
Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
A 38-year-old G5P2 woman presents to antenatal clinic at 35+2 gestation.
Her pregnancy so far has been unremarkable apart from some moderate morning sickness experienced in the first trimester.
She complains of a number of minor symptoms.
Which of symptoms would be cause for concern and warrant further investigation?
(3)
Dysuria may be an indication of urinary tract infection which needs to be promptly treated in all stages of pregnancy.
UTI is associated with premature birth.
It is believed the localised inflammatory mediators associated with UTI trigger pre-term labour by irritating the neck of the uterus and cervix.
A 28-year-old woman presents to her GP with intermenstrual bleeding and dyspareunia. She does not use any hormonal contraceptives. After ruling out a sexually transmitted infection and fibroids, she is referred to colposcopy where she is diagnosed with a grade 1A squamous cell carcinoma of the cervix. She is married and hopes to have children in future.
Which treatment option is most appropriate for this woman’s cancer?
(3)
Women with stage IA cervical cancer may opt for a cone biopsy
with negative margins
if they wish to maintain their fertility
How are cervical intraepithelial dysplasias treated?
Laser ablation
How is cervical cancer managed?
The management of cervical cancer is determined by the FIGO staging and the wishes of the patient to maintain fertility.
A 52-year-old woman presents to her general practitioner (GP) to find out the result of her recent cervical smear.
Her two previous smears, taken 24 and 12 moths ago, were both positive for high-risk human papillomavirus (HPV), but showed no abnormal cytology.
She is informed that her most recent cervical smear was also positive for high-risk HPV.
What is the most appropriate step in this patient’s management?
Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy
Referral for colposcopy is correct because her 2nd repeat cervical smear sample was still hrHPV positive. Under the NHS cervical screening programme, this is an indication for colposcopy referral.
A 30-year-old woman is seen in the gynaecology department to discuss management of her newly diagnosed cervical cancer.
The staging of her disease revealed a small, malignant tumour, only visible on microscopy and 5mm wide.
The depth of the tumour was 2mm, without nodal or distant metastases, therefore classifying her disease as stage IA1.
She would like to maintain her fertility as she hasn’t started her family yet.
What is the most appropriate treatment option for this patient?
Women with stage IA cervical cancer may be considered for a cone biopsy with negative margins if they wish to maintain their fertility
Cone biopsy and close follow-up is correct. This woman’s cervical cancer is stage IA1 and she wishes to maintain fertility. So the best option for her is to have a cone biopsy with a close follow-up.
What is a trachelectomy?
(3)
Radical trachelectomy also called radical cervicectomy. This operation involves removing the cervix, the upper part of the vagina and surrounding supporting tissues.
Often lymph nodes in the pelvis are often removed to check whether cancer has spread beyond the cervix.
This option also preserves fertility but would only be indicated for IA2 tumours.
What is a risk factor for her condition?
Multiple pregnancy is a risk factor for hyperemesis gravidarum
Hyperemesis gravidarum associations
(4)
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
What is the prevalence of hyperemesis gravidum?
During which weeks is it most common?
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels.
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
What are the referral criteria for nausea and vomiting in pregnancy?
(3)
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
What is the hyperemesis gravidarum triad?
(3)
The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Which scoring system is used to evaluate hyperemeis gravaridum?
Validated scoring systems such as the
Pregnancy-Unique Quantification of Emesis (PUQE) score
can be used to classify the severity of NVP.
Management of hyperemesis gravidarum (8)
Complications of hyperemesis gravidarum
(5)
Wernicke’s encephalopathy - is a neurological disease characterized by three main clinical symptoms: confusion, the inability to coordinate voluntary movement (ataxia) and eye (ocular) abnormalities
Mallory-Weiss tear -tear of the tissue of your lower esophagus.
Central Pontine Myelinolysis - In CPM, a rapid increase of sodium to correct low sodium levels (hyponatremia) damages nerve cells.
Acute Tubular Necrosis - kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure
fetal: small for gestational age, pre-term birth
A 24-year-old woman presents to the emergency department concerned that she cannot find the threads for her intra-uterine device and cannot get an appointment at her GP. She denies any pain, pyrexia, or atypical discharge. She has a regular 28-day menstrual cycle, and her last menstrual period was 7 days ago.
She has a transvaginal ultrasound as the threads are not visualised on speculum examination. The device is visualised and threads are found to be drawn back into the cervical canal. The threads are brought back into view. There is also noted to be a 4cm multiloculated cyst with strong blood flow in the right ovary.
What is the most appropriate action?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied with high suspicion of ovarian malignancy
This patient has an incidental finding of a multiloculated cyst on the right ovary. Cysts that are found on ultrasound can be assessed using the IOTA criteria which help to classify cysts as being likely benign (‘B rules’) or malignant (‘M rules’). M rules include:
- Irregular, solid tumour.
- Ascites.
- At least 4 papillary structures.
- Irregular multilocular solid tumour with largest diameter ≥100 mm.
- Very strong blood flow.
Cysts that are found on ultrasound can be assessed using which criteria?
Which features indicate malignancy?
(5)
IOTA criteria
M rules include:
Irregular, solid tumour.
Ascites.
At least 4 papillary structures.
Irregular multilocular solid tumour with largest diameter ≥100 mm.
Very strong blood flow.
What are the types of ovarian cysts? (2)
Benign ovarian cysts - extremely common.
Complex (i.e. multi-loculated) - ovarian cysts should be biopsied to exclude malignancy.
A 22 year-old woman and her male partner present to their GP as they been unsuccessfully trying to conceive for 4 months.
Her periods have been regular and there is no obvious cause in her history.
What is the most appropriate next step in her management?
Address how the couple are having sexual intercourse and reassure the patient
A healthy couple can expect to take up to one year to conceive. Investigations are therefore usually performed after one year of regular attempts to conceive. It may however be prudent to address any mechanical reasons that are preventing the couple from conceiving, hence the sexual intercourse history.
Key conception counselling points
(4)
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Conception statistics
(3)
Infertility affects around 1 in 7 couples.
Around 84% of couples who have regular sex will conceive within 1 year
92% will conceive within 2 year
Causes of infertility
(5)
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
Basic investigations for infertility (2)
Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain.
The pain came on gradually and has been getting progressively worse for 3 days.
She is nauseated and has vomited twice this morning. She has a temperature of 38.4ºC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute.
The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler.
On speculum examination the cervix is closed and there is no blood.
She has a history of menorrhagia due to uterine fibroids.
This is her first pregnancy.
What is the most likely diagnosis?
What is the management?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.
This usually presents with low-grade fever, pain and vomiting.
The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Associations of uterine fibroids
(2)
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Management of menorrhagia secondary to fibroids
(9)
- Management of menorrhagia secondary to fibroids
- levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
- NSAIDs e.g. mefenamic acid
- tranexamic acid
- combined oral contraceptive pill
- oral progestogen
- injectable progestogen
Treatment to shrink/remove fibroids
(5)
medical
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
- ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity
surgical
- myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
- hysteroscopic endometrial ablation
- hysterectomy
uterine artery embolization
A 17-year-old woman presents to general practice concerned that she has never had a menstrual period. On examination, she has minimal axillary or pubic hair and has underdeveloped breast tissue for her age. She is of normal height and weight. She has no noted past medical history.
A beta-HCG test is negative.
The general practitioner orders some blood tests, as shown below.
FSH - High
LH - High
What is the most likely cause of her amenorrhoea?
Gonadal dysgenesis
Raised FSH/LH in primary amenorrhoea - consider gonadal dysgenesis (e.g. Turner’s syndrome)
The above scenario describes a young woman presenting with primary amenorrhoea (given that she has never had a menstrual period before), in addition to underdevelopment of secondary sexual characteristics. Given her raised FSH and LH levels, the most likely cause of her primary amenorrhoea is gonadal dysgenesis.
Gonadal dysgenesis is a congenital condition in which the gonads are atypically developed, and may be functionless. This can be seen in syndromes such as Turner’s syndrome. Due to the abnormal gonads, androgens are not produced in response to FSH and LH from the anterior pituitary gland. This results in the underdevelopment of secondary sexual characteristics, and in females will cause primary amenorrhoea. FSH and LH levels will continue to remain high due to the absence of negative feedback from oestrogen on the hypothalamus.
Amenorrhoea types
Primary:
Seconary:
Amenorrhoea may be divided into:
primary:
- defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development),
- or by 13 years of age in girls with no secondary sexual characteristics
secondary:
- cessation of menstruation for 3-6 months in women with previously normal and regular menses,
- or 6-12 months in women with previous oligomenorrhoea
Primary amenorrhoea causes
(6)
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
(7)
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Initial investigations of amenorrhoea
(6)
- exclude pregnancy with urinary or serum bHCG
- full blood count, urea & electrolytes, coeliac screen, thyroid function tests
- gonadotrophins
- low levels indicate a hypothalamic cause whereas raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- -* raised if gonadal dysgenesis (e.g. Turner’s syndrome)
- prolactin
- androgen levels
- raised levels may be seen in PCOS
- oestradiol
A 26-year-old woman telephones her GP complaining of several day histories of dysuria, vulval itch which is associated with a new thick, creamy vaginal discharge with no odour to it.
The patient is sexually active with one regular male partner, with whom she always uses condoms, and is on day 14 of her regular 28-day menstrual cycle.
She took a pregnancy test this morning which is negative.
The patient takes no regular medications but has recently finished a course of amoxicillin for otitis media.
She has no other medical history and no allergies.
What is the diagnosis?
What is the single most appropriate treatment?
(2)
Oral fluconazole single-dose is first-line for non-pregnant women with vaginal thrush
Vulval itch and thick, creamy, non-odorous discharge are typical of vaginal candidiasis, which can also result in dysuria.
This is a very common condition and likely related to this patient’s recent antibiotic use (antibiotics are a risk factor for Candida infections as they change the normal vaginal flora).
In the absence of other symptoms, examination and swabs are not required unless treatment fails.
The first-line treatment is single-dose oral fluconazole with a clotrimazole intravaginal pessary being used if oral antifungals are contraindicated (e.g. in pregnancy).
In patients with severe vulval symptoms, a topical clotrimazole cream may also be added, however, oral treatment remains the first-line.
How is bacterial vaginosis managed?
What are the characteristics of BV?
What may predispose a patient to BV?
(3)
Metronidazole is the treatment for bacterial vaginosis, a differential for vaginal discharge.
Bacterial vaginosis is associated with an odorous ‘fishy’ discharge and itch is not usually prominent.
A recent course of antibiotics may also point to a diagnosis of vaginal candidiasis.
First-line treatment for a urinary tract infection (UTI)?
Trimethoprim is appropriate treatment for a urinary tract infection (UTI).
When is Clotrimazole cream used?
(3)
Clotrimazole cream is used for second line treatment of vaginal candidiasis, although may be used in addition to oral fluconazole to relieve vulval symptoms.
Studies show that oral, rather than vaginal, treatments are probably more effective and also are usually preferred by patients.
Disadvantages of clotrimazole cream include the fact it can cause irritation (which may be interpreted as treatment failure) and, in the case of this patient, it may damage condoms.
What is the purpose a high vaginal swab?
(4)
A high vaginal swab is a medical procedure generally to test vaginal discharge for the presence of
vaginal thrush
bacterial vaginosis
trichomonas vaginalis.
Features of Vaginal candidiasis
(4)
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
What are satellite lesions?
generally to describe smaller lesions near the edges of a principal lesion.
However, certain factors may make vaginal candidiasis more likely to develop:
(4)
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
What is BASHH
What are their guidlines for recurrent vaginal candidiasis?
British association for sexual health and HIV
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
A 25-year-old undergoes a cervical smear test as part of the UK cervical screening programme. Her test results return as an ‘inadequate sample’.
As such, she undergoes a repeat cervical smear 3 months later, which also returns as an ‘inadequate sample’.
What is the most appropriate action?
(2)
Cervical smear tests performed as part of the NHS cervical screening programme should first be tested for high-risk HPV (hrHPV).
If the first test is an inadequate sample, it should be repeated in 3 months time.
If the second test also returns as inadequate, then colposcopy should be performed, as you will be unable to obtain hrHPV status or perform cytology so the risk of cervical cancer cannot be assessed.
A 34-year-old woman presents to her GP with vulval discomfort and burning with a white vaginal discharge.
She has handed in a urine sample which is negative on urine dip. A urinary pregnancy test is also negative.
What treatment is the first-line for the management of this patient?
Oral fluconazole single-dose is first-line for non-pregnant women with vaginal thrush
- Single dose oral fluconazole with topical antifungal
A 27-year-old woman presents to the GP with a short history of vulval itching associated with a thick ‘cottage cheese’ like discharge that has no odour. On examination, vulval erythema and fissuring are seen.
The patient is sexually active with a regular male partner of 5 years and they always use condoms. She has no past medical history and takes no regular medications. She is not pregnant.
What is the next most appropriate step?
Vaginal candidiasis: Diagnosis does not require a high vaginal swab if the symptoms are highly suggestive
Prescribe empirical treatment without further investigation
When would nucleic acid amplification testing be used?
Nucleic acid amplification testing is used to test for Chlamydia and Gonorrhoea.
A 27-year-old woman attends colposcopy as she had moderate dyskaryosis on her recent cervical smear.
On colposcopy she has aceto-white changes and a punch biopsy followed by cold coagulation.
Histology of the biopsy shows CIN II.
When should she next be offered cervical screening?
6 months
This woman has been treated for cervical intraepithelial neoplasia (CIN) at her colposcopy appointment. She requires follow-up through cervical screening to determine if the lesion has been adequately treated. Women who have been treated for CIN II should be offered cervical screening at 6 months through cervical screening and a HPV test of cure.
If a woman has a positive-test after treatment they should return to colposcopy.
What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation?
Unopposed oestrogen increases risk of endometrial cancer
How is HRT provided to ease menopause?
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Potential complication of HRT
(5)
Increased risk of breast cancer
- increased by the addition of a progestogen
- in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
- the increased risk relates to the duration of use
- the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
Increased risk of endometrial cancer
- oestrogen by itself should not be given as HRT to women with a womb
- reduced by the addition of a progestogen but not eliminated completely
- the BNF states that the additional risk is eliminated if a progestogen is given continuously
Increased risk of venous thromboembolism
- increased by the addition of a progestogen
- transdermal HRT does not appear to increase the risk of VTE
- NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
Increased risk of stroke
Increased risk of ischaemic heart disease if taken more than 10 years after menopause
A 51 year-old woman presents to her GP with a nine month history of urinary incontinence. Examination of her abdomen is normal.
Urinalysis is normal.
A diagnosis of detrusor muscle over-activity is made and the patient is commenced on oxybutynin.
What is the mechanism of oxybutynin?
It competitively inhibits the postganglionic type 1, 2 and 3 muscarinic receptors.
The contraction of the detrusor muscle is controlled by muscarinic cholinergic receptors, with oxybutynin being a direct antimuscarinic agent.
By contrast, serotonin and noradrenaline are important for sympathetic control, which intrinsically reduces detrusor muscle activity.
Classification of incontinence
(5)
overactive bladder (OAB)/urge incontinence
- due to detrusor overactivity
- the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
functional incontinence
- comorbid physical conditions impair the patient’s ability to get to a bathroom in time
- causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
Initial investigations for urinary incontinence
(4)
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
How is urge incontinence initially managed?
Which 3 antimuscarinic drugs are used?
Which drug should be avoided in “frail older women”?
Which drug should be used instead in “frail older women”?
(3)
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line
- NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
- Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
How is stress incontinence managed?
(4)
pelvic floor muscle training
- NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Types of urinary incontinence (3)
A 19-year-old woman was diagnosed with an early miscarriage 2 weeks ago by transvaginal ultrasound.
She was G1P0, with no significant medical history. It was decided to try expectant management.
Today, she presents with light vaginal bleeding which has been ongoing for 10 days. A further urinary pregnancy test taken today is still positive.
She reports no cramps, no purulent vaginal discharges and no systemic symptoms such as fever or muscle aches.
What is the appropriate next step in management?
Medical management of a miscarriage involves giving vaginal misoprostol alone
Medical management of miscarriage is indicated following a failed trial of expectant management, provided there is no indication for immediate surgical intervention.
It consists of giving vaginal misoprostol only.
This is a prostaglandin analogue, which helps stimulate uterine contractions.
This helps expedite the time needed to pass the products of conception.
What is misoprostol only?
(2)
This is a prostaglandin analogue, which helps stimulate uterine contractions.
This helps expedite the time needed to pass the products of conception.
When would oral methotrexate be prescirbed?
This drug is used in the management of an ectopic pregnancy, not within the management of miscarriages.
How might miscarriages be managed?
(3)
Expectant management:
- ‘Waiting for a spontaneous miscarriage’
- First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
- If expectant management is unsuccessful then medical or surgical management may be offered
Medical management:
- ‘Using tablets to expedite the miscarriage’
- Vaginal misoprostol - Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
- The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
- Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
- Should be given with antiemetics and pain relief
Surgical management
- ‘Undergoing a surgical procedure under local or general anaesthetic’
- The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
- Vacuum aspiration is done under local anaesthetic as an outpatient
Expectant management of miscarriages:
(3)
Expectant management:
‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered
Medical management of miscarriages:
(5)
‘Using tablets to expedite the miscarriage’
Vaginal misoprostol - Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief
Surgical management of miscarriages:
(3)
Surgical management
‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are
- vacuum aspiration (suction curettage)
- surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
What is the demographic of endometrial cancer?
What is the prognosis for endometrial cancer?
What is protective against endometrial cancer?
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause.
It usually carries a good prognosis due to early detection
the combined oral contraceptive pill and smoking are protective
The risk factors for endometrial cancer
(9)
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
Features of endometrial cancer
(3)
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Investigation for women who present with postmenopausal bleeding
(3)
Investigation
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
Management of endometrial cancer
(3)
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy.
Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
A 56-year-old woman presents to the postmenopausal bleeding clinic with 2 weeks of constant vaginal bleeding.
What should be your first investigation in the clinic?
(3)
Always the first line investigation in PMB should be TVUS, unless it is contra-indicated.
It gives the clearest image of endometrial thickness, which is a key factor in establishing whether the bleed could be caused by endometrial cancer
healthy endometrium is 4mm
Causes of postmenopausal bleeding
(6)
The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
HRT (hormone replacement therapy) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
Endometrial hyperplasia, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
Endometrial cancer: Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
Cervical cancer: It is important to obtain a full record of prior cervical screening programme attendance
Ovarian cancer: Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
Investigations for postmenopausal bleeding
NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer
A thorough history is necessary
A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen
Immediate testing could include a urine dipstick to look for haematuria or infection
a full blood count to look for anaemia or a bleeding disorder
CA-125 levels
For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required
A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
*Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer
Post menopausal bleeding history
- Enquire about timing
- consistency
- quantity of the bleeding
- a full gynaecological obstetric history
It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause.
A full drug history including HRT use should be sought.
Red flag symptoms for gynaecological cancer should be enquired about
What does a trans-vaginal ultrasound search for?
(3)
The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm.
However, it may miss some pathology and if clinical suspicion is high, further testing is required
How is endometrial cancer definitively diagnosed?
(3)
Endometrial biopsy:
This can either be taken during hysteroscopy
or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
Treatment by cause of postmenopausal bleeding
Caused by vaginal atrophy?
If a bleed is due to the type of HRT?
In the case of endometrial hyperplasia?
Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
If a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
In the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue
A 57-year-old woman presents to her GP with non-offensive white vaginal discharge and superficial itching and inflammation of the vulva.
She has a past medical history of type II diabetes mellitus and a previous right total knee replacement.
What next step should the GP take to care for this patient?
Treat the patient with oral fluconazole and a topical antifungal
Vaginal candidiasis: Diagnosis does not require a high vaginal swab if the symptoms are highly suggestive
Treat the patient with oral fluconazole and a topical antifungal is the correct answer. Vaginal candidiasis is an extremely common condition that many women diagnose and treat themselves. This patient has typical features of vaginal candidiasis and also has a common risk factor. If clinical features are consistent with candidiasis, treatment can be prescribed without a high vaginal swab.
When would you take a high vaginal swab?
A high vaginal swab (HVS) may be indicated to test vaginal discharge for the presence of:
vaginal thrush
bacterial vaginosis
trichomoniasis
Vaginal candidiasis management
(3)
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
- oral fluconazole 150 mg as a single dose first-line
- clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
A 15-year-old girl reports heavy menstrual bleeding since menarche when she was 14.
When she was younger, she frequently suffered from heavy nosebleeds.
What is the most important next step after normal examination and ultrasound?
Blood test for coagulation disorder
Testing for coagulation disorders (for example, von Willebrand’s disease) should be considered in women who have had heavy menstrual bleeding since menarche and have personal or family history suggesting a coagulation disorder.
You are working in general practice and see a 68-year-old female with breast cancer who has recently been diagnosed with endometrial hyperplasia.
She asks you what could have cause this.
Why might she have endometrial hyperplasia?
Tamoxifen
Endometrial hyperplasia is caused by oestrogen which is unopposed by progesterone
Tamoxifen (TAM) is known to have a dual mechanism of action:
- to compete with 17β-estradiol (E2) at the receptor site and to block the promotional role of E2 in breast cancer;
- to bind DNA after metabolic activation and to initiate carcinogenesis.
What medication is most likely to have caused this side effect?
Which condition is she suffering from?
Gonadotrophin therapy is associated with an increased risk of ovarian hyper stimulation syndrome
Typical presentation of ovarian hyperstimulation syndrome is with:
- ascites
- vomiting and diarrhoea
- high haematocrit
Name ovulation induction medications (3)
Letrozole: aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
Clomiphene citrate: selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Gonadotropin therapy: nvolves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
Letrozole mechanism of action
aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
Clomiphene citrate mechanism of action
(2)
Selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens.
This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Gonadotropin therapy mechanism of action
(2)
involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump,
leading to endogenous production of FSH and LH and subsequent follicular development
What causese Ovarian hyperstimulation syndrome (OHSS)
OHSS is a potential side effects of ovulation induction, and can be life-threatening
In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:
- Hypovolaemic shock
- Acute renal failure
- Venous or arterial thromboembolism
OHSS management
(4)
Depending on the severity, the management includes:
- Fluid and electrolyte replacement
- Anti-coagulation therapy
- Abdominal ascitic paracentesis
- Pregnancy termination to prevent further hormonal imbalances
*This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction
A 20-year-old female presents to her GP with ‘cottage cheese’-like vaginal discharge, itching and dyspareunia. A diagnosis of vaginal candidiasis is made and she is commenced on anti-fungal medication. This is her fourth presentation with vaginal candidiasis in the past year. She is otherwise fit and healthy and does not report any other symptoms of note. She does not take any regular medications.
Which of the following tests would be most useful to investigate for a potential underlying cause for this patient’s presentation?
HbA1c
A blood test to exclude diabetes should be considered in women with recurrent vaginal candidiasis
A 62-year-old patient who has not had a hysterectomy attends her GP surgery for review of her hormone replacement therapy (HRT).
Her HRT regime currently consists of an estradiol patch (which she changes once weekly) and norethisterone (an oral daily tablet).
What is the main counselling point that the patient must be aware of regarding taking progestogens?
(5)
Increased risk of breast cancer
- increased by the addition of a progestogen
- in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
- the increased risk relates to the duration of use
- the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
Increased risk of endometrial cancer
- oestrogen by itself should not be given as HRT to women with a womb
- reduced by the addition of a progestogen but not eliminated completely
- the BNF states that the additional risk is eliminated if a progestogen is given continuously
Increased risk of venous thromboembolism
- increased by the addition of a progestogen
- transdermal HRT does not appear to increase the risk of VTE
- NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
Increased risk of stroke
Increased risk of ischaemic heart disease if taken more than 10 years after menopause
What is Norethisterone?
Norethisterone, also known as norethindrone and sold under many brand names, is a progestin medication used in birth control pills, menopausal hormone therapy, and for the treatment of gynecological disorders.
A 36-year-old female presents as she has noticed a curd-like white vaginal discharge.
This is associated with pain during sex.
What is the most likely diagnosis?
Candida
Common features:
- ‘Cottage cheese’ discharge
- Vulvitis
- Itch
A 45-year-old woman presents with a six month history of persistent heavy, prolonged menstrual bleeding despite treatment with mefenamic and tranexamic acid.
A transvaginal ultrasound shows an endometrial thickness of 15mm.
What would be the next appropriate line of investigation?
Endometrial biopsy at hysteroscopy
A 24-year-old woman presents to her GP with lower abdominal pains that have been getting worse over the past two days.
The pain is in the suprapubic area and slightly to the right.
She had some vaginal bleeding this morning which she describes as being like a light period.
The patient also describes some shoulder pain which she thinks came on following a game of squash.
Her last period was eight weeks ago and was described as normal.
In the past, she has been treated for Chlamydia infection and admits to not practicing safer sex.
On examination, she is tender in the right iliac fossa. Blood pressure is 100/60mmHg and the pulse is 102/min.
What is the most likely diagnosis?
Ruptured ectopic pregnancy
This is a classic exam history of ectopic pregnancy - amenorrhoea, abdominal pain and vaginal bleeding in combination with shoulder tip pain suggesting peritoneal bleeding.
In which conditions would you see “cervical excitation”?
PID
ruptured ectopic pregnancy
A 51-year-old woman attends surgery with hot flushes, vaginal soreness, and loss of libido. Her last menstrual period (LMP) was 1 year ago. The patient understands that she is menopausal and would like to start hormone replacement therapy (HRT). However she is concerned about the risk of venous thromboembolism (VTE).
In terms of her VTE risk, which HRT option is safest?
Transdermal HRT does not appear to increase the risk of VTE (vs. oral)
NICE advise that the rates of venous thromboembolism (VTE) in patients on transdermal HRT are no greater than in the baseline population. The reason for this is not understood, although it is possible that first-pass metabolites from orally-ingested oestrogens might promote VTE.
A 53-year-old woman attends her GP surgery for a routine cervical smear.
Based on the initial high-risk human papillomavirus (hrHPV) result, she is invited for a repeat smear in a further 12 months’ time.
At this repeat smear, she is informed that the hrHPV result is now negative.
Her past medical history is unremarkable.
What is the most appropriate management option?
Cervical cancer screening: if 1st repeat smear at 12 months is now hrHPV -ve → return to routine recall
The correct answer is to repeat a smear in 5 years.
The 12-month repeat described in the scenario is due to the initial smear being positive for high-risk human papillomavirus (hrHPV) but cytology negative.
At the subsequent repeat, we are told that this is now negative. As such, guidelines state that she should be returned to routine recall - in her age group, this is 5-yearly. In younger women, the correct answer would be 3-yearly. The other scenario where 12-monthly smears would occur is in HIV-positive patients - but we are told that she has no significant past medical history.
A 22-year-old woman attends the Emergency Department with her boyfriend complaining of abdominal pain, which has worsened in the last couple of hours and is now severe in nature.
She has vomited twice and feels dizzy.
On examination, she is tender in the left iliac fossa. Observations are within normal range except a mild tachycardia. She is otherwise stable. A urine pregnancy test is positive.
An ultrasound is carried out by the Obstetrics SHO and she is found to have an empty uterus but findings consistent with 40mm pregnancy in her left fallopian tube.
How should she be managed?
(2)
She should be taken to theatre for surgical management
All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically
A 26 year-old woman presents to her GP with a 3 month history of inter-menstrual bleeding and occasional post-coital bleeding. She is sexually active and takes Microgynon (a combined oral contraceptive pill). Her last cervical smear was normal.
What is the most likely diagnosis?
Cervical ectropion
In a young woman taking COCP, cervical ectropions are a common finding in the context of post-coital bleeding. Whilst cervical cancer should be considered, a recent normal smear makes this less likely and ectropion would be more likely regardless.
What is Cervical ectropion? (2)
How is it managed? (2)
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.
Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
This may result in the following features
- vaginal discharge
- post-coital bleeding
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
Georgia, a 32-year-old pregnant woman, (gravidity 1, parity 0) currently 27+5, presents to her general practitioner (GP) with reflux.
The GP prescribes a new medication for her reflux.
On looking at Georgia’s records, the GP sees that she is due for a cervical smear test in 2 weeks’ time.
All her previous smears have been normal. Georgia denies any new discharge, bleeding or pain.
When should Georgia have her next cervical smear test?
Cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
What is the age range for the cervical screening program?
How frequently?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
A 62-year-old woman presents to the GP complaining of episodes where she ‘leaks’ small amounts of urine.
She first noticed this a week ago and has recently experienced increased urinary frequency.
On examination, she has slight suprapubic tenderness.
She is worried as she finds this very embarrassing and it is affecting her daily life.
What is the best initial investigation for this patient?
Urinalysis
In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus
In any patient presenting with urinary incontinence or increased urinary frequency, urinalysis should always be the first investigation to rule out a urinary tract infection (UTI) or diabetes mellitus.
In patients over 65 years old, urinalysis is not performed to assess for UTIs as asymptomatic bacteriuria is common in this population and therefore urinalysis will not be reliable. As this patient is below 65 years old, urinalysis should be performed.
