Extra Gynae Content Flashcards
What is adenomyosis?
presence of endometrial tissue within the myometrium, more common in multiparous women towards the end of their reproductive years
Features:
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
How should adenomyosis be investigated? Mx?
Ix:
transvaginal ultrasound first-line investigation
MRI is an alternative
Mx:
tranexamic acid to manage menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy = ‘definitive’ treatment
If a woman has a positive pregnancy test and any of the following she should be referred immediately to an early pregnancy assessment service:
pain and abdominal tenderness
pelvic tenderness
cervical motion tenderness
How should bleeding in early pregnancy be managed?
> 6 weeks gestation (or of uncertain gestation) + bleeding = referral to early pregnancy assessment service, transvaginal USS to identify the location of the pregnancy and whether there is a fetal pole and heartbeat
< 6 weeks gestation + bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly.
These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried
What are the risk factors for developing cervical cancer?
HPV (particularly serotypes 16,18 & 33) is by far the most important factor
smoking
HIV
early first intercourse, many sexual partners
high parity
lower socioeconomic status
COCP
What are the possible complications of surgical cervical cancer tx?
Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies
Radical hysterectomy may result in a ureteral fistula
What are the possible complications of radiotherapy for cervical cancer?
Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
Who gets screened for cervical cancer? How are the samples tested?
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
HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive
hrHPV +ve and cytologically abnormal =
patient referred for colposcopy
hrHPV +ve but cytologically normal =
the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What is the most common treatment for cervical intraepithelial neoplasia?
Large loop excision of transformation zone (LLETZ)
What is a cervical ectropion?
In a cervical ectropion, elevated oestrogen levels (ovulatory phase, pregnancy, COCP use) result in larger area of columnar epithelium (that lines the cervical canal) being present on the ectocervix.
Can be asymptomatic or present with vaginal discharge / post-coital bleeding.
What tx can be used if a cervical ectropion causes troublesome sxs?
Ablative treatment (for example ‘cold coagulation’)
In the case of pregnancy of unknown location, what test can indicate presence of ectopic pregnancy?
serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Give some risk factors for ectopic pregnancy?
Anything slowing the ovum’s passage to the uterus
damage to tubes (PID, surgery)
previous ectopic
IVF
endometriosis
contraceptives: IUCD, POP
How should ectopic pregnancies be managed?
<35mm, unruptured = Expectant management - closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed
<35mm, ruptured = Medical management - methotrexate
> 35mm = Surgical management - salpingectomy first line or salpingotomy for women with other risk factors for infertility e.g. contralateral tube damage
What are the investigations for suspected endometrial cancer?
All women >= 55 years who present with postmenopausal bleeding should be referred using suspected cancer pathway
trans-vaginal USS - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
How is endometrial cancer managed?
mainstay is surgery
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postop radiotherapy
How should endometrial hyperplasia be managed?
without atypia: high dose progestogens with repeat sampling in 3-4 months, can use IUS
with atypia: hysterectomy is usually advised
How should endometriosis be investigated and managed?
laparoscopy is the gold-standard investigation
Mx:
NSAIDs / paracetamol for symptomatic relief
COCP or progestogens e.g. medroxyprogesterone acetate can be added
Secondary treatments:
GnRH analogues - induce a ‘pseudomenopause’
surgery
Give some gynaecological causes of abdominal pain
Mittelschmerz
Endometriosis
Ovarian torsion
Ectopic pregnancy
PID
How does ovarian torsion present?
sudden onset of deep seated colicky abdominal pain
Associated with vomiting and distress
Vaginal examination may reveal adnexial tenderness
How may PID present?
Bilateral lower abdominal pain associated with vaginal discharge +/- dysuria
Peri-hepatic inflammation (Fitz Hugh Curtis Syndrome) may produce RUQ discomfort
Fever >38
Raised WCC and may have raised amylase
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.
What are the potential side effects?
nausea
breast tenderness
fluid retention and weight gain
What are the risks of HRT?
increased risk of breast cancer
increased risk of ovarian cancer
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)
increased risk of VTE (unless transdermal)
increased risk of stroke
increased risk of IHD if taken more than 10 years after menopause
How can suspected infertility be investigated?
semen analysis (repeat 3 months later if abnormal)
serum progesterone 7 days prior to expected next period
What key points can be given when counselling couples struggling with infertility?
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Menopause is defined as the permanent cessation of menstruation caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.
What lifestyle modifications can be suggested to relieve symptoms?
regular exercise, weight loss, stress reduction
good sleep hygiene
light, loose layers of clothing
What are the absolute contraindications to HRT?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
What non HRT medical mx is available for menopausal symptoms?
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, CBT or antidepressants
Urogenital symptoms
urogenital atrophy = vaginal oestrogen can be prescribed
vaginal dryness = moisturisers and lubricants
How may ovarian cancer present? How is it investigated?
abdominal distension and bloating
abdominal and pelvic pain
early satiety
urinary symptoms e.g. Urgency
diarrhoea
CA125 and USS
What is ovarian torsion? How does it present?
partial or complete torsion of the ovary on it’s supporting ligaments that may compromise the blood supply
If the fallopian tube is also involved then it is referred to as adnexal torsion
sudden onset deep-seated colicky abdominal pain
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
What may you see on USS for ovarian torsion?
How would you investigate and manage further?
free fluid or a whirlpool sign
Laparoscopy is usually both diagnostic and therapeutic - surgical detorsion
How should PID be managed?
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Low threshold for tx due to risks incl infertility, chronic pelvic pain and ectopic pregnancy
How can hirsutism and acne be managed in PCOS?
COCP
if doesn’t respond to COCP then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
Postcoital bleeding describes vaginal bleeding after sexual intercourse. What can cause this?
no identifiable pathology is found in around 50% of cases
cervical ectropion
cervicitis e.g. secondary to Chlamydia
cervical cancer
polyps
trauma
Postmenopausal bleeding is defined as vaginal bleeding occurring after 12 months of amenorrhoea. What can cause it?
vaginal atrophy
the most common cause of postmenopausal bleeding
HRT (hormone replacement therapy)
with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy
endometrial hyperplasia
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
ovarian cancer
other uncommon causes include:
trauma
vulval / Vaginal cancer
bleeding disorders
Premature ovarian insufficiency is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
What can cause it?
idiopathic ( most common)
bilateral oophorectomy
radiotherapy / chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
How can POI be diagnosed?
elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
How should POI be managed?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions.
What can cause it?
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders, PCOS
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
What medical and surgical management is available for miscarriage?
Medical:
Vaginal misoprostol alone
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
Surgical :
vacuum aspiration (suction curettage) or surgical management in theatre
How can fibroids be diagnosed and managed?
Diagnosis : transvaginal USS
Mx:
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried to reduce sxs (e.g. IUS, tranexamic acid, COCP)
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects (e.g. osteoporosis)
myomectomy
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Can just be monitored if asymptomatic - usually regress after menopause
Potential complications of fibroids?
Iron deficiency anaemia
Compression of pelvic organs:
Recurrent urinary tract infections, Incontinence, Hydronephrosis, Urinary retention
Subfertility/infertility
Degeneration
Torsion
Vaginal candidiasis (‘thrush’) is an extremely common condition most commonly caused by Candida albicans.
What are the risk factors?
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
How does thrush present?
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
How can thrush be managed?
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
What is recurrent vaginal candidiasis ? How should it be managed?
4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
How does bacterial vaginosis present? Mx?
Caused by gardnerella vaginalis
Offensive, thin, white/grey, ‘fishy’ discharge
Mx : oral metronidazole for 5-7 days
Presentation of vulval cancer?
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
Long-term complications of PCOS?
Subfertility
Diabetes mellitus
Stroke & TIA, Coronary artery disease
Obstructive sleep apnoea
Endometrial cancer
sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity =
? Ruptured ovarian cyst
For how long does a urine pregnancy test remain positive after termination of pregnancy?
Up to 4 weeks
A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
woman >50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months =
suspect ovarian cancer
IBS rarely presents for the first time in this group
Common misconceptions that have actually not been associated with an increased risk of miscarriage include:
Heavy lifting
Bumping your tummy
Having sex
Air travel
Being stressed
When is expectant mx suitable for an ectopic pregnancy?
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
How might cervical polyps present?
abnormal bleeding
increased vaginal discharge
Rarely, they grow large enough to block the cervical canal, causing infertility
visible on speculum exam
Ix for cervical polyps?
Triple swabs – if there is any suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken.
Cervical smear – to rule out cervical intraepithelial neoplasia (CIN)
Mx of cervical polyps?
Small polyps can be removed in the primary care setting. The polyp is grasped with polypectomy forceps, and twisted several times.
larger polyps removed in colposcopy clinic
all sent for histological examination