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
