General Gynae Flashcards
Risk of Endometrial Cancer with PCOS?
2.89 fold increased risk of endometrial cancer.
Prevalence of GDM is 2x as high as control groups.
No association with breast or ovarian Ca.
Prevalence of atypia and malignancy within endometrial polyps?
Atypia - 0.8%
Malignancy - 3.1%
RF for malignant change:
Size > 10mm, postmenopausal status, abnormal uterine bleeding
Risk of re intervention rates following UAE?
Approx 1/3 women will require re intervention by 5 years for symptom recurrence or complication.
Only 4% require a second intervention following Surgery.
Uterine Atery Embolisation for the management of fibroids?
As effective as surgery for symptom control over 5 years.
80-90% will be asymptomatic or have significantly improved symptoms at 1 year.
Risk of requiring hysterectomy following UAE? Other complications?
- 2.9%
- Complications:
- vaginal discharge (16% at 12 months)
- expulsion of fibroid material (10%)
- endometritis (0.5%)
- amenorrhoea (<1% in women under 40 years)
- change in sexual function (worse in 10%, improved in 26%, unchanged in most)
Laparoscopy consent
- Serious complications: 2/1000
- Risk of bowel injury: 0.4/1000
- Vascular Injury: 0.2/1000
- Risk of death: 5/100,000
Prevalence of atypia and malignancy within polyps?
- Atypia 0.8%
- Malignancy 3.1%
Risk factors for malignant change:
1. Size >10mm
2. Postmenopausal status
3. Abnormal uterine bleeding
Risk of chemical peritonitis due to spillage of dermoid cyst contents?
0.2%
Risk of Endometrial cancer with PMB and ET..
1. > 5mm
2. <5mm
- 7.3%
- <0.07%
In postmenopausal women without bleeding the risk of cancer is..
1. ET > 11mm
2. ET < 11mm
- 6.7%
- 0.002%
Pathological causes of HMB?
- Uterine Fibroids (20-30%)
- Uterine Polyps (5-10%)
- Adenomyosis (5%)
- Coagulopathy
- Iatrogenic eg. Anticoagulants
Between 40-60% of women with HMB have no uterine, endocrine, haematological or infective pathology on investigations.
Malignancy rarely presents as HMB but more prolonged IMB, PCB and as a pelvic mass.
When is Ulipristal Acetate licensed for the treatment of moderate to severe symptoms of uterine fibroids?
What is it’s mode of action?
What is the dose?
Contraindications?
- Ulipristal acetate is a selective progesterone receptor modulator
- Licensed for use in women with HMB and fibroids of 3cm or more in diameter and HB < 102.
- Dose is 5mg OD for 3 months and up to 4 courses are recommended
- Contraindications include:
Endometrial abnormality
Asthma
Severe liver disease
Primary Ovarian Failure - define
- 4 months of amenorrhoea
- 2 x FSH levels of at least 25 at an interval of at least one month
Secondary causes of hyperprolactinaemia
- Pituitary Disease - prolactinoma, acromegaly, Cushings, infiltrative disease (granulomas, sarcoidosis)
- Hypothalamic Disease - tumours (craniopharyngomas, non functioning adenomas), meningioma, sarcoidosis, TB, cranial infection
- Medications - neuroleptics, metoclopramide, methyldopa, verapamil, monoamine oxidase inhibitors, tricyclic antidepressants, oestrogens, opiates
- Other - PCOS, pregnancy/lactation, hypothyroidism, chronic renal failure, liver insufficiency, physical/psychological stress, idiopathic
How to calculate RMI?
RMI = U x M x Ca-125
U = ultrasound score
M = Menopausal status
Ca125
% reduction in fibroid size after commencing GnRh analogues?
36% reduction in size after 12 weeks.
Fibroids return to pre treatment volume within 4-6months.
Endometriomas;
1. Ultrasound Characteristics
- Ground glass echogenicity
- One to four compartments (locules) and no papillary structures with detectable blood flow.
Most commonly unilocular. Around 85% will have < 5 locules.
Progression rate to cancer:
1. EH without atypia (overall)
2. Simple EH without atypia
3. Complex EH without atypia
4. EH with atypia
- < 5%
- 1%
- 4%
- 40%
Incidence of chronic pelvic pain following PID or TOA:
1. 1 episode
2. 2 episodes
3. 3 episodes
- 12% after 1 episode
- 30% after 2 episodes
- 67% after 3 or more episodes
International Ovarian Tumour Analysis (IOTA) Group.
Ovarian Cyst B Rules (benign)
- Unilocular
- Presence of solid components where the largest solid component <7mm
- Presence of acoustic shadowing
- Smooth, multi locular tumour with a largest diameter <100mm
- No blood flow
International Ovarian Tumour Analysis (IOTA) Group
Ovarian Cyst M-rules (malignant)
- Irregular, solid tumour
- Ascites
- At least four papillary structures
- Irregular, multilocular solid tumour with largest diameter >10mm
- Very strong blood flow
Define chronic pelvic pain
Intermittent of constant pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with Pregnancy.
Risk of blood transfusion and haemorrhage with hysterectomy for benign conditions?
4% (common)
Risk of haemorrhage 23/100
What feature is always associated with an Accessory Cavitated Uterine Malformation on MRI scan?
Normal uterine cavity
What are accessory cavitated uterine malformations (ACUMs)?
- Isolated cavitated lesions within the lateral aspect of the myometrium, inferior to the attachment of the round ligament
- Rare mullerian anomaly and are increasingly recognised as a cause for dysmenorrhea and pelvic pain
Radiological appearance of ACUMs?
(Accessory cavitated uterine malformation)
- US or MRI
- Well defined lesions with a central cavity containing haemorrhagic content, surrounded by a myometrial mantle
MRI - central cavity, each surrounded by a well defined ring with low T1 and T2 signal enhancements.
Treatment of ACUM (accessory cavitated uterine malformation)
- Hormonal suppression
- Alcohol sclerotherapy to cause destruction of uterine lining
- Complete surgical excision that has demonstrated curative results
Diagnostic criteria for ACUM (accessory cavitated uterine malformation)?
- Location
- solitary lesion located in the lateral myometrium or broad ligament
- no communication with uterine cavity or fallopian tubes - Morphology:
- A cavitated lesion containing functional endometrium surrounded by a myometrial mantle
Histology:
- cavitated lesions filled with dark brown haemorrhagic content
- lined with functional endometrium
- myometrial mantle has concentric arrangement of smooth muscle
Which class of chemotherapy agents are most likely to cause ovarian failure?
Alkylating agents
Ultrasound features of TOA:
- Complex solid/cystic mass
- Pyosalpinx may be seen - elongated, dilated, fluid filled mass with partial septa’s and thick walls.
- Incomplete septal within the tubes is a sensitive sign of tubal inflammation/abscess.
- Cogwheel sign - result of thickened endosalpingeal folds. Considered pathognomonic of acute tubal inflammation.
- Inflamed ovaries may acquire a reactive poly cystic appearance secondary to oedema.
% of women who will have relapse of symptoms after excision or ablation of Endometriosis?
40 - 50%
30% of women are readmitted for Surgery within 5 years.
During a laparoscopy to diagnose endometriosis, consider laparoscopic treatment of the following if present?
- Peritoneal endometriosis not involving bowel, bladder or ureter
- Uncomplicated ovarian endometriomas
% of women woth fertility issues who have endometriosis?
25 - 40% compared with 0.5 - 5% in fertile women
Incidence of pelvic congestion syndrome?
3.8%
US criteria for pelvic congestion syndrome?
- Tortuous pelvic veins with a diameter > 6mm. Mean diameter 8mm.
- Slow blood flow < 3cm/second or reversed caudal flow in the left ovarian vein demonstrated by Doppler waveforms.
- Dilated arcuate veins in the myometrium that communicate between bilateral pelvic varicose veins.
- Poly cystic changes within the ovaries - not amenorrhoeic or hirsute.
Average time from symptom onset to diagnosis of Endometriosis in the UK?
8 years
Presacral neurectomy for endometriosis associated pelvic pain:
1. Evidence ?
2. Complications ?
- Significant benefits at 6 and 12 months
- Complications:
- bleeding
- constipation
- urinary urgency
- painless first stage of labour
The effect of PSN may be specific to midline pain only.
What can be used to prevent adhesion formation after laparoscopic surgery for Endometriosis?
Oxidised regenerated cellulose.
The effect of adhesion prevention on fertility or pain is uncertain.
Follow up for women with simple cysts 50-70mm?
Annual US
Women with larger cysts should be considered for MRI or surgical intervention due to difficulties in examining the entire cyst adequately at the time of US.
Incidence of ovarian cysts in post menopausal women?
5 - 17%
Risks with Hysteroscopy?
1. Perforation
2. Infections
3. Haemorrhage
4. Unintended major operation
- Perforation 6-13/1000
- Infection 3-5/1000
- Haemorrhage 4/1000
- Unintended major operation 1.4/1000 (laparotomy or hysterectomy)
Post hysterectomy vaginal vault prolapse?
1. Hysterectomy performed for prolapse
2. Hysterectomy performed for other benign disease
- 11.6%
- 1.8%
Which class of chemotherapy agents are most likely to cause future ovarian failure?
Alkylating Agents
What fertility sparing treatment would you recommend as giving the best chance of a future pregnancy in case of needing radio/chemotherapy?
Oocyte Vitrification
Treatment of recurrent thrush (not pregnant)?
Fluconazole 150mg for 3 doses every 72 hours, then weekly for 6 months.
What % of women reach menopause before the age of 40?
1%
In otherwise healthy women > 45 years old diagnose:
1. Perimenopause
2. Menopause
Diagnose without lab tests.
- Perimenopause - based on vasomotor symptoms and irregular periods
- Menopause
- women who have not had a period for 12 months and are not using contraception
- based on symptoms in women who do not have a uterus
Consider using FSH to diagnose menopause only..
- In women age 40-45 with menopausal symptoms, including a change in their menstrual cycle
- In women under 40 in whom menopause is suspected
FSH level to diagnose menopause?
FSH > 13 IU/litre increases the chances of being perimenopausal but a level < 13 does not reduce the chances of being perimenopausal.
Pathophysiology of the menopause
Around the menopause, the ovary becomes less responsive to gonadotropins, resulting in a rise in FSH and LH and a fall in oestradiol concentrations which subsequently become too low to stimulate the endometrium, resulting in amenorrhoea.
Around the time of menopause, FSH levels fluctuate markedly and are of limited value as a diagnostic tool.
DHEA and DHEA-S levels fall by % after the menopause?
Testosterone production declines by % after the menopause?
- 70%
- 25%
What % of women are affected by Vasomotor symptoms?
Management of Vasomotor Symptoms for HRT?
75% postmenopausal women affected, 25% severely affected.
Management:
1. Non oral oestradiol + progesterone (highly beneficial in relieving frequency of VMS)
2. Oral Oestradiol + progesterone (degree of uncertainty regarding its efficacy)
3. Isoflavones (some efficacy v placebo)
4. Black cohosh
Women treated with SSRI/NSRIs were more likely to discontinue treatment compared with those treated with placebo, due to SE profile)
SSRIs in women taking Tamoxifen - caution?
Paroxetine and Fluoxetine should be avoided
Ospemifene?
Tablet for vaginal dryness in postmenopausal women.
- significant reduction in dyspareunia
- significant decrease in vaginal pH compared with placebo
- decrease in severity of vaginal dryness
- increase in ET but no cases of hyperplasia or carcinoma during a treatment period of < 12 months
Progesterone use in HRT
1. LMP < 1 year
2. LMP > 1 year
- LMP < 1 year prior to starting HRT, sequential combined regimen should be started with Progestogen for 12-14 days /month.
- LMP > 1 year, women may attempt a switch to a continuous combined regimen which aims to give bleed free HRT
- Tibolone is an alternative
- If breakthrough bleeding occurs after a switch from sequential to continuous HRT and does not settle for 3-6 months, switch back to sequential for at least another 12 months.
- If bleeding is heavy or erratic on a sequential regimen, the dose of progestogen can be doubled or duration increased to 21 days
Bleeding on continuous combined HRT or tibolone:
1. Within 12 months of LMP
- After 12 months since LMP and within 6 months of starting CC HRT
- After 12 months since LMP and after 6 months of CC HRT
- Unpredictable breakthrough bleeding is common and does not need investigation.
- Breakthrough bleeding is often common and does not necessarily need investigation unless the bleeding is unusually heavy.
- Bleeding should be investigated.
Which progesterones are least likely to be associated with progestogenic side effects?
What are progestogenic side effects?
Progesterone and dydrogestetone.
SE’s:
1. Fluid retention
2. Androgenic SE’s such as acne and hirtuism
3. Mood swings and PMS-like symptoms
Which progestogenhad anti-androgenic and anti mineralocortocoid activity ?
Drospirenone - a spironolactone analogue has anti-androgenic and anti-mineralocorticoid properties. It has been incorporated with low dose Oestrogen in a continuous combined formulation.
Systemic and topical oestrogens can be administered following treatment for which gynaecological malignancies?
Can be used following Vulval and cervical and ovarian ca.
Avoid following Granulosa cell rumours.
OK following epithelial or germ cell tumours.
The oestrogen receptor is a.. that has ..
Nuclear protein
Alpha and beta subtypes
In post menopausal women, tamoxifen use is associated with a ? Fold increase in VTE?
5 fold
Tamoxifen use in pre menopausal women:
1. Risk of amenorrrhoea
2. Risk of Ovarian cysts
- 25% amenorrhoea
- 10% ovarian cysts
In women undergoing hysterectomy or myomectomy for fibroids, what is the prevalence of sarcoma diagnosed from histology?
0.2% or 1/500
PALM-COEIN system of classifying AUB?
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not yet classified
% of women with symptom improvement 2 years after UAE for fibroids?
> 80%
For a diagnosis of chronic abnormal uterine bleeding, the patient must describe symptoms for ?
At least 3 months or 3 cycles
Incidence of endometrial Ca in women presenting with HMB?
1. Age < 30
2. Age 30-39
3. Age 40-44
4. Age 45-49
- <1/10,000
- 1/10,000
- 3/10,000
- 8/10,000
Average age of diagnosis of uterine leiomyosarcoma?
51 years
PMS - first line COCP?
Drospirenone containing COCPs
Continuous, not cyclical use
more effective than when compared to desogestrel or levonorgestrel containing COCPs
Rules around TTC with endometrial hyperplasia?
Disease regression should be achieved on at least one endometrial sample before women attempt to conceive.
· Women should be referred to a fertility specialist to discuss the options for attempting conception, further assessment and appropriate treatment.
· Assisted reproduction may be considered as the live birth rate is higher and it may prevent relapse compared with women who attempt natural conception.
· Prior to assisted reproduction, regression of endometrial hyperplasia should be achieved as this is associated with higher implantation and clinical pregnancy rates
Follow up for simple cyst 50-70mm?
Yearly Ultrasound follow up
Conditions which may cause elevated Ca125?
1. Malignant
2. Non Malignant
- Malignant
- ovarian /tubal ca
- endometrial ca
- pancreatic ca, stomach ca, colorectal Ca, mets from breast/lung - Non Malignant
- benign ovarian tumours
- endo
- PID
- pregnancy and menstruation
- leiomyoma, Inc fibroids
- ascites eg. Liver cirrhosis
- diverticulosis
- pleural and pericardial disease
- pancreatitis
- heart failure
Definition of premature ovarian failure?
4 months of amenorrhoea
2x FSH > or = 25 at an interval of at least 1 month
What % of patients become amenorrhoeic following endometrial ablation?
30%
80-90% deposit improvement in their symptoms.
Menorrhagia: definition by quantity of blood lost and duration?
Blood loss > 80ml and / or duration of > 7 days
Prevalence of endometriosis in the reproductive population?
What % of these have Endometriomas?
6-10%
17-44% have Endometriomas
Which progesterone is best for use in women with PMS?
Drosperidone
Risk of dermoid cysts being bilateral?
15%
What % of adolescents presenting with HMB will have ITP?
7%
What % of women suffer from post coital bleeding ?
0.7 - 9% or cumulative incidence of 6% in pre menopausal women.
What % of women undergoing UAE will suffer premature ovarian failure ?
1-2%
Which muscles contact to generate anal squeeze pressure?
EAS and puborectalis
