Genital Tract Disorders Flashcards
What is the blood supply to the uterus?
Ovarian artery comes from aorta, lies in suspensory ligament of ovary
Uterine artery arises from internal iliac and anastamoses with ovarian artery
What is the lymph drainage from the uterus?
Uterus -> common iliac nodes
Cervix -> internal iliac nodes
What supports the uterus?
Uterosacral and cardinal ligaments
What are the layers of the uterus?
Outside - serosa is continuous with posterior peritoneum Smooth muscle (tissue of origin for fibroids) Lined by glandular epithelium (tissue of origin of endometrial carcinomas)
What is the blood supply to the endometrium?
Spiral and basal arterioles
What are fibroids?
Leiomyomata
Benign tumours of myometrium
What are risk factors for fibroids?
Afro-Caribbean Family history Pre-menopause Obesity Early onset and late menopause
What are protective factors for fibroids?
Parity
COCP (low levels of oestrogen cause negative feedback)
What are types of fibroids?
Intramural
Subserosal
Submucosal ->intracavity polyps
What causes fibroids?
Oestrogen and progesterone dependent
During pregnancy can grow, shrink or show no change
Regress after menopause due to reduction in oestrogen
How do fibroids present?
50% asymptomatic - discovered at pelvic or abdo exam
30% menorrhagia
Dysmenorrhoea if torsion
If pressing on bladder - frequency and retention
Fertility if tubes are blocked
What are complications of a fibroid?
Torsion of pedunculated fibroid Degenerations: - red (painful, in pregnancy) - hyaline/cyctic - calcification (asymptomatic)
Malignancy - leiomyosarcomaata
What effect do fibroid have on pregnancy?
Premature labour
Transverse lie
Obstructed labour
PPH
How are fibroids investigated?
Bloods - Hb may be raised or low
Imaging
- USS doesn’t differentiate from mass
- MRI or laparoscopy
How are fibroids medically treated?
Tranexamic acid, NSAIDs and progestogens
GnRH cause temporary menopausal state (pre surgery or menopause)
What is the surgical treatment for fibroids?
Hysteroscopic removal
Myomectomy
Hysterectomy
Uterine artery embolism
What is adenomyosis?
Presence of endometrium and stroma within myometrium -> bleeds with menstrual cycle
Associated with endometriosis and fibroids
How does adenomyosis present and how is it treated?
Painful, regular, heavy menstruation
IUS and COCP
Trial of GnRH analogue to see if hysterectomy will work
What is endometritis?
Type of PID
Caused by: STI, surgery (c-section), IUD, retained products of conception
Post-menopausal - MALIGNANCY
What are intrauterine polyps?
Small, benign tumours that grow into uterine cavity
Most are endometrial but some are submucosal fibroids
In postmenopausal - patients taking tamoxifen for breast cancer
Cause: menorrhagia, intermenstrual bleeding
What is a haematometra?
Menstrual blood accumulating in uterus Canal occluded: - fibrosis after resection - carcinoma - congenital abnormalities
What congenital uterine malformations present?
Result from failure of Mullerian ducts to fuse
Total failure
- > 2 uterine cavities (didelphys) with longitudinal vaginal septum
- > unicornuate if one duct fails
Fundal septum
Linked to renal abnormalities
How can congenital uterine malformations affect pregnancy?
Transverse lie
Preterm labour
Recurrent miscarriage
Retained placenta
What is the histology of the cervix?
Endocervix lined by columnar epithelium
Ectocervix covered in squamous epithelium
What is the blood supply and lymph drainage of the cervix?
Upper vaginal branches and uterine artery
-> obturator and iliac nodes -> para-aortic nodes
What is cervical ectropion?
During puberty and pregnancy, eversion of cervix occurs and columnar epithelium is visible as red area around os
Lower pH so columnar epithelium metaplases to squamous and is vulnerable to neoplastic change
How does ectropion present and how is it managed?
Vaginal discharge or PCB
Cryotherapy after smear and colposcopy
What is cervicitis?
Acute from STI
Chronic from infection of an ectropion
What are cervical polyps?
> 40yrs
Asymptomatic or IMB
What are Nabothian follicles?
Squamous epithelium formed by metaplasia over endocervical cells
Columnar cell secretions are trapped and form cycts
What are the attachments of the ovaries?
Mesovarium -> broad ligament
Infundibulopelvic ligament -> pelvic side wall
Ovarian ligament -> uterus
What are the layers of the ovary?
Outermost layer - germinal epithelium
Middle - cortex containing follicles and theca cells
Inner medulla contains connective tissue and blood vessels
How do ovarian masses present acutely?
Rupture of cyst - intense pain
Haemorrhage - pain, hypovolaemic shock
Torsion - infarction of ovary +/- tube and severe pain
What commonly causes ovarian masses in premenopausal women?
Follicular/lutein cysts
Dermoid cysts
Endometriomas
Benign epithelial tumour
Malignant tumour - dysgerminoma
What commonly causes ovarian masses in postmenopausal women?
Benign epithelial tumour
Malignancy - primary or secondary from breast or GI tract
What tissue lines the vagina?
Squamous epithelium
What is the lymph node drainage of the vulva?
Inguinal -> femoral -> external iliac nodes
What causes pruritus of the vulva?
Candidiasis +/- vaginal discharge Vulval warts Pubic lice/scabies Eczema Psoriasis Lichen simplex/scelrosus/planus Contact dermatitis Carcinoma Vulval intraepithelial neoplasia (VIN)
What is lichen simplex?
Chronic vulval dermatitis
Severe pruritis at night
Thickened labia majora with hyper and hypoPIGMENTATION
Exarcerbated by chemical or contact dermatitis, stress or low iron stores
How is lichen simplex treated?
Potent topical steroids and antihistamines to break itch-scratch cycle
What is lichen planus and how is it treated?
May affect mucosal surfaces anywhere
Flat, papular, purple lesions
Can be errosive - PAIN
Potent topical steroids
What is lichen sclerosus and how is it treated?
Thin vulval epithelium with loss of collagen
Associated with AUTOIMMUNE (thyroid disease/vitiligo)
Typically postmenopausal
Scratching -> bleeding, skin splitting
Pink/white papules -> parchment like skin
Can cause fusion of labia
5% develop vulval carcinoma
Tx: high potency topical steroids
What is vulvodynia and how is it treated?
Diagnosis of exclusion
Associated with GTI, former OCP, psychosexual disorders, IBS, CFS, endometriosis
Tx: amitriptyline or gabapentin
What infections can affect the vulva?
Herpes simplex
Vulval warts
Syphilis
Candidiasis
What is a Bartholin’s gland abscess and how is it treated?
If cyst is infection with staph or E. coli an abscess forms
Very painful and red
Tx: incision and drainage and marsupiasation
What is introital damage?
Commonly following childbirth - overtightening, extensive scar tissue
What are vaginal cysts?
Congenital, smooth white
Can be mistaken for prolapse
Excised if they cause dyspareunia
What is vaginal adenosis?
Columnar epithelium is found in squamous epithelium of vagina
Occurs when mother received DES in pregnancy -> genital tract abnormalities
Occasionally becomes malignant (clear cell carcinoma)
What is vulval intraepithelial neoplasia?
Atypical cells in vulval epithelium
Usual - warty/basaloid/mixed SCC
- 35-55yrs
- associated with HPV 16, CIN, smoking and immunosupression
- multifocal
Differentiated - keratinising SCC
- older women
- associated with lichen sclerosis
- unifocal ulcer/plaque
- higher risk of Ca
How is VIN treated?
Emolients/mild topical steroid
Local surgical excision to relieve symptoms, confirm histology and exclude invasive disease
