Group A - Menstrual Disorders and Gynaecological Cancer Flashcards
Define dysfunctional uterine bleeding (DUB)
Heavy menstrual bleeding, with:
- No recognisable pelvic pathology
- No pregnancy
- No bleeding disorders
I.e. it is a diagnosis of exclusion
List some causes of abnormal/heavy menstrual bleeding
PALM COEIN
Polyps
Adenomyosis
Leiomyomas (fibroids)
Malignancy
Coagulation disorders
Ovulatory pathology
Endometriosis
Iatrogenic
Not yet classified
Outline the factors that determine whether a woman with HMB is low risk or high risk and what investigations they need based on their risk
Low risk:
< 45
No intermenstrual bleeding
No risk factors for endometrial cancer
Investigations: FBC only (anaemia) - then begin treatment for HMB
High risk:
> 45
Intermenstrual bleeding
Risk factors for endometrial cancer
Investigations: FBC (anaemia), ultrasound and hysteroscopy + biopsy
Then begin treatment for HMB
Outline the medical and surgical management of HMB
Medical:
- Tranexamic acid (symptomatic)
- Mefenamic acid (symptomatic)
- GnRH analogues or Ulipristal acetate (fibroids)
- Progesterone hormone products, Mirena coil 1st line
- COCP
Surgical:
- Hysteroscopic removal (polyps)
- Myomectomy (fibroids)
Risk of reducing children in future…
- Uterine artery embolisation
- Endometrial ablation
- Hysterectomy
Outline how to manage HMB in the short term / emergency
- Tranexamic acid
- Norethisterone (progesteron product)
- GnRH analongues
Outline how tranexamic acid works in HMB
Inhibits plasminogen activation
Reduces fibrolysis (encourages clotting)
= Reduces menstrual loss
Outline how mefenamic acid works in HMB
NSAID - reduces production of prostaglandins
= Analgesia, anti inflammatory and reduces menstrual loss (although less effectively than tranexamic acid)
List the following cancers in most common to least common
- Endometrial
- Cervical
- Vulval
- Ovarian
- Endometrial
- Ovarian
- Cervical
- Vulval
For the following cancers, state the peak age of incidence:
- Endometrial
- Ovarian
- Cervical
Endometrial: 65-75 (declines after 80)
Ovarian: 70-75 years (mostly between 50-80)
Cervical: bimodal at 30s and 80s
Outline risk factors for endometrial cancer
Also list some protective factors
Risk factors:
Anything that causes endometrial hyperplasia!
- Obesity
- BRCA1/2
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- Unopposed oestrogen = PCOS or Tamoxifen
- Poorly controlled diabetes
- Untreated endometrial polyps
Protective factors:
- SMOKING
- Combined HRT
- COCP
- Physical activity
Briefly explain endometrial hyperplasia and its management
- Precancerous condition, involving thickening of endometrium
- 2 types:
1. Hyperplasia without atypia
2. Atypical hyperplasia
Most cases will return to normal over time, however <5% can become endometrial cancer
- Risk factors are similar to those for endometrial cancer
Management:
Depends on type of hyperplasia
1. Hyperplasia without atypia = progesterone (POP or Mirena coil)
2. Atypical hyperplasia = hysterectomy +/- bilateral salpingo oophorectomy
List red flag symptoms for endometrial cancer
- Postmenopausal bleeding
- Abnormal vaginal discharge
If premenopausal:
- Heavy vaginal bleeding
- Abnormal bleeding e.g. IMB, PCB
Outline the main cell type of endometrial carcinoma
80% = adenocarcinoma
Outline referral criteria for post-menopausal bleeding and diagnostic tests indicated
Automatic 2 week wait urgent gynae cancer referral for endometrial cancer
- Transvaginal ultrasound (thickness > 4mm)
- If >4mm: endometrial (Pipelle) biopsy
- If high risk/suspicious: hysteroscopy + biopsy
Other than post-menopausal bleeding, suggest other presenting symptoms that prompt a referral for investigation of endometrial cancer in women over 55
In women over 55:
- Unexplained vaginal discharge
- Visible haematuria PLUS anaemia / raised platelets / raised glucose
Outline management options for endometrial cancer in terms of surgical and non-surgical options
Surgical:
- Total hysterectomy +/- bilateral salpingo oophorectomy
Non-surgical:
- Progestagens e.g. Mirena coil
- Primary radiotherapy
PLUS adjuvant therapies:
- External beam
- Brachytherapy
Depends on stage:
Stage 1 (localised) = total hysterectomy +/- bilateral salpingo oophorectomy with peritoneal wash out
Stage 2 = Radical hysterectomy and lymphadenectomy +/- adjuvant therapy
Stage 3 = Maximal debulking surgery + chemotherapy + radiotherapy
Stage 4 = Maximal debulking surgery / palliative approach
Outline the most common cell line types for ovarian cancer
Epithelial:
- Serous
- Mucinoid
Germ cell:
- Teratoma
Stomal / sex cord: rare!
Outline risk factors for ovarian cancer
Also list some protective factors
Risk factors:
- Obesity
- Lifetime exposure to oestrogen e.g. nulliparity, early menarche, late menopause
- BRCA1/2 or family history
- Unexposed oestrogen = PCOS or Tamoxifen
- Endometriosis
Protective factors:
- COCP
- Pregnancy / breastfeeding
- Oopherectomy (+/- hysterectomy)
Outline some red flag symptoms for a patient with ovarian cancer
- Persistent abdominal bloating
- Pain or dyspareunia
- Anorexia
- Nausea and vomiting
- Weight loss
- Vaginal bleeding
- Increased urinary frequency
- Bowel changes
Outline some diagnostic tests to consider for suspected ovarian cancer
Bloods:
- Ca125 tumour marker
- FBC / U&Es, LFTs (routine bloods)
Imaging:
- Ultrasound
- CT to assess for further disease
- Chest x-ray
Outline the possible management options for ovarian cancer: epithelial and non-epithelial
Epithelial:
- Surgery
- Chemotherapy (Platinum and Taxane)
Non-epithelial:
- Chemotherapy only (very chemo-sensitive)
Outline risk factors for cervical cancer
Also list some protective factors
Risk factors:
- Non-compliance with cervical screening
- Known diagnosis of CIN (premalignant changes)
- HPV positive
- Related to HPV exposure: early first sexual experience, multiple sexual partners, lack of barrier contraception
- Immunosuppression
- Smoking
- COCP long term
Protective factors:
- HPV vaccine!
- Compliance with cervical screening
Outline briefly how HPV increases the risk of cervical cancer
- HPV produce E6 and E7 proteins
- These proteins inhibit the tumour suppressor genes in keratinocytes
Briefly explain cervical intraepithelial neoplasia (CIN) and at which area of the cervix CIN occurs
CIN is a grading system for level of dysplasia / premalignant changes in the cells of the cervix
- Can be diagnosed during colposcopy
- Level of CIN grade, suggests the level of premalignant changes and the likely of progression to cervical cancer
Area of the cervix:
- Transformation zone
List some red flag symptoms for cervical cancer
- Post-coital bleeding
- Intermenstrual bleeding
- Post menopausal bleeding
- Dyspareunia
- Blood stained vaginal discharge
Outline the FIGO staging of cervical cancer
Stage 1: confined to cervix
Stage 2: beyond cervix, but not on side pelvic wall or lower 1/3 vagina
Stage 3: spreads beyond cervix, on sides of pelvic wall or lower 1/3 vagina
Stage 4: invades adjacent organs
Outline the management for cervical cancer in the following conditions:
- CIN and early stage 1a (very early disease)
- 1b to 2a (localised)
- 2b to 4a (greater spread)
CIN and early stage 1a:
- LLETZ procedure
- Cone biopsy
1b to 2a (localised):
- Radical hysterectomy and removal local lymph nodes with chemo and radio
2b to 4a (greater spread):
- Chemotherapy
- Radiotherapy
Outline some complications of surgical management and radiotherapy management of cervical cancer
Surgical:
- General e.g. infection, VTE, haemorrhage
- Vesicovaginal fistula
- Bladder dysfunction
- Short vagina
Radiotherapy:
- Vaginal dryness
- Stenosis
- Cystitis
- Proctitis
- Loss of ovarian function
Outline the frequency of cervical smears (for the 2 age groups)
25-50: every 3 years
50-65: every 5 years
After 65: selected patients only
Outline some red flag symptoms for vulval cancer
- Vulval pain / soreness
persistent vulval itching - Lump or thickened, raised patches (red, white or dark)
List some risk factors for vulval cancer
- Lichen sclerosus
- HPV
- Herpes simplex virus type 2
- Smoking
- Immunosuppression
- Chronic vulvar irritation
Briefly outline the following for lichen sclerosus:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Chronic inflammatory skin disease in the anogenital region in women, possibly autoimmune
- Bimodal: pre-puberty and post-menopausal
- Can be debilitating
- Potential to progress to squamous cell carcinoma (vulval cancer)
Presentation:
- White atrophic patches in anogenital region
- Itching (associated excoriations and pain)
- Fusion of vulval tissue
- Dyspareunia
- Can be asymptomatic
Management:
- Conservative e.g. avoid irritants
- Topical steroids
- Regular follow ups due to risk of squamous cell carcinoma
Outline the general management options for vulval cancer
- Wide local excision surgery +/- lymphadenectomy
- Radiotherapy / chemotherapy
2 medications that can cause amenorrhoea
- Antipsychotics
- Breast cancer treatment e.g. Tamoxifen
Plus contraceptives!
- Contraceptive pill
- Mirena coil
State for what ages breast cancer screening is offered
Between 50-70
Outline how smears are conducted in terms of HPV testing and cytology
Initially tested for presence of HPV
If HPV absent -> no further investigation, return to routine screening
If HPV present -> cytology to look for dyskaryosis
Cytology normal = recall in 12 months
Cytology abnormal = refer for colposcopy
Outline the 2 liquids used in cytology to visualise cells and what colours they turn in normal and abnormal cells
- Acetic acid
Normal: no change
Abnormal: white - Iodine
Normal: brown
Abnormal: no change / don’t stain
Outline 2 future tests for biopsy in suspicious looking cells in colposcopy
- Punch biopsy
- LLETZ (large loop excision of transformation zone)
List some complications of a LLETZ procedure
- Risk of infection
- Cervical stenosis
- Cervical incompetence (pregnancy)
Can make follow up smears more difficult
Outline some potential clinical signs (not symptoms) of cervical cancer
On speculum examination:
- Visible irregularity of cervix e.g. ulceration
- Evidence of discharge / bleeding
- Cervical tenderness
If advanced disease:
- Pelvic mass
- PR bleed / PR mass
- Hydronephrosis
- Hepatomegaly
Outline some potential clinical signs (not symptoms) of ovarian cancer
- Abdominal distension
- Abdominal mass (axdendal)
Advanced:
- Pleural effusion
- Ascites
Outline some potential clinical signs (not symptoms) of endometrial cancer
- Abdominal distension
- Abdominal mass (axdendal)
- Abdominal tenderness
- Haematuria
Laboratory:
- Anaemia
- Raised platelet count
Outline some potential clinical signs (not symptoms) of vulval cancer
- Ulceration +/- discharge
- Skin changes e.g. thickened skin, colour change (red, white, dark brown)
- Tenderness on palpation
List the 4 types of fibroid
- Intramural (within myometrium)
- Subserosal (outside layer)
- Submucosal (internal layer)
- Pedunculated (on a stalk)
List some symptoms and signs of fibroids
Symptoms:
- Heavy menstrual bleeding
- Prolonged menstrual bleeding
- Abdominal pain
- Bloating / fullness / reduced appetite
- Urinary or bowel symptoms
- Deep dyspareunia
- Fertility issues
Signs:
- Palpable pelvic mass (abdominal exam)
- Enlarged firm non-tender uterus (bimanual exam)
List some investigations for suspected fibroids
- Hysteroscopy initially (if submucosal causing HMB)
- Pelvic ultrasound if larger
- MRI scan prior to surgical interventions
List some management options for fibroids
Conservative:
- Leave if not causing problems
- Symptomatic management with NSAIDs and tranexamic acid
Medical:
- Mirena coil (first line if small)
- COCP / POP
- GnRH analogues may be used short term
Surgical:
- Endometrial ablation
- Resection during hysteroscopy if submucosal
If >3cm
- Uterine artery embolism
- Myomectomy
- Hysterectomy
List some complications of fibroids
- Heavy menstrual bleeding and anaemia
- Infertility / impact on pregnancy
- Constipation / urinary outflow obstruction
- Red degeneration / ischaemia / necrosis
- Torsion of fibroid if pedunculated
- Malignant change (rare)
State the 3 Rotterdam features for diagnosis of PCOS
Need 2 of 3 features for a diagnosis of PCOS
- Irregular periods (oligoovulation or anovulation)
- Hirsutism
- Polycystic ovaries on USS (>10cm or >12 cysts)
State presenting features of PCOS
- Irregular / absent periods
- Infertility
- Hirsutism
- Acne
- Obesity
- Male pattern hair loss
State some blood tests and other investigations to do in suspected PCOS (also helps to rule out other conditions)
Bloods:
- LH
- FSH
- Testosterone
- Sex hormone binding globulin
- Prolactin
- Thyroid stimulating hormone
Other investigations:
- Pelvic ultrasound which shows ‘string of pearls’ (multiple cysts or large volume cyst)
- OGTT
State the findings for the following blood tests in PCOS:
- LH
- LH:FSH ratio
- Testosterone
- Insulin
- Oestrogen
LH = raised
LH:FSH ratio = raised
Testosterone = raised
Insulin = raised
Oestrogen = normal / raised
List some investigations for suspected endometriosis
- Transvaginal USS = rule out any ovarian masses or chocolate cysts
- Laparoscopy = gold standard
State some presenting symptoms and signs of endometriosis
Symptoms:
- Dysmenorrhoea
- Cyclical abdominal / pelvic pain
- Deep dyspareunia
- Infertility
- Cyclical bleeding from other sites e.g. haematuria
Signs:
- Fixed cervix
- Presence of endometrial tissue in vagina
- Tenderness of vagina, cervix and adnexa
State some presenting symptoms of endometrial polyps
- Irregular bleeding: PCB, PCB, postmenopausal bleeding
- Heavy menstrual bleeding
- Infertility
- Dull pelvic pain
State common causative organisms for pelvic inflammatory disease
- Neisseria gonorrhoeae (more severe)
- Chlamydia trachomatis
- Mycoplasma genitalium
Less common:
- Gardnerella vaginalis
- Haemophilus influenzae
- E coli
State risk factors for pelvic inflammatory disease
- Previous PID
- Existing sexually transmitted diseases
- Intrauterine device
Sexual risk:
- Young age
- Lack of barrier contraception
- Multiple sexual partners
State some presenting symptoms and signs of pelvic inflammatory disease
Symptoms:
- Lower abdo / pelvic pain
- Abnormal discharge
- Abnormal bleeding (IMB / PCB)
- Dyspareunia
- Fever
- Dysuria
Signs:
- Cervical motion tenderness
- Tenderness on palpation
- Inflamed cervix
- Purulent discharge
List some investigations for suspected pelvic inflammatory disease
- Pregnancy test
- HVS for STI screen
- Bloods for CRP and WCC
Outline management for pelvic inflammatory disease
Empirical antibiotic therapy:
- IM Ceftriaxone
- Doxycycline (14 days)
- Metronidazole (14 days)
List some complications of pelvic inflammatory disease
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Fitz-Hugh-Curtis syndrome
- Abscess
- Sepsis
State some initial investigations for primary amenorrhoea
Normal bloods:
- FBC and ferritin (anaemia)
- U&Es (CKD)
- Thyroid function tests
Reproductive bloods:
- LH and FSH
- Testosterone (PCOS)
- Prolactin (hyperprolactinaemia)
Specific bloods:
- Coeliac disease
- ILGF-1 (growth hormone deficiency)
State some initial investigations for secondary amenorrhoea
- Pregnancy test for pregnancy
- LH and FSH for premature ovarian failure
- Thyroid function tests
- Testosterone for PCOS
- Pelvis ultrasound for PCOS
- Prolactin for hyperprolactinaemia
State some initial investigations for irregular periods
- Pregnancy test for pregnancy
- LH and FSH for premature ovarian failure
- Thyroid function tests
- Testosterone for PCOS
- Pelvis ultrasound for PCOS
State some initial investigations for menorrhagia or dysmenorrhoea
- Speculum examination
- Bimanual examination
- STI screen / swabs
- Pregnancy test for pregnancy
- Check up to date with cervical screening
- FBC and ferritin for anaemia
- LH and FSH for premature ovarian failure
- Thyroid function tests
- Testosterone for PCOS
- Pelvic ultrasound
- Hysteroscopy
State some management options for PCOS
Conservative:
- Encourage a healthy lifestyle and optimal weight management (reduce risk of associated T2DM and cardiovascular disease)
Medical:
- Offer COCP
- If acne, offer topical retinoids
- If hirsutism, offer hair removal methods e.g. waxing
-
State some management options for endometriosis
Diagnostic laparoscopy
Medical:
- Analgesia
- COCP / POP
Surgical:
- Laparoscopic endometrial ablation or excision (can add hormonal treatments)
- Laparoscopic hysterectomy (+/- oophorectomy)
State some management options for endometrial polyps
Asymptomatic AND low-risk, may manage conservatively with observation
If suspicious:
- Hysteroscopy and biopsy, including removal of polyp
- Consider use of POP/Mirena coil to prevent formation of future polyps
