GYNAE 1: Ovarian pathology, Amenorrhoea and Subfertility, Menopause/POI/HRT Flashcards
What is a tubo-ovarian abscess?
Complex infectious mass of adnexa that forms as a sequela of PID
Causative organisms:
- 30-40% polymicrobial
- STIs
- Related to FB (coil) = actinomyces israelli
Sx = abdominal pain, fever, often PV discharge (not always)
What are long term consequences of tubo ovarian abscess?
infertility, increased risk of ectopic pregnancy and chronic pelvic pain
How is a tubo ovarian abscess managed?
USS = cogwheel sign may see pyosalpinx
Mx = antibiotic therapy +/- surgical intervention
Resus as appropriate to clinical condition
What is ovarian torsion and how does it present?
Obstruction of blood supply - may be adnexal, ovarian or rarely tubal torsion only
Sx = severe abdominal pain, vomiting, history of ovarian cyst
How is ovarian torsion diagnosed?
CLINICAL DIAGNOSIS
USS - oedematous ovary, peripheral distribution of follicles, whirlpool sign
How is ovarian torsion managed?
Laparoscopic detorsion +/- cystectomy
Necrotic and falling apart = oophorectomy
What is ovulation pain/ovarian cyst accident?
Sx = sharp, unilateral pain around ovulation
Most often simple, haemorrhagic cysts, less often dermoids/endometriomas (thick-walled)
USS = free fluid/blood in POD, probe tenderness, may see collapsing cyst
Mx = conservative
What are some epithelial ovarian tumours/cysts?
BENIGN = serous cystadenoma, mucinous cystadenoma
BORDERLINE = serous BOT, mucinous BOT, seromucinous BOT
MALIGNANT = serous carcinoma, mucinous carcinoma, clear cell carcinoma, endometrioid carcinoma
What are some germ cell ovarian tumours?
BENIGN = teratoma, dermoid
MALIGNANT = dysgerminoma, immature teratoma, yolk sac tumour, embryonal carcinoma, choriocarcinoma
What are some sex cord stromal ovarian tumours?
PURE STROMAL = fibroma, thecoma (benign)
PURE SEX CORD = adult/juvenile granulosa cell tumour (malignant)
MIXED SEX CORD-STROMAL = sertoli-leydig cell tumours (benign or malignant)
These tend to produce hormones e.g. oestrogens, steroids, androgens
What is a krukenberg tumour?
Metastatic adenocarcinoma of the ovary characterised by mucin-rich, signet-ring cells, originating from a GI primary in 70% of cases, but also involving the colon, breast, appendix, and biliary tract.
When should a woman be referred to 2ww ovarian cancer pathway from primary care?
2WW:
- ascites and/or a pelvic or abdominal mass (clear it’s not fibroids)
PRIMARY CARE TESTS if following sx 1 or more times a month:
- persistent abdo distension i.e. bloating
- early satiety or loss of appetite
- pelvic or abdo pain
- increased urinary urgency or frequency
- unexplained weight loss, fatigue, change in bowel habit
How should ovarian cancer be investigated in primary care?
Serum Ca125
- If serum Ca125 >35 IU/ml arrange an USS AP
If USS suggests ovarian cancer, refer woman urgently for further investigation
Risk of malignancy index - if >250 refer to gynae-onc team
How is risk of malignancy index calculated?
ultrasound score x menopausal score x Ca125
US features = multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal metastases (0 = none, 1 = 1 abnormality, 3 = 2 or more abnormalities)
Pre-menopausal score = 1
Post-menopausal = 3
How is ovarian cancer investigated in secondary care?
Ca125 +/- AFP/hcg (<40yo to identify those w/non-epithelial ovarian cancer)
USS abdo and pelvis
CT CAP (can offer MRI if nature of mass remains indeterminate)
How is ovarian cancer managed?
CONSERVATIVE
MEDICAL:
- chemotherapy first line usually paclitaxel + platinum based e.g. cisplatin/carboplatin
- bevacizumab (avastin) only for advanced
SURGICAL:
- usually ultra-radical surgery
- primary or interval debulking
Roughly what are the stages of ovarian cancer?
Stage 1 = cancer in one or both ovaries
Stage 2 = spread within pelvis to fallopian tubes, uterus etc.
Stage 3 = spread within abdomen to nearby lymph nodes, diaphragm, intestines or liver
Stage 4 = spread beyond abdomen e.g. to lungs or spleen
What does a PC of primary amenorrhoea combined with a transabdominal USS showing absence of uterus w/a pelvic kidney suggest?
Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome
When should primary amenorrhoea be suspected?
- girls who haven’t established menstruation by 13yo w/no secondary sexual characteristics e.g. breast development
- girls who haven’t established menstruation by 15yo and normal secondary sexual characteristics
NOTE: normal age of puberty from 8yrs old in girls
What are causes of amenorrhoea?
- Hypothalamic hypogonadism
- Pituitary hypogonadism
- Ovarian pathology
What are causes of amenorrhoea caused by hypothalamic hypogonadism?
Kallman’s syndrome
Tumours
Low BMI
Exercise
Stress
Hyper or hypothyroidism
CAH
Virilising tumours
What are causes of amenorrhoea caused by pituitary hypogonadism?
Sheehan’s syndrome
Pituitary tumours
Prolactinoma
What are causes of amenorrhoea caused by ovarian pathology?
POI
Menopause
Turner’s syndrome
Gonadal dysgenesis
Androgen insensitivity
What are structural causes of amenorrhoea?
Imperforate hymen
Rokitansky syndrome
Asherman’s syndrome
Cervical stenosis
Which embryological duct becomes the body of the tubes, uterus, cervix and upper 1/3 of the vagina?
Paramesonephric ducts (aka Mullerian ducts)
What happens when the Mullerian ducts fuse at around 10 weeks?
Merge to form mesonephric ducts aka Wolffian ducts
(uterine septum temporarily in midline, where edges of 2 paramesonephric ducts meet, cranial ends remain open, where caudal ends meet urogenital sinus, the vaginal plate forms)
What are some paramesonephric duct anomalies?
Mullerian hypoplasia/agenesis (cervical agenesis)
Unicornuate uterus = single horned, hemiuterus
Didelphys (double) uterus
Bicornuate uterus (heart shaped)
Septate = most common anomaly
How does a longitudinal vaginal septum present?
- difficulty inserting tampons
- dyspareunia
- accumulation of menstrual blood
- emergency w/severe dysmenorrhoea and palpable abdominal mass
What is MRKH syndrome?
Congenital disorder of genital tract, typically presenting w/primary amenorrhoea w/normal secondary sexual characteristics
Characterised by uterine and vaginal hypoplasia
How is MRKH syndrome diagnosed?
Clinical diagnosis
EXAMINATION:
- normal secondary sexual characteristics, normal hormone profile, genital examination shows absent or blind vagina
IMAGING: USS/MRI confirms diagnosis
How is MRKH syndrome managed?
Focus on congenital impact and psychological impact
- dilators + psychological therapy
Surgery not usually indicated but high success rate
Transplant
How may imperforate hymen or transverse vaginal septum present?
Vagina becomes distended, usually painless
Results in haematocolpos - cyclical abdominal pain
‘Blue bulge’ on examination = imperforate hymen only
What is the diagnostic criteria for PCOS?
Rotterdam criteria
- oligo/anovulation (>2yrs)
- clinical or biochemical features of hyperandrogenism
- polycystic ovaries on USS (>12 in one ovary measuring 2-9mm in diameter)
Hyperoestrogenic state = conversion to androgens
- assoc. w/insulin resistance
Shouldn’t be diagnosed within 8yrs of menarche
How is PCOS managed?
CONSERVATIVE = weight loss
MEDICAL =
- Dianette COCP (androgenic sx) - contains cyproterone acetate (anti-androgenic)
- Metformin
SX management e.g. laser therapy for excessive hair
If desiring pregnancy:
1. weight loss
2. ovulation induction = clomiphene (SERM)/gonadotrophin +/- metformin
3. laparoscopic ovarian drilling
4. IVF
What does PCOS increase the risk of?
- lifetime risk of diabetes
- endometrial hyperplasia
- endometrial cancer
- depression
How is subfertility investigated?
Blood hormones = day 2-3 FSH, LH and oestradiol. AMH demonstrates ovarian reserve
STI screening
TVUSS, antral follicle count
Tubal assessment (hysterosalpingogram or lap+dye)
Semen analysis
How is anovulation infertility treated?
Ovulation induction w/clomiphene, gonadotrophins
Laparoscopic ovarian drilling
How is male factor infertility treated?
IUI if mild
Donor insemination
How is tubal scarring/failed IUI or ovulation induction infertility treated?
IVF
ICSI (intracytoplasmic sperm injection)
How is lack of oocytes e.g. POI/Turner’s syndrome infertility treated?
Donor egg
How is an anatomical abnormality infertility treated?
Surgical management e.g. adhesiolysis, myomectomy
How is menopause diagnosed?
In women >45yo w/menopausal sx, diagnosis of perimenopause or menopause should be considered based on their symptoms alone, w/o confirmatory blood tests unless uncertainty about diagnosis.
Average age = 51
Menopause = a retrospective diagnosis, absence of menses for 12 months
Generally how should menopause be managed?
IMPORTANT: cannot give oestrogen w/o progesterone if a woman has a uterus in situ
Unopposed oestrogen can cause endometrial hyperplasia which can cause cancer
All women should be offered HRT for menopausal sx first-line
Women w/GU sx should be offered vaginal oestrogen rx
What is POI?
Women experiencing menopause <40yo w/menopausal sx and absent or infrequent periods.
How is POI diagnosed?
2 blood tests for FSH level taken 4-6w apart (>40 IU/l)
Bone mineral density
What does POI increase the risk of?
Cardiovascular disease, osteoporosis and cognitive impairment
How is POI managed?
Hormone replacement w/HRT or COCP continued at least until average age of menopause (51yrs)
Can have intermittent ovarian activity and have a chance of natural conception estimated to be in region of 5-10%.
What are symptoms of menopause/POI?
- vasomotor sx
- cognitive sx and mood disorders
- sleep disturbances
- fatigue, tiredness and low energy levels
- loss of libido
- joint and muscle pains
- headaches
- GU sx
What are potential causes of POI?
Exact causes unknown
GENETICS e.g. fragile X, Turner’s
TOXIC CAUSES e.g. chemotherapy, radiotherapy
SURGERY
AUTOIMMUNE causes e.g. adrenal or thyroid gland problems
What are benefits of HRT?
PROVEN =
- control of menopausal sx
- maintenance of bone mineral density, reduced osteoporosis risk
ADDITIONAL POTENTIAL =
- reduced risk of CHD and reduced risk of Alzheimers disease when oestrogen started early
- reduced risk colorectal Ca
- reduced risk T2DM
What are known risks of HRT?
- endometrial cancer if oestrogen only given, this is reduced by adding a progestogen continuously
- DVT/PE: greatest risk in first 12mths, no increase in risk of VTE w/transdermal
- CHD: possible increase when combined HRT started in women >60yo or pre-existing CHD
- Stroke: increased risk when oral HRT started in >60yo
- Breast cancer: increased slightly after min. 5yrs of combined HRT >50yo, risk assoc. w/oestrogen alone much less. Mortality not increased.
What are indications for transdermal HRT?
- individual preference
- poor sx control w/oral
- GI disorder affecting oral absorption
- prev. or family hx of VTE
- BMI >30
- variable BP control
- migraine
- current use of hepatic inducing enzymes medication
- gallbladder disease
How should vasomotor sx be managed in a women with menopause and history of breast cancer?
1st line = lifestyle changes and HRT alternatives
Avoid paroxetine and fluoxetine in women taking tamoxifen.
If severe, refractory sx, systemic HRT may be offered but requires informed, documented consent and discussion w/breast ca team
Systemic HRT should not be used in women treated w/an aromatase inhibitor
How is vulvo-vaginal atrophy managed in a women with menopause and history of breast cancer?
1st line = vaginal moisturisers
Refractory sx = ultra-low dose topical oestrogen
Topical oestrogen should be avoided in presence of aromatase inhibitor
How is HRT managed if there is endometrial hyperplasia w/o atypia?
Switch from sequential to continuous
If on continuous, increase progestogen component
How is HRT managed if there is endometrial hyperplasia w/ atypia?
- recommend hysterectomy (TLH + BSO) due to high risk of progression to endometrial cancer
- recommend BSO to reduce future risk of ovarian cancer
What is the difference between perimenopause and postmenopause and how is HRT managed differently dependent on these?
Perimenopause = women w/irregular menstrual cycles + vasomotor sx
- Mx = sequential HRT
Postmenopause = women w/o bleeding for at least 1yr in absence of interventions that may cause amenorrhoea
- Mx = continuous HRT
