Gynae Flashcards
What age range is cervical cancer most commonly seen in?
35-44
What are the two most common types of cervical cancer?
- Squamous cell carcinoma (80%)
2. Adenocarcinoma
What is the most common cause of cervical cancer?
HPV
What vaccination is given against cervical cancer?
HPV Vaccine
At what age is the HPV vaccine given and why?
12-13 (hopefully before they become sexually active)
Which strains of HPV are usually responsible for cervical cancer?
Type 16
Type 18
How does HPV promote the development of cancer?
It produces two proteins that inhibit tumour suprrosor genes
What cells make up the ectocervix?
Squamous cells
What cells make up the endocervix?
Collumnar cells
What is the squamocolumnar junction?
The junction at the cervix where the squamous cells transition into collumnar cells.
Where is the squamocolumnar junction?
Location varies throughout life
Why is the squamocolumnar junction the main target for HPV?
There is the largest turnover of cells there and so it can easily enter and remain
When is the squamocolumnar junction cell turnover most active and why does this matter?
During puberty, therefore this is when people are most at risk of HPV
What are the 3 categories of risk factor for cervical cancer?
- Increased risk of HPV
- Later detection of precancerous and cancerous changes (non-engagement with screening)
- Other risk factors
What factors increase the risk of catching HPV?
- Early sexual activity
- Multiple sexual partners
- Sexual partners who have multiple partners
- Unprotected sex
What are other risk factors for cervical cancer?
- Not attending smears
- Smoking
- HIV
- COCP > 5 years
- Multigravida
- Family history
- Exposure to diethylstilbestrol during fetal development
What are the presenting symptoms of cervical cancer?
- Asymptomatic (screening)
- Abnormal vaginal bleeding (intermenstrual, postcoital, post-menopausal)
- Vaginal discharge
- Pelvic pain
- Dyspareunia
How is suspected cervical cancer investigated?
Speculum examination
Swabs to exclude infection
Colposcopy
What appearances on colposcopy may indicate cervical cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
What is dysplasia?
Premalignant change
What is the grading system used to measure the level of dysplasia in the cervix?
CIN- Cervical intraepithelial neoplasia
When is CIN decided?
At colposcopy (not cervical screening)
What are the different grades of cervical cancer?
CIN I: Mild dysplasia (1/3 thickness of epithelial layer- likely to return to normal)
CIN II: Moderate dysplasia( 2/3 thickness of epithelial layer- likely to turn into cancer)
CIN III: Severe dysplasia (very likely to turn into cancer)
What is CIN III otherwise known as?
Cervical carcinoma in situ
What does cervical screening involve?
Speculum examination and smear test to look for precancerous changes in the epithelial cells of the cervix
What is dyskaryosis?
Precancerous changes in cervical cells detected at smear
What is liquid based cytology?
The method of transporting the collected cervical cells: They are deposited from the brush into preservation fluid and taken to the lab to be examined under a microscope
What are smear cells tested for?
High-risk HPV- If not present the smear is considered negative/
What age women have smear tests and how frequently?
25-29 Every 3 years
50-64 Every 5 years
What are the exceptions to the cervical screening programme?
HIV+ve screened anually
Additional tests with previous CIN, immunocompromised
Pregnant women should wait until 12 weeks postpartum
What is cytology?
Diagnosing diseases by looking at single or small clusters of cells
What are the different options of cytology result?
Inadequate Normal Borderline changes Low-grade dyskaryosis High-grade dyskaryosis (moderate) High-grade dyskaryosis (severe) Possible invasive squamous cell carcinoma Possible glandular neoplasia
What is the management of women who are HPV positive with normal cytology?
Repeat HPV test after 12 months
What is the management of woemn who are HPV positive with abnormal cytology on smear?
Refer to colposcopy
What is the management of women who have an inadequate sample on smear?
Repeat after at least 3 months
What is colposcopy?
When a colposcope is used to magnify the cervix, allowing the epithelial lining to be examined in detail
What is used in colposcopy to view abnormal cells?
Acetic acid–> causes abnormal cells to appear white (acetowhite)
Schiller’s iodine test–> iodine solution stains healthy cells brown colour.
Why does acetic acid cause abnormal cells to appear white?
Pre-cancerous cells have more keratin so take up more acetic acid
What method can be used during colposcopy if abnormal cells are found?
LLETZ
Cone biopsy
What is LLETZ?
Large loop excision of the transformation zone: When a loop of electrical wire is used to remove abnormal tissue of the cervix
What method is used during colposcopy to remove a larger area of abnormal tissue?
Cone biopsy
What does a cone biopsy involve?
Cone-shaped piece of cervix is removed using a scalpel and then sent for histology
What are the different stages of cervical cancer?
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
What is CGIN?
Cervical glandular intra-epithelial neoplasia (very high risk dysplasia)
What are the usual treatments of CIN/ 1a?
LLETZ or Cone biopsy
What is the treatment of stage 1B-2A cervical cancer?
Radical hysterectomy and removal or lymph nodes with chemo/ radiotherapy
What is the treatment of stage 2b-4a cervial cancer?
Chemotherapy and radiotherapy
What is the treatment of stage 4b cervical cancer?
Combo of surgery, radio, chemotherapy and palliative care
What is pelvic exenteration?
An operation which removes most or all of the pelvic organs that may be used in advanced cervical cancer
What is Bevacizumab?
A monoclonal antibody that may be used in combination with other chemotherapies in the treatment of cervical cancer
What strains of HPV does the vaccine protect against and what do they cause?
6 & 11= Genital warts
16&18 = Cervical cancer
What type of cancer makes up the majority of endometrial cancer?
Adenocarcinoma (80%)
What does endometrial cancer depend on to grow?
Oestrogen-dependent cancer
What is the diagnosis for any woman presenting with postmenopausal bleeding until proven otherwise?
Endometrial cancer
What is the key risk factor for endometrial cancer?
Increased exposure to unopposed oestrogen
What is endometrial hyperplasia?
Precancerous thickening of the endometrium
What percentage of cases of endometrial hyperplasia go on to become endometrial cancer?
<5%
What are the two types of endometrial hyperplasia?
Hyperplasia without atypia
Atypical hyperplasia
How can endometrial hyperplasia be treated?
With progesterones:
- Mirena coil
- Oral progesterones
What is unopposed oestrogen?
Oestrogen without progesterone
What are the risk factors increase your exposure to unopposed oestrogen?
Increased age Early onset menstruation Late menopause Oestrogen only HRT No/ fewer pregnancies Obesity PCOS Tamoxifen
Why does PCOS lead to an increased exposure to unopposed oestrogen?
There is a lack of ovulation so there is no luteal phase with the corpus luteum producing progesterone.
What should be offered to women with PCOS to decrease their exposure to unopposed oestrogen?
COCP
Mirena coil
Cyclical progesterones
Why is obesity a key risk factor for endometrial cancer?
Because adipose tissue is a source of oestrogen
Why is tamoxifen a risk factor for endometrial cancer?
It has an oestrogenic effect on the endometrium
What are additional risk factors for endometrial cancer not linked to unopposed oestrogen?
T2 Diabetes
Lynch syndrome
What is lynch syndrome?
HNPCC–> Hereditary condition that increases risk of colon and endometrial cancer
Why does T2 diabetes increase the risk of endometrial cancer?
Increased production of insulin may stimulate the endometrial cells.
What are the protective factors against endometrial cancer?
COPC
Mirena coil
Increased pregnancies
Smoking
Why is smoking protective in endometrial cancer/
Anti-oestrogenic
What are the key presenting factors of endometrial cancer?
*Postmenopausal bleeding Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal discharge Haematuria Anaemia Raised platelets
What 3 investigations are done to diagnose endometrial cancer?
- TVUS for endometrial thickness
- Pipelle biopsy
- Hysteroscopy
What endometrial thickness would be a reg flag for cancer in post menopausal women?
> 4mm
What is a pipelle biopsy?
Speculum examination where pipelle (thin tube) is inserted into uterus to take sample of endometrium
What are the different stages of endometrial cancer?
Stage 1: confined to uterus
Stage 2: Invades cervix
Stage 3: Invades ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond pelvis
How is endometrial cancer usually managed?
Total abdominal hysterectomy with bilateral salpinogo-oophorectomy (removal of uterus, cervix and adnexa)
What are the other treatment options for endometrial cancer?
Radical hysterectomy
Radiotherapy
Chemotherapy
Progesterone to slow progression
What does a radical hysterectomy involve?
Removal of uterus, cervix, adnexa, pelvic lymph nodes, surrounding tissues and top of vagina
Why do the majority of ovarian cancer cases present late?
Non-specific symptoms
What are the different types of ovarian cancer?
*Epithelial cell tumours
Dermoid cysts/ germ cell tumours
Sex cord-stromal tumours
Metastasis
What are teratomas?
Tumours that come from germ cells and may contain various tissue types.
How may germ cell tumours be recognised?
Raised alpha-fetoprotein and hCG
What is a Krukenberg tumour?
A metastasis in the ovary that has a characteristic signet-ring histology
What is the peak age for ovarian cancer?
60
What are the risk factors for ovarian cancer?
Age (60) BRCA genes Increased no of ovulations Obesity Smoking Recurrent use of clomifene (infertility treatment) Early onset periods Late menopause No pregnancies
What factors increase the risk of ovarian cancer?
Factors that increase the number of ovulations ( early onset periods, late menopause, no pregnancies)
What are the protective factors for ovarian cancer?
Factors that reduce the number of ovulations:
COPC
Breastfeeding
Pregnancy
How does ovarian cancer present?
Non- specific
- Abdominal bloating
- Early satiety
- Loss of appetite
- Pelvic pain
- Urinary symptoms
- Weight loss
- Abdominal/ pelvic mass
- Ascites
Where may you get referred pain in ovarian cancer and why?
Hip or groin pain due to ovarian mass pressing on obturator nerve
What red flag signs would cause direct referall to 2 week wait clinic?
Ascites
Pelvic mass
Abdominal mass
What investigations can be done to look for ovarian cancer?
CA125 blood test (>35) Pelvic ultrasound RMI CT scan Histology Paracentesis Germ cell tumour markers
What is RMI
Risk of malignancy index
What factors does RMI take into account?
Menopausal status
USS findings
CA125 level
What are causes of raised CA125?
Epithelial cell ovarian cancer Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
What are the stages of ovarian cancer?
Stage 1: Confined to ovary
Stage 2: Inside pelvis
Stage 3: Inside abdomen
Stage 4: Outside of abdomen
How is ovarian cancer managed?
With MDT using combination of surgery and chemotherapy
What is the most common type of vulval cancer?
90% squamous cell carcinomas
What are the risk factors for vulval cancer?
Advanced age (>75)
Immunosuppresssion
HPV infection
Lichen sclerosus
What is VIN?
Vulval intraepithelial neoplasia: premalignant condition affecting squamous epithelium of the skin
What is high grade squamous intraepithelial lesion?
Type of VIN associated with HPV infection (typically in women 35-50)
What is differentiated VIN?
Type of VIN associated with lichen sclerosus (typically in women 50-60)
What are the treatment options for VIN?
Watch & wait
Wide local excision
Imiquimod
Laser ablation
How does vulval cancer present?
Vulval lump--> usually on labia majora (irregular, fungugating) Ulceration Bleeding Pain Itching Lymphadenopathy in groin
How is vulval cancer diagnosed?
2WW referral
Biopsy of lesion
Sentinel node biopsy
Imaging for staging
What are the management options for vulval cancer?
Wide local excision
Groin lymph node dissection
Chemotherapy
Radiotherapy
What two muscles is the pelvic floor made up of?
Levator ani
Coccygeus
What 3 muscles make up the levator ani?
Pubococcygeus
Ileococcygeus
Puborectallis
What two holes are in the pelvic floor?
Urogenital hiatus (passage of urethra) Rectal hiatus (passage of anal canal)
What is the pelvic outlet?
the inferior opening of the pelvis that is bounded by coccyx, the ischial tuberosities, and the pubis symphysis
What makes up the pelvic outlet?
Urogenital and anal triangles
What is the perineal body?
The fibrous node at the centre of the perineum that is the connecting point for many muscles
What is an episiotomy and why is it used in labour?
Horizontal cut, to avoid tearing of the perineal body
What is the function of the pelvic floor muscles?
Support abdominal and pelvic viscera
Resist intra-pelvic/ abdominal pressure
Urinary and faecal continence
What ligaments support the uterus?
Round ligament
Cardinal ligaments
Uterosacral ligament
Where do the round ligaments insert and therefore in what position does this keep the uterus?
Pass through the inguinal canal and insert on the labia majora, keeping uterus anteverted
What happens to the round ligaments during pregnancy?
They stretch and may cause pain. The uterus may be more floppy after birth
Where to the cardinal ligaments originate/ insert and therefore how to they support the uterus?
Arise from cervix and attach to lateral pelvic wall
Where do the uterosacral ligaments insert and therefore how do they support the uterus?
Attach cervix to the sacrum, supporting it posteriorly
What supports the inferior aspect of the uterus?
The pelvic floor: levator ani, perineal membrane and perineal body
What are the 3 categories of ligaments in the female reproductive tract?
Broad ligament
Uterine ligaments
Ovarian ligaments
What is the broad ligament?
A flat sheet of peritoneum that extends from the lateral pelvic walls to support all of the internal femal genitalia/
What are the 3 regions that make up the broad ligament?
Mesometrium
Mesovarium
Mesosalpinx
What is contained in the broad ligament?
The ovarian and uterine arteries
Ovarian ligament
Round ligament
Suspensory ovary ligament
What ligaments are associated with the ovary?
Ovarian ligament
Suspensory ligament of ovary
What is pelvic organ prolapse?
The descent of pelvic organs into the vagina
What causes prolapse?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
What are the different types of prolapse?
Uterine
Vault
Rectocele
Cystocele
What is a vault prolapse and in which patients does it occur?
When the top of the vagina (the vault) descends into the vagina. Only occurs in women that have had a hysterectomy
What is a rectocele?
When the rectum prolapses forward into the vagina
How may a rectocele present?
Constipation due to faecal loading. (may have to press to open bowels)
Urinary retention
Palpable lump in vagina
Where is the defect in a rectocele?
The posterior vaginal wall
What is a cystocele?
When the bladder prolapses backwards into the vagina
Where is the defect in a cystocele?
Anterior vaginal wall
What is a cystourethrocele?
Prolapse of both the bladder and urethra
What are the risk factors for pelvic organ prolapse?
Multiple vaginal deliveries Instrumental delivery Prolonged or traumatic delivery Obesity Advanced age/ postmenopausal COPD (chronic coughing) Chronic constipation Smoking Tissue disorders Hysterectomy
Why does chronic straining (e.g. COPD, constipation) increase the risk of prolapse?
Increases intra-abdominal pressure
How does prolapse usually present?
Dragging/ heavy sensation Urinary symptoms Bowel symptoms Sexual dysfunction Palpable lump/ mass
What are the urinary symptoms that should be taken in a history?
Incontinence (stress or urge) Urgency Frequency Weak stream Retention Dysuria Nocturia
What bowel symptoms should be taken in a history?
Constipation
Incontinence
Urgency
How do you examine a prolapse?
Abdominal exam to look for masses
Sim’s speculum to examine vaginal walls (may need to lie left lateral)
Pelvic USS to look for mass
What are the different grades of uterine prolapse?
Grade 1= Uterus in upper part of vagina
Grade 2= Uterus descended to opening of vagina
Grade 3= Uterus protudes out vagina
Grade 4= Uterus completely out the vagina
What are the 3 management options for pelvic organ prolapse?
- Conservative
- Vaginal pessary
- Surgery
What is the conservative management for prolapse?
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes
Vaginal oestrogen cream (reduce dryness and irritation)
What lifestyle changes are recommended for prolapse?
Weight loss
Reduced caffeine & alcohol intake
Reduce heavy lifting
Incontinence pads
What are the different types of pessaries that can be used?
Ring Shelf Gellhorn Cube Donut Hodge
How often should pessaries be changed?
Every 4 months
What management is no longer recommended to treat prolapse?
Mesh repairs as they have a lot of complications and don’t have good evidence as to effectiveness.
What are the two types of urinary incontinence?
Urge incontinence
Stress incontinence
What is urge incontinence?
Overactivity of the detrusor muscle of the bladder
How does urge incontinence present?
Sudden urge to pass urine
Rush to the bathroom
Leaking before reaching bathroom
What is stress incontinence?
When increased pressure on the bladder overcomes the pelvic floor and sphincter muscles
How does stress incontinence usually present?
Urinary leakage when laughing, coughing, lifting or surprised
What is mixed incontinence?
Combination of urge and stress incontinence
What is overflow incontinence?
When chronic urinary retention (due to an obstruction) results in an overflow of urine without the urge to pass urine/
What can cause overflow incontinence?
Anticholinergics
Fibroids
Pelvic tumours
Neurological conditions (MS, Diabetic neuropathy, spinal cord injuries)
What are the risk factors for urinary incontinence?
Increased age Previous pregnancies and vaginal deliveries Increased BMI Postmenopausal Pelvic organ prolapse Pelvic floor surgery Neurological conditions Cognitive impairment/ dementia
What modifiable risk factors can contribute to incontinence?
Caffeine consumption
Alcohol consumption
Medications
BMI
What should be assessed on examination of incontinence?
Pelvic tone Prolapse Atrophic vaginitis Urethral diverticulum Pelvic masses Ask patient to cough to look for leakage from urethra
What is urethral diverticulum?
Where an outpouching forms next to the urethra which can get filled with urine during urination.
How is the strength of the pelvic muscles assessed?
Using bimanual examination and asking woman to squeeze against fingers
How is pelvic muscle tone graded?
Oxford grading system: 0= no contraction 1= faint contraction 2= weak 3= moderate with some resistance 4= good contraction 5= strong contraction
How is incontinence investigated?
Take thorough history Bladder diary (>3 days) Urine dipstick for infection Bladder scan Urodynamic testing
Why is a bladder scan done in incontinence investigations?
To measure the post- void residual bladder volume to assess for incomplete emptying
What is urodynamic testing?
Range of tests to assess presence and severity of urinary symptoms
What happens in urodynamic testing?
Catheters are inserted into bladder and rectum to measure and compare the pressures. The bladder is filled with liquid and measures are taken
What measures are taken in urodynamic testing?
Cystometry (detrusor muscle contraction/ pressure) Uroflowmetry (flow rate) Leak point pressure Post-void residual bladder volume Video urodynamic testing
What is the leak point pressure?
The point at which the bladder pressure results in leakage of urine
What is the management of stress incontinence?
Lifestyle modification
Pelvic floor excercises
Surgery
Duloxetine
What is the lifestyle management of stress incontinence?
Avoid caffiene, diuretics and overfilling the bladder
Avoid excessive or restricted fluid intake
Weight loss
What is duloxetine and what is its action?
SNRI antridepressant that increases activity of nerve that stimulated urethral sphincter, improving its function
What are the surgical options to treat stress incontinence?
Tension-free vaginal tape
Autologous sling
Colposuspension
Intramural urethral bulking
How long should ladies with stress incontinence try pelvic floor exercises before surgery is advised?
At least 3 months
What is the management of urge incontinence?
Bladder retraining
Anticholinergics
Mirabegron
Invasive procedures
What is the first line treatment for urge incontinence and what does it involve?
Bladder retraining: Gradually increasing time between voiding
What are the side effects of anticholinergic medications?
Dry mouth & eyes Urinary retention Constipation Postural hypotension Cognitive decline Memory problems Worsening of dementia
What is the most common anticholinergic used and what is its action?
Oxybutynin
Block the action of acetylcholine which reduces abnormal bladder contractions/
What is Mirabegron and why would it be used instead of an anticholinergic?
Beta-3 agonist, similar to an antimuscarinic
Less of an anticholinergic burden
When is Mirabegron contraindicated?
In uncontrolled hypertension as it increases blood pressure by stimulating sympathetic nervous system
What are the invasive third line options for treating overactive bladder?
Botulinium toxin (botox) injection
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
What is amenorrhoea?
Lack of menstrual periods
What is primary amenorrhoea?
When the patient has never started periods
What are the causes of primary amenorrhoea?
Abnormal functioning of the hypothalamus or pituitary Abnormal functioning of gonads Structural pathology (imperforate hymen= when the hymen covers opening of the vagina)
What is secondary amenorrhoea?
When the patient has previously had periods that have now stopped (for >6months)
What are some causes of secondary amenorrhoea?
Pregnancy Menopause Physiological stress (excessive excercise, low BMI, chronic disease, psychosocial factors) PCOS Contraceptives Premature ovarian insufficiency Thyroid abnormalities Prolactinoma Cushing's syndrome
What are the different types of abnormal uterine bleeding?
Menorrhagia Amenorrhea Oligomenorrhoea Post-menopausal bleeding Post-coital bleeding Dysmenorrhea Dysfunctional uterine bleeding
What are the differential presentations in gynaecology?
Amenorrheoa Irregular menstruation Intermenstrual bleeding Dysmenorrhoea Menorrhagia Postcoital bleeding Pelvic pain Vaginal discharge Pruritus vulvae
What is oligomenorrhea?
Infrequent menstrual bleeding
What does irregular uterine bleeding indicate?
Annovulation of irregular ovulation
What are the causes of irregular menstruation?
Extremes of reproductive age PCOS Physiological stress Medications Hormonal imbalances
What are the key causes of intermenstrual bleeding?
Hormonal contraception Cervical ectropion Polpys *Cervical, endometrial or vaginal cancer STI's Pregnancy Ovulation Medications
What is dysmenorrhoea?
Particularly painful periods
What are the causes of dysmenorrhoea?
Primary (no underlying pathology) Endometriosis/ adenomyosis Fibroids PID Copper coil Cervical/ ovarian cancer
What is menorrhagia?
Heavy menstrual bleeding
What are the causes of menorrhagia?
Dysfunctional uterine bleeding Extremes of reproductive age Fibroids Endometriosis/ adenomysosis PID Contraceptives (copper coil) Anticoagulants Bleeding disorders Endocrine disorders Connective tissue disorders Endometrial hyperplasia Cancer (PCOS)
What is Dysfunctional uterine bleeding?
Bleeding with no identifiable cause
What are the key causes of postcoital bleeding?
Idiopathic Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
What are some causes of pelvic pain?
UTI Dysmenorrheoa IBS Ovarian cysts Endometriosis PID Ectopic pregnancy Appendicitis Mittelshcmerz Pelvic adhesions Ovarian torsion IBD
What may abnormal discharge indicate?
Bacterial vaginosis Cadidiasis STI's Cervical ectropion Polyps Malignancy pregnancy Contraception
What is pruritis vulvae?
Itching of the vulva and vagina
What are the causes of pruritis vulvae?
Irritants (e.g. soap ) Atrophic vaginitis Infections Skin conditions Malignancy Stress
At what age is primary amenorrhoea defined?
13 with no other evidence of pubertal development
15 with other signs of puberty
When does puberty normally start in girls?
8-14
When does puberty normally start in boys?
9-15
What are the causes of primary amenorrhoea?
Hypogonadism (Hypogonadotropic hypogonadism or Hypergonadotropic hypogonadism) Kallman syndrome Congenital adrenal hyperplasia Androgen insensitivity syndrome Structural pathology
What is hypogonadism?
Lack of oestrogen and testosterone
What is hypogonadotropic hypogonadism?
Deficiency of LH and FSH leading to oestrogen deficiency
What are the potential causes of hypogonadotropic hypogonadism?
Hypopituitarism Hypothalamus or pituitary damage Chronic conditions Excessive exercise/ dieting Constitutional delay in growth and development Endocrine disorders Kallman syndrome
What is Hypergonadotropic hypogonadism?
When the gonads fail to respond to the stimulation from gonadotrophins
What are the gonadotropin hormoness?
LH & FSH
What are the causes of Hypergonadotropic hypogonadism?
Damage to gonads (torsion, cancer, infection)
Congenital absence of ovaries
Turner’s syndrome
What is Kallman syndrome?
Genetic condition that causes hypogonadotrophic hypogonadism, with failure to start puberty
What is congenital adrenal hyperplasia?
A congenital condition causing the underproduction of cortisone and aldosterone and the overproduction of androgens from birth.
What is androgen insensitivity syndrome?
Condition where tissues are unable to respond androgen hormones (testosterone) so male characteristics do not develo, resulting in a female phenotype with male internal pelvic organs.
What is the aims of assessment of primary amenorrhoea?
Look for evidence of puberty and assess for possible underlying causes
What are the conditions for investigating primary amenorrhoea?
No evidence of pubertal changes at 13 or some evidence of puberty with no progression after 2 years
What are the initial steps in the assessment of primary amenorrhoea?
Detailed history
Examine height, weight, stage of development and features of underlying conditions
What are the initial investigations into primary amenorrhoea?
Assess for underlying conditions
Hormonal blood tests
Genetic testing
Imaging
What investigations would be done to look for underlying conditions in primary amenorrhoea?
- FBC/ ferritin (anaemia)
- U&E’s (kidney disease)
- Anti-TTG, anti- EMA
What investigations would be done to look for hormonal abnormalities in primary amenorrhoea?
FSH/ LH Thyroid function Insulin-like growth factor 1 (GH deficiency) Prolactin Testosterone
What imaging can be done to look into primary amenorrhoea?
Wrist X-ray to assess bone age
Pelvic ultrasound
MRI brain (pituitary pathology)
How is primary amenorrhoea?
Treat cause:
- Hormone replacement
- Reassurance and observation
- Weight gain/ stress reduction
- Manage chronic/ endocrine condition
- Pulsatile GnRH
- COCP
What is the definition of secondary amenorrhea?
No menstruation for >3months after previously regular periods
OR >6 months after previous irregular periods
What are the main causes of secondary amenorrhea?
Pregnancy Menopause Hormonal contraception Hypothalamic/ pituitary/ thyroid/ uterine pathology PCOS Hyperprolactinaemia Physiological/ psychological stress
Why does physiological/ psychological stress cause amenorrhoea?
In circumstances where the body may not be fit for pregnancy, the hypothalamus reduces the production of GnRH, leading to hypogonadotropic hypogonadism.
What is the main cause of hyperprolactinaemia and why does it cause amenorrhoea?
Pituitary adenoma secreting prolactin.
High prolactin levels have negative feedback on the hypothalamus, reducing its release of GnRH/
How is secondary amenorrhoea investigated?
History+ examination
Hormonal blood tests
USS pelvis (PCOS)
What hormonal blood tests are done to look into secondary amenorrhoea?
HcG to rule out pregnancy LH/ FSH Prolactin TSH, T3/T4 Testostrone
How is secondary amenorrhoea managed?
Treat cause (may need replacement hormones)
What are patients with amenorrhoea associated with low oestrogen levels at risk of?
Osteoporosis
What is PMS and at what stage of the menstrual cycle does it occur?
Pre-menstrual syndrome
Luteal phase
What are management options for severe PMS?
Lifestyle changes COCP SSRI antidepressants CBT Oestrogen patches GnRH analogues Hysterectomy
How much blood to women typically lose per menstural period?
40ml
How many ml of blood is counted as menorrhagia?
> 80ml
In practice: changing pads 1-2 hours, bleeding >7days, passing large clots
What investigations are performed first line in menorrhagia?
Speculum and bimanual examination
FBC (Anaemia)
What would you be looking for with a speculum examination in menorrhagia?
Fibroids
Ascites
Cancer
When would an outpatient hysteroscopy be arranged for menorrhagia?
Suspected submucosal fibroids
Suspected endometrial hyperplasia/ cancer
Persistent intermenstrual bleeding
When would a pelvic/ transvaginal USS be arranged for menorrhagia?
Possible large fibroids
Possible adenomyosis
Examination difficult to interpret (obesity)
Hysteroscopy declined
What additional tests can be done into menorrhagia after examination?
Hysteroscopy USS Swabs Coagulation screen Ferritin Thyroid function tests
How is menorrhagia managed?
Manage underlying pathology
- Mirena coil
- COPC
- Cyclical oral progesterones
- If contraception not acceptable: TXA
- If all else fails: Endometrial ablation/ hysterectomy
What is TXA and how does it work?
Transexamic acid: antifibronlytic that reduces bleeding
What are fibroids?
Benign tumours of the smooth muscle of the uterus
What percentage of older women have fibroids?
40-60%
What reaction to fibroids have to oestrogen?
Oestrogen-sensitive so grow in response
What are the 4 types of fibroid?
Intramural
Subserosal
Submucosal
Pedunculated
Where are intramural fibroids located?
Within the myometrium
Where are subserosal fibroids located?
Just below the outer layer of the uterus, filling the abdominal cavity
Where are submucosal fibroids located?
Just below the endometrium
What are pedunculated fibroids?
Those on a stalk, often invading the uterine space
How might fibroids present?
Asymptomatic Menorrhagia Prolonged menstruation Abdominal pain (wores on menstruation) Bloating/ fullness in abdomen Urinary/ bowl symptoms due to pressure Deep dyspareunia Reduced dertility
What may abdominal/ bimanual examination reveal with suspected fibroids?
Palpable mass or enlarged firm uterus
Why may fibroids cause heavy/ prolonged menstrual bleeding?
May put pressure against endometrium
May prevent uterus from contracting properly to stop bleeding
May stimulate growth of blood vessels
May increase surface area of endometrium leading to more tissue loss
What investigations are done to confirm fibroids?
Hysteroscopy
Pelvic USS
MRI scanning
What is the medical management for fibroids <3cm?
- Mirena coil
- NSAIDS/ TXA
- COCP
- Cyclical oral progesterones
What are the surgical options for smaller fibroids?
Endometrial ablation
Resection
Hysterectomy
What are the medical management options for fibroids >3cm?
Symptomatic management (NSAIDS/ TXA)
Mirena coil
COCP
Cyclical oral progesterones
What are the surgical options for fibroids >3cm?
Uterine artery embolisation
Myomectomy
Hysterectomy
What is myomectomy?
Surgical removal of fibroids
What might be used to reduce the size of fibroids before surgery?
GnRH agonists (Zoladex, Prostap) to reduce the amount of oestrogen maintaining the fibroid
What is uterine artery embolisation?
When a catheter is inserted into the femoral artery and X-ray guided to the fibroid where particles are injected to block the arterial supply to the fibroid
What is laparoscopic vs laparotomy surgery?
Laparoscopic= key-hole Laparotomy= surgical incision
What are the complications of fibroids?
Heavy menstrual bleeding Reduced fertility Pregnancy complications Constipation UTI/ Urinary outflow obsrtuction Red degeneration Torsion
What is red degeneration of fibroids?
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply (usually during pregnancy), presenting with severe abdominal pain, fever, tachycardia and vomiting.
What is the treatment for red degeneration?
Supportive with rest, fluids and analgesia.
What is endometriosis?
When endometrial tissue grows outside the uterus
What is adenomyosis?
Endometrial tissue within the myometrium
What are the main symptoms of endometriosis?
Cyclical pelvic pain Deep dyspareunia Dysmenorrhoea Infertility Cyclic bleeding in stool/ urine
What is deep dyspareunia?
Pain on deep sexual intercourse
Why is pelvic pain the main symptom of endometriosis?
During menstruation, the ectopic endomatrial tissue also sheds its lining and bleeds, causing irritation and inflammation of the tissues
What complication can localised bleeding and inflammation lead to in endometriosis?
Adhesions (scar tissue that binds organs together).
Can cause chronic, non-cyclic pain
What may examination reveal in endometriosis?
Visible endometrial tissue in the vagina on speculum examination
Fixed cervix
Tenderness in vagina, cervix or adnexa
How is endometriosis diagnosed?
Pelvic USS
Laparoscopic surgery with biopsy of lesions
What is the initial management of endometriosis?
Establish diagnosis with clear explanation
Analgesia for pain (NSAIDs/ paracetamol
What management options can be tried before definitie laparoscopic diagnosis of endometriosis?
COPC POP Medroxyprogesterone acetate injection Implant Mirena GnRH agonist
What are the surgical management options of endometriosis?
Laparoscopic surgery to excise/ ablate tissue and adhesions
Hysterectomy
What is used to treat cyclical pain in endometriosis and why?
- Hormonal contraceptives to stop ovulation and reduce endometrial thickening/
- Induce menopause-like state with GnRH agonists.
In which women is adenomyosis more common?
Older women
Multiparous women
How does adenomyosis present?
Dysmenorrhoea (painful periods)
Menorrhagia (heavy periods)
Dyspareunia (painful intercourse
How is adenomyosis diagnosed?
Examination (enlarged, tender uterus)
TVUS = 1st line
MRI/ abdominal USS
Histological examination after hysterectomy= gold standard
How is adenomyosis managed?
- Same as for heavy menstrual bleeding:
1. Contraception
2. TXA/ Mefenamic acid
What are the complications of adenomyosis associated with pregnancy?
Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage
What is cervical ectropion?
When the columnar epithelium of the endocervix extends out to the ectocervix and is visible
How does cervical ectropion usually present and why?
With postcoital bleeding as the endocervical cells are more fragile and prone to trauma.
What are the risk factors for cervical ectropion?
Higher oestrogen levels:
- Younger women
- COCP use
- Pregnancy
What is the transformation zone?
The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
How else might cervical ectropion present?
Increased discharge
Bleeding
Dyspareunia
When would ectropion be treated and how?
If there is problematic bleeding, it can be cauterised with silver nitrate or cold coagulation during colposcopy.
What is classified as the menopause?
When a woman has had no periods for 12 months
What is the average age of menopause?
51
What is perimenopause?
The time around the menopause, where the woman may be experiencing symptoms and irregular periods
What time period is the perimenopause?
The time leading up to the last period and the 12 months afterwards
What is classified as premature menopause?
Menopause before age 40.
What causes menopause?
Lack of ovarian follicular function, resulting in low oestrogen & progesterone and high LH and FSH
What are the symptoms of perimenopause?
Hot flushes Emotional instability/ low mood Premenstrual syndrome Irregular periods/ change in quantity Joint pains Vaginal dryness/ atrophy Reduced libido
What are the risks of the lack of oestrogen caused by menopause?
Cardiovascular disease
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
What blood test can be used to help diagnose menopause and when would it be necessary?
FSH blood test:
Women <40 with suspected premature menopause
Women 40-45 with symptoms or change in cycle
How long should women continue to use contraception after their last menstrual period?
2 years if <50
1 year if >50
What are vasomotor symptoms?
Those that occur due to the constriction/ dilation of blood vessels (e.g. hot flushes, night sweats, palpitations, BP changes)
How long to perimenopausal vasomotor symptoms usually last?
2-5 years
What are the treatment options for symptomatic menopause?
None HRT Tibolone Clonidine CBT SSRI's Testosterone Vaginal oestrogen Vaginal mousturisers
What is the cause of premature menopause?
Premature ovarian insufficiency
What causes Premature ovarian insufficiency?
Hypergonadotropic hypogonadism:
- Idiopathic
- Latrogenic
- Autoimmune
- Genetic
- Infections
How is Premature ovarian insufficiency diagnosed?
Women <40 presenting with typical menopausal symptoms and elevated FSH on two consecutive occasions
How is premature ovarian insufficiency managed?
Hormone replacement therapy until at least normal menopausal age, to reduce risks of osteoporosis, cardiovascular risks etc.
What are the two options of HRT for women with premature ovarian insufficiency?
Traditional HRT
COCP
What is HRT?
Hormone replacement therapy- giving exogenous oestrogen to alliviate menopausal symptoms
In what women should progesterone be given along with oestrogen and why?
Those with a uterus to prevent endometrial hyperplasia and cancer
What can unopposed oestrogen do to the endometrium?
cause endometrial hyperplasia, increasing the risk of cancer
What HRT therapy would women without a uterus be given?
Oestrogen only
What HRT therapy would women that still have periods be given?
Cyclical HRT with cyclical progesterone and breakthrough bleeds
What HRT therapy would women with a uterus and >12 months without periods be given?
Continuous combined HRT
What are the non-hormonal treatment options for menopausal symptoms?
Lifestyle changes CBT Clonidine SSRI's Venlafaxine Gabapentin
What lifestyle changes may improve menopausal symptoms?
Diet, exercise, weight loss, stop smoking, reduce alcohol, reduce caffeine, reduce stress
What is Clonidine?
Agonist of alpha-adrenergic and imidazoline receptors in the brain.
What is the action of Clonidine?
Lowers blood pressure and heart rate, and can reduce hot flushes and other vasomotor symptoms
What are some common side effects of Clonidine?
Dry mouth
Headaches
Dizziness
Fatigue
What are the indications for HRT?
- Replacing hormones in premature ovarian insufficiency
- Reducing vasomotor symptoms
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
What are the risks of HRT?
Increased risk of:
- Breast cancer
- Endometrial cancer
- VTE
- Stroke
- Coronary artery disease
In which women do the risks of HRT not apply?
- Not increased risk compared to other women <50
- No risk of endometrial cancer in those without a uterus
- No risk of coronary artery disease with oestrogen-only HRT
What are the contraindications to HRT?
Undiagnosed abnormal bleeding Endometrial hyperplasia/ cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or MI Pregnancy
What is assessed before starting HRT?
Full Hx for contraindications FH for risk of cancer/ VTE BMI BP Screening is up to date
What are the 3 steps to consider when choosing HRT formulation?
Step 1: Are the symptoms local or systemic?
Step 2: Does she have a uterus?
Step 3: Have they had a period in the last 12 months?
What is given if the woman has local symptoms?
Topical treatments (e.g. topical oestrogen cream or tablets)
What are the two options for delivering systemic oestrogen?
Oral (tablet)
Transdermal (patches or gels)
What are the 3 options for delivering progesterone?
Oral
Transdermal
Intrauterine system (Mirena coil)
What are progestogens?
Any chemicals that target and stimulate progesterone receptors
What are progestins?
Synthetic progesterones
What are the 2 classes of progesterone used in HRT?
C19 and C21, can be sweitched if woman is having side effects
What is the best way of delivering oestrogen and why?
Via patches due to the decreased rrisk of VTE
What is the best way of delivering progesterone and why?
With and IUD
Has added benefits of contraception and treating HMP
Will not experience progestogenic side effects
What is tibolone?
A synthetic steroid that stimulates oestrogen and progesterone receptors, used as a form of continuous combined HRT.
After how long on HRT should there be a follow up and how long should women persist to allow it to work/ side effects to reside?
3 months
What are the oestrogenic side effects of HRT?
Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps
What are the progestogenic side effects of HRT?
Mood swings Bloating Fluid retention Weight gain Acne and greasy skin
What is PCOS?
Polycystic ovarian syndome
What are the characteristic features of PCOS?
Ovarian cysts Infertility Oligomenorrhea/ amenorrhoea Hyperandrogenism Insulin resistance
What is oligoovulation?
Irregular, infrequent ovulation
What is hirsutism?
The growth of thick, dark hair (often on the face)
What is the diagnostic criteria for PCOS?
2 out of 3:
- Oligoovulation/ Anovulation
- Hyperandrogenism
- Polycystic ovaries on USS
How would oligoovulation/ anovulation present?
Irregular or absent periods
What are the effects of hyperandrogenism?
Hirsutism and acne
What is the Rotterdam criteria?
The criteria for making a diagnosis of PCOS
How does PCOS usually present?
Infrequent/ absent menstruation Infertility Obesity Hirsutism Acne Hair growth in male pattern
What additional features may also be found in PCOS?
Insulin resistance/ diabetes Acanthosis nigricans Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia/ cancer Obstructive sleep apnoea Depression/ anxiety Sexual problems
What is acanthosis nigricans?
Thick, rough skin usually in the axilla and elbows that occurs with insulin resistance
What are other causes of hirsutism?
Medications
Ovarian/ adrenal tumours
Cushing’s syndrome
Congenital adrenal hyperplasia
What happens to insulin levels with insulin resistance?
The pancreas produces more in order to get a response
What effects does insulin have in PCOS?
- Promotes the release of androgens from the ovaries and adrenal glands
- Supresses SHBG production in the liver, therefore promoting hyperandrogenism
What is SHBG and what is its action?
Sex hormone-binding globulin/ Binds to androgens and suppresses their function.
What do higher levels of insulin result in?
Higher levels of androgens (e.g. testosterone)
Halting development of follicles in the ovaries
What does reduced follicle develop cause?
Annovulation
Multiple partially developed follicles (seen as polycystic ovaries on scan)
What investigations are done into PCOS?
Blood tests
Pelvic or transvaginal ultrasound
OGTT for diabetes
What blood tests are done to diagnose PCOS?
Testosterone SHBG (Sex hormone-binding globulin) LH FSH Prolactin TSH
What would hormonal blood tests typically show in PCOS?
Raised LH
Raised LH:FSH ratio
Raised testosterone
Raised insulin
What imaging is the gold standard for visualising the ovaries?
TVUS
What may be seen on USS of PCOS?
‘String of pearl’ appearance of follicles around the ovary
What is the diagnostic criteria for PCOS on USS?
- 12 or more developing follicles in one ovary
- Ovarian volume of >10cm^3
What are the key risks associates with PCOS?
Obesity
T2 Diabetes
Hypercholesterolaemia
Cardiovascular disease
How can the risks associated with PCOS be reduced?
Weight loss Low GI, calorie-controlled diet Exercise Smoking cessation Antihypertensives Statins
What is the main management of PCOS and why?
Weight loss- alone can restore fertility and regular menstrution, improve insulin resistance and reduce other symptoms
What medication can be used to help weight loss in women with BMI over 30?
Orlistat (lipase inhibitor that stops absorption of fat in intestines)
What cancer are women with PCOS more at risk of and why?
Endometrial cancer: -Amenorrhoea means they don't produce sufficient progesterone, resulting in endometrial hyperplasia Also have other RF's= -Obesity -Diabetes -Insulin resistance
At what endometrial thickness would women need to be referred for a biopsy to exclude endometrial hyperplasia/ cancer?
> 10mm
What are the options for reducing the risk of endomtrial cancer in women with PCOS?
- Mirena coil (continuous protection)
- Inducing a withdrawal bleed every 3-4 months with cyclical progesterones of COPC
How can infertility be managed in PCOS?
Weight loss
Clomifene
Laparoscopic ovarian drilling
IVF
What is the action of Clomifene?
Stimulates the release of gonadotropins, leading to the development of follicles and initiating ovulation
How is hirsutism managed in PCOS?
Weight loss
COPC: Co-cyprindiol= has anti-androgenic effect
Topical eflornithine
What is the risk of co-cyprindol and therefore how long should it be used for?
Increased risk of VTE so is stopped after 3 months
How is acne managed in PCOS?
COPC
Topical, retinoids, antibiotics or azelaic acid
What are functional ovarian cysts?
Fluid-filled sacs that relate to the fluctuating hormones of the menstrual cycle
In which women are ovarian cysts more a cause for concern?
Postmenopausal women
How are ovarian cysts usually diagnosed?
Found incidentally on pelvic USS
How may ovarian cysts presents?
- Usually asymptomatic
- Pelvic pain
- Bloating/ fullness
- Palpable mass
- May have acute pelvic pain if there is a complications
What are the two types of functional cysts?
Follicular cycsts
Corpus luteum cysts
What are follicular cysts?
When the developing follicle fails to rupture and release the egg, a cyst can persist
What is the most common ovarian cyst?
Follicular cyst
What are corpus luteum cysts?
Cysts that occur when the corpus luterum fails to break down and instead fills with fluid
What are other types of ovarian cyst?
Serous cystadenoma Mucinous cystadenoma Endometrioma Dermoid cyst/ germ cell tyous Sex cord-stromal tumours
What investigations are done into ovarian cysts?
USS
CA125 tumour marker
What is the management of a <5cm simple cyst in premenopausal women?
No action required- will resolve in 3 cycles
What is the management of a 5-7cm simple cyst in premenopausal women?
Routine referal to gynaecology and yearly USS monitoring
What is the management of a <7cm simple cyst in premenopausal women?
MRI scan or surgical evaluation
What is the management of cysts in postmenopausal women?
If there is raised CA125, 2WW referral to gynaecology
If simple <5cm, USS monitoring every 4-6 months
What is the management of persistent or enlarging cysts?
Laparoscopic surgical intervention (ovarian cystectomy with possible oophorectomy)
What are the main complications of ovarian cysts?
Torsion
Haemorrhage into cyst
Rupture
What is Meig’s syndrome?
Triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleural effusion
- Ascites
What is ovarian torsion?
When the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
What is the main causes of ovarian torsion?
- An ovarian mass >5cm (e.g. cyst or tumour)
- Before menarche when the infundibulopelvic ligaments are longer
What is the main presenting feature of ovarian torsion?
Sudden onset severe unilateral pelvic pain that gets progressively worse and is associated with nausea and vomiting
What would be found on examination of ovarian torsion?
Localised tenderness with possible palpable mass
How is ovarian torsion diagnosed?
Pelvic USS or TVUS
What is found on USS of ovarian torsion?
‘Whirlpool sign’
Free fluid in pelvis
Oedema of ovary
How is a definitive diagnosis of ovarian torsion made?
Laparoscopic surgery
What is the management of ovarian surgery?
Emergency laparoscopic surgery to either untwist it (detorsion) or remove it (oophorectomy)
What are the complications of ovarian torsion?
Ischaemia and necrosis to the ovary
If not removed, infection which can lead to an abscess and sepsis. If it ruptures it can result in peritonitis and adhesions.
What is Asherman’s syndrome?
Where adhesions form within the uterus and cause symptoms
When does Asherman’s syndrome usually occur?
After pregnancy-related dilation and curettage
What is D&C and when would it be performed?
Dilation and curettage: dilating cervix and scraping uterine lining to treat retained products of conception or after uterine surgery or infection
What is endometrial curettage and what are the complications?
Scraping the endometrium, which can damage the basal layer and cause adhesions
What may uterine adhesions cause?
May bind uterine walls together or seal the endocervix shut, leading to physical obstructions and distortion that can cause infertility, frequent miscarriages and menstrual abnormalities
What is the typical presentation of Asherman’s syndrome?
Presents following recent D&C, uterine surgery or endometritis with:
- Secondary amenorrhoea
- Lighter periods
- Dysmenorrhoea
- Infertiity
How is Asherman’s syndrome diagnosed?
Hysteroscopy =GS
Hysterosalpingography
Sonohysterography
MRU scan
How is Asherman’s syndrome managed?
Dissection of adhesions during hysteroscopy
What are Nabothian cysts?
Fluid-filled cysts on the surface of the cervix
Why do nabothian cysts develop?
When the squamous epithelium of the ectocervix covers the mucus-secreting columnar epithelium of the endocervix, the mucus becomes trapped and forms a cyst.
What us atrophic vaginitis?
Dryness and atrophy of the vaginal mucosa related to lack of oestrogen
In what women does atrophic vaginitis occur?
Women entering menopause
What happens to the epithelial lining of the vagina in response to oestrogen?
It becomes thicker, more elastic and produces secretions
What happens to the vaginal mucosa as oestrogen levels fall?
It becomes thinner, less elastic and more dry making it more prone to inflammation
How does atrophic vaginitis present?
Itching
Dryness
Dyspareunia
Bleeding caused by localised inflammation
What are the effects of reduced oestrogen on menopausal women?
atrophic vaginitis
Pelvic organ prolapse and stress incontinence due to lack of oestrogen maintaining connective tissue
Increased infections due to change in vaginal pH and microbial flora
What will examination of atrophic vaginitis show?
Pale mucosa Thin skin Reduced skin folds Erythema Inflammation Dryness Sparse pubic hair
How can atrophic vaginitis be managed?
Vaginal lubricants Topical oestrogen (cream, pessaries, tablets, ring)
What are Bartholin’s glands?
The pair of glands on either side of the vaginal opening
What is a Bartholin’s cyst?
When Bartholin’s gland gets blocked and the gland swells and becomes tender
What happends when a Bartholin’s cyst becomes infected?
It forms a Bartholin’s abscess (red, hot tender abscess draining pus)
How are Bartholin’s cysts managed?
Usually resolve with good hygeine, analgesia and warm compresses
How are Bartholin’s abscesses managed?
Antibiotics
May need surgical intervention
What is lichen sclerosus?
Chronic inflammatory skin condition that presents with patches of shiny white skin
Where is most affected by lichen sclerosus?
The labia, perineum and perianal skin
What causes lichen sclerosus?
Autoimmune condition
What is the typical presentation of lichen sclerosis?
Women aged 45-60
Vulval itching
Vulva skin changes
What is the Koebner phenomenon?
When the signs and symptoms are made worse by friction to the skin
What are other potential symptoms of lichen sclerosus?
Itching Soreness and pain Skin tightness Superficial dyspareunia Erosions Fissures
What is the appearance of lichen sclerosus?
'Porcelain-white' colour Shiny Tight Thin Slightly raised May be fissures, cracks, erosions and plaques
How is lichen sclerosus managed?
Topical steroids (Clobetasol propionate/ Dermovate) Emollients
What are the complications of lichen sclerosus?
5% risk of developing squamous cell carcinoma of vulva
Pain/ discomfort
Sexual dysfunction
Bleeding
What is FGM?
Female genital mutliation
Where is FGM most commonly practiced?
African countries (Somalia most common) , Ethiopia, sudan, Yemen, Kurdistan, Indonesia, Asia
What are the 4 types of FGM?
1: Removal or part/ all of clitoris
2: Removal or clitoris and labia minora and/or majora
3: Narrowing/ closing of vaginal orifice
4: all other unecessary procedures to the female genitalia
What risk factors should be looked out for to identify cases of FGM?
- Coming from community that practices FGM
- Having relatives affected by FGM
- Declining examintaion of cervical screening
What are the immediate complications of FGM?
Pain Bleeding Infection Swelling Urinary retention Urethral damage and incontinence
What are the long term complications of FGM?
Vaginal/ pelvic infections UTI's Dysmenorrhea Dyspareunia/ sexual dysfunction Infertility/ pregnancy complications Psychological issues/ depression
How is FGM managed?
- Mandatory reporting of all cases under 18 to the police (and social services, paeds, specialty FGM services, counselling)
- Educate about the legality and consequences
- In patients >18 use risk assessment tool as to whether to report.
- De-infibulation (corrects closure of vaginal orifice)
What are the main congenital structural abnormalities of the reproductive tract?
Bicornuate uterus
Imperforate hymen
Transverse vaginal septae
Vaginal hypoplasia and agenesis
In embryological development, where do the upper vagina, cervix, uterus and fallopian tubes develop from?
The paramesonephric (Mullerian) ducts
Why do males not develop a uterus?
Anti-Mullerian hormone
What is a bicornuate uterus?
When there are two horns to the uterus, giving it a heart shaped appearance
What are the potential complications of a bicronuate uterus?
Miscarriage
Premature birth
Malpresentation
What is imperforate hymen?
Where the hymen is fully formed without opening and covers the opening of the vagina
When will imperforate hymen be discovered?
When the female starts the menstruate and the menses are sealed in the vagina
What is the presentation of imperforate hymen?
Cyclical pelvic pain and cramping without vaginal bleeding
What is the diagnosis and treatment of imperforate hymen?
Diagnosis= clinical examination Treatment= surgical incision
What happens if imperforate hymen is not treated?
Retrograde menstruation which leads to endometriosis
What is transverse vaginal septae?
When there is a wall of tissue running horizontally across the vagina, either perforate or imperforate (sealed or with a hole)
How will perforate transverse vaginal septae present?
Difficulty with intercourse of tampon use
How will imperforate transverse vaginal septae present?
Cyclical pelvic symptoms without menstruation
How is transverse vaginal septae diagnosed?
Examination
USS
MRI
How is transverse vaginal septae treated?
Surgical correction
What is vaginal hypoplasia?
An abnormally small vagina
What is vaginal agenesis?
An absent vagina
What causes vaginal hypoplasia/ agenesis?
Failure of the Mullerian ducts to develop properly
What is androgen insensitivity syndrome?
Where cells are unable to respond to androgen hormones due to lack of androgen receptors
What causes androgen insensitivity syndrome?
X-linked recessive genetic condition
What happens to the excess androgens in androgen insensitivity syndrome?
They are converted into oestrogen
What is the genotype/ phenotype of patients with androgen insensitivity syndrome?
Genetically male (XY chromosome) with female external phenotype due to lack of androgens.
How does androgen insensitivity syndrome present?
Inguinal hernias in infancy
Primary amenorrhoea at puberty
What will be the results of hormone tests in androgen insensitivity syndrome?
Raised LH
Normal/ raised FSh
Normal/ raised testosterone
Raised oestrogen
How is androgen insensitivity syndrome managed?
MDT Bilateral orchidectomy to avoid testicular tumours Oestrogen therapy Vaginal dilators/ therapy Support/ counselling
How long should a couple try to conceive before investigating for infertility?
12 months
How many couple struggle to conceive naturally?
1 in 7
After how long of trying to conceive should investigation for infertility be initiated in women over 35 ?
6 months
What are the causes of infertility?
Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)
What general advice is given to couples trying to get pregnant?
- Take 400mcg folic acid dily
- Aim for healthy BMI
- Avoid smoking and excessive drinking
- Reduce stress
- Aim for intercourse every 2-3 days
- Avoid timing intercourse and it leads to increased stress
What are the initial infertility investigations performed in primary care?
BMU Chlamydia screen Semen analysis Female hormonal testing Rubella immunity
What does female hormone testing involve when investigating infertility?
- Serum LH/ FSH day 2-5
- Serum progesterone on day 21
- Anti-Mullerian hormone
- Thyroid function tests
- Prolactin
What do high FSH levels indicate?
That there is poor ovarian reserve so the pituitary gland is producing extra FSH to try to stimulate follicular development
What might high LH levels indicate?
PCOS
What does a low level of progesterone on day 21 indicate?
That ovulation has not occurred so there is no corpus luteum secreting it
What hormone is the most accurate marker of ovarian reserve and why?
Anti-Mullerian hormone: released by the granulosa cells in the follicles and falls as eggs are depleted
What other infertility investigations may be completed in secondary care?
USS pelvis for polycystic ovaries/ structural abnormalities
Hysterosalpingogram
Laparoscopy and dye test to look at patency of fallopian tubes/ endometriosis/ adhesions
What is Hysterosalpingogram?
X-ray looking at the shape of the uterus and patency of the fallopian tubes
What are the treatment options when anovulation is the cause of infertility?
Weight loss Clomifene (stimulates ovulation) Letrozole Gonadotropins Ovarian driling Metformin for insulin insensitivity/ obesity in PCOS
What is clomifene?
An anti-oestrogen given on days 2-6 of the menstrual cycle to stop the negative feedback of oestrogen on the hypothalamus, resulting in greater release of GnRH and therefore FSH and LH
What is ovarian drilling?
Laparoscopic surgery where multiple holes are drilling into the ovaries to improve the hormonal profile
What are management options when tubal factors are the cause of infertility?
Tubal cannulation
Laparoscopy to remove adhesions/ endometriosis
IVF
What management options are used when uterine factors are the cause of infertility?
Surgery to correct polyps, adhesions or structural abnormalities
How is male factor infertility assessed?
Semen analysis
What instructions should men be given when providing a sperm sample?
Abstain from ejaculation for at least 3 days Avoid hot baths/ tight underwear Attempt to catch full sample Deliver sample within one hour Keep sample warm
What lifestyle factors may affect the results of semen analysis & quality/ quantity of sperm?
Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine
When is a repeat sperm sample taken with borderline and abnormal results?
Borderline- after 3 months
Abnormal- 2-4 weeks
What things does semen analysis look for and what are the normal results?
Semen volume (>1.5ml) Semen pH (>7.2) Concentration of sperm (>15 million per ml) Total number of sperm (>39 million) Motility of sperm (>40% are mobile) Vitality of sperm (>58% are active Percentage of normal sperm (>4%)
What is polyspermia?
High number of sperm in a semen sample (>250 million per ml)
What is normospermia?
Normal characteristics of sperm in sample
What is oligospermia?
Reduced number of sperm in semen sample
How can oligospermia be classified?
Mild (10-15 million/ ml)
Moderate (5-10 million/ml)
Severe (<5 million/ ml)
What is cryptozoospermia?
Very few sperm in the semen sample (<1 million/ml)
What is azoospermia?
Abscence of sperm in the semen
What causes pre-testicular infertility?
Hypogonadotrophic hypogonadism causing low levels of testosterone needed for sperm production
What are the causes of Hypogonadotrophic hypogonadism in males?
- Pituitary/ hypothalamic pathology
- Suppression due to stress/ chronic conditions/ hyperprolactinaemia
- Kallman syndrome
What are the testicular causes of infertility?
Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer Genetic/ congenital disorders
What are post-testicular causes of infertility?
Obstruction caused by:
- Damage from trauma/ surgery/ cancer
- Ejaculatory duct obstruction
- Retrografe ejaculation
- Scarring from epididymitis (chlamydia)
- Abscence of vas deferens (Cystic fibrosis)
- Young’s syndrome
What initial investigations are done into male factor infertility?
Semen analysis History Examination Repeat sample USS testes
What further investigations may to considered to look into male factor infertility?
Hormonal analysis (FSH/LH/ Testosterone) Genetic testing Imaging Vasography Testicular biopsy
What are the management options for male factor infertility?
Surgical sperm retrieval Surgical correction Intra-uterine insemination Intracytoplasmic sperm injection Donor insemination
What is surgical sperm retrieval and when is it used?
When there is a blockage somewhere along the vas deferens preventing the sperm from being ejaculated, a needle and syringe is used to collect sperm directly from the epididymis
What is intra-uterine insemination?
Collecting and seperating out high-quality sperm and injecting them directly into the uterus
What is intracytoplasmic sperm injection?
Injecting sperm directly into the cytoplasm of an egg
When might intrauterine insemination (IUI) be used instead of IVF?
Donor sperm for same-sex couples
HIV (To avoid unprotected sex)
Practical issues with vaginal sex
What is the success rate of each cycle of IVF?
25-30%
What does one cycle of IVF involve?
Single episode of ovarian stimulation and collection of oocytes. May produce several embryos which can be transferred seperately in multiple attempts at pregnancy
What happens to embryos that are not used immediately?
They are frozen to be used at a later date
What are the steps involved in IVF?
Suppressing menstrual cycle Ovarian stimulation Oocyte collection Insemination/ Intracytoplasmic sperm injection Embryo culture Embryo transfer
What are the two methods of suppressing the natural menstrual cycle in IVF?
GnRH agonists
GnRH antagonists
What happens if a GnRH agonist is used?
An injection of GnRH agonist is given in the luteal phase (day 21) to stimulate the pituitary gland to secrete large amounts of FSH and LH, which causes negative feedback to supress the natural production of GnRH and stop the menstrual cycle
What happens for the GnRH antagonist protocol?
Daily subcutaneous injections of a GnRH antagonist are given starting from day 5-6 of ovarian stimulation to supress the body releasing LH and therefore supressing normal ovulation
Why is it necessary to supress the natural menstrual cycle in IVF?
If the gonadotropins weren’t supressed, ovulation would occur and follicles would be released before it is possible to collect them
What does ovarian stimulation involve?
Using medications to promote the development of multiple follicles in the ovaries:
- Sub-cut FSH injections from day 2-12
- Monitoring the development of follicles with TVUS
- Trigger injection: When there are enough follicles of adequate size, stop FSH and hCG injection given to stimulate final maturation of follicles.
How are oocytes collected?
Under sedation with the guidance of TVUS. Needle inserted through vaginal wall into each ovary to aspirate follicular fluid which contains the mature oocytes.
How are oocytes then inseminated?
Male produces semen sample and sperm and egg mixed in culture medium
Why do thousands of sperm need to be combined with each oocyte?
To produce enough enzymes for a sperm to penetrate the corona radiata and zona pellucide
What happens once the oocyte has been inseminated?
The fertilised eggs are left in an incubator for 2-5 and observed until the reach the blastocyst stage of development when the highest quality embryos are selected for transfer/
How are embryos transferred?
Catheter placed into the uterus. Single embryo is injected and the catheter is removed.
How long after egg collection is a pregnancy test performed?
Around day 16
What needs to be given from the time of oocyte collection until 8-10 weeks gestation and why?
Progesterone suppositories to mimic the progesterone that would be released from the corpus luteum in a normal pregnancy
What are the main complications of IVF?
Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome Pain/ bleeding/ infection during egg collection
What is OHSS?
Ovarian hyperstimulation syndrome
What triggers OHSS?
The hCG trigger injection given 36 hours before oocyte collection–> HCG stimulates the release of vascular endothelial growth factor (VEGF) which increases vascular permiability and causes the ovaries to swell
What are the risk factors for OHSS?
Younger age Low BMI Raised anti-Mullerian hormone Higher antral follicle count PCOS Raised oestrogen levels
How is OHSS prevented?
During gonadotropic stimulation, they are monitored with serum oestrogen levels and USS
How may OHSS present?
Abdominal pain/ bloating N&V Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from ruptured follicles Prothrombotic state
How is the severity of OHSS determined?
Based on clinical features:
Mild= abdo pain/ bloating
Moderate= N&V/ ascites
Severes= Ascites, oliguria, low albumin, high potassium
Critical= tense ascites, anuria, thromboembolism, acute respiratory distress
How is OHSS managed?
Supportive: Oral fluids Monitor urine output LMWH Ascitic fluid removal IV colloids
What are the key methods of contraception?
Natural family planning Barrier methods COPC POP Copper coil Mirena coil Implant Progesterone injection Surgery (sterilisation/ vasectomy Emergency contraception
What are the 4 levels used to assess the risk of different contraceptions in individuals?
UKMEC1= No restriction UKMEC2= Benefits outweigh risk UKMEC3= Risks outweigh benefits UKMEC4= Unacceptable risk
Which are the most reliable methods of contraception with typical use?
Surgery
Coils
Progesterone implant
What contraception should be avoided in women with breast cancer?
Hormonal contraception: use copper coil or barrier methods
What contraception should be avoided in women with cervical or endometrial cancer?
IUD
What contraception should be avoided in women with Wilson’s disease?
Copper coil
What specific risk factors would cause you to avoid the COCP?
Uncontrolled hypertension Migraine with aura History of VTE >35 and smoking >15 per day Major surgery with prolonged immobility Vascular disease/ stroke Ischaemic heart disease/ cardiomyopathy /atrial fibrillation Liver cirrhosis/ tumours SLE/ Antiphospholipid syndrome
How long after the last period should post menopausal be on contraception?
2 years if <50
1 year if >50
Why should the progesterone injection not be given to women over 50?
It increases the risk of osteoporosis
What are the different barrier methods of contraception?
Condoms
Diaphragms/ cervical caps
Dental dams
How effective are condoms?
98% with perfect use
82% with typical use
What should be avoided when using condoms?
Oil-based condoms as they can damage the latex
How should diaphragms be used?
Silicone cup fitted over cervix before having sex and left for at least 6 hours afterwards. Should be used with spermicide gel
What are dental dams used for?
During oral sex to provide a barrier between the mouth and vulva, vagina and anus to prevent infection
How effective is the COCP?
99% with perfect use
91% with typical use
How does the COCP prevent pregnancy?
- Prevents ovulation
- Progesterone thickens cervical mucus
- Progesterone inhibits proliferation of endometrium reducing risk of successful implantation
How does the COCP prevent ovulation?
Negative feedback effect on hypothalamus and anterior pituitary suppresses the release of GnRH, LH and FSH, preventing ovulation
What happens to the endometrium when taking the combined pill?
It is maintained in a stable state
What happens to the endometrium when the pill is stopped?
It breaks down and sheds, leading to a withdrawal bleed
What are the two types of COCP?
Monophasic pills
Multiphasic pills
What are monphasic pills?
Contain the same amount of hormone in each pill
What are multiphasic pills?
Contain varying amounts of hormone to match normal cyclical changes more closely
What is the first line COPC and why?
Microgynon (monophasic with 7 inactive pills)
Lower risk of VTE
What type of oestrogen and progesterone do the first line COCP’s contain?
Oestrogen= ethinylestradiol Progesterone= Levonorgestrel or norethisterone
What type of COCP’s are first line for PMS and why ?
Those containing drosipernone (e.g. Yasmin) as it has anti-mineralocorticoid and anti-androgen activity so can help with bloating, water retention and mood changes
What type of COCP’s are first line for acne and hirsutism and why?
Those containing cyproterone acetate (e.g. Dianette) as it has anti-androgen effects
What are the 3 most common regimes used when taking the COCP?
- 21 days on, 7 days off
- 63 days on (3 packs) and 7 days off
- Continuous use
What are the main side effects of taking the COCP?
- Unscheduled bleeding
- Breast pain/ tenderness
- Mood changes/ depression
- Headaches
- Hypertension
What are the main risks of taking the COCP?
- VTE
- Increased risk of breast/ cervical cancer
- MI/ stroke
What are the benefits of taking the COCP?
- Contraception
- Rapid return of fertility after stopping
- Improvement in PMS, menorrhagia, dysmenorrhoea
- Reduced risk of endometrial, ovarian and colon cancer
- Reduced risk of benign ovarian cysts
What are the contraindications to taking the COCP? (UKMEC 4)
- Uncontrolled hypertension
- Migraine with aura
- History of VTE
- > 35 smoking >15 cigarettes a day
- Major surgery with prolonged immobility
- Vascular disease/ stroke
- IHD/ Cardiomyopathy/ AF
- Liver cirrhosis/ Liver tumours
- SLE/ Antiphospholipid syndrome
What factor makes the risk of taking the COCP UKMEC3?
BMI > 35
At what stage in the cycle should the COCP be started and why?
Day 1 of cycle as this offers protection straight away
What should be used if the COCP is started after day 5 of the cycle?
Extra contraception for 7 days
What should happen if switching between COCPs?
Finish one pack then immediately start the new one without a pill free period
What should happen if switching from a POP to a COCP?
7 days of contraception used
What should be discussed when prescribing the COCP?
Different options including LARC Contraindications Adverse effects Instructions Factors that impact efficacy STI protection Safeguarding concerns
What contraindications should be screened for when prescribing the pill?
Age BMI BP Smoking status PMH (migraine, VTE, Cancer, Cardiovascular disease, SLE) FH (VTE, breast cancer)
What is classified as missing one pill?
More than 24 hours late (48 hours since last pill taken)
What should the woman do if one pill is missed?
- Take missed pill ASAP (even if that means 2 in one day)
- No extra protection required
What should the woman do if more than one pill is missed?
- Take most recent missed pill ASAP
- Additional contraception until have taken pill for 7 days straight
What should the woman do if she missed more than one pill during day 1-7 in the packet?
Need emergency contraception of had unprotected sex
What should the woman do if she missed more than one pill during day 8-14 in the packet?
If day 1-7 was fully compliant need no emergency contraception
What should the woman do if she missed more than one pill during day 15-21 in the packet?
No emergency contraception needed if days 1-14 were fully compliant but should go back-back with next pack of pills
In theory, in what cycle of pill usage will women be protected if taken perfectly?
7 days on, 7 days off
What can reduce the effectiveness of the pill?
Vomiting
Diarrhoea
Certain medications
When should the COCP be stopped?
4 weeks before a major operation or any procedure that requires the lower limb to be immobilised
Age 50
How is the POP taken?
Continuously
How effective is the POP?
99% with effective use
91% with perfect use
Des the COCP or POP have more contraindications/ risks?
POP has far fewer contraindications & risks
What are the 2 types of POP?
Traditional (e.g. Norgeston, Noriday)
Desogestrerl-only pill
When is considered a ‘missed pill’ when taking the traditional progesterone-only pill?
If it is >3 hours late
When is considered a missed pill when taking the desogestrel-only pill?
> 12 hours late
How does the traditional progesterone-only pill work?
Thickens cervical mucus
Alters endometrium to make implantation less successful
Reduces ciliary action in fallopian tubes
How does the Desogestrel pill work?
Inhibits ovulation
At what points in the cycle does starting the POP mean the woman is protected immediately?
Day 1-5
For how long is additional contraception required if the POP is started at other times in the cycle and why?
48 hours (takes 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus)
How long does it take for the POP vs the COCP to become effective and why?
POP- 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus
COCP- 7 days to inhibit ovulation
Can the POP/ COCP be taken even if there is a risk of pregnancy?
POP- Yes
COCP- Must rule out pregnancy first
What should happen when switching between POPs?
No extra protection required
What should happen when switching from a COCP to a POP?
Should aim to change on day 1-7 after finishing COCP pack with no extra protection required.
If switching immediately, need to use contraception for first 48 hours of POP
What are the main adverse effects of the POP?
Unscheduled bleeding
Breast tenderness
Headaches
Acne
After how long does unscheduled bleeding usually settle?
3 months (should investigate for other causes after this)
What changes to bleeding schedule may the POP have and how many women do these effect?
20% No bleeding
40% regular bleeding
40% irregular, prolonged or troublesome bleeding
What can the POP make you more at risk of?
Ovarian cysts
Ectopic pregnancy
Breast cancer
What should happen if a POP is missed?
Take the pill ASAP and continue the next pill at the usual time, with extra contraception for 48 hours
What is the Progesterone-only injection also known as?
Depot medroxyprogesterone acetate (DMPA)
How frequently is the progesterone-only injection given?
12-13 week intervals
How is the progesterone-only injection given?
IM or Sub-cut injection of medroxyprogesterone acetate
How effective is the progesterone-only injection?
99% with perfect use
94% with imperfect use (forgetting to book injection)
How long can it take for fertility to return after stopping injections?
Up to 12 months
What are the two versions of progesterone-only injection used in the UK?
Depo-Provera (IM) Sayana Press (self-injected sub cut)
What are the UKMEC 4 and UKMEC 3 contraindications to the progesterone-only injection?
UKMEC4: Active breast cancer UKMEC3: Ischaemic heart disease/ stroke Unexplained vaginal bleeding Severe liver cirrhosis Liver cancer
What is the main risk factor of the progesterone-only injection and therefore in which women should this be considered?
Osteoporosis
Older women and patients on steroids (for asthma/ inflammatory conditions)
What is the mechanism of action of the progesterone-only injection?
Inhibits ovulation by inhibiting FSH secretion by the pituitary gland
(Also thickens cervical mucus and alters the endometrium to make implantation less successful)
When should the progesterone-only injection be given to offer immediate protection?
Day 1-5
If the progesterone-only injection is given after day 5 of the menstrual cycle, how long should additional contraception be used?
7 days
What are the main sides effects of the progesterone-only injection?
Changes to bleeding schedule (may become highly irregular but usually stops altogether after 1 year) Weight gain Acne Reduced libido Mood changes Headaches Flushes Hair loss Skin reactions at injection site
What is the biggest risk of the progesterone-only injection and why?
Osteoporosis –> Oestrogen helps maintain bone mineral density in women so suppressing the development of the follicles reduces the amount of oestrogen produced
Which two side effects are unique to the progesterone-only injection?
Weight gain
Osteoporosis
What are the benefits of the progesterone-only injection?
Improves dysmenorrhoea
Improves endometriosis symptoms
Reduces risk of endometrial and ovarian cancer
Reduces the severity of sickle cell crisis
Where the the progestogen-only implant placed?
Upper arm, beneath skin and above subcutaneous fat
How long does the progestogen-only implant last before it needs replacing?
3 years
How effective is the progestogen-only implant ?
99%
What is the only contraindication for the progestogen-only implant?
Active breast cancer
What is the name of the implant used in the UK and what does it contain?
Nexplanon, contains 68mg of etonogestrel
How does the progestogen-only implant work?
Inhibits ovulation
Thickens cervical mucus
Makes endometrium less accepting of implantation
What point of the cycle does inserting the implant offer immediate protection and what should happen if its inserted after this?
Day 1-5= immediate protection
After this, need 7 days extra contraception
What are the benefits of the implant ?
Effective contraception Can improve dysmenorrhoea Can make periods lighter/ stop No need to remember to take pills Doesn't cause weight gain No effect on bone mineral density No increase in thrombosis risk
What are the drawbacks of the implant?
Requires minor operation which may have complications
Can worsen acne
No STI protection
May cause problematic bleeding
Can become impalpable or deeply implanted
What changes to bleeding pattern may occur with the implant and how many women does this effect?
1/3 infrequent bleeding
1/3 frequent or prolonged bleeding
1/5 no bleeding
What should be given to help ease problematic bleeding when using a progesterone-only form of contraception?
COCP for 3 months to help settle the bleeding
What is LARC?
Long-acting reversible contraception
What are the two types of IUD?
Copper coil
Levonorgestrel intrauterine system (LNG-IUS) - Mirena
How effective are coils?
99%
How soon after removal of coils does fertility return?
Immediately
What do IUD and IUS refer to?
IUD= Copper coil IUS= Mirena coil
What are the contraindications to coils?
PID/ Infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (fibroids)
What should be screened for before coil insertion?
Chlamydia
Gonorrhoea
What happens during coil insertion?
Bimanual examination to check size/ position of uterus
Speculum insertion to fit device
Forceps stabilise cervix while device is inserted
Record BP and HR during
How long after coil insertion should women be seen and why?
3-6 weeks to check the threads and ensure coil is in place
What are the risks associated with coil insertion?
Bleeding Pain on insertion Vasovagal reactions Uterine perforation PID Expulsion
What needs to happen before the coil can be removed?
Women need to abstain from sex/ use condoms for 7 days
What needs to be excluded when coil threads can’t be seen or palpated?
Expulsion
Pregnancy
Uterine perforation
What investigations would be carried out if coil threads can’t be seen/ palpated?
USS
Abdo/ pelvic xray
Hysteroscopy or laparoscopic surgery may be required
For how long can the copper coil be inserted?
5-10 years
When is the copper coil contraindicated?
Wilson’s disease
How does the copper coil work?
Copper is toxic to the ovum and sperm
Alters endometrium to make it less accepting of implantation
What are the benefits of the IUD?
Reliable contraception
Effective immediately at any time of cycle
Contains no hormones so no risk of VTE/ cancer
What are the drawbacks of the IUD?
Risks of procedure Can cause heavy/ intermenstrual bleeding May have pelvic pain No protection against STI's Increased risk of ectopic pregnancies 5% fall out
What are the 4 types of IUS?
Mirena
Levosert
Kyleena
Jaydess
How long can the mirena coil be inserted?
5 years (4 years as HRT)
For what reasons can the mirena coil be used?
Contraception
Menorrhagia
HRT
How does the mirena coil work?
Releases progesterone (levonorgestrel) into local area to thicken mucus, alter endometrium and inhibit ovulation in some women/
Up to what day of the menstrual cycle can the LNG-IUS be inserted without the need for additional contraception?
Day 7
What are the benefits of the LNG-IUS?
Can make periods lighter/ stop May improve dysmenorrhoea or pelvic pain No effect on bone mineral density No increase in thrombosis risk No restrictions for obese patients Has additional uses
What are the drawbacks of the LNG-IUS?
Risks of procedure Can cause spotting/ irregular bleeding May cause pelvic pain No protection against STI's Increased risk of ectopic pregnancies Increased risk of ovarian cysts Systemic absorption may cause side effects 5% fall out
How long does irregular bleeding usually go on for when the LNG-IUS is inserted?
Around 6 months
What may be found incidentally during a smear test in women with an IUD?
Actinomyces-like organisms (don’t require treatment)
What are the 3 options for emergency contraception?
Levonorgestrel
Ulipristal
Copper coil
What is UPSI?
Unprotected sexual intercourse
How long after intercourse should Levonorgestrel be taken?
Within 72 hours
How long after intercourse should Ulipristal be taken?
Within 120 hours
How long after intercourse can the coil be inserted as emergency contraception?
Within 5 days of UPSI or within 5 days of estimated date of ovulation
What is the most effective form of emergency contraception?
Copper coil
What can the two oral methods of contraception be affected by?
BMI
Enzyme-inducing drugs
Malabsorption
Why is the copper coil the most effective form of contraception?
It is toxic to the ovum and sperm, and inhibits implantation
What may copper coil insertion cause?
Pelvic inflammatory disease
For how long should the coil be kept in if used as emergency contraception?
Until at least the next period (though can be kept in as long-term contraception)
What is Levonorgestrel?
A type of progesterone (used in the IUS or as emergency contraception)
What dose of Levonorgestrel is used as emergency contraception?
1.5mg as single dose
3mg in women >70kg or BMI>26
What is the common side effects of taking Levonorgestrel as emergency contraception?
Nausea and vomiting (need to take another dose if vomit within 3 hours)
What is Ulipristal?
A selective progesterone receptor modulator used as emergency contraception
What is Ulipristal better known as?
EllaOne
What are the notable restrictions to taking Ulipristal?
Avoid breastfeeding for 1 week
Should be avoided in those with severe asthma
What is the female sterilisation procedure?
Tubal occlusion
What happens during tubal occlusion?
Clips are used to occlude the fallopian tubes using laparoscopy under general anaesthesia
What other options are there for female sterilisation?
Tube tying, cutting or removal
What is the male sterilisation procedure?
Vasectomy
What does a vasectomy involve?
Cutting the vas deferens, to prevent the sperm travelling from the testes to join the ejaculated fluid
What must happen after a vasectomy before it can be relied upon as contraception?
Semen testing 12 weeks after to confirm absence of semen
When can children under 16 make decisions about their own treatment?
When they are deemed to have Gillick competence
What is Gillick competence?
Judging whether the understanding/ intelligence of a child is sufficient to consent to treatment.
What are the Frazer guidelines?
Specific guidelines for providing contraception to patients under 16 without parental input/ consent
What criteria is included in the Frazer guideline?
- Mature/ intelligent enough to understand treatment
- Can’t be persuaded to discuss with parents
- Likely to have intercourse regardless
- Physical/ mental health will suffer without treatment
- It’s in their best interests
What is bacterial vaginosis?
(BV) Overgrowth of anaerobic bacteria in the vagina
What causes bacterial vaginosis?
Loss of lactobacilli (friendly bacteria) in the vagina
What is the main component of healthy vaginal bacterial flora?
Lactobacilli
What is the action of Lactobacilli?
Produce lactic acid that keeps the vaginal pH low (<4.5) and prevents other bacteria from overgrowing
Why does an absence of lactobacilli enable anaerobic bacteria to multiply in the vagina?
Lactobacilli produce lactic acid which creates an acidic environment, so when there are reduced numbers the pH rises and the alkaline environment enables anaerobic bacteria to multiply
What can BV increase the risk of in women?
Developing STI’s
What are some examples of anaerobic bacteria associated with BV?
Gardnerella vaginalis
Mycoplasma hominis
Prevotella
What are the main risk factors for developing bacterial vaginosis?
Multiple sexual partners Excessive vaginal cleaning Recent antibiotics Smoking Copper coil
Is BV sexually transmitted?
No
What factors can reduce your risk of BV?
COCP
Using condoms effectively
How does bacterial vaginosis present?
Fishy-smelling watery grey/ white discharge
How is BV investigated?
- Speculum examination to confirm typical discharge
- Vaginal pH test with swab and pH paper
- High vaginal swab to rule out other causes
What does BV look like on microsopy?
‘Clue cells’- Epithelial cells from the cervix that have bacteria stuck inside them
How is BV managed?
If asymptomatic needs no treatment, and may resolve itself. Metronidazole antibiotic (orally or by vaginal gel) Provide advice on how to avoid in future (e.g. cleaning)
What should be avoided when taking Metronidazole?
Alcohol (can cause N&V, flushing etc)
What are the potential complications of BV?
Increases risk of catching STI’s
Can cause pregnancy complications
What is vaginal candidiasis more commonly known as?
Thrush (or candida)
What is the most common cause of vaginal candidiasis?
Candida albicans (type of fungus/ yeast)
What happens after the candida colonises the vagina?
It may not cause symtoms until the right environment occurs
What changes to environment can cause candida to progress to infection?
During pregnancy
After treatment with broad-spectrum antibiotics
What are the risk factors for developing vaginal candidiasis?
Increased oestrogen (e.g. pregnancy)
Poorly controlled diabetes
Immunosuppression
Broad-spectrum antibiotics
What are the symptoms of vaginal candidiasis?
Thick, white discharge (no odour)
Vulval/ vaginal itching/ irritation/ discomfort
How is vaginal candidiasis investigated?
(Treatment often started based on presentation)
Test vaginal pH
Charcoal swab with microscopy can confirm dignosis
What are the treatment options for candidiasis?
Antifungals:
- Cream
- Pessary
- Oral tablets
What is the usual antifungal medication used to treat vaginal candidiasis?
Clotrimazole
What OTC treatment is often used to treat thrush?
Canesten Duo (contains fluconazole tablet and clotrimazole cream)
What should women be advised when using antifungal creams/ pessaries?
That they can damage latex condoms so should use alternative contraceptions for at least 5 days after use
What is the most common STI in the UK?
Chlamydia
What kind of organism is chlamydia trachomatis?
Gram-negative bacteria
How does chlamydia spread in the body?
It is an intracellular organism that enters and replicated in cells before rupturing and spreading to other cells
What are the risk factors for catching chlamydia?
Young
Sexually active
Having multiple partners
What percentage of chlamydia cases are asymptomatic?
50% in men
75% in women
What does the National Chlamydia Screening Programme aim for?
To screen every sexually active person <25 for chlamydia annually or when changing sexual partners
To re-test positive cases after 3 months
What is tested on an STI screen (as a minimum)?
Chlamydia
Gonorrhoea
Syphilis
HIV
What are the two types of swab used in sexual health testing?
Charcoal swabs
Nucleic acid amplification test (NAAT) swabs
What do charcoal swabs allow to be tested for?
Microscopy
Culture
Sensitivities
What type of swabbing can charcoal swabs be used for?
Endocervical swabs
High vaginal swabs
What conditions can charcoal swabs confirm?
BV
Candidasis
Gonorrhoeae
Trichomonas vaginalis
What does NAAT look for?
The DNA/ RNA of an organism
What conditions can NAAT confirm?
Chlamydia
Gonorrhoea
What type of swabbing can be done with NAAT swab?
Vulvovaginal swab
Endocervical swab
First-catch urine sample
(Rectal and pharyngeal)
If gonorrhoea is proven on a NAAT, what needs to happen?
An endocervical charcoal swab must be done to look for microscopy, culture and sensitivities
If chlamydia is symptomatic, how might it present in women?
Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding Painful sex Painful urination
If chlamydia is symptomatic, how might it present in men?
Urethral discharge/ discomfort
Painful urination
Epididymo-orchitis
Reactive arthritis
What should be considered if sexually active patients are presenting with anorectal symptoms (discomfort, discharge, bleeding, change in bowel habits)?
Rectal chlamydia or lymphogranuloma venereum
What may be found on examination of chlamydia?
Pelvic/ abdominal tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
How is chlamydia diagnosed?
NAAT:
Vulvovaginal/ endocervical/ urethral/ rectal/ pharyngeal swab or first-catch urine sample
What is the first-line treatment for uncomplicated chlamydia?
Doxycycline 100mg
Twice a day for 7 days
When would doxycycline be contraindicated as chlamydia treatment?
In pregnancy and breastfeeding
What should happen when someone is being treated for chlamydia?
- They should abstain from sex until treatment is complete
- They should be referred to GUM for contact tracing
What are the main complications of infection with chlamydia?
PID Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lyphogranuloma venereum Reactive arthritis
What are the pregnancy complications of chlamydia?
Preterm delivery PROM Low birth weight Postpartum endometritis Neonatal infection
What is lymphogranuloma venereum?
Condition that affects the lymphoid tissue around site of chlamydia infection
What are the 3 stages of lymphogranuloma venereum?
Primary= Painless ulcer Secondary= Lymphadenitis Tertiary= Inflammation of rectum and anus (may cause tenesmus)
What is tenesmus?
The feeling of needing to empty the bowels when they are empty
How is lymphogranuloma venereum treated?
21 days Doxycycline
What is chlamydial conjunctivitis?
Chlamydia infection of the conjunctiva of the eye (usually happens when genital fluid comes in contact with the eye)
What kind of organism is gonorrhoea?
Gram-negatie diplococcus bacteria
How does gonorrhoea cause infection?
Infects mucous membranes with a columnar epithelium (e.g. endocervix) and then spreads via contact with the mucous secretions from these infected areas
What is the concern with gonorrhoea treatment?
There is a high level of antibiotic resistance and the traditional things used to treat it can no longer be used
What percentage of presentations are symptomatic with gonorrhoea?
90% men
50% women
How may gonorrhoea present in women?
Odourless purulent discharge (may be green/ yellow)
Dysuria
Pelvic pain
How may gonorrhoea present in men?
Odourless purulent discharge (may be green/ yellow)
Dysuria
Testicular pain/ swelling
How is gonorrhoea diagnosed?
NAAT to detect the RNA or DNA
Charcoal swab for microscopy, culture and antibiotic sensitivities to guide antibiotic treatment
What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are not known?
Single dose of IM Ceftriaxone 1g
What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are known?
Single dose of oral Ciprofloxacin 500mg
After how long should patients treated for gonorrhoea have a test of cure?
72 hours after treatment for culture
7 days after treatment for RNA NAT
14 days after for DNA NAAT
What are the complications of gonorrhoea?
PID Chronic pelvic pain Infertility Epididymo-orchitis Prostatitis Conjunctivitis Urethral strictures Disseminated gonococcal nfection Skin lesions
What is a key complication of neonatal gonorrhoea passed down from the mother?
Ophthalmia neonatorum (gonococcal conjunctivitis)- medical emergency associated with sepsis and blindness
What is disseminated gonococcal infection?
Complication of untreated gonococcal infection where bacteria spreads to skin and joints
What is PID?
Pelvic inflammatory disease
What causes PID?
Infection spreading up through the cervix
What are the kay complications of PID?
Tubular infertility
Chronic pelvic pain
What are the 3 most common causes of PID?
Gonorrhoea
Chlamydia
Mycoplasma genitalium
What are non-sexually transmitted causes of PID?
Gardnerella vaginalis
Haemophilus influenzae
E. coli (UTI)
What are the risk factors for PID?
Same as any other STI:
- Not using barrier contraception
- Multiple partners
- Young age
- Existing STI’s
- Previous PID
- IUD
How may PID present?
Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding Dyspareunia Fever Dysuria
What may examination of PID reveal?
Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
How is PID investigated?
NAAT swabs for gonorrhoea, chlamydia and Mycoplasma genitalium
HIV test
Syphilis test
High vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
Microscopy to look for pus cells
Inflammatory markers
How is PID managed?
Refer to GUM for contact tracing
Empirial antibiotics started before confirmation, followed by necessary local antibiotic regime
What is a typical regime for the treatment of PID ?
- Single dose of IM ceftriaxone (for gonorrhoea)
- 14 Dyas Doxyccycline (for chlamydia/ mycoplasma genitalium)
- 14 days Metronidazole (for garnerella vaginalis)
What are the complications of PID?
Sepsis Abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz-Hugh-Curtis Syndrome
What is Fitz-Hugh-Curtis Syndrome?
Complication of PID that causes inflammation of the liver capsule, leading to adhesions between the liver and peritoneum.
What is Trichomonas vaginalis?
A type of parasite spread through sexual intercourse
What type of organism is trichomonas vaginalis?
Protozoan, single-celled organism with flagella (parasite)
Where does trichomonas live in infected men/ women?
Men= Urethra Women= Vagina
What can Trichomonas vaginalis increase the risk of?
Contracting HIV Bacterial vaginosis Cervical cancer PID Pregnancy-related complications
How does Trichomonas vaginalis present?
50 % asymptomatic 50% non specific syptoms: - Vaginal discharge -Itching -Dysuria -Dyspareunia -Balanitis
What is the typical description of discharge with Trichomonas vaginalis?
Frothy, yellow- green discharge with fishy smell
What may examination reveal with Trichomonas vaginalis?
‘Strawberry cervix’ (inflammation with tiny haemorrhages)
Raised vaginal pH
How can Trichomonas vaginalis be diagnosed?
Standard charcoal swab with microscopy
How is Trichomonas vaginalis managed?
GUM referral
Treat with Metronidazole
What is Mycoplasma genitalium?
STI that causes non-gonococcal urethritis
What is the key feature of Mycoplasma genitalium?
Urethritis
How does MG present?
Most are asymptomatic
May present similarly to chlamydia
How is MG diagnosed?
NAAT from first urine sample (men) or vaginal swab (women)
How is MG treated?
Doxycycline for 7 days followed by Azithromycin
What is HSV?
The herpes simplex virus
What is HSV most commonly responsible for?
Cold sores (herpes labialis) Genital herpes
What are the two most common strains of herpes?
HSV-1
HSV-2
What happens after initial infection with herpes?
The virus becomes latent in the associated sensory nerve ganglia
Which nerve ganglia does the herpes virus usually live in with cold sores?
Trigeminal nerve ganglion
Which nerve ganglia does the herpes virus usually live in with genital herpes?
Sacral nerve ganglia
What else can the HSV cause?
Apthous ulcers
Herpes keratitis
Herpetic whitlow
How is HSV spread?
Direct contact with affected mucous membranes or viral shedding in mucous secretions
When is asymptomatic viral shedding most common?
In the first 12 months of infection
What is HSV-1 most associated with?
Cold sores
When is HSV-1 usually contracted?
In childhood (before 5)
When does HSV-1 usually reactivate?
In times of stress
What is HSV-2 most associated with?
Genital herpes
What are the main symptoms of initial genital herpes infection?
May be asymptomatic Ulcers or lesions to the genitals Neuropathic pain Flu-like symptoms Dysuria Inguinal lymphadenopathy
How long do symptoms last with initial infection and do they get better or worse with recurrent infections?
3 weeks
Milder and more quickly resolved with recurrent infections
How is herpes diagnosed?
History to try to establish source of infection
Clinical diagnosis with history/ examination findings
May do viral PCR from lesion to confirm
How is herpes managed?
Aciclovir
Symptomatic management
What is the main complication of genital herpes during pregnancy?
Risk of neonatal herpes simplex infection contraction during labour or delivery
How is primary genital herpes contracted before 28 weeks gestation managed?
Aciclovir followed by prophylactic aciclovir starting from 36 weeks
(may need C-section is symptoms are present)
How is primary genital herpes contracted after 28 weeks gestation managed?
Aciclovir followed immediately by regular prophylactic aciclovir
C-section
How is recurrent genital herpes managed in pregnancy?
Consider prophylactic aciclovir from 36 weeks
What causes Syphilis?
Treponema pallidum bacteria
What is the incubation period between infection and symptoms with syphilis?
21 days
How can syphilis be contracted?
Through oral, vaginal or anal sex
Vertical transmission
IV drug use
Blood transfusions/ transplants
What are the 5 stages of syphilis?
Primary Secondary Latent Tertiary Neurosyphilis
What is primary syphilis?
A painless ulcer (chancre) at the original site of infection
What is secondary syphilis?
Systemic symptoms that resolve after 3-12 weeks
What is latent syphilis?
When symptoms disappear and the patient becomes asymptomatic despite being infected.
After how long does it become late latent syphilis instead of early latent syphilis?
After 2 years
What is tertiary syphilis?
When many years after initial infection, syphilis may affect many organs of the body
What is neurosyphilis?
When the infection involves the CNS and presents with neurological symptoms
How does primary syphilis present?
Painless genital ulcer that resolves in 3-8 weeks
Local lymphadenopathy
How does secondary syphilis present?
Maculopapular rash Condylomata lata (wart) Low-grade fever Lymphadenopathy Alopecia Oral lesions
How may tertiary syphilis present?
Gummatous lesions
Aortic aneurysms
Neurosyphilis
How may neurosyphilis present?
Headache Altered behavious Dementia Tabes dorsalis Ocular syphilis Paralysis Sensory impairment
What is the specific finding found in neurosyphilis?
Argyll-Robertson pupil: constricted pupil that accommodates when focusing on a near object but does not react to light
How is syphilis
diagnosed?
Antibodies for antibodies to T. pallidum
How is syphilis managed?
GUM
Single deep IM dose of penicillin
What comes first, HIV or AIDS?
AIDS= acquired immunodeficiency syndrome that comes as HIV progresses
What type of organism is HIV?
RNA retrovirus
What is the mechanism of HIV?
Enters and destroys CD4-T helper cells
How is HIV transmitted?
Unprotected sex
Vertical transmission
Exposure to infected blood or bodiliy fluids
What is the course of HIV?
Inital flu-like infection, then asymptomatic until progresses to immunodeficiency
What causes AIDS-defining illnesses?
When the CD4 count drops to a level that allows for opportunistic infections
What are some examples of AIDS- defining illnesses?
Kaposi's sarcoma PCP (pneumonia) Cytomegalovirus Candidiasis Lymphomas Tuberculosis
For up to how long after infection can HIV antibody tests remain negative and why?
Up to 3 months as it taes this long to develop antibodies to the virus
Who should be screened for HIV?
Practically everyone admitted to hospital and especially those with risk factors
How is HIV screened for?
Antibody blood test
How is HIV monitored?
CD4 count
What is the normal CD4 rage?
500-1200 cells
What range of CD4 cells indicated end-stage HIV?
<200 cells
How can you assess the HIV viral load?
PCR testing for HIV RNA
How is HIV treated?
ART
What is ART?
Antiretroviral therapy
What does ART involve?
Tailored treatment that aims to achieve normal CD4 count and undetectable viral load
What is HAART?
Highly active anti-retrovirus therapy medication
What are the medications used in HAART therapy?
Protease inhibitors
Integrase inhibitors
Nucleoside reverse transcriptase inhibitors
Non-nucleoside reverse transcriptase inhibitors
Entry inhibitors
What additional management should be used to treat those with HIV?
Prophylactic septrin to protect against PCP
Monitoring of cardiovascular health
Yearly cervical smears
Vaccinations
How can you prevent HIV transmission during birth if there is a high viral load?
C-section and IV zidovudine
Baby given Zidovudine for 4 weeks
Should mothers with HIV breastfeed?
NO
What can be used to prevent HIV developing?
PEP (post-exposure prophylaxis)
How soon after potential exposure should PEP e given?
<72 hours
What does PEP involve?
A combination of ART therapy ( Truvafa and raltegravir for 28 days)
