Gynae Flashcards
1
Q
MENSTRUAL CYCLE
Explain the basics of the menstrual cycle up to ovulation
A
- Multiple follicles develop under presence of FSH + then one dominates causing increased oestrogen conversion which has -ve feedback on FSH/LH
- Oestrogen rises to a point where it stops inhibiting hypothalamus + causes a spike in LH > ovulation
2
Q
MENSTRUAL CYCLE
Explain the basics of what happens after ovulation
A
- Corpus luteum (dominant follicle) produces progesterone which inhibits FSH/LH
- Egg fertilised = syncytiotrophoblast secretes hCG which maintains it
- Egg not fertilised = degenerates + so FSH/LH can rise again
3
Q
1º AMENORRHOEA
What is primary amenorrhoea?
A
Absence of menstruation by –
- 13y if no secondary sexual characteristics
- 15y with secondary sexual characteristics (breast buds)
4
Q
1º AMENORRHOEA
What is the difference between hypogonadotrophic hypogonadism and hypergonadotrophic hypogonadism?
A
- Deficiency in gonadotrophins (LH + FSH) stimulating ovaries due to abnormal hypothalamus or pituitary so low sex hormones (hypogonadism)
- Gonads fails to respond to stimulation of gonadotrophins meaning no negative feedback + increasing amounts of FSH/LH
5
Q
1º AMENORRHOEA
What are some causes of hypogonadotrophic hypogonadism?
A
- Constitutional delay (temporary delay, no pathology, ?FHx)
- Kallmann’s (failure to start puberty + anosmia)
- Excessive exercise, dieting or stress causes hypothalamic failure
- Endo = Cushing’s, prolactinoma, thyroid
- Damage (cancer, surgery, radiotherapy)
6
Q
1º AMENORRHOEA
What are some causes of hypergonadotrophic hypogonadism?
A
- Gonadal dysgenesis e.g., Turner’s syndrome (XO)
- Congenital absence of ovaries
- Previous damage to gonads (torsion, cancer, infections like mumps)
7
Q
1º AMENORRHOEA
What are some other causes of primary amenorrhoea and how may they present?
A
- Congenital adrenal hyperplasia = tall, deep voice, facial hair
- Androgen insensitivity syndrome = 46XY but female phenotype
- Congenital malformations of genital tract e.g., imperforate hymen = regular painful cycles but amenorrhoea > haematocolpos
8
Q
1º AMENORRHOEA
What are some initial investigations for primary amenorrhoea?
A
- FBC + ferritin (anaemia), U+E for CKD, anti-TTG for coeliac, urinary beta-hCG crucial
- FSH + LH (low = hypothalamic, high = gonads)
- TFTs, prolactin, free androgens
9
Q
1º AMENORRHOEA
What further investigations might be useful in primary amenorrhoea?
A
- XR wrist to assess bone age + Dx constitutional delay
- Pelvic USS for structural causes
- Karyotyping for Turner’s syndrome, AIS
10
Q
1º AMENORRHOEA
What is the management of primary amenorrhoea?
A
- Constitutional delay = reassurance + observe
- Primary ovarian insufficiency due to gonadal dysgenesis = HRT to prevent osteoporosis
11
Q
2º AMENORRHOEA
What is secondary amenorrhoea?
A
- Absence of menstruation for 3–6m in women with previously regular menses, or 6–12m in women with previous oligomenorrhoea
12
Q
2º AMENORRHOEA
What is the most common cause of secondary amenorrhoea and the non-pathological causes?
What are the pathological causes of secondary amenorrhoea?
A
- Pregnancy (most common), breastfeeding, menopause (physiological)
- Pituitary = Sheehan’s syndrome, hyperprolactinaemia (prevents GnRH)
- Ovarian = PCOS, premature ovarian failure
- Thyroid = hyper or hypothyroidism
- Asherman’s syndrome
- Hypothalamic failure = excessive exercise, stress or eating disorders
13
Q
2º AMENORRHOEA
What hormonal tests would you do in secondary amenorrhoea?
A
- Urinary pregnancy test
- FSH/LH and androgens
- Mid-luteal (day 21) progesterone to check ovulation happened
- Prolactin + TFTs if indicated
14
Q
2º AMENORRHOEA
What other investigations may you do in secondary amenorrhoea?
A
- Pelvic USS to Dx PCOS
- MRI head if ?pituitary tumour
15
Q
MENORRHAGIA
What is menorrhagia?
A
- Blood loss during menses to the extent in which the woman’s QOL is affected
16
Q
MENORRHAGIA
What are some causes of menorrhagia?
A
- Dysfunctional uterine bleeding = no underlying pathology in about half
- Local = fibroids, adenomyosis, endometrial polyps or cancer, PID, copper IUD
- Systemic = bleeding disorders (vWD), hypothyroidism
17
Q
MENORRHAGIA
What are some investigations for menorrhagia?
A
- FBC for ALL women, ferritin (anaemia), clotting screen
- Transvaginal USS for underlying causes
- TFTs, STI screen if clinically indicated
18
Q
FIBROIDS
What are fibroids?
A
- Benign tumours of the smooth muscle of the uterus (uterine leiomyomas)
19
Q
FIBROIDS
What are the different types of fibroids?
A
- Intramural (most common) = within the myometrium
- Subserosal = >50% fibroid mass extends outside uterus
- Submucosal = >50% projection into the endometrial cavity
- Subserosal + submucosal can be pedunculated (on stalk = risk of torsion)
20
Q
FIBROIDS
What are some associations with fibroids?
What are some risk factors?
A
- Grow in response to oestrogen so rare before puberty
- Black ethnicity, increasing age, early puberty, FHx + obesity
21
Q
FIBROIDS
What is the clinical presentation of fibroids?
A
- Menorrhagia (#1)
- Pelvic pain
- Urinary symptoms (frequency, urgency)
- Subfertility
22
Q
FIBROIDS
What are some investigations for fibroids?
A
- Abdo + bimanual exam = firm, enlarged, irregularly shaped non-tender uterus
- FBC for ALL women (?IDA)
- TV USS
23
Q
FIBROIDS
What is a key complication of fibroids?
How does it present?
How is it managed?
A
- Red degeneration
- Growth in pregnancy due to rise in oestrogen so fibroid outgrows blood supply > ischaemia + degeneration
- Low-grade fever, severe abdo pain + vomiting > analgesia, fluids
24
Q
FIBROIDS
What is the first line management of fibroids <3cm?
How is the management split after that?
A
- IUS (cautious if uterus distortion > specialist advice)
- Non-hormonal = does not want contraception
- Hormonal = wants contraception
- Surgical = severe or submucosal for hysteroscopic removal
25
FIBROIDS
| What are the options for non-hormonal management of fibroids <3cm?
- Tranexamic acid (antifibrinolytic) taken during bleeding to reduce it
- Mefenamic acid (NSAID) to reduce bleeding + pain
26
FIBROIDS
| What are the options for hormonal management of fibroids <3cm?
- COCP
| - Cyclical progesterone (norethisterone)
27
FIBROIDS
| What is the management of fibroids >3cm?
- Same medical Mx but surgery offered too
- GnRH agonists (goserelin) can be given to shrink fibroids by inducing menopausal state (reduced oestrogen) in short-term only (can demineralise bone) for surgery
28
FIBROIDS
| What are the main surgical options for fibroids?
- Uterine artery embolisation
- Myomectomy
- 2nd gen endometrial ablation
- Hysterectomy
29
FIBROIDS
What is...
i) uterine artery embolisation?
ii) myomectomy?
iii) endometrial ablation?
iv) hysterectomy?
i) Injection > blocked arterial supply to fibroid = starves of oxygen + shrinks
ii) Removal of fibroid either laparoscopic, hysteroscopic or laparotomy
iii) Destroys endometrium + superficial myometrium of uterus
iv) Uterus removal, last resort, patient choice, family completed
30
FIBROIDS
| What should you make women aware of before certain surgical procedures?
- Myomectomy is only treatment known to potentially improve subfertility
- Must AVOID subsequent pregnancy + use effective contraception after endometrial ablation
31
ADENOMYOSIS
What is adenomyosis?
What is the epidemiology?
- Endometrial tissue inside the myometrium – oestrogen dependent
- More common in later reproductive years + multiparous
32
ADENOMYOSIS
| How does adenomyosis present?
- Dysmenorrhoea + menorrhagia
| - Examination = bulky + tender uterus, "boggy"
33
ADENOMYOSIS
| What is the management of adenomyosis?
- FBC + TV USS first line, may get MRI pelvis
| - Manage as per fibroids
34
ENDOMETRIOSIS
| What is the pathophysiology of endometriosis?
- Presence of ectopic endometrial tissue outside the uterus potentially due to retrograde menstruation (Sampson's theory) which responds to normal menstruation hormones > bleeding + chronic inflammation and scarring
35
ENDOMETRIOSIS
| Where might endometriosis occur and what might this cause?
- Pouch of Douglas = PR bleeding
- Bladder + distal ureter = haematuria
- Ovaries = endometrioma (chocolate cyst)
36
ENDOMETRIOSIS
What are some risk factors for endometriosis?
What are some protective factors?
- Early menarche, nulliparity or FHx
| - Hence = multiparity and COCP
37
ENDOMETRIOSIS
| What is the clinical presentation of endometriosis?
- Cyclical pelvic pain, deep dyspareunia and secondary dysmenorrhoea (worse 2–3d before menses + better afterwards)
- Cyclical urinary Sx = dysuria, urgency, haematuria
- Dyschezia = painful bowel movements
38
ENDOMETRIOSIS
What are the investigation of endometriosis?
What is the gold standard investigation and what might it show?
- Bimanual = fixed, retroverted uterus 2º to adhesions
- TVS may reveal endometrioma
- Diagnostic laparoscopy (white scars or brown spots "powder burn")
39
ENDOMETRIOSIS
| What are some complications of endometriosis?
- Adhesions 2º to endometriosis or surgery > bowel obstruction
- Subfertility due to inflammatory damage + tubal adhesions
- Reduced QOL > depression, anxiety
40
ENDOMETRIOSIS
What is the first line management of endometriosis?
What is trialled after that?
- NSAIDs ± paracetamol for symptomatic relief
| - Hormonal treatments to abolish cycles = COCP or progestogens (POP/implant/injectable/IUS)
41
ENDOMETRIOSIS
| What is the secondary care management of endometriosis?
- GnRH analogues for 'pseudomenopause'
- Laparoscopic excision or ablation
- Ultimately, hysterectomy may be considered
42
PCOS
| What is polycystic ovarian syndrome (PCOS)?
- Heterogenous endocrine disorder which emerges at puberty due to a combination of hormone imbalances e.g., insulin resistance, raised LH + hyperandrogenism
43
PCOS
| How does insulin resistance contribute to PCOS?
- Low sex hormone-binding globulin (SHBG) which usually binds to testosterone so more testosterone is unbound in blood
- Raised androgens
44
PCOS
| What are the 3 main presenting features of PCOS?
- Hyperandrogenism = hirsutism, acne + male pattern baldness
- Oligo or amenorrhoea
- Insulin resistance (obesity, acanthosis nigricans)
45
PCOS
How does hirsutism present in PCOS?
What are some differentials of hirsutism?
- Growth of thick, dark hair often in male pattern (facial hair)
- Androgen-secreting ovarian/adrenal tumours, CAH, Cushing's
46
PCOS
| What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) –
- Oligo- or anovulation
- Hyperandrogenism (biochemical or clinical)
- Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
47
PCOS
| What blood tests may be used in PCOS diagnosis and what would they show?
- Testosterone (normal/raised)
- SHBG (low)
- LH (raised) + raised LH:FSH ratio (LH>FSH)
- Prolactin + TFTs (exclude causes), OGTT (screen for T2DM)
48
PCOS
What is the gold standard for visualising the ovaries?
What might it show?
- TVS
- "String of pearls" appearance
- Can also visualise endometrial thickness
49
PCOS
| What are some complications of PCOS?
- Metabolic = T2DM, CVD (screen for) + OSA
- Subfertility
- Mental health = depression, anxiety
- Endometrial cancer = unopposed oestrogen from no progesterone as no ovulation
50
PCOS
| What is the most crucial part of PCOS management?
- Healthy lifestyle + weight loss as can improve overall condition + complications
51
PCOS
| How is endometrial cancer risk managed in PCOS?
- IUS (continuous endometrial protection)
| - COCP or cyclical progestogens (medroxyprogesterone) with withdrawal bleed every 3–4m
52
PCOS
| How is infertility managed in PCOS?
- Weight loss #1 if appropriate
- Clomifene first line to induce ovulation
- Metformin may be used ± clomifene
- Laparoscopic ovarian drilling or IVF afterwards
53
PCOS
| How is hirsutism managed in PCOS?
- Co-cyprindiol COCP with anti-androgen effects but increased VTE risk so used <3m
- Hair removal cream, topical eflornithine for facial hair
- Spironolactone (mineralocorticoid anatagonist with anti-androgen effects)
54
PCOS
| How is acne managed in PCOS?
- Co-cyprindiol COCP
| - Standard treatments e.g., retinoids, lymecycline
55
BREAST CANCER
What is the pre-malignant form of breast cancer?
How is it detected?
What is the pathology?
- Non-invasive ductal carcinoma in situ (DCIS) = not invaded basement membrane
- Asymptomatic on screening
- Microcalcification on mammography, unifocal lesion in one area of breast
56
BREAST CANCER
| What are the 2 most common histological types of invasive breast cancer?
- Invasive ductal carcinoma (70%) = abnormal proliferation of ductal cells, invaded basement membrane
- Lobular carcinoma (10%) = more diffuse + frequently impalpable
57
BREAST CANCER
| What are some other types of breast cancer?
- Inflammatory breast cancer (presents like mastitis, no Abx response)
- Medullary cancers (younger, BRCA1)
- Paget's disease of nipple
58
BREAST CANCER
What is Paget's disease of the nipple?
When would you expect it and how is it managed?
- Eczematous change of nipple due to underlying malignancy (invasive #1 or in-situ)
- Suspect if nipple eczema unresolved with 2w of steroid or anti-fungal cream
- Triple assessment
59
BREAST CANCER
| What is the epidemiology of breast cancer?
- 1 in 8 women will develop breast cancer in their lifetime
| - Most common cancer in women + second most common cause of death
60
BREAST CANCER
| What are some modifiable risk factors of breast cancer?
- Obesity, smoking, alcohol, not breastfeeding
61
BREAST CANCER
| What are some non-modifiable risk factors of breast cancer?
- Increased hormone exposure = early menarche, late menopause, nulliparity, COCP or combined HRT
- Genetic = FHx, female, BRCA1, BRCA2, TP53 (Li Fraumeni), Peutz-Jeghers
62
BREAST CANCER
| What are some protective factors of breast cancer?
- Breastfeeding
- Multiparity
- Late menarche + early menopause
63
BREAST CANCER
What are the two most common genetic associations with breast cancer?
What are they?
- BRCA1 #1 = mutation of C17, 60-80% lifetime risk
- BRCA2 = mutation of C13, 45% lifetime risk
- Tumour suppression genes that act as inhibitors of cellular growth
64
BREAST CANCER
| What are some other genetic mutations associated with breast cancer?
- TP53 (Li Fraumeni)
| - Peutz-Jeghers
65
BREAST CANCER
| What is the classic clinical presentation of breast cancer?
- Palpable painless lump (upper outer quadrant) = hard, irregular, tethered to chest wall
- Visually = nipple inversion, bloody nipple discharge, peau d'orange (oedema + pitting due to blockage of lymphatic drainage)
- Palpable lymphadenopathy (axillary > supraclavicular)
66
BREAST CANCER
What warrants an urgent 2ww cancer referral?
What happens under the 2ww referal?
- ≥30 with unexplained breast lump ± pain
- ≥50 with discharge, retraction or other change of concern
- Triple assessment
67
BREAST CANCER
| What is the triple assessment?
- Clinical assessment = Hx + Examination
- Imaging = <40 USS as dense tissue, >40 USS + mammography, ?MRI
- Biopsy = with core needle biopsy (or fine needle aspiration)
68
BREAST CANCER
| What imaging choices are there for investigating breast cancer and what would influence your choice?
- Mammography, high resolution USS (good at Dx + targeting biopsy)
- MRI (good assessment of implants, dense breasts or high-risk screening)
69
BREAST CANCER
If someone has breast cancer, what would you like to check now?
What might this tell you about prognosis?
- Oestrogen receptor (ER) = presence good prognosis (and vice versa)
- Human epidermal growth factor 2 (HER2) = presence bad prognosis (and vice versa)
- Progesterone receptor
70
BREAST CANCER
How is breast cancer staged?
How can you work out someone's prognosis?
What tumour marker is used in breast cancer?
- CT CAP for TNM staging
- Nottingham prognostic index scoring system
- Ca 15-3 = monitor response to treatment + disease recurrence
71
BREAST CANCER
What is the NHS breast screening programme?
What is the process?
- Women 50–70 invited triennially for dual-view (cranio-caudal + medio-lateral oblique) mammography
72
BREAST CANCER
| What are the pros and cons of breast cancer screening?
- Earlier detection, reduces mortality, detects asymptomatic cancers before present, not overly invasive
- Some cancers missed, false positive distressing, ionising radiation risk
73
BREAST CANCER
| What are some reasons that a woman may be recalled for further views, USS or biopsy?
- Mass
- Microcalcification (DCIS)
- Asymmetrical density
- Clinical or technical recall
74
BREAST CANCER
| What is the high risk screening for breast cancer?
- BRCA1/2 = annual MRI from age 30 + mammography from 40
75
BREAST CANCER
What are some complications of breast cancer?
How might this be managed?
- Locally advanced breast cancer = rare presentation
| - Metastatic disease (2Ls 2Bs) = Lungs, Liver, Bones, Brain > bone mets = spinal radiotherapy or bisphosphonates
76
BREAST CANCER
| What is the management of breast cancer prior to surgery?
- Women with no palpable axillary lymphadenopathy = pre-op axillary USS
- Women with clinically palpable lymphadenopathy = axillary node clearance indicated at primary surgery
- Neoadjuvant chemotherapy (FEC-D) to downstage a primary lesion
77
BREAST CANCER
What are some potential complications of axillary node clearance?
How can that be managed?
- Functional arm impairment
| - Lymphoedema (compression bandages, massages)
78
BREAST CANCER
| What are the two main surgical options for breast cancer management and when are they indicated?
- Wide local excision/lumpectomy = solitary lesion, peripheral tumour, small lesion in large breast, DCIS <4cm
- Mastectomy = multifocal or central tumour, large lesion in small breast, DCIS >4cm
79
BREAST CANCER
When is radiotherapy indicated in breast cancer management?
What are some side effects?
- Whole breast radiotherapy if wide-local excision to reduce recurrence
- Radiotherapy if T3-4 tumours or ≥4 +ve axillary nodes if mastectomy
- Breast tissue fibrosis, fat necrosis, fatigue
80
BREAST CANCER
| What endocrine therapy might be used in breast cancer
- ER +ve and pre/peri-menopause = tamoxifen (SERM)
- ER +ve and post-menopause = aromatase inhibitors (e.g., anastrozole, letrozole)
- HER-2 +ve = trastuzumab (Herceptin)
81
BREAST CANCER
What is the mechanism of action of...
i) tamoxifen?
ii) anastrozole?
i) Selective oestrogen receptor modulator = inhibits oestrogen receptors on breast cancer cells
ii) Inhibits aromatase which converts androgens to oestrogen
82
BREAST CANCER
What are some side effects of...
i) tamoxifen?
ii) aromatase inhibitors?
iii) trastuzumab?
i) Menopausal Sx, VTE + endometrial cancer
ii) Hot flushes, osteoporosis, fatigue
iii) Cardiac dysfunction + teratogenicity
83
BREAST CANCER
When considering the surgical management of breast cancer, what else might be offered and when?
Give some examples
- Breast reconstruction surgery either primary (immediate) or delayed
- Latissimus dorsi flap, implant based, transverse rectus abdominis flap
84
BENIGN BREAST DISEASE
| What are some differentials for breast lump?
- Breast cancer
- Fibroadenoma
- Fibrocystic breast disease
- Breast cysts
- Fat necrosis
- Duct papilloma
- Breast abscess
85
BENIGN BREAST DISEASE
What are the features of fibroadenoma?
What is the epidemiology?
What is the management?
- Firm, mobile, well-circumscribed + smooth lump
- Common in younger women <30
- Triple assessment, removal if ≥3cm
86
BENIGN BREAST DISEASE
| What is fibrocystic breast disease?
- Connective tissues, ducts + lobules respond to cyclical hormonal changes becoming fibrous (irregular + hard) + cystic (fluid filled)
87
BENIGN BREAST DISEASE
What are the features of fibrocystic breast disease?
What is the epidemiology?
What is the management?
- Bilateral "lumpy" breasts, mastalgia, Sx worsen with menstrual cycle
- Common in women 25–50y
- Re-examine after menses, exclude cancer, supportive bra, NSAIDs, heat
88
BENIGN BREAST DISEASE
What are breast cysts?
What is the epidemiology?
Give an example of a specific type
- Benign fluid-filled lumps
- #1 cause, 30–50y, small increased risk of breast cancer
- Galactocele = blocked lactiferous duct (painless lump beneath areola)
89
BENIGN BREAST DISEASE
What are the features of breast cysts?
What is the management?
- Smooth, well-circumscribed, mobile, fluctuant lumps
| - Exclude cancer, aspiration/excision if pain
90
BENIGN BREAST DISEASE
What is fat necrosis?
What is the epidemiology and causes?
- Benign inflammatory reaction to adipose tissue damage
- Following trauma, radiotherapy or breast surgery
- Common in obese
91
BENIGN BREAST DISEASE
What are the features of fat necrosis?
What is the management?
- Painless, non-mobile mass with overlying skin inflammation and bruising
- Triple assessment as similar appearance to cancer, often no intervention
92
BENIGN BREAST DISEASE
What are the features of duct papilloma?
What is the management?
- Bloody nipple discharge, usually no palpable mass
| - Triple assessment, microdochectomy
93
BENIGN BREAST DISEASE
What is duct ectasia?
What are the features?
What is the management?
- Inflammation + dilation of large breast ducts
- Nipple retraction, creamy/green discharge
- Troublesome = microdochectomy (young) or total duct excision (older)
94
BENIGN BREAST DISEASE
What is the associations with periductal mastitis?
What are the features?
What is the management?
- Presents younger than duct ectasia with strong association with smoking
- Inflammation, abscess or mammary duct fistula
- Abx, if abscess > draining
95
BENIGN BREAST DISEASE
What is mastitis?
What are the features?
- Inflammation of the breast, associated with lactation in postpartum women
- Localised pain, tenderness, erythema + warmth, systemic illness (fever, rigors, fatigue), unilateral
96
BENIGN BREAST DISEASE
| What is the management of mastitis?
- Reassurance to continue breast feeding
- Analgesia
- Advice on milk removal (manual expression)
- ?Abx
97
BENIGN BREAST DISEASE
| What antibiotics would you give in mastitis and what criteria would you follow?
PO flucloxacillin and give if –
- Systemically unwell
- Nipple fissure
- Sx do not improve 12–24h after effective milk removal
- Culture = infection
98
BENIGN BREAST DISEASE
What is breast abscess?
What are the features?
How is it managed?
- Complication of untreated mastitis
- Fluctuant, tender mass with overlying erythema + systemically unwell
- USS = pus collection, incision + drainage with Abx
99
BENIGN BREAST DISEASE
What is cyclical mastalgia?
What are the features?
- Breast tenderness which fluctuates with menstrual cycle
- Pain starts day before period + subsides by end
- May be associated with fibrocystic changes = breast lumpiness
100
BENIGN BREAST DISEASE
What is gynaecomastia?
What are some causes?
- Enlargement of glandular tissue in males
- Puberty = oestrogen/testosterone imbalance
- Obesity = aromatase in adipose tissue
- Chronic liver disease
- Drugs = spironolactone #1, anabolic steroids, cannabis, GnRH agonists
- Testicular tumour (Leydig cell > oestrogen) or failure (mumps)
101
BENIGN BREAST DISEASE
| What is the management of gynaecomastia?
- Make sure to perform a testicular exam
- Older men >50 exclude breast cancer
- Reassure teenagers
- Tamoxifen + surgery may be trialled
102
CERVICAL CANCER
What is the most common histological types of cervical cancer?
What is the strongest factor associated with cervical cancer?
- Squamous cell carcinoma 80%, adenocarcinoma (20%)
| - Human papillomavirus (HPV 16, 18 + 33)
103
CERVICAL CANCER
| What genes may be implicated in cervical cancer and how does this relate to the pathogenesis?
- P53 + RB are tumour suppressor genes
- HPV produces two oncoproteins (E6 + E7)
- E6 inhibits P53, E7 inhibits RB
104
CERVICAL CANCER
| What are some risk factors for cervical cancer?
- Smoking
- HIV
- High parity
- Multiple sexual partners
- Lower socioeconomic status
- COCP
105
CERVICAL CANCER
| How does cervical cancer present?
- Asymptomatic + smear detected
- Abnormal PV bleeding (POSTCOITAL, intermenstrual)
- PV discharge, pelvic pain, dyspareunia
106
CERVICAL CANCER
What is the initial thing you would do when suspecting cervical cancer?
What would you do based off this?
- Speculum exam (take swabs to exclude infection)
| - Abnormal cervix appearance = urgent colposcopy > ulceration, inflammation, bleeding, visible tumour
107
CERVICAL CANCER
| What other investigations would you do in cervical cancer?
- 1st line = colposcopy (punch biopsy to get tissue sample for histology)
- CT CAP for FIGO staging if confirmed
108
CERVICAL CANCER
Other than cervical cancer, what might colposcopy diagnose and how?
What might colposcopy reveal?
- Dysplasia (premalignant change) in cervical cells using the cervical intra-epithelial neoplasia (CIN) grading system
- CIN I = mild dysplasia
- CIN II = moderate dysplasia
- CIN III/cervical carcinoma in situ = severe dysplasia
109
CERVICAL CANCER
| What is the management of CIN I–III?
- Large loop excision of transformation zone (LLETZ) or cone biopsy
- Cervical screening at 6m as test of cure after
110
CERVICAL CANCER
What is the cervical cancer screening programme?
What are some notable exceptions?
- Sexually active women 25–64 (triennially 25–50, 5y 50–64) smear test
- Exceptions = HIV +ve screened annually, delayed in pregnancy until 3m post-partum unless missed screening or previous abnormal smears
111
CERVICAL CANCER
| What is the process of cervical smears?
- First = tested for high-risk HPV (hrHPV) and if positive then cytological examination to identify precancerous changes (dyskaryosis)
112
CERVICAL CANCER
| Explain how you would initially interpret cervical cancer screening results
- Negative hrHPV = return to normal recall
- Positive hrHPV = examine cytologically
– Abnormal cytology (borderline, mild, moderate or severe dyskaryosis) > colposcopy
– Normal cytology = repeat at 12m
113
CERVICAL CANCER
A patient had positive hrHPV but normal cytology on their cervical screening last year. They ask you what happens this time around, specifically what happens if they are hrHPV +ve again next year too?
- Cytology abnormal at any stage = colposcopy
- Now hrHPV -ve = return to normal recall
- Still hrHPV +ve but cytology -ve = further repeat at 12m
– Now hrHPV -ve at 24m = return to normal recall
– Still hrHPV +ve and cytology -ve at 24m = colposcopy
114
CERVICAL CANCER
| How are inadequate samples managed in cervical screening?
- Inadequate sample = repeat in 3m
| - Two consecutive inadequate = colposcopy
115
CERVICAL CANCER
| What is the prophylaxis for cervical cancer?
- Children 12–13 HPV vaccine
| - Cervical screening
116
CERVICAL CANCER
What is the management of...
i) CIN or early stage 1A cervical cancer?
ii) Stage 1B-2A
iii) Stage 2B-4A
iv) Stage 4B
i) LLETZ or cone biopsy with -ve margins (maintain fertility)
ii) Radical hysterectomy + lymphadenectomy
iii) Chemoradiation
iv) Combination chemotherapy
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CERVICAL ECTROPION
What is cervical ectropion?
What is the consequence of this?
What is it associated with?
- Columnar epithelium of endocervix extends onto stratified squamous ectocervix
- Endocervix cells more fragile so prone to trauma + to bleed (post-coital)
- High oestrogen > young women, COCP, pregnancy
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CERVICAL ECTROPION
| How does cervical ectropion present?
- Increased vaginal discharge
- Abnormal PV bleeding (IMB + PCB)
- Speculum = red ring around cervical os (redder endocervix on pinker ectocervix)
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CERVICAL ECTROPION
| What is the management of cervical ectropion?
- Problematic bleeding = cauterisation (silver nitrate or cold coagulation during colposcopy)
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OVARIAN CANCER
| What are the four main types of ovarian cancer?
- Epithelial cell tumours (85–90%)
- Germ cell tumours (common in women <35)
- Sex cord-stromal tumours (rare)
- Metastatic tumours (secondary)
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OVARIAN CANCER
What is the most common type of epithelial cell tumours and give a secondary example?
What are germ cell tumours and who are they seen in?
- Serous carcinoma #1, endometroid carcinomas
| - Often benign teratomas with various tissue types (skin, teeth, hair), common in women <35y
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OVARIAN CANCER
What are sex cord-stromal tumours?
Give an example of a classic secondary tumour seen in ovarian cancer and a charcteristic feature?
- Arise from connective tissue, rare + aggressive
| - Krukenberg tumour commonly GI (stomach) = characteristic "signet-ring" cells on histology
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OVARIAN CANCER
What are some risk factors for ovarian cancer?
What are some protective factors?
- Unopposed oestrogen = BRCA1/2, early menarche, late menopause
- COCP, early menopause, breastfeeding, childbearing
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OVARIAN CANCER
| What is the clinical presentation of ovarian cancer?
- Non-specific = abdo pain, bloating, early satiety (IBS picture)
- Urinary Sx = frequency, urgency
- Change in bowel habit
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OVARIAN CANCER
What is the NICE recommended initial investigation for suspected ovarian cancer?
What is a limitation?
- CA125 and if ≥35IU/ml then urgent pelvic + abdo USS
| - CA125 falsely raised in endometriosis, menses, fibroids
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OVARIAN CANCER
| What warrants a 2ww gynaecology referral?
- Ascites, unexplained abdominal or pelvic mass
| - USS features suggestive of ovarian cancer = ascites, metastases, bilateral lesions, solid areas, multi-locular cysts
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OVARIAN CANCER
| What can be calculated after CA125 and pelvic USS has been done?
Risk of malignancy index (multiply together) –
- Menopausal status = 1 (pre), 3 (post)
- Pelvic USS findings = 1 (1 feature), 3 (>1 feature)
- CA125 levels
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OVARIAN CANCER
| What other investigations would be done in ovarian cancer?
- Tumour markers = AFP and beta-hCG for germ cell cancers
| - CT CAP for FIGO staging
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OVARIAN CANCER
What is the prognosis of ovarian cancer?
Where does ovarian cancer commonly spread to?
- Poor as often presents late due to non-specific Sx
| - Para-aortic lymph nodes #1 + liver in advanced
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OVARIAN CANCER
| What is the management of ovarian cancer?
- Abdominal hysterectomy + bilateral salpingo-oopherectomy
| - Adjuvant chemotherapy
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OVARIAN CYST
| What are the 4 types of ovarian cysts?
- Functional (physiological)
- Benign epithelial neoplasms
- Benign germ cell neoplasms/dermoid cysts
- Benign sex-cord stromal neoplasms
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OVARIAN CYST
What are functional cysts?
What are the two main types?
- Cysts relating to fluctuating hormones in menstrual cycle
| - Follicular #1 and corpus luteum
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OVARIAN CYST
What is a follicular cyst and its natural course?
What is a corpus luteum cyst and a complication?
- Non-rupture of dominant follicle, regress after few cycles
| - Fills with fluid/blood, more likely to cause intraperitoneal bleeding than follicular
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OVARIAN CYST
| Give examples of benign epithelial cysts and any key features
- Serous cystadenoma
| - Mucinous cystadenoma > if ruptures = pseudomyxoma peritonei
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OVARIAN CYST
What are benign germ cell neoplasms/dermoid cysts?
Who are they seen in?
What is a feature of them?
- Various tissue types (skin hair teeth)
- Common <30y
- Torsion more likely
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OVARIAN CYST
| Give a key sex cord-stromal neoplasm and what it is associated with
- Fibroma
| - Meig's syndrome = ascites + pleural effusion + fibroma
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OVARIAN CYST
| What are some risk factors for ovarian cysts?
- Obesity
- Early menarche
- Infertility
- FHx for dermoid cysts
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OVARIAN CYST
| What is the clinical presentation of ovarian cysts?
- Abdominal mass
- Pelvic pain + dyspareunia
- Pressure effects = urinary frequency, urgency, change in bowel habits
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OVARIAN CYST
| What investigations would you do in ovarian cysts?
- Initial = TV USS to check if simple (benign) or complex (malignant), ?CA125
- Tumour markers for germ cell tumours = AFP, beta-hCG
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OVARIAN CYST
| What are some complications of ovarian cysts?
- Ovarian torsion
- Haemorrhage into cyst (follicular + corpus luteal)
- Cyst rupture
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OVARIAN CYST
What might cause ovarian cyst rupture?
How would it present?
What can it lead to?
- Physical activity (exercise, sexual intercourse)
- Acute, sharp abdo/pelvic pain, PV bleed, N+V
- Peritonitis + shock
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OVARIAN CYST
| What is the management of a ruptured ovarian cyst?
- ABCDE + admission
- Stable = conservative with analgesia, fluids
- Unstable/bleeding = surgery ?laparotomy
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OVARIAN CYST
What is the management of ovarian cysts in pre-menopausal women?
What is the management of ovarian cysts in post-menopausal women?
- Simple cysts <5cm = repeat USS 8–12w as most resolve, referral if persists
- By definition, physiological cysts unlikely so all referred to gynaecology
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OVARIAN TORSION
| What is ovarian torsion?
- Partial/complete twisting of ovary on its supporting ligaments that can lead to ischaemia, if fallopian tube involvement = adnexal torsion
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OVARIAN TORSION
| What are some risk factors of ovarian torsion?
- Ovarian mass
- Pregnancy
- Reproductive age
- Ovarian hyperstimulation syndrome
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OVARIAN TORSION
| What is the clinical presentation of ovarian torsion?
- Sudden onset, severe unilateral iliac fossa pain
- Colicky if twists/untwists
- N+V
- Fever may indicate adnexal necrosis
- Localised tenderness ± palpable pelvic mass
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OVARIAN TORSION
| What are the investigations for ovarian torsion?
- Urinary pregnancy test to exclude ectopic
| - Pelvic USS = free fluid or whirlpool sign
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OVARIAN TORSION
| What are some complications of ovarian torsion?
- Subfertility
| - Necrotic ovary can lead to infection, abscess + sepsis
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OVARIAN TORSION
| What is the management of ovarian torsion?
- Laparoscopy both diagnostic + therapeutic = detorsion ± oophorectomy if necrotic
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ENDOMETRIAL CANCER
What is endometrial cancer?
What is the most common type?
- Cancer of endometrium (lining of uterus) = oestrogen dependent often with good prognosis
- Adenocarcinoma 80%
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ENDOMETRIAL CANCER
What is the most common histological type of endometrial cancer?
What are some others?
- Adenocarcinoma (80%)
| - Adenosquamous, squamous, papillary serous, clear cell + uterine sarcoma
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ENDOMETRIAL CANCER
| What are some risk factors for endometrial cancer?
- Unopposed oestrogen = obesity, nulliparity, early menarche, late menopause, PCOS
- Others = DM, tamoxifen, HNPCC
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ENDOMETRIAL CANCER
| What are some protective factors for endometrial cancer?
- COCP
- Mirena coil
- Multiparity
- Cigarette smoking
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ENDOMETRIAL CANCER
| What is the clinical presentation of endometrial cancer?
- PMB is endometrial cancer until proven otherwise
- May have abnormal bleeding (intermenstrual)
- Abnormal PV discharge, visible haematuria
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ENDOMETRIAL CANCER
When would you refer someone via the 2ww gynaecology pathway?
What is the first line investigation for endometrial cancer?
- Postmenopausal bleeding in ≥55y
| - TVS = endometrial thickness should be <4mm
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ENDOMETRIAL CANCER
| What other investigations is recommended in endometrial cancer?
- Diagnosis = biopsy from Pipelle or hysteroscopy
| - CT CAP for FIGO staging
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ENDOMETRIAL CANCER
| What is the management of stage 1 + 2 endometrial cancer?
- Total abdominal hysterectomy with bilateral salpingo-oopherectomy + pelvic LN
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ENDOMETRIAL POLYP
What is an endometrial polyp?
Key differential?
What is the clinical presentation?
- Benign growths of endometrium, some may be (pre)cancerous
- DDx = fibroids
- Menorrhagia, dysmenorrhoea + subfertility
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ENDOMETRIAL POLYP
| What are the investigations and management of endometrial polyps?
- TV USS, hysteroscopy ± endometrial biopsy
| - Conservative Mx but if troublesome symptoms = hysteroscopy + polypectomy
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VULVAL CANCER
What is the most common histological type of vulval cancer?
What are some risk factors?
- Squamous cell carcinoma
| - HPV, VIN, lichen sclerosus, immunosuppression
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VULVAL CANCER
| What is the clinical presentation of vulval cancer?
- Vulval itching, soreness + persistent lump on labia majora
- Non-healing ulceration
- Inguinal lymphadenopathy
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VULVAL CANCER
| What are the investigations for vulval cancer?
- 2ww urgent gynaecology referral = unexplained vulval lump, ulceration or bleeding
- Diagnosis = biopsy
- CT CAP for FIGO staging
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VULVAL CANCER
| What is the management of vulval cancer?
- Simple = radical/wide local surgical excision
| - Advanced = radio ± chemotherapy
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MENOPAUSE
What is menopause?
What is perimenopause?
- Permanent cessation of menstruation for at least 12m due to ovarian failure + subsequent oestrogen deficiency, average age is 51y
- Period from start of menopausal Sx until 12m after LMP
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MENOPAUSE
| What are the peri-menopausal symptoms?
- Vasomotor (lasts 2–5y) = hot flushes, night sweats
- Sexual dysfunction = vaginal dryness, decreased libido, dyspareunia
- General = depression, short-term memory impairment
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MENOPAUSE
| What are the investigations for menopause?
- Retrospective diagnosis after 12m of amenorrhoea in women >45y
- NICE recommends FSH (high) blood test in women <40 with suspected premature menopause or women 40–45 with menopausal Sx or change in menstrual cycle
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MENOPAUSE
| What are the long-term complications of menopause?
- Osteoporosis
- CVD
- Stroke
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MENOPAUSE
| What is the lifestyle advice given in menopause?
- Regular exercise = improves hot flushes, sleep issues, mood + cognition
- Good sleep hygiene
- Relaxation
- Weight loss
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MENOPAUSE
| What is the medical management of menopause?
- 1st line vaso-motor = HRT
- 2nd line vaso-motor = clonidine (alpha-adrenergic receptor agonist) or SSRI like fluoxetine
- Vaginal dryness = topical oestrogen creams
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MENOPAUSE
| What is the management of contraception in the context of menopause?
- 12m after LMP in women >50y
| - 24m after LMP in women <50y
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HRT
| What is Hormone Replacement Therapy (HRT) and how does it differ to contraceptives?
- Treatment to alleviate Sx associated with menopause by giving a physiological dose of hormones compared to contraceptives which provide supraphysiological doses
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HRT
| What are some contraindications to HRT?
- Current or past breast cancer
- Any oestrogen sensitive cancer (endometrial)
- Undiagnosed PV bleeding
- Untreated endometrial hyperplasia
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HRT
| How do you decide which HRT regime to prescribe?
- No uterus = oestrogen-only HRT
- Uterus = add progesterone (combined HRT)
- Period within last 12m = cyclical HRT
- Period >12m = continuous HRT
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HRT
| What is the management of contraception in the context of HRT?
- Period within last 12m then contraception for 12m after LMP if >50y or 24m if <50y
- Progesterone only is safe to use alongside cyclical HRT
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HRT
| What are some benefits of HRT?
- Relief of vaso-motor symptoms
- Reduced risk of osteoporosis
- Relief of urogenital symptoms
- Improved QOL
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HRT
| What are some risks with HRT?
- Increased risk of breast cancer (combined HRT), reduces after stopping
- Increased risk of VTE (unless patch used)
- Increased risk of CVD + stroke
- Increased risk of endometrial (if oestrogen only)
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HRT
What are the various preparations that HRT comes in?
How might you be guided for which preparation to use?
- Oestrogens = PO, transdermal, topical (urogenital Sx)
- Progestogens = PO, transdermal, IUS
- E.g., patches = patient choice, GI disorders (Crohn's), at risk of VTE
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ATROPHIC VAGINITIS
| What is atrophic vaginitis and what causes it?
- Dryness + atrophy of vaginal mucosa related to lack of oestrogen e.g., menopause, oophorectomy, anti-oestrogens (tamoxifen, anastrozole)
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ATROPHIC VAGINITIS
| What is the clinical presentation of atrophic vaginitis?
- Postmenopausal with PV dryness, dyspareunia + occasional spotting
- Exam = sparse pubic hair, vagina may be pale + dry, painful exam
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ATROPHIC VAGINITIS
| What is the management of atrophic vaginitis?
- Vaginal lubricants + moisturisers like Sylk + Replens
| - Topical oestrogen like estriol cream, HRT if severe
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POI
| What is premature ovarian insufficiency (POI)?
- Onset of menopausal Sx and elevated gonadotropin levels before age 40
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POI
| What are some causes of POI?
- Majority idiopathic or FHx
- Iatrogenic = bilateral oophorectomy, radio/chemotherapy
- Infection = mumps
- Autoimmune
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POI
| What are the clinical features of POI?
- Secondary amenorrhoea + typical peri-menopause Sx before age 40
- FSH level = >40IU/L on 2 samples >4w apart, low oestradiol
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POI
| What are the complications of POI?
- Higher risk of conditions due to lack of oestrogen > CVD, stroke, osteoporosis
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POI
| What is the management of POI?
- HRT or COCP required at least until average age of menopause (51) to reduce risks
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URINARY INCONTINENCE
What is urinary incontinence?
What are some risk factors?
- Involuntary leakage of urine at socially unacceptable times
- Age, multiparity, previous pelvic surgery, high BMI
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URINARY INCONTINENCE
| What are the 5 main types of incontinence?
- Overactive bladder/urge incontinence
- Stress incontinence
- Mixed incontinence (of the 2 above)
- Overflow incontinence
- Functional
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URINARY INCONTINENCE
What causes urge incontinence/OAB?
What causes stress incontinence?
- Detrusor overactivity
| - Weakness of pelvic floor + sphincter muscles
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URINARY INCONTINENCE
| What is overflow incontinence?
- Bladder outlet obstruction leads to overflow + incontinence, more common in men (e.g., BPH, MS, anticholinergics)
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URINARY INCONTINENCE
| What is functional incontinence?
- Comorbidities impair patient's ability to reach bathroom e.g., dementia
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URINARY INCONTINENCE
| What is the clinical presentation of urge incontinence/OAB?
- Urgency, frequency, nocturia
- 'Key in door' + 'handwash' trigger bladder contractions
- Intercourse
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URINARY INCONTINENCE
| What is the clinical presentation of stress incontinence?
- Involuntary leakage when increased pressure (cough, laugh, lifting, exercise)
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URINARY INCONTINENCE
What is the first line investigation in urinary incontinence?
What are some other initial investigations?
- Bladder diary (frequency volume chart) first line
- Urine dipstick + MC&S
- Post void bladder USS scan
- Electronic Personal Assessment Questionnaire = determines impact of urinary, vaginal, bowel + sexual Sx on QOL
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URINARY INCONTINENCE
| What are you looking for in urine dipstick + MC&S?
- Nitrites + leukocytes = infection
- Microscopic haematuria = glomerulonephritis
- Proteinuria = renal disease
- Glycosuria = DM, nephropathy
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URINARY INCONTINENCE
| What more advanced investigations might you consider?
- Urodynamics = measures abdo + bladder pressure to deduce detrusor pressure
- Cystogram with contrast = visualise the bladder
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URINARY INCONTINENCE
| What is some lifestyle advice for urinary incontinence?
- Weight loss
- Stop smoking
- Reduce caffeine + alcohol
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URINARY INCONTINENCE
| What are some conservative treatments for urinary incontinence?
- Barrier bads
| - PV oestrogen if related to menopause
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URINARY INCONTINENCE
| What is the stepwise management of urge incontinence/OAB?
- 1st line = bladder retraining (6w gradually increasing time between voiding)
- 1st line drugs = anti-muscarinics (oxybutynin, tolterodine, darifenacin)
- Mirabegron (beta-3-adrenergic agonist) if anti-muscarinics not tolerated
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URINARY INCONTINENCE
What is the mechanism of action of anti-muscarinics?
What are some side effects?
- Parasympathetic so Pissing = decreases need to urinate + spasms
- "Can't see, spit, pee or shit" > caution in elderly as falls esp oxybutynin immediate release in frail
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URINARY INCONTINENCE
What is the mechanism of action of beta-3-adrenergic agonists?
What is a caution of these?
- Sympathetic so Storage = relaxes detrusor + increases bladder capacity
- C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
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URINARY INCONTINENCE
| What are last resort options for urge incontinence?
- Augmentation cystoplasty
- Bypass (urostomy)
- Botox can paralyse detrusor + block ACh release
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URINARY INCONTINENCE
| What is the stepwise management of stress incontinence?
- Pelvic floor exercises with physio for 3m
- Surgery
- SNRI duloxetine if surgery not preferred
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URINARY INCONTINENCE
| What surgical options are there for stress incontinence?
- Colposuspension
- Tension free vaginal tape
- Mid urethral sling
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PELVIC ORGAN PROLAPSE
What is pelvic organ prolapse?
What are some risk factors?
- Descent of ≥1 pelvic organs resulting in protrusion on the vaginal walls
- Increasing age, obese, multiparity, pelvic surgery, menopause
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PELVIC ORGAN PROLAPSE
| What are the three broad locations where prolapses can occur?
- Anterior vaginal wall
- Posterior vaginal wall
- Apical vaginal wall
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PELVIC ORGAN PROLAPSE
| What prolapses might you get from the anterior vaginal wall?
- Cystocele (bladder > stress incontinence)
- Urethrocele (urethra)
- Cystourethrocele
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PELVIC ORGAN PROLAPSE
| What prolapses might you get from the posterior vaginal wall?
- Enterocele (small intestine)
| - Rectocele (rectum)
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PELVIC ORGAN PROLAPSE
| What prolapses might you get from the apical vaginal wall?
- Uterine prolapse
| - Vaginal vault prolapse (common after hysterectomy)
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PELVIC ORGAN PROLAPSE
| What is the clinical presentation of pelvic organ prolapse?
- "Something coming down" = dragging/heavy sensation in pelvis
- Urinary Sx = incontinence, urgency, frequency
- Bowel Sx = constipation, incontinence + urgency
- Sexual dysfunction = pain, altered sensation + reduced enjoyment
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PELVIC ORGAN PROLAPSE
| What are the investigations for pelvic organ prolapse?
- Sim's speculum (U-shaped) to show if something is there
| - May have urodynamics, USS or MRI
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PELVIC ORGAN PROLAPSE
| What is the management for pelvic organ prolapse?
- Conservative = pelvic floor exercises, weight loss
- Vaginal pessary = ring (preferred + can have sex), shelf or Gellhorn
- Surgery
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PELVIC ORGAN PROLAPSE
What surgical intervention is provided for...
i) cystocele/cystourethrocele?
ii) uterine prolapse?
iii) rectocele?
i) Anterior colporrhaphy or colposuspension
ii) Hysterectomy or sacrohysteropexy
iii) Posterior colporrhaphy
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PREMENSTRUAL SYNDROME
| What is premenstrual syndrome (PMS)?
- Emotional + physical symptoms a woman may experience in the luteal phase of the normal menstrual cycle
214
PREMENSTRUAL SYNDROME
| How may PMS present?
- Mood = anxiety, mood swings, stress, fatigue
- Physical = bloating, headaches, breast pain
- Resolves on menstruation
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PREMENSTRUAL SYNDROME
| What is the management of mild PMS?
- Lifestyle advice = exercise, alcohol + smoking cessation, good sleep
- Regular + frequent small balanced meals with complex carbs
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PREMENSTRUAL SYNDROME
What is the management of moderate PMS?
What is the management of severe PMS?
- New-generation COCP
| - SSRI taken continuously or just during luteal phase (days 15–28)
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FGM
| What is female genital mutilation (FGM)?
- All procedures involving partial or total removal of female external genitalia or injury to female organs for non-medical reasons, often pre-pubertal
218
FGM
| Is FGM illegal?
- Yes as stated in FGM Act 2003 – legal requirement for HCPs to report cases of FGM to the police
219
FGM
| What is the epidemiology in FGM?
- Very common in Africa (Somalia, Egypt, Ethiopia, Sudan)
| - UK hotspots = Sheff, London, Manc, Oxford
220
FGM
| What is the WHO classification for the types of FGM?
- 1 = partial or total clitoridectomy
- 2 = excision
- 3 = infibulation
- 4 = all other non-medical harmful procedures incl. pricking, piercing, incising
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FGM
What is...
i) excision?
ii) infibulation?
i) Partial or total removal of clitoris + labia minora ± excision of labia majora
ii) Narrowing/closing of vaginal orifice with creation of a covering seal (stitch labia together)
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FGM
| Is female labia reduction illegal?
- <18 = FGM
| - >18 = legal but only performed privately
223
FGM
| What are some potential reasons for FGM?
Based on customs –
- It will bring status + respect to family (social norm)
- Rite of passage + being part of woman
- Preserves girls' virginity so acceptable for marriage
- Cleanses + purifies girl with perceived religious requirement
224
FGM
| What are some acute complications of FGM?
- Pain
- Bleeding
- Infection (BBV)
- Sepsis
- Swelling
225
FGM
| What are some chronic complications of FGM?
- Dyspareunia
- Dysmenorrhoea
- Infertility + pregnancy issues
- PTSD
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FGM
| What is the initial management of suspected or confirmed FGM?
- Report ANY FGM in <18 to police + record in notes (consider in >18 after risk assessment e.g. others at risk like unborn children)
- Educate pts + relatives that FGM is illegal + health consequences
- Services = social, safeguarding, child protection
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FGM
| What is the overall management of FGM?
- De-infibulation by specialist in FGM in some type 3 to try restore function
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AIS
| What is androgen insensitivity syndrome (AIS)?
- X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children 46XY to have female phenotype
229
AIS
| What is the clinical presentation of AIS?
- Complete = primary amenorrhoea, female external genitalia, lack of body hair
- Partial = ambiguous genitalia
- Breast development may occur due to conversion of testosterone to oestradiol
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AIS
| What is an important potential complication of AIS?
- Undescended testes cause groin swellings with increased testicular cancer risk
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AIS
| What are the investigations for AIS?
- Pelvic USS = absence of internal female organs
| - Karyotyping (46XY)
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AIS
| What is the management of AIS?
- In general, raised as female but MDT input for support
- Bilateral orchidectomy to avoid testicular cancer
- Oestrogen therapy + vaginal dilators or vaginoplasty
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ASHERMAN'S SYNDROME
What is Asherman's syndrome?
How may it present?
- Adhesion formation within uterus often following pregnancy related dilatation + curettage, uterine surgery or pelvic infection (endometritis)
- Secondary amenorrhoea + infertility
234
ASHERMAN'S SYNDROME
How would you investigate Asherman's syndrome?
What is the management?
- Hysterosalpingography = filling defects
| - Hysteroscopy gold standard to break down adhesions
235
BARTHOLIN CYST
What are the bartholin glands?
What causes a bartholin cyst?
What causes a bartholin abscess? Presentation?
- 2 glands behind labia minora which secrete lubricating mucus for coitus
- Blockage of duct
- Infection (Staph or E.coli) = acutely painful (can't sit), swollen + tender red swelling of labia
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BARTHOLIN CYST
| How is a bartholin abscess managed?
- Incision + drainage
- Abx
- Marsupialisation
237
NABOTHIAN CYST
What is a nabothian cyst?
What is the management?
- Mucus retention cyst found on cervix (white swelling)
| - Cryocautery if discharging
