Gynae Flashcards
Histology cervical cancer
squamous cell cancer (80%)
adenocarcinoma (20%)
Biggest risk factor in developing cervical cancer?
HPV 16,18 & 33
What virsuses cause genital warts
HPV 6 & 11
How does HPV cause cervical cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
screening pathway for cervical cancer
- Test for high-risk human papillomavirus strains (hrHPV)
If negative return to normal recall - If positive → cytology
If cytology negative, retest hrHPV in 12 months
If hrHPV is then negative return to recall, if hrHPV positive repeat again in 12 months
If hrHPV is positive at 24 months, cytology is normal refer to colposcopy anway - If cytology positive → colposcopy
If sample is inadequate HPV cervical screening, what do you do?
Retest in 3 months
If inadequate again –> colposcopy
Normal recall for cervical screening
Age 25 years: first invitation.
Age 25-49 years: screening every 3 years.
Age 50-64 years: screening every 5 years.
Women 65 years of age or older if they have not had a cervical screening test since 50 years of age or a recent cervical cytology sample is abnormal.
cervical screening and pregnancy
cervical screening in pregnancy is usually delayed until 3 months postpartum unless missed screening or previous abnormal smears.
women with HIV and cervical screening
Cervical cytology at diagnosis.
Cervical cytology should then be offered annually for screening.
What is the test of cure pathway for CIN?
Individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
Management of cervical intraepitlealial neoplasia
Large loop excision of the transformation zone (LLETZ)
Cervical cancer stage 1A
Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep
Gold standard of treatment is hysterectomy +/- lymph node clearance
Nodal clearance for A2 tumours
For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
Radical trachelectomy is also an option for A2
Cervical cancer stage 1B
Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter
Radiotherapy with concurrent chemotherapy is advised
Radiotherapy may either be bachytherapy or external beam radiotherapy
Cisplatin is the commonly used chemotherapeutic agent
For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Stage II and III cervical cancer
Stage 2: Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
Stage 3: Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall
NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III
Radiation with concurrent chemotherapy
Radiotherapy may either be bachytherapy or external beam radiotherapy
Cisplatin is the commonly used chemotherapeutic agent
If hydronephrosis, nephrostomy should be considered
Stage IV cervical cancer
Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
Radiation and/or chemotherapy is the treatment of choice
Palliative chemotherapy may be best option for stage IVB
What complications is there with LLETZ and cone biopsy
pre term labour in future pregnancies
What does FSH do?
development of follicle beyond secondary
stimulates granulosa cells to multiply and produce oestrogen
Induces LH receptors on granulosa cells of the dominant follicle
What does oestrogen do?
stimulates proliferation of granulosa cells
exerts negative feedback on the secretion of gonadotrophins
works with progesterone to maintain lining in luteal phase
What does LH do?
stimulates theca cells to synthesise androgens
the mid-cycle surge in LH causes ovulation
What does progesterone do?
Helps to build and maintain endometrial lining
progesterone is produced in large amounts by the corpus luteum to maintain the lining
the drop in progesterone due to degeneration of corpus luteum (due to no hCG) causes endmetrial shedding
what are the 4 key follicular stages
Primordial follicles
Primary follicles
Secondary follicles
Antral follicles (also known as Graafian follicles)
Histology of most endometrail cancers
adenocarcinoma
risk factors for endometrial cancer
obesity
Nulliparity (Nulliparity is a risk factor for endometrial cancer. This is because during pregnancy, the balance of hormones shifts towards progesterone, which is a protective factor.)
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal carcinoma
2 week wait criteria for ?endometrial cancer
Age over 55 with post menopausal bleeding (must be >12 months since last period)
Consider if over 55 and:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
Investigations for endometrial cancer?
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Hysteroscopy with endometrial biopsy
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Stages of endometrial cancer?
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
Managemnet of endometrial cancer
total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
how may endometrial hyperplasia present?
intermenstrual bleeding
What is endometrial hyperplasia ?
types?
abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
types:
hyperprolifertaion without atypia
atypical hyperplasia
Management of endometrial hyperplasia?
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel) and retest in 3 months
If atypia : hysterectomy advised
Invetsigations for ovarian cancer?
CA-125
If CA-125 is over 35 the do abdo USS
Diagnosis is difficult and usually involves CT for staginh and diagnostic laparotomy
Most common ovarian cancer histlogy
epithelial cell tumour - serous tumour
What are teratomas?
germ cell tumours
Particular complication with teratomas?
ovarian torison
Blood tests in teratomas
raised alpha-fetoprotein (α-FP)
raised human chorionic gonadotrophin (hCG)
Risk factors for ovarian cancer
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:
Early-onset of periods
Late menopause
No pregnancies
2 week wait criteria for ovarian cancer
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
What investigation should women under 40 years with a complex ovarian mass have
?teratoma
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
What can raise CA-125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Management ovarian cancer
Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
Management ovarian cancer
Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
Stages of ovarian cancer
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
Most common histology vulval cancer
squamous cell carcinomas
Invetsigations for vulval cancer
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)
management of lichen sclerosus
topical steroids and emollients
Presentation of vaginal cancer?
abnormal discharge
management vulval cancer?
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
what do theca cells do?
stimulated by LH to make androgen which can be converted to oestrogen by granulosa cells
what do granulosa cells do?
stimulated by FSH to produce estrodiol
whirlpool sign
ovarian torsion
masses in the uterine wall
fibroids
Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
fibroids
Investigations for fibroids
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
transvaginal ultrasound is the investigation of choice for larger fibroids.
Management of menorrhagia with no identified pathology, fibroids <3cm, or a suspected or confirmed diagnosis of adenomyosis
- mirena coil
- non-hormonal options: tranexamic acid, NSAIDs such as mefanamic acid (if dysmenorrhoea too)
- hormonal options: COCP, cyclical progestogens
- surgical
- endometrial ablasion
- hysterectomy
management of menorrhagia with fibroids > 3cm in diameter
- mirena coil (fibroids must be less than 3cm with no distortion of the uterus)
- non-hormonal options: tranexamic acid, NSAIDs
- hormonal options: COCP, cyclical progestogens fibroids must be less than 3cm with no distortion of the uterus
- Surgical options:
- uterine artery embolisation
- myomectomy (if want to maintain fertility)
- hysterectomy
what drugs can shrink fibroids eg before surgery
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
complications of fibroids
- sub-fertility
- anaemia
- red-degenration during pregnancy
pregnant lady with severe abdo pain, low grade fever, history of fibroids
red degeneration of fibroids
Initial investigations menorrhagia
- fbc
- transvaginal USS
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.
a benign ovarian tumour
ascites
pleural effusion
Meig’s syndrome
It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.
“string of pearls”
multiple ovarian cysts
Presentation of ovarian cysts
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.
Occasionally, ovarian cysts can cause vague symptoms of:
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Most common type of ovarian cyst
Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.
What type of ovarian cyst may cause pelvic discomfort, pain or delayed menstruation
corpus luteum cyst
What type of ovarian cysts can become huge and take up lots of space in abdomen
Mucinous Cystadenoma
benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.
What type of cysts are particualrly associated with torsion
teratomas
Dermoid Cysts / Germ Cell Tumours
What tests do you need to do after an ovarian cyst has been identified? younger women vs oldeR?
Younger women:
Premenopause with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
Older women/complex on scan/>5cm:
CA-125
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
2ww for ovarian cancer
complex cysts or raised CA125
Management of ovarian cysts - premenopause vs postmenopause
Premenopause:
- simple and < 5cm: no follow up
- 5-7cm: routine gynae rf, uss each year
- >7cm: MRI to see character, surgical rf
Postmenopause:
correlation with CA-125 to consider 2ww
- simple and < 5cm: uss every 4-6 months
- perisistent/enlarging: laparoscopy
Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
has an ovarian cyst, acute onset pain
consider:
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum
what type of cyst causes meig’s syndrome
Ovarian fibroma (a type of benign ovarian tumour)
Risk of malignancy index for ovarian cancer
Risk malignancy index (RMI) prognosis in ovarian cancer is based on
US findings,
menopausal status and
CA125 levels
A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness.
endometriosis
Presentation endometriosis
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria
There can also be cyclical symptoms relating to other areas affected by the endometriosis:
Urinary symptoms
Bowel symptoms
examination of endometriosis may reveal:
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa
Gold standard invetsigation for endometriosis
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
Are USS useful in endometriosis
Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.
Management endometriosis
- NSAIDs - ibruprofen, mefanamic acid, paracetamol
- COCP or progestogens e.g. medroxyprogesterone acetate
Medical (symptom management):
- COCP
- POP
- mirena coil
- Implant
- injection
Secondary care:
Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
Surgical:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy and bilateral salpingo-opherectomy
postmenopausal women with symptoms of:
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding (spotting)
o/e
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
atrophic vaginitis
diagnosis of exclusion so may need to do TVUSS etc.
Management of atrophic vaginitis
- creams/lubricants
- topical oestrogen
When is urodynamic testing appropriate for urinary incontinence
Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
Management of stress incontinence
- Avoid caffiene, alcohol, fluid restriction/excess
- Pelvic floor exercises supervised for 3 months
- Duloxetine where surgery not wanted
- Surgery such as Tension-free vaginal tape (TVT)
Management of urge incontinence
- Bladder retraining for 6 weeks
- Anticholinergic drugs such as oxybutynin, tolterodine and solifenacin
- Mirabegron (a beta-3 agonist) is used in ‘frail elderly women’ as anticholinergic side effects of above may not be tolerated but avoided in uncontrolled HTN
- Invasive: botox, nerve stimulation, augmentation etc
Type 1 FGM
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2 FGM
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3 FGM
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4 FGM
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
What are women with PCOS at particular risk of when undergoing IVF?
ovarian hyperstimulation syndrome
Rotterdam critera
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods (generally defined as fewer than six to nine menstrual cycles per year)
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Invetsigations PCOS
pelvic ultrasound: transvaginal
FSH, LH, prolactin, TSH, and testosterone are useful investigations
(raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes)
2-hour 75g oral glucose tolerance test (OGTT)
General management PCOS
weight loss, orlistat if bmi>30
Managing Hirsutism PCOS
weight loss
Co-cyprindiol (Dianette) for 3 months*
Topical eflornithine
Specialist:
Electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)
Management acne PCOS
Co-cyprindiol (Dianette) for 3 months*
Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)
Managing infertility PCOS
weight loss
Clomifene (causes ovulation, selective estrogen receptor modulator (SERM).)
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)
reducing risk of endometrial cancer pcos
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill
PCOS blood results
high LH
high LH:FSH ratio
turners blood results
high LH and FSH
management turner syndrome
Growth hormone therapy can be used to prevent short stature
Oestrogen and progesterone replacement can help establish female secondary sex characteristics, regulate the menstrual cycle and prevent osteoporosis
Fertility treatment can increase the chances of becoming pregnant
inheritance androgen insensitivity syndrome?
x linked
blood results androgen insensitivity syndrome
High LH, High/normal testosterone
diagnostic invetsigation androgen insensitivity
buccal smear or chromosomal analysis to reveal 46XY genotype
Presentation of CAH neonate? why?
Hyponautramia, shocked, hyperkalaemia
Poor feeding
Vomiting
Dehydration
Arrhythmias
as aldosterone is low so not adequate resorption of sodium and water/excretion of potassium
most common cause CAH?
others?
21-hydroxylase deficiency
11-beta hydroxylase deficiency (5%)
17-hydroxylase deficiency (very rare)
inheritance CAH
autosomal recessive
Management CAH
Hydrocortisone- Cortisol replacement
Fludrocortisone - Aldosterone replacement
Female patients with “virilised” genitals may require corrective surgery
Pathophysiology CAH
21-hydroxylase deficiency (90%) (responsible for biosynthesis of aldosterone + cortisol)
21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol. Progesterone is also used to create testosterone, but this conversion does not rely on the 21-hydroxylase enzyme. In CAH, there is a defect in the 21-hydroxylase enzyme. Therefore, because there is extra progesterone floating about that cannot be converted to aldosterone or cortisol, it gets converted to testosterone instead. The result is a patient with low aldosterone, low cortisol and abnormally high testosterone.
High progesterone also seems to inhibit menstruation and so leads to primary or secondary amenorrhoea.
Most common cause of secondary amenorrhoea
pregnancy
what is hypothalamic amenorrhoea
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example:
Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress
what type of amenorrhoea would prolactin secreting pituitary tumour cause
High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism.
eg pituitary adenoma
what is sheehans syndrome
Sheehan’s syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency.
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
Features may include:
agalactorrhoea
amenorrhoea
symptoms of hypothyroidism
symptoms of hypoadrenalism
definition secondary amenorrhoea
Cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhea
define premature ovarian insufficiency
menopause before the age of 40 years
blood results premature ovarian insufficiency
Raised LH and FSH levels (gonadotropins)
Low oestradiol levels
hypergonadotrophic hypogonadism
diagnosis of premature ovarian insufficiency
FSH level persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis.
menopause symptoms
Management of premature ovarian insufficiency
Traditional hormone replacement therapy
Combined oral contraceptive pill
Adequate vitamin D and calcium intake
Diagnosing menopause
A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.
NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in:
Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
Ashermans presentation
presents following recent dilatation and curettage, uterine surgery or endometritis with:
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
Ashermans diagnosis and management
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
reoccurence is common
When should you refer someone to gynae with dysmenorrhoea
when it is secondary (not developed in 1-2 years after menarche)
Management of priamary dysmenorrhoea
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women
2. COCP
Digital vaginal examination reveals nodularity and marked tenderness in the posterior fornix of the cervix. Bimanual examination reveals a fixed, retroverted uterus.
endo
define priamary amenorrhoea
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
vulval carcinoma
sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
ruptured ovarian cyst
Rokitansky’s protuberance
teratoma
On examination the abdomen is non-tender and the uterus feels bulky.
fibroids
In what patients should oxybutinin be avoided
frail older women due to increased risk of falls
intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis
ruptured endometrioma
inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services? diagnosis? investigation?
vesicovaginal fistula
Urinary dye studies
types of fibroids
Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk
When do you initiate investigations for infertility
After 12 months of trying
After 6 months if >35
Advice for couples trying to conceive
The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse
Initial investigations infertility
BMI
chlamydia screening
Semen analysis
Female hormone testing: FSH, LH, Progesterone, AMH, prolactin
Rubella immunity testing
When is LH and FSH tested - fertility
day 2 to 5 of the cycle
When is progesterone measured - fertility
7 days before end of cycle
What does FSH indicate - fertility
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
What does LH indicate- fertility?
high could indicate PCOS
what does progesterone indicate - fertility
A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
What does AMH indicate- fertility
It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
Secondary care investigations fertility
Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram to look at the patency of the fallopian tubes
Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Management of anovulation
Weight loss for overweight patients with PCOS can restore ovulation
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
How does clomifene work
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
Define oligospermia
Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)
Instructions for providing a sperm sample
Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery
Pre-testicular causes of male factor infertility
Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to:
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
Testicular causes of male factor infertility
Testicular damage from:
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic or congenital disorders that result in defective or absent sperm production, such as:
Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)
Post testicular causes of male factor infertility
Obstruction preventing sperm being ejaculated can be caused by:
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
Further investigations after abnormal semen sample identified
Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy
Repeat in 3 months
success rate of IVF
Each attempt has a roughly 25 – 30% success rate at producing a live birth
complications IVF
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
Basic IVF process
- supression of menstrua cycle with GnRH agonists or antagonists
- ovarian stimulation with FSH
- hCG trigger injection
- oocyte collection
- oocyte insemination
- culture
- transfer
- pregnancy test after 26 days
Pathophysiology of ovarian hyperstimulation syndrome
bHCG injections –> stimulation of granulosa cells –> increase in vascular endothelial growth factor (VEGF) –> increased vascualr permeability –> oedema/ascites/hypovolemia
also renin high due to RAAS activation
what indicates higher risk for OHSS
Serum oestrogen levels (higher levels indicate a higher risk)
Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)
Features OHSS
Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
Management OHSS
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)
What blood test may be useful in monitoring the amount of fluid in intravascualr space - OHSS
Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.
What is adenomyosis
endometrial tissue inside the myometrium
What age/patient does adenomyosis present in?
more common in later reproductive years and those that have had several pregnancies (multiparous)
Presentation adenomyosis
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
It may also present with infertility or pregnancy-related complications
Pathophysiology cervical ectropion
Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).
Think N : canal , endocervix, columnar
Associations cervical ectropion
associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.
Presentation ectropion
post coital bleeding, increased vaginal discharge, vaginal bleeding or dyspareunia
Management ectopion
Asymptomatic: no treatment
Symptomatic: cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
Presentation nabothian cysts
smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.
Investigations and management ovarian torsion
TVUSS
Treatment and definitive diagnosis by laparoscopic surgery
Un-twist the ovary and fix it in place (detorsion)
Remove the affected ovary (oophorectomy)
Grading of pelvic organ prolapse
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
lichen sclerosus
Management lichen sclerosus
Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.
Complication lichen sclerosus
5% risk of developing squamous cell carcinoma of the vulva.
Management bartholin cyst
usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).
Most common infective cause bartholin abscess
e-coli
but may do swabs for chlamydia and gonorrhoea too
Management bartholin abscess
abx
surgical:
Word catheter (Bartholin’s gland balloon) – requires local anaesthetic
Marsupialisation – requires general anaesthetic
GnRH agonists? examples and pharmacology
GnRH agonists (zoladex) Leuprolide, goserelin, triptorelin and histrelin if secondary to fibroids as shrinks it!
GnRH agonists initially cause an increase in gonadotropin secretion that is followed 2–3 weeks later by marked inhibition. This action is due to the development of desensitization of the gonadotroph GnRH receptor, resulting in the suppression of LH and FSH secretion.
Most common cause PID
Chlamydia trachomatis
enlarged, boggy uterus
adenomyosis
Best investigation adenomyosis
MRI pelvis,
definitive diagnosis is biopsy from hysterectomy
Most likely place endometriosis
pouch of douglas
Abx for PID
ceftriaxone
doxycycline
metronidazole
Medication to delay period eg going on holiday
norithisterone
Most common benign ovarian tumour in women under the age of 25 years
teratoma
Components of bishop score
Cervical position (posterior/intermediate/anterior)
Cervical consistency (firm/intermediate/soft)
Cervical effacement (0-30%/40-50%/60-70%/80%)
Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
Foetal station (-3/-2/-1, 0/+1,+2)
types of epithelial ovarian tumours
Arise from the ovarian surface epithelium
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
management of uterine prolapse
Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery
Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
Management endometriosis
Any of
1. paracetamol and/or NSAID for 3 months
2. hormonal contraception eg COCP or progestogen
3. refer to gynae
secondary care:
- GnRH analogues
- Laparascopic surgery
why does breast development occur androgen insensitivity?
Breast development still occurs because testosterone can be converted to oestrogen in the periphery to drive breast development, but it is not present in the reproductive system.
