Gynae Flashcards
Menopause
Retrospective diagnosis - no periods for 12 months - permanent end to menstruation
Usually at ~51 years
Premature ovarian insufficiency + diagnostic test
Menopause before 40 y/o
- aka premature menopause
Diagnosis confirmed with 2 raised FSH levels 4-6 weeks apart (+ clinical presentation and ruling out hypothyroidism, hyperprolactinaemia, and pcos)
Menopause pathophys
- Declining devlopment of ovarian follicles
- Reduced production of oestrogen + progesterone
- Normally, Oestrogen has negative feedback to pituitary -> reduced LH and FSH produce.
- In menopause there is less negative feedback as oestrogn is low so LH and FSH keep getting higher
- Ovulation doesn’t occur (anovulation) -> irregular menstrual cycle
- Endometrium doesn’t develop without enough oestrogen so AMENORRHOEA
- Perimenopausal Sx
Perimenopausal Sx
Vasomotor:
- Hot flushes
- Night sweats
Sexual dysfunction:
- Vaginal dryness and atrophy
- Reduced libido
- Problems with orgasm
- Dyspareunia
Psych:
- Emotional lability or low mood
- Anxiety
- Lethargy
- Reduced conc.
Other:
- Premenstrual syndrome (tender breasts, fatigue, irritibality, cravings)
- Irregular periods
- Joint pains
- Heavier or lighter periods
-
Complications of menopause
- CVD + Stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
Caused by reduced oestrogen
Menopause/perimenopause Dx
- Women OVER 45 YEARS
- Typical Sx
Clinical Dx
FSH blood test in:
- Women UNDER 40 with SUPSECTED Early menopause
- Women 40-45 with Sx / change in menstrual cycle
Menopause Mx
No treatment may be needed
- HRT (both oestrogen + progesterone (for endometrial protection from oestrogen))
- cyclically if still having periods; otherwise continuous
- Increased risk of breast + endometrial cancer if only taking oestrogen; VTE - Testosterone - can improve libido
Non-hormonal:
- Lifestyle measures: activity, avoiding triggers, sleep
- SSRIs / SNRIs
- Clonidine (Alpha-2 adrenergic receptor agonist)
- CBT
- Vaginal moisturisers
Polycystic Ovarian Syndrome (PCOS)
Heterogenous endocrine disorder characterised by:
- Hyperandrogenism (oligomenorrhoea, hirsutism, acne)
- Ovulation disorders
- Polycystic ovarian morphology
PCOS epid
Affects 1/3 of females of childbearing age
PCOS aet
Unkown.
Hyperandrogenism, Insulin resistance, HIgh LH + Raised oestrogen - implicated
PCOS Sx
- Oligomenorrhoea
- In/Subfertility
- Hirsutism + Acne
- Obesity (in ~ 70% of ppl)
- Mood changes
- MALE PATTERN BALDNESS
- Acanthosis nigricans (from INSULIN RESISTANCE)
PCOS DDx
- Menopause
- Congenital adrenal hyperplasia
- Hyperprolactinoma
- Androgen secreting tumours
- Cushing’s
PCOS Dx criteria
ROTTERDAM CRITERIA - at least 2 of the following are needed to Dx:
- Oligo / Anovulation
- Hyperandrogenism
- Polycystic ovaris on USS - >12 cysts / ovaries >10cm^3
+ need to exclude other causes
PCOS Ix
Bloods:
- Testosterone (normal / raised)
- Sex hormone-binding globulin
- Luteinizing Hormone (raised)
- Follicle-stimulating Hormone (LH:FSH ratio = high - >2 ; FSH is lower than LH)
- Prolactin (may be slightly raised in PCOS too)
- TSH / TFTs
- Fasting + oral glocuse tolerance to check for Insulin resistance (Raised)
- DHEA-S + free androgen index (androgen secreting tumours)
- 24hr urine cortisol (Cushing’s)
Scan = TRANSVAGINAL USS OF PELVIS (Transabdominal is also fine)
- Increased ovarian volume + multiple cysts
- Follicles arranged around edge of ovary -> ‘string of pearls’
Dx criteria for PCOS on scan
- 12 or more developing follicles in one ovary
- Ovarian volume > 10cm3
PCOS Mx
Advice:
- Weight loss + exercise
- Education on Increased risk of CVD, DIABETES + ENDOMETRIAL CANCER
- Encourage low sugar, calorie-coltrolled diet
- Smoking ceassation
- Statins + anti-HTN if needed
Asses for complication
Pharm (if not planning preg):
- cOCP - decreases irregular bleeding + reduce risk of endometrial cancer
- Metformin - helps regularise menstruation, hirsutism + acne
- 2nd line - Co-cyprindrol - reduces hirsutism + promotes regular menstruation (VTE risk so can’t use any other hormonal contraception alongside - same as with most oral contraception)
Preg promoting pharm:
- Clomiphene (ovulatory stimulant) - induces ovulation + enhances conception rates
- Metformin (esp in combination with clomiphene) - improves conception rates
- Ovarian drilling - 2nd line (laproscope to damage ovarian hormone-producing cells)
- Gonadotrophins - 2nd line to induce ovulation
Significance of weight loss for PCOS Mx
- Can result in ovulation + restore fertility + regular menstruation
- Improves insulin resistance
- Reduces hirsutism
- Reduces risk of associated conditions
If obese (BMI > 30) - may use Orlistat
- A lipase inhibitor (stops fat being absorbed in intestines)
Pathphys of why PCOS can lead to Endometrial cancer
- Usually the CORPUS LUTEUM releases PROGESTERONE AFTER OVULATION
- In PCOS there is no/irregular ovulation so reduced progesterone to counteract effects of systemic oestrogen
- Oestrogen continues to be released -> Uncontrolled endometrial prolifereation -> hyperplasia + significant risk of cancer
When should a pelvic USS for endometrial thickness be done? What needs to be done prior to the USS?
- If there are extended gaps (> 3 months) between periods
- Give Cyclical progesterones before scan to induce a period
Endometrial thickness >10mm -> refer for biopsy
Tx to reduce risk of endometrial cancer in menopause
- Mirena coil - releases progesterone so acts as continuous protection in HRT (must be replaced after 6 yrs if used for HRT)
- Inducing withdrawal bleed - just need to have at least 3 a year (1 every 3-4 months)
- cOCP (go off it for the week you want the period)
- Cyclical progesterones (need 10mg once a day for 14 days)
RFx for endometrial cancer
- Obesity
- Diabetes
- Insulin resistance
- Amenorrhoea
What is the main side effect of co-cyprindiol
Significantly rised risk of VENOUS THROMBOEMBOLISM as it is anti-androgen
- Usually stopped after 3 MONTHS
Fibroids
Benign smooth muscle tumours in uterus (uterine leiomyomas) - OESTROGEN SENSITIVE (contain more ostrogen receptors than normal uterine cells)
Fibroid epid
- affect 40-60% in later reproductive years
- esp in 40s
- Esp in BLACK women
Types of fibroids
- Intramural (distort shape of uterus with growth)
- most common - Subserosal (just beneath outer layer - grow out; get very large)
- Submucosal (just below endometrium)
- Pedunculated (any of the above but on a stalk)
Remember all are within the myometrium
Fibroids Px
Oft asymp
- Menstrual dysfunction - typically HEAVY +/- PROLONGED (mc)
- Abdo pain (worse during period)
- Bloating / fullness in abdo
- subsequent urinary / bowel Sx - Deep dyspareunia
- Reduced fertility
- Occasionally acute pelvic pain due to fibroid degen during preg or peduculated fibroid torsion (rare)
May feel palpable mass on abdo / bimanual palpation (tho uterus is non-tender)
RFx for developing fibroids
- Obesity
- Early menarche
- Increasing age
- FHx (2.5x risk if 1st degree relative)
- Ethnicity (3x more likely in African-Americans than Caucasians)
Fibroid Ix
IMAGING:
- Pelvic US - typically for larger
- MRI uncommonly - typically to get more info before surgery
HYSTEROSCOPY if HEAVY BLEEDING - typically submucosal fibroids
Fibroid Mx
For smaller fibroids (< 3cm) with menorrhagia:
- MIRENA COIL - not if uertrine distorsion
- Sx Mx e.g. Tranexemic acid + NSAIDs
- cOCP OR Cyclical oral progesterones
- Selective Progesterone Receptor Modulators
- Surgical:
- Endometrial ablation
- Resection
- Hysterectomy
(Basically works in a similar way to trying to reduce endometrial proliferation to avoid endometrial cancer)
If > 3cm REFER to GYNAE. Med management is same as above but consider following surgical:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
What meds can be used to reduce size of fibroids before surg
GnRH AGONISTS (goserelin / leuprorelin) - induces menopause-like state -> reduced oestrogen
Only temporarily used
Uterine Artery Embolisation
Catheter inserted into (usually) Femoral artery -> go to uterine artery guided by x-ray -> inject particles causing blockage to fibroid blood supply (once in right place) -> ischaemic fibroid shrinks
Complications of Fibroids
- Anaemia from bleeding
- Compression of pelvic organs
- Bladder / bowel dysfunction: UTI, Incont, Hydroneph, Retention - Sub/INFERTILITY +/- preg complications
- Red Degeneration -> necrosis of fibroid, typically in 2nd/3rd trimester of preg
- Torsion of pedunculated
- Malignant change
What causes Red Degeneration of Fibroids
- Fibroid rapidly enlarges + outgrows blood supply
- Blood vessels kink as uterus expands
Typically in large fibroids > 5cm
Red degeneration of fibroids Px
Preg woman in 2nd/3rd trimester with:
- SEVERE ABDO PAIN
- Low-grade FEVER
- TACHYCARDIA
- VOMITING
- Hx of fibroids
Red degen of fibroids tx
Supportive: Rest, fluids + analgesia
Ovarian cyst
Fluid filled sac within ovary - common esp in premenopause (functional)
Benign
Ovarian cyst Px
Usually ASYMP + found incidentally on USS
Otherwise still vague:
- Pelvic pain
- Bloating
- Fullness in abdo
- Palpable mass (if v large)
Acute pain only in torsion, haemorrhage or rupture of a cyst
- Acute UNILATERAL pain +/- intra-peritoneal haemorrhage with Haemodynamic compromise = cyst RUPTURE
Types of ovarian cysts
NON-NEOPLASTIC
Functional (main):
- Follicular cysts (most common)
- Corpus luteal cysts
Pathological:
- Endometrioma (from endometriosis)
- Polycystic
- Theca leutin cyst (temporarily caused by raised hCG)
BENIGN NEOPLASTIC:
Epitehlial:
- Serous cystadenoma (Benign epithelial tumour)
- Mucinous cystadenoma (also benign epithelial but can get very big)
- Brenner tumour (unilateral solid grey/yellow)
Germ cell tumours:
- Dermoid cysts / Germ Cell Tumours (benign teratomas)
- Sex Cord-Stromal Tumours (stromal/sex cells - malig or benign)
Ovarian cyst Assessment
Assess if benign or malig
- Abdominal bloating
- Reduce appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
RFx for ovarian cancer
Big thing is that risk is increased the more times you’ve ovulated:
- Age
- Nulliparity
- Early menarche + Late menopause
Also:
- Oestrogen only HRT
- SMOKING
- Obesity
- FHx +/- BRCA1 + BRCA2 genes OR HNPCC (Lynch syndrome)
Protective features for ovarian cancer
- Later menarche / Earlier menopause
- PREG esp miltiparity
- cOCP
- Breastfeeding
Ovarian cancer Px
Oft in Post-menopausal females + vague:
- Bloating
- Change in bowel habit + urinary frequency (due to pressure from tumour)
- chronic pressure can lead to chronic pelvic pain - Weight loss / loss of appetite
- IBS
- Vaginal bleeding
- Ascites
- Palpable mass
- LUTS
May press on obturator nerve + cause reffered HIP / GROIN pain
Meig’s syndrome
Triad of:
- Ovarian fibroma
- Pleural effusion
- Ascites
- uncommon but ~40% of people with Sex-cord stromal tumours / FIbromas present with this
Complications of ovarian cysts
- Torsion
- Haemorrhage
- Rupture + bleeding into peritoneum
What is the tumour marker for ovarian cancer
CA125
Causes of Raised CA125
- Epithelial cell ovarian cancer
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Preg
Ovarian mass/cyst Ix
- Preg test to rule out ectopic
- If pre-menopausal + simple ovarian cyst <5cm on US - DOESN’T NEED FURTHER Ix
- Under 40 with COMPLEX OVARIAN MASS - requires tumour markers for a possible germ cell tumour
- LACTATE DEHYDROGENASE (LDH)
- Alpha-fetoprotein (a-FP)
- human CHORIONIC GONADOTROPIN (HCG) - Diagnostic laparoscopy e.g. if patient unstable
What is the risk of Malignancy Index
Estimates the risk of an ovarian mass being malig:
- Menopausal status
- USS FINDINGS
- CA125 LEVEL
Ovarian cyst Mx
Check guidelines + get advice from collegue
- If suspecting cancer (complex cyst or raised CA125)
- TWO-WEEK WAIT REFERRAL (gynae oncology) - Suspected dermoid cysts -> gynae Ix + consider surgery
- Simple ovarian cysts in premenopausal
- < 5cm = self resolve
- 5-7cm = routine gynae referral + yearly USS
- >7cm = consider MRI or surgiccal evaluation (hard to characterise with USS) -
Postmenopausal -> check CA125
- raised -> 2 week referral
- small + norm Ca125 -> USS monitor 4-6 months - Surgical resection/oophorectomy if enlarging/persistent
Endometriosis
Endometrial tissue located outside of uterine cavity
- ovaries
- pouch of douglas
- uterosacral ligaments
- pelvic peritoneum
- bladder
- umbilicus
- diaphragm (rarely)
Staging of endometriosis
- Small Superficial lesions (may not even have visible endometrioma - just the associated blood vessels visible)
- Mild but deeper lesions
- Deeper + Ovarian endometriosis (chocolate cysts) + mild adhesions
- Deep infiltrating endometriosis (invades into organs/ovaries) + extensive adhesions
Endometriosis Sx
Cyclical Sx - typically get Sx (/gets worse) during periods
- Pelvic Pain (due to irritation + inflam of tissue surrounding endometriomas - particularly as can bleed into abdo cavity during periods)
- Heavy / burning / dull
- Menorrhagia
- Deep dyspareunia
- Sub-fertility
Bladder Sx:
- Cystitis (oft mistaken for UTIs - but NITRITES -VE)
- Haematuria
Bowel Sx:
- Rectal bleeding
- Change in bowel habit
- Dyschaesia (difficulty pooping)
Lung Sx:
- Haemothorax
- Haemotptysis
- Dyspnoea
- Chest pain
Over time nerves get more sensitised -> pain -> low mood -> makes the pain feel worse
- Also general pain due to muscle spasm (due to chronic inflam)
Extent of disease doesn’t correlate with severity of Sx
What can cause CHRONIC, NON-CYCLICAL pain in endometriosis
ADHESIONS formed due to localised bleeding + inflammation -> damage + scar tissue
- possible cause of reduced fertility
What may vaginal examination show in Endometriosis
- Visible endometrial tissue in vagina (esp in posterior fornix)
- Fixed cervix on BIMANUAL examination
- uterus fixed + retroverted - Tenderness of vagina, cervix + adnexa
- N/B: enlarged, tender + BOGGY UTERUS = ADENOMYOSIS
Endometriosis Dx
-
PELVIC USS
- superficial endomet can’t bee seen on scan and USS isn’t diagnostic, but it’s much safer than blindly doing laproscopy - Laproscopic surg (gold standard) + BIOPSY (diagnostic)
- can remove any lesions they find during this
SE/Risks of surgery
- Visceral injury (may need stoma)
- Perforation of IVC or aorta
- Death
- Chronic pain
- May not find anything (50% of endometriosis is diff to identify on surg)
RFx for endometriosis
- Early menarche
- Short menstrual cycles
- Long duration of bleeding
- Heavy bleeding
- Defects in uterus / fallopian tubes
- FHx
Endometriosis Mx
- Explain, Educate, Discuss + ANALGESIA
- HORMONES (can be given even without definitive Dx)
- cOCP
- progesterone only (mini pill)
- Medroxyprogesterone acetate injection
- Nexplanon
- MIRENA coil
- GnRH agonists (induces menopause-like Sx so must regularly check DEXA and change if osteoporotic changes)
- goserelin - SURGERY
- excise (ovarian cystectomy), ablate (diathermy) or adhesiolysis
- may be done if trying to get preg but poor outcomes for deep infiltrating
- Hysterectomy + bilateral salpingo-opherectomy (induces menopause so endometriomas don’t respond to menstrual cycle - still may not resolve Sx)
Adenomyosis definition
Endometrial tissue inside the myometrium - hormone dependant
More common in older age / in multiparosity - BUT - Sx tend to resolve after menopause
Adenomyosis Px
- Dysmenorrhoea
- Menorrhagia
- Dyspareunia
- Potentially infertility / preg related complications
1/3 ppl asymp
Findings on examination of adenomyosis
ENLARGED + TENDER uterus but typically softer than with fibroids
Adenomyosis Dx
- **Transvaginal USS*
- Alt = MRI + transabdo USS - Best way to determine is actually histology post-hysterectomy - but not practical
Adenomyosis Mx
- CONTRACEPTION:
- MIRENA
- cOCP
- Cyclical oral progestogens
- or any progesterone only meds
- If contreception not wanted - Sx relief DURING periods:
1. Tranexemic acid (if no pain - antifibrolynitic only)
2. Mefenamic acid (if YES pain - this is an NSAID) - Other:
- GnRH anologues (goserelin)
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
Preg related complications of Adenomyosis
- Infertility
- Miscarriage
- Prem birth
- Small for gestational age
- Prem rupture of membranes
- Malpresentation
- need for C-section
- Postpartum Haemorrhage
Menorrhagia definitions
Technically - Blood loss > 80 ml during period is considered heavy
(norm = ~40ml)
In practice it is mainly from self reporting / going through a pad every 1-2 hrs or passing large clots
Causes of menorrhagia
- DYSFUNCTIONAL UTERINE BLEEDING (ie idiopathic)
- Extremes of reproductive age
- FIBROIDS
- Endometriosis / Adenomyosis
- Endometrial polyps
- PID
- Contraception - esp COPPER COIL
- Endometrial HYPERPLASIA / CANCER (think esp if post menopausal)
- PCOS
Systemic:
- ANTICOAG meds
- BLEEDING DISORDERS
- Hypothyroidism
- Liver/Kidney disease
- Obesity
- Connective tissue disorders
Key aspects of Hx to consider for any gynae problem
- Age at menarche
- Cycle length + variation
- INTERMENSTRUAL BLEEDING + POST COITAL bleeding
- CONTRACEPTIVE Hx
- SEXUAL Hx
- PREG - possibility, future plans
- Cervical screening Hx
- MIGRAINES if on pill
+ all usual stuff:
- PMHx + DHx
- Smoking + alcohol
- Fhx
Menorrhagia Ix
FBC (anaemia)
PELVIC EXAMINATION -> SPECULUM + BIMANUAL palpation - to assess for fibroids, ascites + cancer
- Not necessary if young + not sexually active; or striaght forward Hx with no other Rfx/Sx
Other:
- Swab (infection suspected)
- Coag screen (FHx of clotting disorder)
- FERRITIN (if clinically anaemic)
- TFTs (if hypothyroid features) / other endocrine tests as indicated
- Transvaginal USS
When would you arrange an outpatient hysteroscopy
- Suspect SUBMUCOSAL fibroids
- Suspect endometrial pathology (hyperplasia/cancer)
- Persistent INTERMENSTRUAL bleeding
When should you arrange a pelvic / transvaginal USS
- You feel a pelvic mass (possible large fibroids)
- They have menorrhagia AND pelvic tenderness (Possible adenomyosis)
- Examination was difficult to interpret (e.g. due to obesity)
- They were recommended a hysterscopy but declined
Menorrhagia Mx
- Exclude underlying pathology + Tx anything identified (e.g. remove copper coil, tx hypothyroid etc)
- CONTRACEPTION
- If contraception not needed/wanted -> TRANEXEMIC / MEFANEMIC ACID
- Refer to 2NDRY care if:
- Tx unsuccessful
- Sx severe
- FIBROIDS > 3CM
- If all medical fails:
- Endometrial ablation
- Hysterectomy
Types of endometrial ablation
- 1st gen = hysteroscopy + direct endometrial destruction (now replaced with…)
- 2nd gen non-hysteroscopic techniques - Safer + Faster
- e.g. Balloon thermal ablation
Primary amenorrhoea define
Not starting menstruation:
- By 13 y/o if no other signs of puberty
- By 15 y/o if other signs of puberty
Hypogonadism definition
Lack of sex hormones - oestrogen or testosterone
Can be:
- hypOgonadotropic hypodonadism (low LH + FSH)
- hypERgonadotropic hypogonadism (gonads not responding to LH/FSH so LH+FSH high to try and compensate)
Causes of primary amenorrhoea
- hypogonadotropic hypogonadism
- Damage to hptothalamus/pituitary
- Reduced nutrition intake
- Significant CHRONIC CONDITIONS (e.g. CF or IBD - only temporarily tho)
- Excessive exercise / dieting
- Extreme physical / psych STRESS
- Reduced nutrition intake
- CONSTITUTIONAL DELAY in gowth + development (temporary)
- Damage to hptothalamus/pituitary
- **ENDOCRINE DISORDERS **(including adrenal hyperplasia)
-
Genetic syndromes e.g.
- Kallman syndrome
- Turner syndrome
- Androgen insensitivity syndrome
- Imperforate hymen -> haematocolpos
- Uterine agenesis
- Pregnancy
Causes of hypergonadotropic hypogonadism
- Damage to gonads (torsion, mumps, cancer)
- Congenital absence of ovaries
- TURNER’S SYNDROME
Examples of structural pathology which can prevent menstruation
- Imperforate hymen
- Transverse vaginal septae
- vaginal agenesis (vagina doesn’t develop)
- Absent uterus
- Female genital
May get cyclical abdominal pain if getting periods but the menses
Ix for delayed menarche
Initial:
- FBC + Ferritin
- U+E (?CKD)
- Anti-TTG / Anti-EMA (?coeliac)
Hormonal:
- FSH + LH
- TFTs
- Insulin-like growth factor (?GH deficiency)
- Prolactin
- Testosterone
Genetic microarray test
- Turner’s
Imaging:
- X-ray wrist (?constitutional delay)
- Pelvic US (assess ovaries + pelvic organs)
- MRI brain (pit gland pathology / olfactory dysfunction -?kallman)
Endometrial cancer
Oestrogen dependent cancer - most commonly adenocarcinoma (glandular)
Consider in any post-menopausal woman with bleeding - more common in postmenopausal group
Endometrial cancer RFx
Anything that increases exposure to unopposed oestrogen
- Increased age
- Earlier onset of menstruation / Late menopause
- Oestrogen only HRT
- No / fewer preg
- OBESITY
- PCOS (due to reduced ovulation -> less corpus leuteums to release progesterone + linked )
- Tamoxifen (blocks oestrogen receptors in breast but oestrogenic in uterus)
Also:
- DIABETES (insulin / insulin-like growth factor -> pro-proliferative effect)
- Hereditary nonpolyposis colorectal cancer
How does obesity increase endometrial cancer risk
- Adipose makes oestrogen
- it contains AROMATASE -> converts androgens into oestrogen - more fat = more aromatase + more oestrogen
- in post-menopause - no corpus luteum to make progesterone to oppose
Ovarian torsion
Ovary twists in relation to surrounding structures (the adnexa)
Causes of ovarian torsion
Usually due to ovarian MASS > 5 cm
- More likely to occur with benign tumours
- esp in preg
Sometimes occurs in pre-pubertal girls when infundibulopelvic ligaments are longer and can twist more easily (sort of mirroring testicular torsion in boys)
Ovarian torsion Px
- SUDDEN onset SEVERE, UNILATERAL pelvic PAIN
- constant + progressive
- associated N+V - sometimes intermittant
- sometimes milder + prolonged course
LOCALISED TENDERNESS + potentially PALPABLE mass on examination
Ovarian torsion Dx
-
Pelvic US
- ideally transvaginal but transabdo works too
- ‘whirlpool sign’ - FREE FLUID in pelvic cavity
- Ovarian OEDEMA
- US Doppler -> lack of blood flow
Dx = Laproscopic SURGERY
Ovarian torsion Mx
- Emergancy admission
- LAPROSCOPIC SURGERY to do either:
- Detorsion
- Oophrectomy
- Laprotomy (big cut surgery) if large mass / malig
Complications of ovarian torsion
- Loss of function of ovary
- usually not infertility + early menopause because there is usually another ovary that can compensate
If necrotic ovary not removed -> infection -> abscess -> sepsis
- can rupture -> peritonitis + adhesions
Protective factors for endometrial cancer
- cOCP
- Mirena coil
- Increased preg
- Cigarette smokin
- in post menopause as it is ANTI-OESTROGENIC (despite increasing risk in breast cancer)
- potentially oestrogen metabolised differently in smokers; or because smokers have less adipose tissue / smoking induces earlier menopause (destroys eggs)
Endometrial cancer Px
POSTMENOPAUSAL BLEEDING
- Postcoital bleeding
- Intermenstrual bleeding
- Unusual MENORRHAGIA
- Abnormal vaginal discharge
- Haematuria
- ANAEMIA
- Raised platelets
Referal criteria for endometrial cancer 2 wk wait
POST MENOPAUSAL BLEEDING
Also - refer for transvaginal US in women > 55 y/o if:
- Unexplained vaginal discharge
- Visible haematuria + raised plts / anaemia / high glucose
Endometrial cancer Ix
- Transvaginal US (endometrial thickness > 4mm post menopausal = abnormal)
- Pipelle biopsy (highly sensitive for endometrial Ca)
- Hysterectomy + endometrial biopsy (if high risk / last resort)
If 1st 2 are normal - v low risk
Pipelle biopsy
- Speculum exam
- Insert pipelle (thin tube) through cervix into uterus
- Fill with sample of endometrium
- Examine for hyperplasia / cancer
Stages of endometrial cancer
International federation of gynae and obs (FIGO) staging system:
- confined to uterus
- Invades cervix
- Invades ovaries, fallopian tubes, vagina OR lymph nodes
- Invades bladder, rectum OR BEYOND pelvis
Endometrial cancer Mx
- Stage 1 = TOTAL abdominal HYSTEROECTOMY with BILATERAL salpingo-oophrectomy + peritoneal washing
Other:
- Radical hysterectomy (remove pelvic lymph nodes, surrounding tissue + top of vagina (from stage 2 onwards) / maximal debulking where possible
- Chemo/Radiotherapy (usually in that order)
- PROGESTERONE may SLOW PROGESSION
DDx for post-menopausal bleeding
- Vulval:
- Atrophy
- Malignancy / pre-malig - Cervical polyps OR cancer
- Endometrial:
- Hyperplasia +/- cancer
- Benign endometrial polyps
- Endometrial atrophy
Types of ovarian cancer
- Epithelial cell tumours
- Serous tumours (main)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated - Dermoid cysts / Germ cell tumours (benign teratomas)
- (higher association with torsion - Sex Cord-Stromal tumours
- Sertoli-Leydig cell tumours
- Granulosa cell tumours - Mets
- Krukengerg tumour = ‘signet ring’ cells; usually from GI cancer
Referral criteria for ovarian cancer
Direct to 2-wk wait if:
- ASCITES
- PELVIC MASS (not clearly due to fibroids)
- ABDO MASS
Further Ix first (CA125 bloods) esp in women > 50 y/o with:
- Change in bowel habit
- Abdo BLOATING
- Early SATIETY
- Pelvic PAIN
- Urinary frequency / urgency
- WEIGHT LOSS
Ovarian cancer Ix
Initial (can be done in primary / seondary care):
- CA125 blood test
- Pelvic US
Further (only in 2ndry):
- CT (Dx + staging)
- Biopsy + HISTOLOGY
- PARACENTESIS if ascitic
If under 40 with complex ovarian mass -> may be teratoma:
- Alpha-Fetoprotein
- Human chorionic gonadotropin
Ovarian cancer staging
FIGO staging:
- Ovary only
- Outside ovary but still inside pelvis
- Outside pelvis but still inside abdo
- Distant mets (spread outside abdo)
Ovarian cancer Mx
Specialist gynae oncology MDT
Usually = Surgery + chemo
Cervical cancer epid
- peaks in reproductive years
- Most commonly squamous cell carcinoma
- strong association with HPV (pretty much always related to HPV infection)
RFx for cervical cancer
Increased risk of catching HPV
- Early sexual activity / increased no. of sexual partners
- Sexual partners who have had more partners
- No condoms
Not engaging with cervical screening
Other:
- SMOKING
- HIV (get annual smears instead of every 3/5 years)
- cOCP use for > 5 years
- FHx
- Increased number of full term preg
- Exposure to dithylstilbesterol
Cervical cancer Px
Can just detect through screening (asymp)
- Abnormal vaginal bleeding
- Abnormal vaginal discharge
- Pelvic pain
- Dyspareunia
(all non-specific)
Referal criteria for 2-wk wait colposcopy
- HPV +ve + Abnormal cytology on pap smear
- Abnormal appearance of cervix on speculum examination:
- Ulceration
- Inflammation
- Bleeding
- Visible tumour
Colposcopy
Inserted into vagina through speculum -> MAGNIFIES cervix + examine epithelium in detail
Can use stains to differentiate abnormal areas:
-
Acetic acid -> abnormal cells = WHITE (acetowhite)
- caused by INCREASED nuclear to cytoplasmic ratio - Schiller’s iodine test -> only healthy areas stain brown
Can also do PUNCH BIOPSY or LARGE LOOP EXCISION of TRANSFORMATIONAL ZONE
Complications of loop biopsy of cervix
- Bleeding (tho the diathermy from the fact the loop is electric should cauterise it)
- Abnormal discharge
- Both potentially for severel weeks after
Potential increase risk of pre-term labour depending on depth of tissue removed
NB: AKA Large Loop Excision of Transformation Zone
Cone biopsy
Tx for CERVICAL INTRAEPITHELIAL NEIPLASIA + early stage cervical cancer
- Remove cone-shaped piece of cervix with scalpel -> Histology
Main risks of cone biopsy
- Pain
- Bleeding
- Infection
- Scar formation leading to cervical stenosis
- Increased risk of miscarriage / prem labour
FIGO staging of cervical cancer
- Stage 1: Confined to the cervix
- A = only microscopic
- B = Gross lesions - Stage 2: Invades the uterus or upper 2/3 of the vagina
- A = No parametrial involvement (connective tissue around uterus)
- B = Obvious parametrial involvement - Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
- A = No sidewall involvement
- B = Extension to sidewall / hydronephrosis - Stage 4: Invades the bladder, rectum or beyond the pelvis (ie mets)
- A = Involves BLADDER / RECTUM
- B = DISTANT ORGANS
Cervical Intraepithelial Neoplasia
Grading system for level of dysplasia (baso pre-cancerous)
- Dx at colposcopy
- CIN 1= Mild dysplasia (1/3 thickness of epithelial layer - will probs return to normal by itself)
- CIN 2 = Mod (2/3 of thickness + likely to progress without Tx)
- CIN 3 = Severe (very likely to progress to Ca without Tx)
Dysplasia vs dyskaryosis
Dysplasia can only be Dx on colposcopy
Dyskaryosis can be determined from smear test
(both are interchangeable words for cell changes)
Cervical cancer screening (when is it done)
Routine:
- Every 3 years 25-49
- Every 5 years 50-64
Other:
- HIV +ve = ANNUAL screening
- If >65 can request one if not had one since 50
- Previous CIN needs further testing
- More screening if on cytotoxic drugs, dialysis, organ transplant etc (immunocompromise)
Don’t do routine smear while peripartum (min = 12wks post-partum)
Cervical screening method
- Speculum exam + small brush to collect cells
- Deposit cellls into perservation fluid
- (Transport via liquid-based cytology)
- Microscopy
- 1st high-risk HPV infection
- 2nd IF high-risk HPV present THEN -> cells exam for dyskaryosis
Can also detect:
- bacterial vaginosis
- Candidiasis
- Trichomoniasis
- Actinomyces-like organisms in ppl with IUDs (no Tx required unless Sx)
Mx of cervical smear results
- Normal = back to routine testing
- Inadequate sample = repeat smear after at least 3 months
- HPV +ve but NORMAL cytology = Repeat for HPV after 1 YEAR
- HPV +ve with ABNORMAL cytology = COLPOSCOPY
Cervical cancer Tx
- CIN and Early stage 1A = Loop biopsy / cone biopsy
- 1A = can do trachelectomy (cervix + upper vagina only) -> fertility preservation
- Stage 1B - 2A = RADICAL HYSTERECTOMY + removal of local LYMPH nodes +/- chemo/radio
- Stage 2B-4A = CHEMO + RADIO
- Stage 4B = Combination of surg, chemo/radio + palliative
Pelvic exenteration
Remove most/all of pelvic orgams (femal reporoductive, bladder + rectum)
- in severe / recurrent cancer
HPV vaccination
- given ideally before kid becomes sexually active
- Gardasil (current NHS version) protects against strains 6, 11, 16, 18
6+11 -> genital warts
16+18 -> cervical cancer
Follow-up after cervical cancer Tx
- every 4 MONTHS after Tx completion for FIRST 2 YRS
- every 6-12 MONTHS for NEXT 3 YRS
Must do vag/cervical exam each time if they haven’t been removed
Vulval cancer epid
Rarer
- 90% SQUAMOUS cell carcinomas
- Sometimes malignant melanoma
RFx for vulval cancer
- AGE esp >75 yrs
- ImmunoSUPPRESS
- HPV INFECTION
- Lichen sclerosis
Vulval cancer Px
Oft incidental e.g. found during catheterisation
- Vulval LUMP
- Ulcers
- Bleeding
- Pain
- Itching
- LYMPHADENOPATHY
Most commonly in LABIA MAJORA
- IRREGULAR mass
- FUNGATING lesion
- ULCER
- Bleeding
Vulval Intraepithelial Neoplasia
Premalig affecting squamous epithelium
- High grade squamous intraepithelial lesion is associated with HPV (typically in 35-50 y/o)
- Differentiated VIN associated with LICHEN SCLEROSUS (typically in 50-60 y/o)
Can only be Dx with BIOPSY
Tx for VIN
- Watch + wait (cloe follow-up)
- Wide LOCAL EXCISION
- IMIQUIMOD CREAM
- Laser ablation
Mx of vulval cancer
2-WK WAIT if suspected
- BIOPSY
- Sentinal NODE biopsy
- CT abdo + pelvis for staging
Tx:
- Wide local EXCISION
-
Lymph node dissection (groin)
- ideally removing deeper femoral nodes as superficial only = higher risk of recurrance
- CHEMO / RADIO
FIGO staging of vulval cancer
- vulval only
- lower 1/3 of vagina, uterus / anus
- upper 2/3 of vagina / urethra OR bladder/rectal mucosa OR non-ulcerated lymph nodes
- Ulcerated lymph nodes, fixation to pelvic bone OR distant mets
Complications of groin lymphadenectomy (for vulval cancer)
- Wound dehiscence (seperation of previously approximated wound edges due to failure of proper healing)
- Infection
- LymphoCYSTs
- LymphOEDEMA
- Immobility
- Prolonged hospitalisation
Lichen sclerosus define + epid
Inflam skin condition - mainly affecting GENITAL / ANAL areas
- more common in women
Vulvar lichan sclerosus involves inner vulva
Lichen sclerosus aet
Possibly autoimmune - associated with:
- T1DM
- Alopecia
- Hypothyroid
- Vitiligo
Possible link with previous skin damage
Lichen sclerosus Px
Porcelain White patches which may scar
- Shiny, tight, thin, slightly raised
- Possibly papules / plaques
Sx (can be asymp):
- Itching
- sometimes pain
- May be worse on urination / sexual intercourse
- Tightness
- Erosions / Fissures
KOEBNER PHENOMENON (made worse by friction on skin)
DDx for lichen sclerosus
- Lichen planus (purplish, itchy, bumpy, white lacy, can be in mouth)
- Psoriasis
- Vitiligo
Lichen sclerosus Mx
No cure - follow up every 3-6 months (gynae or derm specialist)
- POTENT TOPICAL STEROIDS
- Clobetasol propionate 0.05% (dermovate)
- OD for 4 WKS then reduce in freq every 4 WKS till only using TWICE WEEKLY
- Increase ti daily during flare-ups
- Reduces risk of malig - EMOLLIENTS
- Avoid soaps in affected areas
Lichen sclerosus Ix
Mainly just clinical exam
- can sometimes do biopsy to confirm
- Bloods to rule out AI conditions
Complications of lichecn sclerosus
- 5% risk of Squamous cells carcinoma
- Sexual dysfunction
- Bleeding
- Narrowing of vaginal / urethral openings
Hydatidiform mole ie molar pregnancy
Gestational trophoblastic disease
- caused by imbalance in no. of chromosomes from mother / father during conception
basically forms a tumour
RFx fro molar preg
Extremes of age:
- < 16 Y/O
- > 45 Y/O
What are the 2 types of molar preg
- Complete mole
- ie has no foetal tissue
- But does have proliferation of chorionic villi
- Only paternal DNA (the ova is empty)
- either 2 sperm or 1 sperm which replicates (ends with 46 paternal chromosomes) - Partial mole:
- some foetal tissue
- 2 sperm + normal egg -> haploid cell with 3 SETS of chromosomes
Molar preg Px
- Vaginal bleeding
- Nausea
- Hyperemesis gravidarum
- Thyrotoxicosis (due to hCG activating TSH receptors)
- Enlargement of uterus beyond expected gestational size (excessive trophoblast growth + retained blood)
Molar preg DDx
- Normal preg
- Ectopic
- Miscarriage
Molar preg Ix
- B-hCG levels
- HIGHER than in normal pregs - TRANS-VAGINAL US
- Snow storm appearance if complete molar
- Low resistance of blood vessel flow
- Absence of foetus
Confirm Dx retroscpectively from biopsy after mole removed
Molar preg Mx
Specialist referral (gestational trophoblastic disease centre) to avoid complications (choriocarcinoma / invasion)
- SUCTION CURETTAGE to Evacuate then Histology
- Can do hysterectomy if not wanting to preserve fertility
- SURVAILLANCE
- Bimonthly serum + urine hCG until levels normal
- 1st follow-up should be 4 wks after if a partial mole then can stop surrvailance if norm
- if complete mole -> remeat monthly for 6 months even if normal levels
It is possible for it to metastesise
Atrophic vaginitis
Inflammation, thinning of genital tissue after menopause due to LOW OESTROGEN
Aet of atrophic vaginitis
Normally oestrogen stimulates vagina + urinary tract to become thicker, more elastic + producing secretions
Low oestrogen -> thinner, less elastic, drier mucosa
- becomes more prone to inflammation
- causes change in vaginal pH + microbes -> contribute to localised infection
Oestrogen also helps maintain pelvic connective tissue so postmenopausal people more prone to pelvic organ prolapse + stress incontinence
Atrophic vaginitis Sx / Px
- Thinning of vaginal mucosa
- Narrowing of opening
- Loss of vaginal rugae (folds)
- Vaginal dryness + itching
- Dyspareunia
- Post-coital bleeding
- Vaginal discharge (due to inflam)
- Dysuria / recurrent UTIs / other urinary Sx
- (associated incontinence, prolapse)
- Loss of pubic hair
Atrophic vaginitis Ix
- Clinical examination
- Pale, dry mucose +/- erythema; inflam
- Thin skin + sparse pubic hair
- Reduced skin folds - Infection screen if itching + discharge
If needed:
- Transvaginal US + endometrial biopsy to exclude endometrial cancer
- Biopsy abnormal skin
Atrophic vaginitis Mx
- Lubricants (short term for e.g. dyspareunia)
- Moisterisers (regularly)
- HORMONES (needs annual monitoring for endometrial complications):
- Systemic HRT OR
- TOPICAL OESTROGEN
- Estriol cream (syringed in at bedtime)
- Estriol PESSARIES (overnight)
- Estradiol TABLETS (OD)
- Estradiol ring (only replaced every 3 months)
Contraindications of oestrogen
- Breast cancer
- Angina
- VTE
Summary of main DDx in gynae
https://zerotofinals.com/obgyn/gynaecology/differentialdiagnosis/
Endometrial polyps
Abnormal growth of glands, stroma + vasculature affecting only endometrial layer - mainly in fundus (sometimes also cervix and rarely vagina)
- usually immature endometrium so no menstrual cycle changes
Can get during reproductive / postmenopausal years (esp in 40s)
Potential link to oestrogen (higher incidence in ppl on HRT or TAMOXIFEN)
Endometrial polyps Px
Usually asymp
- Bleeding
- Infertility
- Sometimes may progress to malig
Endometrial polyps Ix
- Transvaginal US
- +/- Colour Doppler - SALINE INFUSION SONOGRAPHY (gold)
- Can check histology
Endometrial polyps Mx
Conservative - usually self-resolving
If infertility -> Surgical excision e.g. hysteroscopic polypectomy; lilation + curettage
Consider Post surgical progesterone therapy or just progesterone HRT in general
Asherman’s syndrome
When adhesions form WITHIN the Uterus following damage
- Only considered Asherman’s syndrome if SYMPTOMATIC
Usually iccurs after pregnancy- related dilation + curettage (as it can damage basal layer causing scarring)
- or uterine surgery or multiple pelvic infections
these physical abnormalities cause obstructions / distortion
Asherman’s syndrome Sx
Typically after recent uterine procedure
- 2ndry amenorrhoea
- Lighter periods
- Dysmenorrhoea
Or infertility / recurrent miscarriages
Asherman’s syndrome Dx
- HYSTEROSCOPY (gold)
- Hysterosalpingography
- Sonohysterography (saline infusion sonography)
- MRI scan
Asherman’s syndrome Tx
- dissect during hysteroscopy
- commonly reoccur
Pelvic inflammatory disease epid
Highest prevalence in sexually active women 15-24 (YOUNG SEXUALLY ACTIVE WOMEN)
PID pathophys / causative organisms
Caused by spread of infection through cervix
Most common causes = STIs
- Neisseria gonorrhoeae tends to produce more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
Less commonly:
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae
- Escherichia coli
PID RFx
- Sexually active:
- No barrier contraception
- Multiple sexual partners / recent new partner
- existing / previous STIs
- Younger age (15-24)
- PMHx of PID
- INTRAUTERINE DEVICE
Can also get vis INSTRUMENTATION (e.g. in gynae surgery / insertion of IUD etc)
Presentation of PID
- Pelvic / lower abdo PAIN
- Abnormal vaginal DISCHARGE
- Abnormal BLEEDING
- Deep DYSPAREUNIA
- Dysuria
If severe:
- severe pain, FEVER, N+V
Examination findings indicative of PID
- Pelvic TENDERNESS
- Cervical motion tenderness (cervical excitation)
- Cervicitis
- Purulent discharge
Signs of sepsis if severe
PID Ix
-
ENDOCERVICAL SWABS (chlamydia + gonnorhoea) / HIGH VAGINAL SWAB (trichomoniasis + vaginosis)
- NAAT
- microscopy for PUS CELLS - Full STI screen (esp HIV, SYPHILIS)
- Urine dipstick +/- MSU (to exclude UTI)
- Preg test (to exclude)
- Transvaginal US (if severe / uncertainty)
- Laparoscopy (+ peritoneal biopsy) - only if severe AND uncertainty
- Bloods (RAISED INFLAM MARKERS)
PID Mx
GUM referral
- EMPIRICAL ABx (before swab comes back)
- e.g. combination of cefriaxone, doxy + metranidazole for broad cover (check local guidelines)
- Consider analgesia
- Rest + avoid sex
- CONTACT TRACING - everybody in LAST 6 MONTHS
When should ppl be admitted to hospital for PID
- If PREG - esp if risk of ECTOPIC
- Severe Sx: N+V + FEVER (sepsis)
- Signs of PERITONITIS
- UNRESPONSIVE TO ORAL ABx (as will then need IV)
- Need emergancy surg
- e.g. PELVIC ABCESS drainage - Suspicion of other diagnosis
Complications of PID
- Sepsis
- Abscess
- Infertility / Ectopics
- Chronic pelvic PAIN
- Fitz-Hugh-Curtis syndrome (perihepatic adhesions due to infalm of liver capsule -> RUQ pain -> Laparoscopy + adhesiolysis)
esp if prolonged / recurrent
Amenorrhoea / oligomenorrhoea summary
https://teachmeobgyn.com/gynaecology/menstrual/oligomenorrhoea/
Prolactinoma
Tumour of anterior pituitary gland -> excessive prolactin secretion from LACTOTROPHS
- can be associated with multpiple endocrine neoplasia type 1 (autosomal dominant)
Can be:
- Micro = <10mm
- Macro = >10mm
Prolactinoma Px
If macro -> raised ICP / headaches + bitemporal hemianotopia etc
Also:
- High prolactin -> negative feedback to hypothalamus -> reduced GnRH -> reduced LH + FSH -> Reduced oestrogen / testosterone
- Inhibits ovulation / spermatogenesis - a/oligomenorrhoea - Erectile dysfunction - Low oestrogen also leads to OSTEOCLAST PROLIFERATION (oestrogen usually inhibits osteoclasts) - Osteoporosis / frax - Vaginal dryness - Gynecomastia - GLACTORRHOEA
- Low LIBIDO + INFERTILITY
Microprolactinomas are often asymp
Prolactinoma Dx
- Raised prolactin in blood
- Raised Thyrotropin- releasing hormone (if 2ndry prolactinoma)
- MRI BRAIN (classify)
Prolactinoma Tx
Medical = DOPAMINE AGONISTS (oft enough to make tumour regress)
- Bromocriptine
- Cabergoline
Surgery if macro / not responsive to dopamine
+/- Radiotherapy
Examples of congenital abnormalities of female reproductive tract
- Bicornate uterus
- Imperforate hymen
- Transverse Vaginal septae
- Vaginal hypoplasia + agenesis
Bicornate uterus
- uterus has 2 ‘horns’
- Dx on USS
- ADVERSE PREG outcomes tho USUALLY SUCCESSFUL PREG
- Miscarriage
- Prem birth
- Malpresentation
Usually no specific Mx needed
Imperforate hymen
- no hole in hymen at entrance of vagina
- Oft discovered when menstruation starts but menses unable to be expelled
- Cyclical pelvic pain + cramping but NO bleeding - Dx with EXAMINATION
- Tx = Surgical incision
If not treated - could lead to retrograde menstruation + endometriosis
Transverse vaginal septae
- Septum transversely across vagina
- If perforate:
- Menstruation can occur but difficulty with sex / tampons - If imperforate:
- Similar to imperforate hymen - Associated with INFERTILITY / PREG COMPLICATIONS
Dx via exam, US / MRI
Tx = SURGICAL
- complications = vaginal stenosis / recurrance
Vaginal hypoplasia / agenesis
- Abnormally small vagina / NO vagina respectively
- due to failure of Mullarian duct development
- Can be associated with absent uterus / cervix as well
- BUT OVARIES USUALLY NORMAL
- Except in androgen insensitivity syndrome (internal testes)
- BUT OVARIES USUALLY NORMAL
- Mx -> vaginal dilater over prolonged period; vaginal surgery etc
Pelvic organ prolapse
Descent of one/more pelvic structures from normal anatomical position -> moving towards/through vaginal opening
- common condition esp in postmenopausal + post childbirth
RFx for pelvic organ prolapse
Anything that cuases stretched muscles / ligaments
- Multiple vaginal delivaries
- Instrumental, traumatic / prolonged delivery
- Advanced age / postmenopausal
- OBESITY
- COPD -> Coughing OR Chronic constipation + straining (Chronic RAISED ABDOMINAL PRESSURE)
- Hysterectomy
- Heavylifting
- Connective tissue disorders
Pelvic organ prolapse Px
- Feeling of ‘something coming down’
- Dragging / Heavy sensation
- Visible protrusion - LUTS / recurrent UTIs
- Defecatory Sx e.g. constipation / tenesmus
- Sexual dysfunction (pain altered sensation)
Examination of pelvic organ prolapse
- attempt various positions INCLUDING DORSAL + LEFT LATERAL
- SIM’S SPECULUM
- Ask to cough / bear down to assess full descent
Types of pelvic organ prolapse
Anterior vaginal wall:
- Cystocele (may lead to stress incontinence)
- Urethrocele
- Cystourethrocele
Posterior wall:
- Enterocele (small intestine)
- Rectocele
Apical wall:
- Uterine prolapse
- Vault prolapse (roof of vagina - common after hysterectomy)
- (cervical prolapse?)
Rectocele
- associated with CONSTIPATION
- Can develop faecal loading in prolapsed part
-> Constipation, urinary retention (due to compression), palpable lump (women may push lump back themselves)
Grades of uterine prolapse
Pelvic organ prolapse quantification (POP-Q):
- 0 = Normal
- 1 = Lowest part >1cm above interoitus (opening)
- 2 = Lowest part within 1 cm of interoitus (above OR below)
- 3 = Lowest part >1cm below interoitus but not full descended
- 4 = Full descent + EVERSION of vagina
Anything extending beyond interoitus = uterine procidentia
Mx of pelvic organ prolapse
- Conservative (if mild OR can’t tolerate other options)
- Physio (PELVIC FLOOR EXERCISES)
- Weight loss
- Lifestyle changes (e.g. reduced caffine intake / incontinence pad for associated stress incontinence)
- Treat associated Sx e.g. anticholinergics for stress incont
- Vaginal oestrogen cream
- Vaginal pessaries (-> extra support + easily removed if needs)
- Ring pessaries (around cervix)
- Shelf + Gellhorn (flat disk with stem)
- Cube
- Donut
- Hodge pessaries (almost rectangular - hooks around posterior cervix then extends into vagina)
+/- Oestrogen cream to protect vaginal walls from irritation / erosion
- Surgery (e.g. hysterectomy)
Possible complications of pelvic organ prolapse surgery
- Pain, bleeding, infection, DVT, anaesthesia risk
- Damage to bladder / bowel
- Recurrance
- Altered experience of sex
Why are mesh repairs of pelvic organ prolapses no longer recommended
Many associated complications:
- Chronic pain
- Altered sensation
- Dyspareunia
- Abnormal bleeding
- Urinary / bowel problems
Types of miscarriage
- Threatened (mild bleeding, pain may be absent, cervical is closed, foetus visible on uss)
- Inevitable (heavy bleeding and pain, cervical os open, but foetus still currently inside)
- Complete (all products of conception now fully expelled and cervical os usually closed again)
- Missed miscarriage (foetus has died but cervical os remained closed so no symptoms)
Causes of miscarriage
Foetal causes:
- genetic disorder
- abnormal development
- placental failure
Maternal causes:
- Physical uterine abnormality
- Cervical incompetence
- PCOS
- Poorly controlled diabetes
- Poorly controlled thyroid disease
- Anti phospholipid syndrome
Miscarriage definition
Loss of pregnancy before 24 weeks gestation
Miscarriage Sx
- Vaginal bleeding
- pain (potentially more than with normal period)
- Vaginal tissue loss
Miscarriage Vs ectopic pregnancy
In ectopics, pain is usually the initial and dominant feature and any bleeding that occurs is less so than in miscarriages
Miscarriages are characterised by heavy bleeding and pain
Miscarriage Ix
- Transvaginal USS to check for any interuterine foetal components and check for foetal heartbeat
- if not present start doing serial serum hCG measurements 48 hours apart
- falling hCG = no more foetal development / miscarriage
- plateau / small rise = possibly ectopic
- normal rise = foetus growing normally but may still be ectopic
Miscarriage Mx
Cannot be reversed so need to get rid of pregnancy
- Expectant management = allow it to naturally expel
- Medical = ** Misoprostol - synthetic prostaglandin** which stimulates expulsion of products of conception
- Mifepristone is a progestérone receptor antagonist that is used to terminate pregnancy but it is also needed for a missed miscarriage
- Surgical - dilation and curettage
Anti-D prophylaxis if mother is rhesus negative
Recurrent miscarriages definition
Loss of 3 or more consecutive pregnancies
Recurrent miscarriages definition
Loss of 3 or more consecutive pregnancies
Investigating recurrent miscarriages
- Bloods
- Anti phospholipid antibodies
- Thrombophilia screen
- Cytogenic analysis of products of conception
- karyotype the parents if this is abnormal
- Pelvic USS (check for uterine abnormalities)
Managing recurrent miscarriages
Depends on underlying cause
- Genetic = genetic counseling, consider prénatal diagnosis or donor egg/sperm if still trying for kids
- structural abnormality = some can be surgically treated
- cervical incompetence = regular USS monitoring; can use cervical cerclage
- PCOS - Unsure of best treatment, follow local guidelines
- Anti phospholipid syndrome = heparin / low dose aspirin
- thrombophilia = try heparin
- Diabetes = improve glycaemic control
Lifestyle factors affecting infertility
- increasing age
- obesity
- smoking
- excessive alcohol
- illicit drug use
- anabolic steroids and tight underwear more so in men
Lifestyle factors affecting infertility
- increasing age
- obesity
- smoking
- excessive alcohol
- illicit drug use
- anabolic steroids and tight underwear more so in men
Causes of infertility
- Genetic (Turner’s / Kleinfelter’s)
- Ovulation / Endocrine (pcos, pituitary tumor, Sheehan’s, hyperprolactinaemia, Cushing, premature ovarian failure)
- Tubal abnormalities (congenital or adhesions)
- Uterine abnormality
- Endometriosis
- Cervical abnormality
- Testicular disorder
- Ejaculatory disorder
Infertility Ix
- Serum progesterone 7 days before end of menstrual cycle (usually day 21)
- assess TFTs, prolactin, androgens
- semen analysis
- Imaging studies (uss, hysterosalpingography, laproscopy)
Examples of gonadotrophin releasing hormone analogues
- Leuprorelin
- Triptorelin
Works by activating GnRH receptors for prolonged period till they get desensitized - eventually leading to suppression of gonadotrophin (FSH and LH) secretion
Can be used to stimulate a menopausal state and switch off the ovaries e.g. to treat endometriosis (tho this is not the first line)
How long do you need to wait to do a pap smear after giving birth / having a miscarriage
3 months
Define pre-menstrual syndrome
Cluster of psychological, physical + behavioural Sx occuring in the LEUTEAL pahase of the menstrual cycle which causes DITRESS / DISRUPTION to patient’s life
PMS Sx
Varies widely but common Sx include:
- Mood swings + irritability
- Depression + anxiety
- Fatigue + sleep problems
- Change in appetite + food cravings
- Difficulty concentrating
- Physical Sx e.g. bloating, breast tenderness, headaches, joint / muscle pain
PMS DDx
- Tyroid disease
- Chronic fatigue syndrome
- Depression / anxiety disorders
PMS Dx
Clinical Dx
- Sx diary for at least 2 menstrual cycles can be helpful
Do further investigations if uncertain / suspect other conditions
PMS Mx
Conservative:
- Dietary modification
- LESS fat, sugar, caffeine, alcohol
- MORE fibre, fruit + more frequent snacks
- Increase exercise
- Vitamin supps (vit B)
- Relaxation techniques to reduce stress
- CBT
Pharm:
- cOCP (with short / no pill free interval to avoid progestogenic side effects)
- Danazol (synthetic steroid + pituitary GnRH inhibitor)
- Transdermal oestrogen
- GnRH analogues (menopausal state)
- Antidepressants (esp SSRIs / SNRIs)
Investigations for overactive bladder syndrome
- Urinalysis + culture to rule out infection
- Frequency/volume chart - to assess severity
- Urodynamics - to evaluate bladder muscle function (e.g. cystometry, pressure flow study / voiding pressure study)
Overactive bladder syndrome Mx
- Behavioural modifications:
- reduce oral intake, avoid caffeine + alcohol
- Bladder retraining
- ANTICHOLINERGICS
- Oxybutynin
- Solifenacin
- Vaginal oestrogens if urogenital atrophy is a likely factor
- Botulism toxin if REFRACTORY
Gravidity definition
Number of times person has been pregnant REGARDLESS of outcome, INCLUDING current pregnancies.
Mutliple pregnancies are counted as 1 event.
Parity definition
Number of times person has given birth to a pregnancy with gestational age at least 24+0 weeks, regardless of if they were alive or still born, or method of delivery.
Multiple pregnancies are counted as 1 event.
NB if they have had terminations/miscarriages before 24wks, can write it as
- number or of births (+ terminations/miscarriages)
Termination of pregnancy legal time frame + Act
Less than 24 wks gestation
Can be more if meets certain criteria:
- continuing preg would cause grave permanent injury to physical + mental wellbeing of woman
- Continuing preg would involve greater risk to the life of the woman
- Substantial risk child would suffer from physical or mental abnormalites and be seriously handicapped (e.g. spina bifida, Down’s)
Medical termination of pregnancy
- Mifepristone (progesterone antagonist) blocks progesterone needed for preg to continue
- oft 200 mg orally
- Misoprostol (prostaglandin analogue) causes smooth muscle contraction to expel uterine contents
- oft 800 micrograms vaginal, buccal, or siblingual
Given within 24-48 hours of each other
Surgical termination of pregnancy
- Suction termination
- can be done if less than 14 wkjs preg
- Dilation + evacuation / Curettage
Risk factors for prelabour rupture of membranes at term
- infection
- inflam
- stress
- mechanical stress
Prelabour rupture of membranes at term Sx
- Foul smelling / greenish amniotic fluid
- Maternal fever
- Reduced foetal movements
DDx for PROM
- Urinary incontinence
- Vaginal discharge / infection (can be ruled out if no other infective sx / no infected seeming discharge)
Forms of emergency contraception
Oral progesterone receptor modulators
-
Levonorgestrel (1.5mg)
- Needs to be taken within 72 hours after unprotected sex (efficacy decreases with time)
- One-off tablet; can’t be used long-term
- but can start hormonal contraception immediately after
- Safe and well tolerated - can disrupt menstrual cycle; sometimes causes vomiting
- If vomiting within 3 hours of taking pill -> repeat dose
-
Ulipristal (EllaOne) - (30mg)
- Needs to be taken within 5 days after unprotected sex
- One off tablet; can’t be used long-term
- can disrupt effectiveness of hormonal contraception so need to use barrier contraception for 5 days after
- Can cause side effects in patients with ASTHMA
- also need to stop breastfeeding for a week after taking ulipristal (don’t have to with levonorgestrel)
Copper Intrauterine device
- most effective
- Needs to be inserted within 5 days of unprotected sexual intercourse OR up to 5 days after estimated ovulation date (whichever comes later)
- Can be left in situ to provide long-term contraception
- can give Abx if patient at high risk of STI
From which day post-partum is contraception required
day 21 after giving birth
Exmples of post-partum contraception
Progesterone only pill
-
Can be started at any point post-partum
- need to use additional contraception for 2 days after day 21
- only a small amount of progesterone enters breastmilk so it is safe to breastfeed while on POP
cOCP
- ABSOLUTELY CONTRAINDICATED if BREASTFEEDING less than 6 wks post-partum (UKMEC cat 4)
- Some risk present if using while breastfeeding between 6wks - 6 months but generally advantages outweigh risk (UKMEC cat 2)
- can potentially reduce breast milk production
- CONTRAINDICATED in FIRST 21 DAYS for all mothers due to VTE RISK
- If using after 21 days - need to use additional contraception for 7 days
IUD
- needs to be inserted EITHER within 48 HOURS post-partum OR postponed till 4 WKS post-partum (can’t insert from 2 days till 4 weeks)
Lactational amenorrhoea
- less effective
- only 98% effective if:
- FULLY breastfeeding
- AMENORRHOIC
- less than 6 months post-partum
Examples of UKMEC 3 conditions for using cOCP
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
- DM diagnosed > 20 years ago (tho if more severe = cat 4)
UKMEC 4 conditions for cOCP use
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
Recurrent thrush definition, ix and mx
- 4 or more per year
- check if compliant with treatment
- HIGH VAGINAL SWAB MS+C +/- blood glucose to check for diabetes
- exclude differentials e.g. lichen sclerosus
- try INDUCTION MAINTENANCE RÉGIME
- Oral FLUCONAZOLE every 3 days for 3 doses
- oral FLUCONAZOLE every week for 6 months
