Gynae Flashcards
Define the different types of urinary incontinence
Stress: involuntary leakage of urine on effort/ exertion (e.g. coughing/ sneezing).
Urgency: involuntary leakage of urine preceded by a strong desire to pass urine. Can be caused by overactive bladder syndrome.
Mixed: a combination of these symptoms.
Investigations for urinary incontinence
Urine dipstick/ MSU - rule out infection
Frequency volume chart - record voided volume/ frequency or urination/ quantity + frequency of LUTS
Urodynamic tests e.g. cystometry - measures the detrusor muscle contraction and pressure whilst voiding, used to confirm diagnoses
Risk factors for stress incontinence
Pregnancy
Vaginal delivery
Obesity
Post-menopausal
Age
Neurological conditions e.g. multiple sclerosis
Pathophysiology of stress incontinence
Increased intra-abdominal pressure –> increased bladder pressure. Combine with weak pelvic floor support–> bladder neck slip below pelvic floor –> involuntary voiding.
Pathophysiology of overactive bladder
over activity of the detrusor muscle –> increased bladder pressure –> urgency + urge incontinence preceded by strong desire to pass urine
Management of stress incontinence
Conservative = physiotherapy + lifestyle (lose weight, reduce fluid intake)
Medical = duloxetine (SNRI)
Surgical = TVT (tension-free vaginal tape) or TOT (trans obturator tape)
Common finding on examination of patient with stress incontinence
Rectocele/ Cystocele
Management of urge incontinence
Conservative = bladder retraining
Medical = anticholinergic medication (e.g. oxybutynin), alternative = mirabegron
Surgical = botulinum toxin type A injection, augmentation cystoplasty
Caution for medical management of urge incontinence
Anticholinergic medications e.g. oxybutynin cause side effects (dry eyes, urinary retention, constipation, postural hypotension) and cognitive decline which can be problematic to the patient SO THEY SHOULD BE USED WITH CAUTION AND MIRABEGRON CAN BE CONSIDERED AS AN ALTERNATIVE.
Pathophysiology of pelvic organ prolapse
Structures of the levator ani are weakened which causes the pelvic fascia to be overstretched. As a result, the pelvic organs descend into the vagina
Types of pelvic organ prolapse
Rectocele - rectum bulges through posterior wall of the vagina
Cystocele - bladder bulges through anterior wall of the vagina
Uterine prolapse - uterus hangs down into the vagina
Vault prolapse - in patients who have had a hysterectomy, the top of the vagina (the vault) may descend into the vagina
Define rectocele
rectum bulges through posterior wall of the vagina
Define cystocele
bladder bulges through anterior wall of the vagina
Define uterine prolapse
Uterine prolapse - uterus hangs down into the vagina
Define vault prolapse
Vault prolapse - in patients who have had a hysterectomy, the top of the vagina (the vault) may descend into the vagina
Risk factors for pelvic organ prolapse
Multiple vaginal deliveries
Instrumental/ prolonged/ traumatic delivery
Obesity
Advanced age
Pelvic surgery (e.g. hysterectomy)
Clinical presentation of pelvic organ prolapse
Patient experiences dragging/ heavy sensation in their pelvis. They may have identified a lump/ mass and have to push this to initiate bowel movements.
Urinary symptoms - urgency, frequency, incontinence, retention
Bowel symptoms - constipation, incontinence, urgency
Sexual dysfunction - pain, altered sensation, reduced enjoyment
Management of pelvic organ prolapse
Conservative = physiotherapy (pelvic floor exercises) + lifestyle (weight loss, avoid high-impact exercise)
Medical = vaginal oestrogen cream + vaginal pessary
Surgical = pelvic floor repair
Purpose of vaginal pessary + types
Purpose = provide extra support to pelvic organs from within the vagina. Significantly improve symptoms non-invasively but can cause vaginal irritation and erosion long-term. Good for patients who are considering having children in the future.
Ring - sit around the cervix and hold the uterus up
Shelf/ Gellhorn - flat disc with a stem that sits below the uterus (make it challenging to have sex)
Define a genital tract fistula
Abnormal connection(s) between the bladder and vagina which creates a single, or multiple openings and causes urine to leak from the vagina
Aetiology: congenital, external trauma, radiotherapy, difficult childbirth (forceps laceration, C-section, uterine rupture), surgery (hysterectomy, ant-incontinence surgery, prolapse surgery)
CP: continuous incontinence from the vagina after a recent pelvic operation (small = watery discharge from the vagina + normal voiding)
Ix: 3 swab test, cystoscopy, urodynamics
Mx: catheter (small/ early) –> surgery
Aetiology of genital tract fistula
Congenital
Difficult childbirth (forceps laceration, uterine rupture, C-section)
Surgery (hysterectomy, anti-incontinence surgery, prolapse surgery)
External trauma
Radiotherapy
Clinical presentation of a genital tract fistula (vesico-vaginal fisutla)
CP: continuous incontinence from the vagina after a recent pelvic operation (small = watery discharge from the vagina + normal voiding)
Investigations for a genital tract fistula
3 swab test (gauze @ top/ middle/ bottom of vagina, insert catheter and blue dye into bladder, blue dye on swabs = leak)
Cystoscopy and EUA (examination under anaesthetics)
Urodynamics
Management of a genital tract fistula
Small/ diagnosed early = catheter (chance to heal itself)
Definitive = surgery
Aetiology of cervical cancer
> 70% of cases caused by HPV-16 or HPV-18.
HPV infection –> inhibition of tumour suppressors p53 + pRb by E6 + E7 oncoproteins –> uncontrolled proliferation of cells
Risk factors for cervical cancer
Increased risk of HPV (early sexual activity, not using condoms, numerous sexual partners, sexual partner with increased no. of sexual partners)
Non-engagement with screening programme
Others: smoking, HIV, FHx, COCP (>5yrs)
Define cervical intraepithelial neoplasia (CIN)
Premalignant dysplasia of cervical epithelium, often at squamocolumnar junction, driven by HPV infection
Grading of CIN
Done using colposcopy
CIN-1 = low-grade cervical lesions (LSIL): dysplasia in the basal 1/3rd of epithelium
CIN-2 = high-grade cervical lesions (HSIL): dysplasia in the basal 2/3rd of epithelium
CIN-3 = carcinoma-in-situ (CIS): dysplasia of more than 2/3rd of the epithelium, without invasion of the basement membrane
Clinical presentation of cervical cancer
Detected in asymptomatic women at cervical screening
Symptomatic = abnormal vaginal bleeding (intermenstrual, postcoital, post-menopausal), vaginal discharge, dyspareunia
Investigations for suspected cervical cancer
Cytology - look at cervical cells under a microscope to detect cellular abnormalities
Colposcopy - visualise cervix in detail + use stains to differentiate abnormal areas + perform biopsy
(Acetic acid - abnormal cells turn white, highlights CIN and cervical cancer cells with more nuclear material
Schiller’s iodine test - abnormal areas will not stain
LLETZ - local anaesthetic administered, use diathermy to remove abnormal epithelial tissue + cauterise tissue
Cone biopsy - treatment for CIN/ early-stage cervical cancer, performed under GA, use scalpel to excise piece of cervix)
Stains/ procedures conducted during colposcopy
Acetic acid - abnormal cells turn white, highlights CIN and cervical cancer cells with more nuclear material
Schiller’s iodine test - abnormal areas will not stain
LLETZ - local anaesthetic administered, use diathermy to remove abnormal epithelial tissue + cauterise tissue
Cone biopsy - treatment for CIN/ early-stage cervical cancer, performed under GA, use scalpel to excise piece of cervix
HPV vaccination schedule + target groups
Girls + boys aged 11-14YO, 2 doses 6/24 months apart, aim = protect before the onset of sexual activity
Other eligible groups (2 doses 6 months apart): MSM aged 15-45YO, high-risk individuals (e.g. sex workers)
NHS cervical screening programme
3 investigations: high-risk HPV testing, cytology, colposcopy
Program: every 3yrs aged 25-49/ 5yrs if aged 50-64
HIV +ve = annual, immunocompromised people may have additional screening, pregnant women wait until 12/52 postpartum
Management of cervical cancer
Stage IA1 = manage conservatively
Stage IA-IIA (early-stage disease) = radical hysterectomy w/ lymphadenectomy
Stage IIb-IVa (locally advanced) = chemoradiation
Stage IVb (metastatic disease) = combination chemotherapy
Management of CIN
CIN-1 = watch and wait
CIN-2/3 = consider excision/ ablation
HPV types associated with cervical cancer
Type 16
Type 18
Drug used to prevent miscarriage up until 1971 that causes an increased risk of cervical cancer
Diethylstilboestrol (DES)
Types of cervical cancer
Squamous cell carcinoma (80%)
Adenocarcinoma
Small cell cancer (v. rare)
Differential for cervical cancer
Ectropion (benign growth of columnar epithelium on the outside of the cervix) - can cause vaginal discharge/ bleeding/ dyspareunia
What is ectropion?
benign growth of columnar epithelium on the outside of the cervix
can cause vaginal discharge/ bleeding/ dyspareunia
Define endometrial cancer
(mostly) oestrogen-dependent cancer affecting the lining of the uterus (endometrium)
mainly affects post-menopausal individuals
Aetiology of endometrial cancer
Unopposed oestrogen due to endogenous/ exogenous lack of progesterone
Endogenous - PCOS, obesity, nulliparity, early menarche + late menopause
Exogenous - HRT (oestrogen-only), tamoxifen
Endogenous causes of endometrial cancer
PCOS, obesity, nulliparity, early menarche + late menopause
Exogenous causes of endometrial cancer
HRT (oestrogen-only), tamoxifen
Risk factors for endometrial cancer
Obesity + T2DM
HTN, hypothyroidism, nulliparity, early menarche + late menopause, tamoxifen use, PCOS
Protective factors against endometrial cancer
smoking, caffeine, exercise, aspirin use, parity, COCP
Clinical presentation of endometrial cancer
Post-menopausal bleeding, heavy/ irregular periods in younger individuals
Other: vaginal discharge, advanced = pelvic pain/ oedema/ rectal bleeding/ weight loss/ fatigue, metastatic = cough/ abdo pain/ bone pain/ jaundice
Investigations for endometrial cancer
Transvaginal ultrasound + pipelle biopsy (v. specific for endometrial cancer)
Consider hysteroscopy w/ endometrial biopsy
Staging of endometrial cancer
Stage 1a = endometrium only
stage 1b = <1/2 myometrium
stage 1c = >1/2 myometrium
stage 2a = cervical glands
stage 2b = cervical stoma
stage 3 = invades through uterus
stage 4 = further spread (e.g. in bowel/ bladder/ distant metastases)
Management of endometrial cancer
Laparoscopic hysterectomy + bilateral salpingoophrectomy (BSO) = most common
Adjuvant = external beam radiotherapy (indications= high risk of extrauterine disease, proven extrauterine disease, inoperable/ recurrent disease, palliation for symptoms)
Define ovarian cancer
malignant neoplasm of the ovary with a vague and insidious onset, often causing patients to present with a pelvic mass + late stage disease
most commonly affects older women 60-70YO
Risk factors for ovarian cancer
Incessant ovulation - nulliparity, early menarche + late menopause, use of HRT>5yrs
Other: FHx (BRCA1/ BRCA2), occupational carcinogen exposure (asbestos), obesity/ diabetes/ sedentary lifestyle
((Protective = lactating, pill, parity))
Protective factors for ovarian cancer
lactating
pill
parity
Clinical presentation of ovarian cancer
Non-specific symptoms: abdominal bloating, early satiety, loss of appetite, pelvic pain, urinary symptoms (frequency/ urgency), weight loss, abdominal/ pelvic mass, ascites
Investigations for ovarian cancer
Raised CA125 blood test (>35IU/mL) = indication for ultrasound
Raised CA125 = non-specific, can also be caused by: endometriosis, fibroids, adenomyosis, pregnancy etc.
Ultrasound/ physical examination find pelvic/ abdominal mass OR ascites = urgent secondary-care referral
Woman <40YO with complex ovarian mass = check tumour markers for germ cell tumour (alpha-fetoprotein + hCG)
What can cause a raised CA125, aside from ovarian cancer?
Endometriosis
Fibroids
Adenomyosis
Pregnancy
Liver disease
Management of ovarian cancer
Exploratory laparotomy (may feature TAH + BSO, omentectomy, lymph node sampling)
Adjuvant chemotherapy (first-line = carboplatin + paclitaxel)
Second-line = pegylated liposomal doxorubicin (PLDH) + topotecan
First-line chemotherapy drugs for ovarian cancer
carboplatin + paclitaxel
Staging 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)
Epidemiology of ovarian cancer
Older women (60-70YO), <40YO = extremely rare
Most common type of vulval cancer
squamous cell carcinoma (>90%)
What conditions are commonly associated with vulval cancer?
VIN - vulval intraepithelial neoplasia (pre-malignant condition affecting squamous epithelium of the skin)
Lichen sclerosus - 5% of patients with lichen sclerosus develop vulval cancer
What is VIN?
Vulval intraepithelial neoplasia (VIN) = pre-malignant condition affecting squamous epithelium of skin that precedes vulval cancer
Risk factors for vulval cancer
Lichen sclerosus
Advanced age (>70YO)
Immunosuppression
HPV
VIN
Clinical presentation of vulval cancer
Often an incidental finding in an older woman, most frequently affects labia majora
Vulval lump, ulceration, bleeding, pain, itching
Investigating vulval cancer
Biopsy of the lesion - establish histological type
Management of vulval cancer
Wide local excision +/- inguinal lymphadenectomy. Radiotherapy if lymph nodes are involved.
Risk factors for vaginal cancer
HPV infection, CIN/ vaginal intraepithelial neoplasia (VAIN), SLE, HIV/ AIDs, PMHx of gynae cancer
Clinical presentation of vaginal cancer
Unexplained palpable mass in/ at entrance to the vagina
Other: smelly/ bloodstained vaginal discharge, IMB, post-menopausal bleeding, post-coital bleeding, mass/ ulcer in the vagina, pruiritus, painful urination
Diagnosis of vaginal cancer
Colposcopy with biopsy
Management of vaginal cancer
Intravaginal radiotherapy
Radical surgery
Define menarche
The first occurrence of menstruation, resulting from the hypothalamic pituitary axis ‘waking up’ the ovaries
The physiology of menarche
Hypothalamic GnRH pulses increase –> FSH + LH release (pituitary) –> secretion of oestrogen from ovaries –> development of secondary sexual characteristics (breast development, pubic hair, menarche)
Typical ages of the development of secondary sexual characteristics in girls
9-11YO = breast development
111-12YO = pubic hair
13-16YO = menarche
Define the menstrual cycle
hormonal changes → ovulation + inducing change in endometrium to prepare for implantation (should fertilisation occur)
Normal parameters of the menstrual cycle
Menarche <16YO + menopause > 45YO
3-8 days of menstruation
<80mL blood loss
24-38 day cycle
No intermenstrual bleeding
The phases of the menstrual cycle
Menstruation (Day 1-4): get rid of it all
Endometrium sheds, aided by myometrial contractions (cramps)
Proliferative phase (Day 5-13): create one follicle + oocyte
GnRH (hypothalamus) → LH + FSH release (pituitary) → follicular growth
Follicles produce oestradiol + inhibin → FSH suppression → one follicle + oocyte mature
Oestradiol reaches maximum → i) endometrial proliferation + ii) LH surge (–> ovulation within 36hrs)
Ovulation (Day 14): egg released from follicle (now known as corpus luteum)
Luteal/ secretory phase (Day 14-28): implantation or menstruation
Corpus luteum produces oestradiol + progesterone → secretory changes in endometrium (stromal cells enlarge/ glands swell/ blood supply increases)
Day 21 = progesterone peak
Corpus luteum fails if egg not fertilised → oestrogen + progesterone fall (hormonal support withdrawn) + endometrium breaks down
Describe the menstruation phase of the menstrual cycle
Menstruation (Day 1-4): get rid of it all
Endometrium sheds, aided by myometrial contractions (cramps)
Describe the proliferative stage of the menstrual cycle
Proliferative phase (Day 5-13): create one follicle + oocyte
GnRH (hypothalamus) → LH + FSH release (pituitary) → follicular growth
Follicles produce oestradiol + inhibin → FSH suppression → one follicle + oocyte mature
Oestradiol reaches maximum → i) endometrial proliferation + ii) LH surge (–> ovulation within 36hrs)
Define ovulation
Ovulation (Day 14): egg released from follicle (now known as corpus luteum)
Describe the luteal/ secretory phase of the menstrual cycle
Corpus luteum produces oestradiol + progesterone → secretory changes in endometrium (stromal cells enlarge/ glands swell/ blood supply increases)
Day 21 = progesterone peak
Corpus luteum fails if egg not fertilised → oestrogen + progesterone fall (hormonal support withdrawn) + endometrium breaks down
Day of menstrual cycle (if 28 days) when progesterone peaks
day 21
Day of menstrual cycle (if 28 days) when ovulation occurs
day 14
Secretory changes in endometrium caused by progesterone (+ oestradiol)
Stromal cells enlarge
Glands swell
Blood supply increases
What drives ovulation?
LH surge in the proliferative phase of the menstrual cycle
Define menopause
retrospective diagnosis of last menstrual period made after 12 months of amenorrhoea, typically occurring @ 51YO, premature = <40YO
Define perimenopause
The time leading up to the last menstrual period and 12 months after. Characterised by vasomotor symptoms + irregular periods.
Define premature menopause
menopause <40YO, the result of premature ovarian insufficiency
Describe the physiology of menopause
Caused by a lack of ovarian follicular function
↓ in development of ovarian follicles → ↓ production of oestrogen → ↑ LH+FSH release from pituitary → anovulation + amenorrhoea + menopausal symptoms
Clinical features of menopause
Early - hot flushes, night sweats, poor sleep, irritability, insomnia, psychological
Late - skin + breast atrophy, hair loss, atrophic vaginitis, prolapse, urinary symptoms, osteoporosis, cardiovascular disease, sexual problems (e.g. decreased libido), urogenital problems (e.g. dyspareunia, burning, dryness)
Regimens of HRT
No uterus = oestrogen-only pill (Elleste Solo/ Premarin)/ patch (Evorel)
Perimenopausal w/ periods = cyclical combined tablets (Elleste-Duet/ Femoston)/ patches (Evorel Sequi)
OR mirena coil + oestrogen-only pills/ patches
Postmenopausal w/ uterus = continuous combined tablets (Elleste-Duet Conti/ Femoston Conti)/ patches (Evorel Conti)
OR mirena coil + oestrogen-only pills/ patches
HRT Regimen for patient with no uterus
oestrogen-only pill (Elleste Solo/ Premarin)/ patch (Evorel)
HRT Regimen for postmenopausal patient with a uterus
Postmenopausal w/ uterus = continuous combined tablets (Elleste-Duet Conti/ Femoston Conti)/ patches (Evorel Conti)
OR mirena coil + oestrogen-only pills/ patches
HRT Regimen for perimenopausal patient with periods
Perimenopausal w/ periods = cyclical combined tablets (Elleste-Duet/ Femoston)/ patches (Evorel Sequi)
OR mirena coil + oestrogen-only pills/ patches
Risks of HRT
increased risk of breast/ endometrial cancer, VTE, and cardiovascular events
BUT risk not increased in women < 50YO AND no risk of endometrial cancer if people w/o uterus
Symptomatic relief, apart from HRT, available for menopause
Testosterone - low libido
CBT/ SSRI - psychological symptoms
Vaginal oestrogen/ moisturiser - vaginal dryness/ atrophy
What is atrophic vaginitis?
dryness and atrophy of vaginal mucosa due to oestrogen deficiency, occurs as most women enter menopause
CP: pruritus, dryness, dyspareunia, bleeding (localised inflammation), redness, raised pH of vagina
Mx: if symptomatic → oestrogen (topical options OR systemic HRT if postmenopausal)
Estriol cream/ pessaries/ tablets (Vagifem OD)/ ring (Estring)
Management of atrophic vaginitis
Mx: if symptomatic → oestrogen (topical options OR systemic HRT if postmenopausal)
Estriol cream/ pessaries/ tablets (Vagifem OD)/ ring (Estring)
How do the female organs form?
upper vagina/ cervix/ uterus/ fallopian tubes develop from paramesonephric ducts (Mullerian ducts) along the outside of the urogenital region. They fuse/ mature at 9wks to become reproductive structures + errors in development → congenital structural abnormalitie
What is a bicornate uterus?
uterus has two horns (heart-shaped appearance)
Dx: pelvic ultrasound
Complications: miscarriage, premature birth, malpresentation
What is an imperforate hymen? CP? Mx?
hymen at entrance of vagina fully formed
CP: cyclical pelvic pain + cramping w/o vaginal bleeding (menses sealed in vagina)
Mx: surgical incision to create opening
What is a transverse vaginal septae? Complications? Mx?
septum forms transversely across the vagina, can be perforate (hole allows for menstruation) or imperforate (similar to imperforate hymen)
Complications: infertility, pregnancy-related complications
Mx: surgical correction
What is vaginal hypoplasia/ agenesis? Mx?
failure of Mullerian ducts to develop → abnormally small or absent vagina, may be associated w/ absent uterus/ cervix
Mx: vaginal dilator or vaginal surgery
Causes of abnormal uterine bleeding (gynae)
PALM-COEIN
Structural = polyps, adenomyosis, leiomyoma (fibroids), malignancy + hyperplasia
Non-structural = coagulapathy, ovulatory dysfunction (e.g. PCOS), endometriosis, iatrogenic (e.g. 2ry to anticoagulant Tx), not yet identified (systemic cause e.g. liver disease)
Structural causes of abnormal uterine bleeding
polyps
adenomyosis
fibroids
malignancy + hyperplasia
Non-structural causes of abnormal uterine bleeding
Coagulopathy (e.g. VWD)
Ovulatory dysfunction (e.g. PCOS)
Endometriosis
Iatrogenic (e.g. 2ry to anticoagulant therapy)
Not yet specified (e.g. systemic causes = liver disease)
Define polyps
Small benign tumours that grow into the uterine cavity, common in women 40-50YO (high oestrogen levels)
CP: asymptomatic, menorrhagia, IMB, prolapse through cervix
Dx: ultrasound/ hysteroscopy
Mx: resection of polyp w/ cutting diathermy or avulsion
Clinical presentation of polyps
common in women 40-50YO (high oestrogen levels)
CP: asymptomatic, menorrhagia, IMB, prolapse through cervix
Mx of polyps
resection of polyp w/ cutting diathermy or avulsion (if symptomatic)
Define adenomyosis
Presence of endometrium + underlying stroma within myometrium, >40YO, associated w/ endometriosis + fibroids, symptoms subside after menopause
((CP: asymptomatic, painful/ irregular/ heavy menstruation, uterus mildly enlarged/ tender on examination
Ix: ultrasound/ MRI
Mx: medical (progesterone IUS/ COCP) for symptoms, hysterectomy often necessary))
Clinical presentation of adenomyosis
asymptomatic, painful/ irregular/ heavy menstruation, uterus mildly enlarged/ tender on examination
> 40YO, associated w/ endometriosis + fibroids, symptoms subside after menopause
Management of adenomyosis
medical (progesterone IUS/ COCP) for symptoms, hysterectomy often necessary
Define fibroids (leiomyomas)
Benign tumours of myometrium, growth = oestrogen + progesterone dependent (regress after menopause/ change during pregnancy)
((CP: asymptomatic, dysmenorrhoea, pressure effects (urinary symptoms), subfertility
Ix: ultrasound, hysteroscopy
Mx: if symptomatic
Selective progesterone receptor modulators (SPRMs, e.g. ulipristal acetate) - reduce heavy menstrual bleeding (HMB) and shrink fibroids
Surgical - hysteroscopic resection (if intrauterine/ <3cm), myomectomy (fertility preserving, if medical treatment failed), embolization, radical hysterectomy))
Clinical presentation of fibroids
asymptomatic, dysmenorrhoea, pressure effects (urinary symptoms), subfertility
oestrogen + progesterone dependent (regress after menopause/ change during pregnancy)
Management of symptomatic fibroids
Selective progesterone receptor modulators (SPRMs, e.g. ulipristal acetate) - reduce heavy menstrual bleeding (HMB) and shrink fibroids
Surgical - hysteroscopic resection (if intrauterine/ <3cm), myomectomy (fertility preserving, if medical treatment failed), embolization, radical hysterectomy
Medication used to shrink fibroids
Selective progesterone receptor modulators (SPRM) e.g. ulipristal acetate
Define PCOS
common (5% of women) condition causing metabolic and reproductive problems in women. Characterised by multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.
Clinical presentation of PCOS
obesity, acne, hirsutism, oligomenorrhoea/ amenorrhoea, miscarriage
Diagnostic criteria for PCOS
Two or more out of…
Ovaries polycystic morphology on ultrasound - >12 small (2-8mm) follicles in an enlarged (>10mL in volume) ovary, present in 20% of women (most will have regular menstrual cycles)
Irregular periods 5wks or more apart
Hirsutism (clinical and/or biochemical)
Management of PCOS
lifestyle (weight loss) + COCP (regulate periods + treat hirsutism) + fertility treatment
Complications associated with PCOS
increased risk of developing T2DM/ gestational diabetes + endometrial cancer (unopposed oestrogen action w/ amenorrhoea)
Define endometriosis
presence and growth of ectopic endometrial tissue outside the uterus causing pelvic pain and often subfertility
Clinical presentation of endometriosis
Can be asymptomatic
Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Urinary/ bowel symptoms - endometriosis affects other sites
Investigating Endometriosis
Pelvic ultrasound
Laparoscopy = gold-standard
Definitive diagnosis of endometriosis
Laparoscopy w/ biopsy
Surgical management of endometriosis
Depends on whether fertility is a priority
If not: laparoscopic hysterectomy +/- oophorectomy
If it is: excision/ ablation of endometriosis, adhesiolysis + removal of endometriomas may improve chance of spontaneous pregnancy
Medical management of endometriosis
Analgesia - paracetemol/ NSAIDs
Hormonal - COCP/ progesterone, mirena coil, GnRH analogue injections (e.g. Prostap + Zoladex)
Define Heavy menstrual bleeding
Excessive menstrual loss that interferes with physical, emotional, social and material QOL, >80mL
Define intermenstrual bleeding (IMB)
any bleeding that occurs between menstrual periods. Red flag for cancers but often alternative cause.
Define postcoital bleeding
vaginal bleeding following intercourse that isn’t menstrual loss. Red flag for cancers but often no cause.
Define amenorrhoea
Absence of menstruation (primary = by 16YO, secondary = ceased for >3/12)
Define oligomenorrhoea
Infrequent menstruation (every 35 days to 6 months)
Aetiologies of oligmenorrhoea
Hypothalamus hypogonadism - due to anorexia, excessive exercise, low BMI
Hyperprolactinaemia
Hypothyroidism
PCOS, premature menopause, Turner’s syndrome
Imperforate hymen, transverse vaginal septum, cervical stenosis, Asherman’s syndrome
Iatrogenic - drugs e.g. progesterone, GnRH analogues, antipsychotics
What is the most common type of ovarian cyst?
Follicular cyst - functional type of cyst that arises when a follicle fails to rupture/ release an egg –> persistent cyst
What is an ovarian cyst?
A fluid-filled sac present in/ surrounding the ovaries
Clinical presentation of an ovarian cyst
Often asymptomatic + found incidentally via pelvic ultrasound OR present acutely:
Rupture/ haemorrhage/ torsion
Management of an ovarian cyst in premenopausal women
<5cm = leave to resolve by itself within 3 cycle
5-7cm = monitor with ultrasound
>7cm = consider MRI/ surgical evacuation
Management of an ovarian cyst in postmenopausal women
Raised CA125 = 2wk-wait referral
Normal CA125 + <5cm = monitor w/ ultrasound
Why does management for an ovarian cyst differ depending on whether they are menopausal or not?
Postmenopausal = more concerned RE: malignancy
Define ovarian torsion
twisting of the adnexa that is most likely to occur during pregnancy and most commonly caused by an ovarian mass > 5cm. Medical emergency that will lead to necrosis if not resolved
Pathophysiology of an ovarian torsion
twisting of the adnexa (contains blood supply to ovaries/ fallopian tubes/ connective tissue) → blood supply to ovaries restricted → ischemia → necrosis + loss of ovary’s function
Clinical presentation of ovarian torsion
Sudden-onset severe unilateral pelvic pain, progressive worsening, N+V, tenderness/ palpable mass on examination
What does a whirlpool sign on a transvaginal ultrasound indicate?
Ovarian torsion - free fluid in the pelvis/ oedema of ovary
Management of an ovarian torsion
Laparoscopic surgery - detorsion or oophorectomy
Ovary removal → sub/infertility + menopause
Complications arising from surgical management of ovarian torsion
Ovary removal –> sub/ infertility + menopause
If ovary not removed it can become infected –> abscess formation –> rupture/ sepsis (potentially)
What is androgen insensitivity syndrome?
X-linked recessive genetic condition that causes genetically male individuals to appear phenotypically female.
Cells unable to respond to androgens e.g. testosterone –> converted into oestrogen –> female secondary sexual characteristics develop
Inheritance of Androgen insensitivity syndrome
X-linked recessive genetic condition that causes genetically male individuals to appear phenotypically female.
Clinical presentation of androgen insensitivity syndrome
Appear female (often w/ normal female genitalia), typically present w/ amenorrhoea
Other: lack of pubic hair/ facial hair, slightly taller than female average, infertility
Infancy: presents w/ inguinal hernias containing testes or @ puberty with 1ry amenorrhoea
Management of androgen insensitivity syndrome
Bilateral orchiectomy + oestrogen therapy + vaginal dilators/ surgery (create adequate vaginal length)
What is lichen sclerosus?
chronic inflammatory skin condition caused by a loss of collagen → vulval epithelium thinning + formation of shiny, porcelain-white skin, most common in postmenopausal women
Clinical presentation of lichen sclerosus
Most common in postmenopausal women
Severe pruritus (worse at night), bleeding/ skin breaking, pain, dyspareunia, discomfort
Skin changes - pink-white papules coalesce
Loss of vulval architecture - inflammatory adhesions –> fusion of labia + narrowing of introitus
Investigations in lichen sclerosis
Biopsy - confirm diagnosis + exclude carcinoma
Management of lichen sclerosis
Long-term potential topical steroids (e.g. Clobetasol propionate 0.05% - dermovate) + emollients
Female patient with short stature, webbed neck and widely space nipples
Turner’s syndrome: genetic condition that occurs when occurs a female has a single X chromosome (45XO), characterised by short stature, a webbed neck and widely spaced nipples
What is Turner’s syndrome?
A genetic condition that occurs when occurs a female has a single X chromosome (45XO), characterised by short stature, a webbed neck and widely spaced nipples
Patient presents with secondary amenorrhoea/ significantly lighter periods/ dysmenorrhoea following recent uterine surgery. What might cause this?
Asherman’s syndrome: formation of adhesions within the uterus, following damage to it
What can cause Asherman’s syndrome?
Adhesions in the uterus can be caused by:
Dilatation + curettage procedures (e.g. Evacuation of retained products of conception, ERPC)
Uterine surgery (e.g. myomectomy)
Pelvic infection (e.g. endometritis)
Features of Asherman’s syndrome
amenorrhoea
severely lighter periods
dysmenorrhoea
Management of Asherman’s syndrome
Dissect adhesions present in uterus during hysteroscopy (reoccurrence common)
What is a hydatidiform mole?
Type of tumour that grows like a pregnancy inside the uterus
Complete - two sperm cells fertilise ovum w/ no genetic material, no foetal material will form
Partial - two sperm cells fertilise ovum w/ genetic material, some foetal material may form
Clinical presentation of a hydatidiform mole
Behaves like a normal pregnancy BUT more severe morning sickness, vaginal bleeding, increased enlargement of uterus, abnormally high hCG, thyrotoxicosis
What pathology would show a snowstorm appearance on an ultrasound?
Hydatidiform mole
Management of hydatidiform mole
Evacuation of uterus
What is a prolactinoma?
non-cancerous tumour of the pituitary gland → excess secretion of prolactin → menstrual irregularities (oligomenorrhoea/ amenorrhoea) + galactorrhoea
Clinical presentation of a prolactinoma
Menstrual irregularities - oligomenorrhoea/ amenorrhoea
Galactorrhoea
Headaches
Reduced libido
Bitemporal hemianopia (compression of optic chiasm)
Management of a prolactinoma
Medical - dopamine agonist e.g. cabergoline
If fail: Surgical - trans-sphenoidal surgical removal of tumour
What is Pelvic Inflammatory Disease?
inflammation and infection of organs of the pelvis caused by an infection spreading up through the cervix, significant cause of tubular infertility + chronic pelvic pain
Most common causes of PID?
most = STIs - Neisseria gonorrhoea (more severe), Chlamydia trachomatis, mycoplasma genitalium
((Other (non-STIs) - Gardnerella vaginalis (associated w/ BV), Haemophilus influenzae, E. coli))
RFs for PID
not using barrier contraception, multiple sexual partners, young age, existing STIs, prev. PID, intrauterine device (e.g. copper coil)
Clinical presentation for PID
Pelvic/ lower abdominal pain + deep dyspareunia
Other: PCB/ IMB, fever, dysuria, abnormal vaginal discharge
Examination: cervical motion tenderness (cervical excitation), inflamed cervix, pelvic tenderness
Management of PID
Outpatient: first-line = 1g IM ceftriaxone single dose, 100mg oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days
Inpatient: (systemic illness/ no response to outpatient Mx) first-line = 2g IV ceftriaxone OD, 100mg IV/ oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days
Ix for PID
HVS - look for STIs, pregnancy test (exclude ectopic pregnancy), transvaginal ultrasound (exclude ovarian pathology), MSU (exclude UTI)
What is Fitz-Hugh-Curtis syndrome?
Inflammation of liver as PID spreads across peritoneum.
Associated with chlamydia + RUQ pain
Complications of PID
Fitz-Hugh-Curtis Syndrome
Chronic pelvic pain, increased risk of future ectopic pregnancies, subfertility, abscess in ovaries + fallopian tubes
