Gynae 2 Flashcards
What is PID
infection of the upper genital tract. Infection spreads upwards from the endocervix causing one or more of: Endometritis. Salpingitis. Parametritis. Oophoritis. Tubo-ovarian abscess. Pelvic peritonitis.
What causes PID
Chlamydia trachomatis (14–35% of cases) Neisseria gonorrhoeae (2–3% of cases) Mycoplasma genitalium
Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.
What are some risk factors for PID
Factors related to sexual behaviour, such as:
<25
Early age of first coitus.
Multiple sexual partners.
New partner within least 3 months
History of STI in the woman or her partner.
Recent instrumentation of the uterus or interruption of the cervical barrier, such as due to: TOP Insertion of an intrauterine device Hysterosalpingography. IVF and intrauterine insemination.
What are the symptoms of PID
asymptomatic Lower abdominal pain Deep dyspareunia PCB menorrhagia, dysmenorrhoea or IMB Dysuria (painful urination) Abnormal vaginal discharge (especially if purulent or with an unpleasant odour)
fever and N+V if severe
What are the signs of PID on examination
Lower abdominal tenderness (usually bilateral).
Adnexal tenderness
cervical motion tenderness,
or uterine tenderness
Abnormal cervical or vaginal mucopurulent discharge
What investigations should be considered in PID
Pregnancy test, urine dip
FBC, CRP, ESR, GIV, syphilis
Endocervical swabs - gonorrhea and chlamydia,
high vaginal swab - trichomonas vaginalis and bacterial vaginosis
How is PID managed
immediate start of 14-day course of broad spectrum antibiotics - Ceftriaxone 500 mg IM, oral doxycycline 100 mg BD and oral metronidazole 400 mg BD for 14 days.
avoid sexual intercourse until the antibiotic course is complete and partner(s) are treated.
All sexual partners from the last 6 months should be tested and treated to prevent recurrence and spread of infection.
How should a woman with diagnosed PID be followed up?
R/V in 72 hours
should be clinical improvement. if not, consider admission or review the diagnosis.
Check the antibiotic sensitivities from swab result and adjust antibiotics treatment if necessary.
Continue treatment even if swabs are negative.
R/V in 2-4 weeks to check:
compliance with, and response to, treatment.
Confirm that sexual contacts have been screened and treated.
Discuss the potential sequelae of PID
Ensure repeat pregnancy test, if clinically indicated
What are the long term complications of PID
Tubal infertility. Ectopic pregnancy. Chronic pelvic pain. Tubo-ovarian abscess. Fitz-Hugh Curtis syndrome
What is an ovarian cyst
fluid filled sac within the ovary
What is the difference between a simple and complex ovarian cyst
simple - fluid only
complex - not simple! may contain blood, solids, septation or vascularity
Name some non-neoplastic types of ovarian cysts
follicular corpus luteal endometriomal PCOS theca lutein
Name some benign neoplastic types of ovarian cysts
serous cystadenoma mucinous cystadenoma benign cystic teratoma - germ cells benign mature teratoma - germ cells fibroma
What are the risk factors for ovarian cyst formation
obesity
tamoxifen
early menarche
infertility
What are the symptoms of ovarian cysts
dull ache or pain in lower abdomen
dyspareunia
swollen abdomen
pressure effects - frequency
if torsion - severe pain
if rupture - pain, peritonitis, shock
What investigations should be done in ovarian cysts
pregnancy test, urine dip
FBC CA125 AFP BhCG
TVUS
FNA and cytology of cyst
When should ca125 not be done for an ovarian cyst
for premenopausal women who have a simple cyst on ultrasonography
When should AFP and betahCG be done for an ovarian cysts
if it is a germ cell tumour and the woman is under 40
What is the RMI in relation to ovarian problems
risk of malignancy index
How is the RMI calculated
ultrasound score x menopausal score x CA 125 level in U/mL.
The ultrasound score is the number of the following findings on scan: multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal metastases. (0 = no abnormalities, 1 = one abnormality, 3 = two or more)
menopausal score is where 1 = premenopausal and 3 = postmenopausal).
How are ovarian cysts managed
expectant - if simple <50mm. repeat TV US in 6 weeks - if persistent then monitor with ultrasound and CA125 3-6 monthly and calculate RMI.
surgery - if persistent and 5-10cm, symptomatic or complex
How is the RMI used in management of ovarian cysts
in postmenopausal women:
Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.
Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).
High RMI (over 250): referral for staging laparotomy
State the different kinds of ovarian cancer
epithelial - 90%
germ cell
sex cord stromal
What are the risk factors for ovarian cancer
age
lifestyle: smoking obesity asbestos exposure low exercise
hormonal:
infertility, clomifene, nulliparity, early menarche, late menopause, HRT
FH
BRCA1/2
endometriosis
history of breast, ovarian or bowel cancer
What are the symptoms of ovarin cancer
abdominal discomfort abdo distention or bloating frequency dyspepsia any new IBS if >50Y fatigue, weight loss, anorexia, depression pain - late sign ascites breathlessness - pleural effusion PMB
What investigations should be done in suspected ovarian cancer
ca125, AFP, beta hCG
TV USS/ abdo US
CT AP
staging laparotomy
What can cause a raised ca-125
ovarian cancer PID pregnancy torsion, rupture or haemorrhage of ovarian cyst other cancer trauma heart failure
What are the management options for ovarian cancer
surgery
chemo - cisplatin
What is chronic pelvic pain
Intermittent or constant pain in the lower abdomen or pelvis in women.
Lasting for at least six months.
Not occurring exclusively with menstruation or sexual intercourse.
Not being associated with pregnancy.
What can cause chronic pelvic pain
Endometriosis: Adhesions: IBS. Interstitial cystitis. Musculoskeletal problems. Pelvic organ prolapse. Nerve entrapment: Psychological and social issues
What investigations could be done in chronic pelvic pain
urine dip
FBC, CRP, ca125
endocervical swab - gonorrheoa, chlamydia
TV US
Diagnostic laparoscopy - if results inconclusive
How is menopause defined
12 months of amenorrhoea due to the loss of ovarian follicular activity
What is premature menopause
menopause occurring before the age of 40 years
What is the perimenopause
the period of change leading up to the last period.
What is early menopause
menopause between 40-45 years.
State the hormonal changes that occur in the menopause
reduced sensitivity of the ovary to circulating FSH and LH - due to reduction in follicle numbers.
leads to reduction in oestrogen secretion
leads to increased levels of FSH and LH
The decrease in developing follicles also reduces the amount of inhibin released causing an enhanced rise of FSH.
What are the key symptoms of the perimenopause
irregular menstrual bleeding hot flushes - affect the face, head, neck and chest and last for a few minutes depression and mood change joint and muscle aches and pains vaginal discomfort and dryness, dyspareunia Loss of libido recurrent lower urinary tract infection. sleep disturbance
Why does amenorrheoa occur in the menopause
Estradiol production, which occurs in the granulosa and thecal cells surrounding the oocyte, becomes insufficient to stimulate the endometrium, and amenorrhoea occurs.
What causes the urogenital problems associated with menopause
loss of the trophic effect of oestrogen.
there is atrophy of the vagina, thinning of vaginal walls and dryness
What causes the sleep disturbance in menopause
hot flushes and night sweats
may also be due to mood disorders
What investigations are needed in menopause
clinical diagnosis!
only done in premature ovarian failure;
FSH
to exclude other diagnoses: TFT Blood glucose
A pelvic scan - may be considered for those women with atypical symptoms
How does the menopause affect bone metabolism
Oestrogen protects bone mass and density through reducing the activity of oesteoclasts.
Decreased oestrogen leads to an increase in bone reabsorption
leads to loss of bone density and increased frequency in fractures e
How does the menopause affect cardiovascular health
Oestrogen offers a protective effect against heart disease. It is thought that oestrogen reduces levels of LDL cholesterol whilst raising HDL cholesterol.
After the menopause women experience the same frequency of cardiovascular disease as men.
What are the management options for the menopause
HRT
non hormonal
lifestyle
Give some lifestyle interventions for the management of symptomatic menopause
Hot flushes and night sweats — regular exercise, weight loss, wearing lighter clothing, sleeping in a cooler room, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).
Sleep disturbances — avoiding exercise late in the day and maintaining a regular bedtime.
Mood and anxiety disturbances — adequate sleep, regular physical activity, and relaxation exercises.
Cognitive symptoms — exercise and good sleep hygiene.
Give some non-hormonal interventions for the management of symptomatic menopause
For vasomotor symptoms, consider a 2-week trial of fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine (37.5 mg twice a day). (off label)
For vaginal dryness, prescribe a vaginal lubricant or moisturizer, such as Replens MD®.
For psychological symptoms consider self-help groups, cognitive behavioural therapy (CBT), or antidepressants.
Which symptoms of menopause is HRT effective in treating
Vasomotor symptoms (hot flushes/night sweats).
Mood swings.
Vaginal and bladder symptoms.
Which women should be prescribed combined or oestrogen only HRT
In woman with a uterus - combined (oestradiol plus progestogen) HRT
without a uterus - oestrogen-only preparation.
How can urogenital symptoms of menopause be managed with HRT
if urogenital atrophy (including those already using systemic HRT) - low-dose vaginal oestrogen.
if vaginal dryness - moisturisers and lubricants can be used alone or in addition to vaginal oestrogen.
What are the risks of HRT
VTE - more so for oral than transdermal
Coronary heart disease (CHD) and stroke -combined associated with small increase in risk
Breast cancer - combined increases risk
Endometrial cancer - oestrogen-only increases the risk of endometrial cancer in women with a uterus.
What are the benefits of HRT
reduction in vasomotor symptoms improvement in QOL improvement in mood changes improvement of urogenital symptoms reduction in osteroporosis risk` improvement in muscle mass and strength
How long is contraception required for after the menopause
Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period.
Those over the age of 50 require only 1 year of contraception.
What does cervical screening look for?
Liquid based cytology (LBC) to detect early abnormalities of the cervix, which if untreated could lead to cancer of the cervix.
- abnormalities in the appearance of the nucleus and other aspects of cell morphology (dyskaryosis)
Who is screened for cervical cancer
First invitation for screening at age 25
Routine recall three-yearly recall between ages 25-49, then five-yearly recall until aged 65.
Women over the age of 65 are only screened if they have not been screened since the age of 50 or have had recent abnormal tests.
How is the smear test carried out?
A speculum made from disposable plastic inserted vaginally to view the squamocolumnar junction of the cervix.
A brush is rotated against the squamocolumnar junction (usually in the cervical canal).
Brush top broken off into preservative or rinsed in preservative. Sent off for testing
What can be the histological result of cervical smear test
Negative - . Endocervical cells with normal nuclei are seen.
Inadequate
Borderline - Cells are seen with abnormal nuclei, but the pathologist cannot say for certain that they are indicative of dyskaryosis
Mild dyskaryosis -usually equates to CIN 1. Cancer is very unlikely.
Moderate dyskaryosis - usually equates to CIN 2 a pre-cancerous condition with an intermediate probability of developing into cancer.
Severe dyskaryosis - equates to CIN 3. It is at the higher risk end of the cancer spectrum.
Glandular neoplasia - suggestive of adenocarcinoma in situ, adenocarcinoma of the cervix, endometrial adenocarcinoma, or adenocarcinoma of an organ outside the uterus.
What can cause a cervical smear to come back as inadequate
insufficient or unsuitable material sampled (vaginal cells, endocervical cells, insufficient cells)
unlabelled specimens
inadequate fixation/poor spreading of the material on the slide in the laboratory.
What should be done if the smear comes back inadequate
Repeat sample as soon as possible
If persistent (three inadequate samples), advise assessment by colposcopy.
What should be done if the smear comes back borderline or mild dyskaryosis
tested the sample for HPV
If HPV is negative, women are returned to normal recall.
If the HPV test is inadequate or unreliable, they are advised to have a repeat smear/HPV test in six months time.
If HPV is positive, women are referred for colposcopy within 6 weeks
What should be done if the smear comes back moderate or severe dyskaryosis
refer for colposcopy within 2 weeks
What happens at colposcopy
Look for any abnormal changes in the cervix which may indicate CIN or the presence of cancer.
Apply acetic acid is applied to the cervix, abnormal areas (such as CIN) tend to turn white (sometimes referred to as acetowhite).
May take a biopsy to confirm the diagnosis.
What types of cervical cancer are there
Squamous cell carcinoma - more common
Cervical adenocarcinoma
What causes cervical cancer
HPV16 and HPV18 are responsible for about 75% of cervical cancers.
integration of viral DNA into the host genome, interference of HPV E6 and E7 proteins with the normal cell regulatory functions
How long between infection with HPV and cervical cancer
10 years at least
What are the risk factors for HPV
Heterosexual women.
Women with multiple sexual partners, or partners of promiscuous males.
Smoking.
Lower social class.
Immunosuppression - eg, HIV and post-transplant.
There is a slight increase in risk with use of a combined oral contraceptive.
Non-attendance at the cervical screening programme
What are the symptoms of cervical cancer
asymptomatic - picked up on screening!
IMB PCB PMB Blood-stained vaginal discharge. Mucoid, or purulent vaginal discharge. Pelvic pain/dyspareunia.
What is seen on examination in cervical cancer
The cervix may appear inflamed or friable and bleed on contact
visible ulcerating or fungating lesion
foul-smelling serosanguineous vaginal discharge.
Give some differentials for cervical cancer
Cervicitis. Cervical erosion (ectropion). PID Endometrial cancer. Side-effects of intrauterine contraceptive device (IUCD) use. Endometrial hyperplasia. Fibroids. Atrophic vaginitis.
What is the difference between CIN and invasive cervical cancer
CIN does not breach the basement membrane
invasive breaches the basement membrane
What are the subclassifications within CIN
CIN I: disease confined to the lower third of the epithelium.
CIN II: disease confined to the lower and middle thirds of the epithelium.
CIN III: affecting the full thickness of the epidermis.
What is the difference between microinvasive and invasive cervical cancer
micro-invasive carcinoma = the deepest invasive element is <5 mm from the surface of the epithelium
invasive = extends beyond 5 mm or is wider than 7 mm
What investigations should be done in suspected cervical cancer
FBC, U+E, LFTs
endocervical swab - chlamydia
colposcopy and core biopsy
CXR and CT CAP for mets
How is cervical cancer managed
radical hysterectomy and lymphadenectomy
chemoradiation
What causes a pelvic prolapse
weakness of the supporting structures
allows the pelvic organs to protrude within the vagina
What increases the risk of prolapse
prolonged labour, trauma from instrumental delivery, lack of postnatal pelvic floor exercise, obesity, chronic cough and constipation. Poor perineal repair
What is a cystocoele
the anterior wall of the vagina, and the bladder attached to it, bulge.
What symptoms can a cystocele cause
Residual urine within the cystocele may cause frequency and dysuria.
What is a rectocele
The lower posterior wall, which is attached to rectum, may bulge through weak levator ani.
What might a woman with a rectocele need to do to aid defecation
reduce herniation prior to defecation by putting a finger in the vagina, or pressing on the perineum.
What is an enterocele
Bulges of the upper posterior vaginal wall may contain loops of intestine from the pouch of Douglas.
What is a uterine prolapse
Protrusion of the uterus downwards into the vagina, taking with it the cervix and upper vagina.
What is the difference between first, second and third degree prolapses
First degree: The lowest part of the prolapse descends halfway down the vaginal axis to the introitus.
Second degree: The lowest part of the prolapse extends to the level of the introitus, and through the introitus on straining.
Third degree: The lowest part of the prolapse extends through the introitus and outside the vagina.
What are the symptoms of prolapse
Dragging sensation, discomfort, feeling of a lump ‘coming down,’ dyspareunia, backache.
With cystocele, urinary urgency and frequency, incomplete bladder emptying, urinary retention if the urethra is kinked.
With rectocele, constipation and difficulty with defecation.
How is a prolapse examined
Bimanual to exclude pelvic masses.
Examine for prolapse with the woman in left lateral position using a Sims speculum.
Inspect anterior and posterior walls for atrophy and descent.
If no obvious prolapse, ask the woman to strain or stand.
How is prolapse managed
Conservative:
lose weight, stop smoking, and stop straining.
Improve muscle tone with exercises or physiotherapy. Pessaries - should be changed every 6 months and if the woman is post-menopausal, topical oestrogen is useful to prevent vaginal erosion.
Surgery:
Repair operations excise redundant tissue and strengthen supports, but may reduce vaginal width.
How do pessaries for prolapse work?
Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.
Most are ring shaped.
When is surgery for pevic organ prolapse useful?
if symptoms are severe,
the woman is sexually active,
and pessaries have failed
What are the different surgical options for prolapse
vaginal vault prolapse = sacrocolpoplexy to suspen the vaginal apex to the sacral promontory.
cystocele = Anterior colporrhaphy to repair vaginal wall or colposuspension
rectocele: posterior colporrhaphy
uterine prolapse: hysterectomy, sacrohysteropexy
