Gynae 4 Flashcards
(44 cards)
1
Q
What is cervical cancer?
A
Malignancy of the uterine cervix
2
Q
What are the types of cervical cancer?
A
- 80% squamous (from CIN)
- 20% adenocarcinoma (from CGIN)
3
Q
What is the aetiology of cervical cancer?
A
HPV (types 16 and 18) in most cases
4
Q
What are the RFs for cervical cancer?
A
Major = HPV
Minor…
- Smoking
- Early first intercourse
- Many sexual partners
- Immunosuppression / HIV
- COCP
5
Q
What are the S/S of cervical cancer?
A
May be asx and detected during routine cervical cancer screening
- PV discharge (offensive or bloodstained)
- Abnormal vaginal bleeding - PCB, IMB, PMB
- Dyspareunia (deep)
- Pelvic or back pain
- Symptoms of late metastasis - lower limb oedema, haematuria, rectal bleeding, signs of fistulae, pressure symptoms, SoB, DIC
- FLAWS
> Metastasises to iliac LNs (not para-aortic)
6
Q
What are the investigations for cervical cancer?
A
1st line:
- Vaginal or speculum examination - may show cervical mass or bleeding
- HPV testing + cytology
- Colposcopy - punctated blood vessels, mosaics, white rings around the gland openings, acetic white epithelium, leukoplakia and atrophic changes
- Biopsy - Confirms diagnosis histologically and identifies subtype
Consider:
- MRI > CT-CAP
- Bloods – FBC (anaemia), U&Es (obstructive picture / elevated creatinine), LFTs (metastasis - elevated ALP)
7
Q
Describe the difference in imaging for cervical / endometrial / ovarian cancer
A
MRI > CT-CAP = cervical cancer
CT-CAP > MRI = ovarian cancer, endometrial cancer
8
Q
Describe HPV screening
A
Main aim of cervical screening is to detect pre-malignant changes rather than to detect cancer (cervical adenocarcinomas are frequently undetected by screening)
HPV first system i.e. a sample is tested for high-risk strains of HPV (hrHPV) first and cytological examination is only performed if this is positive
- It is said that the best time to take a cervical smear is around mid-cycle.
9
Q
Describe the follow-up of HPV screening
A
Negative hrHPV: Return to normal recall
Unless:
- TOC pathway (treated for CIN = repeat sample in 6m)
- Untreated CIN1 pathway = repeat sample in 12m
- Follow-up for incompletely excised CGIN / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- Follow-up for borderline changes in endocervical cells
Positive hrHPV: Samples examined cytologically
If cytology abnormal = colposcopy <2w
Includes the following results:
- Borderline changes in squamous or endocervical cells
- CIN I / II / III
- Invasive squamous cell carcinoma
- Glandular neoplasia
If cytology normal = test repeated at 12 months:
- If repeat test hrHPV -ve → return to normal recall
- If repeat test still hrHPV +ve and cytology still normal → further repeat test 12 months later:
- If hrHPV -ve at 24 months → return to normal recall
- If hrHPV +ve at 24 months → colposcopy
If the sample is ‘inadequate’:
- Repeat sample within 3 months
- If 2 inadequate samples → colposcopy
10
Q
What is the management of Stage IA1 cervical cancer?
A
Microinvasive Disease
Cone Biopsy:
- If fertility preservation is desired
- Cold knife cone biopsy is preferred method
- LLETZ may be acceptable
OR Simple Hysterectomy
- If fertility preservation not desired
±lymphadenectomy
11
Q
What is the management of stage IA2 to IIa cervical cancer?
A
(Early stage):
- Radical hysterectomy (resection of the cervix, uterus, parametria, and cuff of upper vagina) with bilateral pelvic lymphadenectomy
- Radical trachelectomy (removal of the cervix) and lymphadenectomy may be considered instead for smaller tumours
- Consider adjuvant chemotherapy or radiotherapy
12
Q
What is the management of stage IIb to IVa cervical cancer?
A
(Locally advanced disease):
- Chemoradiotherapy
13
Q
What is the management of stage IVb cervical cancer?
A
(Metastatic disease):
- 1st line = Combination chemotherapy (e.g. Cisplatin) with or without bevacizumab
- 2nd line = Single agent therapy and palliative care
14
Q
What types of radiotherapy are used for cervical cancer?
A
- External beam radiotherapy (10 minutes of delivery, completed over 4 weeks)
- Internal radiotherapy (brachytherapy; rods of radioactive selenium is inserted into the affected area)
15
Q
What is the management of cervical cancer if pregnant?
A
MDT care
- Surgery is typically avoided
- Radiotherapy absolutely contraindicated as it would result in pregnancy termination and foetal death.
16
Q
What are the complications of the management of cervical cancer?
A
Surgical risk (Wertheim’s hysterectomy):
- Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
- Bladder dysfunction (atony) > common, may require intermittent self-catheterisation
- Sexual dysfunction (due to vaginal shortening)
- Lymphoedema (due to pelvic lymph node removal) > leg elevation, good skin care and massage
Radiotherapy (more often used than chemotherapy, which is used for later stage cancer):
- Short-term: diarrhoea, vaginal bleeding, radiation burns, dysuria, tiredness/weakness, urgency, incontinence
- Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
17
Q
Describe FIGO staging for cervical cancer
A
IA:
Confined to cervix, only visible by microscopy and <7mm wide
- A1 = <3mm deep
- A2 = 3-5mm deep
IB:
Confined to cervix, clinically visible or larger than 7mm wide
- B1 = <4cm diameter
- B2 =>4cm diameter
II:
Extension of tumour beyond cervix but not to the pelvic wall
- A = upper 2/3 of vagina
- B = parametrial involvement
III:
Extension of tumour beyond the cervix and to the pelvic wall
- A = lower 1/3 of vagina
- B = pelvic side wall
IV:
Metastatic
- A = involvement of bladder or rectum
- B = involvement of distant sites outside pelvis
18
Q
What is dysfunctional uterine bleeding?
A
Abnormal uterine bleeding in the absence of organic pathology
- Diagnosed by excluding pregnancy, iatrogenic causes, systemic conditions, and genital tract pathology
- Affects ~10% of women
19
Q
What are the RFs for DUB?
A
Extremes of reproductive age, obesity
20
Q
What are the types of DUB?
A
Anovulatory (90%)
- Failure of follicular development > no increase in progesterone > cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation
- Shedding of this may be prolonged or long-term
Ovulatory (10%)
- Prolonged progesterone secretion > irregular shedding
21
Q
What is menorrhagia?
A
Menorrhagia is defined as what the individual woman believes is menorrhagia – there is no need to quantify it
22
Q
What are the causes of DUB?
A
- Polyps
- Adenomyosis
- Malignancy
- Coagulopathy
- Endometriosis
- Iatrogenic
23
Q
What are the S/S of DUB?
A
- Bleeding (menorrhagia, IMB, dysmenorrhoea)
- Anaemia signs/symptoms
S/S of the cause:
- Relation to the menstrual cycle
- Fertility issues
- Compression symptoms
- Cervical screening history
- DHx, FHx, sexual history (fevers, previous STIs, sexual contacts)
Coagulopathy disorders (von Williebrand disease)
24
Q
What are the investigations for DUB?
A
If menorrhagia without other related symptoms (i.e. persistent IMB, pelvic pain, pressure symptoms), consider starting management without any physical examination (unless LNG-IUS)
- Examination: Speculum (i.e. ectropion), bimanual (i.e. bulky, fibroids)
1st line:
- FBC (anaemia), TFTs (hypothyroid)
- Clotting screen (if primary menorrhagia or FHx)
2nd line
- TVUSS (PCOS, fibroids, malignancy)
3rd line
- OPD hysteroscopy / laparoscopy ± biopsy (endometriosis)
25
What is the management of DUB?
**If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis:**
- 1st line (contraception required; hormonal): LNG-IUS (may not be possible in large fibroids distorting uterus)
- 2nd line (fertility required; 1st line declined/unsuitable):
BLEED = Tranexamic acid (contraindications: renal impairment, thrombotic disease)
PAIN = Mefenamic acid (NSAIDs; contraindications: IBD)
- 2nd line (contraception required; 1st line declined/unsuitable):
1st = COCP
2nd = cyclical oral progestogens
- Norethisterone 5 mg TDS for 10 days can be used to arrest bleeding acutely
- When you stop taking this, it causes a heavy bleed
*Surgical: (last resort)*
- Endometrial ablation (will need continued contraception)
- Hysterectomy
*If fibroids >3cm = see fibroids management*
26
What is endometrial hyperplasia?
**An abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle**
*A minority of patients with endometrial hyperplasia may develop endometrial cancer*
EH without atypia = cells are normal
EH with atypia = cells are abnormal
27
What are the RFs for EH?
- Increasing age
- Excess oestrogen (early menarche, late menopause, nulliparous, tamoxifen, HRT without progesterone, COCP, obesity)
- Sex-cord stromal ovarian tumours are functional I.E. Granulosa cell tumour > oestrogen > EH
- High insulin levels (T2DM, PCOS)
- FHx ovarian, bowel (HNPCC, Lynch Syndrome – same as per Ovarian Cancer) or uterine cancer
28
What are the S/S of EH?
- Heavy PV bleeding
- IMB
- PMB
- Secondary changes in periods
29
What are the investigations for EH?
*Same as endometrial cancer pathway*
**1st: TVUSS** (if PMB, otherwise must be matched with ovulatory cycle)
- <4mm = endometrial cancer unlikely (<10mm if pre-menopausal)
- >4mm = 2nd line investigations: hysteroscopy ± biopsy (>10mm if pre-menopausal)
**2nd: Biopsy [Diagnostic Gold-Standard]:**
- Either Hysteroscopy with biopsy (performed as outpatient under LA) or pipelle biopsy
- Complex hyperplasia with atypia is a premalignant condition that often co-exists with low-grade endometrioid tumours of the endometrium (25-50% risk of progression to endometrial cancer)
- Sonohysterography = replacing hysteroscopy as a method of visualisation
30
What is the management of EH?
**EH without Atypia:**
<5% risk of becoming malignant in 20 years
- 1st line = high dose progesterone (IUS > continuous oral)
- +Reverse risk factors (e.g. obesity, HRT)
- +Endometrial surveillance (ie repeat biopsy) every 6 months
- Can discharge once 2x consecutive negative biopsies but encourage to continue progesterone treatment
- 2nd line / if does not regress / recurs = Hysterectomy
**EH with Atypia:**
- 1st line = Hysterectomy +/- BSO
*If wishes to preserve fertility:*
- MRI to exclude malignancy
- 1st line: LNG-IUS
- 2nd line: PO progestogens
- Until 2x negative biopsies (ideally every 6m, if keen to start family then can be every 3m)
- Once regressed, consider assisted reproduction
- Once family complete = hysterectomy
31
What is endometrial cancer?
Malignancy arising from endometrial tissue
- Classically seen in post-menopausal women (~25% before menopause)
- Uncommon in <40yo (mean age 54yo)
- If PMB, diagnosis is endometrial cancer until proven otherwise
- Usually carries a good prognosis due to early detection
- 2nd most common gynae malignancy in UK (1% lifetime risk)
- 90% = adenocarcinoma
32
What are the RFs for endometrial cancer?
Excess oestrogen:
- Nulliparity
- Early menarche / late menopause
- Obesity
- Unopposed oestrogen (HRT without progesterone)
Also:
- Diabetes mellitus
- PCOS
- Tamoxifen (breast cancer drug)
- Hereditary non-polyposis colorectal carcinoma / Lynch syndrome
33
What are protective factors for endometrial cancer?
- Multiparity
- COCP
- Smoking (the reasons for this are unclear)
34
What are the types of endometrial cancer?
**Type 1 = SEM - secretory, endometrioid, mucinous carcinoma** (85%)
- Younger patients; oestrogen-dependent; superficially invade; low-grade
- ≥4 mutations must accumulate to cause this…
-PTEN
-PI3KCA
-K-Ras
-CTNNB1
-FGFR2
-P53
**Type 2 = SC - uterine papillary serous carcinoma (UPSC), clear cell carcinoma** (15%)
- Older patients; less oestrogen-dependent; deeper invasion, higher grade
- Mutations associated:
Serous Carcinoma: p53 (90%), PI3KCA (15%), Her 2 amplification
Clear Cell Carcinoma: PTEN, CTNNB1, Her-2 amplification
35
What are the S/S of endometrial cancer?
- PMB (as opposed to ovarian cancer which is more associated with palpable masses)
- Bulky uterus
- Metastasises to para aortic LNs
36
Describe the FIGO staging of endometrial cancer
I = limited to uterus
II = spread to cervix
III = spread adjacent
IV = distant spread
37
What are the investigations for endometrial cancer?
**All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway (2ww)**
- Vaginal examination (speculum and bimanual)
**1st: TVUSS** (if PMB, otherwise must be matched with ovulatory cycle)
*Looking at endometrial thickness*
- <4mm = endometrial cancer unlikely
- >4mm = requires further investigation
**2nd: Hysteroscopy + biopsy**
- Hysteroscopy under GA as outpatient or pipelle biopsy
38
What is the management of endometrial cancer?
**Stage 1:**
- Total hysterectomy + bilateral salpingoopherectomy (BSO)
- +Peritoneal washings
- Curative in most cases
**Stage 2+:**
- Radical hysterectomy + BSO with radiotherapy
- Can be brachytherapy or external
>>Chemotherapy is of limited use and used if a cancer is not amenable to radiotherapy
**Hormone treatments:**
- High-dose oral or intrauterine progestins (LNG-IUS)
- Indication: women with complex atypical hyperplasia + low-grade stage 1A endometrial tumours
- Relapse rates are high but may be suitable for those not fit for surgery or for fertility reasons
39
What is the prognosis of endometrial cancer?
5-year survival = 80% (dependent on type, stage and grade)
**Bad prognostic features:**
- Age
- Grade 3 tumours
- T2 histology
- Distant metastasis
- Deep invasion
- Lymphovascular space invasion
- Nodal involvement
Hormone receptor expression may influence a better prognosis/treatment (Her2)
40
What is endometriosis?
**Presence/growth of endometrial tissue outside the uterus**
Affects 1 in 10 women (of reproductive age), mainly 30-45y
41
What are the RFs for endometriosis?
- Early menarche
- FHx
- Nulliparity
- Prolonged menstruation (>5 days)
- Short menstrual cycles
Sampson’s theory – retrograde menstruation and implantation may be the cause
Associations = clear cell ovarian carcinoma > endometroid ovarian carcinoma
42
What are the S/S of endometriosis?
- Cyclical or chronic pelvic pain occurring before or during menstruation
- Dyspareunia (deep), dyschezia (pain on defecation)
- Dysmenorrhoea (N.B. no menorrhagia differentiates this from fibroids)
- Symptoms of extra-uterine endometriosis (i.e. rectal pain, bleeding)
- Subfertility
43
What are the investigations for endometriosis?
**Bimanual & speculum examination:**
- Findings: reduced mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions, fixed retroverted uterus= ectopic tissue on utero-sacral ligament
**1st line = TVUSS**
- May show endometrioma, may show nothing
- Other = HSG or HyCoSy
- Association to clear cell (20%) and endometroid (<20%) ovarian carcinoma
**Diagnostic laparoscopy (GOLD-STANDARD):**
- Red vesicles or punctate marks on peritoneum = active lesions
- White scars / brown spots = less active endometriosis
44
What is the management of endometriosis?
*Medical treatment of presumed endometriosis can begin if clinical examination / TVUSS normal (without need for laparoscopy). However, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:*
**1st line (3m trial) = Paracetamol ± NSAIDs**
- Adjunct: Tranexamic acid
*If analgesia doesn't help then hormonal treatments should be tried:*
**2nd line (3m trial) = COCP or progesterone (POP, implant, injectables or LNG-IUS)**
- COCP can provide cycle control and contraception whilst alleviating symptoms of endometriosis
- Continue until pregnancy required
- Progesterone used to induce amenorrhoea in those where COCP contraindicated
*If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include:*
**Laparoscopic ablation**
- If mild endometriosis superficially
- Recurrence rate is high at 30% so supplement with medical therapy (COCP)
**Hysterectomy with BSO**
**GnRH analogues (e.g. leuprorelin) can induce a ‘pseudo-menopause’**
- Used to shrink endometriosis in the approach to surgery
- Inhibits oestrogen release > don’t use for longer than 6 months (osteoporosis risk)
- Menopause-like side effects (hot flushes, night sweats)
**Subfertility**
- Laparoscopic ablation ± endometrioma cystectomy (no hormonal treatment if trying to conceive)
