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Year 5 - Fatty > Gynae > Flashcards

Gynae Flashcards

1
Q

What is asherman’s syndrome?

A
  • Presence of intrauterine adhesions that may partially or completely occlude the uterine cavity
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2
Q

What is asherman’s syndrome caused by?

A
  • Trauma or infection causing damage to the basal layer of the endometrium which leads to fibrosis and adhesion formation
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3
Q

What is the epidemiology of asherman’s syndrome?

A

5-40% of D&C (dilation and curettage) after miscarriages

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4
Q

What are the risk factors of asherman’s syndrome?

A
  • Endometrial resection
  • D&C
  • Surgery -myomectomy, c section
  • Endometriosis
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5
Q

Signs and symptoms of asherman’s syndrome?

A
  • Amenorrhoea
  • Sub-fertility
  • Cyclical abdominal pain
  • Often no external physical changes
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6
Q

Investigations for asherman’s syndrome?

A
  • Imagining - saline hysterosonography (HSG), TVUSS (sub-endothelial linear striations + ‘boggy’ uterus)
  • Other - hysteroscopy
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7
Q

Management of asherman’s syndrome?

A
  • Hysteroscopic adhesiolysis + post-op copper IUD –> PO oestrogen (2-3m) + reassess cavity
  • PO oestrogen induce endometrial proliferation
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8
Q

Complications of asherman’s syndrome?

A
  • Infertility
  • Miscarriage
  • Menstrual disturbances
  • Abnormal placentation
  • Complications of operation
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9
Q

What is atrophic vaginitis?

A

Vaginal irritation caused by thinning of the vaginal epithelium

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10
Q

Aetiology of atrophic vaginitis?

A

Reduction in circulating oestrogen level (post-menopause)

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11
Q

Risk factors of atrophic vaginitis?

A
  • Menopause

- Prolonged lactation

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12
Q

Epidemiology of atrophic vaginitis?

A

10-40% post menopausal women

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13
Q

Signs and symptoms of atrophic vaginitis?

A
  • Vaginal irritation
  • Superficial dysuria
  • Dyspareunia
  • Dischage - may be bloody
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14
Q

What do you find on examination of atrophic vaginitis?

A
  • Pale and thin vaginal walls with loss of rugal folds, cracks and fissures
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15
Q

Investigations of atrophic vaginitis?

A
  • Clinical
  • Swabs for any potential infection
  • Biopsy for any potential malignancy or ulcers
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16
Q

Management of atrophic vaginitis?

A

Depends on complaint:

  • Systemic HRT (systemic progesterone + PV oestrogen)
  • Bleeding on intercourse: water based moisturisers and lubricants
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17
Q

Complications of atrophic vaginitis?

A
  • Increased incidence of superinfection due to increase vaginal PH
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18
Q

Prognosis of atrophic vaginitis?

A
  • Substantial relief can be achieved with treatment
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19
Q

What should you check when doing a history of infections or vaginal discharge?

A
  • Discharge: smell, consistency, colour, amount
  • Blood
  • Pain
  • Urinary symptoms
  • Itch
  • FLAWS: infection, immunosupression, cancer
  • Pregnant
  • Sexual history: partners, barrier, STI
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20
Q

Investigations for vaginal infections?

A
  1. PH
    - Lateral wall of vagina (avoid cervix): normal PH 3.5-4.5 due to lactobacilli in vagina
    - Sensitive, not specific
    - Low PH = candida
    - Normal PH = physiological, candida
    - Raised PH = contamination (blood, semen, lubrication), BV, TV
  2. SWABS: 1st endocervical, 2nd high vaginal

Double swabs :

  • Endocervical swab –> (2 in 1 NAAT testing) gonorrhoae, chlamydia
  • High vaginal charcoal swab –> (fungal and bacterial) BV, TV, candica, GBS

Triple swabs:

  • Swab 1: endocervival –> chalmydia
  • Swab 2: endocervical charcoal swab –> gonorrhoea
  • Swab 3: high vaginal charcoal swab –> (fungal and bacterial) BV, TV, candida and GBS
  • NAAT: gonorrhoea , chamydia (endocervical/VVS)
  • MC&S - gonorrhoea, candida, TV, BV
  1. Bloods
    - HIV, syphillis
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21
Q

What is the commonest cause of vaginal discharge?

A

Bacterial Vaginosis

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22
Q

How is BV transmitted?

A

Sexually and non sexually transmitted

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23
Q

What are the risk factors of BV?

A
  • Smoking
  • Vaginal douching
  • Bubble baths
  • Sex
  • New sexual partner
  • Other STIs
  • Copper IUD
  • Vaginal PH increase
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24
Q

What are protective factors for BV?

A
  • Condoms
  • Circumcised partner
  • COCP
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25
Q

What is the pathophysiology of BV?

A
  • Overgrowth of anaerobic bacteria (Gardnerella vaginalis, prevotella spp, mycoplasma homonis, mobiluncus spp.)
  • Loss of lactobacilli –> increase PH –> increase likelihood of PC
  • Gardnerella normally found but commensal in 30-40% of women
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26
Q

Signs and symptoms of BV?

A
  • 50% are asymptomatic

- Offensive foul smelling discharge

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27
Q

Investigations of BV?

A
  • Diagnosis = clinical + microscopy –> offensive foul smelling discharge (no soreness or irritation), high PH
  • HSV - microscopy (clue cells - vaginal epithelium cells coated with lots of bacilli)
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28
Q

What is the Hay-Ison criteria or Amsels criteria for BV?

A

Amsels = 3 out of 4

  • Thin, white, homogeneous discharge
  • Clue cells on microscopy
  • Vaginal PH / 4.5 (only BV and TV)
  • Fishy odour on adding 10% KOH

Hay-Ison critera applied to gram stain:
- Grade 3=BV

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29
Q

Management of BV?

A

1st line - metronidazole, PO, 400mg, BD, 7 days
2nd line - intravaginal clindamycon PV cream, 5g 2%, 7 days

Avoid vaginal douching, shower gel, use of shampoo in bath

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30
Q

Complications of BV?

A
  • Associated with late miscarriage, preterm birth, PROM and postpartum endometriosis
  • Increase risk of acquiring transmitting STIs
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31
Q

What type of organism is TV?

A
  • Flagellated Protozoan
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32
Q

How is TV transmitted?

A

It is sexually transmitted

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33
Q

Signs and symptoms of TV?

A
  • Asymptomatic in 50%

Symptomatic:

  • Green/yellow frothy vaginal discharge
  • Offensive odour
  • Dyspareunia
  • Vulval itch or soreness
  • Lower abdo pain and dysuria
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34
Q

What do you see on examination of TV?

A

A strawberry cervix

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35
Q

Investigations of TV?

A
  • High vaginal swab –> direct microscopy (wet mount of vaginal fluid shows flagellated organism in the middle)
  • Endocervical swabs for other STIs
  • Culture and gram stain
  • HIV test, NAAT, VDRL
  • pH (>4.5 - only in BV and TV), Whiff test
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36
Q

Management of TV?

A
  • 1st line - metronidazole, PO, 400mg, BD, 7 days
  • 2nd line -Metronidazole, 2g, PO STAT
  • contact tracing, abstinence for 7 days, follow-up
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37
Q

Complications of TV?

A
  • Pregnancy = PTL, LBW, PPROM

- Enhance HIV/STI transmission

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38
Q

What are the causative organisms of Thrush (Candidiasis)?

A
  • Candida albicans (90%)

- Candida globrata (5%)

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39
Q

What is the second common infection after BV?

A
  • Candidiasis
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40
Q

What are the 2 classifications of candidiasis?

A
  • Oral (local invasion of oral tissue)

- Invasive (systematic invasion of sterile sites)

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41
Q

What are the risk factors of thrush?

A
  • Oestrogen exposure (more common in pregnancy, reproductive years)
  • Diabetes (poorly controlled)
  • Intercourse
  • Immunocompromised (HIV)
  • Recent antibiotics (ie for UTI)
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42
Q

Signs and symptoms of thrush?

A
  • Vulval itching, soreness, irritation, ‘cottage-cheese’ like discharge
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43
Q

Investigations for thrush?

A
  • No investigations usually required (pH low/normal <4.5) –> if high consider BV or TV
  • Diagnostic= HVS = microscopy, culture and gram stain (Speckled gram +ve spores, pseudohyphae)
  • Other=MSU (UTIs), HbA1c (diabetes)

NB. Pseudohyphae only in C albicans.

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44
Q

What is the complications of thrush?

A
  • Hepatotoxicity associated with systematic azole antifungal therapy - monitor LFT
  • Oesophageal candidiasis or disseminated candidiasis in immunocompromised
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45
Q

Management of thrush?

A

1st line - clotrimazole pessary (500mg, PV, STAT) + 1% clotrimazole (BD, topical)

2nd line/severe - fluconazole (150mg, PO, STAT)

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46
Q

General advice given for thrush?

A
  • Avoid tight synthetic clothing, avoid local irritants (perfume), do not wash female area with soap/shower gels (or wash >1 day), do not douche, use simple emollients to moisturise
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47
Q

What is recurrent thrush?

A

> or equal to 4 proven symptomatic episodes

  • Check adherence, recheck initial diagnosis
  • Tx: induction and maintenance fluconazole
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48
Q

What is used to treat pregnant women with thrush?

A

Only use topical treatment

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49
Q

What causes cutaneous warts?

A
  • Condylomata acuminate

- Caused by HPV infection (HPV 6 and 11)

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50
Q

How is cutaneous warts transmitted?

A
  • Most are sexually active

- 10% prevalence in the sexually active population

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51
Q

How to prevent cutaneous warts?

A
  • HPV vaccine ‘Gardsli’ - protects against stbtypes 6,11,16,18
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52
Q

What does HPV 6 and 11 cause?

A

90% of cutaneous warts

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53
Q

What does HPV 16 and 18 cause?

A

Over 70% of cervical cancers

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54
Q

Signs and symptoms of cutanous warts?

A
  • Often asymptomatic
  • Vaginal discharge, PCB or IMB (local trauma), pain
  • Genital warts on vulva, cervix, anus –> generally painless but may itch or bleed or become inflamed
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55
Q

Investigations for cutaneous warts?

A
  • Often clinical diagnosis

- STI screen –> triple swab, HIV, syphillis, HBV

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56
Q

Management of cutaneous warts?

A
  • Often no treatment required, might refer to GUM for STI risk factors
  • Medical (contraindicated in pregnancy):
    Keratinised warts - imiquimid cream
    Non-keratinised warts - podophyllin/tri-chloro-acetic acid
  • Surgical - crotherapy, laser, electroautery
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57
Q

What are the complications of cutaneous warts?

A
  • May be high risk HPV leading to increased risk of anogenital cancers
  • Disfiguring - distress or psychosexual dysfunction
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58
Q

What causes chlamydia?

A
  • Chlamydia trachomatis

- Obligate intracellular gram -ve parasite (cannot see under microscope)

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59
Q

Where does chlamydia affect?

A

Women: Endocervixs and/or urethra
Men: Urethra

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60
Q

Signs and symptoms of chlamydia?

A
  • Asymptomatic in at least 70-80% of men

- Symptomatic (<30%) = purulent PV discharge, dyspareunia, IMB, PCB, abdo pain, dysuria

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61
Q

What are the investigations for chlamydia?

A
  • If there are signs and symptoms of chlamydia, can treat on suspicion alone, unlike gonorrhoea
  • Direct microscopy (non-gonococcal urethritis - just neutrophils, no organisms)

1st (NAAT):

  • MEN: Urethral swabs or first catch urine
  • WOMEN: vulvovaginal swabs or first catch urine

2nd:
- Culture and sensitivities

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62
Q

Management of chlamydia?

A
  • Can treat suspicion before getting lab results back

1st line: Doxycycline, 100mg, BD, 7days (contraindicated in pregnancy and breastfeeding)
2nd line / pregnant/ breastfeeding - azithromycin (1g STAT)

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63
Q

What else needs to be done after managing chlamydia?

A
  • Contact tracing (6 months)
  • Recommend STI screen
  • Avoid sex until treatment has been completed
  • Follow up appointment by 5 weeks
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64
Q

Complications of chlamydia?

A
  • PID
  • Infertility
  • Ectopic
  • Reactive arthritis (arthritis, conjunctivitis, urethritis)
  • Pregnancy
  • Fitz-hugh-curtis (perihepatitis)
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65
Q

What causes gonorrhoea?

A
  • Neisseria gonorrhoea

- Gram -ve intracellular diplococci

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66
Q

What are the risk factors for STIs?

A
  • Unprotected sex
  • Multiple partners
  • Presence of other STIs
  • HIV
  • Age < 25
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67
Q

Signs and symptoms of gonorrhoea?

A
  • Asymptomatic in up to 50% of patients
  • PV discharge
  • IMB
  • PCB
  • Dysuria
  • Dyspareunia
  • Lower abdo pain
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68
Q

What do you see in a speculum examination for gonorrhoea?

A
  • Mucopurulent endocervical discharge

- Easily induced endocervical bleeding

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69
Q

What do you see in a bimanual examination for gonorrhoea?

A
  • Cervial motion/adnexal tenderness

- Uterine tenderness

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70
Q

Investigations for gonorrhoea?

A
  • Empirical treatment only if recent sexual contact with confirmed gonococcal infection
  • Direct microscopy (neutrophils, gram -ve diplococci) –> prescribe antibiotics

1st (NAAT):

  • MEN: First catch urine
  • WOMEN: Vulvovaginal swabs
  • -> prescribe antibiotics

2nd:

  • Culture and sensitivities
  • -> prescribe antibiotics
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71
Q

What is the management of gonorrhoea?

A
  • After confirmation by NAAT, confirmation by culture (& sensitivities), or direct microscopy +ve)

1st line: Ceftriaxone 1g (IM)

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72
Q

What else needs to be done after managing gonorrhoea?

A
  • Screening for other STIs/HIV
  • Contact tracing
  • Avoid sex for 1 week
  • Follow-up appointment after 1 week
  • Cure rate = 95% with treatment
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73
Q

What are the complications of gonorrhoea?

A
  • PID, infertility, ectopic, conjucntivitis
  • Fitz-Hugh-Curtis syndrome (perihepatitis) - a PID characterised by adhesions from liver to abdominal wall
  • Increased HIV susceptibility
  • Disseminated disease in 1%
  • Vertical transmission - ophthalmia neonatorum - bilateral conjunctivitis
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74
Q

What is a bartholin’s cyst?

A
  • A cyst of abscess of Bartholin’s gland (greater vestibular glands)
  • Overlying superinfection by Staph or GBS
  • Blockage of a duct or gland in vagina has become infected
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75
Q

What are the risk factors for bartholin’s cyst?

A
  • Nulliparous
  • Pervious bartholin’s cyst?
  • Sexually active
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76
Q

What is the different between bartholin’s cyst and labial cyst?

A

Bartholin’s cyst may extend into the vaginal canal and labial cyst will remain in the labia

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77
Q

Signs and symptoms of bartholin’s cyst?

A
  • Unilateral labial swelling, often asymptomatic/painless
  • Infected:
    Abscess with cardinal signs of infection
    Fever
    Dyspareunia
    Pain or sitting or walking
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78
Q

Investigations for bartholin’s cyst?

A
  • If >40 y/o consider vulval biopsy

- If infected –> MC&S from abscess - most sterile but may help organism differentiation

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79
Q

Management of bartholin’s cyst?

A
  • Conservative (if draining and patient well)
  • Incision and drainage + Word catheter + Flucloxicillin, OD
  • Marsuplalisation (forming an open pouch to stop the cyst from reforming)
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80
Q

Complications for bartholin’s cyst?

A
  • Rupture

- Recurrence

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81
Q

What is PID?

A
  • Pelvic inflammatory disease

- Result of ascending infection of the genital tract (endometritis, salpingitis, tuboovarian abscess)

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82
Q

What is the most common organism for PID?

A 
- Chlamydia Trachomatis 
Other:
- N Gonorrhoea 
- M genitalium 
- M hominis
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83
Q

Risk factors for PID?

A
  • <25 y/o
  • Early age of first coitus
  • Multiple sexual partners
  • Recent new partner
  • History of STI
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84
Q

Signs and symptoms of PID?

A
  • Asymptomatic (with infertility + chronic pelvic pain)

- Acutely - bilateral lower abdo pain, PV discharge, fever, irregular PVB, dyspareunia

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85
Q

Investigations for PID?

A
  • Start with antibiotics if you suspect PID
  • Triple swabs: 2x endocervical and 1x HVS
  • Speculum: looks for signs of inflammation/discharge
  • Bimanual: cervical excitation, adnexal massess (tubo-ovarian abscess - confirm with TVUSS)
  • If febrile: blood culture, FBC, CRP
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86
Q

Management of PID?

A
  • Assess patient for admission: admit if pyrexial or septic
    If not treat then in the community.

Outpatient antibiotics:

  • Ceftriaxone 500mg IM (single dose)
  • Doxycycline 100mg BD PO for 14 days
  • Metronidazole 400mg BD PO for 14 days

Alternative (treat for 14 days):

  • Ofloxacin
  • Metronidazole

Inpatient antibiotics (if pyrexcial or oral tx failed)

  • IV cefoxitin
  • IV doxycycline

Alternative treatment:

  • IV clindamycin
  • IV gentamycin
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87
Q

Complications of PID?

A
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy (paralyse cillia in the Fallopian tubes)
  • 30% require hospital admission
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88
Q

What are the phases or normal menstrual cycle?

A
  • Proliferative stage: hyperplasia of endometrium
  • Secretory phase: maintain endometrium
  • Menstrual phase (drop in progesterone): zona compacta and spongiosa shedding
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89
Q

What are thecal cells in the ovaries?

A
  • Responds to LH

- Produce progesterone

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90
Q

What are granulosa cells?

A
  • Respond to FSH
  • Produce aromatase (convert androgen to oestriol)
  • Produce progesterone
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91
Q

What are the primary causes of amenorrhoea?

A
  • Turners syndrome
  • Testicular feminisation
  • Congenital adrenal hyperplasia
  • Congenital malformations of the genital tract
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92
Q

What are the secondary causes of amenorrhoea?

A
  • Hypothamalic amenorrhoea (stress, excessive exercise)
  • PCOS
  • Hyperprolactinaemia
  • Premature ovarian failure
  • Thyrotoxicosis
  • Sheehans syndrome
  • Ashermans syndrome (intrauterine adhesions)
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93
Q

What are the s/s and Ix for imperforate hymen?

A

S/S: all other sexual characteristics developed, cyclical pelvic pain, amenorrhoea

IX: USS –> haematometra

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94
Q

What are the investigations for amenorrhoea?

A
  • b-HCG: Pregnancy
  • Gonadotrophins: Hypothalamic cause
  • Prolactin: Prolactinoma
  • Androgens: PCOS, CAH
  • Oestradiol: Pregnancy
  • Thyroid function: Hypothyroid
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95
Q

What is a colposcopy?

A

A diagnostic procedure obtaining a magnified view of the cervic, the lower part of the uterus and the vagina in order to examine the transformation zone and detect malignant or premalignant changes

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96
Q

What is a cervical punch biopsy?

A

Small amount of tissue removed from the cervix

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97
Q

What are the indications for colopscopy and cervical punch biopsy?

A
  • Severe or moderate dyskaryosis
  • 3x inadequate smear
  • Glandular neoplasia on smear
  • Borderline/mild dyskaryosis smear with HPV +ve test
  • Suspicious looking cervix
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98
Q

Complications of colopscopy and cervical punch biopsy

A
  • Few complications for colopscopy alone
  • Colopscopy + excisional treatment = bleeding and infection, cervical incompetence in future pregnancies
  • Biopsy = rare but include excessive bleeding for more than 1 week, mild cramping, vaginal soreness, dark discharge
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99
Q

what is endometrial ablation?

A

Outpatient procedure to remove or destroy endometrial layers (can prevent periods/heavy bleeding)

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100
Q

Indications for endometrial ablation?

A
  • Menorrhagia in premenopausal or perimenopausal women with normal endometrial cavities
  • Postmenopausal bleeding of unknown origin
  • Anovulatory bleeding and bleeding secondary to fibroids (intramural or submucosal <2cm for GEA, microwave ablation for submucosal up to 3cm) - higher risk of failure as does not remove fibroids
  • No desire for future fertility but desire to retain uterus or avoid hysterectomy
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101
Q

Complications of endometrial ablation?

A

General= infection, bleeding, failure, damage to local structures (os, lining)

Minor= cramping, nausea, frequent urination, watery discharge mixed with blood

Rarely= Pulmonary oedema due to fluid used to expand uterus being absorbed into the bloodstream

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102
Q

What is endometrial biopsy?

A
  • Biopsy of the endometrium

- Pipelle is the most widely used device - can be used without cervical dilation)

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103
Q

What are the indications for endometrial biopsy?

A

Over 55 and:

  • PMB (unexplained bleeding 12 months after LMP)
  • Unexplained discharge if it is new, has thrombocytosis or report haematuria
  • Visible heamaturia and low Hb, thrombocytosis, raised blood glucose

Under 55 and:
- unexplained bleeding 12 months after LMP

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104
Q

Complications of endometrial biopsy?

A

General= infection, bleeding, failure, damage to local structures (os, lining)

Pipelle has blood NVP (true -ve/ total -ve)

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105
Q

What is an epidural?

A

Regional anaesthesia performed by injecting anaesthetic into the epidural space (diff from a spinal)

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106
Q

Indications for epidural?

A
  • Pain relief during labour
  • Anaesthetic for C section

NB: stop any thromboprophylaxis 24 hours before epidural

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107
Q

Complications of epidural?

A

General= infection, bleeding, failure, damage to local structures

Urinary retention, shivering, pruritus, headache, (anaesthesia going to head)

Hypotension, epidural haematoma, epidural meningitis, resp depression

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108
Q

What is a gynaecological laparoscopy?

A

Endoscopic pelvic surgical diagnostic procedure used to examine the organs inside the abdomen

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109
Q

Indications for gynaecological laparoscopy?

A

Diagnostic:
- pelvic pain, diagnose endometriosis, infertility, (dye test for tubal potency)

Therapeutic:
- Sterilisation, adhesiolysis, ovarian cystectomy, salpingectomy, endometrial ablation

Major surgery:
- Myomectomy, hysterectomy

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110
Q

Complications for gynaecological laparoscopy?

A

General= infection, bleeding, failure, damage to local structures

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111
Q

What is an ovarian cystectomy?

A

Surgical excision of an ovarian cyst

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112
Q

Indications for ovarian cystectomy?

A
  • Diagnostic (and exclude an ovarian cyst)
  • Cyst > 7.6cm
  • Bilateral leisions
  • Removal of symptomatic cysts
  • Cysts that do not resolve after 2-3 months
  • USS finding that deviate from simple functional cyst
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113
Q

Complications of ovarian cystectomy?

A

General= infection, bleeding, failure, damage to local structures

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114
Q

What is a myomectomy?

A

Surgical removal of fibroids from the uterus

the only fibroid treatment can improve pregnancy chances

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115
Q

What should be done prior to myomectomy?

A

GnRH analogues used to shrink size to reduce bleeding

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116
Q

Indications for myomectomy?

A
  • Hysterectomy- fibroids on the inner wall
  • Laparoscopy - removing 1/2 fibroids <2 inches that are growing outside the uterus
  • Open - large fibroids, many fibrouds, fibroids deep into the uterine wall
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117
Q

Complications of myomectomy?

A

General= infection, bleeding, failure, damage to local structures

Hysterectomy is large haemorrhage

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118
Q

What is a LLETZ?

A

Large loop excision of the transformation zone

Use a small wire diathermy to cut away affected cervical tissue and seal the wound (examine cuttings for CIN)

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119
Q

Indications for LLETZ?

A
  • High grade squamous intraepithelial lesions of the cervix (CIN 2/3)
  • Persistent low grade squamous intraepithelial lesions of the cervix (CIN 1)
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120
Q

Complications for LLETZ?

A

General= infection, bleeding, failure, damage to local structures (os, lining) –> recurrence of up to 10%

Bleeding, discharge for 3-4 weeks (avoid tampons, sex, swimming until discharge has stopped)

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121
Q

What is a hysteroscopy?

A

Involves passing a small diameter telescope (flexible or rigid) through the cervix in inspect the uterine cavity

  • Flexible hysteroscope can be used in OPD setting with CO2 as filling medium
  • Rigid instruments use circulating fluids so can be used to visualise uterine cavity even if the women is bleeding
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122
Q

Indications of hysteroscopy?

A
  • Abnormal bleeding
  • PMB, IMB, PCB
  • Menorrhagia and or abnormal discharge
  • Suspected uterine malformations or suspected Ashermans
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123
Q

Complications of hysteroscopy?

A

General= infection, bleeding, failure, damage to local structures (os, lining)

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124
Q

What are the 3 approaches to hysterectomy?

A
  • Vaginal
  • Laparascopic assisted vaginal
  • Laparascopic hysterectomy
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125
Q

What structures are removed in a hysterectomy?

A 
Total: uterus and cervix 
Cervix removed (no smears needed)

Radial: removal of structures +/- BSO 
I.E Wertheim's hysterectomy 
Cervix removed (no smears needed)

Subtotal: upper part of the uterus removed
Cervix NOT removed (smears needed)

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126
Q

When are smears needed for a hysterectomy?

A

If total or radical hysterectomy and done due to cancer/CIN, smears are still done at 6 and 18 months

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127
Q

Indications of a hysterectomy?

A

Vaginal hysterectomy:

  • menstrual disorders with uterus <12w size
  • Microminvasive cervical carcinoma
  • Uterovaginal prolapse

Abdominal hysterectomy:

  • Pfannestiel incision (midline incision if larger masses or malignancy)
  • Uterine, ovarian, cervical, fallopian tube carcinoma
  • Pelvic pain from chronic endometriosis or chronic PID where pelvis is frozen and vaginal impossible
  • Symptoms fibroid uterus 12w++ uterus in size
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128
Q

Complications of hysterectomy?

A

General= infection, bleeding, failure, damage to local structures (os, lining), GA complications, VTE

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129
Q

What is given intra-operatively for hysterectomy?

A

Augmentin (co-amoxiclav)

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130
Q

What are the contraindications of vaginal hysterectomy?

A

Malignancy

Uterus with 12 weeks ++ pregnancy

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131
Q

What is the Figo staging for endometrial cancer?

A 
I = Uterus
II = Uterus + cervix 
III = adnexa
IV =  distant metastasis/bladder/bowel
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132
Q

What is the Figo staging for ovarian cancer?

A 
I = limited to ovaries
II = pelvic extension (ie. uterus)
III = abdominal extension (extra-pelvic)
IV =  distant metastasis
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133
Q

What is the Figo staging for cervical cancer?

A 
I = cervix
II = invade beyond cervix, not into pelvic wall or lower 1/3rd vagina 
III = extend to pelvic wall +/- lower 1/3rd of the vagina +/- hydronephrosis
IV =  extend to pelvic wall + involve the mucosa of bladder or rectum
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134
Q

What are the 3 types of functional ovarian cyst?

A

Follucilar (most common)

  • Cyst: >3cm (>5cm risk of torsion)
  • USS: thin walled, unilocular, anechoic

Corpus luteal:

  • Occur after ovulation, may rupture at the end of the menstrual cycle
  • USS: diffusely thick walls, <3cm, lacey pattern

Theca lutein:
- Associated with pregnancy (high circulating ganadotrophins eg. hCG)
- USS: bilaterally enlarged, multicystic ovaries, thin-walled and anechoic
- Features:
Can cause hypertension, often bilateral and resolve spontaneously

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135
Q

What are the 3 types of inflammatory ovarian cyst?

A

Tubo-ovarian abscess:

  • Features of PID
  • Tender to adnexal mass
  • USS: Ovary and tube cannot be distinguished from mass

Endomatrioma:

  • Chocolate cyst
  • Associated with endometriosis
  • USS: unilocular with ground- glass echos (50% cases)
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136
Q

What are the 1 type of germ cell ovarian cyst?

A

Dermoid

  • Mature: benign, solid or cystic
  • USS: unilocular, diffusely or partially echogenic, may contain teeth, no internal vascularity
  • Immature: contains embryonic elements, malignant
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137
Q

What are the 3 types of sex cord ovarian cyst?

A

Thecoma:

  • Benign, may produce oestrogens (and, rarely, androgens)
  • USS: variable - echogenic mass, hyperechoic and anechoic

Fibroma:

  • Benign, no endocrine production
  • USS: solid, hyperechoic mass

Granulosa cell:

  • Produce oestrogen
  • USS: variable - may appear solid or cystic
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138
Q

What are the 3 types of epithelial ovarian cyst?

A

Brenner’s tumour:

  • Small
  • Contain urothelial-like epithelium
  • USS: hyperachoic, occasionally calcifications may be seen

Mucinous Cystsdenoma:

  • Usually LARGE
  • USS: multiloculated, many thin seperations, low echogenicity due to mucin

Serous cystadenoma (most common ovarian neoplasm)

  • Usually unilocular
  • Often bilateral
  • USS: unilocular, anechoic, no flow on colour Doppler
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139
Q

What is Vulval cancer (VIN)?

A
  • Malignant neoplasm of the vulva

- Majority are squamous cell carcinomas

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140
Q

Risk factors for Vulval cancer?

A

Usual type:
- (warty/basaloid SCC) –> VIN (HPV type 16), immunosupression, smoking

Differential type:
- (Keratenised SCC) –> lichen sclerosis

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141
Q

What is the aetiology of vulval cancer?

A

Progression of certain vulval dermatoses, progression of VIN

  • VIN splits into 1,2 and 3 (how deep the cancer goes)
  • VIN classified by low-grade squamous, high-grade and differentiated
LSIL = low grade squamous
HSIL = high grade squamous 
dVIN = differentiated VIN (keratinised)
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142
Q

Investigations for vulval cancer?

A
  • Tissue diagnosis: full thickness biopsy, sentinel node biopsy
  • Cervical smear: exclude CIN if VIN-associated
  • Imaging: CT or MRI to assess lymphadenopathy
  • Other: staging by cytoscopy, proctoscopy
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143
Q

Management of vulval cancer?

A
  • Vulvectomy + bilateral inguinal lymphadenectomy

1a –> wide local insicion +/- neoadjuvant chemo = radical surgical excision with 10mm clear margin

> 1a –> radical vulvectomy + bilateral inguinal lymphadenectomy

  • a dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node
  • if removed, groin lymphadenopathy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema
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144
Q

Management of vulval cancer?

A
  • Vulvectomy + bilateral inguinal lymphadenectomy

1a –> wide local insicion +- neoadjuvant chemo = radical surgical excision with 10mm clear margin

> 1a –> radical vulvectomy + bilateral inguinal lymphadenectomy

  • a dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node
  • if removed, groin lymphadenopathy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema

unsuitable for surgery –> radiotherapy

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145
Q

What is toxic shock syndrome?

A

Septicaemia from toxin (TSST 1) produced by staph and strep bacteria

  • Staph: endotoxins (TSS toxin 1)
  • Strep: inflammatory cascade initiation
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146
Q

What is the aetiology of TSS?

A

Multi-system inflammatory response to bacterial endotoxins

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147
Q

What are the risk factors for TSS?

A

Tampons in higher absorbency, infrequent change of tampons, overnight tampon use

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148
Q

Signs and symptoms of TSS?

A
  • Fever
  • D&V
  • Myalgia
  • Sore throat
  • Shock
  • Diffuse red macular rash
  • Headache
  • Desquamation of palms and soles
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149
Q

Investigations for TSS?

A
  1. Bloods- FBC (raised WBC, low platelets), U&Es (impaired renal function), LFT, raised CK, raised CRP
  2. Microbiology - HVS, blood culture, culture of tampon
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150
Q

Management of TSS?

A
  • ABCs and remove tampons

- Antibiotics (broad-spectrum IV)

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151
Q

Complications of TSS?

A
  • Septic shock, MOF, DIC, ARDS, death
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152
Q

What are the types or urogenital prolapse?

A
  • Uterine prolapse = prolapse of uterus into the vagina
  • Cystocele = prolapse of anterior vaginal wall involving the bladder
  • Rectocele = prolapse of lower posterior vaginal wall involving the anterior wall of the rectum
  • Enterocele = prolapse of the upper vaginal wall containing loops of small bowel
  • Vault prolapse = prolapse of vaginal vault after hysterectomy
153
Q

What is the aetiology of urogenital prolapse?

A

Weak pelvic floor muscles

154
Q

Risk factors of urogenital prolapse?

A
  • Increasing age
  • Parity
  • Menopause
  • obesity
  • pelvic surgery
  • chronic cough
  • occupations associated with heavy lifting
  • high impact sports
  • constipation
  • pelvic mass
  • FHx
  • spinal cord injury/mascular atrophy
155
Q

Signs and symptoms of urogenital prolapse?

A
  • Feelings of heaviness of descent PV
  • Recurrent UTI
  • Urinary symptoms if cystocele
  • Back pain
  • Dyspareunia
  • Constipation or faecal incontinence if rectocele
156
Q

Investigations of urogenital prolapse?

A
  • Speculum (grade and severity)
  • Urodynamics (incontinence)
  • MC&S (urine infections)
157
Q

Management of urogenital prolapse?

A

1st line: conservative

  • weight loss
  • minimise weightlifting
  • stop smoking

2nd line:

  • Pelvic floor exercises
  • Topical oestrogen in elderly patients
  • Pessary

3rd line:
- Surgical options - depends on what organs have been prolapsed

  1. Uterine prolapse (depends on whether the patient wants to preserve the uterus or not)
  2. Vault prolapse
    - 1st line: sacrocolpopexy (abdonimal or laparoscopic) with mesh
    - Other: vaginal sacrospinous fixation with sutures (risk of sciatic nerve damage)
  3. Anterior prolapse (cystocele) or posterior prolapse (rectocele)
    - 1st line: anterior/posterior colporrhaphy (without mesh)
158
Q

What are the 5 types of pessary?

A

Ring: common type, soft, does not prevent sex

Shelf: common type, hard, more support than a ring, DOES prevent sex

Gelhorn: similar to shelf but are soft instead of hard, DOES prevent sex

Gehrung: disk-shaped and used for more serious prolapse (easier to remove)

Cube: for very advanced prolapse - uses suction to keep things in place

159
Q

What are the grading systems for urogenital prolapse?

A
  1. POP-Q (measures different anatomical landmarks in relation to the hymen)
    - NICE recommended
    - These positions are recorded as co-ordinates relative to the physiological position of the pelvic organs. The hymen is used as a reference point.
    - Distal to the hymen is a +ve number and proximal is a -ve number
  2. Shaw’s (more commonly used, looks at the extent of descent of prolapse)
    - 1st degree: descent to the introitus
    - 2nd: extends to the introitus but decreased past the introitus on straining
    - 3rd degree: prolapse descends throught the introitus
  3. Baden-walker (Like Shaw’s but uses the hymen as a reference point)
160
Q

What is pruritis vulvae?

A

Commonly caused by vulvoganitis (vulvovaginal candidiasis, atrophic vaginitis, vulvar vestibulitis and contact dermatitis) –> infection, eczema, contact dermatitis

161
Q

What are the signs and symptoms of pruritis vulvae?

A

Vulvovaginal candidiasis:

  • vulvar pruritis
  • burning
  • erythema
  • oedema of the vestibule and labia
  • thick curd like PVD
  • Chronic: grey-sheen of epithelia cells, severe pruritus, irritation and pain, lichenification of vulva

Atrophic vaginitis:

  • soreness
  • dyspareunia
  • burning leucorrhoae (white mucous discharge)
  • occasional spotting

Vulvar vestibulitis:

  • primary: introital dyspareunia
  • Secondary: introital dyspareunia that develops after period of comfortable sexual relations
  • pain
  • soreness
  • burning
  • rawness

Contact dermatitis:

  • pruritis
  • can get burning
  • pain
  • red
  • ulcerative skin following contact
162
Q

What are the investigations for pruritis vulvae?

A
  • Vulvovaginal candidiasis: wet-mount test or KOH preparation
  • Atrophic vaginitis: vaginal PH and wet-mount test (often shows white blood cells and paucity of lactobacillus)
163
Q

What is the management of pruritis vulvae?

A

Vulvovaginal candidiasis:

  • Ketaconazole (400mg/day) or fluconazole (100mg/week) for 6 weeks
  • Clotrimazole 500mg suppositories once per week

Atrophic vaginitis:
- topical vaginal oestrogen or HRT

Vulvar vestibulitis:

  • pain management with sex therapy
  • behaviour modification
  • topical steroid
  • anaesthetic
  • petroleum jelly
  • anti-inflammatories
  • surgical excision at last resort

Contact dermatitis:

  • remove itching agent
  • MILD = 1% hydrocortisone
  • MODERATE = betamethasone
  • Triamcinolone ointment applied BD
  • Wet compresses of aluminium acetate for several lesions
  • seborrhoeic dermatitis, consider ketoconazole shampoo body wash
164
Q

What are the complications of pruritis vulvae?

A

Atrophic vaginitis:
- super infection due to raised vaginal PH

Candida:
- disruption to social and sexual life

165
Q

What is ovarian torsion?

A

Complication of ovarian cysts of tumours

  • dermoid cysts are most likely to undergo torsion, whereas endometriomas are least likely
  • Any ovarian cyst >5cm diameter is at risk of torsion
166
Q

What are the risk factors for ovarian torsion?

A
  • Ovarian cysts or tumours
  • Long ovarian ligaments
  • Pregnancy
  • Tubal ligation
167
Q

What are the signs and symptoms of ovarian torsion?

A
  • Severe right/left illiac fossa pain

- Vomitting

168
Q

What are the investigations for ovarian torsion?

A
  • Pregnancy test
  • FBC (might show high WCC)
  • Speculum if PID is a differential
  • Bimanual examination (adnexal mass)
  • Urinalysis (rule out ureteric colic)

USS with dopplers:

  • Doppler may be false -ve due to dual blood supply to the ovary (ovarian artery and uterine artery)
  • Ovarian necrosis may cause lactic acidosis

USS –> whirlpool sign

169
Q

What is the management of ovarian torsion?

A

1st line: laparoscopic detorsion +/- cystectomy

2nd line: salpingo-oophrectomy

170
Q

What is stress incontinence?

A

Increased pressure on the bladder –> incontinence (small losses)

171
Q

What is urge incontinence?

A

Strong urge to urinate and often don’t get to the toilet in time –> incontinence (big losses)

172
Q

What is mixed incontinence?

A

> 2 types (often stress and urge together)

173
Q

What is overflow incontinence?

A

Difficulty emptying bladder –> filling –> incontinence

174
Q

What is functional incontinence?

A

Cannot get to the toilet in time due to mobility issues

175
Q

What are the investigations for urinary incontinence?

A
  • Speculum exam –> can exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercises) –> ask patient to cough (Vasalva) during exam to check for fluid leakage

1st:
- Urine dipstick
- Urine MC&S (rule out DM or UTI)
- bladder diaries (min 3 days)

2nd:
- urodynamic testing (if mixed incontinence) 3 pressures measured from inside rectum and urethra
- bladder pressure = detrusor + IAP
- Detrusor = bladder - IAP

176
Q

What is the voiding in men and women?

A

Men - hold 400ml and void at a rate of 10-15mL/s

Women - hold 500ml and void at a rate of 15-20mL/s

177
Q

What is the risk factor of stress incontinence?

A
  • Age
  • Children
  • Traumatic delivery
  • Pelvic surgery
  • Obesity
178
Q

What is the risk factor of urge incontinence?

A
  • Age
  • Obesity
  • Smoking
  • FHx
  • DM
179
Q

What is the management of stress incontinence?

A

Check need for referral to specialist (ie. trigone tumour –> need to be checked)

1st line:
- lifestyle advice, WL (BMI>30), pelvic floor exercises (8 contractions, TDS, 3 months)

2nd line: (surgical treatment) or SNRI duloxetine

  • Burch colposupression –> stitching the neck of the bladder higher (coopers ligaments)
  • Autologous rectus facial sling –> a sling placed around the neck of the bladder
  • Bulking agents –> put bulking agents into urethral wall to provide more force
180
Q

What is the management of urge incontinence?

A

Check need for referral to specialist (ie. trigone tumour –> need to be checked)

1st Line: lifestyle advice, bladder training:

  • Bladder training (6 weeks) –> progressive hold off going to the toilet for up to 25 minutes
  • Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles)
  • Control diabetes (avoid diabetic nepropathy)

2nd line: antimuscarinics (oxybutynin, tolterodine), ADH analogues (desmopressin)

  • Antimuscarinics (oxybutynin, tolterodine, darifenacin)
  • DO NOT give a patient with closed angle glaucoma
  • oxybutynin (increased risk of falls do not give elderly)
  • darifenacin = M3 receptor antagonist

3rd line:

  • mirabegron (beta-3 agonist)
  • used if concerns about during anticholinergics in older, frail women

4th line:

  • botox injection
  • sacral nerve stimulation
  • cystoplasty
  • urinary diversion
181
Q

What is the management of overflow incontinence?

A

Refer to specialist urogynaecologist

1st line: timed voiding

182
Q

When should you suspect vesicovaginal fistula?

A

Dribbling incontinence after having a child with a prolonged labour

urinary dye studies

183
Q

What is the rotterdam criteria for PCOS?

A

2 or more of the following

  • Oligo/anovulation (>2 years)
  • Clinical or biochemical features of hyperandrogenism
  • Polycystic ovaries on USS
184
Q

What are the risk factors of PCOS?

A
  • Family history

- Obesity

185
Q

What are the signs and symptoms of PCOS?

A
  • Hirsutism
  • Sub-fertility
  • Amenorrhoea
  • Weight gain
  • Acne
  • Insulin resistance (acanthosis nigricans)
186
Q

What are the investigations of PCOS?

A

TVUSS –> polycystic ovaries (Pear necklace sign)

LH>FSH index –> 2/3:1

Other: testosterone, SHBG, TSH

DM monitoring:
- OGTT at diagnosis for BMI>25, non-caucasian ethnicity, any BMI and >40yo, FHx, DM, GDM Hx

Annual OGTT for:

  • IFG (fasting 6.1-6.9 mmol/L)
  • IGT (OGTT 7.8-11.1 mmol/L)

CVD monitoring (assess risk with QRISK2):

  • Lipid profile
  • Blood pressure
  • Diet, exercise, smoking and weight loss
187
Q

What is the management of PCOS oligo/amenorrhoea?

A

Oligomenorrhoea (>3m) –> refer for TVUSS to assess endometrial thickness

  • Weight reduction
  • COCP (indication: contraception and hyperandrogenism)
  • Cyclical progesterone (indication: contraception)
  • LNG-IUS (indication: contraception)
188
Q

What is the management of PCOS hyperandrogenism (acne and hirsutism)?

A
  • Weight reduction
  • 1st line: COCP (indication: contraception and hyperandrogenism)
    Increases SHBG to relieve androgenic symptoms (co-cyprindiol better)
  • Co-cyprindoil (indication: contraception and hyperandrogenism)
    COCP and enhanced anti-androgenic activity. Cyproterone acetate and ethinylestradiol
  • Topical eflornithine cream (indication hyperandrogenism)
189
Q

What is the management of PCOS infertility?

A

1st line: weight loss

2nd line: clomiphene –> clomiphene and metformin (after 3 failed clomiphene cycles)
Induces ovulation if subfertility is an issue
Increased risk of multiple pregnancy
SERM (blocks ER in hypothalamus –> reduce -ve feedback –> more GnRH pulsatile release)

3rd line:

  • Gonadotrophins
  • IVF

Surgery:
- laparascopic ovarian drilling (destroy ovarian stroma and prompt cycles)

190
Q

What are the complications of PCOS?

A
  • Metabolic syndrome (DM and heart disease)
  • CVD
  • Sleep apnoea
  • Endometrial cancer (if >7mm may be pathalogical)
  • Subfertility
  • Recommend withdrawal bleeding every 3-4 months
191
Q

What is OHSS?

A

Ovarian hyperstimulation syndrome

  • Multi luteinized cysts
  • loss of oestrogen (VEGF)
  • Pain + bloating
192
Q

What is premature ovarian insufficiency?

A

Secondary amenorrhoea before the age of 40 years old

193
Q

What are the causes of POI?

A
  • Iatrogenic (oophorectomy)

- Unknown (Addison’s - steroid cell autoantibodies cross-react with granulosa cells and theca interna)

194
Q

What are the signs and symptoms of POI?

A

Menopause signs and symptoms

195
Q

What are the investigations of POI?

A
  • Diagnosis = = 40 years old, 2x FSH results >30 (these should be repeated 4-6 weeks apart) + menopause symptoms
  • Oestrogen Low
  • LH/FSH high
  • Antral follicle count, AMH levels (test ovarian reserve)
196
Q

What is the management of POI?

A

Fertility management:

  • Donor Oocyte IVF
  • Surrogacy and adoption are other options
  • only 5-10% POI women can get pregnant without fertility treatment
197
Q

What are future complications of POI?

A

Osteoporosis: Regular DEXA scans, all should get HRT
Other: hypothyroid, sexual dysfunction, insomnia (vasomotor symptoms), stroke, heart disease

198
Q

What is PMS?

A
  • Distressing symptoms occurring in the luteal phase of the menstrual cycle (in the absence of disease)
199
Q

What is the cause of PMS?

A

Unknown, likely due to the cyclical effect of oestradiol and progesterone on neurotransmitters (serotonin and GABA)

200
Q

What are the risk factors of PMS?

A
  • Obesity
  • Lack of exercise
  • Dietary
  • Smoking
  • FHx
201
Q

What are the signs and symptoms of PMS?

A
  • Mood swings
  • Anxiety
  • Headache
  • Poor concentration
  • Lack of energy
  • Changes in appetite
  • Disturbed sleep
  • Bloating
  • Breast tenderness
202
Q

What are the investigations of PMS?

A

Diagnosis requires a symptom diary over 2 cycles

203
Q

What is the management of PMS?

A

ALL PMS:

  • Conservative lifestyle measures, painkillers
  • regular meals, exercise, sleep
  • stress reduction, smoking cessation, alcohol restriction
  • Painkillers (NSAIDs, paracetamol)

Moderate: (some impact on personal, social and professional life)

  • COCP (cyclical or continuous) +/- CBT
  • Paracetamol or NSAIDs
  • Referral to CBT

Severe: (withdrawal from social and professional activities, prevents normal functioning)

  • SSRI (continuous or just during the luteal phase, try initially for 3 months) +/- CBT
  • Alternatives: GnRH analogues, transdermal oestrogen, surgery
204
Q

What is syphilis?

A

Syphilis is a systemic infection caused by the gram -ve spirochete (Treponema pallidum)

205
Q

What is the aetiology of syphilis?

A
  • Sexual contact
  • Blood bourne
  • Vertical
206
Q

What are the risk factors of syphilis?

A
  • Young age
  • African american
  • Use of illicit drugs
  • Infection with other STIs
  • Sex worker
207
Q

What are the primary and secondary signs and symptoms of syphilis?

A

Primary (3-4 weeks):

  • painless chancres +/- local lymphadenopathy
  • resolves in 3-8 weeks

Secondary (4-10 weeks after chancre):

  • rough papulonodular rash (hands, feet, trunk)
  • uveitis
  • condylomata lata
  • lymphadenopathy + systematic symptoms
  • Snail tack oral ulcers
  • Resolves in 2-12 weeks
208
Q

What are the latent signs and symptoms of syphilis?

A

No symptoms, detected on routine tests

  • Early latent: (<2 years after infection - exposure to or symptoms of 1st/2nd in <2 year)
  • Late latent: (>2 years after infection - exposure to or symptoms of 1st/2nd in >2 year)
209
Q

What are the tertiary signs and symptoms of syphilis?

A
  • 1 to 20 years
  • Gummatous syphilis (erosive skin and bone lesions)
  • Cardiovascular syphilis (aortic, aortic regurgitation - early diastolic decrescendo, heart failure)
  • Neurosyphilis

Neurosyphilis:

  • meningovascular –> ischaemia, insomnia, emotionally labile
  • general paresis –> dementia
  • tabes dorsalis –> sensory problems, lightning pains, absent reflexes (affects the dorsal column)
210
Q

What are the investigations of syphilis?

A

Microbiology: dark-ground (from chancre with dark field illuminations), PCR

Serology:

  • routine antenatal screening offered to all pregnant women –> detects treponemal antibodies
  • takes 3/12 weeks for syphilis to become positive in serology

Non-treponemal tests - high false positive rate due to cross-reactivity:

  • RPR (rapid plasmin reagin) –> how many dilutes to lose the reagin
  • If positive, must be followed by a more specific treponemal test

Treponemal tests:

  • EIA - very sensitive and specific
  • TPHA/TPPA (treponemal pallidum haemagglutinin assay)
  • FTA-ABS (flourescent treponemal antibody absorption)

Neurosyphilis:

  • CT/MRI head
  • LP (raised WCC, raised protein)
  • TPPA >1:320
211
Q

What is the management of syphilis?

A

Early: (1st, 2nd, early latent)
- Benzathine-Pen IM STAT
or
- Doxycyclin (BD, 14/7)

Late: (late-latent, non-neuro 3rd)
- Benzathine-Pen IM OW, 3/52
or
- Doxycyclin (BD, 28/7)

Neurosyphillis:
- Penicillin (IV, 4-hourly, 14/7)
or
- Doxycycline (BD, 28/7)

Prednisolone (OD, 3/7) started 24 hours before treatment to avoid Jarish-Harxheimer reaction

212
Q

What is Jarish-Harxheimer reaction?

A
  • Release of pro-inflammatory cytokines in response to dying organisms
    S/S: 24-hours of febrile myalgia, rare/serious consequences, admit mother >22w when treating
213
Q

What is the follow up of syphilis?

A
  • Partner notification

- Repeat bloods at 3/12 (4-fold drop in RPR)

214
Q

What are the complications of syphilis in pregnancy?

A

Congenital syphilis:
- rash on soles of feet and hands +/- bone lesions

Risks in pregnancy: (benzathine penicillin greatly improves foetus outcomes)

  • FGR
  • Foetal hydrops
  • Congenital syphilis
  • Stillbirth
  • Preterm birth
  • Neonatal death
215
Q

What are the 4 types of FGM?

A

Type 1 - clitoridectomy - removing part of the clitoris

Type 2 - Excision - removing part of all of the clitoris, labia minora +/- major

Type 3 - infibulation - narrowing vaginal opening by creating a seal by cutting and repositioning the labia

Type 4 - any other procedure to the genitals including pricking, piercing, cutting, scraping, burning

216
Q

What are the signs and symptoms of FGM?

A
  • Constant pain
  • incontinence
  • Dyspareunia
  • Depression, flashbacks, self-harm
  • Bleeding, cysts, abscesses
217
Q

What is the management of FGM?

A

Deinfibulation:
- offered to those unable to have sex, pass urine, or pregnant women at risk during delivery

Must record in notes

If under 18, record in notes and report to the police and social services

If over 18, record in notes, no obligatory duty to report though

218
Q

What are the complications of FGM?

A
  • Repeated infections –> infertility
  • Life-threatening complications during labour, childbirth
  • Short-term - haemorrhage, urinary retention, genital swelling, menstrual difficulties, infertility, HIV, HBV
219
Q

What is a fibroid?

A

Benign tumour (leiomyomas) arising from the myometrium

220
Q

What are the types of fibroids?

A
  • Submucosal (within cavity)
  • Intramural
  • Subserosal (can undergo secondary changes)
221
Q

What changes can fibroids go through?

A
  • Hyaline degeneration - fibroids outgrow their blood supply. Hyaline degeneration involves the presence of homogeneous eosinophilic bands or plaques in the extracellular space, which represent the accumulation of proteinaceous tissue
  • Calcification - postmenopausal
  • Red degeneration - coagulation necrosis in pregnancy, cystic changes
222
Q

What is the aetiology of fibroids?

A

Hormone dependant (contain lots of oestrogen and progesterone receptors)

  • Enlarge in pregnancy (due to oestrogen)
  • Shrink in menopause
223
Q

What is the epidemiology of fibroids?

A

1/3 women of reproductive age

224
Q

What are the signs and symptoms of fibroids?

A
  • Asymptomatic (O/E: palpable pelvic masses, uterine enlargement)
  • Symptoms: DUB, miscarriage, sub-fertility
  • Signs: abdo swelling, pressure symptoms on bowel or bladder
225
Q

What are the investigations of fibroids?

A

1st line: TVUSS (>4mm when not expected, do a hysteroscopy)

226
Q

What are the risk and protective factors of fibroids?

A

B - Black women (plus FHx)
O - Obesity
N - Nulliparity
E - Expecting (pregnancy)

S - Smoking
M - Multiparity (grand)
C - COCP

BONE - Risk
SMC - protective

227
Q

What is the management of fibroids?

A

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis –> DUB management

Fibroids >3cm:

1st line non-hormonal (not contraceptive)

  • Tranexamic acid, 1g, TDS (contraindications: renal impairment, thrombotic disease)
  • Mefenamic acid/NSAIDS (Contraindications: IBS)

1st line hormonal (contraceptive):

  • COCP
  • Cyclical oral progestogens

Surgical/radiological treatment:

Injectable GnRH Agonist (short-term usually prior to surgery):

  • Shrinks fibroids
  • Induces a menopausal state (shuts down ovarian oestrodiol production)
  • Side effects (menopausal)

Ulipristal acetate (short-term, selective progesterone receptor modulator), OD

  • Shrinks fibroids, reduce bleeding (use for 6/12)
  • As effective as GnRH agonists BUT no menopausal state induced
  • Not yet widely accepted into clinical practice
  • Long term use associated with live injury
228
Q

What is the surgical management of fibroids?

A

Hysteroscopic (TCRF):
- Indication: small submucosal or polypoid

Myomectomy: (best for improving fertility)
- Open or laparoscopic
- Power morcellation is used to shrink the fibroids for renewal
Side effects:
- Uncontrolled life-threatning bleed
- More likely to need C section in the future as they have to make an incision into the uterus –> risk of uterine rupture

Hysterectomy

Endometrial ablation:

  • removed fertility
  • must use contraception
229
Q

What is the radiological management of fibroids?

A

Uterine artery ablation:
- May preserve fertility (may also make ovaries fail)
- Embolise both uterine arteries –> infarct/degenerate fibroids
- Patients need admission to deal with pain (opiate analgesia)
- As effective as myomectomy for alleviating fibroid DUB and pressure symptoms
Complications:
- Fever
- infection
- fibroid expulsion
- potential ovarian failure (need to council)

230
Q

What are the complications of fibroids?

A

Pregnancy:

  • red degeneration
  • miscarriage
  • malpresentation
  • transverse lie
  • PTL
  • PPH
231
Q

What are the symptoms of red degeneration?

A

low fever
pain
vomitting

232
Q

What is the management of red degeneration?

A

Conservative

Resolve in 4-7 days

233
Q

What happens to fibroids after menopause?

A

Regress and calcify

234
Q

What is a leiomyosarcoma?

A

Very rare cancer: smooth muscle cancer of the uterus

Associated with Gardner’s syndrome (subtype of FAP with extra-colonic polyps)

235
Q

What is a gynaecological polyp?

A

Normal epithelium of the cervix is endocervix (columnar) –> transformation zone –> ectocervix (squamous)

236
Q

What is a cervical ectropion?

A

Ectropion = ectocervical migration of columnar epithelium (linked to oestrogen - pregnancy, COCP)

237
Q

What are the signs and symptoms of cervical ectropion?

A

Present with IMB, PCB, increased discharge

238
Q

What are the investigations of cervical ectropion?

239
Q

What is the management of cervical ectropion?

A
  • Reassure
  • Cauterisation
  • Cryotherapy
  • Move more oestrogen based contraceptives
240
Q

What is a cervical polyp?

A

Overgrowth of endocervical columnar epithelium, benign, solitary (can be linked to oestrogen)

241
Q

What is the management of a cervical polyp?

242
Q

What are the signs and symptoms of cervical polyp?

A

Asymptomatic or small bleeding and discharge

If at cervix, PCB might be more apparent

243
Q

What is the management of cervical polyp?

A

Reassurance:

  • Generally advised to remove (twist off if small or surgery)
  • Send for histology
244
Q

What is the investigation of endometrial polyps?

A 
TVUSS
Outpatient hysteroscopy (OPH) and saline infusion sonography (SIS) are the most accurate
245
Q

What is the management of endometrial polyps?

A
  • May resolve spontaneously (if small)
  • Polypectomy to alleviate DUB symptoms, optimise fertility and exclude hyperplasia/cancer
  • Day case under GA or under LA in OPD
246
Q

What are the types of HPV?

A

Low-risk subtypes (6 & 11):
- benign genital warts

High-risk subtypes (16 & 18):

  • CIN, VIN, VAIN
  • implicated in 70% of cervical cancers
247
Q

What is the aetiology of HPV?

A

Transmission is by physical or sexual contact but occasional vertical

248
Q

What are the risk factors for HPV?

A
  • Smoking
  • Multiple sexual partners
  • Unprotected intercourse
  • Immunosuppression
249
Q

How common is HPV?

A

50% of sexually active adults have HPV

250
Q

What are the signs and symptoms of HPV?

A
  • Asymptomatic
  • Genital warts on vulva, cervix, and anus (painless, may itch/bleed +/- inflamed)
  • pink/red/brown warty papules (single or multiple)
  • Four types - small popular, cauliflower, keratotic, flat papules/plaques (usually cervix)
251
Q

What are the investigations for HPV?

A

Clinical diagnosis - (dermatoscope)
Histology - (biopsy)
Cytology - (smear)

252
Q

What is the management of HPV?

A

Medical: imiquimod cream or podophyllin/trichloroacetic acid (both contraindicated in pregnancy)

Surgical: cryotherapy, laser, electrocautery

Prevention - HPV vaccines

253
Q

What are the signs and symptoms of lichen planus?

A
  • Clusters of shiny, raised, purple-red blotches on your arms, legs or body
  • May see fine white lines on the blotches
  • White patches on your gums, tongue or the insides of your cheeks
  • Sore patches on the vulva or ring-shaped purple/white patches on the penis
254
Q

What are the investigations of lichen planus?

A

Clinical diagnosis

255
Q

What is the management of lichen planus?

A

1st line: High-dose topical steroids (clobetasol)
2nd line: topical calcineurin inhibitor (tacrolimus)

If vaginal stenosis, dilatation with manual measures should be attempted in the first instance

256
Q

What is lichen sclerosus?

A

Chronic inflammatory skin condition, usually affective genital skin (vulva and perineum)

  • not contagoius
  • occurs at extremes of age: <10, >60
257
Q

What is the aetiology of lichen sclerosus?

A

Unknown but associated with autoimmunity and genetics

  • Autoimmune - hypothyroid, graves disease, T1DM
  • Genetic
258
Q

What are the signs and symptoms of lichen sclerosis?

A
  • White polygonal papules
  • Hypopigmentation + atrophy
  • White/shiny vulva (Figure of 8 pattern)
  • Pruritis
  • May be raised or thickened
  • Dyspareunia (due to tightened skin)
  • Dysuria (due to tightened skin)
  • Can be on wrists, upper trunk, around breast, neck, armpits
259
Q

What is the investigation of lichen sclerosus?

A

Clinical diagnosis

260
Q

What is the management of lichen sclerosus?

A
  • Good skin care
  • 1st line (3 months): clobetasol propionate (strong steroid ointment)
  • 2nd line: tacrolimus (topical calcineurin inhibitor) + biopsy (as steroid resistant)
261
Q

What are the complications of lichen sclerosus?

A
  • Never can be completely cured

- Squamous cell cancer

262
Q

What is Raynauds disease of the nipple?

A
  • Intermittent pain
  • During and before feeding
  • Blanching followed by cyanosis and erythema of the nipple
263
Q

What is engorgement?

A
  • Occurs in the first few days of birth
  • Affects both breasts
  • Pain often before breast feeding, which can relieve it
264
Q

What is mastitis/breast abscess?

A
  • Breast infection –> staph aureus is the most common
  • Affects in 1/10 breastfeeding women due to backup of milk in ducts
  • Associated with nipple injury and smoking
265
Q

What are the signs and symptoms of mastitis/breast abscess?

A
  • Coryzal symptoms - aches, chills, fever
  • Nipple discharge
  • Red, tender breast with possible abscess
266
Q

What are the investigations of mastitis/breast abscess?

A

Clinical diagnosis

267
Q

What is the management of mastitis/breast abscess?

A

Consider admission if:

  • sepsis,
  • rapid progression
  • haemodynamically unstable
  • immunocompromised

Abscess: USS diagnosis

  • Incision and drainage
  • culture of fluid

Non-severe or lactational:

  • simple analgesia
  • supportive care (warm compression)
  • continue breastfeeding

Non-lactational or severe:

  • infected nipple fissure
  • not improved after 12-24 hours
  • breast milk culture +ve
  • 1st line: flucloxacillin 50-mg QDS, oral, 10-14 days
  • 2nd line (failure to settle after 48 hours): co-amoxiclav
  • MRSA: trimethoprim 160-800mg BD PO
268
Q

What are the complications of mastitis/breast abscess?

A
  • Sepsis, scarring, functional mastectomy, breast hyperplasia
  • Most have resolution of mastitis after 2-3 days of antibiotic therapy
269
Q

What is menopause?

A
  • Absence of menses for >12 months (retrospective diagnosis)
  • Average age 50 +/- 2
  • If less than 45, consider investigating
  • if <40, premature ovarian insufficiency
270
Q

Why does menopause occur?

A

Depletion of the oocytes –> reduction in ovarian production of progesterone, oestrodiol and testosterone

271
Q

What are the signs and symptoms of menopause?

A
  • Presistent amenorrhoea - often initial oligomenorrhoea/irregular shortened cycles
  • Vasomotor symptoms - hot flushes, night sweats, palpitations, headaches
  • Urogenital - vaginal dryness, dyspareunia, frequency, dysuria, recurrent UIT
  • Psychological - poor concentration, lethargy, mood disturbances, reduced libido (present first)
272
Q

What are the investigations of menopause?

A
  • Pregnancy test
  • FH:LSH = high (unopposed)
  • serum oestrodoil = low (no oocytes to produce)
  • Prolactin
  • TFTs
  • TVUSS (endometrial/ovarian cancer –> bleeding= endometrial; no bleeding and mass = ovarian)
273
Q

What is an important question to take into account when thinking about the management of Menopause?

A

Uterus = combines with progesterone to protect against endometrial carcinoma
No uterus = systemic oestrogen (think about contraindications eg. DVT)

274
Q

What are the routes of HRT?

A

Systemic - oral, implant
Transdermal - hx of DVT/stroke
Topical - hx of DVT/stroke

275
Q

What is the normal mensteual cycle?

A
  1. Thecal Cells (ovaries and eggs)
  2. Androgens (oestrogen)
  3. Endometrial growth
  4. Corpus luteum
  5. Progesterone
  6. Secretory changes (maintains endometrium)
  7. Drops
  8. Menses
276
Q

What is the 1st line of menopause management?

A

Lifestyle changes - exercise, alcohol, caffeine, weight loss, stress reduction

  • Hot flushes (regular exercise, WL, reduce stress)
  • Sleep disturbances (sleep hygiene, no late evening exercise)
  • Mood (sleep hygiene, regular exercise, relaxation techniques)
  • Cognitive symptoms (sleep hygiene, regular exercise)
277
Q

What is the 2nd line treatment for menopause?

A

HRT:

Oestrogen alone (Elleste Solo) = only in post-hysterectomy

  • OD, oral, oestrogen (standard therapy)
  • Transdermal oestrogen patch (BMI>30, due to lower VTE risk)
  • You can only have oestrogen only preperation combined with an LNG-IUS (Mirena)

Oestrogen with progesterone (Elleste Duet) = progesterone protects endometrium

  • oral, transdermal (less clot risk), vaginal creams/gel (less clot risk), implant
  • adding progesterone increases the risk of breast cancer

Cyclical/sequential pattern/SCT (peri-menopausal):

  • Monthly: oestrogen everyday of month + progesterone for the last 14 days
  • Indication = regular periods and menopause symptoms
  • 3 months: oestrogen everyday for 3 months + progesterone for the last 14 days
  • Indication = irregular periods and menopause symptoms (common cause of IMB = endometrial polyps)

Continuous/CCT (post-menopausal so no period for >1 year)
- oestrogen and progesterone everyday

278
Q

What are the benefits of HRT?

A
  • Improved menopause symptoms (vasomotor, sleep and genital symptoms like dryness and dyspareunia)
  • Prevention of osteoporosis
279
Q

What are the risks of HRT?

A

Cancer:

  • Oestrogen-only = breast and endometrial cancer
  • Combines = breast cancer

VTE:
- 2-4x higher

280
Q

What are the side effects of HRT?

A

Should pass in a few weeks of starting HRT:

  • Oestrogenic: breast tenderness, nausea, headaches
  • Progestogenic: fluid retention, mood swings, depression
  • Unscheduled vaginal bleeding (common in the first 3 months of HRT, investigate if it continues >6 months)

Sequential > continuous

281
Q

What are absolute contraindications of HRT?

A
  • Undiagnosed vaginal bleeding
  • Pregnancy
  • Breast cancer
  • Sever liver disease
  • History of VTE
  • Current thrombophilia (AT-III, FV leiden)
282
Q

What are the non-hormonal alternatives for menopause?

A

Vasomotor symptoms:

  • 1st line: (SSRI) - fluoxetine
  • 2nd line: citalopram, venlafaxine
  • 3rd line: gabapentin
  • Alpha agonist (clonidine) are licenced but there are lots of anti-ACh side effects

Vaginal dryness:
- Lubricants

Osteoporosis treatments:
- Bisphosphonates

283
Q

What is the contraception requirement of menopause?

A

Until >1 year amenorrhoeic if >50

Until >2 years amenorrhoeic if <50

284
Q

What is CIN?

A

Premalignant cellular atypia with squamous epithelium of the cervix (FIGO stage 0) - before cervical cancer
- HPY 16 and 18 is indicated in 95% of the cases

285
Q

What are the risk factors of CIN?

A

Smoking
Multiple sexual partners
Early age of first intercourse
HIV

286
Q

What is the HPV vaccine?

A 
National vaccine for girls and boys age 12-13
Quadrivalent vaccine (Gardisil) against HPV 6,11,16 and 18
287
Q

When does the smear vaccine happen?

A

Invited less than 6 months before 25

25-49 = every 3 years
50-64 = every 5 years
65+ = only if one of your last 3 tests was abnormal
High-risk = every 1 year
Pregnancy = delayed until >3 months post-partum
288
Q

What are inadequate results?

A

Inflammation
Age-related atrophic change
Blood on smear

289
Q

What are dysplastic epithelial changes?

A
  • Increase nuclear to cytoplasmic ration
  • Increase nuclear size
  • Decrease cytoplasm
  • Abnormal nuclear shape - poikilocytosis
  • increase nuclear density - koikilocytosis
290
Q

What are the CIN grades?

A

CIN 1 (low grade) = mild dysplasia confined to lower 1/3 of epithelium

CIN 2 (high grade) = moderate dysplasia affecting 2/3 of epithelial sickness

CIN 3 (high grade) = severe dysplasia extending to upper 1/3 of epithelium (risk of Stage 1a FIGO)

291
Q

What are the signs and symptoms of cervical cancer?

A

Symptoms of cervical cancer (PV bleeding - IMB, PCB, PMB)

292
Q

What are the high-risk HPV subtypes?

A

16
18
(33)

293
Q

What are the different smear screening follow up outcomes?

A

Boderline/mild/ CIN 1 –> HPV test (+ve colposcopy, -ve routine call)

Moderate/ CIN 2 –> urgent colposcopy (<2 weeks)

Severe/ CIN 3 –> urgent colposcopy (<2 weeks)

Suspected invasive cancer –> urgent colposcopy (<2 weeks)

Inadequate sample –> repeat 3x, refer to colposcopy

294
Q

What is the management of CIN?

A

Conservative for CIN 1 –> smear in 12 months

LLETZ/ Loop diathermy

  • involves removal of abnormal cells during a thin wire loop that is heated by electric current under LA
  • SE: cervical stenosis, cervical incontinence, pyometra, smear follow up difficulties
  • Risks: increase risk of miscarriage due to bigger lumen of the cervix so harder to follow close

Cone biopsy:

  • used less frequently and under GA
  • Only performed in a large area of tissue need to be removed

Other:

  • cryotherapy
  • laser treatment
  • cold coagulation
  • hysterectomy

If hysterectomy for CIN –> a vault smear must be done at 6m and 18m

Follow up-to cure (6 months later = smear and HPV test)

  • Negative: routine recall
  • Positive: repeat colposcopy to identify residual/untreated CIN
295
Q

What are the complications of CIN?

A

Miscarriage and PTL

CIN can progress to cervical carcinoma (but may also regress spontaneously, esp when young)

296
Q

What are the types of cervical cancer?

A

80% squamous and 20% adenocarcinoma

  • SCC from CIN
  • Adenocarcinoma from cGin
297
Q

What is the aetiology of cervical cancer?

A

HPV 16,18 in >70% of the cases

  • FIGO staging system
  • Age 45-50 y/o
298
Q

What are the main risk factors of cervical cancer>

A 
Major = HPV 
Minor = smoking, early first intercourse, many sexual partners, immunosupression
299
Q

What are the signs and symptoms of cervical cancer?

A
  • PV discharge (offensive or bloodstained) = PCM, PMB, IMB
  • Dyspareunia (deep_
  • Symptoms of las metastasis (SOB, DIC) and FLAWS
300
Q

Where does cervical cancer metastasize to?

A

Illiac lymph nodes (not para-aortic)

301
Q

What are the investigations of cervical cancer?

A
  • Cervical screening pathway
  • MRI>CT-CAP = cervical cancer
  • CT-CAP > MRI = ovarian cancer, endomatrial cancer
  • Blood: FBC (anaemia), U&E (obstructive picture), LFTs (metastasis), clotting and G&S
302
Q

What is the management of cervical cancer?

A

MDT approach

Stage Ia1 (microinvasive)

  • conservative
  • LLETZ, cone biopsy (followed by smear pathway)

Stage Ia2 to IIa (early stage):

  • Fertility sparing = radical trachelectomy (remove cervix) + bilateral pelvic node dissection
  • Tumour = 4cm = radical hysterectomy + bilateral pelvic node dissection (Wertheim’s)
  • Tumour >/= 4cm = Chemoradiation

Stage IIb to IVa (locally advanced disease)
- Chemoradiation

Stage IVb (metastatic disease)

  • Combo chemo
  • Single-agent therapy and palliative care

Radiotherapy +/- chemo (cisplastin based therapy):

  • External beam radiotherapy (10 minutes delivery, completed over 4 weeks)
  • Internal radiotherapy (brachytherapy, rods of radioactive selenium is inserted into the affected area)
303
Q

What is dysfunctional uterine bleeding (DUB)?

A

Abnormal uterine bleeding in the absence of organic pathology
- Hormonal influences in anvoluntary and ovulatory cycles (Ovulatory/Endometrial dysfunction)

304
Q

What are the risk factors of DUB?

A

Extremes of reproductive age

Obesity

305
Q

What are the types of DUB?

A

Anvoluntary (90%) = failure of follicular developement –> no increase in progesterone –> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelia due to unopposed oestrogen stimulation

Ovulatory (10%) = prolonged progesterone secretion –> irregular shedding

306
Q

What is the definition of menorrhagia?

A

What the individual women believes is heavy periods, no need to quantify it. Used to be 80ml

307
Q

What is the definition of menorrhagia?

A

What the individual women believes is heavy periods, no need to quantify it. Used to be 80ml

308
Q

What are the signs and symptoms of DUB?

A

Diagnosis of exclusion:

  • Bleeding (menorrhagia, IMB, dysmenorrhoea)
  • Anaemia signs and symptoms

S/S of the cause:

  • relation to menstrual cycle
  • fertility issues
  • compression symptoms
  • cervical screen history
  • DHx, FHx, sexual history
  • Coag disorders (von Williebrand disease)
309
Q

What are the causes of DUB?

A 
Pathology: PALM
Polyps
Adenomyosis
Leiomyoma
Malignancy

Endocrine:
Coagulopathy - von Williebrand disease
Ovulation - PCO, hypothryroid
Endometriosis
Iatrogenic
Not classified
310
Q

What are the investigations of DUB?

A

Examine with speculum and bimanual

1st line:

  • FBC (anaemia)
  • TFT (hypothyroid)
  • Clotting screen (if primary menorrhagia or FHx)

2nd line:
- TVUSS (PCOS, fibroids, malignancy)

3rd line:

  • OPD hysteroscopy
  • laparoscopy +/- biopsy (endometriosis)
311
Q

What is the management of DUB?

A

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis

1st line:

  • contraception required (hormonal)
  • LNG-IUS (may not be possible with large fibroids distorting the uterus)

2nd line: (fertility required, 1st line declined/unsuitable)

  • BLEED = tranexamic acid, 1g, TDS (contraindications: renal impairment, thrombotic disease)
  • PAIN = mefanamic acid (NSAIDs, contraindication: IBD)

2nd line: (contraception required, 1st line declined/unsuitable)
- 1st: COCP
- 2nd: cyclical progesterone
(Norethisterone 5mg TDS for 20 days to arrest bleeding acutely)

Surgical:

  • Endometrial ablation (will need continued contraception)
  • Hysterectomy
312
Q

What is endometrial hyperplasia?

A

From excess endometrial growth which usually occurs after the menopause and can progress to cancer:

  • EH without atypia (cells are normal)
  • EH with atypia (cells are abnormal)
313
Q

What are the risk factors of endometrial hyperplasia?

A

(Oestrogen)

  • Increasing age
  • Oestrogen (early menarche, late menopaus, nulliparous, tamoxifen, HRT)
  • Sex cord stromal ovarian tumours are functional (granulosa cell tumours –> oestrogen –> EH)
  • High insulin (T2DM, PCOS)
  • Obesity, smoking
  • FHx ovarian, bowel (HNPCC, Lynch syndrome) or uterine cancer
314
Q

What are the signs and symptoms of endometrial hyperplasia?

A

PV bleeding - usually PMB

315
Q

What are the investigations of endometrial hyperplasia?

A

1st line: TVUSS (if PMB, otherwise must be matched with ovulatory cycle)

  • <4mm = endometrial cancer unlikely
  • > 4mm = 2nd line investigations (hysteroscopy +/- biopsy)

2nd line: (Gold standard) Hysteroscopy - outpatient under LA +/- pipelle biopsy

  • Complex hyperplasia with atypia is a premalignant condition that often co-exsists with low grade endometrioid tumours on the endometrium
  • Sonohysterography = replacing hysteroscopy as a method of visualisation
316
Q

What is the management of endometrial hyperplasia without atypia?

A

<5% risk of becoming malignant in 20 years

  • Reverse risk factors
  • Endometrial surveillance every 6 months (biopsies recommended in high-risk women)

1st line: Progesterones

  • LNG-IUS (5 years)
  • Oral (continuous progestogens should be used rather than cyclical), continue for min 6 months to induce histological regression

2nd line:
- hysteroscopy is an option

317
Q

What is the management of endometrial hyperplasia with atypia?

A

Fertility non-sparing = total hysterectomy (+ BSO if post-menopausal)

Fertility sparing:

  • LNG-IUS
  • Oral progestogens
  • (routine endometrial surveillance with biopsies every 3 months)
318
Q

What is endometrial cancer?

A
  • Malignancy arising from endometrial tissue
  • 2nd most common gynae malignancy in the UK
  • Uncommon in <40 y/o (mean age 54 y/o)
319
Q

What is the aetiology of endometrial cancer?

A
  • Unclear

- Involves unopposed oestrogen stimulation of endometrium (exogenous or endogenous)

320
Q

What are the risk factors of endometrial cancer?

A

Same as endometrial hyperplasia

321
Q

What are 90% of endometrial cancer?

A

Adenocarcinoma

322
Q

What is Type 1 endometrial cancer?

A
  • 85%
  • SEM = secretory, endometrioid, mucinous carcinoma
  • Younger patients, oestrogen dependant, superficially invade, low grade
  • > /= 4 mutations must accumulate to cause: PTEN, PI3KCA, k-ras, ctnnb1, fgfr2, p53
323
Q

What is Type 2 endometrial cancer?

A
  • 15%
  • SC = uterine pappilary serous carinoma (UPSC), clear cell carcinoma
  • Older patients, less oestrogen dependant, deeper invasion, higher grade

Mutations associated:

  • Serous Carcinoma P53, PI3KCA, Her-2 amplification
  • Clear cell carcinoma PTEN, CTNNB1, Her-2 amplification
324
Q

What are the signs and symptoms of endometrial carcinoma?

A
  • Most people present in stage 1 (PV bleeding) –> surgery is enough to treat
  • PV bleeding
  • Bulky uterus
  • Metastasis to para aortic LNs
325
Q

What are the investigations of endometrial carcinoma?

A

1st: TVUSS (if PMB, otherwise must be matched with ovulatory cycle)
- <4mm = endometrial cancer unlikely
- >4mm = 2nd line investigations: hysteroscopy +/ biopsy

2nd line: Hysteroscopy (performed as outpatients under LA) +/ biopsy
- Complex hyperplasia with atypia is a premalignant condition that often co-exsists with low grade endometroid tumours of the endometrium

326
Q

What is the management of endometrial cancer?

A

FIGO staging (CT-CAP>MRI)

Stage 1 - requires all

  • total abdo hysterectomy (TAH)
  • bilateral salpingoophorectomy (BSO)
  • Peritoneal washings

Stage 2+:

  • Radical hysterectomy (including cervix)
  • Radiotheraoy adjunct

Chemo 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 high but may be suitable for those not fit for surgery or for fertility reasons
327
Q

What is the prognosis of endometrial carcinoma?

A

5-year survival rate = 80%

dependant on type, stage and grade

328
Q

What are bad prognostic factors of endometrial carcinoma?

A
  • Age
  • Grade 3 tumours
  • T2 Histology
  • Distant metastasis
  • Deep invasion
  • Nodal involvement
  • Lymphovascular space invasion

Hormone receptor expression may influence a better prognosis/treatment (HER-2)

329
Q

What is the Figo staging for endometrial carcinoma?

A 
I = limited to the uterus
II = spread to cervix 
III = spread adjacent 
IV = distant spread
330
Q

What is an ovarian cyst?

A

Fluid-filled sac in ovarian tissue

331
Q

What is the prevalence of ovarian cysts?

A
  • 8% in premenopausal women have large cysts

- 90% of ovarian tumours are benign

332
Q

What are the risk factors of ovarian cysts?

A
  • PCOS
  • Endometriosis
  • Pregnancy
333
Q

What are the types of ovarian cysts?

A

Physiological/functional:

  • Follicular cysts (most common)
  • Corpus luteal cysts

Benign germ cell:
- Dermoid cysts/ Mature cystic teratoma

Benign epithelia:

  • Serous cystadenoma
  • Mucinous Cystadenoma
334
Q

What are Physiological/functional cysts?

A

Follicular (failure rupture of dominant graafian follicle or nondominant follicles to degenerate):

  • Lined with granulosa cells
  • May occasinally continue to produce oestrogen and lead to EH

Luteal (following rupture, follicle reseals, distends with fluid) - normal in early pregnancy:
- Lined with luteal cells

Haemorrhagic (bleeding into functional cysts)

335
Q

What are dermoid cysts?

A

Dermoid cysts/ Mature cystic teratoma (most common benign tumour in those <30y/o)

  • lined with epithelial cells
  • Often asymptomatic but most likely to tort
  • Rokitansky protuberance = single or multiple white shiny masses that protrude out
336
Q

What are benign epithelial cysts?

A

Serous cystadenoma

Mucinous Cystadenoma (typically very large)
- If ruptures can cause pseudomyxoma peritonei (mucin in the abdomen)
337
Q

What are the signs and symptoms of ovarian cysts?

A
  • Lower abdo pain
  • Swelling with pressure symptoms (urinary symptoms)
  • Deep dyspareunia
  • Acute abdomen (torsion/haemorrhagic) - severe right or left illiac fossa pain (+/- vomiting in torsion)
338
Q

What are the investigations for ovarian cysts?

A
  • Pregnancy test
  • TVUSS (outcome dependant on menopause symptoms)

Pre-menopausal:

  • simple –> manage depending on size
  • complex (< 40 y/o) –> LDH, aFP, B-HcG levels

Post-menopausal:
- simple or complex –> CA-125 level –> RMI calculation

339
Q

What is used to calculate RMI?

A

USS score
Menopause status
CA-125 score

340
Q

What is the management of premenopausal women with ovarian cysts?

A

Simple/unilocular cyst:

  • <5cm - no follow up required
  • 5-7cm - repeat USS yearly
  • > 7cm - MRI +/- surgery

Indications for watchful waiting:

  • Unilateral
  • Unilocular (no solid parts)
  • Pre-MP (3-10cm)
  • Post-MP (2-6cm)
  • Normal Ca-125
  • No free fluid

If recurrent or unresolved –> medical (COCP - prevent ovulation will prevent recurrent cysts)

If recurrent, sustained >5cm, suspicious/multiloculated –> surgical (laparoscopic cystectomy, usually curative)

341
Q

What is the management of post-menopausal women with ovarian cysts?

A

RMI calculated and management based on this:

RMI <200:

  • All of asymptomatic, simple cysts, <5cm, unilocular, unilateral –> repeat USS, Ca-125 in 4-6cm –>
    (1) resolved
    (2) unchanged –> repeat USS, Ca-125 in 4-6cm
    (3) Changed –> laparoscopic cystectomy
  • Any of symptomatic, non-simple features, >5cm, miltilocular, bilateral –> BSO

RMI >200 –> CT-AP –> MDT management:
- TAH, BSO +/- omentectomy

342
Q

What is Ca-125 indicative of?

A

Serous epithelial ovarian cancer

343
Q

What is Ca 19-9 indicative of?

A

Mucinous epithelial ovarian cancer

Pancreatic cancer

344
Q

What is CEA indicative of?

A

Bowel cancer

345
Q

What is Inhibin indicative of?

A

Granulosa cell tumours

346
Q

What is AFP indicative of?

A

Liver cancer
Endodermal yolk sac tumour
Teratoma

347
Q

What is Her-2 indicative of?

A

Breast cancer (receptor)

348
Q

What is LDH indicative of?

A

Dysgerminoma

349
Q

What is B-HCG indicative of?

A

Dysgerminoma

Choriocarcinoma

350
Q

What percentage it ovarian tumours make up female cancers?

A

Makes up 5% of female cancers

5th most common malignancy in females

351
Q

What are the protective factors of ovarian tumors?

A
  • Pregnancy

- COCP

352
Q

What are the protective factors of ovarian tumors?

A
  • Pregnancy/breastfeeding
  • COCP
  • hysterectomy
353
Q

What are the associated of ovarian tumours?

A
  • Lynch syndrome (AD HNPCC, MLH1, MSH2)
  • Breast cancer (BRCA1/2)
  • Many genetic associations exist (p53 - serous, BRAF, K-ras)
354
Q

What is the most common ovarian tumor?

A
  • 70% epithelial origin (most are benign, however, if malignant likely to be epithelial)
355
Q

What are epithelial tumors?

A
  • 70%
  • Post menopausal women
  • Present late with bad diagnosis
  • Endometriosis associated with clear cell (>20%) > endometrioid (10-20%) ovarian cancer
  • Endometrioid ovarian carcinoma often found alongside endometroid endometrial carcinoma
356
Q

What are germ-cell tumours?

A
  • 15-20%
  • young women 20s and old women 70s
  • Mature teratomas = benign
  • immature = malignant
357
Q

What are germ-cell tumours?

A
  • 15-20%
  • young women 20s and old women 70s
  • Mature teratomas = benign
  • immature = malignant
358
Q

What are sex-cord stromal tumors?

A
  • 5-10%

- All ages but more common in post menopausal

359
Q

What are hilus cell tumours?

A

Leydig cell tumours that secrete androgens

360
Q

What is Meig’s syndrome?

A

Triad of:

  • benign ovarian fibroma
  • ascites
  • right-sided pleural effusion
361
Q

What is peutz-jegher’s syndrome?

A
  • Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited condition that puts people at an increased risk for developing hamartomatous polyps in the digestive tract, as well as cancers of the breast, colon and rectum, pancreas, stomach, testicles, ovaries, lung, cervix, and other types
  • granulosa cell tumours (sex cord turmous)
362
Q

What is Gorlin’s syndrome?

A
  • Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome, is a condition that affects many areas of the body and increases the risk of developing various cancerous and noncancerous tumors. Ovarian fibromas, often calcified and bilateral, develop in 15 to 25 percent of women with Gorlin syn-drome.
  • Fibroma
363
Q

What does mucinous and serous mean?

A

Mucinous = resemble gastric or cervical epithelium

Serous = Psammoma bodies

364
Q

What is an Endometrioma?

A
  • From endometriosis
  • If ruptures can cause acute pain
  • Rule out ectopic from LMP
365
Q

What is metastatic ovarian tumours?

A
  • 5%

- Spread to breast, colon, endometrium, gastric, cervical cancers

366
Q

What is a Krunkenburg tumour?

A
  • Bilateral metastasis from breast/gastric cancer, malignancy in the ovary that metastasized from a primary site
  • Mucin-producing signet ring cell
367
Q

What are the FIGO stages of ovarian cancer?

A

Stage 1 - confined to ovary
Stage 2 - outside ovary but within pelvis
Stage 3 - Outside pelvic but within abdomen
Stage 4 - Distant metastasis

368
Q

What are the signs and symptoms of ovarian cancers?

A

Late presentation: 75% present in stage 3

  • vague symptoms
  • bloating
  • B symptoms
  • No PV bleeding
369
Q

What is the difference in the presentation of ovarian and endometrial cancer?

A

Ovarian = adnexal mass with no PV bleeding

Endometrial = uterine mass and PMB

370
Q

What are the investigations of ovarian cancer?

A

1st:

  • Tumour markers (CA125); if >35 IU/ml –> 2ww referral to O&G for TVUSS
  • Raised in >80% of epithelial cancers
  • CA125 also raised in pregnancy, endometriosis and alcoholic liver disease

1st:
- TVUSS
- Characterise: size, consistency, presence of solid elements, bilateral or not, presence of ascites, extraovarian disease (peritoneal thickening and omental deposits)

1st:
- Risk of malignancy index (RMI), calculated from:
- Features: menopausal status, USS features, CA125
- Score >250 is considered high-risk (<25 low risk)

Staging:
- CT-PAP > MRI

371
Q

What is the management of ovarian cancers?

A

Surgery +/- chemo (2nd line = just chemo)

Neoadjucant (before surgery) or 2nd line adjuvant = chemo (in OPD, 3 weeks apart for 6 cycles):
- Type: platinum compounds with paclitaxel
Follow up with:
- CT scan to assess response to treatment
- CA-125 measurement (tends to rise prior to onset of clinical evidence of disease recurrence)

Platinum compounds (cross-linkage of DNA leading to cell cycle arrest)

  • Carboplatin (most commonly used as less nephrotoxic and less nausea than cisplatin)
  • More effective in ovarian cancer
  • Dose calculated in line with patient’s GFR

Paclitaxel (microtubular damage –> prevents cell division):

  • Pre-emptive steroids given to reduce hypersensitivity reactions and side effects (eg. peripheral neuropathy, neutropenia and myalgia)
  • Causes total loss of body hair

Bevacizumab (monoclonal antibody against VEGF and inhibits angiogenesis)

  • not routinely prescribed in ovarian cancer due to cost
  • Available for the treatment of recurrent disease

Surgery = Laparotomy (TAH + BSO + extra debulking)

  • Consider fertility sparing surgery in young women (ie. germ cell tumours)
  • Chemotherapy is not useful in sex cord stromal tumours, surgery is the mainstay
372
Q

What is endometriosis?

A
  • Presence and growth of endometrial tissue outside the uterus
  • Affects 1 in 10 women of reproductive age, mainly 30-45 y/o
373
Q

What are the risk factors of endometriosis?

A
  • Early menarche
  • FHx
  • Prolonged menstruation
  • Short menstrual cycles
  • Nulliparity
374
Q

What is Sampson’s theory?

A
  • Retrograde menstruation and implantation may be the cause of endometriosis
375
Q

What are the associations of endometriosis?

A

Clear cell ovarian carcinoma > endometroid ovarian carcinoma

376
Q

What are the signs and symptoms of endometriosis?

A
  • Cyclical or chronic pelvic pain occurring before or during menstruation
  • Deep dyspareunia
  • Dyschezia (pain on defecation)
  • Subfertility

Extra-uterine endometriosis:

  • Rectal pain
  • Bleeding
377
Q

What are the investigations for endometriosis?

A

Bimanual and speculum:

  • reduced mobility
  • tender nodularity in posterior vaginal fornix
  • visible vaginal endometriotic lesions
  • fixed retroverted uterus = ectopic tissue on utero-sacral ligament

TVUSS (may show endometrioma, may show nothing): other may include HSG or HyCoSy
-Association to clear cell (20%) and endometroid (20%) ovarian cancer

Diagnostic laparoscopy (GOLD-STANDARD):

  • Red vesicles or punctate marks on peritoneum = active lesions
  • White scars/brown spots = less active endometriosis
378
Q

What is the management of endometriosis?

A

Medical treatment of presumed endometriosis can begin in clinical examinations/TVUSS normal (without need for laparoscopy) however, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:

379
Q

What is the management of endometriosis?

A

Medical treatment of presumed endometriosis can begin in clinical examinations?TVUSS normal (without need for laparoscopy) however, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:

1st line (3 months):

  • Paracetamol +/- NSAIDS (inhibit PG synthesis = main reason for pain)
  • Avoid opiates due to pre-existing constipation
  • Adjunct: Tranexamic acid

1st line (3 months):

  • COCP, progesterone (POP, implant, injectables or LNG-IUS)
  • COCP can provide cycle control and contraception whilst alleviating symptoms of endometriosis
  • Progesterone used to induce amenorrhoea in those where COCP contraindicated

2nd line (surgical):

  • Laparoscopic ablation (mild endometriosis superficially)
  • Recurrence is high at 30% so supplement with medical therapy (COCP)
  • Superficial peritoneal endometriosis can be easily ablated
  • Hysterectomy with BSO (radical surgery)
  • GnRH analogues (eg. leuprorelin) can induce a ‘preudo-menopause’
  • Used to shrink endometriosis in the approach to surgery
  • Inhibits oestrogen release (do not use longer than 6 months due to osteoporosis risk)
  • Menopause like side effects (hot flushes, night sweats)

Subfertility:
- laparoscopic ablation +/- endometrioma cystectomy (no hormone treatment if trying to conceive)

Year 5 - Fatty (4 decks)

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