Gynaecology Flashcards
Organic causes of Menorrhagia
• Extremes of reproductive age
• Fibroids
• Adenomyosis
• Endometriosis
• Pelvic inflammatory disease (infection)
• Contraceptives, particularly the copper coil
• Connective tissue disorders
• Endometrial hyperplasia or cancer (uterus and cervix)
• Polycystic ovarian syndrome
• Cervical eversion: Cervical ectropion
• Trauma e.g. sex
• Others e.g. arteriovenous malformations on endometrium
• Systemic causes
o Endocrine disorders e.g. Hyper/ hypothyroidism, Diabetes mellitus, Adrenal disease and Prolactin disorders: can cause amenorrhea if very high
o Disorders of haemostasis e.g. Von Willebrand’s disease, ITP (autoimmune thrombocytopenia) and Factor II, V, VII and XI def
o Liver disorders
o Renal disease
o Anticoagulants e.g. artificial heart valves, AF, past stroke
• Pregnancy: Miscarriage, Ectopic pregnancy, Gestational trophoblastic disease & postpartum haemorrhage
Non-organic Menorrhagia
• DUB: Dysfunctional uterine bleeding (no identifiable organic cause)
• Anovulatory: no eggs is released (85% of all DUB)
o Occurs at extremes of reproductive life
o Irregular cycle
o More common in obese women
• Ovulatory
o More common in women aged 35-45 years
o Regular heavy periods
o Due to inadequate progesterone production by corpus luteum
Menorrhagia Ix
Pelvic examination with a speculum and bimanual: fibroids, ascites and cancers
- Full blood count: iron deficiency anaemia
• Cervical smear, TSH, coagulation screen, U&Es and LFTS
- Hysteroscopy
o Suspected submucosal fibroids
o Suspected endometrial pathology
o Persistent intermenstrual bleeding
• Pelvic and transvaginal ultrasound should be arranged if the is:
o Endometrial thickness for screening for endometrial carcinoma
o Possible large fibroids (palpable pelvic mass)
o Possible adenomyosis
- Swabs if there is evidence of infection
• Endometrial sampling
o Pipelle biopsies
o Hysteroscopic directed
o Dilatation & curettage (D & C)
Menorrhagia Mx (without contraception)
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Menorrhagia Mx (with contraception)
- Mirena Coil
- COCP
- Cyclical oral progesterones e.g. norethisterone
- Progesterone only contraception
- Danazol (androgenic hormones):
GnRH Analogues: e.g. Goserelin, Decapeptyl, Buserelin
Menorrhagia surgical Mx
- Endometrial ablation (combined HRT required)
- Hysterectomy (oestrogen only HRT)
Intermenstrual bleeding causes
o Cervical ectropion
o Pelvic inflammatory disease (PID) and sexually transmitted disease
o Endometrial or cervical polyps
o Cervical cancer
o Endometrial cancer
o Undiagnosed pregnancy/ pregnancy complications
o Hyatidiform molar disease.
Premenstrual syndrome
Cyclical somatic, psychological and emotional symptoms that occur in the luteal (premenstrual) phase of the menstrual cycle and resolve by the time menstruation
ceases.
Contributing factors are decreased progesterone synthesis and increased prolactin, oestrogen, aldosterone and prostaglandin synthesis during the luteal phase.
Premenstrual syndrome signs/symptoms
depression, irritability and emotional lability.
physical manifestations include fluid retention, weight gain and breast tenderness. • Bloating • Cyclical weight gain • Mastalgia • Abdominal cramps • Fatigue • Headache • Depression • Changes in appetite and increased craving • Irritability
Premenstrual syndrome Mx
Severe symptoms: - SSRIs e.g. fluoxetine or SNRI daily or during luteal phase
- CBT
Mild
- Medical treatment includes combined oral contraceptive pill, transdermal oestrogen, short-term GnRH analogues (to reduce risk of osteoporosis).
Refractory
- last resort of hysterectomy with bilateral salpingo-oophorectomy
Post coital bleeding
Bleeding from sex
Cervical ectropion • Cervical carcinoma • Trauma • Atrophic vaginitis • Cervicitis secondary to sexual transmitted diseases. • Polyps • Idiopathic
Endometritis
barrier to ascending infection (acid, vaginal pH and cervical mucus) is broken e.g. after miscarriage, TOP and childbirth, IUCD insertion or surgery
Endometritis causes
• Micro-organisms: Neisseria, Chlamydia, TB, CMV, Actinomyces and HSV o Intra-uterine contraceptive device o Postpartum o Post-abortal o Post curettage o Chronic endometritis NOS o Granulomatous (TB, sarcoid, foreign body post ablation) o Associated with leiomyomata or polyps
Endometritis signs/symptoms
- Lower abdominal pain and fever/sepsis
- Uterine tenderness on bimanual palpation
- Offensive vaginal discharge
- Bleeding that gets heavier or does not improve with time
Endometritis Ix
High vaginal swabs
Blood cultures
Urine culture
USS: retained products of contraception
Endometritis Mx
- Antibiotics e.g. cefalexin 500mg/8h PO with metronidazole 400mg/8h for 7 days
- Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics Blood tests will show signs of infection (e.g. raised WBC and CRP).
- IV Amoxicillin + Metronidazole + Gentamicin
Endometrial polyps
occur around and after menopause
Transvaginal USS
Adenomyosis
Endometrial tissue inside the myometrium (muscle layer of the uterus).
Later reproductive years and several pregnancies (tend to resolve after menopause due to being hormone dependent)
Adenomyosis signs/symptoms
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- It may also present with infertility or pregnancy-related complications
- enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.
Adenomyosis Ix and
Transvaginal USS
Adenomyosis Mx
No contraception
o Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
o Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Contraception
- Mirena coil
- Combined oral contraceptive pill
- Cyclical oral progestogens
- Progesterone only medications such as the pill, implant or depot injection may also be helpful.
- GnRH analogues
- endometrial ablation
- uterine artery embolisation
- hysterectomy
PCOS diagnosis
• Endocrine features: high free androgens (↑testosterone, ↓SHBG, ↑prolactin), high LH, impaired glucose tolerance
• Diagnosis: score 2 out of 3:
o chronic anovulation: Oligio/amenorrhoea
o polycystic ovaries – ultrasound
12/more 2-9mm follicles (tiny cysts at periphery of ovary)
Increased ovarian volume >10ml
Unilateral / bilateral
o hyperandrogenism (clinical or biochemical) e.g. acne, hirsutism
• Insulin resistance: Insulin lowers SHBG levels: increased free testosterone leads to hyperandrogenism.
PCOS Mx
- ) Clomifene citrate
- ) Metformin
- ) Gonadotrophin therapy (daily injections)
- ) Laparoscopic ovarian diathermy
Post menopausal bleeding week aim
NICE guidelines state that women over the age of 55 with PMB should be investigated within 2 weeks by ultrasound for endometrial cancer. (2)
PMB causes
atrophic vaginitis endometrial hyperplasia endometrial carcinoma cervical cancer cervical ectropion endometrial polyps Ovarian cancer (theca cell) Vaginal - rare
PMB Ix
Transvaginal USS
- <3mm - reassured
>4mm - endometrial biopsy
if HRT - 5mm cut off
CT/MRI - further imaging
PMB Mx
Atrophic vaginitis
topical oestrogen and vaginal lubricants
Endometrial hyperplasia: dilatation and curettage, progestogen treatment e.g. Mirena coil
Primary dysmenorrhoea
no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.
Excessive endometrial prostaglandin production
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
Secondary dysmenorrhoea
develops many years after the menarche and is the result of an underlying pathology.
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
Dysmenorrhea Mx
NSAIDs such as mefenamic acid and ibuprofen
inhibiting prostaglandin production
- Combined oral contraceptive pills
- Levonogestrel intrauterine system (LNG-IUS) – when dysmenorrhea occurs with menorrhagia
- GnRH analogues
Urinary incontinence
loss of control of urination
o Urethral sphincter incompetence (urinary stress incontinence)
o Detrusor instability (overactive bladder: bladder contracts)
o Retention with overflow (prolapse)
o Mixed
o Functional
Urge incontinence
overactivity of the detrusor muscle of the bladder
increased urgency and frequency. may experience nocturia
OAB wet or dry
Causes: idiopathic, pelvic surgery, MS and spina bifida
Stress incontinence
Involuntary leakage of urine when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction. Weakness in pelvic floor and sphincter muscles
Causes: Commonly seen after childbirth, pelvic surgery and oestrogen deficiency
o Triggers: Coughing, sneezing, exercise
Overflow incontinence
- occur when there is chronic urinary retention due to an obstruction to the outflow of urine.
- anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.
Incontinence Ix
Bladder diary - 3 days
Urine dipstick: UTI, microscopic haematuria
Post void residual
Urodynamic testing
Mx of stress incontinence
- Lifestyle: wt loss etc
- Supervised pelvic floor exercises for at least three months
- Medical: Duloxetine (increase inraurethral closure pressure)
Surgery - Tension-free vaginal tape (TVT): mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall
- Autologous sling procedures
- Laparoscopic or open Colposuspension: stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra
- Intramural urethral bulking
- artificial urinary sphincter
Urge Mx
Lifestyle
Bladder retraining 6 weeks
Anticholinergic medication e.g. oxybutynin, tolterodine and solifenacin (oral/patch)
- reduce intra-vesical pressure, increase compliance, raise volume threshold for micturition and reduce uninhibited contractions
- Mirabegron
- Surgery
- Botulinum toxin A injection
- Percutaneous sacral nerve stimulation -Augmentation cystoplasty
- ## urinary diversion
Pelvic organ prolapse
descent of pelvic organs into the vagina
Uterine prolapse
Uterus itself prolapses into vagina
Vault Prolapse (middle/apical)
- Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
- Symptoms: bulging, pressure, “mass”, difficulty voiding, incomplete emptying, splinting vaginal wall, difficulty inserting tampon, pain with intercourse.
Rectocele
defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
• Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.
Cystocele
defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
• Prolapse of the urethra is also possible (urethrocele).
• Prolapse of both the bladder and the urethra is called a cystourethrocele.
Risk factors for pelvic organ prolapse
o Multiple vaginal deliveries
o Instrumental, prolonged or traumatic delivery
o Advanced age and postmenopausal status
o Obesity
o Chronic respiratory disease causing coughing
o Chronic constipation causing straining
Pelvic organ prolapse signs/symptoms
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
mass
Grades of uterine prolapse
1st degree: mild protrusion on examination (-1cm of introitus)
2nd degree: prolapse present at introitus of vagina/anus/urethra (between -1 cm and +1cm of introitus)
3rd degree: prolapse protruding outside of the introitus (beyond +1cm introitus)
4th degree: procidentia (complete prolapse)
above hymen: -ve
below hymen: +ve
Pelvic organ prolapse Mx
Physiotherapy (pelvic floor exercises): minimum 4-6 months supervised
o Weight loss
o Lifestyle changes
Vaginal pessaries
Surgery
- Cystocele/cystourethrocele: anterior colporrhaphy
- Rectocele: posterior colporrhaphy
- Repair of Uterine Prolapse/Vault prolapse
- Vaginal hysterectomy (remove uterus via vagina)
- Manchester repair (cervix amputated, uterosacral ligaments shortened)
- Sacrospinous Fixation
- Others: Abdominal/laparoscopic sacrocolpopexy, mesh techniques, colpocleisis
Breast cancer: avoid what contraception?
avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid
intrauterine system (i.e. Mirena coil)
Wilson’s disease
avoid the copper coil
Over 50 and under 50 women contraception
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
contraception after childbirth
After 21 days women are considered fertile, and will need contraception (including condoms for 7 days when starting the combined pill or 2 days for the progesterone only pill).
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Natural family planning
o Length of menstrual cycle varies & should be measured for at least 3 consecutive months
o As sperm can live for up to 7 days in female genital tract, sex should be restricted 7 days before ovulation and at least 2 days after ovulation.
• Temperature: A record of body temperature is also done as an increase in temperature 3 days in a row could indicate that fertility has decreased.
Diaphragms and Cervical Caps
• The woman fits them before having sex, and leaves them in place for at least 6 hours after sex.
• If they want sex again, just reapply spermicide gel within 6 hours
- No protection against STIs
Combined oral contraceptive pill
licensed up to 50 years old
- Preventing ovulation (this is the primary mechanism of action)
o Progesterone thickens the cervical mucus
o Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Yasmin and other COCPs containing drospirenone are considered first-line for
premenstrual syndrome.
continuous use. Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
COCP regimes
o 21 days on and 7 days off
o 63 days on (three packs) and 7 days off (“tricycling“)
o Continuous use without a pill-free period
COCP side effects
- Unscheduled bleeding (breakthrough): first three months and should settle with time
- Can interact with other medicines – liver enzyme inducing drugs e.g. anti-epileptic
- Hormonal side effects: Breast pain, tenderness, Mood changes, depression & Headaches
- Hypertension
- Venous & arterial thromboembolism
- Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
- Small increased risk of myocardial infarction and stroke esp in smokers
COCP benefits
contracpetion
improved premenstrual symptoms, meorrhagia and dysmenorrhoea
reduced risk of endometrial, ovarian and colon cancer
reduced risk of ovarian cysts
COCP contradictions
o Uncontrolled hypertension (particularly ≥160 / ≥100): <140/90
o Migraine with aura (risk of stroke)
o History of VTE
o Aged over 35 and smoking more than 15 cigarettes per day
o Major surgery with prolonged immobility
o Vascular disease or stroke
o Ischaemic heart disease, cardiomyopathy or atrial fibrillation
o Liver cirrhosis and liver tumours
o Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
o It is worth noting that a BMI above 35 is UKMEC 3 for the combined pill (risks generally outweigh the benefits).
Starting pill
day 5 of cycle - fine
after day 5 - extra contraception for 7 days
COCP pill - missed pills
• Missing one pill (less than 72 hours since the last pill was taken):
o Take the missed pill as soon as possible (even if this means taking two pills on the same day)
o No extra protection is required provided other pills before and after are taken correctly
• Missing more than one pill (more than 72 hours since the last pill was taken):
o Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
o Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
o If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
o If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
o If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
Combined Transdermal Patch (CTP)
releases a daily dose of oestrogen and progesterone through the skin into the blood to prevent ovulation. It also thickens cervical mucus.
worn for 7 days and changed on day 8. This is to be continued for 3 weeks and a patch-free week should happen in week 4, to allow a withdrawal bleed.
CTP - missed patch
- If patch falls off for less than 48 hours, stick it back as soon as possible or use a new patch. Protection against pregnancy remains as long as patch was used correctly for 7 days before it was removed.
- If patch was removed for more than 48 hours, a new patch should be started immediately, and additional contraception used for the next 7 days.
Combined Vaginal Ring (CVR)
- Continuous release of oestrogen and progesterone into the bloodstream, preventing ovulation.
- The ring should be in the vagina for 21 days before it is removed for 7 days to allow a withdrawal bleed
CVR - Missed
• If the ring is expelled for <3 hours, rinse the ring with cool water and reinserted immediately, no additional contraception is needed.
• If the ring remains out of the vagina for >3 hours, contraceptive protection may be reduced.
o If this occurs during week 1 or 2 of the menstrual cycle, additional protection should be used for the next 7 days after the ring is re-inserted.
o If expulsion occurs during week 3, a new ring can be inserted to start a new cycle or a withdrawal bleed can be allowed. A new ring should be inserted no later than 7 days after the ring was expelled.
Progesterone Only Pill (POP): mini pill
only contains progesterone and taken continuously
o Traditional progestogen-only pill (e.g. Norgeston or Noriday)
o Desogestrel-only pill (e.g. Cerazette)
POP mechanism?
• Traditional progestogen-only pills work mainly by:
o Thickening the cervical mucus
o Altering the endometrium and making it less accepting of implantation
o Reducing ciliary action in the fallopian tubes
• Desogestrel works mainly by:
o Inhibiting ovulation
o Thickening the cervical mucus and altering the endometrium
o Reducing ciliary action in the fallopian tubes
POP missed pills
• More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
• More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use.
• Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.
Progestogen only injection
- depot medroxyprogesterone acetate (DMPA).
- 12 to 13 week intervals as an intramuscular or subcutaneous injection
- Depo-Provera: given by intramuscular injection (healthcare administers)
- Sayana Press: a subcutaneous injection device that can be self-injected
• Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks
Progesterone injection side effects
weight gain
osteoporosis
small risk of breast and cervical cancer
Progesterone injection mechanism
inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.
Progestogen Only Implant
releases progestogen into the systemic circulation (3 years)
• Nexplanon: contains 68mg of etonogestrel.
- Inhibiting ovulation
- Thickening cervical mucus
- Altering the endometrium and making it less accepting of implantation
Contradictions for coil
- Pelvic inflammatory disease or infection
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity distortion (e.g. by fibroids)
Risks relating to insertion of the coil
o Bleeding
o Pain on insertion
o Vasovagal reactions (dizziness, bradycardia and arrhythmias)
o Uterine perforation (1 in 1000, higher in breastfeeding women)
o Pelvic inflammatory disease (particularly in the first 20 days)
o The expulsion rate is highest in the first three months
if coil threads are not seen: what to worry about
uterine perforation
pregnancy
expulsion
Copper coil
3 – 10 years after insertion (depending on the device).
• It can also be used as emergency contraception, inserted up to 5 days after an episode of unprotected intercourse.
• It is notably contraindicated in Wilson’s disease and submucosal fibroids and uterine malformation
toxic to ovum and sperm
copper coil benefits
reduce risk of VTE
risk of endometrial and cervical cancer
copper coil drawbacks
heavy bleeding
pelvic pain
risk of ectopic pregnancies
Mirena coil mechanism
releasing levonorgestrel (progestogen) into the local area:
o Thickening cervical mucus
o Prevents endometrium proliferation and making it less accepting of implantation
o Inhibiting ovulation in a small number of women
Mirena coil benefits
- periods lighter or stop altogether: licensed for heavy periods
- It may improve dysmenorrhoea or pelvic pain related to endometriosis
- No restrictions for use in obese patients (unlike the COCP)
- Safe: breastfeeding and postpartum. Fewer hormonal S/E than systemic hormones
Mirena coil drawbacks
irregualr bleeding
• Increased risk of ectopic pregnancies
• Increased incidence of ovarian cysts
• systemic absorption causing side effects of acne, headaches, or breast tenderness
• Intrauterine devices can occasionally fall out (around 5%)
female sterilisation methods
removal, band, clip, essure
elective or c section
female sterilisation risks
ectopic pregnancy
irreversible
Vasectomy
cutting vans deferens
requires 2 months of contracpetion after
semen testing at 12 weeks after procedure
Emergency contraception types and duration
o Levonorgestrel should be taken within 72 hours of UPSI
o Ulipristal should be taken within 120 hours of UPSI
o Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation (most effective - not affected by BMI, enzyme inducing drugs or malabsoption)
Levonorgestrel (EC)
preventing or delaying ovulation
Extra contraception (i.e. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill
Dose
o 1.5mg as a single dose
o 3mg as a single dose in women above 70kg or BMI above 26
Can be used more than once in a menstrual cycle and breastfeeding allowed
Ulipristal
selective progesterone receptor modulator (SERM) that works by delaying ovulation. The common brand name is EllaOne
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal and don’t take more than once during menstrual cycle
There are several notably restrictions with ulipristal:
o Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
o Ulipristal should be avoided in patients with severe asthma
o Don’t take with levonorgestrel
STI causes
•Bacterial o Chlamydia trachomatis (chlamydia) o Neisseria gonorrhoeae (gonorrhoea) o Mycoplasma genitalium o Treponema pallidum (syphilis)
Viral
o Human papilloma virus (genital warts)
o Herpes simplex (genital herpes)
o Hepatitis and HIV
Parasites
o Trichomonas vaginalis
o Phthirus pubis (pubic lice or “crabs”)
o Scabies (not covered in this lecture)
Charcoal swabs
microscopy, culture and senstivities
endocervical swabs and high vaginal swabs (HVS).
Can confirm:
• Bacterial vaginosis
• Candidiasis
• Gonorrhoeae (specifically endocervical swab)
• Trichomonas vaginalis (specifically a swab from the posterior fornix)
• Other bacteria, such as group B streptococcus (GBS)
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism.
chlamydia and gonorrhoea
In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample
In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.
Chlamydia
gram negative bacteria
Infects columnar epithelium at mucosal sites at urethra, rectum, throat and eyes
Obligate intracellular bacteria
Chlamydia types
o Serovars A-C = Trachoma (eye infection) (NOT an STI)
o Serovars D-K = Genital infection
o Serovars L1-L3 = Lymphogranuloma venereum: men who have sex with men. Presents with proctitis
Chlamydia female signs/symptoms
mostly asymptomatic o Abnormal vaginal discharge o Pelvic pain or abdominal tenderness o Abnormal vaginal bleeding (intermenstrual or postcoital) o Painful sex (dyspareunia) o Painful urination (dysuria) o Cervical motion tenderness (cervical excitation) o Inflamed cervix (cervicitis)
Males chlamydia signs/symptoms
o Urethral discharge or discomfort (milky) o Painful urination (dysuria) o Epididymo-orchitis o Reactive arthritis o Abdominal pain o Urethritis o Proctitis
Chlamydia Ix
NAAT - 14 days - first catch urine sample (male and female) o Vulvovaginal swab o Endocervical swab o Urethral swab in men o Rectal swab (after anal sex) o Pharyngeal swab (after oral sex) o Eye swabs (babies and adults)
Chlamydia Mx
Doxycycline 100mg bd 7 days (not in preg or breastfeeding)
o Azithromycin 1g stat then 500mg once a day for 2 days (removed as 1st line due to mycoplasma genitalium resistance to azithromycin)
o Erythromycin 500mg four times daily for 7 days
o Erythromycin 500mg twice daily for 14 days
o Amoxicillin 500mg three times daily for 7 days
PID Mx
Ceftriaxone 1G IM (GN), Doxycycline 100mg BD (CL) x 2 weeks and metronidazole 400 mg BD x 2 weeks (anaerobes)
Lymphogranuloma Venereum
condition affecting the lymphoid tissue around the site of infection with chlamydia.
• Serovars of Chlamydia trachomatis (L1-3)
• It most commonly occurs in men who have sex with men (MSM).
Lymphogranuloma Venereum stages
o The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.
o The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.
o The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.
Lymphogranuloma Venereum Mx
- Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH.
- Erythromycin, azithromycin and ofloxacin are alternatives
Neisseria Gonorrhoeae
- Gram-negative diplococcus bacterium.
- columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx.
short lived (2-5 days)
Neisseria Gonorrhoeae signs/symptoms
Male: produce an intense neutrophil response that leads to a purulent discharge (pus) and pain with urination, testicular pain (epididymo-orchitis)
Female: Odourless, dsyuria and pelvic pain
Gonorrhoeae Ix
NAAT: RNA and DNA
Charcoal endocervical swabs: microscopy, culture and antibiotic sensitives
Gonorrhoeae Mx
Ceftriaxone IM 1g
Test of cure: 2 weeks later
Disseminated Gonococcal Infection
bacteria spreads to the skin and joints. It causes:
o Various non-specific skin lesions
o Polyarthralgia (joint aches and pains)
o Migratory polyarthritis (arthritis that moves between joints)
o Tenosynovitis
o Systemic symptoms such as fever and fatigue
Mycoplasma genitalioum
bacteria that causes non-gonococcal urethritis.
• It is a sexually transmitted infection.
• There are developing problems with antibiotic resistance, particularly with azithromycin.
Mycoplasma genitalioum Ix
NAAT
- first urine sample in morning for men
- vaginal swabs for women
Mycoplasma genitalioum Mx
- Doxycycline 100mg twice daily for 7 days then;
* Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
Syphilis
- Treponema pallidum.
- This bacteria is a spirochete, a type of spiral-shaped bacteria
- incubation period between the initial infection and symptoms is 21 days on average (9-90 days).
MSM highest rates
- sex, vertical transmission and IV drug use and blood transfusions
syphilis stages
Primary syphilis involves a painless ulcer called a chancre at the original site of infection
Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes
Latent syphilis: symptoms disappear
- Early latent syphilis occurs within two years
- Late latent syphilis occurs from two years after the initial infection onwards
Tertiary syphilis
secondary syphilis signs/symptoms
o (“snail-track” mouth ulcers)
o Maculopapular rash (macular, follicular or pustular rash on palms + soles)
Condylomata lata
Generalised Lymphadenopathy: fever, sore throat
syphilis Ix
Sample sites of infection: dark field microscopy and PCR (1st line)
•Further serological testing (secondary): Rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)
Syphilis Mx
o Early Syphilis: 2.4 MU Benzathine penicillin (stat)
o Late Syphilis: 2.4 MU Benzathine penicillin weekly x 3 weeks
HIV types
o HIV-1 (group M) is the most common type and responsible for global epidemic
o HIV-2 is rare outside West Africa.
HIV stages
Primary HIV infection: 2-4 weeks after infection - fever, rash, myalgia, pharyngitis
asymptomatic HIV infection
AIDs defining conditions
HIV testing
- Antibody testing is the typical screening test for HIV (home tests available)
- p24 antigen (specific HIV antigen in the blood): earlier positive test – 6 weeks
- PCR for the HIV RNA levels tests (viral load)
- Rapid HIV tests (POCT): Fingerprick blood specimen or saliva, Results within 20-30 minutes. 3rd generation (Ab only) or 4th generation (Ab/Ag)
- 4th generation Ab/Ag laboratory test 99% sensitive at 45 days (6 weeks)
End stage HIV viral CD4 count
Under 200
HIV Mx
Combination of 3 drugs from at least 2 drug classes to which the virus is susceptible
BHIVA guidelines (2015) recommend a starting regime of two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent.
Pre-Exposure Prophylaxis (i.e. contraception)
Rx –Tenofovir/emtricitabine
Post-Exposure Prophylaxis (emergency contraception)
commenced within 72 hours
• The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days.
HIV and breastfeeding
not recommended
HIV: Pneumocystis pneumonia (PCP): fungus signs/symptoms
Diffuse rather than local
- insidious onset, SOB and dry cough and o2 desat
HIV: Pneumocystis pneumonia (PCP): fungus Ix
- CXR: May be normal, Interstitial infiltrates & Reticulonodular markings
- BAL and immunofluorescence +/- PCR
- CD4 threshold: <200
HIV: Pneumocystis pneumonia (PCP): fungus Mx
- high dose co-trimoxazole (+/- steroid)
* Prophylaxis: low dose co-trimoxazole
HIV: cerebral toxoplasma gondii
Reactivation of latent infection
- multiple cerebral abscess and chorioretinitis
HIV: cerebral toxoplasma gondii signs/symptoms
- Headache
- Fever
- Focal neurology
- Seizures
- Reduced consciousness
- Raised intracranial pressure
CD4 threshold: <150
CMV HIV
CD4: <50
o Reactivation of latent infection → retinitis, colitis, oesophagitis
Progressive multifocal leukoencephalopathy (PML)
JC (John Cunningham) virus (reactivation) – dementing virus
• CD4 threshold: <100
HPV Genital warts types
- Type 6 and 11 causes genital warts
* Type 16 and 18 – more likely to cause cancer
Genital warts signs/symptoms
• non-painful, non-pruritic genital lumps
HPV treatment
Vaccination
- Podophyllotoxin (Condyline)
- Imiquimod (Aldara)
- Ablative: Cryotherapy
- Surgical: diathermy, curettage, surgical excision Electrocautery
Genital herpes
HSV-2 Mainly (double stranded DNA)
exquisitely painful multiple small vesicles, which are easily deroofed. Flu like symptoms, dysuria and inguinal lymphadenopathy
o Virus migrates to sacral root ganglion and “hides” from the immune system there (probably remains for life)
o Virus can reactivate from there causing recurrent genital herpes attacks (trigger factors for this not understood)
Herpes Mx
Aciclovir 400mg TDS x 5/7 is used to treat genital herpes.
Additional measures: o Paracetamol o Topical lidocaine 2% gel (e.g. Instillagel) or 5% ointment o Cleaning with warm salt water (saline bath) o Topical vaseline o Additional oral fluids o Wear loose clothing o Avoid intercourse with symptoms
Primary genital herpes before 28 weeks gestation Mx
treated with aciclovir (initial infection)
regular prophylactic aciclovir starting from 36 weeks
asymptomatic: vaginal
symptomatic: C section
Primary genital herpes contracted after 28 weeks gestation Mx
treated with aciclovir (initial infection)
immediately by regular prophylactic aciclovir
C section in all cases
Candida Infection risk factors
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
Candida signs/symptoms
Thick, white discharge
vulval and vaginal itching, irritation and discomfort
Candida Ix and Mx
vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
• A charcoal swab (high vaginal swab) with microscopy can confirm the diagnosis.
- Clotrimazole
- Clotrimazole pessary
- Oral fluconazole
Trichomonas vaginalis
protozoan and binary fission
Trichomonas vaginalis signs/symptoms
o Vaginal discharge: offensive, frothy, yellow/green o Vulvovaginitis: Itching o Dysuria (painful urination) o Dyspareunia (painful sex) o The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
Strawberry cervix
Trichomonas vaginalis Ix and Mx
vaginal ph: >4.5
charcoal swab with microscopy - posterior fornix
urethral swab or first catch urine in men
Mx: Metronidazole 5-7 days
Bacterial vaginosis
overgrowth of bacteria in the vagina, specifically anaerobic bacteria.
Loss of lactobacilli bacteria
Bacterial vaginosis risk factors
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
- Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
BV signs/symptoms
- fishy-smelling watery grey or white vaginal discharge. May contain bubbles
- Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
BV Ix and Mx
vaginal ph
charcoal: clue cells - epithelial cells coated in coccobacilli
Metronidazole for 7 days
Prostatitis
caused by E. coli, other coliforms and Enterococcus sp. However, it may also (very uncommonly) be caused by gonorrhoea or chlamydia infection.
Prostatitis risk infections
recent a urogenital procedure, recent prostate biopsy, intermittent bladder catheterisation or recent urinary tract infection (rare) are at risk of prostatitis
Prostatitis Signs/symptoms
- Symptoms of UTI,
- Lower abdominal pain/back/perineal/penile pain
- Obstructive voiding symptoms
- Fever and rigors
- Digital rectal examination will reveal a tender, boggy prostate gland
Prostatitis Ix and Mx
MSSU
ofloxacin 400mg bad for 28 days
Pubic lice Mx
Malathion lotion
Menopause
No periods for 12 months
Post menopause vs perimenopause
Period from 12 months after the final menstrual period onwards.
Peri: refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
Premature ovarian insufficiency vs early menopause
<40 vs 40-44
Perimenopausal symptoms
- night sweats
- mood swings
- hot flushes
- genitourinary problems (dry vagina, painful sex and urinary symptoms)
Menopausal risks
• A lack of oestrogen increases the risk of certain conditions: o Cardiovascular disease and stroke o Osteoporosis o Pelvic organ prolapse o Urinary incontinence
Perimenopause Dx
diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations
FSH, LH and oestradiol are only useful unless patient is young and presenting with amenorrhea
* only women aged ≥ 50 on hormonal contraception who do not want to continue until the age of 55
FSH test - when to do
o FSH levels x 2 (6 weeks apart) indicated:
in women > 45 with atypical symptoms
in women between 40 and 45 with menopausal symptoms and/or iatrogenic amenorrhoea (IUS, hysterectomy, endometrial ablation.)
Menopause Mx
- HRT (1st line for vasomotor and low mood/anxiety related to menopause)
•Transdermal HRT carries low or no increased VTE risk is better for symptom control and associated with less CVD risks.
o Tibolone
o Clonidine,
o Testosterone
o Vaginal moisturisers
HRT benefits
o Reduction of vasomotor symptoms (hot flushes, night sweats)
o Improvement of low mood associated with the (peri-)menopause
o Reduction of osteoporosis risk and fragility fractures,
o Improvement of sexual function,
o Prevention and treatment of urogenital / vulvovaginal atrophy (“genitourinary syndrome of the menopause”) (which can usually also be controlled by topical oestrogen alone).
HRT contradictions
History of breast cancer o Increased risk of VTE o Coronary heart disease o Transient ischaemic attack or previous stroke o Unexplained vaginal bleeding o Active liver disease
Urogenital atrophy signs/symptoms
loss of vaginal fornix
thinning of vaginal wall
loss of rugal folds
decrease in vaginal length
Vulvodynia
vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder
- high tone
- very tender
- mucosae unremarkable
Vulvodynia Mx
Localised provoked pain
o Lidocaine 5% ointment
o Vaginal trainers
o Physiotherapy
Unprovoked pain
o Tricyclics
o Gabapentin/pregabalin
o Psychosexual interventions
FGM types
- Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
- Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)
- Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)
- Type 4: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization
Endometriosis
ectopic endometrial tissue (including stroma) outside the uterus.
Lump - endometrioma
Endometriosis mechanism
Retrograde menstruation
Embryonic cells
lymphatic system
metaplasia
Endometriosis signs/symptoms
- Cyclical abdominal or pelvic pain
- Deep dyspareunia (pain on deep sexual intercourse)
- Dysmenorrhoea (painful periods)
- Pain of defecation (dyschezia)
- Pelvic inflammation
- Infertility
- Cyclical bleeding from other sites, such as haematuria
Endometriosis Ix
Pelvic USS: endotriomas and chocolate cysts
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis
Can also remove deposits of endometriosis and potentially improve symptoms.
Endometriosis Mx
NSAIDs and paracetamol
Hormonal management
- COCP, POP, injection, implant, mirena coil and GnRH agonists
Surgical: laparoscopic surgery and hysterectomy
Ovarian torsion
Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
- ovarian mass larger than 5 cm
Ovarian torsion risk factors
benign tumours and during pregnancy
normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments
more likley with cysts > 5cm (dermoid most common)
Ovarian torsion signs/symptoms
sudden onset severe unilateral pelvic pain
o constant, gets progressively worse
o Does not go away with analgesia
o associated with nausea and vomiting
palpable mass in pelvis
localised tenderness
Ovarian torsion Ix
Pelvic USS: whirlpool sign - free fluid in pelvis and oedema of ovary
laparoscopic surgery: definitive surgery
Ovarian torsion Mx
detorsion
cystectomy
oophorectomy
Cyst rupture
- Commonly occur in functional cysts
- May also occur dermoid or endometrioma
- Rupture can be spontneous or after trauma (SI, contact sports)
- Cyst can heamorrhage
Cyst rupture Ix
- FBC, CRP and G&S
- Peritonism
- Ultrasound
- Pain goes away from analgesia
Cyst rupture Mx
- Conserative
- Resusistation
- Lapraropscopy
- Lavage – to wash out the blood (blood is the source of pain – irriatting)
- Stop bleeding (diathermy)
- ?oophorectomy: if bleeding is too bad
Meig’s syndrome
Ovarian fibroma
pleural effusion
ascites
PID signs/symptoms
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge (offensive)
- Patients may have a fever and other signs of sepsis.
PID Mx
IM ceftriaxone + oral doxycycline + oral metronidazole
Fitz-Hugh-Curtis Syndrome
inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum.
RUQ pain and right shoulder tip pain if diaphragmatic irritation
Bartholin’s Cyst
The Bartholin’s glands are a pair gland located either side of the posterior part of the vaginal introitus (the vaginal opening) at sit at 5 and 7 o’clock
Bartholin’s Abscess Mx
antibiotics
Word catheter
Marsupialisation
Lichen sclerosis
chronic inflammatory condition of unknown aetiology affecting the skin.
It is characterised by areas of atrophy and systematic destruction to the skin cells include melanocytes and hair follicles.
Lichen sclerosis signs/symptoms
Pruritus and skin irritation
hypopigmented and atrophied (shiny appearance)
white polygonal papules - plaques
with time: atrophy and fusion of labia, stensois of introitus and difficulties in defecation
without treatment: vulvar intraepithelial neoplasia
figure of 8 patterns
Lichen sclerosis Mx
Emollients
topical high dose steriods e.g. dermovate
2nd line: topical calcineurin inhibitors e.g. tacrolimus
Extra-mammary Paget’s disease of the vulva.
- May extend towards the anus and presents as an erythematous, eczematous area with a crusting rash.
- It is often a sign of other malignancy in the body therefore a full body work-up is indicated in patients presenting with this condition.
- Tumour cells are within the epidermis and contain mucin and it is thought that the tumour arises from the sweat glands in the skin.
Ovarian cyst signs/symptoms
o Pelvic pain
o Bloating
o Fullness in the abdomen
o A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
o Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Functional cysts
occur when ovulation doesn’t occur
- Follicle doesn’t rupture but grows until it becomes a cyst (fluid filled space)
- Lined by granulosa cells
Types of ovarian cysts
Benign epithelial ovarian tumours: Arise form ovarian surface epithelium
o Serous Cystadenoma
-Mucinous Cystadenoma
Endometrioma
Dermoid Cysts / Germ Cell Tumours e.g. teratomas - associated with ovarian torsion
Sex Cord-Stromal Tumours - sertoli-leydig cell tumours and granulosa cell tumours
Ovarian cancer assessment - symptoms
o Abdominal bloating, reduce appetite, early satiety and weight loss o Urinary symptoms o Pain o Ascites o Lymphadenopathy
Ovarian cysts Ix
simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
CA125
Women under 40: complex ovarian mass - do LDH, a-FP and HCG
Risk of malignancy index: menopausal status, USS and CA125 level
Ovarian cysts Mx
Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery.
simple cysts:
- less than 5cm - resolve within 3 cycles
- 5 to 7cm: routine & USS yearly
- > 7cm: MRI scan or surgical evulation
• Surgical intervention: Persistent or enlarging cysts: laparoscopic
o Surgery may involve removing the cyst (ovarian cystectomy)
o along with the affected ovary (oophorectomy).
Ovarian Cancer epithelial types
Epithelial
- serous (fallopian tube)
- high grade with precursor: Serous tubal intraepithelial carcinoma (STIC)
- low grade with precursor: serous borderline tumour
- endometrioid carcinomas (endocervix)
- endometriosis
- usually malignant
- low grade and lynch syndrome
- Clear cell (glandular uterus)
- almost all malignant
- ovarian endometriosis and lynch syndrome
- Brenner: transitional type epithelium
- Mucinous
- often benign
- often malignant is bilateral
- Rarely, pseudomyxoma peritonei may also be present – characterized by a gelatinous tumour in the peritoneal cavity
dermoid cysts/germ cell tumours
- benign ovarian tumours and teratomas
- may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
- Other germ cell tumours
o Immature teratoma: embryonic element (8 weeks gestation)
o Dysgerminoma: Most common malignant germ cell tumour (HCG increases)
o Yolk sac tumour
Choriocarcinoma (Secrete hCG so patients may present with precocious pseudopuberty)
Sex Cord-Stromal Tumours
They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles).
o Fibroma/Thecoma (commonest): produces a collagenous solid tumour
- Benign (want to exclude ovarian fibrosarcoma)
- produce oestrogen causing uterine bleeding
- Meigs syndrome can result
2) Granulosa cell tumour
- All are potentially malignant but low grade
precocious
- pseudopuberty, abnormal menstrual bleeding / postmenopausal bleeding
- cells with ‘coffee bean’ nuclei and ‘gland-like’ spaces called Call-Exner bodies
3) Sertoli-Leydig cell tumours
- may produce androgens
Krukenberg tumour
refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
• Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
Ovarian cancer risk factors
• Age (peaks age 60) • Genetic predisposition: BRAC1/2 • Endometriosis • Increased number of ovulations • Obesity • Smoking • Recurrent use of clomifene • Increase number of ovulations. These include: o Early-onset of periods, Late menopause and No pregnancies
Protective: Combined contraceptive pill, Breastfeeding and Pregnancy
Ovarian cancer signs/symptoms
- Abdominal bloating
- Early satiety (feeling full after eating)
- Loss of appetite
- Pelvic pain
- Urinary symptoms (frequency / urgency)
- Weight loss
- Abdominal or pelvic mass
- Ascites
- An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
Ovarian cancer referral
2 week if: ascites, pelvic mass and abdominal mass
CA125 if o New symptoms of IBS / change in bowel habit o Abdominal bloating o Early satiety o Pelvic pain o Urinary frequency or urgency o Weight loss
Ovarian cancer Ix
• CA125 blood test (>35 IU/mL is significant)
• Pelvic ultrasound
• The risk of malignancy index (RMI)
Carcino-embryonic antigen (CEA)
• CT scan to establish the diagnosis and stage the cancer
• Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
Paracentesis
Women under 40 years
o Alpha-fetoprotein (α-FP)
o Human chorionic gonadotropin (HCG)
Causes of Raised CA125
o Endometriosis o Fibroids o Adenomyosis o Pelvic infection o Liver disease o Pregnancy
Staging ovarian cancer
• Stage 1: Confined to the ovary
- A (one ovary), B (Both), C (in or surface)
• Stage 2: Spread past the ovary but inside the pelvis
- 2A (uterus/fallopian tube)
- 2B (other pelvic - bowel/bladder)
• Stage 3: Spread past the pelvis but inside the abdomen
- 3A (lining of abdomen: peritoneal)
- 3B (2cm in dimension: lining)
- 3C (>2cm and in lymph nodes)
• Stage 4: Spread outside the abdomen (distant metastasis)
Benign Ovarian tumours Mx
Excision or drainage
Borderline tumour: Surgery as chemotherapy needs to target cells that are multiplying at a higher rate
o Cyst removal
o Ovary removal (oophorectomy)
o Hysterectomy
o All depends on their fertility and menopause status
Treatment for epithelial tumours (Ovarian)
combination of chemo/surgery
- Surgery is usually in the form of debulking which is the process where tumour deposits are removed as much as possible to decrease tumour size to below 1-2cm.
- Chemotherapy can then be used as an adjuvant
Chemo for unfit surgical patients
Younger patients with unilateral tumour - conservative to preserve fertility
relapse: chemo
Treatment for non-epithelial tumours (Ovarian)
- Fertility preservation is important as these tumours are common in younger women
- Many are sensitive to chemotherapy
- Limited surgery and chemotherapy can produce good results in many cases
Cervical cancer
• 80% of cervical cancers are squamous cell carcinoma (HPV 16 & 18)
• Adenocarcinoma (HPV 18) is the next most common type.
strongly associated with human papillomavirus
HPV pathology
HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes.
• The E6 protein inhibits p53, and the E7 protein inhibits pRb.
Cervical cancer risk factors
- Non-engagement with screening
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
- Non-engagement with cervical screening
- Smoking
- HIV (patients with HIV are offered yearly smear tests)
- Combined contraceptive pill use for more than five years
- Increased number of full-term pregnancies
- Family history
- Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
Cervical cancer signs/symptoms
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Brownish or blood stained vaginal discharge
- Contact bleeding – friable epithelium
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
- Once the disease becomes advanced further symptoms such as backache, leg pain, haematuria, weight loss, anaemia or changes in bowel habit may be experienced.
Cervical cancer speculum
o Ulceration o Inflammation o Bleeding o Visible tumour - colposcopy referral
Cervical Intraepithelial Neoplasia
grading system for the level of dysplasia (premalignant change) in the cells of the cervix (maturation/differentiation, nuclear abnormalities and excess mitotic activity)
Nuclear abnormalities
o Hyperchromasia: nucleus looks really dark
o increase nucleocytoplasmic ratio: takes up much more of the cell
o Pleomorphism: lot of variation in nucleur size
Cervical Intraepithelial Neoplasia Grades
o CIN I - Basal 1/3 of epithelium occupied by abnormal cells.
o CIN II - Abnormal cells extend to middle 1/3.
CIN III - Abnormal cells occupy full thickness of epithelium
Cervical glandular intraepithelial neoplasia (CGIN)
preinvasive phase of endocervical adenocarcinoma.
Cervical screening
- Every three years aged 25 – 49
- Every five years aged 50 – 64
cervical smear test: under a microscope for precancerous changes (dyskaryosis: low grade, moderate and severe)
If HPV negative - return to routine screening
If HPV positive - normal cytology – repeat the HPV test after 12 months
If HPV positive with abnormal cytology – refer for colposcopy
Colposcopy staining
• Acetic acid causes abnormal cells to appear white. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.
Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
Punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.
Cervical cancer staging
- Stage IA1 - depth up to 3mm, width up to 7mm
- Stage IA2 - depth up to 5mm, width up to 7mm (Low risk of lymph node metastases)
• Stage IB - confined to the cervix
• Stage II - spread to adjacent organs (vagina, uterus, etc..)
o IIA – upper two thirds of vagina
o IIB – upper two thirds of vagina plus parametrial disease
• Stage III - involvement of pelvic wall
o IIIA – lower third of vagina
o IIIB – Pelvic sidewall and/or hydronephrosis
• Stage IV - distant metastases or involvement of rectum or bladder.
o IVA – bladder, rectum
o IVB – beyond pelvis
• PET scan: degree of lymphatic spread
Cervical cancer spread
spreads to adjacent structures and via the draining lymphatics
• Lymphatic spread usually results in metastases to the pelvic and para-aortic-nodes.
• It rarely metastasizes through the blood.
• Invasion past the cervix usually involves the parametrium, upper vagina, pelvic sidewall, bladder and rectum.
Cervical cancer Mx
Stage IA1-IA2
o IA1: cured by local excision. Cone biopsy with close follow up may be an adequate alternative where preservation of fertility is required.
o IA2 simple hysterectomy as well as pelvic lymphadenectomy.
o Adjuvant radiotherapy would be required if the nodes are positive.
Stage IB-IIA (1B either option)
o Radical hysterectomy and pelvic lymphadenopathy.
o Oophorectomy can be performed if required, although cervical cancer rarely spreads to the ovaries.
o Radical radiotherapy is an alternative to surgery. Combining this with cisplatin chemotherapy increases survival rate.
o If there is extension past the cervix then chemo-radiotherapy would be advised over surgery. Therefore, this is the recommended treatment for stage IIA.
Stage IIB-IV
o Usually involves radical radiotherapy plus cisplatin chemotherapy.
Chemo drugs used in cervical cancer
- Cisplatin (40mg/m2 weekly)
- Carboplatin/paclitaxel
- Give ondansetron prior to administering chemotherapy to reduce N&V (given in combination with dexamethasone and is effective in controlling nausea)
Neutropenic sepsis
- A temperature >38C + neutrophils 0.5×10^9 is diagnostic of neutropenic sepsis.
- Bone marrow suppression leading to immune system or GI gut flora getting through GI barrier
• Initiate Sepsis 6 protocol
• Start empirical antibiotic therapy – NICE recommends Piperacillin with Tazobactam.
o Gentamicin, vancomycin and ciprofloxacin can be used if penicillin allergic.
Vulva cancer
squamous cell carcinomas
• Spreads to inguinal lymph nodes
• If adenocarcinoma – the site is usually Bartholin’s gland
Vulva cancer risk factors
- Advanced age (particularly over 75 years)
- Immunosuppression
- Human papillomavirus (HPV) infection
- Lichen sclerosus:
Vulva cancer signs/symptoms
• Vulval lump • Ulceration • Bleeding • Pain • Itching • Lymphadenopathy in the groin • Vulval cancer most frequently affects the labia majora, giving an appearance of: o Irregular mass o Fungating lesion o Ulceration o Bleeding
Vulval Intraepithelial Neoplasia
• Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer.
• Strong association with HPV types 6 and 11
High grade squamous intraepithelial lesion is a type of VIN associated with HPV
women aged 35 – 50 years.
Differentiated VIN is
associated with lichen sclerosus
• older women (aged 50 – 60 years).
Vulva cancer Ix
USS Groin: lymph nodes
MRI perineum
biopsy diagnose VIN
sentinel node biopsy: lymph spread
VIN Mx
• Wide local excision (surgery) to remove the lesion: Lesions confined to the vulva or perineum, with stromal invasion less than or equal to 1.0 mm (FIGO Stage Ia)
If lesions confined to pelvis, but more than 1mm depth of invasion – with and without wide local excision/bilateral groin node dissection (WLE/BGND)
- Imiquimod cream
- Laser ablation
Vulva cancer Mx
• Wide local excision to remove the cancer
o radical vulvectomy and inguinal lymphadenectomy
- Inguinal lymph node dissection
- Chemotherapy: Lesions with obvious groin node involvement
- Radiotherapy: esp if spread to inguinal lymph nodes
Endometrial cancer
endometrium, the lining of the uterus.
• Around 80% of cases are adenocarcinoma.
• young women, consider underlying predisposition e.g. polycystic ovary syndrome or Lynch syndrome
Two main groups with different precursor lesions
o Endometrioid carcinoma: precursor atypical hyperplasia
o Serous carcinoma: precursor serous intraepithelial carcinoma
Endometrial hyperplasia
- precancerous condition involving thickening of the endometrium.
- Increased number of endometrial cells leading to a thick endometrium
- It may occur due to persistent oestrogen stimulation
- Can be simple, complex or atypical
- Atypical hyperplasia can progress to endometrial carcinoma
Endometrial hyperplasia Mx
o Intrauterine system (e.g. Mirena coil): due to its delivery of progesterone to the endometrium
o Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
o In atypical hyperplasia, hysterectomy is recommended
Types of endometrial carcinoma
Type I (Endometrioid and mucinous) is most common (80%) and after menopause. o It is oestrogen dependent and is often diagnosed at an early stage o Associated precursor lesion = atypical hyperplasia
Type II (serous and clear cell) is usually observed in older women and has a much poorer prognosis as it is more aggressive and develops much more rapidly.
o It is not associated with unopposed oestrogen.
o TP53 mutation: serous
o clear cell is very rare: have to differentiate from mets
o Precursor lesion = serous endometrial intraepithelial carcinoma (within epithelium itself)
o Spreads along fallopian tube mucosa and peritoneal surfaces so may present with extrauterine disease.
Endometrial cancer risk factors
o Increased age
o Earlier onset of menstruation
o Late menopause
o Oestrogen only hormone replacement therapy
o No or fewer pregnancies
o Tamoxifen
o Polycystic ovarian syndrome:
Obesity
o Oestrogen secreting tumours (granulosa/theca ovarian tumours)
• Type 2 diabetes: increased production of insulin.
• Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome (AD)
Endometrial protective factors
- Combined contraceptive pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
Endometrial cancer signs/symptoms
- postmenopausal bleeding.
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Raised platelet count
Endometrial cancer Ix
• Transvaginal ultrasound for endometrial thickness (normal < 4mm post-menopause)
Pipelle biopsy
Hysteroscopy with endometrial biopsy (dilation and curettage)
Endometrial cancer spread
myometrium and cervix
• Serous carcinoma may spread early to the peritoneal cavity
• lymphatic spread can occur followed by hematogenous
Endometrial stage
- Stage 1: Confined to the uterus
- Stage 2: Invades the cervix
- Stage 3 (local/regional spread): Invades the ovaries, fallopian tubes, vagina or lymph nodes
- Stage 4: Invades bladder, rectum or beyond the pelvis
Endometrial cancer Mx
• Stage 1 and 2 endometrial cancer:
o Hysterectomy
o total abdominal hysterectomy with bilateral salpingo-oophorectomy (removal of uterus, cervix and adnexa).
Other treatment options depending on the individual presentation include:
o A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
o Radiotherapy: adjuvant to prevent recurrence
o Chemotherapy: widespread disease
o Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Endometrial sarcoma
endometrial stroma
Locally aggressive and metastasizes early
Typically presents with abnormal uterine bleeding but initial presentation may be as metastasis (most commonly ovary or lung)
Carcinosarcoma (malignant mixed Müllerian tumour)
- Mixed tumours with malignant epithelial and stromal elements
- The presence of a rhabdomyosarcomatous component has the worst prognosis
Leiomyoma (fibroids) types
- Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk.
fibroids signs/symptoms
- Fibroids are often asymptomatic.
- Heavy menstrual bleeding (menorrhagia)
- Prolonged menstruation, lasting more than 7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
- Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Fibroids Ix
Hysteroscopy
Pelvic ultrasound
MRI scanning
Fibroids Mx
For fibroids < 3 cm
• Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
• Symptomatic management with NSAIDs and tranexamic acid
• Combined oral contraceptive
• Cyclical oral progestogens e.g. norethisterone
• Progesterone only contraception
Surgical options for managing smaller fibroids with heavy menstrual bleeding are:
Endometrial ablation
• Transcervical resection of submucosal fibroids during hysteroscopy
• Hysterectomy
For fibroids > 3 cm, • Symptomatic management with NSAIDs and tranexamic acid • Mirena coil • Combined oral contraceptive • Cyclical oral progestogens
Surgical options for larger fibroids are:
• Uterine artery embolisation
- Myomectomy
• Hysterectomy
- GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap),
Red degeneration of the fibroid
refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting.
Management is supportive, with rest, fluids and analgesia.
