Gynaecology Flashcards
– Cluster 1: Menstrual Cycle –
Describe the hormonal control of the menstrual cycle.
- follicular (days 1-14; variable): rise in FSH, causing growth of endometrium and increased depth of spiral arteries. Primordial follicle matures to a Graafian follicle, then a mature follicle. Receptibility to sperm increases, and mucous becomes abundant and watery
- ovulation (day 14): LH surge causes mature follicle to break, releasing an oocyte and producing the corpus luteum
- luteal phase (days 14-28): negative feedback by LH increases progesterone production (by corpus luteum, which also produces oestradiol); mucous thickens (hostile to sperm), and hypothalamic temperature increases
Describe the actions of FSH and LH.
- LH stimulates theca cells to produce progesterone and androstenedione by activating cholesterol desmolase
- FSH stimulates granulosa cells to convert androstenedione to testosterone, then to 17-beta-oestradiol, by aromatase
Describe the normal blood content of menses.
- Blood volume: ranges from slight spotting to 80ml (average 30ml)
- Menstrual blood is chiefly arterial (25% is venous)
- Usual duration of menstrual flow is 3-5 days (normal range 1-8 days)
- Blood contains prostaglandins, tissue debris, and fibinolysates (lyses clots)
- Loss >80ml is considered abnormal
– Cluster 2a: Menstrual disorders (PMS) –
Describe the physical, psychological, and behavioural changes observed in PMS.
- physical: headache, mastalgia, weight gain, fluid retention, joint/skin pain
- psychological: irritability, emotional lability, low mood, tension, mood swings
- behavioural: sleep disturbance, change in appetite, restlessness, poor conc., confusion, social withdrawal
What is the difference between PMD and PMDD?
- postmenopausal dysphoric disorder: occurs with accompanying mood swings, anxiety, and/or depression
- SSRIs can benefit
Describe the management options for PMD.
- lifestyle: sleep, exercise, smoking and alcohol, small balanced meals rich in complex carbohydrates
- 1st line: despiramine-containing COC (Yasmin, Eloine)
- 2nd line: GnRH agonists [can cause vasomotor symptoms, such as hot flushes, & osteoporosis]
- SSRIs/SNRIs, CBT
- hysterectomy with bilateral salpingo-oophorectomy: last resort
- additional: vitamin B6, oil of evening primrose, oestrogen patches/implants
- SSRIs / psychotherapy for PMDD
– Cluster 2b: Menstrual disorders (menorrhagia) –
Define heavy menstrual bleeding (HMB).
Blood loss that interferes with physical, social, emotional or material aspect of a woman’s life.
* previously defined as total blood loss >80ml/menses, but this is obviously difficult to quantify
* now is shifted to what the woman considers prolonged and increased flow
- accounts for 20% of gynae appts.
- most common cause of iron deficiency anaemia
What are the key causes of menorrhagia?
- gynae: fibroids, adenomyosis, polyps, endometrial hyperplasia, endometriosis, uterine/cervical malignancy
- obstetric: miscarriage, ectopic, gestational trophoblastic disease, placenta praevia
- sexual health: copper IUD, PID, surgical TOP, hormones (oestrogen/tamoxifen)
- endocrine: hormone-producing ovarian tumours, thyroid dysfunction, DM, adrenal disease, prolactin disorders
- vascular: AVM, coagulation disorders (von Willebrand, ITP, factor deficiencies)
- systemic: cirrhosis, renal disease
- drugs: anticoagulants (warfarin, clopidogrel, DOACs)
Define the relationship between dysfunctional uterine bleeding (DUB) and menorrhagia, and describe its investigation.
- DUB: non-organic menorrhagia occuring in the absence of pathology; therefore is a diagnosis of exclusion
- therefore requires exclusion of other causes of menorrhagia
– FBC
– systemic tests (TFTs, coag, renal, LFTs)
– TVUS (endometrial thickness, fibroids)
– endo sampling (Pipelle biopsy, D&C etc.)
– colposcopy (abnormal cervix)
Describe the management options for DUB.
- 1st line: Mirena coil IUS (LNG-IUS)
- 2nd line: tranexamic acid (anti-fibrinolytic) / COCP
- 3rd line: DMPA
- 4th line: surgery
- unsure in role: mefenamic acid (an NSAID; C/I in PUD, asthma); progestogens, GnRH agonists (goserelin, buserelin), androgen (danazol)
Describe the surgical management of DUB.
- two major options: endometrial resection/ablation, and hysterectomy
- ablation: day-case procedure, requires combined HRT
- hysterectomy: major operation, oestrogen-only HRT
– Cluster 2c: Dysmenorrhoea –
Define dysmenorrhoea.
- excessive pain during the menstrual period
- primary: no underlying pathology, affects 50% of menstrual women
- secondary: due to underlying pathology
Describe the aetiologies of dysmenorrhoea.
- primary (no underlying pathology): normal examination
- endometriosis: endometrial tissue in the peritoneum/pelvic cavity; occurs with menorrhagia and dyspareunia
- adenomyosis: endometrial tissue between muscle layers of the uterus; occurs with prolonged menorrhagia
- fibroids: menstrual pain with pressure effects on adjacent organs
- chronic PID: history of STI, pain not limited to menstruation
Define adenomyosis and leiomyoma.
- adenomyosis: presence of endometrial tissue in the myometrium
- leiomyoma: benign, smooth muscle tumour
Describe the investigations of dysmenorrhoea.
- high vaginal and endocervical swabs (pelvic infection)
- pelvic USS (endometriosis, adenomyosis, fibroids)
- diagnostic laparoscopy (other investigations normal but symptoms persist, or when Hx is suggestive of endometriosis)
Describe the management of dysmenorrhoea.
- 1st line: NSAIDs (mefenamic acid, ibuprofen): effective in 80%
- 2nd line: COCP
- additional options: LNG-IUS, GnRH analogues
– Cluster 2d: Menstrual disorders (IMB/PCB/PMB) –
Describe the causes of IMB (intermenstrual bleeding).
- cervical ectropion
- PIDs, STDs
- endometrial/cervical cancers/polyps
- undiagnosed pregnancy/complications, hydatidiform molar disease
Define and describe the causes of PCB (postcoital bleeding).
- PCB: bleeding brought on by sexual intercourse
- most common cause is cervical ectropion
- cervical carcinoma, trauma, polyps
- atrophic vaginitis
- cervicitis secondary to STDs
Describe the pathology, presentation, investigation, and treatment of cervical ectropion.
- cervix develops a red, raw appearance that may bleed on contact, most often occuring due to high oestrogen states in pregnancy, or use of hormonal contraceptives (esp. COCP)
- commonly presents with PCB (raw area irritated by penis during intercourse) or IMB
- often diagnosed during smears or colposcopy
- treatment usually not necessary and ectropion resolves (3-6 months following birth). if Mx necessary: cauterisation
Describe the causes of PMB (postmenopausal bleeding).
-PMB in a woman >55 is endometrial cancer until proven otherwise
- atrophic vaginitis (most common)
- endometrial polyps, hyperplasia, carcinoma
- cervical carcinoma
- ovarian carcinoma
- vaginal carcinoma (rare)
Describe the investigation surrounding PMB.
-
TVUS is first-line to assess endometrial thickness
– <3mm: low likelihood of cancer
– >4mm: further Ix (endometrial biopsy)
– <5mm: cutoff for patients taking HRT - hysteroscopy + endometrial biopsy: indicated for patients on tamoxifen (thickened, cystic, irregular endometrium)
- CT/MRI of uterus, pelvis, abdomen
Describe the management of PMB.
- atrophic vaginitis: topical oestrogen, vaginal lubricants, HRT
- endometrial hyperplasia: D&C, progestogen (Mirena IUS first-line)
- cancer: refer to oncology
– Cluster 2e: Menstrual disorders (PCOS) –
Describe the pathology of PCOS.
- increased frequency of the GnRH pulse generator, causing an increase in LH pulses and androgen secretions
- hyperinsulinaemia and insulin resistance, hypertension etc.: mechanism not completely understood
Describe the clinical features of PCOS.
- subfertility, infertility
- oligo/amenorrhoea (increased risk of endometrial hyperplasia and carcinoma)
- hyperandrogenism (hirsutism, acne, acanthosis nigricans, virilisation)
- metabolic (obesity, insulin resistance, diabetes, lipid abnormalities, increased cardiovascular risk)
Describe the diagnostic criteria for PCOS.
These are the Rotterdam criteria.
- oligo/amenorrhoea
- hyperandrogenism (e.g. acne, hirsutism, raised testosterone)
- USS: polycystic ovaries (12+ follicles 2-9mm; or increased ovarian volume >10cm^3)
2/3 criteria are diagnostic.
Describe the investigations of PCOS.
- serum testosterone, free androgen index (testosterone/SHBG x 1000)
- other androgens
- LH:FSH (>2); classically used, current utility is doubtful
- exclusion of other disorders (17a-hydroxyprogesterone for CAH, TFTs, prolactin, 24hr urinary cortisol for Cushing’s)
- ovarian/pelvic ultrasound
Describe the management of PCOS.
- health promotion is appropriate for all; this includes weight loss and exercise
- metformin is beneficial for restoring menstrual regularity, hirsutism, acne, and fertility
- otherwise, management depends largely on what the patient presents with and what their main concerns are.
Hirsutism and acne
- first line: co-cyprindol (Dianette)
- other options: COCP, elfornithine (antiprotozoal), specialist guided (spironolactone, flutamide, finasteride)
Infertility
- first line: weight loss if BMI >30 indicated before ovulation treatment
- medical first line: clomiphene citrate
- additional treatments: metformin, gonadotrophins, ovarian drilling, IVF as a last resort
Amenorrhoea
- COCP, cyclical medroxyprogesterone, or Mirena IUS (for endometrial risk)
- refer for TVUS to assess endometrial thickness
– Cluster 2f: Amenorrhoea –
Define primary and secondary amenorrhoea.
- primary: failure to establish menstruation by 15 years in girls with normal 2ndry sexual characteristics, or 13 in girls with no 2ndry sexual characteristics
- secondary: cessation of menstruation in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Name the causes of primary amenorrhoea.
- anatomical/congenital
– congenital malformation of the genital tract
– Mullerian agenesis
– imperforate hymen
– genetic (Turner’s, androgen insensitivity, 5-alpha reductase deficiency) - premature ovarian failure/insufficiency
- endocrine
– hypothalamic (Kallmann’s, anorexia)
– pituitary (adenoma, sarcoidosis)
– testicular feminisation
– congenital adrenal hyperplasia
Name the causes of secondary amenorrhoea.
- hypothalamic (e.g. secondary stress, excessive exercise)
- hyperprolactinaemia
- Sheehan’s syndrome, Asherman syndrome
- thyrotoxicosis, hypothyroidism
- premature ovarian failure
Describe the investigation and management of amenorrhoea.
- Ix: exclude pregnancy, FBC, U&Es, TFTs, gonadotrophins (?hypothalamic or ovarian dysfunction), prolactin, androgens (PCOS), oestradiol
- primary: investigate and treat any underlying cause
- gonadal dysgenesis: HRT to prevent osteoporosis etc.
Describe the broad differential diagnosis of infertility based on sex hormone analysis.
- raised LH/FSH, low E2: normogonadotropic hypogonadism, e.g. the problem is with the gonads. can include ovarian failure, POI, steroid defect, chemotherapy etc.
- low LH/FSH/E2: hypogonadotropic hypogonadism, e.g. the problem is with the hypothalamus. can include Kallmann syndrome, weight, exercise, anorexia etc.
- low LH/FSH/E2, raised PRL: prolactin-related. can include prolactinoma, PCOS, lactation, or dopamine antagonists
- raised LH/PRL/T: PCOS, or rarely Cushing’s
- low LH/FSH/E2, raised T: androgen excess: can include gonadal or adrenal tumour, CAH etc.
- raised E2/PRL: pregnancy
- normal: anatomical disorder, e.g. uterine/vaginal disorder, imperforate hymen, absent uterus, lack of endometrium
Define premature ovarian insufficiency (POI), and describe its causes, investigation findings, and management.
- the ovaries stop functioning fully before age 40
- aetiologies: autoimmune (fragile X, Turner’s), radio/chemotherapy, infectious (e.g. mumps), autoimmune
- elevated LH/FSH (akin to menopause), reduced E2. FSH should be sampled twice 4-6 weeks apart
- primary disease is rarely treatable, but HRT/COCP is usually given for oestrogen deficiency until the average age of menopause (51) to protect against osteoporosis
– Cluster 3: Menopause –
Define and describe the menopause.
- occurs in all menstruating females due to a non-pathologic oestrogen deficiency
- granulosa cells (oestrogen production) diminish with age, increasing FSH and LH
- average age 51, premature menopause defined as <45
- surgical menopause: hysterectomy with bilateral oophorectomy
- chemical menopause: antioestrogens, chemotherapy
Describe the symptoms associated with menopause.
- vasomotor: hot flashes, night sweats, palpitation, migraine without aura
- urogenital: vaginal atrophy, urethral atrophy (incontinence etc.), sexual dysfunction
- joint aches and pains, dry and itchy skin
- psychogenic: anger/irritability, anxiety, depression, sleep disturbance, loss of self-esteem
- hypertension, weight gain
- decreased height, associated with osteoporosis
Describe the lifestyle management of menopause.
- hot flashes: regular exercise, weight loss, reduction of stress
- sleep disturbance: avoiding exercise in the late evening, good sleep hygiene
- mood: improving sleep, regular exercise, relaxation
- cognitive: regular exercise, good sleep hygiene
What is HRT? What are its indications?
- HRT consists of an oestrogenic compound (replaces reduced levels experienced through menopause), normally combined with a progestogen (if the woman has a uterus, to reduce risk of endometrial cancer)
- main indication is vasomotor symptoms
- HRT is also used in premature menopause to prevent osteoporosis
Describe the side effects and complications of HRT.
- oestrogen: breast enlargement, cramps, dyspepsia, fluid retention, nausea, headaches
- progestogen (similar to PMS): fluid retention, mastalgia, headaches, acne, psychogenic, constipation, increased appetite
- risk of breast cancer, VTE, stroke, ischaemic heart disease, and ovarian cancer is increased related to duration taken
- oestrogen alone increases risk of endometrial cancer; progestogen mitigates this risk
Name the absolute contraindications of HRT.
- suspected pregnancy
- gynae: breast, endometrial cancers
- active liver disease
- cardiovascular: uncontrolled hypertension, known VTE
- known thrombophilia
- otosclerosis
Describe the non-HRT medical management of menopause symptoms.
- vasomotor: SSRIs (fluoxetine, citalopram, venlafaxine)
- vaginal dryness: lubricants, moisturisers (second line: oestrogen cream)
- psychogenic: self-help groups, CBT, SSRIs
Name the causes of vulval pruritis.
- dermatological: eczema, atopic dermatitis, psoriasis, candida
- lichen sclerosus
- lichen planus
- infection: candida, trichomonas
- Extramammary Paget’s disease of the vulva
Describe the appearance, presentation, and management of lichen sclerosus and lichen planus.
- both are chronic inflammatory conditions of unknown aetiology; they are, however, thought to be autoimmune and often co-present with thryoid issues or pernicious anaemia
- pruritis, skin irritation, atrophy (‘parchment paper’ appearance), plaques, fusion of labia, dyspareunia
- as they are similar conditions they are difficult to differentiate; Wickham’s striae are specific for lichen planus
- both are premalignant lesions and may lead to vulvar intraepithelial neoplasia (VIN), meaning biopsy is often used to exclude malignancy
- first-line: topical high-dose steroids and emollients
- second-line: TCIs (e.g. tacrolimus), imiquimod
– Cluster 4: Abdominopelvic pain –
Name the differential for unilateral pelvic pain in the female.
- ectopic pregnancy
- appendicitis
- ovarian torsion, cyst accident, fibroid degeneration
- renal calculi
Name the differential for diffuse pelvic pain in the female.
- miscarriage
- PID, UTI, diverticulitis
- endometriosis
- constipation, IBS, urinary retention
What is the likely diagnosis for a female who experiences sudden unilateral pelvic pain after sexual intercourse or contact sport?
Cyst rupture/accident
– Cluster 4a: Abdominopelvic pain (ectopic pregnancy) –
Define ectopic pregnancy.
- the implantation of a fertilised ovum outside the uterus
- 97% are tubal, with most in the ampulla; isthmus is more dangerous
Name the risk factors associated with ectopic pregnancy.
- damage to the tubes (PID, surgery)
- previous ectopic pregnancy
- endometriosis
- IUCD
- progesterone-only pill
- IVF (3% of IVF pregnancies)
What are the symptoms and signs of ectopic pregnancy?
Symptoms
- pain (constant and unilateral tubal spasm) > bleeding (less than a normal period, may be dark brown)
- dizziness, eclampsia, shoulder tip pain (peritoneal bleeding), dyspnoea
- pallor, haemodynamic instability, peritonism
- red flag: abdominal/pelvic pain requiring opiates
Signs
- abdominal tenderness
- pelvic examination: cervical excitation (cervical motion tenderness)
- vaginal examination: not recommended, as there is an increased risk of rupturing the pregnancy; if performed, however, may demonstrate an adnexal mass
What is pregnancy of unknown location (PUL), and how is it managed?
- a halfway diagnosis of ectopic pregnancy (i.e., not found on any scans)
- M6 model: measurement of progesterone guides follow-up management
- theoretically reveal IU/ectopic pregnancy
- can be managed with methotrexate
Describe the management of ectopic pregnancy.
- acutely unwell: laparoscopic salpingectomy (98% of ectopic pregnancies are in Fallopian tubes)
- stable: manage with methotrexate
- GEM II: adds gefitinib to MTX; may reduce surgery
Describe the types of management of ectopic pregnancy, their associated findings, and the management itself.
- expectant: HCG <1000 and <35mm; no symptoms; manage with close observation and monitor beta-HCG
- medical: HCG <1500 and <35mm; no significant symptoms; manage with methotrexate and follow-up
- intermediate: HCG 1500-5000; offer patient choice of methotrexate and surgery
- surgical: HCG >5000 and/or >35mm; pain and visible foetal heartbeat; managed with either salpingectomy (no risk factors for infertility) or salpingotomy (risk factors for infertility)
– Cluster 4b: Abdominopelvic pain (acute abdomen, gynae)
Describe the clinical features, investigation, and management of Mittelschmerz.
- mid-cycle pain, often sharp pain, little systemic disturbance
- may be recurrent, settles over 24-48hrs
- FBC normal, USS may show
- Mx is conservative: simple analgesics and reassurance
Describe the clinical features, investigation, and management of endometriosis.
- asymptomatic (25%), other pelvic pathology (25%), menstrual irregularity, infertility, pain, deep dyspareunia, subfertility (50%)
- USS shows free fluid; laparoscopy shows lesions; vaginal examination shows tender nodularity in the posterior fornix
- medical management: NSAIDs, paracetamol, COCP, progestogens
- surgical management: removal of lesions, possible colonic/rectal resection
Describe the clinical features, investigation, and management of ovarian torsion.
- sudden onset of deep colicky abdominal pain with vomiting and distress; vaginal examination may reveal adnexal tenderness
- USS: free fluid/classic whirlpool sign
- laparoscopy is both diagnostic and therapeutic. necrotic ovaries need to be removed.
Describe the clinical features, investigation, and management of pelvic inflammatory disease (PID), briefly.
- bilateral lower abdominal pain with vaginal discharge +/- dysuria; fever >38; Fitz-Hugh-Curtis may develop
- pregnancy test usually negative; FBC (leucocytosis), amylase (normal); take high vaginal and urethral swabs
- antibiotics and surgical drainage in the case of pelvic abscess
Describe the presentation of ovarian cyst rupture/haemorrhage.
- unilateral dull ache which may be intermittent, or present only during intercourse (dyspareunia)
- torsion or rupture may lead to severe abdominal pain
- large cysts may cause abdominal swelling or pressure effects on the bladder
Describe the clinical features, investigation, and management of fibroids.
- may be asymptomatic, present with menorrhagia, dysmenorrhoea, intramenstrual pain, subfertility, and/or pressure symptoms (urinary symptoms)
- Ix is with TVUS
- first-line management is Mirena IUS
- additional options include myomectomy, hysterectomy, short-term GnRH agonist (goserelin), or uterine artery embolization
What are the main causes of abnormal uterine bleeding (AUB, aka DUB)?
- uterine: anovulatory cycles, pregnancy, miscarriage, endometritis, polyp, leiomyoma, adenomyosis
- endocrine: PCOS, thyroid disorders, hyper PRL, hormone changes
- bleeding disorders
- hyperplasia, neoplasia
– Cluster 4c: Abdominopelvic pain (ovarian cysts) –
Describe ovarian cysts.
- follicular, luteal, endometriotic, epithelial, mesothelial
- follicular cysts are very common, occurring when menstruation doesn’t
- rarely >5cm, formed of thin-walled granulosa cells
- may cause menstrual disturbance, may bleed/rupture, may cause acute abdomen, may be incidental
Describe the pathology and clinical features of dermoid cysts.
- formed from pluripotent stem cells (germ cells), material can include teeth, sebaceous tissue, thyroid tissue etc.
- may be asymptomatic, pelvic pain, dyspareunia etc.
Regarding a pelvic mass, the pelvis can be split into 4 main compartments. What are these, and what are the main pathologies that can affect each?
- anterior (bladder): bladder tumour, distension
- middle (uterus): fibroids, adenomyosis, carcinoma, sarcoma
- posterior (bowel): bowel tumours, appendiceal mass, hernia, diverticular abscess
- lateral (adnexae): ovarian, tubal mass, hydrosalpinx, ectopic pregnancy
– Cluster 5: Ovarian cancer –
Name the five main categories of ovarian malignancy.
- epithelial (90%): serous (70-80% of these), mucinous, endometrioid, clear cell, Brenner, undifferentiated
- germ cell: mature cystic teratoma (‘dermoid cyst’), immature teratoma (embryonal), dysgerminoma, yolk sac, choriocarcinoma
- stromal: fibroma, thecoma, granulosa, Sertoli, Sertoli-Leydig, steroid
- metastatic
- miscellaneous
Describe the risk and protective factors associated with ovarian cancers.
Risk factors
- genetic: BRCA1/2, TTN, TP53, HNPCC (Lynch syndrome)
- many ovulations (early menarche, late menopause, nulliparity)
- endometriosis
- smoking and obesity
- it was traditionally thought infertility treatments increased risk; recent evidence, however, does not suggest a significant link
Protective factors
- reduced number of ovulations (COCP, pregnancies)
- breastfeeding
- sterilisation
Describe the symptoms associated with ovarian malignancy.
Presentation is notoriously vague. Some symptoms can be remembered by BEAT:
- bloating and distension
– may be associated with ascites +/- pleural effusion
– women >50 with ‘IBS’
- early satiety (eating less, feeling fuller)
- abdominal and pelvic pain
- tell your GP
Others include
- urinary symptoms (e.g. urgency)
- PV bleeding
- diarrhoea
Name the tumour markers that are associated with ovarian cancers.
- CA-125 (produced by mesothelium, increased in mucinous cancers)
- CEA (most useful with CA-125/CEA ratio, suspicious when <25)
- AFP, HCG, LDH
— RESUME EDITING FROM HERE —
Describe the risk of malignancy index (RMI) score used for ovarian cancer risk.
- premenopausal, postmenopausal [1, 3]
- USS findings (multiloculated, solid areas, bilateral, ascites, metastases) [none 0, 1 = 1, >1 = 3]
- serum CA-125 [absolute level]
- RMI = above 3 parameters multiplied
Describe the management options for ovarian cancer.
- staging laparotomy and debulking first used, where abdomen and pelvis are assessed for deposits and allow staging
- early: open hysterectomy, BSO, infracolic omentectomy
- late: radical debulking with aggressive cytoreduction
- neoadjuvant chemo
What is a Kruckenberg tumour?
Has a characteristic signet ring histology which metastasise from the GI tract (usually the stomach).
– Cluster 6: Endometrial cancer –
Describe the classification of endometrial hyperplasia.
- simple: general distribution, dilated glands, normal cytology
- complex: foetal, crowded glands, normal cytology
- atypical: atypical cytology, cancer precursor
Describe the classification of uterine adenocarcinoma.
- type 1: endometrioid, mucinous - unopposed oestrogen, atypical hyperplasia, PTEN, KRAS, PK3CA
- type 2: serous, clear cell - elderly postmenopausal women, more aggressive
How does obesity increase the risk of uterine adenocarcinoma?
- endocrine and inflammatory changes to adipocytes, which express aromatase
- dec. SHBG (inc. free biologically active hormone)
- altered insulin (IGF can then exert effects of the endometrium)
Describe the management options for uterine malignancy, including the complications.
- surgical removal of uterus and cervix, traditionally by open approach
- other options: BSO and/or PLND
- complications: haemorrhage, infection, bladder/bowel problems, DVT/PE, hernias etc.
– Cluster 7: Cervical cancer –
Name and describe the main histological areas of the cervix.
- endocervix (inner): mainly glandular
- ectocervix (outer): squamous epithelium
- transitional zone (squamocolumnar junction): between ecto- and endo-, most likely to be infected by HPV
Describe the categories of pathology affecting the cervix.
- inflammation (cervicitis, follicular, chlamydia, HSV)
- CIN (HPV 16/18, many sexual partners, young at first intercourse etc.)
- condylomata acuminatum (HPV 6/11; thickened papillomatous squamous epithelium with cytoplasmic vacuolisation ‘koilocytosis’)
- cervical cancers (SCC 75-95%, adenocarcinoma 5-25%)
Describe the histological findings and classification of cervical intraepithelial neoplasia (CIN).
- delayed maturation and differentiation (immature basal cells)
- nucleolar hyperchromasia, increased N:C ratio, pleomorphism)
- excess mitotic activity
- CIN I, II, III (basal 1/3, extends to middle 1/3, then full thickness)
Cervical SCC is commonly asymptomatic and is highly preventable by screening. What are the possible presentations?
- AUB (PCB/PMB)
- brownish/blood staining
- contact bleeding due to friable epithelium
- pelvic pain
- haematuria, UTI
- ureteric obstruction, renal failure etc.
Describe the different types of vulvar pathology.
- VIN: usual-type (HPV-driven), dVIN (differentiated, independent of HPV)
- vulvar invasive SCC
- vulvar Paget’s (crusting rash with sharp demarcation, pruritis, and pain). may be primary (intraepithelial glandular) or secondary (colorectal, urothelial)
- candida
- Bartholin gland abscess
- dermatoses (lichen sclerosis, planus, psoriasis)
- vulvovaginal atrophy
Describe the surgical management of cervical cancer.
- stage 1a, 2: LLTEZ, coneloscopy (fertility desired); hysterectomy (family completed)
- stage Ib: trachelectomy (fertility), radical hysterectomy (family completed)
- > stage Ib: chemotherapy
Describe the surgical management of vulvar cancer.
- wide local incision of vulval lesions with 1cm free margin
- if depth >1mm, surgery should involve groin node removal (unilateral / bilateral depending on site)
Regarding public health and cervical pathology:
- who is eligible for screening?
- who is now vaccinated against HPV?
- why are both vaccination and screening required?
- all women or those with a cervix aged 25-64
- girls and boys of school age (12-13); two doses separated by 6 months
- the vaccination (HPV16/18) only offers protection against 70% of cancers, as 30% are not caused by these subtypes
Describe the screening pathway associated with cervical screening.
speculum exam, brush sample of transformation zone, testing for HPV 16/18
- negative: repeat 5y
- positive: perform cytology test
- positive: colposcopy
- negative: repeat screen 12m
Describe the risk factors for prolapse.
female sex, childbirth, forceps delivery, obesity
- stressors (smokers cough, COPD, heavy lifting, constipation)
- Marfan’s, Ehlers-Danlos
Describe the symptoms and classification of uterine prolapse.
- heaviness/pressure, bulging, tissue protrusion, urinary incontinence / retention, splinting, vaginal wall, trouble with bowel movements, dyspareunia
- 1st degree: within the vagina
- 2nd: at the introitus
- 3rd: outside the vagina
- 4th / proincidenta: entirely outside without the vagina
Describe the management options for gynaecological prolapse [3+3].
- lifestyle: weight loss, smoking cessation, avoiding heavy lifting, caffeine reduction etc.
- physiotherapy, pessaries etc.
- surgeries:
- cystocele: anterior colporrhaphy
- rectocele: posterior colporrhaphy
- uterine: sacrospinous fixation, mesh treatment etc.
Regarding ultrasound:
- describe the benefits and difficulties
- describe the two O&G approaches and their differences
[4]
- benefits: cheap and safe (no ionising radiation), very good definition of different pelvic organs and can be used as an adjunct to clinical examination
- difficulties: obesity, gaseous distension, operator dependant
- TA (transabdominal): requires full bladder, good initial view
- TV (transvaginal): requires empty bladder, higher frequency and spatial resolution, can be used to evaluate ovarian volume
Describe the key indications for CT [4], MRI [3], and HSG [1] in O&G disease.
- CT: acute abdomen (after USS), post-surgical complications, staging malignancy, assessing response to cancer treatment
- MRI: cervical cancer staging, evaluation of adnexal masses, subfertility (in conjunction with pituitary MRI)
- HSG (hysterosalpingogram): infertility by tubal patency
