Gynaecology Flashcards
What is Amenorrhoea?
Primary amenorrhoea
Secondary amenorrhoea
refers to a lack of menstrual periods.
Primary amenorrhoea is when the patient has never developed periods
Secondary amenorrhoea is when the patient previously had periods that subsequently stopped
Primary amenorrhoea can be due to
- Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
- Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
- Imperforate hymen or other structural pathology
Secondary amenorrhoea is due to
- Pregnancy (the most common cause)
- Menopause
- Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
- Polycystic ovarian syndrome
- Medications, such as hormonal contraceptives
- Premature ovarian insufficiency (menopause before 40 years)
- Thyroid hormone abnormalities (hyper or hypothyroid)
- Excessive prolactin, from a prolactinoma
- Cushing’s syndrome
Abnormal uterine bleeding or menstral bleeding is due to?
- Extremes of reproductive age (early periods or perimenopause)
- Polycystic ovarian syndrome
- Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
- Medications, particularly progesterone only contraception, antidepressants and antipsychotics
- Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
What is Intermenstrual Bleeding
Intermenstrual bleeding (IMB) refers to any bleeding that occurs between menstrual periods.
Intermenstrual bleeding is a red flag that should make you consider ______ and ________ _____, although other causes are more common.
This is a red flag that should make you consider cervical and other cancers, although other causes are more common.
The key causes of intermenstrual bleeding are:
- Hormonal contraception
- Cervical ectropion, polyps or cancer
- Sexually transmitted infection
- Endometrial polyps or cancer
- Vaginal pathology, including cancers
- Pregnancy
- Ovulation can cause spotting in some women
- Medications, such as SSRIs and anticoagulants
What is Dysmenorrhoea
Dysmenorrhoea describes painful periods.
Causes of Dysmenorrhoea are
- Primary dysmenorrhoea (no underlying pathology)
- Endometriosis or adenomyosis
- Fibroids
- Pelvic inflammatory disease
- Copper coil
- Cervical or ovarian cancer
What is Menorrhagia
Menorrhagia refers to heavy menstrual bleeding
What is the causes of Menorhagia?
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes and hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cance
- Polycystic ovarian syndrome
What is Postcoital Bleeding
Postcoital bleeding (PCB) refers to bleeding after sexual intercourse.
Postcoital Bleeding
is a red flag that should make you consider ________ and _____ _____, although other causes are more common. Often no cause is found.
is a red flag that should make you consider cervical and other cancers, although other causes are more common. Often no cause is found.
Postcoital Bleeding
The key causes are:
- Cervical cancer, ectropion or infection
- Trauma
- Atrophic vaginitis
- Polyps
- Endometrial cancer
- Vaginal cancer
Pelvic Pain Causes
- Urinary tract infection
- Dysmenorrhoea (painful periods)
- Irritable bowel syndrome (IBS)
- Ovarian cysts
- Endometriosis
- Pelvic inflammatory disease (infection)
- Ectopic pregnancy
- Appendicitis
- Mittelschmerz (cyclical pain during ovulation)
- Pelvic adhesions
- Ovarian torsion
- Inflammatory bowel disease (IBD)
g. Excessive, discoloured or foul-smelling discharge may indicate:
- Bacterial vaginosis
- Candidiasis (thrush)
- Chlamydia
- Gonorrhoea
- Trichomonas vaginalis
- Foreign body
- Cervical ectropion
- Polyps
- Malignancy
- Pregnancy
- Ovulation (cyclical)
- Hormonal contraception
What is Pruritus Vulvae
Pruritus vulvae refers to itching of the vulva and vagina.
Pruritus Vulvae Causes
- Irritants such as soaps, detergents and barrier contraception
- Atrophic vaginitis
- Infections such as candidiasis (thrush) and pubic lice
- Skin conditions such as eczema
- Vulval malignancy
- Pregnancy-related vaginal discharge
- Urinary or faecal incontinence
- Stress
What is Endometriosis?
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus
A lump of endometrial tissue outside the uterus is described as an__________. ___________ in the ovaries are often called “chocolate cysts”. ____________ refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
A lump of endometrial tissue outside the uterus is described as an endometrioma. Endometriomas in the ovaries are often called “chocolate cysts”. Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
Causes of Endometriosis?
One notable theory for the cause of ectopic endometrial tissue is that during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity.
- Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue.
- There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer.
- Cells outside the uterus somehow change, in a process called metaplasia, from typical cells of that organ into endometrial cells.
Presentation of endometriosis?
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
- Cyclical abdominal or pelvic pain - main symptom
- Deep dyspareunia (pain on deep sexual intercourse)
- Dysmenorrhoea (painful periods)
- Infertility
- Cyclical bleeding from other sites, such as haematuria
There can also be cyclical symptoms relating to other areas affected by the endometriosis:
- Urinary symptoms- blood in urine
- Bowel symptoms- blood in stool
Examination may reveal:
- Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
Having Endometriosis means you are infertile
TRUE OR FALSE
FALSE- reduced fertility
Diagnosis of Endometriosis?
Pelvic ultrasound may reveal large endometriomas and chocolate cysts
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis.- biopsy
What staging can you use for endometriosis?
American Society of Reproductive Medicine (ASRM)
Initial management for Endometriosis?
Initial management involves:
- Establishing a diagnosis
- Providing a clear explanation
- Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
- Analgesia as required for pain (NSAIDs and paracetamol first line)
Hormonal management for Endometriosis?
- Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
- Progesterone only pill
- Medroxyprogesterone acetate injection (e.g. Depo-Provera)
- Nexplanon implant
- Mirena coil
- GnRH agonists
Surgical management options for Endometriosis?
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
What are Fibroids?
Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas.
They are oestrogen sensitive, meaning they grow in response to oestrogen.
What are different types of fibroids
Explain them
- 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.
Presentation of Fibroids?
Fibroids are often asymptomatic. They can present in several ways:
- Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
- 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
Investigations for Fibroids?
Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
Pelvic ultrasound is the investigation of choice for larger fibroids.
MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
Management for for fibroids less than 3 cm
For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding:
- 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
Surgical options for managing smaller fibroids with heavy menstrual bleeding are:
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are:
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil – depending on the size and shape of the fibroids and uterus
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for larger fibroids are:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
________ _______, such as goserelin (_________) or leuprorelin (_______), may be used to reduce the size of fibroids before surgery.
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.
What is Uterine Artery Embolisation
Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists. The radiologist inserts a catheter into an artery, usually the femoral artery. This catheter is passed through to the uterine artery under X-ray guidance. Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid. This starves the fibroid of oxygen and causes it to shrink.
What is Myomectomy
Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.
What is Endometrial Ablation
Endometrial ablation can be used to destroy the endometrium. Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation. This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus
There are several potential complications of fibroids:
WHat are they?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What is Red Degeneration of Fibroids
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy
Typical presentation of Red Degeneration of Fibroids
Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
WHat is classed as Heavy menstral bleeding
Excessive menstrual blood loss involves more than an 80 ml loss. The volume of blood loss is rarely measured in practice. The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. Heavy menstrual periods can have a significant impact on quality of life.
History of Heavy menstral bleeding
What should you cover?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
When would you NOT do any examinations/Ix with heavy menstral bleeding
straightforward history heavy menstrual bleeding without other risk factors or symptoms, or they are young and not sexually active
Ix for heavy menstral bleeding?
- Pelvic examination with a speculum and bimanual should be performed- This is mainly to assess for fibroids, ascites and cancers.
- Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.
- Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
- Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
- Ferritin if they are clinically anaemic
- Thyroid function tests if there are additional features of hypothyroidism
- Pelvic and transvaginal ultrasound
Management of Heavy Menstral Bleeding
When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Management when contraception is wanted or acceptable:
- Mirena coil (first line)
- Combined oral contraceptive pill
- Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)
What is the most common type of cervical Cancer
squamous cell carcinoma.
Adenocarcinoma is the next most common type.
Very rarely there are other types, such as small cell cancer.
Which virus is cervical ca commonly associated with
human papillomavirus- HPV 16 and 18
____ and ____ are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (___ and ___) that inhibit these tumour suppressor genes.
The___ protein inhibits ___, and the ____ protein inhibits ____. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes.
The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
Risk Factors for Cervical Ca
- Increased risk of catching HPV
- Later detection of precancerous and cancerous changes (non-engagement with screening)
- Other risk factors
Increased risk of catching HPV occurs with:
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
Other Risk Factors
- 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)
Presentation of cervical Ca
- Cervical cancer may be detected during cervical smears in otherwise asymptomatic women.
- The presenting symptoms that should make you consider cervical cancer as a differential are:
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
Ix for Cervical Ca
Speculum + swab - examine cervix
Where there is an abnormal appearance of the cervix suggestive of cancer, an urgent cancer referral for colposcopy should be made to assess further. Appearances that may suggest cervical cancer are:
Ulceration
Inflammation
Bleeding
Visible tumour
Explain the Cervical Intraepithelial Neoplasia grading system?
- CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
- CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
- CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
The cervical screening program involves performing a smear for women (and transgender men that still have a cervix):
Ages
Years
- Every three years aged 25 – 49
- Every five years aged 50 – 64
There are some notable exceptions to the cervical smear programme
- Women with HIV are screened annually
- Women over 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
Infections such as______ _______,________ and________ may be identified and reported on the smear result.
Infections such as bacterial vaginosis, candidiasis and trichomoniasis may be identified and reported on the smear result.
What are the next steps for these smear results
Inadequate sample –
HPV negative –
HPV positive with normal cytology –
HPV positive with abnormal cytology –
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
During Colposcopy what additional things can you do other than look at cervix?
. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas.
Acetic acid causes abnormal cells to appear white. This
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.
A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.
What is a Large Loop Excision of the Transformation Zone (LLETZ)
A large loop excision of the transformation zone (LLETZ) procedure is also called a loop biopsy. It can be performed with a local anaesthetic during a colposcopy procedure. It involves using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix. The electrical current cauterises the tissue and stops bleeding.
Bleeding and abnormal discharge can occur for several weeks following a LLETZ procedure
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer:
Explain the staging
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
The HPV vaccine Gardasil protects against which strains of HPV
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
*
MC Endometrial Cancer
adenocarcinoma
Typical Presentation of Endometrial Cancer
TOM TIP
For your exams, any woman presenting with postmenopausal bleeding has endometrial cancer until proven otherwise. The key risk factors to remember are obesity and diabetes.
is Endometrial Hyperplasia cancerous?
no it is precancerous condition involving thickening of the endometrium
WHat are the two types of endometrial hyperplasia
Hyperplasia without atypia
Atypical hyperplasia
What are RF for endometrial Cancer
- Increased age
- Earlier onset of menstruation
- Late menopause
- Oestrogen only hormone replacement therapy
- No or fewer pregnancies
- Obesity
- Polycystic ovarian syndrome
- Tamoxifen
- Type 2 diabetes
- Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome
What are some protective factors against endometrial cancer
Protective factors against endometrial cancer include:
- Combined contraceptive pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
Presentation of endometrial Cancer
The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding.
Endometrial cancer may also present with:
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Raised platelet count
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia or elevated glucose levels
Ix for Endometrial Cancer
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer:
Explain it
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
Management for endometrial cancer
The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
Other treatment options depending on the individual presentation include:
- A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
- Radiotherapy
- Chemotherapy
- Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Types of Ovarian Cancer
Epithelial Cell Tumours
Dermoid Cysts / Germ Cell Tumours
Sex Cord-Stromal Tumours
Metastasis
What is the common type of Ovarian Epithelial Cell Tumours
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
Are Dermoid Cysts / Germ Cell Tumours benign or malignant
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone.
What are Dermoid Cysts / Germ Cell Tumours commonly associated with
They are particularly associated with ovarian torsion. Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG)
Name some Types of Sex Cord-Stromal Tumours
There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
WHat is A Krukenberg tumour
A 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
Risk factors of Ovarian Cancer
- Age (peaks age 60)
- BRCA1 and BRCA2 genes (consider the family history)
- Increased number of ovulations
- Obesity
- Smoking
- Recurrent use of clomifene
Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:
- Early-onset of periods
- Late menopause
- No pregnancies
Protective Factors for Ovarian Cancer
Combined contraceptive pill
Breastfeeding
Pregnancy
Presentation of Ovarian Cancer
- 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 ________ _____ and cause referred ____ or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
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
Refer directly on a 2-week-wait referral if a physical examination reveals:
- Ascites
- Pelvic mass (unless clearly due to fibroids)
- Abdominal mass
Carry out further investigations before referral in women presenting with symptoms of possible ovarian cancer, starting with a CA125 blood test. This is particularly important in women over 50 years presenting with:
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
Investigations for Ovarian Cancer
- The initial investigations in primary or secondary care are:
- CA125 blood test (>35 IU/mL is significant)
- Pelvic ultrasound
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
- Menopausal status
- Ultrasound findings
- CA125 level
Further investigations in secondary care include:
- CT scan to establish the diagnosis and stage the cancer
- Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
- Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
- Alpha-fetoprotein (α-FP)
- Human chorionic gonadotropin (HCG)
Causes of Raised CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is:
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
Management for Ovarian cancer
Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
What is Adenomyosis
Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). I
Adenomyosis typically presents with:
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
It may also present with infertility or pregnancy-related complications. Around a third of patients are asymptomatic.
Examination can demonstrate an enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.
Diagnosis of Adenomyosis?
- Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
- MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
- The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.
Pregnancy and Adenomyosis
Adenomyosis is associated with:
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
Anovulation refers to
Oligoovulation refers to
Amenorrhoea refers to
Oligomenorrhoea refers to
Androgens are
Hyperandrogenism refers to
Hirsutism refers to
Insulin resistance refers to
Anovulation refers to the absence of ovulation
Oligoovulation refers to irregular, infrequent ovulation
Amenorrhoea refers to the absence of menstrual periods
Oligomenorrhoea refers to irregular, infrequent menstrual periods
Androgens are male sex hormones, such as testosterone
Hyperandrogenism refers to the effects of high levels of androgens
Hirsutism refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
Insulin resistance refers to a lack of response to the hormone insulin, resulting in high blood sugar levels
characteristic features of PCOS
multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance
What is used to make the diagnosis of polycystic ovarian syndrome
Rotterdam Criteria
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Women with polycystic ovarian syndrome present with some key features:
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
PCOS
In addition to the presenting features, women may also experience:
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
Acanthosis nigricans describes thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.
An important feature of polycystic ovarian syndrome is hirsutism. Hirsutism can also be caused by:
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
How is insulin resistance related to PCOS
Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
Diet, exercise and weight loss help reduce insulin resistance.
The NICE clinical knowledge summaries recommend the following blood tests to diagnose PCOS and exclude other pathology that may have a similar presentation:
- Testosterone -raised
- Sex hormone-binding globulin
- Luteinizing hormone-
- Follicle-stimulating hormone
- Prolactin (may be mildly elevated in PCOS)
- Thyroid-stimulating hormone
The key thing to remember for your exams is the raised LH, and the raised LH:FSH ratio.
Pelvic ultrasound is required when suspecting PCOS. A __________ ____ is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a _____ ___ _____ appearance.
Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.
PCOS Pelvic ultrasound
The diagnostic criteria are either:
- 12 or more developing follicles in one ovary
- Ovarian volume of more than 10cm3
Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS.
The screening test of choice for diabetes in patients with PCOS is a….
2-hour 75g oral glucose tolerance test (OGTT).
Results of OGTT
Impaired fasting glucose –
Impaired glucose tolerance –
Diabetes –
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
PCOS
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease. These risks can be reduced by:
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
PCOS
Patients should be assessed and managed for the associated features and complications, such as:
- Endometrial hyperplasia and cancer
- Infertility
- Hirsutism
- Acne
- Obstructive sleep apnoea
- Depression and anxiety
Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30.
Orlistat is a _____ _______ that stops the absorption of fat in the intestines.
Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.
Women with polycystic ovarian syndrome have several risk factors for endometrial cancer:
Obesity
Diabetes
Insulin resistance
Amenorrhoea
Managing Infertility
Weight loss is the initial step for improving fertility. Losing weight can restore regular ovulation.
A specialist may initiate other options where weight loss fails. These include:
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)
PCOS
Managing Hirsutism
Weight loss
Co-cyprindiol (Dianette) is a combined oral contraceptive pill
Topical eflornithine
Other options that may be considered by a specialist experienced in treating hirsutism include:
Electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)
Management of Acne
The combined oral contraceptive pill is first-line for acne in PCOS. Co-cyprindiol may be the best option as it has anti-androgen effects; however, there is a significantly increased risk of venous thromboembolism.
Other standard treatments for acne include:
- Topical adapalene (a retinoid)
- Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
- Topical azelaic acid 20%
- Oral tetracycline antibiotics (e.g. lymecycline)
What is Ovarian Torsion
Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa)
Cause of ovarian torsion
Who does it affect
Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
Ovarian torsion can lead to
Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.
Presentation and Examination findings of ovarian torsion
The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting.
The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.
On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.
Diagnosis of ovarian torsion
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow.
The definitive diagnosis is made with laparoscopic surgery
Ovarian torsion managemtn
Patients need emergency admission under gynaecology for urgent investigation and management. Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.
Ovarian torsion Complications
A delay in treating ovarian torsion can result in loss of function of that ovary. The other ovary can usually compensate, so fertility is not typically affected. Where this is the only functioning ovary, loss of function leads to infertility and menopause.
Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.
What is Asherman’s Syndrome
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
Asherman’s Syndrome
When does it occur
Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
What is Endometrial curettage
Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut.
Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
It may also present with infertility.
Asherman’s Syndrome
There are several options for establishing a diagnosis of intrauterine adhesions:
- Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
- Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
- Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
- MRI scan
Asherman’s Syndrome
Management
Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common
What is Atrophic Vaginitis
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause.
Atrophic vaginitis presents in postmenopausal women with symptoms of:
- Itching
- Dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding due to localised inflammation
You should also consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse. Treatment with topical oestrogen where appropriate may improve the symptoms of these conditions.
Atrophic Vaginitis
Examination of the labia and vagina will demonstrate:
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
Management Atrophic Vaginitis
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen can make a big difference in symptoms. Options include:
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.
What is Bartholin’s Cyst
The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
When the ducts become blocked, the Bartholin’s glands can swell and become tender, causing a Bartholin’s cyst. The swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm.
Cysts can become infected, forming a Bartholin’s abscess. A Bartholin’s abscess will be hot, tender, red and potentially draining pus.
Management
Bartholin’s cysts
Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).
A Bartholin’s abscess will require antibiotics. A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. E. coli is the most common cause. Send specific swabs for chlamydia and gonorrhoea.
Surgical interventions may be required to treat a Bartholin’s abscess. There are two options for surgical management:
- Word catheter (Bartholin’s gland balloon) – requires local anaesthetic
- Marsupialisation – requires general anaesthetic
What is A Word catheter
A Word catheter is a small rubber tube with a balloon on the end. The procedure may be performed by an appropriately experienced person in a treatment room, rather than a theatre. Local anaesthetic is used to numb the area. An incision is made, and any pus is drained from the abscess. The Word catheter is inserted into the abscess space, and inflated up to 3 ml with saline. The balloon fills the space and keeps the catheter in place. Fluid can drain around the catheter, preventing a cyst or abscess reoccurring. The tissue heals around the catheter, leaving a permanent hole. The catheter can be deflated and carefully removed at a later date, once epithelisation of the hole has occurred.
What is Marsupialisation
Marsupialisation involves a general anaesthetic in a surgical theatre. An incision is made, and the abscess is drained. The sides of the abscess are sutured open. Suturing the abscess open allows continuous drainage of the area and prevents recurrence of the cyst or abscess.
What is Lichen sclerosus
Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.
Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as …..
Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.
he diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a ____ _____ can confirm the diagnosis.
he diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis.
What is the difference between Lichen simplex and Lichen planus
Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
Lichen planus is an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae
Lichen Sclerosus Presentation
The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.
Appearance
Lichen Sclerosus
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears:
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
Management Lichen Sclerosus
The management here is based on the 2018 guidelines from the British Association of Dermatologists. Lichen sclerosis cannot be cured, but the symptoms can be effectively controlled. Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist.
Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.
Steroids are initially used once a day for four weeks, then gradually reduced in frequency every four weeks to alternate days, then twice weekly. When the condition flares patients can go back to using topical steroids daily until they achieve good control. A 30g tube should last at least three months.
Emollients should be used regularly, both with steroids initially and then as part of maintenance.
Complications of Lichen Sclerosus
The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.
Other complications include:
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
