Gynaecology Flashcards
Androgen insensitivity syndrome
X-linked recessive condition caused by a mutation in the androgen receptor gene which results in cells being unable to respond to androgen hormones due to lack of androgen receptors. Extra androgens are converted to oestrogen giving female sexual characteristics. Patients are genetically male. Patients have testes in the abdomen but female external genitalia.
Presentation of androgen insensitivity syndrome
Presents in infancy with inguinal hernias containing testis.
In puberty presents with primary amenorrhoea
Hormone test results for patients with androgen insensitivity syndrome
Raised LH
Normal or raised FSH
Normal or raised testosterone (for a male)
Raised oestrogen levels for a male
Management of androgen insensitivity syndrome
Bilateral orchidectomy
Oestrogen therapy
Vaginal dilators or vaginal surgery
Support and counselling
Typical complications of bicornate uterus
Miscarriage
Premature birth
Malpresentation
Imperforate hymen - what is it? how does it present and diagnosed? how is it treated? complications?
Imperforate hymen is where the hymen at the entrance of the vagina is fully formed without an opening.
Presents with cyclical pain and cramping that would ordinarily be associated with menstruation but without ny vaginal bleeding
Diagnosed on clinical examination
Surgically managed by creating an opening in the hymen.
Complications: can lead to endometriosis
Transverse vaginal septae - what is it? what types are there? how would they present? how is it treated? complications?
Caused by an error in development where a septum forms transversely across the vagina. Septum can be either imperforate or perforate.
If perforate, then girls will still menstruate but can have difficulty with intercourse or tampon use.
If imperforate, it will present similarly to an imperforate hymen with cyclical pain and cramping without menstruation.
Diagnosis is by examination, USS or MRI.
Treatment is surgical.
Complications: vaginal stenosis and recurrence of the septa
Immediate complications of female genital mutilation
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
Long term complications of FGM
Vaginal infections
Pelvic infections
UTIs
Dysmenorrhoea
Sexual dysfunction and dyspareunia
Infertility and pregnancy-related complications
Significant psychological issues and depression
Management of FGM
Report all cases of FGM and refer to FGM specialist.
What is Lichen Sclerosis?
Chronic inflammatory autoimmune skin condition which presents with patches of shiny white skin.
What areas does lichen sclerosis affect?
Labia, perineum and perianal skin in women.
In men, foreskin and glans of penis
How does lichen sclerosis present?
Itching
Soreness and pain - possibly worse at night
Skin tightness
Painful sex
Erosions
Fissures
How would lichen sclerosis appear on the skin?
Porceline-white in colour
Shiny
Tight
Thin
Slightly raised
Management of lichen sclerosis
No cure. Followed up every 3-6 months
Topical steroids are main treatment - OD for 4 weeks.
Emollients as well used regularly
Complications of lichen sclerosis
Squamous cell carcinoma of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings
Bartholin’s Cyst/abscess
Blockage of the bartholin’s glands which are located on either side of the vaginal opening. Ducts can become blocked and cause the glands to swell forming a cyst. Cysts can become infected and form an abscess.
Management of bartholin’s cyst/abscess
Cysts usually resolve
Biopsy may be required to exclude vulval malignancy in women over 40.
Abscess will require antibiotics - swab of pus or fluid can be taken for culture and sensitivity.
Most common cause of bartholin abscess (organism)
E.coli
What is urge incontinence?
Overactivity of the detrusor muscle.
What is stress incontinence?
Due to weakness of the pelvic floor and sphincter muscles which allows urine to lead at times of increased pressure on the bladder.
What is mixed incontinence?
Combination of urge and stress incontinence
What is overflow incontinence?
Occurs when there is chronic urinary retention due to an obstruction to the outflow of urine.
Causes of overflow incontinence
Fibroids, pelvic tumours, neurological conditions such as MS, diabetic neuropathy and spinal cord injuries
Risk factors for urinary incontinence
Increased age
Postmenopausal status
Increased BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions such as MS
Investigations for urinary incontinence
A bladder diary - for at least 3 days
Urine dipstick testing - assess for infection, microscopic haematuria
Post-void residual bladder volume - should be measured using a bladder scan to assess for incomplete emptying
Urodynamic testing
Describe urodynamic testing
Assesses the presence and severity of urinary symptoms.
Catheter inserted into the bladder and another into the rectum to measure the pressures in the bladder and rectum for comparison. The bladder is then filled with liquid and various measures are taken.
Management of stress incontinence
Avoid caffeine, diuretics and overfilling bladder
Weight loss
Supervised pelvic floor exercises at least 3 months before surgery
Surgery
Duloxetine (SNRI)
Management of urge incontinence
Bladder retraining (for at least 6 weeks - first line)
Anticholinergic medication - oxybutinin, tolterodine and solifenacin
Mirabegron
Invasive procedures - Botulism toxin type A, percutaneous sacral nerve stimulation, urinary diversion (involves redirecting urinary flow to a urostomy on the abdomen)
Side-effects of anticholinergics (e.g. oxybutinin, tolterodine and solifenacin)
Dry eyes, dry mouth, urinary retention, constipation and postural hypotension. Cognitive decline, memory problems and worsening dementia
What is a vault prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus. The top of the vagina descends into the vagina.
What is a rectocele? What are they associated with?
Rectoceles are caused by a defect in the posterior vaginal wall which allows the rectum to prolapse forward into the vagina. They are associated with constipation.
What is a cystocele?
Caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
What is a prolapse of both the bladder and urethra called?
Cystourethrocele
Risk factors or pelvic organ prolapse
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and post menopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
How would a pelvic organ prolapse present?
Feeling something coming down the vagina
Dragging or heavy sensation in the pelvis
Urinary symptoms - incontinence, urgency, frequency, weak stream, retention
Bowel symptoms - constipation, incontinence and urgency
Sexual dysfunction - pain, altered sensation and reduced enjoyment
How would you examine someone that has a pelvic organ prolapse?
Use a sim’s speculum to support the anterior and posterior vaginal wall whilst the other vaginal walls are examined. Women can be asked to cough to assess the full descent of the prolapse.
Grading for uterine prolapses
POP-Q - pelvic organ prolapse quantification system
Grade 0 - Normal
Grade 1: The lowest part is more than 1 cm above the introitus
Grade 2: the lowest part is within 1 cm of the introitus (above or below)
Grade 3: the lowest part is more than 1 cm below the intoitus but not fully descended
Grade 4: Full descent with eversion of the vagina
Management options for vaginal prolapses
- Conservative management
- Vaginal pessary
- Surgery
How do you conservatively manage vaginal prolapses and who are they for?
For women with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management includes:
- Physio
- Weight loss
- Treat related symptoms
- Vaginal oestrogen cream
Types of vaginal pessaries
Ring
Shelf
Cube
Donut
Complications of surgery for vaginal prolapse
Pain, bleeding, infection, DVT and anaesthetic risk
Damage to the bladder or bowel
Recurrence of prolapse
Altered experience of sex
What is cervical ectropion?
When the columnar epithelia of the endocervix extends out to the ectocervix
Cervical ectropion presentation?
Most are asymptomatic and found incidentally during speculum examination.
Increased vaginal discharge
Vaginal bleeding
Dyspareunia
Postcoital bleeding
Management of cervical ectropion
Asymptomatic - no treatment required
Problematic bleeding - cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
What is Asherman’s syndrome?
It is when adhesions form within the uterus following damage. Adhesions form physical obstructions and distort the pelvic organs.
What usually causes Asherman’s syndrome?
Pregnancy related dilatation and curettage procedure e.g. from treatment of retained products of contraception.
Uterine surgery or several pelvic infection
Complications of Asherman’s syndrome
Menstruation abnormalities, infertility and recurrent miscarriages.
How would Asherman’s syndrome present?
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
Infertility
How would you diagnose Asherman’s syndrome?
Hysteroscopy (gold-standard)
Hysterosalpingograph (contrast injected into uterus and imaged with x-rays)
Sonohysterography - uterus filled with fluid and a pelvic ultrasound performed
MRI scan
Management of Asherman’s syndrome
Dissecting adhesions during hysteroscopy. Recurrence of adhesions is common.
Ovarian torsion is usually caused by?
ovarian masses larger than 5cm - tumour or cyst.
Why is ovarian torsion more common in in girls prior to menarche?
Because they have longer infundibulopelvic ligaments which can twist more easily
Why is ovarian torsion an emergency?
Twisting of the adnexa (Fallopian tubes and surrounding tissue) and blood supply with cause ischaemia -> necrosis -> emergency
How would ovarian torsion present?
Sudden onset severe unilateral pelvic pain which gets progressively worse and is associated with nausea and vomiting.
What would you find on examination if you suspect ovarian torsion?
Localised tenderness +/- palpable mass
How would you diagnose ovarian torsion?
Pelvic USS (initial investigation of choice)
Transvaginal is ideal -> Whirlpool sign - free fluid in pelvic and oedema around the ovary.
Definitive diagnosis - laparoscopic surgery
How would you manage ovarian torsion?
Laparoscopic surgery to either - untwist the ovary and fix it in place or remove the affected ovary (oophorectomy)
Complications of ovarian torsion
If necrotic ovary is not removed -> it will become infected which will form an abscess and lead to sepsis. It could also rupture causing peritonitis and adhesions
Are ovarian cysts a cause for concern?
In premenopausal women -> no
In postmenopausal women -> yes and warrants further investigations
How would ovarian cysts present?
Most are asymptomatic.
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
What are serous cystadenomas?
Benign tumours of epithelial cells
What are mutinous cystadenomas?
Benign tumours of epithelial cells which can become huge and take up lots of space in the pelvic and abdomen
What are endometriomas?
Lumps of endometrial tissue within the ovary - occurring in patients with endometriosis
What are germ cell tumours?
Dermoid cysts (teratomas) - they contain various tissue types such as skin, teeth, hair and bone
How would you assess whether an ovarian cyst is benign or malignant?
Abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
Risk factors for ovarian malignancy
Age
Post menopause
Increased number of ovulations
Obesity
HRT
Smoking
BRCA1 and BRCA2 genes
Investigations for ovarian cysts
Premenopausal -> USS and no more investigations
Postmenopausal:
Tumour markers: CA124, LDH, AFP. HCG
Causes of raised CA125
Fibroids
Endometriosis
Adenomyosis
Pelvic inflammation
Liver disease
Pregnancy
Management of ovarian cysts
Possible ovarian cancer -> 2 week wait referral
Dermoid cyst - refer to gynae
Simple cyst <5cm - no follow up
5-7cm - will require routine referral to gynae and yearly USS monitoring
>7cm - consider MRI and surgical evaluation
post menopausal women - CA125 result and refer to gynae, if raised -> 2 week wait referral
Simple cyst under 5cm with normal CA125 - USS monitoring every 4-6 months
Complications of ovarian cysts
Torsion
Haemorrhage
Rupture
What is Meig’s syndrome?
PAO!
Triad of:
Ovarian fibroma
Pleural effusion
Ascites
Characteristic features of PCOS
Multiple ovarian cysts
Infertility
Oligomenorrhea
Hyperandrogenism
Insulin resistance
Diagnostic system for PCOS
Rotterdam criteria requires at least two of the three key features:
- Oligoovulation or an ovulation - irregular or absent menstrual periods
- Hyperandrogenism - hirsutism and acne
- Polycystic ovaries on USS
Presentation of PCOS
Oligomenorrhoea or amenorrhoea
Infertility
Obesity
Hirsutism
Acne
Hair loss in a male pattern
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
Investigations for PCOS
Testosterone
LH
FSH
Prolactin
TSH
Pelvic USS. Transvaginal USS is gold standard - ‘string of pearls’ appearance
Management for PCOS
Weight loss
Exercise
Smoking cessation
Complications of PCOS
Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety
How would you manage endometrial cancer risk in women with PCOS?
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3-4 months with either cyclical progestogens or COCP
How would you manage infertility in women with PCOS?
Weight loss.
Clomifene
Laparoscopic ovarian drilling
IVF
Metformin
How would you manage hirsutism in women with PCOS?
Weight loss
COCP
Topical eflornithine (takes 6-8 weeks to see significant improvement)
Laser hair removal
Spironolactone
Finasteride
How would you manage acne in women with PCOS?
COCP (first-line)
Why do you give progesterone to women with uteruses in HRT?
To prevent endometrial hyperplasia and endometrial cancer
What are non-hormonal treatment for menopausal symptoms?
Diet
Exercise
CBT
Clonidine
SSRI (fluoxetine)
Venlafaxine (SNRI)
Gabapentin
What is clonidine and how does it manage menopausal symptoms?
It is an alpha 2 adrenergic receptor agonist. It lowers blood pressure, heart rate and helpful for vasomotor symptoms and hot flushes
Indications for HRT
Replacement of hormones in premature ovarian insufficiency
Reducing vasomotor symptoms - hot flushes and night sweats
Improves symptoms such as low mood, decreased libido, poor sleep and joint pain
Reduces the risk of osteoporosis
Risks of HRT
Increases risk of breast cancer (combined HRT - lower in oestrogen only HRT)
Increased risk of endometrial cancer (without oestrogen)
Increased risk of VTE
Increased risk of stroke
Contraindications for HRT
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled HTN
VTE
Liver disease
Pregnancy
What is premature ovarian insufficiency?
Menopause before the age of 40
Causes of premature ovarian insufficiency
Idiopathic
Iatrogenic - due to chemo, radiotherapy, or surgery
Autoimmune - coeliac, adrenal insufficiency, T1DM, thyroid disease
Genetic
Infections
Presentation of premature ovarian insufficiency
Irregular periods, secondary amenorrhoea
Hot flushes
Night sweats
Vaginal dryness
How would you diagnose premature ovarian insufficiency?
Women <40 years
Typical menopause symptoms
Elevated FSH
Management of premature ovarian insufficiency
HRT
What is menopause?
Lack of periods for 12 months
What would hormonal blood results show in someone experiencing menopause?
Low oestrogen and progesterone
High LH and FSH
Perimenopausal symptoms
Hot flushes
Low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness
Reduced libido
Night sweats
How do you diagnose menopause?
Diagnosis can be made in women over 45 with typical symptoms without performing any investigations
Management of perimenopausal symptoms
No treatment
HRT
Tibolone
Clonidine
CBT
SSRI - fluoxetine
Vaginal oestrogen cream or tablets
What is adenomyosis?
Endometrial tissue inside the myometrium
How does adenomyosis present?
Dysmenorrhoea
Heavy periods
Dyspareunia
1/3 of patients are asymptomatic
How would you diagnose adenomyosis?
Transvaginal USS is first-line investigation
MRI and transabdominal USS are alternatives
Gold standard - histological examination of uterus after hysterectomy
Management of adenomyosis
Women who do not want contraception:
no associated pain - tranexamic acid
associated pain - mefenamic acid
When contraception is wanted:
Mirena (first-line)
COCP
Progestogens
Adenomyosis is associated with:
Infertility
Miscarriage
Preterm birth
Small for gestational age
Malpresentation
Need for Caesarean section
Postpartum haemorrhage
What is endometriosis?
Where there is ectopic endometrial tissue outside the uterus
How does endometriosis present?
Cyclical abdominal pain or pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
What would you find on examination of a patient with endometriosis?
Endometrial tissue visible in the vagina on speculum examination
Tenderness in the vagina, cervix and adnexa
How would you diagnose endometriosis?
Pelvic USS
Laparoscopic surgery is gold standard
Definitive diagnosis can be established with a biopsy
How would you manage endometriosis?
NSAIDS and paracetamol (first-line)
Hormonal management: COCP, POP, depo, implant, mirena coil
Surgical: laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions. Hysterectomy.
What are fibroids made of?
Smooth muscle
Types of fibroids
Pedunculated
Intramural
Subserosal
Submucosal
Presentation of fibroids
Normally asymptomatic
Menorrhoea
Abdominal pain
Bloating
Urinary or bowel symptoms
Deep dyspareunia
Reduced fertility
Investigations of fibroids
Hysteroscopy - submucosal fibroids presenting with heavy menstrual bleeding
Pelvic USS - investigation of choice for larger fibroids
MRI scanning - prior to surgery
Management of fibroids <3cm
<3cm:
Mirena coil (first-line)
Symptomatic management with NSAIDs and tranexamic acid
COCP
Cyclical oral progestogens
Management of fibroids >3 cm
Refer to gynae
Symptomatic - NSAIDs and tranexamic acid
Mirena coil
COCP
Cyclical oral progestogens
Surgical management of large fibroids
Uterine artery embolisation
Myomectomy
Hysterectomy
What can be given prior to surgical removal of fibroids?
GnRH agonists such as goserelin to reduce the size of the fibroid prior to surgery
Placenta praevia - labour options
Women with grade III/IV placenta praevia should be offered an elective caesarean section at 37-38 weeks
