Gynaecology Flashcards
What are the presentations of fibroids?
Often asymptomatic
Heavy menstrual bleeding (menorrhagia)
Prolonged menstruation
Abdominal pain (especially when menstruating)
Bloating
Urinary/bowel symptoms (due to pressure on surrounding structures)
Deep dyspareunia
Reduced fertility
What investigations are done with fibroids?
Hysteroscopy –> Initial investigation for submucosal fibroids
Pelvic ultrasound –> Larger fibroids
MRI –> Determine size, shape and blood supply before surgery
What is the management of fibroids less than 3cm?
Same as heavy menstrual bleeding:
Mirena coil (first line)
Manage symptoms –> NSAIDs, tranexamic acid
Combined oral contraceptive pill
Cyclical oral progestogens
Surgical options:
Endometrial ablation
Resection
Hysterectomy
What is the management of fibroids >3cm?
Refer to gynaecology
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil
COCP
Cyclical oral progestogens
Surgical options:
Uterine artery embolisation
Myomectomy
Hysterectomy
What drug can help reduce the size of a fibroid?
Triptorelin (GnRH agonists)
What are possible complications of fibroids?
Heavy menstrual bleeding –> anaemia
Reduced fertility
Miscarriage/premature labour
Constipation
UTI/urinary outflow obstruction
Ischaemia/infarction/necrosis of the fibroid
Malignant change to leiomyosarcoma
What is the difference in significant in ovarian cysts in pre- vs post-menopausal women?
Pre-menopausal = often benign
Post-menopausal = more concerning, potentially malignant, need further investigation
What is the presentation of ovarian cysts?
Mostly asymptomatic and found incidentally
Pelvic pain
Bloating/fullness
Palpable pelvic mass
What are the different types of ovarian cysts?
Follicular cyst = When the follicle fails to rupture and release the egg –> Often disappears after a few menstrual cycles
Corpus luteum cyst = When the corpus luteum fails to break down and fills with fluid –> Seen in early pregnancy
Serous/mucinous cystadenoma = Benign tumour of epithelium
Endometrioma = Lumps of endometrium in the ovary due to endometriosis
Dermoid cyst/germ cell tumour = Benign ovarian tumours
What are the risk factors for ovarian malignancy?
Increasing age
Post-menopausal
Increased number of ovulations (eg. early menarche, late menopause, no Mirena/COCP etc, no pregnancies, infertility treatment)
Obesity
HRT
Smoking
No breastfeeding (breastfeeding is protective)
Family history/BRCA1 and BRCA2 genes
What factors reduce the risk of ovarian cancer?
Later menarche
Early menopause
Any pregnancies
Use of COCP/Mirena
Breastfeeding
What is the management of ovarian cysts?
Raised CA125/complex cyst = 2 week wait
Dermoid cyst = Referral
Simple + <5cm = Self limiting and will most likely resolve
Simple + 5-7cm = Routine referral to gynaecology
Simple + >7cm = MRI/surgical evaluation
What is Meig’s syndrome?
Ovarian fibroma (benign ovarian tumour)
Pleural effusion
Ascites
Removal of tumour resolves symptoms
What is the presentation of ovarian cancer?
Bloating/fullness
Loss of appetite
Pelvic pain
Urinary symptoms
Weight loss
Abdominal/pelvic mass
Ascites
What findings on physical examination would indicate a 2-week-wait referral for suspected ovarian cancer?
Ascites
Pelvic mass (unless clearly due to fibroid)
Abdominal mass
What are the initial investigations in suspected ovarian cancer?
CA125 blood test
Pelvic ultrasound
What are the stages of ovarian cancer?
Stage 1 = Confined to the ovary
Stage 2 = Spread past the ovary but still in the pelvis
Stage 3 = Spread past the pelvis but in the abdomen
Stage 4 = Spread outside abdomen (distant metastasis)
What is the management of ovarian cancer?
Surgery and chemotherapy
What are non-ovarian cancer causes of a raised CA125?
Breast, endometrial and metastatic lung cancer
Adenomyosis
Ascites
Endometriosis
Menstruation
Ovarian torsion
Liver disease
NOT VULVAL CANCER
What is endometrial hyperplasia?
Precancerous condition involving thickening of the endometrium
Risk factors, presentation and investigations are the same as for endometrial cancer
Most cases return to normal over time
What is the management of endometrial hyperplasia?
IUS (Mirena)
Continuous oral progestogens
What are the risk factors for endometrial cancer?
Increase exposure to unopposed oestrogen
Increased age
Early menarche
Late menopause
Oestrogen-only HRT
No/fewer pregnancies
Obesity –> Adipose tissue is a source of oestrogen in post-menopausal women
PCOS
Tamoxifen
Also:
Type 2 diabetes
Lynch syndrome
What factors are protective against endometrial cancer?
COCP
Mirena
Increased pregnancies
Cigarette smoking
What is the presentation of endometrial cancer?
Postmenopausal bleeding –> Endometrial cancer until proven otherwise
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelets
What is the referral criteria for a 2-week-wait referral for endometrial cancer?
Postmenopausal bleeding more than 12 months after last period
What are the investigations for endometrial cancer?
Transvaginal US –> endometrial thickness
Pipelle biopsy
Hysteroscopy with biopsy
What are the stages of endometrial cancer?
Stage 1 = Confined to uterus
Stage 2 = Invades the cervix
Stage 3 = Invades uterus, fallopian tubes, vagina or lymph nodes
Stage 4 = Invades bladder, rectum or beyond
What is the management of endometrial cancer?
Stage 1 + 2 = Total abdominal hysterectomy with bilateral salpingo-oopherectomy
Other options:
Radical hysterectomy (also removing the pelvic lymph nodes, surrounding tissues and top of vagina)
Radiotherapy
Chemotherapy
Progesterone to slow the progression
What is the most common type of cervical cancer?
Squamous cell carcinoma (80%)
What is the most common cause of cervical cancer?
HPV
What are the risk factors for cervical cancer?
Increased risk of catching HPV –> Not using condoms, early sexual activity, increased number of sexual partners
Not engaging with screening
Smoking
HIV
COCP for > 5 years
Increased number of full-term pregnancies
Family history
What is the presentation of cervical cancer?
Detected on smears in asymptomatic women
Abnormal vaginal bleeding
Vaginal discharge
Pelvic pain
Dyspareunia
What are the stages of cervical cancer?
Stage 1 = Confined to cervix
Stage 2 = Invades uterus or upper 2/3 of vagina
Stage 3 = Invades pelvic wall or lower 1/3 of vagina
Stage 4 = Invades bladder, rectum or beyond
What is the management of cervical cancer?
Early stage 1A = Cone biopsy or large loop excision of the transformation zone (LLETZ)
Stage 1B-2A = Radical hysterectomy and removal of local lymph nodes with chemo/radiotherapy
Stage 2B-4A = Chemo/radiotherapy
Stage 4B = Combination of surgery, chemo/radiotherapy and palliative care
What are the risk factors for vulval cancers?
Advanced age
Immunosuppression
HPV infection
Lichen sclerosus
What is the presentation of vulval cancer?
Vulval lump
Ulceration
Bleeding
Pain
Itching
Groin lymphadenopathy
What is the management of vulval cancer?
2 week wait
Biopsy
Excision to remove the cancer
Groin lymph node dissection
Chemo/radiotherapy
What is the presentation of lichen sclerosus?
Vulval itching
Soreness/pain
Skin tightness
Superficial dyspareunia
Erosions
Fissures
Skin changes: Porcelain white colour, shiny, tight, thin, slightly raised
What is the management of lichen sclerosus?
Topical steroids (dermovate)
Emollients
What are the complications of lichen sclerosus?
Squamous cell carcinoma of the vulva
What is the presentation of ovarian torsion?
Sudden onset, severe, unilateral pelvic pain that is constant and gets progressively worse
Nausea and vomiting
What is the initial investigation of choice for ovarian torsion?
Transvaginal US, or abdominal US in TV not possible
“Whirlpool” sign
What is the management of ovarian torsion?
Emergency admission
Laparoscopic surgery to untwist or remove the ovary
What is the diagnostic criteria for polycystic ovarian syndrome?
Rotterdam criteria
At least 2 of:
Oligo/anovulation –> Irregular/absent periods
Hyperandrogenism –> Hirsutism and acne
Polycystic ovaries on US
What do hormonal blood tests typically show in PCOS?
Raised LH
Raised LH:FSH ratio
Raised testosterone
Raised insulin
Normal or raised oestrogen
What is the management of PCOS?
Reduce risk factors –> Weight loss, smoking cessation, exercise, reduce hypertension, lower glycaemic index
Treat complications eg. infertility, hirsutism, acne
What is endometriosis?
A condition where there is ectopic endometrial tissue outside of the uterus
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain (for over 6 months)
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites eg haematuria
What is the gold standard way to investigate and diagnose endometiosis?
Laparoscopic surgery with biopsy
What is the staging of endometriosis?
Stage 1 = Small superficial lesions
Stage 2 = Mild but deeper lesions than stage 1
Stage 3 = Deeper lesions with lesions on the ovaries and mild adhesions
Stage 4 = Deep and large lesions affecting the ovaries with extensive adhesions
What is the management of endometriosis?
Analgesia (paracetamol and NSAIDs)
COCP
POP
Depo injection
Nexplanon implant
Mirena
GnRH agonists
Surgery –> Excision or ablation of the endometrium
Hysterectomy
What is adenomyosis?
Endometrial tissue found in the myometrium
What is the presentation of adenomyosis?
Painful periods
Heavy periods
Dyspareunia
What is the gold standard investigation for adenomyosis?
Histological examination after hysterectomy. However, this is obviously not always a suitable way, so instead transvaginal US (1st line) or abdominal US or MRI are performed
What is the management of adenomyosis?
Management without contraception:
Tranexamic acid if no pain (reduce bleeding)
Mefenamic acid if pain (reduces pain and bleeding)
Management with contraception:
Mirena (1st line)
COCP
Cyclical oral progestogens
How long after the last period can a diagnosis of menopause be given?
12 months
What are the symptoms of perimenopause?
Hot flushes
Emotional lability/low mood
Irregular periods
Joint pains
Heavier/lighter periods than normal
Vaginal dryness
Reduced libido
What is the physiology of the menopause?
At the start of the menstrual cycle, FSH stimulates development of secondary follicles.
As these follicles grow, granulosa cells secrete increasing amounts of oestrogen.
In menopause, there is a decline in the development of ovarian follicles, and therefore reduced oestrogen.
Reduced follicle development means that there is no ovulation.
Reduced oestrogen means that the endometrium doesn’t develop and therefore there is no menstruation.
What conditions are consequences of low oestrogen?
Cardiovascular disease
Stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
What is the management of perimenopausal symptoms?
No treatment –> Likely to resolve after 2-5 years
HRT
CBT
SSRIs
Vaginal oestrogen
What is the presentation of atrophic vaginitis?
Occurs in postmenopausal women
Itching
Dryness
Dyspareunia
Bleeding
What are the management options for atrophic vaginitis?
Vaginal lubricants
Topical oestrogen –> cream, pessary, tablets, ring
What is the genetic cause of androgen insensitivity syndrome?
X-linked recessive condition where androgen receptors do not form properly
How do patients with androgen insensitivity syndrome present?
Genetically male (XY)
Female phenotype externally
Normal female external genitalia but have testes in the abdomen and no uterus, cervix, fallopian tubes or ovaries
What are the results of a hormone test for patients with androgen insensitivity syndrome?
Raised LH
Normal or raised FSH
Normal or raised testosterone
Raised oestrogen levels (for a male)
What is the management of androgen insensitivity syndrome?
Bilateral orchidectomy –> Reduce risk of testicular cancer
Oestrogen therapy
Vaginal dilators/surgery
MDT support including counselling
What is the definition of primary amenorrhoea?
Not starting menstruation by 13 years old when there is no other evidence of pubertal development
OR
Not starting menstruation by 15 years old when there are other signs of puberty eg. breast bud development
What is hypergonadotropic vs hypogonadotropic hypogonadism?
Hypergonadotropic = Lack of a response to LH and FSH by the gonads
Hypogonadotropic = Deficiency in LH and FSH
What are causes of hypogonadotropic hypogonadism (LH/FSH deficiency)?
Hypopituitarism
Hypothalamus/pituitary gland damage
Cystic fibrosis/inflammatory bowel disease
Excessive exercise or dieting
Unexplained delay in puberty
GH deficiency/hypothyroidism/Cushing’s
Kallman syndrome
What are causes of hypergonadotropic hypogonadism (lack of response to LH/FSH)?
Previous damage to gonads
Congenital absense of ovaries
Turner’s syndrome
What is the definition of secondary amenorrhoea?
No menstruation for more than 3 months after previous regular menstrual periods
What are the causes of secondary amenorrhoea?
Pregnancy
Menopause
Premature ovarian failure
Hormonal contraception
Hypothalamic or pituitary pathology
PCOS
Uterine pathology
Thyroid pathology
Hyperprolactinaemia
What is the management of secondary amenorrhoea?
Manage underlying cause
What does amenorrhoea with cyclical pain suggest?
Imperforate hymen
What is the management of an imperforate hymen?
Surgery
What are the causes of menorrhagia?
Extremes of reproductive age
Fibroids
Endometriosis/adenomyosis
Pelvic inflammatory disease
Contraceptive (eg. copper coil)
Anticoagulants
Bleeding disorders
Endocrine disorders
Endometrial hyperplasia/cancer
PCOS
What is the management of menorrhagia?
Exclude underlying pathology
Tranexamic acid –> If don’t want contraception and no pain
Mefenamic acid –> If don’t want contraception and in pain
Mirena (1st line if also want contraception)
COCP
Cyclical oral progestogens
Endometrial ablation
Hysterectomy
What are the presentations of premenstrual syndrome?
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
What is the management of premenstrual syndrome?
General lifestyle changes
COCP
SSRIs
CBT
Transdermal oestrogen patches
When can oestrogen-only HRT by used?
After hysterectomy –> Progesterone only used to prevent endometrial hyperplasia/cancer caused by unopposed oestrogen
What non-hormonal options are available for management of menopausal symptoms?
Lifestyle changes
CBT
Clonidine –> helps vasomotor symptoms and hot flushes
SSRIs
Venlafaxine
Gabapentin
When is HRT indicated?
In premature ovarian insufficiency, even without symptoms
To reduce vasomotor symptoms eg. hot flushes and night sweats
To improve symptoms such as low mood, decreased libido, poor sleep and joint pain
To reduce risk of osteoporosis in women under 60
What are the risks of HRT?
Increased risk of breast cancer
Increased risk of endometrial cancer
Increased risk of VTE
Increased risk of stroke/coronary artery disease
What are contraindications to starting HRT?
Undiagnosed abnormal bleeding
Endometrial hyperplasia/cancer
Breast cancer
Uncontrolled hypertension
VTE
Liver disease
Active angina or MI
Pregnancy
How does HRT delivery differ between women having periods and women not having periods?
Perimenopausal = cyclical HRT
Postmenopausal = Continuous HRT
What is Asherman’s syndrome?
Where adhesions form within the uterus following damage to the uterus
What are some precursors to Asherman’s syndrome?
Removal of retained products of conception
Uterine surgery
Pelvic infection
What is the presentation of Asherman’s syndrome?
Secondary amenorrhoea
Lighter periods
Dysmenorrhoea
Infertility
What investigations are done for Asherman’s syndrome?
Hysteroscopy (gold standard)
Hysterosalpingography
Sonohysterography
MRI
What is the management of Asherman’s syndrome?
Dissecting the adhesion during hysteroscopy
What is the presentation of cervical ectropion?
Post-coital bleeding
No pain
What is cervical ectropion?
Where the columnar epithelium of the endocervix extends to the ectocervix
What are the risk factors for cervical ectropion?
High oestrogen –> COCP, pregnancy
What is a uterine prolapse?
When the uterus descends into the vagina
What is a vault prolapse?
When the top of the vagina descends into the vagina following hysterectomy
What is a rectocele?
A fault in the posterior vaginal wall that allows the rectum to prolapse into the vagina
What is a cystocele?
A defect in the anterior vaginal wall that allows the bladder to prolapse into the vagina
What are the risk factors for pelvic organ prolapses?
Multiple vaginal deliveries
Instrumental/prolonged/traumatic delivery
Advanced age
Obesity
Chronic respiratory disease–> Coughing
Chronic constipation –> Straining
What are the presentations of a pelvic organ prolapse?
Feeling of something coming down
Dragging/heavy sensation
Urinary symptoms (eg. frequency, incontinence, urgency)
Bowel symptoms (eg. constipation, incontinence, urgency)
Sexual dysfunction (eg. pain, altered sensation)
What is the grading system for uterine prolapse?
Grade 0 = Normal
Grade 1 = Lowest part is more than 1cm above the opening of the vagina
Grade 2 = Lowest part is within 1cm (above or below) opening of vagina
Grade 3 = Lowest part is more than 1cm below vaginal opening but not fully descended
Grade 4 = Full descent and eversion of the vagina
What is the management of a uterine prolapse?
Conservative –> physiotherapy, weight loss, lifestyle changes for stress incontinence
Vaginal pessaries –> Ring, shelf, donut etc
Surgery
What is urge incontinence?
Overactivity of the detrusor muscle causes sudden urges to pass urine
What is stress incontinence?
Weakness of the pelvic floor and sphincter muscles allows urine to leak when there is increased pressure on the bladder, eg. when laughing or coughing
What is overflow incontinence?
Chronic urinary retention due to an obstruction to the outflow of urine results in overflow of urine without the urge to pass urine
What are the risk factors for urinary incontinence?
Increased age
Postmenopausal
Increased BMI
Previous pregnancies/vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions eg. MS
Cognitive impairment/dementia
What investigations are done for urinary incontinence?
Bladder diary
Urine dipstick
Post-void residual bladder volume
Urodynamic testing
What is the management for stress incontinence?
Avoid caffeine, diuretics and overfilling bladder
Avoid excessive/restricted fluid intake
Weight loss
Pelvic floor exercises
Surgery
Duloxetine
What is the management of urge incontinence?
Bladder retraining
Anticholinergic medication eg. oxybutynin, solifenacin, tolterodine
Mirabegron (alternative to anticholinergic medication)
Botox injection
Surgery
What is the recall period following different cervical smear results?
Negative and 25-49 = 3 years
Negative and 50-65 = 5 years
Positive = Cytological examination
Positive but cytological examination normal = 12 months
Insufficient test = 3 months
What is the definition of premature ovarian failure?
Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40
What are the causes of premature ovarian failure?
Idiopathic
Bilateral oophorectomy
Radiotherapy
Chemotherapy
Infection eg. mumps
Autoimmune disorders
What are the features of premature ovarian failure?
Hot flushes
Night sweats
Infertility
Secondary amenorrhoea
Raised LH + FSH
Low oestradiol
What is the management of premature ovarian failure?
HRT or COCP until the age of the average menopause
What are the risk factors for breast cancer?
Female
Increased oestrogen exposure (earlier menarche and later menopause, COCP, HRT)
More dense breast tissue
Obesity
Smoking
Family history
What is a ductal carcinoma in situ?
Pre-cancerous/cancerous epithelial cells of the breast ducts that are localised to a single area but have the potential to spread and become invasive.
Often picked up on mammogram
Good prognosis if lump fully excised and adjuvant treatment used
What is lobular carcinoma in situ?
A pre-cancerous condition occurring typically in pre-menopausal women
Usually undetectable on mammogram, diagnosed incidentally on breast biopsy
Managed with close monitoring
What is an invasive ductal carcinoma?
Invasive cancer originating in the breast ducts
Can be detected on mammograms
Around 80% of invasive breast cancers
What is invasive lobular carcinoma?
Invasive breast cancer originating from the breast lobules
Not always visible on mammogram
Around 10% of invasive breast cancers
What is inflammatory breast cancer?
Presents similarly to abscess or mastitis with swelling, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
1-3% of breast cancers
Worse prognosis than other types
What is Paget’s disease of the nipple?
Looks like eczema of the nipple/areola
Erythematous, scaly rash
May represent DCIS or invasive breast cancer
What clinical features suggest breast cancer?
Hard, irregular, painless and/or fixed lumps
Lumps that are tethered to the skin or chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in axilla
What are the most common locations for breast cancer to metastasise to?
Lings
Liver
Brain
Bones
Can spread to any region –> common primary carcinoma for metastasis
What are the symptoms of breast abscess?
Swollen, fluctuant (able to move fluid within the lump), tender lump
Muscle aches
Fatigue
Fever
Sepsis signs
What are the symptoms of non-lactational mastitis?
Nipple changes
Purulent nipple discharge
Localised pain
Tenderness
Warmth
Erythema
Hardening of the skin or breast tissue
Swelling
What is the management of non-lactational mastitis?
Analgesia
Broad spectrum antibiotics (co-amoxiclav OR erythromycin/clarithromycin + metronidazole)
Treat underlying cause (eg. eczema or candidiasis)
What is the management of a breast abscess?
Referral to surgical team
Antibiotics
US
Drainage
Microscopy, culture and sensitivities
What is a fibroadenoma?
Common benign tumours of the stromal/epithelial breast duct tissue
Small and mobile
What are the features of a breast fibroadenoma?
Painless
Smooth
Round
Well-defined border
Firm
Mobile
Up to 3cm diameter
What is the management plan for pelvic inflammatory disease?
Start broad-spectrum antibiotics (doxycycline, metronidazole and IM ceftriaxone) immediately
Leave in a recently inserted coil and monitor any improvement in 48 hours –> if no improvement, remove coil and start other contraception
