Gynaecology Flashcards

Question

What is hypogonadotropic hypogonadism?

Answer 1

deficiency of LH and FSH due to hypothalamic or anterior pituitary dysfunction, leading to deficiency of the sex hormone. This could be due to: - hypopituitarism - damage to hypothalamus or pituitary from radiotherpay/surgery/cancer - significant chronic conditions (e.g. CF/IBD) - Excessive exercising or dieting - constitutional delay in growth and development - endocrine disorders e.g. cushings - kallman syndrome

Answer 2

the gonads fail to respond to stimulation from LH and FSH. Without negative feedback from the sex hormones (oestrogen), the anterior pituitary produces increasing amounts of LH and FSH. Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”). This could be due to: - Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps) - Congenital absence of the ovaries - Turner’s syndrome (XO)

Answer 3

A female has a single X chromosome, making them 45 XO. The O referrs to an empty space where the other X chromosome should be. Presents with: Short stature Webbed neck High arching palate Downward sloping eyes with ptosis Broad chest with widely spaced nipples Cubitus valgus Underdeveloped ovaries with reduced function Late or incomplete puberty Most women are infertile

Answer 4

Recurrent otitis media Recurrent urinary tract infections Coarctation of the aorta Hypothyroidism Hypertension Obesity Diabetes Osteoporosis Various specific learning disabilities

Answer 5

There is no way to treat the underlying genetic cause of Turner syndrome. Treatment aims to help with the symptoms of the condition: 1. Growth hormone therapy can be used to prevent short stature 2. Oestrogen and progesterone replacement can help establish female secondary sex characteristics, regulate the menstrual cycle and prevent osteoporosis 3. Fertility treatment can increase the chances of becoming pregnant Patients need monitoring for the associated conditions and complications.

Answer 6

an X-linked recessive disorder characterised by failure of migration of GnRH cells and anosmia

Answer 7

congenital deficiency of the 21-hydroxylase enzyme causing underproduction of cortisol and aldosterone, and overproduction of androgens from birth. It is a genetic condition inherited in an autosomal recessive pattern. In a small number of cases, it involves a deficiency of 11-beta-hydroxylase rather than 21-hydroxylase. In severe cases, the neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. In mild cases, female patients can present later in childhood or at puberty with typical features: Tall for their age Facial hair Absent periods (primary amenorrhoea) Deep voice Early puberty High levels of 17- hydroxyprogesterone are present in the blood.

Answer 8

cells are unable to respond to androgen hormones due to a lack of androgen receptors. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. It was previously known as testicular feminisation syndrome. There is complete and partial. Partial is less severe with more ambiguous signs such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics

Answer 9

Genetically male with an XY genotype

Answer 10

Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue. Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes. The insensitivity to androgens also results in a lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed.

Answer 11

Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.

Answer 12

Raised LH Normal or raised FSH Normal or raised testosterone levels (for a male) Raised oestrogen levels (for a male)

Answer 13

Specialist MDT - Bilateral orchidectomy (removal of the testes) to avoid testicular tumours - Oestrogen therapy - Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.

Answer 14

If the ovaries are unaffected, there will be typical secondary sexual characteristics, but no menstrual periods. There may be cyclical abdominal pain as menses build up but are unable to escape through the vagina. Structural pathology that can cause primary amenorrhoea include: Imperforate hymen Transverse vaginal septae Vaginal agenesis Absent uterus Female genital mutilation

Answer 15

The threshold for initiating investigations is no evidence of pubertal changes in a girl aged 13. Investigation can also be considered when there is some evidence of puberty but no progression after two years.

Answer 16

1. Initial investigations assess for underlying medical conditions: Full blood count and ferritin for anaemia U&E for chronic kidney disease Anti-TTG or anti-EMA antibodies for coeliac disease 2. Hormonal blood tests assess for hormonal abnormalities: FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism Thyroid function tests Insulin-like growth factor I is used as a screening test for GH deficiency Prolactin is raised in hyperprolactinaemia Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia 3. Genetic testing with a microarray test to assess for underlying genetic conditions: Turner’s syndrome (XO) 4. Imaging can be useful: Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay Pelvic ultrasound to assess the ovaries and other pelvic organs MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

Answer 17

Depends on the cause... - if necessary, replacement hormones can induce menstruation and puberty - constitutional delay may just need observation - if it is due to stress/ED then they need CBT, stress reduction and healthy weight gain - if it's an underlying condition then treatment of that cause needs optimisation - in hypogonadotropic hypogonadism, pulsatile GnRH can induce ovulation and menstruation. If pregnancy is not wanted then COCP can induce menstruation and prevent symptoms of oestrogen deficiency - COCP can also be used with ovarian causes

Answer 18

no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.

Answer 19

1. Pregnancy is the most common cause 2. Menopause and premature ovarian failure 3. Hormonal contraception (e.g. IUS or POP) 4. Hypothalamic or pituitary pathology 5. Ovarian causes such as polycystic ovarian syndrome 6. Uterine pathology such as Asherman’s syndrome 7. Thyroid pathology 8. Hyperprolactinaemia

Answer 20

- High prolactin levels act on the hypothalamus to prevent the release of GnRH. - Without GnRH, there is no release of LH and FSH. - This causes hypogonadotropic hypogonadism. NB only 30% of women with a high prolactin level will have galactorrhea (breast milk production and secretion). The most common cause is a pituitary adenoma secreting prolactin. A CT or MRI scan of the brain is used to assess for a pituitary tumour. Often there is a microadenoma that will not appear on the initial scan, and follow up scans are required to identify tumours that may develop later. Often no treatment is required for hyperprolactinaemia. Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production. These medications treat hyperprolactinaemia, Parkinson’s disease and acromegaly.

Answer 21

1. Pregnancy test 2. LH and FSH 3. Prolactin 4. TSH + T3+4 5. Testosterone

Answer 22

High FSH suggests primary ovarian failure High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome

Answer 23

polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.

Answer 24

Management of secondary amenorrhoea involves establishing and treating the underlying cause. Where necessary, replacement hormones can induce menstruation and improve symptoms. Patients with amenorrhoea associated with low oestrogen levels are at risk increased risk of osteoporosis. Where the amenorrhoea lasts more than 12 months, treatment is indicated to reduce the risk of osteoporosis: Ensure adequate vitamin D and calcium intake Hormone replacement therapy or the combined oral contraceptive pill

Answer 25

Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen. RFs: - Previous ectopic pregnancy - Previous pelvic inflammatory disease - Previous surgery to the fallopian tubes - Intrauterine devices (coils) - Assisted conception - Older age - Smoking

Answer 26

1 in 90 pregnancies are ectopic

Answer 27

It typically presents around 6-8 weeks gestation Missed period Constant lower abdominal pain in the right or left iliac fossa Vaginal bleeding/Prune juice coloured discharge Lower abdominal or pelvic tenderness Cervical motion tenderness (pain when moving the cervix during a bimanual examination) Dizziness/Syncope (blood loss) Shoulder tip pain (peritonitis) On examination - cervical excitation and/or adnexal tenderness

Answer 28

the patient may also be haemodynamically unstable (pallor, increased capillary refill time, tachycardia, hypotension), with signs of peritonitis (abdominal rebound tenderness and guarding). Vaginal examination may reveal fullness in the pouch of Douglas.

Answer 29

1. pregnancy test 2. transabdominal USS, if no intrauterine pregnancy seen then offer transvaginal 3. if positive preganancy test but no uterine pregnancy then this is a pregnancy of unknown location meaning it is a very early intrauterine pregnancy, a miscarriage or an ectopic pregnancy 4. in this scenario a serum beta HCG should be taken

Answer 30

- non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” - adnexal mass that moves separately to the ovary. Sensitivity of 87-99%. Do not confuse with corpus luteum which moves with the ovary - In 20% of cases a pseudosac may be seen as fluid within the uterine cavity - Free fluid may be seen but is not diagnostic of an ectopic pregnancy - If there's been a miscarriage then a gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.

Answer 31

If there is no intrauterine pregnancy on transvaginal ultrasound, then this should be considered an ectopic pregnancy until proven otherwise, and a diagnostic laparoscopy should be offered.

Answer 32

if the patient is stable, a further blood test can be taken 48 hours later: - In a viable pregnancy, HCG level would be expected to double every 48 hours. - In a miscarriage, HCG level would be expected to halve every 48 hours - Where the increase or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded and the patient should be managed accordingly.

Answer 33

an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.

Answer 34

ectopic pregnancy. When this happens the patient needs close monitoring and review.

Answer 35

a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

Answer 36

It must be terminated as it is not a viable pregnancy. Options: 1. Expectant management (awaiting natural termination) 2. Medical management (methotrexate) 3. Surgical management (salpingectomy or salpingotomy)

Answer 37

Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l

Answer 38

Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 5000 IU / l Confirmed absence of uterine pregnancy on ultrasound If a woman fits the criteria she will receive an IM dose of methrotrexate

Answer 39

Contraindications include thrombocytopaenia, hepatic or renal dysfunction, immunocompromised, breastfeeding and peptic ulcer disease

Answer 40

The serum β-HCG level is monitored regularly to ensure the level is declining (by >15% in day 4-5). If there isn’t such a decline, a repeat dose is administered.

Answer 41

Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long. Common side effects of methotrexate include: Vaginal bleeding Nausea and vomiting Abdominal pain Stomatitis (inflammation of the mouth)

Answer 42

Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management. This include those with: Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l

Answer 43

Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube. Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed. There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy. NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.

Answer 44

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.

Answer 45

An untreated ectopic pregnancy can lead to fallopian tube rupture. The resulting blood loss can cause hypovolaemic shock, resulting in organ failure and death.

Answer 46

Structural = PALM = Polyp, Adenomyosis, Leiomyoma (Fibroid) and Malignancy & hyperplasia Non-structural = COEIN = Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 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 cancer Polycystic ovarian syndrome

Answer 47

- age (more likely at menarche and approaching the menopause) - obesity There are also other risk factors that relate to the specific causes of HMB. One example would be previous caesarean section – as a risk factor for adenomyosis.

Answer 48

- Bleeding during menstruation deemed to be excessive for the individual woman. - Fatigue - SOB (if associated anaemia) - A menstrual cycle history should be taken - Date of LMP - Intermenstrual bleeding and post coital bleeding - Smear history - Contraception, medical history and medications - Sexual history - Possibility of pregnancy - Plans for future pregnancies - Cervical screening history - Migraines with or without aura (for the pill)

Answer 49

Examination of the patient should include a general observation, abdominal palpation, speculum and bimanual examination. - Pallor (anaemia) - Palpable uterus or pelvic mass - Try to ascertain if the uterus is smooth or irregular (fibroids) - A tender uterus or cervical excitation point toward adenomyosis/endometriosis - Inflamed cervix/cervical polyp/cervical tumour - Vaginal tumour

Answer 50

1. Urine pregnancy test 2. FBC 3. Other bloods to consider = TFT, hormones for pcos, coag + vWF 4. Pelvic US - transvaginal 5. Cervical smear - don't need to if up to date 6. High vaginal and endocervical swabs 7. Pipelle endometrial biopsy: Indications for biopsy include persistent intermenstrual bleeding, >45 years old, and/or failure of pharmacological treatment. 8. Hysteroscopy and endometrial biopsy: Typically performed when ultrasound identifies pathology, or is inconclusive.

Answer 51

1. Exclude underlying pathology 2. Treatment depends on whether woman wants contraception: If she does not want contraception: - Tranexamic Acid and Mefanamic Acid during menstruation If she does: - Mirena IUS - COCP - Cyclical oral progestogens - POP, Depo, Implant

Answer 52

1. Pharmacological: gonadotrophin-releasing hormone (GnRH) analogues (induce hypogonadal state). Use of GnRH analogues is reserved for specialists and may be a bridge to other therapies. 2. Surgical: endometrial ablation, hysterectomy. Uterine artery embolization and myomectomy can be used for fibroids.

Answer 53

1. Failure of medical therapy 2. Need for surgery 3. Iron-deficiency anaemia not responding to medical therapy 4. Cancer red flags: - Persistent intermenstrual or post-coital bleeding - Unexplained vulval lump or vulval ulceration and bleeding - Palpable abdominal mass that is not obviously a fibroid - Clinical features of cervical cancer

Answer 54

Uterine fibroids (leiomyomas) are benign smooth muscle tumours of the uterus. They are the most common benign tumours in women, with an estimated incidence of 20-40%. The risk of a fibroid becoming malignant is 0.1%.

Answer 55

Benign smooth muscle tumours coming from the myometrium. Poor understanding but growth is thought to be stimulated by oestrogen. - Intramural (most common) – confined to the myometrium of the uterus. - Submucosal – develops immediately underneath the endometrium of the uterus, and protrudes into the uterine cavity. - Subserosal – protrudes into and distort the serosal (outer) surface of the uterus. They may be pedunculated (on a stalk).

Answer 56

Obesity Early menarche Increasing age Family history- Women with a 1st degree relative affected carry a 2.5x increased risk. Ethnicity- African-Americans are 3x more likely to develop fibroid than Caucasians. Pregnancy and Progestogen only contraception seem to reduce risk

Answer 57

- Often asymptomatic - 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 (frequency or retention) - Deep dyspareunia (pain during intercourse) - Reduced fertility

Answer 58

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. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy. Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia. Rarely, pedunculated fibroids can undergo torsion.

Answer 59

A solid mass or enlarged uterus may be palpable on abdominal or bimanual examination. The uterus is usually non-tender.

Answer 60

Endometrial polyp Ovarian tumours Leiomyosarcoma – malignancy of the myometrium. Adenomyosis – presence of functional endometrial tissue within the myometrium.

Answer 61

1. Transvaginal Pelvic ultrasound - the main reason for requesting a pelvic ultrasound is identification of a pelvic mass or menorrhagia that is not responsive to conventional treatment. Gold - Pelvic MRI +/- hysteroscopy. MRI is usually reserved for operative planning or complicated cases to differentiate from other diagnoses Can also do bloods for FBC - anaemia

Answer 62

Depends on HPC which is usually HMB so you would do: 1. Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus 2. Symptomatic management with NSAIDs and tranexamic acid 3. Combined oral contraceptive 4. Cyclical oral progestogens

Answer 63

- GnRH analogues (goserelin (Zoladex) or leuprorelin (Prostap)) suppress ovulation, inducing a temporary menopausal state. They are useful pre-operatively to reduce fibroid size and lower complications. Can be used for 6 months only, due to the risk of osteoporosis - Selective Progesterone Receptor Modulators (Ulipristal / Esmya) reduce size of fibroid and menorrhagia so they are useful pre-operatively or as an alternative to surgery. Use of Ulipristal is restricted due to risk of severe liver injury.

Answer 64

- Hysteroscopy and Transcervical Resection of Fibroid (TCRF) is useful for submucosal fibroids - Myomectomy is an option in women wanting to preserve their uterus and can potentially improve fertility - Uterine Artery Embolization (UAE) Performed by a radiologist via the femoral artery - Commonly causes pain and fever post-operatively - Hysterectomy Endometrial ablation can be used for small fibroids

Answer 65

Pregnancy-related complications: - Infertility (distortion of uterine cavity) - Miscarriage - Malpresentation - Placental abruption - Intrauterine growth restriction - Preterm or obstructed labour - Red degeneration Non-pregnancy-related complications: - Prolapsed fibroid - Constipation, urinary obstruction or UTIs - Anaemia from HMB - Endocrine effects (polycythaemia, hypercalcaemia, hyperprolactinaemia) - Torsion - Malignant change

Answer 66

a chronic condition in which endometrial tissue is located at sites other than the uterine cavity. It can occur in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs. Around 2 million women in the UK are affected, with most diagnoses made between the ages 25 and 40.

Answer 67

This is not fully understood but there are some theories: 1. Retrograde menstruation: endometrial cells travel backwards from the uterine cavity, through the Fallopian tubes, and deposit on pelvic organs – where they can seed and grow. It has also been suggested that these cells may also be able to travel to distant sites through the lymphatic system and vasculature. Other theories: - 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. - Spread through lymphatic system, in a similar way to the spread of cancer. - Metaplasia, from typical cells of that organ into endometrial cells.

Answer 68

Early menarche Late menopause Nulliparity Delayed childbearing Short menstrual cycle Family history White ethnicity

Answer 69

Main Sx is cyclical pelvic pain (but may be constant if adhesions have formed) Other Sx = dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficult, painful defecating), bleeding from other sites e.g. haematuria and subfertility.

Answer 70

A fixed, retroverted uterus Uterosacral ligament nodules General tenderness Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix

Answer 71

- Pelvic Inflammatory Disease: This can present with dyspareunia, pelvic pain and abnormal and/or heavy bleeding. - Ectopic pregnancy: This can present with dyspareunia, pelvic pain and abnormal and/or heavy bleeding, and sometimes collapse. - Fibroids: This can present with pelvic pain, long duration of menstrual bleedings, heavy menstrual bleeding, a feeling of a mass or bloating. - Irritable Bowel Syndrome: abdominal pain, dyspareunia and bloating.

Answer 72

1. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy. Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

Answer 73

Chocolate cysts Adhesions Peritoneal deposits A skilled operator can demonstrate “kissing ovaries” – where bilateral endometrioma are adherent together. Pelvic mobility can be demonstrated, including any involvement of bowel.

Answer 74

American Society of Reproductive Medicine: 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 NICE guidelines do not use this, just recommend detailed documentation

Answer 75

- manage pain using the analgesic ladder - Hormonal management -COCP which can be used back to back without a pill-free period if helpful, POP, Medroxyprogesterone acetate injection (e.g. Depo-Provera), Nexplanon implant, Mirena coil, GnRH agonists - Surgical - Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) or Hysterectomy. It will almost always relapse after surgery.

Answer 76

The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore, treatment options are based on stopping ovulation.

Answer 77

GnRH agonists induce a menopause-like state. e.g. goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.

Answer 78

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.

Answer 79

Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus.

Answer 80

10% - It may occur alone, or alongside endometriosis or fibroids. High parity Uterine surgery e.g. any endometrial curettage, endometrial ablation Previous caesarean section Hereditary occurrence has been reported, suggesting a potential genetic predisposition

Answer 81

Occurs when the endometrial stroma (connective/supporting tissue) is allowed to communicate with the underlying myometrium after uterine damage. Such interaction may occur in association with Pregnancy and childbirth & Uterine surgery (e.g dilation+ curettage).

Answer 82

It can be focal or diffuse and is more commonly found in the posterior wall of the uterus. The extent of invasion is variable, but in severe cases pockets of menstrual blood can be seen in the myometrium of hysterectomy specimens.

Answer 83

When a collection of endometrial glands form grossly visible nodules, they are described as an adenomyoma. Oestrogen, progesterone and androgen receptors are found in the ectopic endometrial tissue, making it responsive to hormones.

Answer 84

- Painful periods (dysmenorrhoea) - Heavy periods (menorrhagia) - Irregular bleeding - Pain during intercourse (dyspareunia) - It may also present with infertility or pregnancy-related complications. - Around a third of patients are asymptomatic. NB. The dysmenorrhoea is commonly progressive; beginning as cyclical pain, but can worsen to daily pain.

Answer 85

On examination (abdominal and bimanual palpation), a symmetrically enlarged tender uterus may be palpable. It will feel more soft than a uterus containing fibroids. "Boggy uterus"

Answer 86

1. Transvaginal ultrasound of the pelvis 2. 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. Potential for hysteroscopic biopsy.

Answer 87

- a globular uterine configuration - poor definition of the endometrial-myometrial interface - myometrial anterior-posterior asymmetry - intramyometrial cysts - heterogeneous myometrial echo texture

Answer 88

‘endo–myometrial junctional zone’ that can be distinguished from the endometrium and outer myometrium. An irregular thickening of this zone is now recognised as the hallmark of adenomyosis

Answer 89

The only curative therapy is hysterectomy

Answer 90

Same as for endometriosis - Tranexamic and Mefenamic acid - Hormonal = COCP, Progestogens (oral or Intrauterine system e.g. Mirena), GnRH agonists, aromatase inhibitors

Answer 91

In the UK, uterine artery embolisation can be used as an alternative treatment option in the short and medium term for women who wish to avoid hysterectomy and or preserve their fertility. The aim is to block the blood supply to the adenomyosis, causing it to shrink. Other treatment options include endometrial ablation and resection, laparoscopic excision and magnetic resonance–guided focused ultrasound.

Answer 92

Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Answer 93

benign growths protruding from the inner surface of the cervix. They are typically asymptomatic, but a very small minority can undergo malignant change. 2-5% of women

Answer 94

Cervical polyps develop as a result of focal hyperplasia of the columnar epithelium of the endocervix. The aetiology is unclear, but suggested causes are: Chronic inflammation Abnormal response to oestrogen (cervical polyps are associated with endometrial hyperplasia) Localised congestion of the cervical vasculature

Answer 95

They are more common in multigravidae, with a peak in incidence between 50 and 60 years of age.

Answer 96

- often asymptomatic, identified only via routine cervical screening. - most common clinical feature is abnormal vaginal bleeding. This can be in the form of menorrhagia, or intermenstrual, post-coital, or post-menopausal bleeding. - can also cause increased vaginal discharge. - Rarely, they grow large enough to block the cervical canal, causing infertility.

Answer 97

On speculum examination, cervical polyps are usually visible as polypoid growths projecting through the external os. It can be confused with endometrial polyp – which could be projecting through cervical canal.

Answer 98

- Triple swabs – endocervical and high vaginal swabs should be taken - Cervical smear – to rule out cervical intraepithelial neoplasia (CIN) - Definitive = histology after removal of the polyp

Answer 99

Approximately 27% of women with cervical polyps have associated endometrial polyps. Especially the post-menopausal age group. If symptoms of bleeding persist after removal of the polyp, an ultrasound scan should be arranged to assess the endometrial cavity.

Answer 100

Cervical polyps have a small (less than 0.5%) risk of malignant transformation – and so it is common practice to remove them whenever they are identified (even if asymptomatic).

Answer 101

- GP - polypectomy forceps+ twist so it is avulsed as the pedicle becomes twisted. The polyp should not be pulled off as it will result in more bleeding. Any resulting bleeding can be cauterised with silver nitrite. - 2nd care - Larger polyps, or those that are more difficult to access can be removed by diathermy loop excision in the colposcopy clinic, or under general anaesthesia if the base of the polyp is broad. Any excised polyps should be sent for histological examination to exclude malignancy. They have a recurrence rate of 6-12%.

Answer 102

Infection, haemorrhage and uterine perforation (rare) - in outpatients setting only remove the ones you can actually see

Answer 103

there is eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu. It is also known as a cervical erosion, although no “erosion” of cells actually occurs.

Answer 104

commonly seen on examination of the cervix in adolescents, in pregnancy, and in women taking oestrogen containing contraceptives.

Answer 105

the more proximal, and ‘inner’ part of the cervix. It is lined by a mucus-secreting simple columnar epithelium.

Answer 106

the part of cervix that projects into the vagina. It is normally lined by stratified squamous non-keratinised epithelium.

Answer 107

the presence of everted endocervical columnar epithelium on the ectocervix

Answer 108

The columnar epithelium contains mucus-secreting glands, and thus some individuals with cervical ectropion experience increased vaginal discharge. It may also give rise to post-coital bleeding, as the fine blood vessels present within the epithelium are easily broken during intercourse.

Answer 109

Oestrogen: COCP Pregnancy Adolescence Menstruating age (it is uncommon in post-menopausal women)

Answer 110

Asymptomatic, post-coital bleeding, intermenstrual bleeding, dyspareunia or excessive discharge (non-purulent).

Answer 111

On speculum examination, there will be a well-demarcated border between the redder, velvety everted columnar epithelium extending from the external os, and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone.

Answer 112

cervical cancer, cervical intraepithelial neoplasia, cervicitis (inflammation of the cervix, typically caused by infection), and pregnancy

Answer 113

The border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination). When the transformation zone is located on the ectocervix, it is visible during speculum examination as a border between the two epithelial types.

Answer 114

Usually a clinical diagnosis based on examination. You can do the following to rule out other things: - Pregnancy test - Triple swabs – suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken - Cervical smear – to rule out cervical intraepithelial neoplasia. If a frank lesion is observed, a biopsy should be taken (note that biopsies are not performed as routine).

Answer 115

Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.

Answer 116

cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy. This will result in significant vaginal discharge until healing is completed. Medication to acidify the vaginal pH has been suggested, such as boric acid pessaries.

Answer 117

A cyst is a fluid-filled sac. Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women. The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.

Answer 118

Nulliparity Early menarche Late menopause Hormone replacement therapy containing oestrogen only Smoking Obesity Asbestos IVF Positive FHx BRCA1&2 Lynch II Syndrome

Answer 119

Multiparity Combined contraceptive methods Breastfeeding

Answer 120

Ovarian cancers are believed to derive from surface epithelial irritation during ovulation. Therefore, the more ovulations that take place, the increased risk of developing malignancy

Answer 121

BRCA 1&2 and Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)

Answer 122

these mutations increase the risk of breast and ovarian cancers. Ovarian cancer risk is as much as 46% at age 70 in BRCA1 positive families and 12% in BRCA2. Prophylactic bilateral salpingo-oophorectomy can be performed in these patients however this does not completely eradicate the risk of developing malignancy. BRCA 1 is chromosome 17, 2 is chromosome 13

Answer 123

RMI = U x M x CA125 U is ultrasound features and M is menopausal status RMI >250 should be referred to gynae specialist

Answer 124

Most asymptomatic Pelvic pain Bladder and bowel (freq+constipation) Bloating Fullness in the abdomen PV bleeding A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst Look out for red flags like weight loss

Answer 125

Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.

Answer 126

Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy.

Answer 127

Follicular and non-neoplastic cysts

Answer 128

Endometriomas, Polycystic Ovaries and Theca Lutein Cysts

Answer 129

These are also called chocolate cysts and are present in those with endometriosis. There has been bleeding into the cyst resulting in the appearance.

Answer 130

An ultrasound diagnosis. The ovaries contrain more than 12 antral follicles, or ovarian volume greater than 10ml. The classic ‘ring of pearls’ sign is seen on ultrasound scanning. PCO is present as one of the features of polycystic ovarian syndrome (Rotterdam criteria criteria). Isolated PCO does not equate to PCOS.

Answer 131

These result as a consequence of markedly raised hCG e.g. molar pregnancy. They regress upon resolution of the raised hCG.

Answer 132

Epithelial, Benign Germ Cell tumours and sex cord stromal tumours

Answer 133

Serous cystadenoma – reflects the most common type of malignant ? ovarian tumour and is usually unilocular with up to 30% being bilateral. Mucinous cystadenoma – these are often multiloculated and usually unilateral. Brenner tumour – unilateral with a solid grey or yellow appearance.

Answer 134

Mature cystic teratoma (Dermoid cysts) – 10% are bilateral, usually occur in young women and occur frequently in pregnancy. As germ cell in origin they can contain teeth, hair, skin and bone.

Answer 135

These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours. Fibroma is the most common stromal tumour. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.

Answer 136

Ultrasound - TV or Abdo

Answer 137

Premenopausal <5cm watch and wait 5-7 cm gynae referral and yearly scan >7cm surgery Postmenopausal CA125 tumour marker and gynae referral

Answer 138

No further investigations

Answer 139

Need to investigate incase there is a germ cell tumour: Lactate dehydrogenase (LDH) Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 140

glycoprotein and tumour marker for epithelial cell ovarian cancer. Not very specific and can be raised by various things. Non-malignant causes include endometriosis, fibroids, adenomyosis, pelvic infection, liver disease and pregnancy.

Answer 141

Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Answer 142

Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).

Answer 143

High RMI (over 250): referral for staging laparotomy

Answer 144

Meig’s syndrome involves a triad of: Ovarian fibroma (a type of benign ovarian tumour) Pleural effusion Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

Answer 145

characterised by Psammoma bodies

Answer 146

characterised by mucin vacuoles

Answer 147

- Surgery – staging laparotomy for those with a high RMI with attempt to debulk the tumour. - Adjuvant chemotherapy – recommended for all patients apart from those with early, low grade disease and uses platinum based compounds. - Follow up – involves clinical examination and monitoring of CA125 level for 5 years with intervals between visits becoming further apart according to risk of recurrence.

Answer 148

Epithelial (serous is the most common within this and then endometrioid)

Answer 149

Germ cell tumours: most common non-epithelial ovarian cancer, and is a common cause of ovarian cancer in patients younger than 35

Answer 150

Abdominal distension Early satiety (feeling full earlier than normal) Anorexia Change in bowel habit Abnormal or postmenopausal bleeding Pelvic or abdominal pain Urinary urgency Urinary frequency Weight loss Ascites Pelvic mass NB. because ovarian cancer can be diagnosed very late, some patients may present with complications e.g. bowel obstruction, DVT, paraneoplastic syndrome, torsion or lung mets

Answer 151

Ascites and/or A pelvic or abdominal mass (which is not obviously uterine fibroids)

Answer 152

Polycystic ovary syndrome (PCOS) is a common endocrine disorder, characterised by menstrual disruption and excess androgen production and the presence of multiple immature follicles (“cysts”) within the ovaries.

Answer 153

Excess luteinising hormone (LH) – produced by the anterior pituitary gland in response to an increased GnRH pulse frequency, this stimulates ovarian production of androgens. Insulin resistance – resulting in high levels of insulin secretion. This suppresses hepatic production of sex hormone binding globulin (SHBG), resulting in higher levels of free circulating androgens. Despite the high levels of LH, the increased circulating androgens suppress the LH surge (which is required for ovulation to occur). Follicles develop within the ovary, but are arrested at an early stage (due to the disturbed ovarian function) – and they remain visible as “cysts” within the ovary.

Answer 154

diabetes, irregular menstruation and/or a family history of PCOS

Answer 155

Oligo/amenorrhoea Infertility/sub-fertility Acne Hirsutism Obesity Sleep apnea Anxiety/depression Hirsutism Obesity Male pattern baldness Acanthosis nigricans

Answer 156

A diagnosis requires at least two of the three key features: 1. Oligoovulation or anovulation, presenting with irregular or absent menstrual periods 2. Hyperandrogenism, characterised by hirsutism and acne 3. Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Answer 157

Insulin resistance and diabetes Acanthosis nigricans Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia and cancer Obstructive sleep apnoea Depression and anxiety Sexual problems

Answer 158

- Hypothyroidism – obesity, hair loss and insulin resistance. - Hyperprolactinaemia – oligomenorhoea/amenorrhoea, acne and hirsutism. - Cushing’s disease – obesity, acne, hypertension, insulin resistance and depression. - Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids, congential adrenal hyperplasia and Ovarian or adrenal tumours that secrete androgens also cause Hirsutism

Answer 159

1. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. 2. 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). 3. 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).

Answer 160

Testosterone Sex hormone-binding globulin Luteinizing hormone Follicle-stimulating hormone Prolactin (may be mildly elevated in PCOS) Thyroid-stimulating hormone 17-hydroxyprogesterone Also consider oral glucose tolerance test, especially in women with a BMI higher than 30

Answer 161

Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH, ratio of 3:1 will disrupt) Raised testosterone Raised insulin Normal or raised oestrogen levels

Answer 162

Typical ultrasound findings are numerous peripheral ovarian follicles (“cysts”), and/or ovarian volume >10cm3. Often described as a "String of Pearls". Diagnostic criteria are either: - 12 or more developing follicles in one ovary - Ovarian volume of more than 10cm3 Not reliable in adolescents

Answer 163

Endometrial hyperplasia which can become malignant. This is because in anovulatory menstrual cycles, the effect of oestrogen is unopposed due to lower levels of progesterone.

Answer 164

by inducing at least 3 bleeds per year. This can be done by using: - Combined oral contraceptive pill (low dose). - Dydrogesterone – a progesterone analogue. This is often used if the combined pill is contraindicated. - Levonorgestrel-releasing intrauterine system can also be used in the long term prevention

Answer 165

achieving a BMI of under 30 may be enough to trigger a regular menstrual cycle so encourage healthy diet and exercise. This will increase insulin sensitivity. In severe cases, orlistat (pancreatic lipase inhibitor) can be prescribed.

Answer 166

NICE advises a cyclical progestogen to induce a withdrawal bleed and referral for a TV USS (any abnormalities will require further investigation).

Answer 167

1. Clomiphene - Induces ovulation and improves conception rates. 2. Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy. 3. Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary. 4. Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed. Letrozole can also be used - this is an aromatase inhibitor (AI). AIs work by inhibiting aromatase, an enzyme involved in the conversion of androgens to oestrogens.

Answer 168

a selective oestrogen receptor modulator (SERM) commonly used in the treatment of oligo/anovulatory infertility.

Answer 169

- cosmetically - acne treatment - weight loss - anti-androgens

Answer 170

anti-androgen medication such as cyproterone, spironolactone or finasteride can be used to reduce hirtuism but can't use in pregnancy Eflornithine is a topical cream

Answer 171

Those planning a pregnancy should have an oral glucose tolerance test, if they are already pregnant it should be conducted prior to 20 weeks. Additional testing should be carried out at 24-28 weeks.

Answer 172

Cervical intraepithelial neoplasia = dyskaryosis – mutations in the squamous cells in the transformation zone of the cervix. Mutations are much more likely to happen here at the squamocolumnar junction as the cells are already ‘transforming’ from squamous to columnar known as metaplasia.

Answer 173

HPV 16 and 18 Missed screening Early first sexual experience Multiple partners Partner who has had multiple factors Smoking Immunosuppression with HIV High parity (over 5) Family history COCP In daughters of women treated with diethylstilbestrol (DES), there is an increased risk of clear cell adenocarcinoma of the cervix. DES was a synthetic oestrogen used to prevent premature labour and miscarriage and was later found to be associated with cervical cancer.

Answer 174

HPV strains 6,11 (to prevent genital warts) and 16 and 18 (to prevent cervical neoplasia and cervical, vulval, vaginal and anal cancer)

Answer 175

25-49 - 3 years 50 -64 - 5 years >60 - if recent smear abnormal or not had one since 50

Answer 176

HPV screening – testing for HPV first is more sensitive and accurate. LBC (liquid based cytology) looks for dyskaryosis.

Answer 177

1. consider smear to also be negative and just continue with routine screening 2. repeat smear in 12 months 3. refer for colposcopy 4. repeat smear in 3 months, if it remains inadequate then refer for colposcopy

Answer 178

Dyskaryosis Borderline changes Any invasive carcinoma or glandular neoplasia

Answer 179

Contains an obscuring element like blood, lubricant or inflammation Taken Inappropriately Incorrectly labelled Cervix not fully visualised

Answer 180

- visualise cervix - stain with acetic acid (abnormal turns white = acetowhitening, happens bcos it coagulates abnormal proteins) - iodine staining - Normal squamous tissue contains glycogen whereas columnar cells do not. As Iodine is glycophillic, application will cause uptake of the stain in the normal tissue (where there is no glycogen) but the CIN or cancer will remain unstained (a saffron-yellow) - biopsy for histology

Answer 181

Only high-grade dysplasia – CIN II or III should be treated. Can treat in colposcopy – ‘see and treat’ or at an additional time. The most common form of treatment is large loop excision of the transformation zone – a LLETZ biopsy. Can increase risk of miscarriage and pre-term birth.

Answer 182

cryotherapy, laser or cold coagulation to destroy or excise the abnormal area. If the abnormal area extends into the cervical canal a Cone Biopsy is indicated.

Answer 183

12 weeks post partum

Answer 184

half of all cases are diagnosed before the age of 47, with a peak age of diagnosis in those aged 25-29. There is a second peak in women in their 80s.

Answer 185

majority (70%) of cervical cancers are squamous cell carcinomas. Of the remainder, 15% are adenocarcinoma and 15% are mixed in type.

Answer 186

The most common sites of metastasis are the lung, liver, bone and bowel.

Answer 187

Asymptomatic Intermenstrual bleeding Post-coital bleeding Post-menopausal bleeding Malodorous discharge Blood-stained discharge Pelvic pain Dyspareunia In late stages: oedema, loin pain, rectal bleeding, radiculopathy and haematuria

Answer 188

Speculum examination – assess for evidence of bleeding, discharge and ulceration. Bimanual examination – assess for pelvic masses. GI examination – assess for hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.

Answer 189

test for chlamydia trachomatis infection + = treat for chlamydia infection. If symptoms persist after treatment, refer for colposcopy and biopsy. - = a colposcopy and biopsy is usually performed.

Answer 190

Urgent colposcopy and biopsy

Answer 191

- Basic bloods - CT chest, abdo, pelvis - Further staging Ix - MRI pelvis, PET - +/- examination under anaesthesia with further biopsies

Answer 192

The International Federation of Gynaecology and Obstetrics (FIGO) staging system

Answer 193

Stage 0 – Carcinoma in-situ Stage 1 – Confined to cervix A) Identified only microscopically. B) Gross lesions, clinically identifiable. Stage 2 – Beyond cervix but not pelvic sidewall/ involves vagina but not lower 1/3 A) No parametrial involvement. B) Obvious parametrial involvement. Stage 3 – Extends to pelvic sidewall/ involves lower 1/3 vagina/ hydropnephrosis not explained by another cause. A) No extension to sidewall. B) Extension to sidewall and/or hydronephrosis. Stage 4 – Extends to bladder or rectum, or metastases A) Involves bladder/rectum. B) Involves distant organs

Answer 194

- Unexplained cervical symptoms (including discharge) - Postmenopausal bleeding if not on HRT or persistent/unexplained bleeding 6 weeks after stopping HRT - Persistent premenopausal bleeding (intermenstrual or post-coital) or blood-stained vaginal discharge and: Polyp, ectropion, cervicitis, or warts and any infection treated - Persistent intermenstrual bleeding - Patients with suggestive features who have not attended screening, have bleeding > 3 months, change in symptoms/bleeding pattern or failure of contraception to regulate bleeding.

Answer 195

Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy. Cervical smear assesses dyskaryosis

Answer 196

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

Answer 197

LLETZ, Cone biopsy, radical trachelectemy or hysterectomy.

Answer 198

Radical (Wertheim’s) hysterectomy as a curative treatment modality. Involves removal of the uterus, vagina and parametrial tissues up to the pelvic sidewall, plus lymphadenectomy. Chemo and radiotherapy may also be given.

Answer 199

chemoradiation

Answer 200

Metastatic disease is treated with a combination of surgery, radiotherapy, chemotherapy and palliative care. Anterior/posterior/total pelvic extenteration may be used. This is the removal of all pelvic adnexae plus bladder (anterior)/rectum (posterior or both (total).

Answer 201

Cisplatin based

Answer 202

Gynae- every 4 months after treatment has been completed for the first 2 years, and every 6-12 months for the subsequent 3 years. All follow-ups should involve a physical examination of the vagina and cervix (if they haven’t been removed). Note – Cervical smear testing is no longer valid after radiotherapy.

Answer 203

Most are adenocarcinomas which are caused by stimulation of the endometrium by unopposed oestrogen, without the protective effects of progesterone. Progesterone is made by the corpus luteum after ovulation so in scenarios where there is anovulation, risk increases.

Answer 204

- Early menarche and/or late menopause– at the extremes of menstrual age, menstrual cycles are more likely to be anovulatory. - Low parity – just under 1/3 of women developing endometrial cancer are nulliparous. With each pregnancy, the risk of endometrial cancer decreases. - Polycystic ovarian syndrome – with oligomenorrhoea, cycles are more likely to be anovulatory. - HRT with oestrogen alone. - Tamoxifen use - Age 65-75 - Obesity - (40%) more fat = faster rate of peripheral aromatisation of androgens to oestrogen - Genetic - hereditary non-polyposis colorectal cancer (Lynch syndrome) - T2DM

Answer 205

Precancerous condition involving thickening of the endometrium, less than 5% become endometrial cancer. 2 types = Hyperplasia without atypia and Atypical hyperplasia. Managed with progestogens such as Mirena coil ror continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel).

Answer 206

Combined contraceptive pill Mirena coil Increased pregnancies Cigarette smoking

Answer 207

- PMB (abnormal vaginal bleeding ≥12 months after the last menstrual period) in someone not on HRT - AUB (Intermenstrual bleeding, heavy menstrual bleeding, etc) - Abnormal vaginal discharge (clear/white) - Haematuria - Anaemia - Raised platelet count - Constitutional symptoms

Answer 208

- Abdominal examination – for abdominal or pelvic masses. - Speculum examination – for evidence of vulval/vaginal atrophy, or cervical lesions. - Bimanual examination – to assess the size and axis of the uterus prior to endometrial sampling. Fixed+hard = advanced disease

Answer 209

- age > 55 years and PMB - Consider referral: age < 55 years and PMB - NICE recommends TVUSS in women over 55: *Unexplained vaginal discharge *Visible haematuria plus (raised platelets, anaemia or elevated glucose levels)

Answer 210

- 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 - May need bloods, CT and MRI if cancer

Answer 211

FIGO staging 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

Answer 212

total abdominal hysterectomy + bilateral salpingo-oophorectomy. If this surgery is contra-indicated, regular surveillance biopsies should be performed.

Answer 213

Total hysterectomy and bilateral salpingo-oophorectomy. Peritoneal washings should also be taken. Traditionally, this has been performed as an open procedure, but laparoscopic surgery is increasingly performed.

Answer 214

Radical hysterectomy (whereby vaginal tissue surrounding the cervix is also removed, alongside the supporting ligaments of the uterus), and assessment and removal of pelvic lymph nodes (lymphadenectomy). May need adjuvant radiotherapy.

Answer 215

Maximal de-bulking surgery (if possible) Additional chemotherapy is usually given prior to radiotherapy.

Answer 216

Maximal de-bulking surgery (if possible) In many stage IV patients, a palliative approach is preferred, e.g. with low dose radiotherapy, or high dose oral progestogens.

Answer 217

Squamous Cell Carcinoma Relatively rare Other types = primary vulval melanoma, basal cell carcinoma, Bartholin’s gland carcinoma, adenocarcinoma, and rarely, sarcoma

Answer 218

Advanced age (particularly over 75 years) Immunosuppression HPV infection Lichen sclerosus (5% get cancer)

Answer 219

Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years. Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).

Answer 220

Biopsy to diagnose Mx - Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation

Answer 221

Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin Irregular mass Fungating lesion Ulceration Bleeding

Answer 222

Usually a unifocal lesion on labia majora, other sites include the clitoris and perineum

Answer 223

- 2WW referral - Diagnosis is made by biopsy. This can be performed under local anaesthetic through a Keye’s punch biopsy. - Sentinel node biopsy to demonstrate lymph node spread - Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 224

FIGO staging Stage I – Carcinoma confined to the vulva Stage II – Carcinoma extending to the lower third of the vagina, urethra or anus Stage III – Carcinoma extending to the upper two thirds of vagina or urethra, OR invasion in to bladder or rectal mucosa OR lymph nodes (non-ulcerated) Stage IV – ulcerated lymph nodes, disease fixed to the pelvic bone OR distant metastases

Answer 225

In simple cases of primary vulval cancer this can be treated with radical/wide local excision. If there is multi-focal disease then a radical vulvectomy is preferred. Reconstructive surgery can be done to retain the structure of the vulva Lymphadenectomy is an important part of treatment in preventing recurrence. In cases of advanced vulval cancer, radiotherapy is now being used, with or without chemotherapy in addition.

Answer 226

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.

Answer 227

It 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

Answer 228

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

Answer 229

Largely unknown but may be: - Genetics – family history of lichen sclerosus can increase risk. - Other autoimmune disorders – such as thyroid disease, type 1 diabetes, alopecia areata. - Two peaks of onset in prepubertal girls and peri- or post-menopausal women

Answer 230

- Itching - Soreness and pain possibly worse at night - Skin tightness - Painful sex (superficial dyspareunia) - Erosions - Fissures - Skin affected is “Porcelain-white”, shiny, tight, thin and slightly raised - Papules or plaques - Scarring - Clitoral hood fusion, fusion of the labia minora to the labia majora and posterior fusion resulting in loss of vaginal opening

Answer 231

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.

Answer 232

Normally a clinical diagnosis is made but a biopsy can be performed when there is failure of treatment or malignancy needs to be ruled out

Answer 233

Cannot be cured but can be effectively managed under gynae or derm 1st - potent topical steroids, such as clobetasol propionate 0.05% (dermovate) plus emoilents Other options: - Intralesional corticosteroids: injection of some preparations of corticosteroids may be used for thickened areas that fail to respond to topical therapy. - Topical calcineurin inhibitors: this is an immunosuppressive agent that is second-line treatment. - Oral/topical retinoids - UVA1 phototherapy - Oestrogen pessaries or creams may be used to reduce symptoms of atrophic vulvovaginitis in post-menopausal women that may be contributing to symptoms.

Answer 234

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.

Answer 235

The cystic dilatation of one of the greater vestibular glands due to obstruction. A build-up of mucus secretions can cause the duct of the gland to become blocked, from which a cyst can develop. The cyst itself can become infected, and if untreated, develop into an abscess. Abcess is commonly caused by E.Coli, Staph Aureus or STIs.

Answer 236

Personal history of Bartholin’s cyst Sexually active (STIs can cause a Bartholin’s cyst or abscess) History of vulval surgery Nulliparous Child bearing age

Answer 237

- Usually on the posterior aspect of the labia majora - Unilateral, painless swelling: ~1-3cm in size - Discomfort (if large): may be experienced on sitting, walking or during sexual intercourse - Disfiguring: large cysts may significantly alter the appearance of the vulva - Vaginal examination: soft, non-tender, fluctuant mass. A normal Bartholin gland should not be palpable

Answer 238

Unilateral, painful swelling Difficulty sitting, walking or having sex Surrounding erythema Fever (uncommon) Purulent exudate (if spontaneous drainage) Vaginal examination: tense, hard, painful, surrounding cellulitis

Answer 239

Usually a clinical diagnosis If age > 40 then consider biopsy to exclude vulval carcinoma If suspicion of STI then take endocervical and high vaginal swabs

Answer 240

- warm compress or salt bath - Incision and Drainage plus either Word catheter or marsupialisation - Antibiotics are generally reserved for patients with recurrent abscess, systemic features, complicated infection (e.g. immunosuppressed, extensive cellulitis), or resistant organisms. If an STI is detected, antibiotics should be directed towards this isolated organism.

Answer 241

fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts. They are usually up to 1cm in size, but rarely can be more extensive. They are harmless and unrelated to cervical cancer.

Answer 242

columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

Answer 243

Normally asymptomatic and seen on speculum Rarely can cause a feeling of fullness in the pelvis if they are very large They appear as smooth rounded bumps on the cervix, usually near to os White/yellow appearance

Answer 244

If the diagnosis is certain then reassure and discharge, they are harmless. If uncertain, refer for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.

Answer 245

twisting of the ovary and/or fallopian tube on its vascular and ligamentous supports, blocking adequate blood flow to the ovary, this is a surgical emergency as if left it leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost

Answer 246

It 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.

Answer 247

sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. On exam = localised tenderness and sometimes there is a palpable adnexal mass.

Answer 248

1st - TVUSS which shows “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow. Gold - Laparoscopic surgery

Answer 249

Emergency laparoscopic surgery to either un-twist the ovary and fix it in place (detorsion) or remove the affected ovary (oophorectomy), this depends on how it looks once the surgery has started. Sometimes it may need to become laparotomy if malignancy or large mass

Answer 250

Delay in treatment leads to loss of function of that ovary. If there is another functioning ovary then fertility is not affected but if the only functioning ovary gets twisted then it 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.

Answer 251

occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina

Answer 252

caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.

Answer 253

caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

Answer 254

Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and postmenopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining Previous surgery for prolpase

Answer 255

A feeling of “something coming down” in the vagina Vaginal bulge/protrusion A dragging or heavy sensation in the pelvis Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention Bowel symptoms, such as constipation, incontinence and urgency Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Answer 256

pelvic organ prolapse quantification (POP-Q) system: Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina A prolapse extending beyond the introitus can be referred to as uterine procidentia.

Answer 257

Post-void residual urine (PVR) volume (catheter or ultrasound) Urodynamics Urinalysis as higher risk of UTI

Answer 258

women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery can be offered this Physiotherapy (pelvic floor exercises) Weight loss Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations Vaginal oestrogen cream

Answer 259

They're inserted into the vagina to provide extra support to the pelvic organs. Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Answer 260

Pain, bleeding, infection, DVT and risk of anaesthetic Damage to the bladder or bowel Recurrence of the prolapse Altered experience of sex

Answer 261

Sim's Speculum

Answer 262

- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up - Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards - Cube pessaries are a cube shape - Donut pessaries consist of a thick ring, similar to a doughnut - Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina

Answer 263

It's caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.

Answer 264

It's weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised. Childbirth = most common cause, other RFs = oestrogen deficient states, pelvic surgery and irradiation.

Answer 265

a combination of urge incontinence and stress incontinence

Answer 266

Occurs when there is chronic urinary retention due to an obstruction to the outflow of urine. This is either due to bladder outlet obstruction or detruser under activity. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women.

Answer 267

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Answer 268

Caffeine consumption Alcohol consumption Medications Body mass index (BMI)

Answer 269

Frequency of urination Frequency of incontinence Nighttime urination Use of pads and changes of clothing

Answer 270

Urinalysis/MSU Bladder scan - for post void residual urine volume Bladder diary Urodynamics

Answer 271

Stop taking anticholinergics 5 days before. A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. - Cystometry measures the detrusor muscle contraction and pressure - Uroflowmetry measures the flow rate - Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. - Post-void residual bladder volume tests for incomplete emptying of the bladder - Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 272

Avoiding caffeine, diuretics and overfilling of the bladder Avoid excessive or restricted fluid intake Weight loss (if appropriate) Supervised pelvic floor exercises for at least three months before considering surgery Surgery Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 273

- Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence. - Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape - Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra - Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support

Answer 274

- Bladder retraining 1st line - Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin - Mirabegron is an alternative to anticholinergic medications - Invasive procedures where medical treatment fails

Answer 275

dry mouth dry eyes urinary retention constipation postural hypotension cognitive decline memory problems worsening of dementia

Answer 276

contraindicated in uncontrolled hypertension. BP needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke

Answer 277

- Botulinum toxin type A injection into the bladder wall - Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves - Detrusor myomectomy augmentation cystoplasty involves using bowel tissue to enlarge the bladder - Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

Answer 278

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. It occurs in women entering the menopause.

Answer 279

Atrophic vaginitis is characterised by inflammation and thinning of the genital tissues due to a fall in oestrogen levels, hence is most common after menopause. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections. Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.

Answer 280

Thinning of the vaginal mucosa +skin Loss of pubic hair Narrowed introitus Loss of vaginal rugae (folds) Vaginal dryness and itching Dyspareunia Post-coital bleeding Vaginal discharge from inflammation Urinary symptoms such as dysuria, recurrent UTI Pale mucosa Erythema and inflammation

Answer 281

- Clinical examination, including speculum examination if tolerated, looking for vaginal signs of atrophy - Transvaginal ultrasound and endometrial biopsy may be necessary to exclude endometrial cancer - An infection screen may be done if there is itching or discharge - A biopsy of any abnormal skin lesions may be required

Answer 282

- Of postmenopausal bleeding: malignancy, endometrial hyperplasia - Of genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes - Of narrowed introitus: female genital mutilation - Of urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis - Of dyspareunia: malignancy, vaginismus

Answer 283

- vaginal lubricants - oestrogen replacement (either systemic hormone-replacement therapy oral or transdermal OR topical oestrogen preparations)

Answer 284

Same as HRT: breast cancer, angina and VTE. 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.

Answer 285

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus- asymptomatic adhesions are not referred to as Asherman's

Answer 286

Often caused by pregnancy-related D&C e.g. for RPOC or after uterine surgery or several pelvic infections. 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. These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages.

Answer 287

- typically presents following recent D&C, uterine surgery or endometritis - Secondary amenorrhoea - Significantly lighter periods - Dysmenorrhoea - Infertility.

Answer 288

- Hysteroscopy is the gold standard investigation, and can involve dissection for 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

Answer 289

FGM involves any procedure resulting in the partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical purposes. It is illegal to carry out FGM in the UK and it is internationally recognised as a human rights violation. It mainly happens to girls before they turn 15.

Answer 290

Type 1: Removal of part or all of the clitoris. Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed. Type 3: Narrowing or closing the vaginal orifice (infibulation). Type 4: All other unnecessary procedures to the female genitalia.

Answer 291

Pain Bleeding Infection Swelling Urinary retention Urethral damage and incontinence Vaginal infections e.g. BV Pelvic infections UTI Dysmenorrhea Sexual dysfunction and dyspareunia Infertility and pregnancy-related complications Significant psychological issues and depression Reduced engagement with healthcare and screening

Answer 292

It is illegal to perform FGM in the UK or to aid someone in carrying out FGM on themselves or others and to assist in the planning and procurement of FGM practices abroad. If you identify anyone with it under 18 then it must be reported to the police/social services. No obligation to report in adults unless risk posed to a child. Should be documented in notes. Pregnant women assessed on case by case basis but needs to be documented in child's personal health records.

Answer 293

- A special gynae/FGM referral - A psych referral - Sexual health screening - Education about how it is illegal - Social services/Paeds - A de-infibulation surgical procedure may be performed by a specialist in FGM in cases of type 3 FGM. NB. Re-infibulation may be requested after childbirth. Performing this procedure is illegal.

Answer 294

The upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina. In male fetuses, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear.

Answer 295

- where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance - Ix = pelvic ultrasound scan - A bicornuate uterus may be associated with adverse pregnancy outcomes (miscarriage, premature birth or malpresentation) - However, successful pregnancies are generally expected. In most cases, no specific management is required

Answer 296

- where the hymen at the entrance of the vagina is fully formed, without an opening - may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina causing cyclical pelvic pain and cramping without any vaginal bleeding. - diagnosed during a clinical examination - Tx = surgical incision to create an opening in the hymen Theoretically, if an imperforate hymen is not treated retrograde menstruation could occur leading to endometriosis.

Answer 297

- Septum forms transversely across the vagina - Can be perforate (with a hole) or imperforate (completely sealed). - Perforate = will still menstruate, but can have difficulty with intercourse or tampon use. - Imperforate = will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation. - Vaginal septae can lead to infertility and pregnancy-related complications. - Ix = examination, ultrasound or MRI - Tx = surgical correction. - The main complications of surgery are vaginal stenosis and recurrence of the septae.

Answer 298

- Vaginal hypoplasia = abnormally small vagina. - Vaginal agenesis = absent vagina. - These occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix. - The ovaries are usually unaffected, leading to normal female sex hormones. The exception to this is with androgen insensitivity syndrome, where there are testes rather than ovaries. - Tx = vaginal dilator over a prolonged period to create an adequate vaginal size or surgery

Answer 299

defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.

Answer 300

characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism)

Answer 301

Raised LH and FSH levels (gonadotropins) Low oestradiol levels

Answer 302

- Idiopathic = >50% of cases - Iatrogenic = chemotherapy, radiotherapy or surgery - Autoimmune = possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease - Genetic = + FHx or Turner’s syndrome - Infections = mumps, TB or CMV

Answer 303

- Irregular menstrual periods - secondary amenorrhea - symptoms of low oestrogen levels: Vasomotor: hot flushes, night sweats Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia Psychological: depression, anxiety, mood swings, lethargy, reduced concentration

Answer 304

- women younger than 40 years with typical menopausal symptoms plus elevated FSH The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.

Answer 305

Cardiovascular disease Stroke Osteoporosis Cognitive impairment Dementia Parkinsonism

Answer 306

- HRT until at least the age at which women typically go through menopause to reduce risk of disease - Use either traditional HRT or COCP - HRT gives lower BP but COCP has less stigma and provides contraception - Still small risk of pregnancy so use contraception - HRT gives risk of VTE but may be less transdermally

Answer 307

Premenstrual syndrome is psychological, physical or behavioural symptoms occurring in the luteal phase of the menstrual cycle, that are causing distress or disruption to the patient. The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause.

Answer 308

Caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.

Answer 309

Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido Premenstrual dysphoric disorder = When features are severe and have a significant effect on quality of life

Answer 310

Symptom diary spanning two menstrual cycles. It should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.

Answer 311

- dietary modification: reduce fat, sugar, caffeine, alcohol and increase fibre, fruit and aim for more frequent snacks. - Increasing exercise - Vitamin supplementation: some evidence for vitamin B supplementation - Stress reduction: relaxation techniques - Cognitive behavioural therapy

Answer 312

- COCP - Danazol - Transdermal oestrogen - GnRH analogues: effectively induce a menopausal state - Antidepressants: particularly SSRIs and SNRIs

Answer 313

COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.

Answer 314

Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist. Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

Answer 315

Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen. This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.

Answer 316

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain. - Endometritis is inflammation of the endometrium - Salpingitis is inflammation of the fallopian tubes - Oophoritis is inflammation of the ovaries - Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus - Peritonitis is inflammation of the peritoneal membrane

Answer 317

Usually STIs but can be others: - Neisseria gonorrhoeae tends to produce more severe PID - Chlamydia trachomatis - Mycoplasma genitalium - Gardnerella vaginalis (associated with bacterial vaginosis) - Haemophilus influenzae (a bacteria often associated with respiratory infections) - Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

Answer 318

Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil) Instrumentation of the cervix

Answer 319

Pelvic or lower bilateral abdominal pain Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Dyspareunia Fever Dysuria Adnexal tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Fever + N&V if severe RUQ pain - 10%

Answer 320

- Urine pregnancy test - Endocervical swabs for gonorrhea and chlamydia, and a high vaginal swab for trichomonas vaginalis and bacterial vaginosis. NAAT done - negative swabs do not exclude the diagnosis. - Full STI screen – (HIV, syphilis, gonorrhoea and Chlamydia as a minimum) - Urine dipstick +/- MSU - ESR + CRP - TVUSS - Laparoscopy

Answer 321

- IM Ceftriaxone + oral doxycycline + oral metronidazole - OR ofloxacin + metronidazole - analgesia - contact tracing - no sex until antibiotics finished

Answer 322

- If pregnant and especially if there is a risk of ectopic pregnancy. - Severe symptoms: nausea, vomiting, high fever. - Signs of pelvic peritonitis. - Unresponsive to oral antibiotics, need for IV therapy. - Need for emergency surgery or suspicion of alternative diagnosis.

Answer 323

- Sepsis - Abscess - Chronic pelvic pain - Ectopic pregnancy – due to narrowing and scarring of the fallopian tubes - Infertility – 10% - Tubo-ovarian abscess - Chronic pelvic pain - Fitz-Hugh Curtis syndrome

Answer 324

- A complication of PID when adhesions form between the anterior liver capsule (Glisson's) to the anterior abdominal wall or diaphragm. - Liver function tests are often normal. - An abdominal ultrasound should be used to exclude stones. - Laparoscopy is required for a definitive diagnosis and treatment involves adhesiolysis and the use of antibiotics.

Answer 325

- The permanent cessation of menstruation - at least 12 months of amenorrhoea in otherwise healthy woman over than age of 45, who are not using hormonal contraception. - 45-55, 52 is average - Caused by ovarian follicular failure leading to low oestrogen and progesterone levels. LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

Answer 326

the period from when symptoms of menopause start, until 12 months after the last menstrual period.

Answer 327

No. of oocytes is fixed as a foetus, peaks between 20-28 weeks gestation and falls after that. The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen and inhibin. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH. The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.

Answer 328

Hot flushes + night sweats Emotional lability or low mood Anxiety Lethargy Difficulty concentrating Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido Problems with orgasm & dyspareunia

Answer 329

Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Answer 330

A woman is considered still fertile for 2 years after her last menstrual period if she is <50, and for 1 year after her last menstrual period if she is over 50 years of age In general all women are considered no longer fertile after the age of 55.

Answer 331

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations. You can do an FSH blood test if: - Women under 40 years with suspected premature menopause - Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 332

- 2 years after the last menstrual period in women under 50 - 1 year after the last menstrual period in women over 50

Answer 333

two key side effects of the progesterone depot injection (e.g. Depo-Provera): weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Answer 334

Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation

Answer 335

COCP is UKMEC2 after aged 40, and can be used up to age 50 years if there are no other contraindications. Consider COCPs containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of VTE compared with other options.

Answer 336

Usually resolves after 2-5 years - HRT - Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) - Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors - CBT and SSRI antidepressants, such as fluoxetine or citalopram - Testosterone can be used to treat reduced libido (usually as a gel or cream) - Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) - Vaginal moisturisers, such as Sylk, Replens and YES

Answer 337

- Endometrial and endocervical polyps are focal proliferations of glandular, vascular, fibromuscular, and connective tissue - Can cause intermenstrual bleeding in particular. Many are asymptomatic and do not cause AUB - Prevalence is 10% to 15% - Incidence increases with age and the vast majority of symptomatic polyps are benign.

Answer 338

a disease of the reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sex (without contraception) between a man and a woman

Answer 339

Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%) 40% of infertile couples have a mix of male and female causes.

Answer 340

Turner's syndrome (XO) Kleinfelter's syndrome (XXY)

Answer 341

Polycystic ovary syndrome Pituitary tumours Sheehan's syndrome (pituitary infarction due to haemorrhagic shock during labour) Hyperprolactinaemia Cushing's syndrome Premature ovarian failure

Answer 342

Congenital anatomical abnormalities Adhesions following pelvic inflammatory disease - secondary to chlamydia or gonorrhoea

Answer 343

Bicornate uterus Fibroids Asherman's syndrome Endometriosis Cervical damage from biopsy or LLETZ

Answer 344

Cryptorchidism Varicocele Testicular cancer Congenital testicular defects Obstruction of the ejaculatory system (either congenital or acquired) Disorders of ejaculation e.g. retrograde ejaculation, premature ejaculation

Answer 345

Increasing age Obesity Smoking Tight-fitting underwear (males) Excessive alcohol consumption Anabolic steroid use Illicit drug use

Answer 346

The woman should be taking 400mcg folic acid daily Aim for a healthy BMI Avoid smoking and drinking excessive alcohol Reduce stress as this may negatively affect libido and the relationship Aim for intercourse every 2 – 3 days Avoid timing intercourse

Answer 347

Offer after 1 year of unsuccessful conception or after 6 months in women over 35 - Mid-luteal phase progesterone – to assess ovulation, 7 days before period - Chlamydia screening - Testing for susceptibility to rubella - Semen testing The following investigations may be considered: Serum progesterone in women with prolonged irregular menstrual cycles FSH and LH – may help identify ovulation disorders TFTs Anti-Mullerian hormone Prolactin

Answer 348

- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus - Hysterosalpingogram (xray with contrast) to look at the patency of the fallopian tubes (do in first 10 days of cycle and do chlamydia test before) - Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

Answer 349

Surgical sperm retrieval is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen. Surgical correction of an obstruction in the vas deferens may restore male fertility. Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. Donor insemination

Answer 350

Symptomatic relief of vasomotor symptoms such as flushing, insomnia, headaches, vaginal atrophy and dryness Decreases the risk of osteoporosis and colorectal cancer

Answer 351

Breast and endometrial cancer (no endo Ca in people without uterus), VTE and stroke, coronary artery disease (no CAD risk in osetrogen only) and some minimal evidence suggesting increased risk of ovarian cancer (patches reduce risk of VTE)

Answer 352

Undiagnosed vaginal bleeding Pregnancy Breastfeeding Oestrogen receptor-positive breast cancer Endometrial cancer Acute liver disease Uncontrolled hypertension History of breast cancer or venous thromboembolism (VTE) Recent stroke, myocardial infarction or angina

Answer 353

agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers BP and reduces HR, and is also used as an antihypertensive medication. Helps vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT. Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.

Answer 354

- Premature ovarian insufficiency, even without symptoms - Vasomotor symptoms such as hot flushes and night sweats - Low mood, decreased libido, poor sleep and joint pain - Reducing risk of osteoporosis in women under 60 years

Answer 355

The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus

Answer 356

1. Local or systemic symptoms? If local then prescribe oestrogen cream 2. Is there a uterus? No uterus = continuous oestrogen-only HRT, if they have a uterus then use combined 3. Have they had a period in the last 12 months? Yes = cyclical combined, No = continuous combined

Answer 357

Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches

Answer 358

- Cyclical progesterone, given for 10 – 14 days per month, is used for women that have had a period within the past 12 months - Continuous progesterone is used when the woman has not had a period in the past: 2 years if under 50 years, 1 year if over 50 years - You can switch from cyclical to continuous HRT after at least 1 yr of treatment in women over 50, and 2 yrs in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed.

Answer 359

Oral (tablets) Transdermal (patches) Intrauterine system (e.g. Mirena coil) licensed for 4 years

Answer 360

C19 and C21 progestogens, referring to the chemical structure and number of carbon atoms in the molecule. C19 progestogens are derived from testosterone, and are more “male” in their effects. Examples are norethisterone, levonorgestrel and desogestrel. These may be helpful for women with reduced libido. C21 progestogens are derived from progesterone, and are more “female” in their effects. Examples are progesterone, dydrogesterone and medroxyprogesterone. These may be helpful for women with side effects such as depressed mood or acne.

Answer 361

Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps

Answer 362

Mood swings Bloating Fluid retention Weight gain Acne and greasy skin

Answer 363

By using a Mirena coil for endometrial protection

Answer 364

Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 365

Polyspermia (or polyzoospermia) refers to a high number of sperm in the semen sample (more than 250 million per ml). Normospermia (or normozoospermia) refers to normal characteristics of the sperm in the semen sample. Oligospermia (or oligozoospermia) is a reduced number of sperm in the semen sample. It is classified as: Azoospermia is the absence of sperm in the semen.

Answer 366

Pathology of the pituitary gland or hypothalamus Suppression due to stress, chronic conditions or hyperprolactinaemia Kallman syndrome

Answer 367

Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer Genetic/congenital diseases affecting sperm production: Klinefelter syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia (absent testes)

Answer 368

Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens (may be associated with cystic fibrosis) Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Answer 369

Hormonal analysis with LH, FSH and testosterone levels Genetic testing Further imaging, such as transrectal ultrasound or MRI Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction Testicular biopsy

Answer 370

Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.

Answer 371

- increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. - VEGF increases vascular permeability, causing fluid to leak from capillaries. - This results in oedema, ascites and hypovolaemia. - Using LH and FSH during ovarian stimulation results in the development of multiple follicles. - OHSS is provoked by the “trigger injection” of hCG 36 hours before oocyte collection. HCG stimulates the release of VEGF from the follicles. The features of the condition begin to develop after the hCG injection. - RAAs also stimulated- raised renin level correlates with the severity of the condition.

Answer 372

Younger age Lower BMI Raised anti-Müllerian hormone Higher antral follicle count Polycystic ovarian syndrome Raised oestrogen levels during ovarian stimulation

Answer 373

During stimulation with gonadotrophins, they are monitored with: Serum oestrogen levels (higher levels indicate a higher risk) and USS monitor of the follicles (higher number and larger size indicate a higher risk) High risk: Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol) Lower doses of gonadotrophins Lower dose of the hCG injection Alternatives to the hCG injection (i.e. a GnRH agonist or LH)

Answer 374

Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)

Answer 375

supportive with treatment of any complications: Oral fluids Monitoring of urine output Low molecular weight heparin (to prevent thromboembolism) Ascitic fluid removal (paracentesis) if required IV colloids (e.g. human albumin solution) Mild/moderate = outpatient. Severe cases require admission, and critical cases may require admission to the intensive care unit (ICU). Haematocrit assesses intravascular fluid volume, raised = dehydration

Answer 376

a single episode of ovarian stimulation and collection of oocytes (eggs). A single cycle may produce several embryos. Each of these embryos can be transferred separately in multiple attempts at pregnancy, all during one “cycle” of IVF.

Answer 377

Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfer

Answer 378

GnRH agonist protocol, an injection of a GnRH agonist (e.g. goserelin) is given in the luteal phase 7 days before the expected onset of the menstrual period (usually day 21 of the cycle). This stimulates the pituitary gland to secrete a large amount of FSH and LH. After this surge there is negative feedback to the hypothalamus, and the natural production of GnRH is suppressed. This causes suppression of the menstrual cycle. For the GnRH antagonist protocol, daily subcutaneous injections of a GnRH antagonist (e.g. cetrorelix) are given, starting from day 5 – 6 of ovarian stimulation. This suppresses the body releasing LH and causing ovulation to occur.

Answer 379

Without suppression of the natural gonadotropins (LH and FSH) using one of the above protocols, ovulation would occur and the follicles that are developing would be released before it is possible to collect them

Answer 380

Ovarian stimulation promotes the development of multiple follicles in the ovaries. This starts at the beginning of the menstrual cycle with subcutaneous injections of FSH over 10 to 14 days. Monitored with TVUSS. When enough follicles have developed to an adequate size, the FSH is stopped, and an injection of hCG is given 36 hours before collection of the eggs. The hCG works similarly to LH does naturally, and stimulates the final maturation of the follicles, ready for collection. This is referred to as a “trigger injection”.

Answer 381

The oocytes are collected from the ovaries under the guidance of a TVUSS. A needle is inserted through the vaginal wall into each ovary to aspirate the fluid from each follicle. This fluid contains the mature oocytes from the follicles. The procedure is usually performed under sedation (not a general anaesthetic). The fluid from the follicles is examined under the microscope for oocytes.

Answer 382

The sperm and egg are mixed in a culture medium. Thousands of sperm need to be combined with each oocyte to produce enough enzymes (e.g. hyaluronic acid) for one sperm to penetrate the corona radiata and zona pellucida and fertilise the egg. Intracytoplasmic sperm injection (ICSI) is a treatment used mainly for male factor infertility. The highest quality sperm are isolated and injected directly into the cytoplasm of the egg.

Answer 383

Dishes containing the fertilised eggs are left in an incubator and observed over 2 – 5 days to see which will develop and grow. They are monitored until they reach the blastocyst stage of development (around day 5).

Answer 384

After 2 – 5 days, the highest quality embryos are selected for transfer. A catheter is inserted under ultrasound guidance through the cervix into the uterus. A single embryo is injected through the catheter into the uterus, and the catheter is removed. Generally, only a single embryo is transferred. Two embryos may be transferred in older women (i.e. over 35 years). Any remaining embryos can be frozen for future attempts at transfer.

Answer 385

A pregnancy test is performed around day 16 after egg collection. When this is positive, implantation has occurred. Even after a positive test, there is still the possibility of miscarriage or ectopic pregnancy. Progesterone vaginal pessaries is used from the time of oocyte collection until 8 – 10 weeks gestation to mimic the progesterone that would be released by the corpus luteum during a typical pregnancy. From 8 – 10 weeks the placenta takes over production of progesterone, and the suppositories are stopped. An ultrasound scan is performed early in the pregnancy (around 7 weeks) to check for a fetal heartbeat, and rule out miscarriage or ectopic pregnancy. When the ultrasound scan confirms a health pregnancy, the remainder of the pregnancy can proceed with standard care, as with any other pregnancy.

Answer 386

Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome There is a small risk of complications relating to the egg collection procedure: Pain Bleeding Pelvic infection Damage to the bladder or bowel