Gynaecology Flashcards
1
Q
What are uterine fibroids?
A
Leiomyomas
Benign smooth muscle tumours of the uterus.
2
Q
What are the classifications of fibroids?
A
Intramural (most common)
- confined to the myometrium of the uterus
Submucosal
- develops immediately under the endometrium of the uterus and protrudes into the uterine cavity
Subserosal
- protrudes into and distorts the serosal (outer) surface of the uterus
- may be pedunculated (on a stalk)
3
Q
What is the pathophysiology of fibroids?
A
Growth is stimulated by oestrogen.
Benign. Very rarely become malignant.
4
Q
What are the risk factors for fibroids?
A
Obesity
Increasing age
African-american
Early menarche
FHx
5
Q
What are the clinical features of fibroids?
A
Most asymptomatic
- Pressure symptoms (urinary frequency/retention)
- Abdominal distension
- Heavy bleeding
- Subfertility
- Acute pelvic pain (red degeneration- fast growing fibroid undergoes necrosis and haemorrhage) (pedunculated fibroids can undergo torsion)
6
Q
What do you witness on examination of a patient with fibroids?
A
Solid mass
Enlarged uterus
Non-tender
7
Q
What do you witness on examination of a patient with fibroids?
A
Solid mass
Enlarged uterus
Non-tender
8
Q
What are the differential diagnoses for uterine fibroids?
A
Endometrial polyp
Adenomyosis (endometrial tissue within the myometrium)
Ovarian tumour
Leimyosarcoma (malignancy of myometrium)
9
Q
How do you investigate for a uterine fibroid?
A
Pelvic USS
(MRI only if sarcoma suspected)
10
Q
What is the medical management for fibroids?
A
Tranexamic/mefanamic acid
Hormonal contraceptives (COCP/POP/IUS)
- control menorrhagia
GnRH analogues (Zolidex)
- suppresses ovulation, inducing temporary menopausal state
- used pre-operatively to reduce fibroid size and lower complications
- only used for 6 months due to risk of osteoporosis
Selective Progesterone Receptor Modulators (Ulipristal/Esmya)
- reduces size of fibroid and menorrhagia
- useful pre-operatively or as an alternative to surgery
- Ulipristal use is restricted due to risk of severe liver injury
11
Q
What are the complications of fibroids?
A
Iron deficiency anaemia
Compression of organs
Subfertility/infertility
Degeneration
Torsion
12
Q
What is endometriosis?
A
Chronic condition in which endometrial tissue is located at site other than the uterine cavity.
Can occur in:
- Ovaries
- Pouch of Douglas
- Uterosacral ligaments
- Pelvic peritoneum
- Bladder
- Umbilicus
- Lungs
13
Q
What is the pathophysiology of endometriosis?
A
Retrograde menstruation
- endometrial cells travel backwards from uterine cavity through Fallopian tubes and deposit own pelvic organs
- these cells may also be able to travel through the lymphatic system and vasculature to distant sites
Sensitive to oestrogen
- women will have heavy bleeding from the ectopic tissue during menstruation causing pain and bloating
- repeated inflammation and scarring can lead to adhesions
- during pregnancy and menopause symptoms will be reduced
14
Q
What are some risk factors for endometriosis?
A
Early menarche
FHx
Short menstrual cycles
Long duration of menstrual bleeding
Heavy bleeding
Defects in the uterus/Fallopian tube
15
Q
What are the clinical features of endometriosis?
A
Cyclical pelvic pain at time of menstruation (when adhesions form pain may be constant)
Dysmenorrhoea
Dysparenuria
Dysuria
Subfertility
Dyschezia (painful defaecating)
Focal symptoms of bleeding e.g. haemothorax
16
Q
What do you see on bimanual examination for endometriosis?
A
Fixed, retroverted uterus
Uterosacral ligament nodules
General tenderness (enlarged boggy uterus is indicative of adenomyosis)
17
Q
What are the differential diagnosis for endometriosis?
A
PID
Ectopic pregnancy
Fibroids
IBS
18
Q
How do you investigate for endometriosis?
A
Laparoscopy
- chocolate cysts
- adhesions
- peritoneal deposits
Pelvic USS (determine severity and should be done before surgery
19
Q
How do you manage endometriosis?
A
Pain: analgesia ladder
Ovulation:
- suppressing ovulation for 6-12 months can cause atrophy of the endometriosis lesions and a reduction in symptoms
- COCP/IUS/Depot can be used
Surgery (severely affecting person’s life)
- Excision
- Fulgaration
- Laser ablation
(relapses will occur and surgery may have to be repeated)
- Hysterectomy and removal of ovaries with replacement of hormones until menopause
20
Q
How common in endometrial cancer?
A
4th most common cancer affecting women in UK
Most common gynaecological cancer in the world
21
Q
Why has the incidence of endometrial cancer risen over the past 20 years?
A
Ridse in obesity
22
Q
What is the peak incidence of endometrial cancer?
A
65-75 yo
23
Q
What is the pathophysiology of endometrial cancer?
A
Adenocarcinoma (neoplasia of epithelial tissue that has glandular origin)
- caused by stimulation of endometrium by oestrogen without protective effects of progesterone (unopposed oestrogen)
- progesterone is produced by corpus lute after ovulation (where women have experienced longer periods of anovulation are thought ti predispose)
- unopposed oestrogen can also cause endometrial hyperplasia
24
Q
What are the risk factors for endometrial cancer?
A
Anovulation
- early menarche/late menopause
- low parity
- PCOS (oligomenorrhoea)
- HRT (oestrogen only)
- Tamoxifen
Age
Obesity (greater amount of fat, faster the rate of peripheral aromatisation of androgens to oestrogen)
Hereditary
- Hereditary non-polyposis colorectal caner (Lynch Syndrome)
25
What are the clinical features of endometrial cancer?
Post-menopausal bleeding (bleeding 1 year after periods have stopped)
Clear/white vaginal discharge
Abnormal cervical smears
If before menopause (irregular bleeding/intermenstrual bleeding)
Advanced cases:
Abdominal pain
Weight loss
26
What do you see on examination for endometrial cancer?
Abdominal= abdo/pelvic masses
Speculum= vulval/vaginal atrophy or cervical lesions
Bimanual examination= assess size and axis of uterus prior to endometrial sampling
27
What are some differential diagnosis for endometrial cancer?
Vulval atrophy
Vulval pre-malignant/malignant conditions
Cervical polyps
Cervical cancer
Endometrial hyperplasia
Benign endometrial polyps
Endometrial atrophy
28
What investigations do you do for endometrial cancer?
Trans-vaginal USS: 1st line
(most people with it will have endometrial thickness >5mm)
Endometrial thickness >/=4mm in post menopausal woman= endometrial biopsy
If patient high risk (heavy bleeding/risk factors/very thick endometrium)= hysteroscopy with biopsy
Endometrial thickness <4mm= defer sampling but if they continue to have bleeding sampling may be required
Malignancy confirmed
- MRI/CT for staging
- Bloods prior to operation: FBC/U&Es/LFTs/G&S
29
What is the staging system for endometrial cancer?
FIGO staging
1- carcinoma within uterine body
2- carcinoma may extend to cervix but not beyond uterus
3- carcinoma extends beyond uterus but confined to pelvis
4- carcinoma involves bladder/bowel and has metastasised
30
How do you manage endometrial hyperplasia?
Without atypia
- Mirena
- Surveillance biopsies
Atypical
- total abdominal hysterectomy and bilateral saplingo-oophorectomy
- if CI regular surviellance biopsies
31
How do you manage endometrial carcinoma?
Stage 1
- total hysterectomy and bilateral salpingo-oophorectomy
- peritoneal washings taken
Stage 2
- radical hysterectomy (vaginal tissue around cervix removed and supporting ligaments)
- may be offered adjuvant radiotherapy
Stage 3
- de-bulking surgery
- chemotherapy
- radiotherapy
Stage 4
- de-bulking surgery
- palliative approach (low dose radiotherapy/high dose oral progesterones)
32
What is the follow up after having endometrial cancer?
Frequent follow up up to 5 years post op
32
What is the follow up after having endometrial cancer?
Frequent follow up up to 5 years post op
33
What are cervical polyps?
Benign growths protruding from the inner surface of the cervix.
Asymptomatic but some can undergo malignant change.
34
What is the pathophysiology of cervical polyps?
Focal hyperplasia of the columnar epithelium of the endocervix.
Causes
- chronic inflammation
- abnormal response to oestrogen (polyps are associated with endometrial hyperplasia)
- localised congestion of the cervical vasculature
35
In whom are cervical polyps more common?
Multiparous women
50-60 yos
36
What are the clinical features of cervical polyps?
Asymptomatic: usually identified on routine cervical screening
- Abnormal vaginal bleeding
- Increased vaginal discharge
- Blockage of the cervical canal: infertility
Speculum
- Polypoid growths projecting through the external os
37
What are the differential diagnosis for cervical polyps?
Cervical ectropion
Cervical cancer
STI
Fibroids
Endometritis
Pregnancy related bleeding
Endometrial polyp
In post-menopausal women always exclude endometrial carcinoma.
38
What investigations do you do for a cervical polyp?
Histological examination after its removal
Triple swabs (endocervical and high vaginal)
Cervical smear (rule out CIN)
Lots of women also have associated endometrial polyps. If symptoms persist after removal and USS should be arranged to assess the endometrial cavity.
39
How do you manage cervical polyps?
Small polyps
- removed in primary care
- polypectomy forceps and twisted (not pulled off as can cause bleeding)
- any bleeding can be cauterised with silver nitrate
Larger polyps
- diathermy loop excision in colposcopy clinic or under GA
Any excised polyps should be sent for histological examination
40
What are the complications of cervical polyp removal?
Infection
Haemorrhage
Uterine perforation (do not blindly attempt to remove polyps from within cervical canal/intrauterine)
41
What is cervical cancer caused by?
Persistent infection (>2 years) with high-risk HPV (human papillomavirus)
42
What is cervical cancer preceded by?
Pre-cancerous change: cervical intraepithelial neoplasia (CIN)
Only picked up on screening
43
What is CIN?
Defined by dyskaryosis: mutations in the squamous cells in the transformation zone of the cervix
Mutations are more likely to happen at the squamocolumnar junction as the cells are transforming from squamous to columnar (metaplasia)
44
What are the risk factors for CIN?
HPV 16 & 18
Early first sexual experience
Multiple partners
Smoking
Immunosuppression with HIV
COCP (link with use of non-barrier contraception)
45
How do you prevent CIN?
Between 11-13 all school children are offered the HPV vaccine.
Protects against HPV 6 & 11 (prevent genital warts) and 16 & 18 (prevent CIN and cervical/vulval/vaginal/anal cancer)
46
How does the cervical screening programme work?
Available for all women with a cervix aged 25-64
1st invitation: 24.5 years
3 yearly screening: 25-49 years
5 yearly screening: 50-64 years
>65= if recent smear abnormal or not had screening since 50 yo
Women with HIV are screened annually
Women undergoing transplant/dialysis should be offered additional screening at that time.
Transgender men who have retained their cervix should be invited unless they have made the informed decision to opt-out
47
What does the cervical smear look for?
HPV screening
LBC (liquid based cytology) looks for dyskaryosis (only if HPV is positive)
48
What happens if the smear is hrHPV positive?
Normal smear
- repeat smear in 12 months
Abnormal smear
- colposcopy
49
What happens if the hrHPV is negative?
Routine screening
50
What happens if there is an inadequate smear?
Repeat smear within 3 months.
If this remains inadequate
- colposcopy
51
What does an abnormal smear mean?
Dyskaryosis (low/high grade)
Borderline changes
Invasive carcinoma/glandular neoplasia
52
What does an inadequate smear mean?
Contains obscuring element (lubricant/blood/inflammation)
Taken inappropriately/incorrectly labelled
Contains insufficient cells
Cervix not fully visualised
53
How do you diagnose and stage CIN?
Colposcopy (visualise cervix and stain it with acetic acid making abnormal areas turn white)
Iodine stain is used to look for abnormal cells
- CIN normally occurs in the squamous cells at the squamocolumnar junction
- Normal squamous tissue contains glycogen whereas columnar cells fo not
- Iodine is glycophilic so application will cause uptake in normal tissue (where there is no glycogen) but CIN will remain unstained
Biopsy
54
How do you manage CIN?
Only high grade CIN (CIN II/III) should be treated
- occur at same time as colposcopy
- large loop excision of the transformation zone (LLETZ biopsy)
Can use cryotherapy, laser, or cold coagulation
Given local anaesthetic before removal.
If abnormal areas extends into cervical canal a Cone Biopsy is indicated.
55
What can procedures for pre-cancerous changes of the cervix increase the risk of?
Miscarriage
Pre-term delivery
56
What happens if you are due your cervical smear and you are pregnant?
Delay the smear until 12 weeks post-partum
57
What is cervical ectropion?
Presence of everted endocervical columnar epithelium on the ectocervix
Normal physiological condition
58
In whom is cervical ectropion more common?
Adolescents
Pregnancy
Women taking oestrogen containing contraceptives
59
What is the cervix?
Lower potion of the uterus
60
What are the 2 regions of the cervix?
Endocervical canal (endocervix)
- proximal inner part of the cervix
- lined by mucus secreting simple columnar epithelium (contains mucus secreting glands so therefore some people with cervical ectropion experience increased vaginal discharge)
Ectocervix
- part of the cervix the projects into the vagina
- normally lined by stratified squamous non-keratinised epithelium
61
What are the risk factors for cervical ectropion?
Cervical ectropion is induced by high levels of oestrogen
- Use of COCP
- Pregnancy
- Adolescence
- Menstruating age (uncommon in post-menopausal women)
62
What are the clinical features of cervical ectropion?
Usually asymptomatic
- Post-coital bleeding
- Intermenstrual bleeding
- Excessive discharge
Speculum examination
- everted columnar epithelium has a reddish appearance (ring around the os)
63
What is the differential diagnosis for cervical ectropion?
Cervical cancer
CIN
Cervicitis (inflammation of the cervix caused by infection)
Pregnancy
64
What investigations should you do if you suspect cervical ectropion?
It is a clinical diagnosis so these investigations are done to exclude any other causes
- Pregnancy test
- Triple swab
- Cervical smear (+/- biopsy)
65
What is the management for cervical ectropion?
No treatment unless symptomatic
1st line
- stop any oestrogen containing medications (COCP)
2nd (if symptom persist)
- ablation (cryotherapy/electrocautery)
(results in signifiant vaginal discharge until healing is complete)
Medication to acidify the vaginal pH has been suggested (boric acid pessaries)
66
What is cervical cancer?
Neoplasia arising from the cervix
67
How common is cervical cancer?
3rd most common worldwide
12th most common in UK
68
What is the peak age of onset for cervical cancer?
25-29 yos
Second peak in women in their 80s
69
What is the most common type pf cervical cancer?
SCC
70
What is the pathophysiology of cervical cancer?
Progression from CIN over the course of 10-20 years.
Caused by persistent HPV infection.
Invasive cervical cancer: basement membrane of the epithelium has been breached
71
Where are the most common sites of metastases in cervical cancer?
Lung
Liver
Bone
Bowel
72
Why are serotypes 16 & 18 HPV high risk?
Produce proteins which inhibit the tumour suppressor protein p53 in cervical epithelial cells allowing uncontrolled division of cells.
73
What are the risk factors for cervical cancer?
HPV
Smoking
Other STIs
Long term (>8 years) COCP
Immunodeficiency (HIV)
74
What are the clinical features of cervical cancer?
Abnormal vaginal bleeding (post-coital/intermenstrual/post-menopausal)
Vaginal discharge (blood stained/foul smelling)
Dysparenuria
Pelvic pain
Weight loss
Usually asymptomatic and most cases detected on screening
Advanced disease
- oedema
- loin pain
- rectal bleeding
- radiculopathy
- Haematuria
75
What would you see on clinical examination for cervical cancer?
Speculum: assess for bleeding, discharge, ulceration
Bimanual: pelvic massess
GI examination: hydronephrosis, hepatomegaly, rectal bleeding, mass on PR
76
What are some differential diagnosis for cervical cancer?
STI
Cervical ectropion
Polyps
Fibroids
Pregnancy related bleeding
Endometrial carcinoma in post-menopausal bleeding
77
What investigations would you do if you suspect cervical carcinoma?
Pre-menopausal
- Test for chlamydia trachomatis infection
- +ve= treat. If symptoms persist after treatment refer for colposcopy and biopsy
- -ve= colposcopy and biopsy
Post-menopausal
- urgent colposcopy and biopsy
78
What is a colposcopy?
Colposcope used to produce a magnified view of the cervix.
Acetic acid is used to stain dysplastic areas, and a biopsy is taken.
79
What investigations do you need to do after cervical cancer is confirmed?
Bloods: FBC, LFTs, U&Es
CT CAP: looking for metastases
MRI pelvis/PET (further staging scans)
+/- examination under anaesthesia with further biopsies
80
How do you stage cervical cancer?
FIGO staging
0: carcinoma in situ
1: confined to cervix
a- Identified microscopically only
b- gross lesions, clinically identifiable
2: beyond the cervix but not pelvic sidewall/ involves vagina but not the lower 1/3rd
a- no parametrial involvement
b- obvious parametrical involvement
3: extends to the pelvic side wall/ involves lower 1/3rd of vagina/hydronephrosis not explained by another cause
a- no extension to sidewall
b- extension to sidewall and/or hydronephrosis
4: extends to bladder/rectum/mets
a- involves bladder/rectum
b- involves distant organs
81
How do you manage cervical cancer?
SURGICAL
1a:
- radical trachelectomy if fertility preservation is priority (removal of cervix and upper vagina)
- otherwise a laparoscopic hysterectomy with pelvic lymphadenectomy is offered
1b/2a
- Radical hysterectomy (removal of uterus, vagina and parametrical tissues up to the pelvic side wall plus lymphadenectomy)
4a/recurrent
- Anterior/posterior/total pelvic extenteration (removal of all pelvic adenexae plus bladder (anterior) and rectum (posterior))
RADIOTHERAPY
External beam therapy and intracavity brachytherapy
1b-3
- offered in conjunction with chemotherapy over a 5-8 week course
- hysterectomy offers no benefits of survival in these stages so chemoradiation therapy is gold standard
CHEMOTHERAPY
- cisplatin based
- before treatment by surgery or radiotherapy (neoadjuvant) or after treatment (adjuvant)
- mainstay of treatment in palliative setting
82
How should patients be followed up after treatment for cervical cancer?
Reviewed by gynaecologist every 4 months after treatment in complete for the first 2 years.
Then every 6-12 months for the subsequent 3 years.
All follow ups involve a physical examination of the vagina and cervix
(cervical smear is now longer valid after radiotherapy)
83
What is PCOS?
Polycystic Ovary Syndrome.
Common endocrine disorder characterised by excess androgen production and the presence of multiple immature follicles (cysts) within the ovaries.
84
What are the most common hormonal abnormalities in PCOS?
Excess LH (luteinising hormone)
- Produced by anterior pituitary gland in response to increased GnRH pulse frequency
- Stimulates ovarian production of androgens
Insulin resistance
- resulting in high levels of insulin secretion
- suppresses hepatic production of sex hormone binding globulin 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 in the ovary but are arrested at an early stage and they remain visible as cysts in the ovary.
85
What are the risk factors for PCOS?
Diabetes
Irregular menstruation
FHx
86
What are the clinical features of PCOS?
Oligomenorrhoea/amenorrhoea
Infertility
Hirsutism
Obesity
Chronic pelvic pain
Depression
Acne
Acanthosis nigricans
Male pattern hair loss
Obesity
Hypertension
87
What are the differential diagnosis for PCOS?
Hypothyroidism
Hyperprolactinaemia
Cushing's Disease
88
What is the diagnostic criteria used for PCOS?
Rotterdam Criteria: diagnosis if 2/3 criteria are met
- oligo/amenorrhoea
- clinical/biochemical signs of hyperandrogenism
- polycystic ovaries on imaging
89
What investigations do you want to do if you suspect PCOS?
Bloods
- Testosterone (RAISED)
- SHBG (sex hormone binding globulin) (LOW)
- LH (best measured during days 1-3 of menstrual bleed) (RAISED)
- FSH (NORMAL)
LH:FSH ratio should be noted (level of 3:1 is enough to disrupt ovulation)
- Progesterone (LOW)
TFTs
Serum prolactin
OGTT
USS (Cysts/ ovarian volume >10cm3)
90
How do you manage PCOS?
Oligomenorrhoea/amenorrhoea
- Effect of oestrogen is unopposed due to lower progesterone levels, this can cause endometrial hyperplasia
- Protect women from hyperplasia by inducing 3 bleeds per year
- COCP/dydrogesterone
Weight management (healthy lifestyle, will increase insulin sensitivity, in severe cases orlistat (pancreatic lipase inhibitor) can be used)
Infertility
- Clomifene +/- metformin helps induce ovulation (increased risk of multiple pregnancies/ovarian hyper stimulation syndrome/ ovarian cancer so use is limited to 6 cycles)
- Normal BMI: laparoscopic ovarian drilling
Hirsutism
- anti-androgen medication (cyproterone/spironolactone/finasteride: avoid in pregnancy as teratogenic)
- Eflornithine (topical cream used to reduce growth of facial hair)
91
What is an ovarian cyst?
Fluid filled sac within the ovary
Common, especially in premenopausal women where benign, physiological cysts predominate throughout the menstrual cycle
92
When should women with small ovarian cysts raise concern?
Symptomatic
Resolution confirmed on scanning at 12 weeks
93
What cancer is the leading cause of death from gynaecological malignancy in the UK?
Ovarian cancer
94
What are the risk factors for ovarian cancer?
Nulliparity
Early menarche
Late menopause
HRT (oestrogen only)
Smoking
Obesity
95
What is the pathophysiology of ovarian cancer?
Surface epithelial irritation during ovulation.
So the more ovulations that take place, the increased risk of developing malignancy.
96
What are the protective factors for ovarian cancer?
Multiparity
Combined contraceptive methods
Breastfeeding
97
What genetic mutations increase the risk of ovarian cancer?
BRCA1&2
- prophylactic bilateral sapling-oophorectomy can be done but this does not completely eradicate risk of developing malingnancy
Hereditary nonpolyposis colorectal cancer
98
What cancer antigen is associated with ovarian cancer?
CA125
99
What is the risk of malignancy index (RMI) for ovarian cancer?
RMI= U x M x CA125
M= menopausal status
- 1 point for premenopausal
- 3 points for postmenopausal
U= USS score
- 1 point if 1 feature
- 3 points if 2 or more features
CA125
Patient of RMI>250 should be referred to specialist gynaecologist
100
What are the clinical features of ovarian cysts/tumours?
Incidental and asymptomatic
Chronic pain (may be secondary to pressure on the bladder/bowel also causing frequency/constipation)
Dysparenuria/cyclical pain in those with endometriosis who have developed chocolate cysts.
Acute pain (bleeding into cyst/rupture/torsion): resuscitate a shocked patient
Bleeding per vagina
101
Why are there lots of advanced cases of ovarian cancer?
Presentation of ovarian cancer is quite vague causing a delay in diagnosis and presentation with advanced disease.
Therefore never ignore a post-menopausal woman with non-specific gynaecological/GI symptoms
Ask about
- bloating
- change in bowel habit
- change in urinary frequency
- WL
- IBS
- Vaginal bleeding
102
What is the classification of ovarian cysts?
Simple ovarian cyst: fluid only
Complex ovarian cyst: irregular, contains solid material, blood, septations or vascularity
103
How do you manage ovarian cysts?
Pre-menopausal women
- CA125 does not need to be undertaken when simple ovarian cyst is diagnosed USS
- CA125 can be raised by anything that irritates the peritoneum so in pre-menopause that is high
- LDH/AFP/hCG measured in all women <40 due to the possibility of germ cell tumours
- Rescan cyst in 6 weeks, if persistent monitor with USS and CA125 3-6 monthly and calculate RMI
- if persistent />5cm consider laparoscopic cystectomy/oophorectomy
Post-menopausal women
- Low (RMI <25): follow up for 1 year with USS and CA125 if <5cm
- Moderate (RMI 25-250): bilateral oophorectomy and if malignancy is found then staging is required
- High (RMI>250): referral for staging laparotomy
104
What are the most common types of ovarian cancer?
Epithelial subtypes
- Serous cystadenocarcinoma (Psammoma bodies)
- Mucinous cystadenocarcinoma (Mucin vacuoles)
105
How do you investigate for ovarian cancer?
FBC
U&E
LFT
Albumin
Abdominal & pelvic USS
Confirmed cancer
- CXR
- CTAP
106
How do you manage ovarian cancer?
Surgery
- staging laparotomy (high RMI with attempt to debunk the tumour)
Adjuvant chemotherapy
Follow up (clinical exam and monitoring of CA125 levels for 5 years with intervals becoming further apart according to risk of recurrence)
107
What is infertility?
A disease of the reproductive system defined by the failure to achieve a pregnancy after 12 months or more or regular unprotected sex between a man and woman.
108
What are the 2 different classifications of infertility?
Primary: couple has never been able to conceive
Secondary: when a couple cannot get pregnant again, despite previously being able to without difficulty
109
Over 80% of couples will conceive within 1 year if:
The woman is aged under 40
AND
They do not use contraception and have regular sexual intercourse (every 2-3 days)
110
What are some general causes of infertility?
Male infertility (30%)
Ovulatory disorders (25%)
Tubal damage (20%)
Uterine/peritoneal disorders (10%)
No identifiable cause (25%)
111
How do you investigate for infertility in primary care?
Semen analysis
Female hormonal testing
112
When do you refer someone to a specialist clinic for infertility from the GP?
Couples who despite having normal investigations/examinations, are still unable to conceive after 1 year.
113
When would you refer someone early for specialist infertility input?
Women aged >36 (refer after 6 months)
OR
Suspected underlying cause for infertility as suggested by history/examination
114
What is some general advice for couples who are trying to conceive?
Regular sexual intercourse
Preparation for pregnancy (folic acid)
Smoking cessation
Avoid drinking alcohol excessively (women avoid it)
Women should aim for a BMI of 19-25 kg/m2
115
What are the 3 main types of treatment for infertility?
Medical management (drugs to induce ovulation e.g. Clomifene
Surgical treatment (tubal microsurgery for tubal damage)
Assisted conception (intrauterine insemination/IVF)
Manage psychological impact on the couple.
116
What are some causes for male infertility?
PRIMARY SPERMATOGENIC FAILURE
(Any spermatogenic abnormality caused by a condition other than hypothalamic pituitary disease)
- Congenital: absence of testes, cryptorchidism, genetic abnormalities
- Acquired: testicular trauma/torsion, mumps orchitis, testicular tumour, systemic disease (liver cirrhosis), varicocele, cytotoxic agents
- Idiopathic
GENETICS
- Klinefelter's Syndrome (47 XXY)
- Kallman Syndrome (hypogonadotrophic hypogonadism)
- Androgen insensitivity syndrome (karyotype XY, phenotypically female)
OBSTRUCTIVE AZOOSPERMIA
- Bilateral obstruction of seminal ducts leading to absence of sperm in semen (absent vas deferens/post-infection/post-surgery)
VARICOCELE
HYPOGONADISM
- Primary: hypergonadotrophic hypogonadism due to testicular failure
- Secondary: hypogonadotrophic hypogonadism due to reduced GnRH and/or FSH/LH secretion
- Androgen insensitivity (end organ resistance to gonadotrophins)
OTHER
- Medications (chemo, cytotoxic agents, sulfasalazine, anabolic steroids)
- Psychological factors (leading to ejaculation disorders/ED)
-Lifestyle factors (smoking, obesity, excessive alcohol, illicit drug use)
117
What do you need to ask about in a male history for infertility?
Length of time trying to conceive
Frequency and type of sexual intercourse
Children born to the man
Ejaculatory/ED
Medications
PMHx (mumps/STIs/trauma/undescended testes/systemic disease-DM/liver cirrhosis/prior surgery)
FHx including genetic disorders e.g. CF
Social and occupational Hx
118
What do you look for on examination for male infertility?
BMI calculation
Genital examination
- position of the urethral meatus
- structural abnormalities of the penis
- testicular volume and consistency
- varicocele
- hernia
- undescended testes
Check for signs of hypogonadism
- gynaecomastia
- lack of hair growth
- reduction in muscle mass
Look for signs of anabolic steroid use
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What are some primary care investigations you would do to investigate male infertility?
Semen analysis (results compared to WHO reference values)
If results are abnormal, repeat testing is offered 3 months after initial test to allow time for spermatozoa cycle to be complete (repeat testing sooner if severe deficiency in initial sample)
If normal results no further testing.
Chlamydia testing
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When do you refer a male about infertility to secondary care?
2 abnormal semen analysis results
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When would you refer a male early to secondary care regarding infertility?
Previous genital pathology
Previous urogenital surgery
Previous STI
Varicocele
Significant systemic illness
Abnormal genital examination
Known reason for infertility
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What investigations are done in secondary care for male infertility?
Genetic testing
Sperm culture
Endocrine tests (FSH/testosterone)
Imaging of urogenital tract
Testicular biopsy
123
How do you manage male infertility?
Lifestyle
- weight management
- psychological stress management
- smoking and alcohol cessation
Medical management
- hypogonadotrophic hypogonadism (gonadotrophin drugs offered)
Surgical management
- Surgical correction if obstructive azoospermia
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What is heavy menstrual bleeding?
Excessive menstrual loss which interfere with a woman's QoL
Not related to pregnancy
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What is AUB (Abnormal Uterine Bleeding)?
Heavy menstrual bleeding that cannot be attributed to any uterine, endocrine, haematological or infective pathology after investigation.
126
How do you classify causes of heavy menstrual bleeding?
PALM (structural causes)
Polyp
Adenomyosis
Leimyoma (fibroid)
Malignancy & hyperplasia
COEIN (Non-structural causes)
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
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What are the risk factors for heavy menstrual bleeding?
Age (at menarche, approaching menopause)
Obesity
Previous C section (risk for Adenomyosis)
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What are the clinical features of heavy menstrual bleeding?
Bleeding deemed excessive for woman
Fatigue
SOB (anaemia)
129
How do you take a menstrual cycle history?
Frequency
Duration
Volume
LMP
Smear History
Contraception
Medical history
DHx
130
What examinations are done to investigate heavy bleeding?
General observation
Abdominal palpation
Speculum
Bimanual examination
Assess for:
- Pallor
- Palpable uterus/pelvic mass
- Inflamed cervix/cervical polyp/cervical tumour
- Vaginal tumour
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What are some differential diagnosis for heavy menstrual bleeding?
Pregnancy/ectopic/miscarriage
Endometrial/cervical polyps
Adenomyosis
Fibroids
Malignancy/hyperplasia
Coagulopathy (vWD/warfarin)
Ovarian dysfunction (PCOS/hypothyroidism)
Iatrogenic (contraceptives)
Endometriosis
