Gynaecology Flashcards
1
Q
What is the most common cause of ovarian cancer?
A
Epithelial ovarian tumours
2
Q
What are the risk factors of ovarian cancer?
A
- Increasing age
- Lifestyle (smoking, obesity and lack of exercise)
- Nulliparous
- Early menarche/ late menopause
- BRCA1& 2
- Endometriosis
- Infertility
- FHx
3
Q
Presentation of germ cell tumours in ovarian cancer?
A
- Common in women <35
- Rapidly enlarging abdominal mass
4
Q
What is the clinical presentation of ovarian cancer?
A
- Majority in 3rd/4th stage
-
IBS (ABC):
- Abdominal pain
- Bloating
- Change in bowel habits: urgency
- Urinary frequency
- Dyspepsia
- Fatigue
- Weight loss
- Painful mass
5
Q
Who is most affected by ovarian cancer?
A
Elderly
6
Q
What are the investigations for ovarian cancer?
A
- CA125 tumour marker
- Abdominal US + CT
7
Q
What is the staging for ovarian cancer?
A
1) Ovaries
2) One/both ovaries + pelvic extension/implants
3) One/both ovaries + microscopically confirmed peritoneal implants outside pelvis
4) One/both ovaries + distant metastasis
8
Q
What is the management of ovarian cancer?
A
Abdominal hysterectomy + bilateral salpingo-oopherectomy
Chemotherapy: stages 2-4
Radiotherapy
9
Q
What is endometrial cancer?
A
Cancer of the endometrium (lining of the uterus)
Oestrogen dependent tumour
Includes myometrial sarcoma
10
Q
What is the pathophysiology of endometrial cancer?
A
Unopposed oestrogen → endometrial hyperplasia → increased risk of endometrial adenocarcinoma
11
Q
What are the risk factors for endometrial cancer?
A
Prolonged exposure of unopposed oestrogen:
- Obesity
- Diabetes
- Nulliparity
- Late menopause
- HRT
- Pelvic irradiation
12
Q
What is the most common type of endometrial cancer?
A
Adenocarcinomas
13
Q
What are the two types of endometrial cancer?
A
Type 1= Oestrogen dependent endometrioid carcinomas
Type 2= Oestrogen-independent non-endometrioid carcinomas
14
Q
Who does endometrial cancer affect the most?
A
Majority >50 years old
15
Q
What is the most common type of gynaecological cancer?
A
Endometrial cancer
16
Q
What is the clinical presentation of endometrial cancer?
A
- Post-menopausal bleeding/abnormal uterine bleeding
- Menorrhagia/oligomenorrhea in pre-menopausal
17
Q
What are the investigations for endometrial cancer?
A
- Pelvic and abdominal examination
- Transvaginal US: endometrial thickness >4mm
- Endometrial pipelle biopsy: if US >4mm
- Hysteroscopy
18
Q
What staging is used for endometrial cancer?
A
FIGO
19
Q
What is the management of endometrial cancer?
A
- Total abdominal/laparoscopic hysterectomy
- Bilateral salpingo-oopherectomy
- Post-operative chemotherapy
- Pelvic lymph node removal
- Adjuvant radiotherapy + progesterone therapy
20
Q
What are the causes of cervical cancer?
A
Human papillomavirus (HPV)
21
Q
What is Cervical Intraepithelial Neoplasia (CIN)?
AKA cervical dysplasia
A
Abnormal cervical cell growth that can potentially lead to cervical cancer
22
Q
Describe the 3 grades of CIN
A
CIN I= lower basal 1/3 of cervical epithelium
CIN II= affects <2/3 of cervical epithelium
CIN III= affects >2/3 of full thickness epithelium
23
Q
Who is screened for cervical cancer?
A
25-49: every 3 years
50-65: every 5 years
24
Q
What is dyskaryosis?
A
Abnormal nucleus: the abnormal epithelial cell in cervical smears
25
What test would you order if you see borderline/mild dyskaryosis in a smear?
Test for HPV:
- -ve = back to routine screening
- +ve= colposcopy
26
What test would you order if you see moderate dyskaryosis in a smear?
- Urgent colposcopy: within 2 weeks
- Consistent with CIN II
27
What test would you order if you see severe dyskaryosis or suspected invasive cancer?
- Urgent colposcopy: within 2 weeks.
- Consistent with CIN III
28
What test would you order if you see inadequate smears?
What if they keep being inadequate?
- Inadequate = repeat smear
- Consistently inadequate = colposcopy
29
Why is the incidence of cervical cancer decreasing?
1. Screening: cervical smears
2. HPV vaccine
30
What is the most common type of cervical cancer?
Squamous cell
31
What are the risk factors for cervical cancer?
- Persistent HPV infection
- Early intercourse (<16yrs)
- STI's
- Multiparty
- Multiple sexual partners
- Smoking (limits ability to clear HPV)
- Immunosuppression
- COCP
- Non-attendance of cervical screening programme
32
What % of cervical cancers are found through screening?
30%
33
What age group does cervical cancer primarily affect?
25-34
34
What is the clinical presentation of cervical cancer?
- Pelvic mass
- Vaginal discomfort/urinary symptoms
- Vaginal discharge
- Red or white patches on cervix
- Haematuria
- Abnormal vaginal bleeding
- Post-micturition bleeding
- Post-coital bleeding
- Polyuria
- Haematuria
35
What is the red flag symptom for cervical cancer?
Post-coital bleeding
36
What are the investigations for cervical cancer?
- Bimanual examination (rough and hard cervix)
- CA125 tumour marker
- Trans-vaginal USS
- Calculate the RMI (risk of malignancy index): if >250 = 2 week wait referral
- Colposcopy + cystoscopy
- Punch biopsy
- CT: metastasis
- PET: for staging (FIGO)
37
What type of staging is used for cervical cancer?
FIGO
38
What is the management of cervical cancer?
- <2cm: loop removal
- >2cm: radical hysterectomy
- >4cm: radiotherapy + chemotherapy + palliative care
39
What must you consider when treating cervical cancer?
Fertility
40
What is the cause of vulval cancer?
Vulval intraepithelial neoplasia
41
What is the most common form of vulval cancer?
Squamous
42
What is the clinical presentation of vulval cancers?
- Vulval itch/sore
- Persistent lump
- Post-menopausal bleeding
- Painful micturition
43
What is the management of vulval cancers?
- Surgery: radical or conservative
- Radiotherapy
- Chemotherapy
44
What is the cause of vaginal cancers?
- HPV
- Metastatic spread from cervical/uterine
45
What are the symptoms of vaginal cancer?
Bleeding
46
What is the treatment of vaginal cancers?
Radiotherapy
47
What is the prognosis of vaginal cancers?
Poor
48
What is the pathophysiology of BRACA1/2 genes in breast cancer?
Faulty BRCA1 and 2 gene (tumour suppressant) increases risk of breast cancer
49
What are the majority of carcinomas split into?
1) Ductal **OR** lobular
2) In situ (not penetrating BM) **OR** invasive
50
What can In situ ductal carcinomas progress into?
Invasive
51
What is the most common breast invasive breast cancer?
Invasive ductal: oestrogen receptor positive
52
What staging is used in breast cancer?
**TMN**:
- **Tumour**
- **T0**= No evidence primary
- **T1**= <2 cm
- **T2**= 2-5 cm
- **T3**= >5 cm
- **T4**= Extends to chest wall or skin or inflammatory
- **Nodes**
- **N0**= No Nodes
- **N1**= Mobile Nodes
- **N2**= Fixed/matted nodes
- **N3**= Internal Mammary nodes
- **Metastasis**
- **M0**= No Metastases
- **M1**= Metastases
53
What’s the referral criteria for breast cancer?
2WW= >30 with breast lump ± pain
2WW= >50 with 1 of: discharge, retraction OR concerning nipple
54
What is the screening for breast cancer?
50-71yrs Mammogram:
- Satisfactory
- Unsatisfactory
- Unclear
55
What are the modifiable and non-modifiable risk factors for breast cancer?
Modifiable:
- Weight
- Exercise
- Smoking
- Alcohol
- HRT
Non-modifiable:
- Age
- Breast density
- Menopause age
- BRCA1& 2
56
Why is the incidence of breast cancer thought to be increasing?
1. Western lifestyle
2. Screening
3. Increasing life expectancy
57
What is the clinical presentation of breast cancer?
May be asymptomatic in early stages
Breast and/or axillary lump: normally painless
Irregular
Hard/firm
Fixed to skin/muscle
Breast skin:
- Change to normal appearance
- Skin tethering
- Oedema
- Peau d'orange: thickened and dimpled skin
Nipples:
- Inversion
- Discharge (especially if bloody)
- Dilated veins
- Paget's disease of the nipple
Features of metastatic spread (2Ls 2BS; bone, liver, lung, brain)
58
What is the triple assessment in breast cancer?
Triple assessment:
- Mammography
- High resolution US
- Core needle biopsy
Scored against:
- Clinical score: 1-5
- Imaging score: 1-5
- Biopsy score: 1-5
Followed by MDT meeting
59
What are the investigations you can order for breast cancer?
Triple assessment
MRI/US breast
Receptor testing:
- Oestrogen receptor status
Genetic testing (BRCA2)
FBC, CRP, ESR
Sentinel node biopsy
60
What biopsy should you do to ensure that the breast cancer hasn’t spread to the axillary lymph nodes?
Sentinel node biopsy
61
What is the tumour marker for breast cancer?
CA 15-3
62
What can microcalcifications indicate on a mammogram?
Ductal Carcinoma In Situ (DCIS)
63
Give 4 treatment options for patients with breast cancer
1. Conservative surgery + radiotherapy
2. Mastectomy + radiotherapy
3. Mastectomy + reconstruction + radiotherapy (BUT can damage a lot of reconstructions)
4. Axillary lymph node removal (limited or full)
+ Adjuvant trastuzumab, tamoxifen OR anastrozole
64
When would you perform breast conservation in breast cancer?
- Small tumour relative to breast size (<25%)
- Pre-op chemotherapy and radiotherapy also offered
- Contradicted if under nipple
65
When would you perform a mastectomy in breast cancer?
- Large tumour relative to breast size
- Tumour underneath nipple/ in drawing nipple
- More than one cancer in same breast
- Delayed reconstruction
- Patient choice
66
What percentage of breast cancers have axillary disease?
40%
67
When would you use full-axillary clearance in breast cancer?
If glands are clinically involved
No need for further surgery
68
What are the complications of full-axillary clearance in breast cancer?
- Lymphedema
- Seromas
- Arm stiffness
- Drain
- Axillary numbness
69
When would you perform limited axillary surgery in breast cancer?
Glands are clinically normal
70
What are the benefits of limited surgery in breast cancer?
- Day surgery
- No significant complications
- No drains
71
What medication would you offer HER-2+ve breast cancer post-op?
Biologic: a HER2 monoclonal antibody
- Trastuzumab
72
What medication would you offer ER/PR+ve breast cancer post-op for women:
- Pre-menopausal?
- Post-menopausal?
Endocrine therapy:
- Pre= Tamoxifen (inhibits oestrogen receptors on breast cancer cells)
- Post= Anastrozole (aromatase inhibitor; prevents androgens → oestrogen conversion)
73
When in breast cancer would you offer:
- Radiotherapy?
- Chemotherapy?
Radiotherapy: lumpectomy + aggressive after mastectomy
Chemotherapy: aggressive + high risk (e.g young age, HER-2 +ve, triple-negative receptor, Grade 3, Node +ve and tumour size)
74
Who is atrophic vaginitis common in and why?
Post-menopausal women due to falling levels of oestrogen
75
What are the causes of atrophic vaginitis?
- Menopause
- Oophorectomy
- Anti-oestrogen treatments (e.g Tamoxifen and Anastrozole )
- Radiotherapy
- Chemotherapy
- Post-partum: reduced oestrogen levels
76
What changes are seen to the vaginal mucosa when oestrogen falls?
- Thinner
- Drier
- Less elastic
- More fragile
77
When oestrogen levels fall, what changes are seen to the vaginal epithelium?
Inflammation →urinary symptoms
78
When oestrogen levels fall, this changes vaginal pH, flora and periurethral tissues.
Why is this bad?
- Vaginal pH/flora: UTI's or vaginal infections
- Periurethral tissues: pelvic laxity and stress incontinence
79
What is the clinical presentation of atrophic vaginitis?
- Vaginal dryness
- Burning/itching of vagina
- Dyspareunia
- Vaginal discharge
- Post-menopausal bleeding
- Reduced pubic hair
- Painful vaginal examination
- Lack of vaginal folds
- Polyuria
- Nocturia
- Dysuria
- UTIs
- Stress/urgency incontinence
80
Which investigations are used for atrophic vaginitis?
- Diagnosis of exclusion
- TVS: rules out pathology
81
What is the management of atrophic vaginitis?
- Vaginal lubricants and moisturisers
- Vaginal oestrogen
- HRT
82
What are fibroids?
Benign tumours of uterine myometrium smooth muscle cells
83
What are fibroids stimulated by?
Oestrogen and progesterone
84
Why may fibroids go through benign degeneration and calcification?
Centre of larger fibroids not receiving adequate blood supply
85
How are fibroids classified?
- Intramural
- Submucosal
- Subserosal
86
What is the most common type of fibroid?
Intramural
87
Define intramural fibroids
Growing within the endometrium
88
Define submucosal fibroids
Growing into the uterine cavity (can be pedunculated and may protrude through cervical os)
89
Define subserosal fibroids
Growing outwards from the uterus (abdominal)
90
What causes fibroids?
- Acquired genetic change
- Hormones
- Growth factors
91
What are the risk factors for fibroids?
- Obesity
- Early menarche
- Afro-caribbean
- 30-40 yrs
- FHx
- COCP
- Pregnancy
92
What is the most common indication for a hysterectomy?
Fibroids
93
What is the clinical presentation of fibroids?
- Asymptomatic
- 30-50 yrs
- Infertility/sub-fertility
- Menorrhagia
- Pressure symptoms e.g. urinary frequency if pressing on bladder
- Menorrhagia → Iron deficiency anaemia → lethargy and pallor
- Pelvic pain
- Recurrent miscarriages
94
What may be found on a physical examination for fibroids?
Palpable abdominal mass arising from pelvis
95
What investigations are ordered for fibroids?
- Abdominal + bimanual examination: palpable abdominal mass arising from pelvis
- Pregnancy test
- FBC (anaemia)
- TVUS
- MRI: if US not definitive
- Hysteroscopy
96
What is the management for fibroids?
Conservative: watch and wait
Suppression of ovarian function for at least 6 months:
- Mirena coil: 1st line
- COCP: e.g. triphasing (3 months continuous then break)
- Medroxyprogesterone acetate (injectable contraception)
- Progestogens: norethisterone (no bleeding)
- POP: e.g. mini pill (no bleeding)
Anti-fibrinolytics: e.g. Tranexamic acid (during bleeding)
NSAIDS: e.g. Mefanamic acid (during bleeding)
GnRH agonist: e.g. Goserelin (max 6 months)
Myomectomy
Hysterectomy (only cure for fibroids in women who have completed their family)
Ulipristal acetate (shrinks fibroid)
97
When would you do a myomectomy in fibroids?
- Excessively enlarged uterine size
- Pressure symptoms
- Symptoms uncontrolled by medication
- Subfertility
98
Name a GnRH agonist and its cons for use in fibroids
Goserelin: shrinks fibroids, but then they regrow once discontinued
Not a long term option- demineralises bone
99
What is ulipristal acetate and when is it used in fibroids?
- Selective progesterone receptor modulator
- Shrinks fibroids and induces amenorrhoea
- Used before surgery and as an emergency contraception
100
What is the gold standard treatment for uterine fibroids?
Hysterectomy
101
What are the three main types of ovarian cysts?
- Benign (70%)
- Functional (24%)
- Malignant (6%)
102
Name some benign neoplastic ovarian cysts
- Benign epithelial neoplastic cysts
- Benign neoplastic cystic tumours of germ cell origin
- Benign neoplastic solid tumours (Fibroma <1% malignant)
103
Name some benign fibrous ovarian cysts
- Adenofibroma
- Teratoma
- Brenner tumour
104
What are brenner tumour ovarian cysts?
Brenner tumours are part of the surface epithelial-stromal tumour group of ovarian neoplasms.
Majority benign
105
Name some causes hormone secreting tumours ovarian cysts
- Virilisation
- Menstrual irregularities
- Post-menopausal bleeding
106
What are 5 risk factors for ovarian cysts?
- Obesity
- Tamoxifen
- Early menarche
- Infertility
- Dermoid cysts: can run in families (teratomas)
107
Who does ovarian cysts primarily affect?
Pre-menopausal women
108
What is the most common ovarian cysts type?
Benign neoplastic cystic tumours of germ cell origin
109
What is the clinical presentation of ovarian cysts?
- Chronic
- Pain
- Unilateral dull ache in the abdomen (intermittent or only coital pain)
- Lower back pain
- Dyspareuria
- Irregular vaginal bleeding
- Rupture/torsion = severe abdo pain + fever
- Large cysts = abdominal swelling or pressure effects on bladder
110
What are complications of ovarian cysts?
- Torsion
- Infarction
- Hhaemorrhage
111
What investigations are ordered for ovarian cysts?
- Abdominal examination: swollen abdomen with palpable mass + dull to percussion
- Pregnancy test
- FBC: infection/haemorrhage
- TVS/USS
- CT/MRI: if USS not definitive
- Diagnostic laparoscopy
- Serum CA125 levels
112
What would ascites suggest in ovarian cancer?
Malignancy
113
For suspected ovarian cancer we do a Risk of Malignancy Index (RMI)
What does this consist of?
USS score + menopausal status + serum CA125 levels
114
In the RMI we do a USS score.
What findings are involved in this (out of 5)?
USS scores 1 point for each of the following:
- Multi ocular cysts
- Solid areas
- Metastases
- Ascites
- Bilateral lesions
115
How would Rokitansky's Protuberance appear on histopathology?
A solid protuberance from a mature dermoid cyst (teratoma).
Contains calcific, dental, adipose, hair and/or sebaceous components.
Region has the highest propensity to undergo malignant transformation.
116
What is the is management of Small, Moderate and Large Ovarian Cysts?
Cystectomy
Oopherectomy
Acute onset of symptoms: hospital admission
- Small (<50mm): do not require follow up
- Moderate (50-70mm): yearly US follow up
- Large: furtherMRI imaging
117
What are the complications of a Ovarian Cyst rupture?
-Peritonitis
-Shock
118
What is the clinical presentation of Ovarian Torsion?
- Sudden onset deep unilateral colicky pain (brought on by exercise)
- Iliac fossa pain radiating to loin, groin or back
- Unilateral tender adnexal mass on examination
- Pain may improve after 24hrs (when the ovary is dead)
- localised tenderness
- Palpable mass
- Fever
- N&V
119
What investigations are ordered for Ovarian Torsion?
- Ultrasound: oedema (due to venous supply cut off) + whirlpool sign (twisting/volvulus)
- Laparoscopy
120
What is the management for Ovarian Torsion?
Laparoscopic detorsion
Laparoscopic oophorectomy
121
What is Mittelschmerz?
Ovulation pain (abdominal) that can last up to 48 hours
Usually unilateral pain
122
What is endometriosis?
Chronic oestrogen-dependent condition
Endometrial tissue growth outside the uterine cavity
123
Where can endometriosis occur?
- Pelvic cavity (including ovaries)
- Uterosacral ligaments
- Pouch of Douglas
- Recto-sigmoid colon
- Bladder
- Distal ureter
- Lungs
124
What is the cause of endometriosis?
- Retrograde menstruation
- Impaired immunity (retrograde tissue isn't destroyed)
125
What are the risk factors of endometriosis?
- Early menarche
- Late menopause
- Delayed childbearing
- Short menstrual cycles
- Obstruction to vaginal outflow
- Fallopian or uterus defects
- Genetic predisposition
- Alcohol use
- Low body weight
126
What are protective factors against endometriosis?
- Multiparity
- COCP
127
Who does endometriosis affect the most?
- Higher prevalence in infertile women
- Exclusive to women of reproductive age
128
Why does endometriosis improve after menopause?
- Endometriosis relies on oestrogen
- Oestrogen falls after menopause
129
What is the classic triad of symptoms found in endometriosis?
- Dysmenorrhoea- pain often starts days before bleeding
- Deep dyspareuria
- Cyclical or chronic pelvic pain
(Chronic/constant inflammation brings pain)
130
What is the clinical presentation of endometriosis outside of the triad?
- Sub fertility
- Dysuria
- Bloating
- Lethargy
- Constipation
- Lower back pain
- Dyschezia
- Lump
131
What investigations are ordered for endometriosis?
Gold= Laparoscopy with biopsy
- Bimanual examination: fixed, retroverted uterus
- Transvaginal US
- MRI good: if bowel involved
132
What grading classification is used in endometriosis?
AFS
133
What non-specific protein marker might be raised in a woman with endometriosis?
CA125
Non-specific: anything that irritates the peritoneum
134
What is the management of endometriosis?
Suppression of ovarian function for at least 6 months:
- Mirena coil: 1st line
- COCP: e.g. triphasing (3 months continuous then break)
- Medroxyprogesterone acetate (injectable contraception)
- Progestogens: norethisterone (no bleeding)
- POP: e.g. mini pill (no bleeding)
Anti-fibrinolytics: e.g. Tranexamic acid (during bleeding)
NSAIDS: e.g. Mefanamic acid (during bleeding)
GnRH agonist: e.g. Goserelin (max 6 months)
NSAIDs/Paracetamol: for pain
Laparoscopic excision or ablation
Hysterectomy + salpingo-oophorectomy (last resort)
135
How would you treat endometriosis in a woman who is wanting to get pregnant?
Surgery
136
What is Adenomyosis?
The invasion of endometrial tissue into the myometrium
137
Compare the epidemiology of Adenomyosis to Endometriosis.
Adenomyosis: older, multiparous women
Endometriosis: younger, nulliparous women
138
Give 3 symptoms of adenomyosis
1. Menorrhagia
2. Dysmenorrhoea
3. Dyspareunia (cyclical)
139
What investigations might you do to confirm adenomyosis?
1. Transvaginal USS
2. MRI
3. Hysterectomy: definitive
140
What is the treatment for adenomyosis?
Hysterectomy
141
What is polycystic Ovarian Syndrome (PCOS)
Polycystic ovaries + systemic symptoms causing reproductive, metabolic and psychological disturbances
142
What is the pathophysiology of PCOS?
Excessive androgen production by theca cells of the ovaries due to either:
1) Hyperinsulinaemia
2) High luteinising hormone (LH) levels
143
How does hyperinsulinaemia produce excess androgens in PCOS?
1) Insulin resistance → weight gain → further insulin resistance → increased androgen production
2) Reduced production of sex hormone-binding globulin (SHBG) in the liver
3) Free testosterone subsequently raised
144
Why does hyperinsulinaemia cause increased androgen production PCOS?
1) Insulin mimics the action of insulin growth factor 1 (IGF-1) n response to LH via theca cells.
2) Insulin decreases levels of SHBG → increased free testosterone
145
Why may you have raised LH?
- Increase production in the anterior pituitary
- Genetic conditions: e.g. Turner syndrome or Klinefelter syndrome
146
What is the classic triad of symptoms seen in PCOS?
1) Oligomenorrhoea (<9 periods/year) /Amenorrhoea
2) Infertility/subfertility
3) Signs of androgen production (excess testosterone):
- Acne
- Hirsutism
- Deep voice
- Alopecia
- Male pattern balding
- Reduced breast size
147
Name some signs of insulin resistance in PCOS
- Acanthosis nigricans
- Psychological symptoms (depression, mood swings, anxiety or poor self-esteem)
- Obesity
- Sleep apnoea
148
What is the commonest cause of secondary infertility?
PCOS
149
What is the rotterdam diagnostic criteria for PCOS?
2/3= PCOS
**SHOP**
**S**trings of pearls on US: Polycystic ovaries (>12 in one ovary)/ ovarian volume >10cm3
**H**yperandrogenism: clinically or biochemically:
**O**ligomenorrhoea/ Anovulation
**P**rolactin normal
150
What biochemical results would you expect in PCOS?
- Raised testosterone
- low SHBG
- Raised LH levels (1:1 ratio to FSH)
- Impaired glucose tolerance (insulin resistance)
151
Which hormone is always normal when testing for PCOS?
Prolactin
152
What is the management of PCOS?
**TREAT THE SYMPTOMS**
Encourage weight loss:
- Orlistat
- Lifestyle
Acne and hirsutism:
- COCP
- Co-cyprindol /Eflornithine
- SEVERE= Isotretinoin
For pregnancy (need 4 periods a year to develop lining of the womb):
- Clomifene (anti-oestrogen)/tamoxifen.
- Metformin: increases insulin sensitivity
- Letrozole
- Laparoscopic ovarian drilling or gonodotrophins
153
What is Menopause?
Permanent cessation of menstruation due to loss of follicular activity for 12 months
154
Define peri-menopause.
The period leading up to the menopause: irregular periods and symptoms
155
What is the average age of menopause?
40-60 (average 51)
156
If a woman goes through menopause <50, for how many years is she still fertile for?
2 years
157
If a woman goes through menopause >50, for how many years is she still fertile for?
1 year
158
What is the pathophysiology of menopause?
Reduction in oocytes → decreased ovarian production of progesterone, estradiol, testosterone and fertility
159
A depletion in what hormone is thought to trigger the symptoms of the menopause?
Oestrogen
160
What are the consequences of menopause?
- CV disease (cause of death of 1/3 of women)
- Vasomotor symptoms
- Urogenital problems: due to oestrogen deficiency
- Osteoporosis
161
What are the early signs of menopause?
- Oligomenorrhea
- Vasomotor:
- Hot flushes
- Night sweats
- Palpitations
- Vaginal dryness
- Reduced libido
- Poor concentration and fatigue
- Headaches
- Joint pain
162
What are 3 ongoing signs of menopause?
- GU symptoms (frequency, urgency, dyspareunia, incontinence and UTIs)
- Atrophic vaginitis
- PMB
163
What are the 3 late signs of menopause?
- Osteoporosis
- CVD
- Dementia
164
What investigations are ordered in menopause?
Bloods:
- Raised FSH = fewer oocytes
- Anti-mullerian hormone = ovarian reserve
DEXA scan: bone density estimation
165
What is the management of menopause?
- Lifestyle advice
- Reduce modifiable RF’s
- HRT
- Bisphosphonates: osteoporosis
- Vaginal oestrogens
- Progesterone, Clonidine, SSRIs: hot flushes and night sweats
- Non-hormonal options e.g. clonidine
- Non-pharmaceutical e.g. CBT
166
What are the pros and cons of HRT?
Pros:
- Symptom management
- Osteoporosis prevention
- Colo-rectal cancer prevention
Cons:
- Risk breast Ca: if COCP
- Risk of endometrial Ca- if oestrogen only
- Risk of gallbladder disease
- Risk of VTE
- Risk of CV disease
167
What is a ectopic pregnancy?
Pregnancy implanted outside the uterus
168
What is the clinical presentation of a ectopic pregnancy?
Acute
6-8 weeks of Amenorrhoea
Lower abdominal pain
Shoulder tip pain
Late vaginal bleeding
Cervical excitation
169
What are common symptoms of a:
Appendicitis?
Acute
Colicky abdominal pain and guarding:
- Central abdomen pain that localises to the RLF within 24 hours
- Due to visceral **→**parietal peritoneum irritation
Low grade pyrexia
Tachycardia + Dyspnoea= perforation
N&V: anorexia
Foetor oris
Constipation/diarrhoea
Rebound and percussion tenderness at McBurney’s point: peritonitis
Appendix mass may be palpable in RIF
Pain PR suggests pelvic appendix
Rovsing's sign
Psoas sign
Cope sign
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What is Pelvic Inflammatory Disease?
Infection and inflammation of the female pelvic organs
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What usually causes PID?
Ascending infection from the cervix e.g.
- Chlamydia
- Gonorrhoea
- +/- E.coli
WORRIED ABOUT GROUP A STREP
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What are the risk factors for Pelvic Inflammatory Disease?
- Young
- New sexual partner
- Lack of barrier contraception
- Lower socio-economic group
- TOP
- IUD
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What is the clinical presentation of Pelvic Inflammatory Disease?
- Bilateral lower abdominal pain
- Acute
- Pelvic pain
- Fever
- Deep dyspareunia
- Purulent discharge
- Dysuria
- Amenorrhea
- Oligomenorrhea
- Cervical excitation on examination
174
What are the investigations of Pelvic Inflammatory Disease?
- Pregnancy test
- Cervical swabs
- Elevated ESR & CRP
- Endometrial biopsy
- USS
- Urinalysis
- Laparoscopy: direct visualisation of fallopian tubes
175
What is the treatment for PID?
- Ceftriaxone (1 dose IM) + doxycycline (2 doses PO) + metronidazole (BD for 14 days PO)
- Remove IUD
176
Define menstruation
Monthly bleeding from the reproductive tract due to hormonal changes
177
Define Menarche?
Last manifestation of puberty following development of secondary sex characteristics by oestrogen
178
What causes a menstrual cycle?
Hormonal changes causes ovulation and induce endometrial change to prepare for implantation
179
Describe the hypothalamic- pituitary axis
Hypothalamus → GnRH → FSH + LH → Ovaries release oestrogen + progesterone
Oestrogen + progesterone → negative feedback on hypothalamus + anterior pituitary
180
What happens in days 1-4 of the menstrual cycle?
- Hormonal support withdrawn
- Endometrium sheds
- Sometimes painful myometrial contraction
- Raised Oestradiol causes endometrium reform and thickening
- Positive feedback on LH = ovulation 36 hours later
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What happens on days 5-13 of the menstrual cycle?
- GnRH stimulates FSH & LH
- LH induces follicular growth → oestradiol and
inhibin production→ FSH suppression due to negative feedback
- Only one oocyte matures
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What happens in days 14-28 of the menstrual cycle?
- Follicle becomes Corpus Luteum
- Produces more progesterone than oestradiol → increased blood supply and endometrium enlargement
183
What happens if the corpus luteum is not fertilised?
Corpus luteum will collapse → fall in oestrogen and progesterone
184
What hormone is responsible for ‘growing’ the endometrium and what hormone ‘shrinks’ the endometrium?
- Oestrogen grows
- Progesterone shrinks
185
What is premenstrual syndrome?
The emotional and physical symptoms women experience prior to menstruation (luteal phase)
186
What is the clinical presentation of premenstrual syndrome?
- Anxiety
- Stress
- Fatigue
- Mood swings
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What is the management of premenstrual syndrome?
- Healthy diet
- Exercise
- Stress reduction methods
- Regular sleep
- Paracetamol
- COCP
- SSRIs
188
Define menorrhagia
- Excessive menstrual blood loss (>80mL) within a normal menstrual cycle.
- Interferes with their physical, emotional and social QOL.
189
What are the causes of menorrhagia?
- Most = no histological problem
- Fibroids/polyps (majority)
- Coagulation problems
- Endometriosis/adenomyosis
- Hypothyroidism
- Infection
- Ovulatory problems
- Endometrial dysfunction
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What investigations are ordered for menorrhagia?
- FBC
- TSH/T4
- Coagulation function
- STI screen
- B12/Folate/Iron
- Smear if due
- TVS: assess endometrial thickness and masses
- Endometrial biopsy + hysteroscopy: if TVS shows endometrial thickness >10mm and >40yrs (to exclude cancer)
191
What is the management of menorrhagia?
Conservative: watch and wait
Suppression of ovarian function for at least 6 months:
- Mirena coil: 1st line
- COCP: e.g. triphasing (3 months continuous then break)
- Medroxyprogesterone acetate (injectable contraception)
- Progestogens: norethisterone (no bleeding)
- POP: e.g. mini pill (no bleeding)
Anti-fibrinolytics: e.g. Tranexamic acid (during bleeding)
NSAIDS: e.g. Mefanamic acid (during bleeding)
GnRH agonist: e.g. Goserelin (max 6 months)
Myomectomy
Hysterectomy (only cure for fibroids in women who have completed their family)
Endometrial ablation
Resection of fibroids
Uterine artery embolization
Ulipristal acetate (shrinks fibroid)
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What is Post-Coital bleeding?
Non-menstrual bleeding that occurs immediately after sexual intercourse
193
What are causes of Post-Coital bleeding?
Infection
Cervical ectropion
Polyps
Carcinoma
194
What are investigations of Post-Coital bleeding?
- Bimanual and abdominal examination
- Smear
195
What is primary amenorrhoea?
- No menstruation by age 16.
- Absence of secondary sexual characteristics by 14 + no menarche
196
What is secondary amenorrhoea?
When previously normal menstruation stops for >6 months
197
What are the causes of primary amenorrhoea?
- Turner's Syndrome
- Androgen Insensitivity Syndrome
- Congenital malformations of genital tract
- Congenital adrenal hyperplasia
- Imperforate hymen
198
What is Oligomenorrhoea?
Menses >35 days apart
199
Why may a low birth weight cause secondary amenorrhoea?
- Low birth weight is linked to increased Ghrelin
- Ghrelin normally inhibits the hypothalamic-pituitary ovarian axis
- Decreased GnRH → decreased pituitary release of FSH and LH
200
What are the causes of secondary amenorrhoea?
- Drug induced
- Pregnancy (breast-feed)
- Hyperprolactinaemia (inhibits GnRH secretion)
- Hypothyroidism
- Ovarian causes (PCOS)
- Pituitary tumour
- Hypothalamic hypogonadism
201
What are the investigations for secondary amenorrhoea?
- BhCG (check for pregnancy)
- FSH/LH: low
- Prolactin
- TFTs
- Testosterone levels
202
What would a low FSH/LH mean in amenorrhoea?
Hypothalamic pituitary ovarian axis pathology
203
What would a high FSH/LH but low oestrogen mean in amenorrhoea?
Premature ovarian failure
204
What is premature ovarian failure?
Primary ovarian insufficiency in <40yrs + menopausal symptoms
205
What is the diagnostic criteria for premature ovarian failure?
1. FSH >25IU/I (2 samples 4 weeks apart)
2. 4 months of amenorrhoea
206
What is the management of premature ovarian failure?
**Cannot be reversed with HRT**
- HRT/COCP: symptomatic relief + prevents osteoporosis
- Donor eggs: fertility
207
What is the management of amenorrhoea due to HPO axis malformation?
Mild = stress/exercise (activity to stimulate enough oestrogen to produce an endometrium)
Severe = GnRH analogues
208
How would you manage fertility issues caused by amenorrhoea?
Clomifene
209
What is the pathophysiology of dysmenorrhoea?
- High prostaglandin levels in the endometrium
- Contractions
- Uterine Ischaemia
210
What are some causes of Secondary Dysmenorrhoea?
- Fibroids
- Adenomyosis
- Endometriosis
- PID
- Tumours
211
Name 4 reproductive disorders that are associated with obesity
1. PCOS.
2. Miscarriage.
3. Infertility.
4. Obstetric complications
212
What is Genitourinary Prolapse?
Descent of 1≥ of the pelvic organs:
- Uterus/vaginal walls
- Bladder
- Rectum
- Small/large bowel
- Vaginal vault
213
What is the clinical presentation of Genitourinary Prolapse?
Urinary
Bowel
Sexual
Local pelvic symptoms
214
What are the risk factors for Genitourinary Prolapse?
- Increasing age
- Vaginal delivery
- Increasing parity
- High BMI
- Spina bifida and spina bifida occulta
- Pelvic mass
- Menopause
- Iatrogenic (pelvic surgery)
215
What is the pathophysiology of Genitourinary Prolapse?
- Pelvic organs losing their structure through muscle trauma, neuropathic injury or stretching.
- Orientation and shape of pelvic bones
216
Name the three anterior compartment prolapses
1) Urethrocele (urethra → vagina)
2) Cystocele (bladder → vagina)
3) Cystourethrocele (both)
217
Name the three middle compartment prolapses
1) Uterine prolapse (→ vagina)
2) Vaginal vault prolapse (descent of vaginal vault post hysterectomy)
3) Enterocele
218
What is an enterocele?
Pouch of Douglas (small bowel) into the vagina
219
What is a posterior compartment prolapse?
Rectocele (rectum into the vagina)
220
What are the 4 stages of vaginal prolapse?
Stage 1: >1cm above the hymen
Stage 2: within 1cm proximal/distal of the hymen
Stage 3: >1cm below the plane of the hymen, but protrudes no further than <2cm of the total length of the vagina
Stage 4 : complete eversion of the vagina
221
What is the clinical presentation of Genitourinary Prolapse?
- Older women
- Asymptomatic
- Dragging down, pressure and heaviness
- Pain
- Lump
- Discomfort
- Dyspareuria
- Urinary symptoms: incontinence, frequency and urgency **(anterior symptoms)**
- Constipation/straining **(posterior symptoms)**
222
What investigations are ordered for Genitourinary Prolapse?
- Assessment of post-void residual urine (PVR) volume
- Assessing pelvic floor muscles- bimanual examination + exclude pelvic masses
- Urinalysis
- Urodynamics
- Bladder diaries
- Symptom scoring and quality-of-life assessment
- Measure post-void residual volume by bladder scan or catheterisation
- Defecography, anal manometry and endoanal ultrasound (constipation or faecal incontinence)
- Imaging + cystoscopy as a last resort
223
What is the management of Genitourinary Prolapse?
CONSERVATIVE (reduction of intrabdominal pressure):
- Weight loss
- Stop smoking
- Reduce straining i.e constipation or heavy lifting
- Pelvic floor muscle exercises
- Vaginal pessaries e.g. ring
Surgical (last resort):
- Hysterectomy
- Colporrhapy (all prolapse tx)
- Colposuspension (stress incontinence tx)
- Sacrohysteropexy (uterine prolapse tx)
- Sacrospinous fixation (uterine prolapse tx)
224
What is a sacrospinous fixation?
- Stitches the top of the vagina/cervix to a pelvic ligament (sacrospinous ligament)
- Treats uterine prolapses
225
What is a sacrohysteropexy
- Re-suspends the prolapsed uterus to the anterior longitudinal presacral ligament via polypropylene mesh
- Treats uterine prolapses
226
What is colposuspension?
- Stitches pull up the vagina around the bladder opening
- Treats stress incontinence
227
What is a Colporrhaphy?
- Repairs defective vaginal walls
- Treats most prolapses
228
Describe the epithelium of the detrusor muscle
Smooth muscle with transitional epithelium
229
What is the nerval innervation of the detrusor muscle?
Parasympathetic S2-S4
230
What is the functional bladder capacity?
400ml
231
Define incontinence
The involuntary leakage of urine
232
What are the two types of incontinence?
1) Urgency
2) Stress
233
What is urge incontinence?
Overactive bladder: involuntary detrusor muscle bladder contractions
234
What is stress incontinence?
-Weak urethral sphincter: detrusor pressure > closing pressure of urethra).
-Increase in intra-abdominal pressure results in the leakage of urine.
235
What is the clinical presentation of a Overactive Bladder (urge incontinence)?
- 'Key in door' urgency
- Frequency
- Nocturia
- Enuresis
236
What is the clinical presentation of Stress Incontinence?
Leakage on:
- Coughing
- Laughing
- Lifting
- Exercise
- Movement
237
What are the causes of Stress Incontinence?
- Menopause = low oestrogen = weakening pelvic support
- Radiotherapy
- Congenital weakness
- Pelvic surgery
238
What investigations are ordered in Incontinence?
- Bimanual examination
- MSU
- Bladder diary (frequency volume chart).
- Urinalysis
- Post-void residual bladder volume e.g. catheter or USS
- Urodynamic testing
- ePAQ.
239
What information from a urinalysis will aid you in diagnosing incontinence?
- Nitrates & Leukocytes = infection
- Haematuria= Glomerulonephritis
- Proteinuria = Renal Disease
- Glycouria = diabetes
240
What information can you obtain from a bladder diary?
1. Frequency
2. Quantity of urine
3. Fluid intake
4. Diurnal variation
241
How do you measure the Post-void residual bladder volume in incontinence?
Urine in and out of the catheter/US
242
What is the ePAQ questionnaire in incontinence?
Explores impact on life to determine management plan
243
What questions are involved in the ePAQ questionnaire in incontinence?
Urinary: pain, voiding, stress and overactive bladder
Vaginal: pain, capacity and prolapse
Bowel: IBS, constipation and continence
Sexual: dyspareunia and overall sex life
244
What is the general management of incontinence?
- Weight loss
- Reduce caffeine
- Smoking cessation
- Avoid straining
- Pads and pants
- Catheters
245
What is the management of Stress incontinence?
Pelvic floor exercises
Duloxetine (SNRI- antidepressant)
Surgery (supports + restores pressure to the urethra):
- Colposuspension
- Sling
- TVT (tension free vaginal tape)
246
How do pelvic floor exercises work in treating someone with stress incontinence?
- Pelvic floor muscle contraction → urethra compression → increased urethral pressure → reduced leakage
- Vaginal cones can also be used
247
What is the management of overactive bladder incontinence?
Antimuscarinics/Anticholinergics: Oxybutynin
Adrenergic agonist: Mirabegron
Botox: Botulinum Toxin
Surgery:
- Bladder Drill
- Bypass
248
How does botulinum toxin work in treating OAB incontinence?
Blocks ACh release → reduced destrusor muscle contraction
249
Give 5 side effects of oxybutynin
1. Dry mouth
2. Constipation
3. Blurred vision
4. Cognitive impairment
5. Tachycardia
250
Name an adrenergic agonist used in OAB
Mirabegron
251
How does mirabegron work in treating OAB?
- Beta 3 agonist
- Relaxes the detrusor muscle and increases bladder capacity
252
Where are FSH and LH produced
Anterior pituitary gland
253
Where is GnRH produced?
Hypothalamus
254
When LH and FSH have binding to the various cells, what is produced?
1) Theca cells produce Androstenedione
2) Granulosa cells produce aromatase
3) Aromatase converts Androstenedione into oestrogen
4) Oestrogen creates negative feedback to stop producing FSH
5) Once oestrogen becomes really high → becomes positive feedback to produce FSH and LH
6) Influx of FSH and LH = release of oocyte
255
What effect does high oestrogen levels have on the endometrium?
1) Thickening of endometrium
2) Growth of endometrial glands
3) Emergence of spiral arteries to supply the released oocyte
4) Makes cervical mucus more hospitable for incoming sperm
256
What is the dominant hormone in the luteal phase?
- Progesterone
- Luteinised granulosa and theca cells produce progesterone and inhibin → negative feedback on FSH/LH and oestrogen
257
What does the corpus luteum become?
1) Corpus albicans (doesn't produce hormones)
2) Low progesterone → spiral arteries collapse and functional layer sloughs off
258
What are the two phases of the uterus in the menstrual cycle?
- Days 1-14 = Menstrual/ follicular/ proliferative phase
- Days 15-28 = luteal/ secretory phase
259
Define FGM
Procedures involving damaging or removing external female genitalia for non-medical reasons.
260
What problems can FGM cause?
- Conception
- Labour
- Infections
- PTSD
- Chronic pain
- PPH
- Increased need for C-section and episiotomy
