Gynaecology Flashcards
What is a pelvic organ prolapse?
- The descent of the pelvic organs into the vagina
- The prolapse is a result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
What are the different types of prolapse?
- Uterine
- Vault
- Rectocele
- Cystocele
What is a vault prolapse?
- When a women has had a hysterectomy and no longer have a uterus
- The top of the vagina (the vault) descends into the vagina
What is a rectocele?
- They are caused by weakness in the posterior vaginal wall
- This allows the rectum to prolapse forward into the vagina
What are the signs and symptoms of a rectocele?
- They are associated with constipation and women can develop faecal loading in the part of the rectum that has prolapsed
- The loading of faeces causes urinary retention due to compression on the urethra and a palpable lump in the vagina that can be pushed backwards
What is a cystocele?
- Caused by a defect in the anterior vaginal wall allowing the bladder to prolapse backwards into the vagina
- Can also happen with the urethra (urethrocele) and a combined one is called a cystourethrocele
What are the risk factors for developing pelvic organ prolaspe?
- Multiple vaginal deliveries
- Prolonged traumatic delivery
- Age
- Obesity
- Coughing/constipation strain
- Menopause
What is the presentation of a pelvic organ prolapse?
A feeling of “something coming down” in the vagina
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
How would you examine a pelvic organ prolapse?
- Dorsal and left lateral position
- A Sim’s speculum would be used to support opposing vaginal wall to one being examined
What is the grading system and what are the grades for pelvic organ prolapse?
rade 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
What is the conservative management of pelvic organ prolapse?
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
What are vaginal pessaries?
- They are inserted into the vagina to provide extra support to the pelvic organs
What are the two types of urinary incontinence?
urge incontinence
stress incontinence.
What causes urge incontinence?
Overactivity of the detrusor muscle
What causes stress incontinence?
Weakness of the pelvic floor and sphincter muscles
What are the ways of testing for urinary incontinence?
- A bladder diary
- Urodynamic tests
What ate the managements for stress incontinence?
- Avoid dirutetics
- Weight loss
- Pelvic floor exercises
- Duloxetine
What is the management for urge incontinence?
- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
They have side effects which include dry mouth dry eyes, postural hypotension and can lead to cognitive decline
What is an alternative treatment for urge incontinence?
Mirabegron but is a beta-3 agonist so raises BP
What are the risk factors for developing kidney stones?
- Dehydration
- Previous kidney stones
- Stone forming foods
- Metabolic
- Systemic disease: Crohn’s disease (calcium oxalate stones)
- Metabolic:hypercalcaemia, hyperparathyroidism, hypercalciuria (calcium stones)
- Loop diuretics
What are some stone forming foods?
- Chocolate
- Spinach
- Nuts
- Tea
What are the most common types of kidney stones?
Calcium-based stones they account for 80%. Having a raised serum calcium and low urine output are key risk factors for calcium collecting into a stone
What are the two types of calcium stone?
- Calcium oxalate (most common) results in a black or dark coloured stone.
- Calcium phosphate- results in a dirty white colour stone
What are some other types of kidney stones?
-
Uric acid: red-brown in colour and not visible under an x-ray.
Risk factors: food high in purines e.g. shellfish, anchovies, red meat or organ meat, as uric acid is a breakdown product of purine - Struvite- produced by bacteria (Proteus mirabilis, Proteus vulgaris, and Morganella morganii) therefore are associated with infection. Forms dirty white stones visible on X-ray.
- Cystine – associated with cystinuria, an autosomal recessive disease form yellow or light pink coloured stones not visible on x-ray
What causes struvite stones to form?
Bacteria release enzyme urase which causes ammonia to form. Ammonia makes urine more alkaline so favours the precipitation of phosphate, magnesium and ammonium.
These form jagged crystals called Staghorns
What is the cause of the pain associated with kidney stones?
- The peristaltic action of the collecting duct against the stone.
- Pain is worse at the uteropelvic junction and down the ureter pain subsides once stone gets to the bladder
What are the symptoms of renal stones?
- Acute severe flank pain: loin to groin pain that lasts minuets to hours . Fluctuating pain
- Nausea and vomiting
- Haematuria
- reduced urine output
What are some first-line investigations for renal stones?
- Urine dipstick can show blood
- FBC check kidney function and calcium levels
- X-ray can show calcium based stones but not uric
What is the gold standard test for renal stones?
- Non contrast CT scan of kidney, ureters and bladder (CT KUB) .
Should be performed within 14 hours of admission
May use ultrasound if radiation needs to be avoided
What is the best form of pain relief for renal stones?
- NSAIDs are typically used. IM diclofenac is most commonly used. Opiates are typically used as not good
What is the conservative/medical treatment for renal stones?
- Watchful waiting is usually used in stones less than 5mm, as there is a 50-80% chance they will pass without any interventions. It
- Tamsulosin is an alpha blocker that can be used to help passage of stones not indicated for renal more for ureteric
What are the surgical treatments for renal stones?
ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.
Ureteroscopy and laser lithotripsy:
A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.
Percutaneous nephrolithotomy (PCNL):
PCNL is performed in theatres under a general anaesthetic. A nephoscopy (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.
What is the advice for a patient suffering from recurrent renal stones?
- Increase oral fluids
- Reduce salt intake
- Reduce oxalate/urate rich food intake
- Avoid carbonated drinks
- Add lemon juice to waters
What medications can be used to reduce the risk of renal stone formation?
Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium
What are the complications of renal stones?
- Obstruction and hydronephrosis: acute kidney injury and renal failure
- Urosepsis: an infected, obstructing stone is a urological emergency and requires urgent decompression
What is Androgen insensitivity syndrome?
- It is a condition where cells are unable to respond to androgen hormones due to a lack of receptors.
- Patients with this condition are genetically male however the absent response to testosterone and the extra production of oestrogen leads to a female phenotype b
What type of genetic condition is Androgen insensitivity syndrome?
X-linked recessive
What anatomical features will someone with Androgen insensitivity syndrome have?
- They will have testes in the abdomen or inguinal canal
- They will not have a uterus, upper vagina, cervix, fallopian tubes and ovaries.
- This is because the testes produce anti Mullerian hormone which prevents them from forming
What other features will someone with Androgen insensitivity syndrome have?
- Lack of pubic and facial hair and male muscle development
- Will be taller than average female
- They are infertile and there is an increased risk of testicular cancer
What is the presentation of Androgen insensitivity syndrome?
- Will often present in infancy with inguinal hernias containing testes
- Presents a puberty with primary amenorrhoea
What will the hormone tests show in Androgen insensitivity syndrome?
Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)
What is the management of Androgen insensitivity syndrome?
- Bilateral orchidectomy
- Oestrogen therapy
- Vaginal dilators or surgery to create an adequate vaginal length
What is partial androgen insensitivity syndrome?
- Where the cells are partially responsive to androgens,
- Will present with more ambiguous symptoms such as micropenis of clitoromegaly
What is menopause?
- A retrospective diagnosis made after a woman has had no periods for 12 months
- It is defined as a permanent end to menstruation
- Menopause is the point at which menstruation stops
What is perimenopause, postmenopausal and premature menopause?
- Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
- Postmenopausal describes the period from 12 months after the final menstrual period onwards.
- Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
What causes menopause?
- It is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle
- Oestrogen and progesterone levels are low
- LH and FSH levels are high in response to an absence of negative feedback from oestrogen
Describe how oestrogen is released during the menstrual cycle ?
- In the ovaries the process of primordial follicles maturing is into primary and secondary follicles is always occurring
- At the start of the menstrual cycle FSH stimulates the further development of secondary follicles
- As the follicles grow the granulosa cells that surround them secrete increasing amounts of oestrogen
How does the menopause begin?
- The menopause begins with a decline in the development of ovarian follicles
- Without the growth and development of the follicles there is reduced production of oestrogen
- This results in increasing levels of LH and FSH as oestrogen has a negative feedback on these hormones in the pituitary gland
How is the menstrual cycle affected in the menopause?
- Falling follicular development means ovulation does not occur (anovulation)
- Without oestrogen the endometrium does not develop leading to a lack of menstruation (Amenorrhoea)
- The low levels of oestrogen lead to the perimenopausal symptoms
What are the perimenopausal symptoms?
- Hot flushes
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier or lighter periods
- Vaginal dryness and atrophy
- Reduced libido
What does a lack of oestrogen increase the risks of?
- CVD
- Osteoporosis
- Pelvic organ collapse
- Urinary incontinence
How can menopause be diagnosed?
- Symptoms without blood test
- Use FSH blood test in women under 40 or aged 40-45 with menopausal symptoms
How long do women need to use contraception for after the menopause?
- Two years after the last menstrual period in women under 50
- One year after the last menstrual period in women over 50
What is the management of perimenopausal symptoms?
Hormone replacement therapy (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
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
What can be used to help with the vasomotor symptoms of the menopause?
Clonidine which is a alpha-2 agonist
What are the indications of HRT?
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
What are the risks of HRT
- Breast and endometrial cancer
- Increased risk of VTE with oral pill
- Women are not at increased risk under 50
What are some contraindications for HRT?
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
What is adenomyosis?
- When endometrial tissue (tissue that lines the uterus) grows in the Myometrium (the muscular layer of the uterus)
- It is more common in later reproductive years and those that have had several pregnancies
What is the presentation of Adenomyosis?
- Painful periods
- Heavy periods
- Pain during intercourse
It may also present with infertility or pregnancy related complications. 1/3 of patients will be asymptomatic
What will an examination of Adenomyosis show?
- An enlarged tender uterus that will feel mores soft than a uterus containing fibroids
How would you diagnose Adenomyosis?
- First-line is transvaginal ultrasound: can also use MRI and transabdominal where not appropriate
- The gold standard is a histological examination of the uterus after a hysterectomy
What is the management of Adenomyosis when contraception is not wanted?
- Tranexamic acid when there is no associated pain (antifibrinolytic so reduces bleeding)
- Mefenamic acid where there is associated pain (NSAID reduces bleeding and pain)
What is the management of Adenomyosis when contraception is wanted or acceptable?
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
What complications can adenomyosis cause in pregnancy?
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
What is Asherman’s syndrome?
- It is where adhesions (sometimes called synechiae) form within the uterus following damage to the uterus
When does Asherman’s syndrome usually occur?
- It happens following damage to the uterus and often happens after a pregnancy related dilation and curettage procedure
- For example retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
What happens as a result of the adhesions Asherman’s syndrome?
- The damage endometrium forms scar tissue which connects areas of the uterus that are not usually connected
- These adhesions may bind the uterine walls together or the endocervix sealing it shut
- These adhesions form physical obstructions and distort the pelvic organs
What are the symptoms Asherman’s syndrome?
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
If a patient is asymptomatic then it is not classified as Asherman’s syndrome
How would you diagnose and manage Asherman’s syndrome?
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with x-rays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan
Management is dissecting the adhesions during hysteroscopy
What is lichen sclerosus?
- It is a chronic inflammatory skin condition that presents with patches of shiny porcelain white skin
Where is commonly affected with lichen sclerosus?
- Labia, perineum and perineal skin
- Can also affect the axilla and thighs and men on foreskin and glans
What causes lichen sclerosus and what conditions is it associated with?
- Autoimmune condition
- Linked to T1DM, alopecia, hypothyroid and vitiligo
- Can be diagnosed with clinical presentation
What are the typical presentations of lichen sclerosus?
- 45-60 with vulval itching and skin changes
- Can be asymptomatic or have symptoms such as:
Soreness (worse at night)
Skin tightness
Painful sex
Erosions
Fissures
What is the koebner phenonmenon?
When the signs and symptoms are made worse by friction to the skin such as wearing tight underwear, urinary incontinence and scratching
What is the treatment for lichen sclerosus?
- Topical potent steroids (dermovate) used long term and reduce the risk of malignancy
What is the main complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
What are the types of vulval cancer?
- 90% are squamous cell carcinomas
- They can also malignant melanomas
What are the risk factors for vulval cancer?
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
What is Vulval Intraepithelial Neoplasia?
- A premalignant condition affecting the squamous epithelium
- High grade squamous intraepithelial lesion is a type of VIN associated with a HPV infection
- A differentiated VIN is associated with lichen sclerosus
What are the symptoms of vulval cancer?
- Vulval lump
- Ulceration
- Bleeding
- Pain
- Itching
- Lymphadenopathy in the groin
What is the management of a suspected vulval caner?
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Establishing the diagnosis and staging involves:
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)
What is the staging system used for vulval cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
What are the types of cervical cancer?
- 80% are squamous cell carcinomas
- Adenocarcinoma
- Rarely small cell cancer
What is the main risk factor for cervical cancer?
HPV
At what age are girls vaccinated against HPV?
12-13
What is HPV?
- It is a sexually transmitted infection that can cause anal, vulval, vaginal, penis, mouth and throat cancers
- HPV proteins e6 and e7 inhibit tumour suppressor genes p53(e6) and pRb(e7)
What types of HPV are the main causes of cervical cancer?
Type 16 and type 18. There is no treatment for HPV most resolve spontaneously
What are the risk factors for cervical cancer?
Increased risk of catching HPV
Later detection of precancerous and cancerous changes (non-engagement with screening)
Other risk factors
What puts you at increased risk of catching HPV?
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
What are some other risk factors for cervical cancer?
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
What are the symptoms of cervical cancer?
- Many paitents are asymptomatic and picked up on screening
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
What appearance of the cervix is suggestive of cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
Patients should be referred for a colposcopy
What is Cervical Intraepithelial Neoplasia?
it is a grading system for the level of dysplasia in the cells of the cervix
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
How cervical cancer screened for?
- A cervical smear test which is a collection of cells for the cervix
- Cells are examined under a microscope for precancerous changes (Dyskaryosis)
This method is called liquid-based cytology
How often should screening occur?
Every three years aged 25 – 49
Every five years aged 50 – 64
What are the exceptions to the normal cervical screening program?
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
What is the management of a cervical screen?
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the
HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
What are the different stages of cervical cancer?
FIGO staging
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
What is the management for the different stages of cervical cancer
Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
5 year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4
What monoclonal antibody can be used to treat cervical cancer?
Bevacizumab (avastin)
What is the vaccine for HPV?
Needs to be given to boys and girls before they become sexually active
Gardasil protects against strains 6, 11, 16 and 18:
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
What is the main type of endometrial cancer?
80% of cases are adenocarcinomas
It is an oestrogen dependant cancer meaning that oestrogen stimulates the growth of endometrial cancer cells
What is the key presentation of endometrial cancer?
- Post menopausal women with bleeding
What is endometrial hyperplasia?
- Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium
- Treated by a specialist using progestogens, with either:
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
What are the risk factors for endometrial cancer?
- Unopposed oestrogen (oestrogen without progesterone)
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Why is obesity a risk factor for endometrial cancer?
- Fat tissue is a source of oestrogen as it produces aromatase which converts androgens