1
Q
What is a pelvic organ prolapse?
A
- 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
2
Q
What are the different types of prolapse?
A
- Uterine
- Vault
- Rectocele
- Cystocele
3
Q
What is a vault prolapse?
A
- When a women has had a hysterectomy and no longer have a uterus
- The top of the vagina (the vault) descends into the vagina
4
Q
What is a rectocele?
A
- They are caused by weakness in the posterior vaginal wall
- This allows the rectum to prolapse forward into the vagina
5
Q
What are the signs and symptoms of a rectocele?
A
- 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
6
Q
What is a cystocele?
A
- 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
7
Q
What are the risk factors for developing pelvic organ prolaspe?
A
- Multiple vaginal deliveries
- Prolonged traumatic delivery
- Age
- Obesity
- Coughing/constipation strain
- Menopause
8
Q
What is the presentation of a pelvic organ prolapse?
A
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
9
Q
How would you examine a pelvic organ prolapse?
A
- Dorsal and left lateral position
- A Sim’s speculum would be used to support opposing vaginal wall to one being examined
10
Q
What is the grading system and what are the grades for pelvic organ prolapse?
A
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
11
Q
What is the conservative management of pelvic organ prolapse?
A
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
12
Q
What are vaginal pessaries?
A
- They are inserted into the vagina to provide extra support to the pelvic organs
13
Q
A
14
Q
What are the two types of urinary incontinence?
A
urge incontinence
stress incontinence.
15
Q
What causes urge incontinence?
A
Overactivity of the detrusor muscle
16
Q
What causes stress incontinence?
A
Weakness of the pelvic floor and sphincter muscles
17
Q
What are the ways of testing for urinary incontinence?
A
- A bladder diary
- Urodynamic tests
18
Q
What ate the managements for stress incontinence?
A
- Avoid dirutetics
- Weight loss
- Pelvic floor exercises
- Duloxetine
19
Q
What is the management for urge incontinence?
A
- 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
20
Q
What is an alternative treatment for urge incontinence?
A
Mirabegron but is a beta-3 agonist so raises BP
21
Q
What are the risk factors for developing kidney stones?
A
- Dehydration
- Previous kidney stones
- Stone forming foods
- Metabolic
- Systemic disease: Crohn’s disease (calcium oxalate stones)
- Metabolic:hypercalcaemia, hyperparathyroidism, hypercalciuria (calcium stones)
- Loop diuretics
22
Q
What are some stone forming foods?
A
- Chocolate
- Spinach
- Nuts
- Tea
23
Q
What are the most common types of kidney stones?
A
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
24
Q
What are the two types of calcium stone?
A
- Calcium oxalate (most common) results in a black or dark coloured stone.
- Calcium phosphate- results in a dirty white colour stone
25
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
26
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**
27
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
28
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
29
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
30
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
31
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
32
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
33
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.
34
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
35
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
36
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
37
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
38
What type of genetic condition is Androgen insensitivity syndrome?
X-linked recessive
39
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
40
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
41
What is the presentation of Androgen insensitivity syndrome?
- Will often present in infancy with inguinal hernias containing testes
- Presents a puberty with primary amenorrhoea
42
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)
43
What is the management of Androgen insensitivity syndrome?
- Bilateral orchidectomy
- Oestrogen therapy
- Vaginal dilators or surgery to create an adequate vaginal length
44
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
45
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
46
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.
47
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
48
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
49
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
50
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
51
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
52
What does a lack of oestrogen increase the risks of?
- CVD
- Osteoporosis
- Pelvic organ collapse
- Urinary incontinence
53
How can menopause be diagnosed?
- Symptoms without blood test
- Use FSH blood test in women under 40 or aged 40-45 with menopausal symptoms
54
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
55
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
56
What can be used to help with the vasomotor symptoms of the menopause?
Clonidine which is a alpha-2 agonist
57
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
58
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
59
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
60
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
61
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
62
What will an examination of Adenomyosis show?
- An enlarged tender uterus that will feel mores soft than a uterus containing fibroids
63
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
64
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)
65
What is the management of Adenomyosis when contraception is wanted or acceptable?
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
66
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
67
What is Asherman’s syndrome?
- It is where adhesions (sometimes called synechiae) form within the uterus following **damage** to the uterus
68
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).
69
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
70
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
71
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**
72
What is lichen sclerosus?
- It is a chronic inflammatory skin condition that presents with patches of **shiny porcelain white skin**
73
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
74
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
75
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
76
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
77
What is the treatment for lichen sclerosus?
- Topical potent steroids (dermovate) used long term and reduce the risk of malignancy
78
What is the main complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
79
What are the types of vulval cancer?
- 90% are squamous cell carcinomas
- They can also malignant melanomas
80
What are the risk factors for vulval cancer?
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
81
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
82
What are the symptoms of vulval cancer?
- Vulval lump
- Ulceration
- Bleeding
- Pain
- Itching
- Lymphadenopathy in the groin
83
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)
84
What is the staging system used for vulval cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
85
What are the types of cervical cancer?
- 80% are squamous cell carcinomas
- Adenocarcinoma
- Rarely small cell cancer
86
What is the main risk factor for cervical cancer?
HPV
87
At what age are girls vaccinated against HPV?
12-13
88
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)
89
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
90
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
91
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
92
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)
93
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)
94
What appearance of the cervix is suggestive of cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
Patients should be referred for a colposcopy
95
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.
96
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**
97
How often should screening occur?
Every three years aged 25 – 49
Every five years aged 50 – 64
98
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
99
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
100
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
101
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
102
What monoclonal antibody can be used to treat cervical cancer?
Bevacizumab (avastin)
103
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
104
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
105
What is the key presentation of endometrial cancer?
- Post menopausal women with bleeding
106
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)
107
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
108
Why is obesity a risk factor for endometrial cancer?
- Fat tissue is a source of oestrogen as it produces aromatase which converts androgens
109
Why is T2DM a risk factor for endometrial cancer?
Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer.
PCOS is also associated with insulin resistance and increased insulin production. Insulin resistance further adds to the risk of endometrial cancer in women with PCOS.
110
What are some protective factors for endometrial cancer?
- Combined pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
Oestrogen may be metabolised differently in smokers
Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
Smoking destroys oocytes (eggs), resulting in an earlier menopause
111
What are the symptoms of endometrial cancer?
**postmenopausal bleeding**
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
112
What is the referral criteria for endometrial cancer?
- Postmenopausal bleeding (12 months after last period)
Transvaginal ultrasound in women over 55 with:
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets anaemia or raised glucose levels
113
What are the investigations for endometrial cancer?
- Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
114
What are the FIGO stages for endometrial cancer?
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
115
What is the treatment for endometrial cancer?
- Stage 1 and 2 is a total abdominal hysterectomy with bilateral salpingo-oophorectomy
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
116
Why is ovarian cancer dangerous?
- It has very non-specific symptoms more than 70% of patients present when it has spread beyond the pelvis
117
What are the different types of ovarian tumours?
- Epithelial cell tumours (most common)
- Germ cell tumours they are associated with ovarian torsion and can cause raised ** alpha fetoprotein** and **hCG**
- Sex cord-stromal tumours
They may also be a metastasis called a **krukenberg tumour** usually from a GI tumour. They produce **signet ring cells** on histology
118
What are the risk factors and protective factors for ovarian cancer?
Risk factors:
- Age (peaks age 60)
- BRCA1 and BRCA2 genes (consider the family history)
- Increased number of ovulations
- Obesity
- Smoking
- Recurrent use of clomifene
Protective factors:
- Combined contraceptive pill
- Breastfeeding
- Pregnancy
119
What are the symptoms of ovarian cancer?
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
Can cause hip or groin pain due to compression on the **obturator nerve**
120
What is the criteria for the 2 week wait for ovarian cancer?
- Ascites
- Pelvic mass
- Abdominal mass
121
What are the the initial investigations for ovarian cancer?
- Raised CA125 blood test
- Pelvic ultrasound
122
What else can cause a raised CA125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
123
What is the FIGO staging for ovarian cancer?
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
124
What is classified as heavy menstrual bleeding?
80ml or more blood loss (normal is 40ml)
Diagnosed by symptoms such as frequent pad changing, more than 7 days and passing large clots
125
What are some causes of heavy menstrual bleeding?
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Bleeding disorders (e.g. Von Willebrand disease)
126
Questions to ask with heavy bleeding?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital - bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
127
What is the management for heavy menstrual bleeding if women do not want to use contraception?
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
128
What is primary amenorrhoea?
- By 13 years when there is no other evidence of pubertal development
- By 15 years of age where there are other signs of puberty, such as breast bud development
129
What are some causes of primary amenorrhoea?
Hypogonadism
Kallman Syndrome
Congenital Adrenal Hyperplasia
Androgen Insensitivity Syndrome
Structural Pathology
130
What are the two types of hypogonadism?
Hypogonadotropic hypogonadism: a deficiency of LH and FSH
Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
131
What is Secondary amenorrhea?
No menstruation more than 3 months after regular periods
Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.
132
What are some causes of Secondary amenorrhea?
Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
133
What can cause the hypothalamus to reduce production of GnRH?
Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress
134
Why can a prolactinoma cause secondary amenorrhoea?
- As prolactin inhibits the production of GnRH
135
What is a risk of secondary amenorrhoea?
Osteoporosis
Ensure adequate vitamin D and calcium intake
Hormone replacement therapy or the combined oral contraceptive pill
136
What is endometriosis?
- Where there is ectopic endometrial tissue outside the uterus
-Endometrial tissue outside the uterus is described as an **endometrioma**.
- .Endometriomas in the ovaries are often called “chocolate cysts”.
- Adenomyosis refers to endometrial tissue within the myometrium
- In females over 17 years of age endometriosis should be considered for if symptoms have been present for over 6 months
137
What is believed to cause endometriosis?
- Retrograde menstruation when endometrial tissue flows back into the fallopian tubes
- Embryonic cells remain outside the uterus
- Lymphatic system spread of endometrial cells
- Metaplasia of the cells to endometrial cells
138
What is the pathophysiology of endometriosis?
- The cells outside of the uterus respond in the same way as the ones in the uterus
- This causes inflammation of tissue around the site of the endometriosis
- Can lead to adhesions which causes chronic non-cyclical pain. These can also lead to reduced fertility
- Can also deposit in the bladder or bowels leading to blood in urine or stools
139
What are the symptoms of endometriosis?
The main symptom if **cyclical pelvic pain**.
- Deep dyspareunia (pain on deep sexual intercourse)
- Dysmenorrhoea (painful periods)
- Infertility
- Cyclical bleeding from other sites, such as haematuria
140
What will an examination reveal for endometriosis?
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual
Tenderness in the vagina, cervix and adnexa
141
How would you diagnose Endometriosis?
- Pelvic ultrasound may reveal endometriomas and chocolate cysts but are often unremarkable so need to be referred for laparoscopy
- Laparoscopic surgery is the gold standard diagnosis with a biopsy of the lesions and deposits can be removed to improve symptoms
142
What is the initial management for endometriosis?
- Establish diagnosis and explain it to patient
- Analgesia
143
What is the hormonal management of endometriosis?
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g.
Depo-Provera)
Nexplanon implant
Mirena coil
**All these methods will stop ovulation and reduce endometrial thickening**
GnRH agonists (goserelin)- will induce a menopause like state
144
What are the surgical options for endometriosis?
- Laparoscopic surgery used to excise or ablate endometrial tissue and remove adhesions
- Hysterectomy and bilateral salpingo-oophorectomy is the final surgical option. **This will induce the menopause**
145
What are fibroids?
- They are benign tumours of the smooth muscle of the uterus. **uterine leiomyomas**
- They are very common and affect 40-60% of women.
- They are oestrogen sensitive meaning they grow in response to oestrogen
146
What are the different types of fibroids?
Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.
147
What is the presentation of fibroids?
Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
148
What are the investigations for fibroids?
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
Pelvic ultrasound is the investigation of choice for larger fibroids.
MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
149
What is the management for fibroids less than 3cm?
- Some form of hormonal contraceptives
- Symptomatic control with NSAIDs and tranexamic acid
- Ablation/resection or hysterectomy
150
What is the management for fibroids more than 3cm?
Same but refer to gynaecologist but also can have:
Uterine artery embolization- blocking artery that supplies fibroid
Myomectomy
Hysterectomy
GnRH such as goserelin may be needed before surgery
151
What are the complications of fibroids?
- Anaemia
- Reduced fertility
- Pregnancy complications
- Constipation
- UTIs/ outflow obstructions
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%
152
What is red degeneration of fibroids?
- Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
- More likely to occur with large fibroid and big risk during pregnancy due to growth and kinking of vessels in uterus
153
What is the presentation of a red degeneration of a fibroid?
- Severe abdominal pain, low-grade fever, tachycardia and often vomiting
- Treat with fluids, rest and analgesia
**Pregnant women with history of fibroids and these symptoms**
154
What is a hydatidiform mole?
- A type of tumour that grows like a pregnancy inside the uterus
- This is called a molar pregnancy
155
What are the two types of hydatidiform mole?
- **Partial mole**: when two sperm cells fertilise a normal ovum at the same time and it has 3 sets of chromones called a haploid cell
- **Complete mole**: when two sperm fertilise and ovum that contains no genetic material
156
How would you diagnose a molar pregnancy?
**Will behave like a normal pregnancy**
Indications will be:
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of uterus
- Abnormally high hCG
- Thyrotoxicosis as hCG can mimic TSH
**Ultrasound will show snowstorm appearance of the pregnancy**
157
What is the treatment for a molar pregnancy?
- Evacuation of the uterus
- Monitoring of hCG levels
- Can metastasise so maybe chemo required
158
What can cause a prolactinoma?
Multiple endocrine neoplasia type 1
Prolactinomas can be:
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
159
What is the management for a prolactinoma?
Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms.
Trans-sphenoidal surgical removal of the pituitary tumou
160
What are the symptoms of a prolactinoma?
Menstrual irregularities, particularly amenorrhoea (absent periods)
Reduced libido (low sex drive)
Erectile dysfunction (in men)
Gynaecomastia (in men)
Due to prolactin supressing GnRH from the hypothalamus
161
What is an ovarian cyst?
- A fluid-filled sac: functional ones are related to fluctuating hormones of the the menstrual cycles
- Are very common in premenopausal women and are normally benign
- Postmenopausal cysts are more concerning for malignancy and need further investigations
162
What is required for a diagnosis of polycystic ovarian syndrome?
at least two of:
Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound
163
What are the symptoms of an ovarian cyst?
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
164
What is the key for an ovarian cyst?
Assessing whether it is benign or malignant.
A simple cyst less than 5cm does not need further investigation
165
What is the risk of malignancy index?
Estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
166
What are the complications of a ovarian cyst?
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum
167
What is meig syndrome?
Triad of:
- Ovarian fibroma
- Pleural effusion
- Ascites
Occurs in older women
168
What is an ovarian torsion?
- Where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
169
What can cause an ovarian tissue?
- Usually due to an ovarian mass larger than 5cm such as a cyst or tumour (more likely with benign and with pregnancy)
- Can also occur before girls first period when girls have longer infundibulopelvic ligaments
170
What is the presentation of an ovarian torsion?
- Sudden onset constant severe unilateral pelvic pain associated with nausea and vomiting
- Pain is not always severe and can come and go
- On examination there will be localised tenderness there may be a palpable mass absence does exclude the diagnosis
171
What is used to diagnose an ovarian torsion?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal,
Will show a **whirlpool sign, free fluid** in pelvis and oedema of the ovary
Definitive diagnosis is made with laparoscopic surgery
172
What are the complications of an ovarian torsion?
- Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.
- Can cause infertility and menopause if only ovary
173
What is Polycystic ovarian syndrome?
It is a common condition causing metabolic and reproductive problems in women
174
What are the characteristic features of PCOS
- Multiple ovarian cysts
- Infertility
- Oligomenorrhea
- Hyperandrogenism
- Insulin resistance
175
Key terms for PCOS
Anovulation refers to the absence of ovulation
Oligoovulation refers to irregular, infrequent ovulation
Amenorrhoea refers to the absence of menstrual periods
Oligomenorrhoea refers to irregular, infrequent menstrual periods
Androgens are male sex hormones, such as testosterone
Hyperandrogenism refers to the effects of high levels of androgens
Hirsutism refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
Insulin resistance refers to a lack of response to the hormone insulin, resulting in high blood sugar levels
176
What criteria for PCOS called?
The **Rotterdam criteria** which is 2/3 of the ley features:
- Oligoovulation or anovulation presenting with irregular or absent menstrual periods
- Hyperandrogenism: acne and hirsutism
- Polycystic ovaries on the ultrasound (10cm3 or more)
177
What is the presentation of PCOS?
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
178
What are some other key features and complications of PCOS?
- Insulin resistance and diabetes
- Acanthosis nigricans (thickened rough skin in axilla and elbows)
- CVD
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
179
What else can cause hirsutism?
Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
180
Why is insulin resistance a key part of PCOS?
- Insulin resistance(means more insulin is released) causes greater release of androgens for the the ovaries and adrenal glands as insulin stimulates the release
- Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
- This contributes the halting the development of the follicles in the ovaries leading to anovulation
181
What will hormonal blood tests show in PCOS?
**Raised luteinising hormone**
**Raised LH to FSH ratio (high LH compared with FSH)**
Raised testosterone
Raised insulin
182
What scan is required for PCOS?
A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a **“string of pearls” appearance**. The diagnostic criteria are either:
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
**Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS**
183
What test is sued for diabetes in PCOS?
oral glucose tolerance test
184
What is the general management for PCOS?
Reduce the risks of obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease
185
Why is weight loss key in PCOS?
Can result in the restoration of fertility and improve insulin resistance and hirsutism
**Orlistat** may be used to help weight loss in women with BMI above 30
186
Why are women with PCOS at risk of endometrial cancer?
Obesity
Diabetes
Insulin resistance
Amenorrhoea
There is lots of things leading to unopposed oestrogen
187
What are some risk factors for breast cancer?
- Alcohol
- Obesity
- Not breastfeeding
- HRT
- Not having kids early
1 in 8 women will get it most common
188
What are the genes associated with breast cancer?
BRAC - 1 found on **chromosome 17** - 80% chance of breast cancer, and 40% of ovarian cancer
BRAC - 2 found on **chromosome 13**- Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer
189
What is the screening program for breast cancer?
- Offer a mammogram every 3 years for women between 50-70
190
What are the main types of breast cancer?
- Ductal Carcinoma In Situ (DCIS): pre cancerous
- Lobular Carcinoma In Situ (LCIS): pre cancerous in pre-menopausal women
- Invasive ductal carcinoma (NST): originate from cells from the breast ducts and 80% of cancers fall in this category
- Invasive lobular carcinomas: around 10% of cases originate from breast lobules
191
What are some other types of breast cancer?
Inflammatory Breast Cancer
1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers
Paget’s Disease of the Nipple
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer
192
What are the criteria for being deemed a high risk patient for breast cancer?
A first-degree relative with breast cancer under 40 years
A first-degree male relative with breast cancer
A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
Two first-degree relatives with breast cancer
193
What is the chemoprevention offered to women who are are at high risk of breast cancer?
Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)
194
What is the presentation of breast cancer?
- Lumps that are hard and irregular that are fixed in place
- Nipple retraction
- Skin dimpling (peau d'orange)
- Lymphadenopathy (in axilla)
195
What is the criteria for a 2 week wait for breast cancer?
- Unexplained breast lump in women above 30
- Unilateral nipple changes in patients aged 50 or above
- Unexplained lump in the axilla aged 30 or above
- Skin changes
If lump and under 30 consider no urgent referral
196
What are the different imaging tools used to screen for breast cancer?
Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.
197
What are the 3 types of receptors that breast cancer can have?
- Oestrogen receptors
- Progesterone receptors
- Human epidermal growth factors
These can be targeted with different treatments. Triple negative where the cancer does not express any of these receptors has a worse prognosis
198
Where does breast cancer metastasize?
2Ls and 2Bs
L- Lungs
L- Liver
B- Breast
B- Bones
Breast cancer can spread to any region though similar to a melanoma
199
What is used to stage breast cancer?
TMN
200
What are the 3 types of chemotherapy given?
Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer
201
What are the two main treatment options for oestrogen receptor positive breast cancer?
- Tamoxifen (pre-menopausal women)
- Aromatase inhibitors (post menopausal women)
202
What is the action of tamoxifen and aromatase inhibitors?
- Tamoxifen is a selective oestrogen receptor modulator. It blocks the oestrogen receptors in the breast tissue and stimulates them in uterus and bones. Helps with osteoporosis but does increase the risk of endometrial cancer.
- Aromatase is an enzyme found in fat tissue and converts androgens to oestrogen. After menopause action of aromatase is the primary source of oestrogen
They are both given for 5-10 years
203
What is the follow up for a patient who has had breast cancer?
A mammogram every year for 5 years
204
What is a fibroadenoma?
- Common benign tumours of epithelial breast tissue. They are typically small and mobile within the tissue.
- They are more common in younger women aged between 20 and 40
- They are painless smooth and round
205
What are fibrocystic breast changes?
- Where there is generalised lumpiness in the breast. These changes will fluctuate during the menstrual cycle
- Symptoms will often occur prior to menstruation and will include: lumpiness, breast pain and fluctuation of breast size
Recommendations include: NSAIDs, avoid caffeine, applying heat to the area
206
What are breast cysts?
They are benign, individual fluid-filled lumps. They are the most common cause of breast lumps and most often occur between the ages of 30-50
On examination they are:
- Smooth
- Well-circumcised
- Mobile
- Fluctuant
They require further assessment to exclude cancer
207
What is fat necrosis?
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It at necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
On examination, fat necrosis can be:
Painless
Firm
Irregular
Fixed in local structures
There may be skin dimpling or nipple inversion
Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.
208
What is duct ectasia?
- Is a benign condition where there is dilation of the large ducts in the breasts.
- This will lead to intermittent discharge from the nipple that is white, grey or green
- Occurs in perimenopausal women and smokers most commonly
209
What is the presentation of ductal ecatsia>?
- Nipple discharge
- Tenderness or pain
- Nipple retraction
- A breast lump
210
What are the key findings of ductal ectasia on a mammogram?
- Microcalcifications
211
What is an intraductal papilloma?
- A warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells
-Will typically present with clear or blood stained discharge
- Can be associated with atypical hyperplasia or breast cancer
212
What is the management of an intraductal papilloma?
They require surgical excision
213
What is atrophic vaginitis?
- It refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen .
- It occurs in women entering the menopause
214
What happens to the epithelial lining in atrophic vaginitis?
- The mucosa become thinner and less elastic
- This makes it more prone to inflammation and infection as there is a change in vaginal pH
215
What are the symptoms of AV?
- Itching
- Dryness
- Pain during sex
- Bleeding due to localised inflammation
216
What are the treatments for AV?
- Vaginal lubricants
- Topical oestrogen ( think estriol)
217
What are some presentations of AV in older patients?
- Recurrent UTIs
- Stress incontinence
- Pelvic organ prolapse
218
What will an examination of the vagina show in AV?
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
219
What is bacterial vaginosis?
- It refers to an overgrowth of bacteria in the vagina specifically **anaerobic bacteria**
- It is not **Sexually transmitted**
220
What causes BV?
Loss of lactobacilli which produce lactic acid and keep the vaginal pH low
221
What bacteria can cause BV?
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
222
What are the risk factors for BV?
- Multiple sexual partners
- Excessive vaginal cleaning
- Recent antibiotics
- Smoking
- Copper coil
223
What is the presentation of BV?
Fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
224
What are the investigations for BV?
- Test vaginal pH anything above 4.5 is bad
-
charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
225
What cells are shown with BV?
Clue cells
226
What is treatment for BV?
Metronidazole
Or clindamycin but is less effective
227
What can't you take with metronidazole?
Alcohol
228
What are the complications of BV?
It increases risk of **STI**
- Also can cause problems in pregnancy
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
229
What are the two types of breast abscesses?
Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)
230
What does mastitis refer to?
Inflammation of breast tissue often related to breastfeeding but can be caused by an infection
231
What is a key risk factor for infective mastitis?
- Smoking
- Damage to the nipple
- Underlying breast disease affecting the drainage of the breast
232
What are the causes of mastitis?
Staphylococcus aureus (the most common)
Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
233
What are the symptoms of mastitis?
- Nipple changes
- Purulent nipple discharge (pus from the nipple)
- Localised pain
- Tenderness
- Warmth
- Erythema (redness)
- Hardening of the skin or breast tissue
Swelling
234
What is the key feature of a breast abscess?
- Swollen fluctuant (can move around on palpation) tender lump within the breast
235
What is the management of non-lactational mastitis?
- Analgesia
- Antibiotics - need to be broad spectrum
- Treatment for underlying cause
236
What are the antibiotics used to treat non-lactational mastitis?
Co-amoxiclav
Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)
237
What is the treatment for Lactational mastitis?
Managed conservatively, with continued breastfeeding, expressing milk and breast massage.
Heat packs, warm showers and simple analgesia can help symptoms.
Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve
238
What is Candidiasis?
Commonly referred to as thrush. It refers to a yeast infection most commonly **candida albicans**
239
What are the risk factors for thrush?
- Increased oestrogen: pregnancy
- Poorly controlled diabetes
- Immunosuppression
- Broad spectrum antibiotics
240
What are the symptoms of thrush?
- Thick, white discharge that does not typically smell
- Vulva and vaginal itching, irritation or discomfort
241
What can a severe thrush infection lead to?
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
242
What are the investigations for thrush?
- Testing vaginal pH often it is below 4.5 in thrush but will be higher with vaginosis
- Charcoal swab is gold standard
243
What is the treatment for thrush?
- A single dose of intravaginal clotrimazole cream
- A single clotrimazole pessary
- A single dose of fluconazole
244
What is trichomonas vaginalis ?
A type of parasite spread through sexual intercourse
245
What is the presentation of trichomonas vaginalis ?
-Vaginal discharge (frothy green which may have a fishy smell
- Itching
- Dysuria
- Balanitis
- Painful sex
50% of cases are asymptomatic
246
What is the sign of trichomonas vaginalis ?
Strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection
Also vaginal pH would be high like bacterial vaginosis
247
What is the treatment for trichomonas vaginalis ?
Metronidazole
248
How successful is the COCP?
More than 99% effective with perfect use and 891% effective with typical use
249
What age is the COCP licensed up to?
50
250
How does the COCP work?
- Prevents ovulation
- Progesterone thickens cervical mucus
- Progesterone inhibits the proliferation of the endometrium reducing chances of successful implantation
251
How do oestrogen and progesterone work in the COCP?
- Negative feedback on the hypothalamus and pituitary suppressing the release of GnRH, LH and FSH.
- Without LH and FSH ovulation does not occur
- With the COCP the lining of the endometrium is maintained in a stable state, will then have a withdrawal bleed when the pill is stopped
252
What are the two types of COCP and which are the main ones used?
Monophasic pills contain the same amount of hormone in each pill
Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
The NICE Clinical Knowledge Summaries (2020) recommend using a pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin). These choices have a lower risk of venous thromboembolism.
**Microgeon or Loestrin**
253
What are the side effects of COCP?
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
254
What are the contraindications of the COCP?
- Uncontrolled hypertension
- Migraine with aura
- History of VTE
- Aged 35 and smoking 15 cigarettes a day
- Surgery
- Vascular disease
- IHD
- Liver cirrhosis
- SLE
255
How long after taking the pill are you protected?
- If started on day 1-5 of menstrual cycle then protection is immediate
- If started after this then it takes 7 days to have protection
256
What to do if you miss a COCP pill?
Missing a pill is when one pill is more than 24 hours late e.g 48 hours since last pill was taken
- If missed but within 72 hours of when last taken then take as soon as possible and no additional protection is required
- Missing more than one pill (more than 72 hours since the last pill was taken):
Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
257
What is the POP?
It offers 99% protection but 91% with typical use. The only contraindication to taking it is **breast cancer**
258
What are the two types of POP?
- Traditional progestogen-only pill: can't be delayed for more than 3 hours
- Desogestrel only pill : can't be delayed for more than 12 hours
259
How do the two types of POP work?
Traditional progestogen-only pills work mainly by:
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Desogestrel works mainly by:
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
260
How long does POP take to become affective?
If started on days 1-5 then protection starts immediately
If taken after day 1-5 then protection takes 48 hours. Causes no harm in pregnancy so can be started without need to check
261
What are the side effects of the POP?
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
Other side effects include:
Breast tenderness
Headaches
Acne
262
What are the two phases of the menstrual cycle?
- Follicular phase: is from the start of menstruation to the moment of ovulation
- Luteal phase: the moment of ovulation to the start of menstruation
263
What are the cells that can go on to form an egg called?
- Oocytes and they are surrounded by granulosa cells and they combine to from structures called follicles
264
What are the 4 key stages of development of follicles in the ovaries?
- Primordial follicles
- Primary follicles
- Secondary follicles
- Antral follicles
265
How often do primordial follicles mature into primary and secondary follicles?
They are always maturing
266
What happens once the follicles reach the secondary follicle stage?
They develop receptors for follicle stimulating hormone which is required to develop the secondary follicles further
267
How does FSH stimulate the development of secondary follicles?
The follicles grow and the granulosa cells secrete increasing amounts of oestrogen.
This has a negative feedback on the pituitary reducing the quantity of LH and FSH
The rising oestrogen also causes the cervical mucus to become more permeable allowing sperm to penetrate the cervix
268
What happens before ovulation?
- One of the follicles will develop further than the others and become the dominant follicle
- LH spikes (and FSH to some degree) and this causes the dominant follicle to release the ovum
269
What happens at the beginning of the luteal phase once the ovum has been released?
- The follicle become the corpus luteum which secretes high levels of progesterone which maintains the endometrial lining
- It also causes the cervical mucus to become thick and no longer penetrable
- When fertilisation occurs HCG maintains the corpus luteum
270
What happens if there is no fertilisation of the ovuM?
271
3A
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Decks in class (11)
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