Gynaecology Flashcards
1
Q
What is androgen insensitivity syndrome
A
X-linked recessive
Cells are unable to respond to androgen hormones due to lack of androgen receptors
- Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics
- Genetically male (XY) but absent response to testosterone
- Female phenotype externally = normal female external genitalia and breast tissue
- Testes in abdomen or inguinal canal and absence of uterus, upper vagina, cervix, fallopian tubes and ovaries
- Testes produce anti-Mullerian hormone
2
Q
Presentation of androgen insensitivity syndrome
A
- Inguinal hernia in infancy containing testes
- Primary amenorrhoea
- Lack of pubic hair, facial hair and male type muscle development
- Taller than female average
- Infertility
3
Q
Hormone tests for androgen insensitivity syndrome
A
o Raised LH
o Normal/raised FSH
o Normal/raised testosterone (for male)
o Raised oestrogen levels (for male)
4
Q
Management of androgen insensitivity syndrome
A
- MDT approach
- Bilateral orchidectomy
- Oestrogen therapy
- Vaginal dilators/vaginal surgery
- Counselling
5
Q
Complications of androgen insensitivity syndrome
A
Testicular cancer
6
Q
What is Ashermann’s syndrome
A
- Adhesions form within uterus following damage to uterus
- Endometrial curettage (scraping) can damage basal layer of endometrium
- Adhesions form physical obstructions and distort pelvic organs
7
Q
Risk factors for Ashermann’s syndrome
A
- Pregnancy-related dilatation and curettage procedure
- Uterine surgery
- Several pelvic infections (endometritis)
8
Q
Presentation of Ashermann’s syndrome
A
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
9
Q
Investigations/management of Ashermann’s syndrome
A
- Hysteroscopy (+ dissection)
10
Q
Complications of Ashermann’s syndrome
A
- Menstruation abnormalities
- Infertility
- Recurrent miscarriages
11
Q
What is atrophic vaginitis
A
- Epithelial lining of vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions.
- As women enter the menopause, oestrogen levels fall, so mucosa becomes thinner, less elastic and more dry
12
Q
Risk factors for atrophic vaginitis
A
Menopause = lack of oestrogen
13
Q
Presentation of atrophic vaginitis
A
- Itching
- Dryness
- Dyspareunia
- Bleeding due to localised inflammation
- Recurrent UTI
- Stress incontinence
- Pelvic organ prolapse
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Sparse pubic hair
14
Q
Management of atrophic vaginitis
A
- Vaginal lubricants
- Topical oestrogen
o Estriol cream
o Estriol pessaries
o Estradiol tablets (vagifem)
o Estradiol ring (Estring) - Monitored annually
15
Q
Risk factors for cervical cancer
A
- Multiple sexual partners
- Early first intercourse
- High parity
- Low SES
- Smoking
- COCP
- HIV/ Immunosuppression
16
Q
Causes of cervical cancer
A
HPV 16, 18, 33
17
Q
Histology of cervical cancer
A
- Squamous cell carcinoma (most common)
- Adenocarcinoma
18
Q
Presentation of cervical cancer
A
- Asymptomatic
- Abnormal vaginal discharge/bleeding = purulent, red/brown
- Dyspareunia
- Post-coital bleeding
- Intermenstrual bleeding
- Late Sx Haematuria, PR bleeding, Urinary/bowel symptoms
- Unusual appearance of cervix
- Bulky masses on bimanual PB
- Hepatosplenomegaly
19
Q
Screening for cervical cancer
A
- Cervical smear
o 3 yearly from 25-50
o 5 yearly from 50-64
20
Q
Investigations for positive smear
A
- Colposcopy and biopsy Abnormal cells in cervix removed by large loop excision of transformation zone
o Followed by cervical cancer screening test 6m later with HPV test - STI testing
21
Q
Staging of cervical cancer
A
- 1a = microscopic intraepithelial tumours
- 1b = confined to cervix
- 2 = spread into upper 2/3rd vagina or parametrium but not pelvic wall
- 3 = spread throughout vagina or to pelvic sidewall
- 4 = involvement of bladder, rectum or distant sites
22
Q
Management of cervical cancer
A
- CIN treatment
o CIN1 = spontaneous regression within 2yrs
o CIN2/3 = LLETZ
o CGIN = LLETZ or cone biopsy - Hysterectomy and lymph node clearance (GS)
23
Q
Risk factors for ovarian cancer
A
- BRCA1/2 (FHx)
- Early menarche, late menopause
- Oestrogen HRT
- Nulliparity
- Smoking
- Obesity
- Clomifene
- Hysterectomy
24
Q
Protective factors for ovarian cancer
A
OCP, pregnancy, lactation
25
Presentation for ovarian cancer
- Often late presentation as asymptomatic
- Bloating
- Eating difficulty (loss of appetite/early satiety)
- Abdominal/pelvic pain/distention
- Toilet changes urinary/bowel Sx
- Bleeding/discharge
- Weight loss
- Diarrhoea
- Ascites +/- pleural effusion
26
Investigations for ovarian cancer
- 2WW for any woman with ascites +/- pelvic mass that is not fibroids
- Pregnancy test
- CA125 >35IU/ml
- Pelvic and abdominal USS
- Biopsy
- RMI score >250 = urgent referral to secondary care
- Diagnostic laparoscopy
27
Other causes of raised Ca125
- Adenomyosis
- Ascites
- Endometriosis
- Menstruation
- Breast cancer
- Ovarian torsion
- Endometrial cancer
- Liver disease
- Metastatic lung cancer
28
Management of ovarian cancer
- Early stage = excision of all tumour during surgery, with adjuvant chemo
- Late stage = debulking with amount of residual disease corresponding with prognosis
- Chemo, radio
- Hormonal/targeted therapy
- Fertility preservation
29
Risk factors for endometrial cancer
- Early menarche
- Late menopause
- Unopposed oestrogen (oestrogen only HRT)
- Nulliparity
- Endometrial hyperplasia
- Obesity
- DM
- Tamoxifen
- PCOS
- HNPCC
30
Protective factors for endometrial cancer
- Combined oral contraceptive pill
- Pregnancy
- Lactation
- Smoking
31
Histology of endometrial cancer
Adenocarcinoma
32
Presentation of endometrial cancer
- Postmenopausal bleeding
- If premenopausal = change intermenstrual bleeding
- Abnormal bleeding or discharge
- Pelvic pain/pressure
- Haematuria
33
Investigations for endometrial cancer
- Women >55 referred to suspected cancer pathway
- TV USS = endometrial thickness >4mm
- Hysteroscopy with Endometrial biopsy
34
Staging of endometrial cancer
1. confined to endometrium and myometrium
2. invades cervical stroma but not extend outside uterus
3. local or regional spread beyond uterus
4. involvement of bladder, bowel or distant metastasis
35
Management of endometrial cancer
- Total abdominal hysterectomy with bilateral salping-oophorectomy
o +/- pelvic LN removal
- Chemo, radio
- Fertility preservation
- Progesterone therapy
o in frail elderly women not considered suitable for surgery
o If they still have a uterus must be given progesterone
36
Risk factors for vaginal cancer
- Age
- HPV
- Early age of 1st intercourse
- HIV
- Typically spreads from cervix or endometrial
37
Presentation of vaginal cancer
- Abnormal bleeding/discharge
- Change in toilet habits
- Mass/lump
- Itching
- Soreness
- Dysuria
38
Risk factors for vulval cancer
- Age
- HPV
- Smoking
- Skin disease = Lichen sclerosus
- Immunosuppression
- Vulval intraepithelial neoplasia
39
Presentation of vulval cancer
- Delayed presentation
- Vulval lump or ulcer on labia majora
- Bleeding due to ulceration
- Itching/burning of vulva
- Pain
- Skin changes
- Inguinal lymphadenopathy
40
Staging of vulval cancer
1. confined to vulva/perineum
2. tumour extending to adjacent perineal structures
3. inguino-femoral lymph node metastasis
4. tumour invading other regional structures or with distant metastasis
41
Complications for vulval cancer
- Psychological
- Scarring and painful sex
- Nerve damage
- Groin and leg swelling
- Bowel and bladder problems
42
2WW for vulval cancer
any woman presenting with unexplained vulval lumps, ulceration, bleeding
43
What is infertility
- Failure to conceive after 1 year of trying
- Primary = inability to conceive with no prior pregnancy
- Secondary = inability to conceive but prior pregnancy occurred
44
Risk factors for infertility
- Increasing age
- Obesity
- Smoking
- Tight-fitting underwear
- Excessive alcohol consumption
- Anabolic steroid use
- Illicit drug use
45
Female causes of infertility
- Ovulatory (25%) = not ovulating or poor ovarian reserve
o Hypogonadotropic hypogonadal anovulation = hypothalamic amenorrhoea, pituitary tumours, Sheehan’s syndrome, hyperprolactinaemia, Cushing’s syndrome
o Normogonadotropic normoestrogenic anovulation = PCOS
o Hypergonadotropic hypoestrogenic anovulation = premature ovarian failure, chromosomal abnormalities
- Tubal (15%) = obstruction
o Congenital anatomical abnormalities
o Adhesions following PID
- Uterine/peritoneal (10%) =
o Fibroids/polyps
o Bicornate uterus
o Asherman’s syndrome
o Endometriosis
- Cervical abnormalities
o Cervical damage after biopsy or LLETZ
- Genetic causes = Turner’s syndrome
46
Male causes of infertility
o Cryptorchidism
o Varicocele
o Testicular cancer
o Congenital testicular defects
o Obstruction of ejaculatory system
o Disorders of ejaculation
o Kleinfelter’s syndrome
47
Referral criteria for infertility
- Refer for testing after 1 yr of trying
- Refer to treatment after 2 yrs of trying
48
Investigations for infertility
- Ovulation/ovarian function
- Semen quality
o Count >15m/ml
o Motility >32%
o Morphology >4%
o Total >39m
o Repeat after 3 months if abnormal
- Tubal patency (+uterus)
- Ovarian reserve testing = need low FSH, high antral follicle count, high antimullerian hormone
- Female hormone profile
o Serum LH and FSH on day 2-5 = high FSH poor ovarian reserve, high LH PCOS
o Serum progesterone on day 21 (7 days before end of cycle)
o Anti-Mullerian hormone
o TFTs
o Prolactin = high anovulation
- BMI = low anovulation, high PCOS
- Chlamydia screening
- USS pelvis
- Hysterosalpingogram
- Laparoscopy and dye test
49
Early referral for infertility
- Female age>35
- Menstrual disorder
- Previous abdominal/pelvic/urogenital surgery
- Previous PID/STD
- Abnormal pelvic/genital examination
- Previous male genital pathology
- Systemic illness
50
Preconception advice
- Intercourse 2-3x week (don’t time with ovulation)
- Folic acid daily – 0.4mg or 5mg (high risk)
- Smear
- Rubella
- Smoking cessation and avoid alcohol
- Pre-existing medical conditions
- Drug history
- Environmental/ occupational exposure
- Reduce stress = affect libido and relationship
- Weight (BMI 19-30)
51
Male infertility treatments
o Mild = intrauterine insemination
o Moderate = IVF
o Severe = intracytoplasmic sperm injection
o Azoospermia = surgical sperm recovery, donor insemination
o Surgery – correction of epidymal block, vasectomy reversal
o Hormonal – gonadotrophins
52
Male lifestyle advice
o Heat avoidance
o Underpants/boxers
o Smoking
o Alcohol
o Occupational exposure
o Diet/supplements = folic acid and zinc
o Weight
53
What is lichen sclerosis
Chronic autoimmune inflammatory skin condition often affecting labia, perineum and perianal skin
54
Risk factors for lichen sclerosis
- T1DM
- Alopecia
- Hypothyroid
- Vitiligo
55
Presentation of lichen sclerosis
- Vulval itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
- Worse with tight underwear, urinary incontinence, scratching
- Shiny “porcelain-white” patches of skin
- Tight and thin skin
- Slightly raised skin
- Papules or plaques
- Koebner phenomenon = sx worse by friction to skin
56
Management of lichen sclerosis
- Follow up every 3-6 months
- Potent topical steroids = clobetasol propionate 0.05% (dermovate)
- Emollients regularly
57
Complications of lichen sclerosis
- 5% risk of developing squamous cell carcinoma of vulva
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of vaginal or urethral openings
58
What is premenstrual syndrome
Psychological, emotional and physical symptoms that occur during luteal phase of menstrual cycle
59
Presentation of premenstrual syndrome
- Cyclical symptoms that occur just before and resolve after the onset of menstruation
- Low mood
- Anxiety
- Mood swings
- Irritability
- Bloating
- Fatigue
- Headaches
- Breast pain
- Reduced confidence
- Cognitive impairment
- Clumsiness
- Reduced libido
60
Management of premenstrual syndrome
- Lifestyle Diet, exercise, alcohol, smoking, stress, sleep
- COCP 1st line containing drospirenone (Yasmin)
o Continuous use as opposed to cyclical use
- SSRI antidepressants ± CBT
- Continuous transdermal oestrogen + Cyclical progestogens or Mirena coil a
- GnRH analogues = induce menopausal state
o Add HRT to reduce adverse effects (osteoporosis)
- Hysterectomy and bilateral oophorectomy
o Induce menopause
o Use where severe symptoms and medical management failed
o HRT required (mostly for women <45)
- Danazole and tamoxifen
o Options for cyclical breast pain
o Initiated and monitored by breast specialist
- Spironolactone = Reduce breast swelling, water retention, bloating
61
What is menorrhagia
- Excessive menstrual blood loss which affects a woman’s quality of life
- Previously defined as >80ml blood loss
62
Causes of menorrhagia
- Structural
o Polyp
o Adenomyosis and endometriosis (PAINFUL)
o Leiomyoma (Fibroid)
o Malignancy and hyperplasia
- Non-Structural
o Coagulopathy (Von Willebrand’s, anticoagulant)
o Ovulatory dysfunction (PCOS, hypothyroidism)
o Endometrial
o Iatrogenic (copper IUD)
o Not yet classified (40-60%)
63
Presentation of menorrhagia
- Heavy menstrual bleeding
o Changing pads every 1-2 hrs
o Bleeding lasting >7days
o Passing large clots
- Affects QoL
- Fatigue
- Shortness of breath (anaemia)
- Bruising (clotting)
- Pallor
64
History taking for menorrhagia
- Age at menarche
- Cycle length, days menstruating, variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancy
- Cervical screening history
- Migraines with or without aura
- PMH and DHx
- Smoking and alcohol history
- FHx
65
Investigations for menorrhagia
- FBC, Ferritin, TFTs, Coagulation screen
- Pelvic + transvaginal USS
o Possible large fibroids
o Possible adenomyosis
o Obese
o Hysteroscopy declined
- Swabs (high vaginal and endocervical) = infection
- Cervical smear if due
- Pipelle endometrial biopsy
- MRI (fibroid mapping)
- Outpatient hysteroscopy
o Intermenstrual or irregular bleeding (>40)
o Infrequent heavy bleeding who are obese/PCOS
o Tamoxifen
o Unsuccessful medical Tx
66
Management of menorrhagia
- Aim to improve QoL rather than reduction in volume of menstrual loss
- Not contraceptive symptom relief (1st line if want fertility)
o Tranexamic acid 1g (reduce bleeding)
o Mefenamic acid 500mg (reduce bleeding and pain)
- Contraceptive symptom relief
1. Mirena coil
2. COCP
3. Long-acting progestogens
- Cyclical oral progestogens (norethisterone) = short-term option to stop heavy menstrual bleeding but not a contraceptive
- Surgical options
o Endometrial ablation (balloon thermal)
o Hysterectomy
67
Causes of dysmenorrhoea
- Primary = excessive endometrial prostaglandin production
- Secondary
o Endometriosis
o Adenomyosis
o PID
o Copper coil
o Fibroids
68
Management of dysmenorrhoea
1. NSAIDs (mefenamic acid or ibuprofen)
2. COCP
69
Causes of primary amenorrhoea
- Hypothalamic
o Functional disorders = eating disorders, exercise
o Severe chronic conditions = psychiatric, thyroid disease, sarcoidosis
o Kallmann syndrome
- Pituitary
o Prolactinomas
o Other pituitary tumours = Acromegaly, Cushing’s syndrome
o Sheehan’s syndrome
o Destruction of pituitary gland = radiation, autoimmune
o Post-contraception amenorrhoea
- Ovarian PCOS, Turners syndrome
- Adrenal gland Late onset/mild congenital adrenal hyperplasia
- Genital tract abnormalities
o Ashermann’s syndrome
o Imperforate hymen/transverse vaginal septum
o Androgen insensitivity syndrome
70
Investigations of primary amennorhoea
- Do not perform internal examination
- TFTs and prolactin
- FSH, LH, oestradiol, progesterone, testosterone
- 17 hydroxyprogesterone
- Coeliac screen
- Karyotyping (genetic abnormality)
- Imaging XR (constitutional delay), Pelvic US, MRI brain (pituitary)
- Progesterone challenge withdrawal bleed
o Bleed = normal oestrogen levels but not ovulating (PCOS)
o No bleed = low levels of oestrogen or outflow obstruction
71
Management of primary amennorhoea
- Lifestyle advice
o Hypothalamic = Increase body fat to stimulate GnRH production
o PCOS = balanced diet and regular exercise
- Haematocolpos = incision and drainage of blood
72
Referral to secondary care for primary amenorrhoea
- Girls with no secondary sexual characteristics at 13 with primary amenorrhoea
- Refer at 15y if secondary sexual characteristics present
- Refer to gynaecologist earlier if concern regarding: growth retardation, genital tract problems, intracranial tumour, chromosomal problems, anorexia, puberty >5y with no menarche
- Refer to endocrinologist if: signs of raised prolactin, thyroid disease or androgen excess
73
What is secondary amenorrhoea
Cessation of periods for >6months after menarche
74
Causes of secondary amenorrhoea
- Physiological Pregnancy, Lactation, Menopause
- Hypothalamic hypogonadism = stress, excessive exercise
- PCOS
- Hyperprolactinaemia
- Premature ovarian failure
- Hyper/hypothyroidism
- Sheehan’s and Asherman’s syndromes
75
Investigations for secondary amenorrhoea
- Urinary or serum beta-hCG = exclude pregnancy
- Gonadotrophins (FSH/LH)
o Low levels = indicate hypothalamic cause
o Raised levels = ovarian problem
- Androgen levels Raised in PCOS
- Prolactin
- Oestradiol
- TFTs
- 17 hydroxyprogesterone
76
Management of secondary amenorrhoea
- Lifestyle advice = stress, exercise, diet
- Treat underlying disorder (hyper/hypothyroidism)
- Contraception (still become pregnant)
- Regulate periods COCP or progesterone-only pill, IUS
- Hormone replacement
o Cyclical hormone replacement therapy with oestrogen (and progesterone if have uterus)
o Calcium and vit D supplements after bone density scan
- Surgery Remove pituitary tumours and genital tract abnormalities
77
Symptom control in secondary amenorrhoea
o Excess hair = COCP (Yasmin), cyropterone acetate, spironolactone
o Acne = Abx, benzoyl peroxide, topical retinoids
78
Fertility management in secondary amenorrhoea
o Clomifene = stimulate ovulation
o Metformin in PCOS
o IVF
79
Referral to secondary care for secondary amennorhoea
- Gynaecologist
o Persistent high LH and FSH in women <40 (premature ovarian failure)
o Suggestive of Asherman’s or cervical stenosis
o Infertility
- Endocrinologist
o High prolactin (1 >1000 or 2 >500)
o Low LH and FSH
o Raised testosterone
o Cushing’s/adrenal hyperplasia
80
Causes of oligomenorrhoea
- PCOS
- Contraceptive/hormonal treatments
- Perimenopause
- Thyroid disease/diabetes
- Eating disorders/excessive exercise
- Medications = anti-psychotics, anti-epileptics
81
Presentation of oligomenorrhoea
- Interval between menstrual cycles of >35 days
- or less than 9 periods per year
82
Perimenopausal symptoms
- Hot flushes
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier/lighter periods
- Vaginal dryness and atrophy
- Reduced libido
83
Management of menopause
- Contraception need for 2 years after LMP <50 or 1 year if >50
- HRT
o Relieve perimenopausal symptoms
o Decreased risk of osteoporosis and CVD
o Oral, topical (patches and gels), IUS, vaginal ring
o If uterus present, progesterone must be given as well as oestrogen
- Tibolone = steroid hormone acts as continuous combined HRT
- Clonidine = agonist of alpha-adrenergic and imidazoline receptors
- CBT ± SSRI antidepressants (fluoxetine or citalopram)
- Testosterone = reduced libido
- Vaginal oestrogen = vaginal dryness
- Vaginal moisturisers/lubricants
- Bisphosphonates
84
Complications of menopause
- CVD and stroke
- Osteoporosis
- Pelvic organs prolapse
- Urinary incontinence
85
What is premature ovarian insufficiency
Onset of menopausal symptoms and elevated gonadotrophin levels before age of 40
86
Causes of premature ovarian insufficiency
- Idiopathic (most common)
- Bilateral oophorectomy
- Radiotherapy
- Chemotherapy
- Infection
- Autoimmune disorders
- Resistant ovary syndrome
87
Presentation of premature ovarian insufficiency
- Climacteric symptoms: hot flushes, night sweats
- Infertility
- Secondary amenorrhoea
88
Investigations for premature ovarian insufficiency
- Raised FSH, LH levels
o FSH >40IU/l
o Elevated FSH levels on 2 blood samples taken 4-6 wks apart
- Low oestradiol = <100pmol/l
89
Management of premature ovarian insufficiency
- HRT or COCP until age of average menopause (51y)
o HRT not provide contraception
90
Presentation of ovarian cysts
- Asymptomatic
- Pelvic pain
- Bloating
- Fullness in abdomen
- Palpable pelvic mass
91
Red Flags for ovarian cysts
- Abdominal bloating
- Reduced appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
92
Investigations for ovarian cysts
- TV/pelvic USS = no concern if <5cm
- CA125 tumour marker (ovarian cancer)
- Complex ovarian cysts biopsy
- Risk of malignancy index Menopausal status, USS findings, CA125 level
93
Management of ovarian cysts
- Possible ovarian cancer = 2WW
- Dermoid cysts = refer to gynae for Ix and surgery
- Simple ovarian cysts in premenopausal women
o <5cm = likely resolve in 3 cycles so no follow-up scan
o 5-7cm = refer to gynae and yearly USS monitoring
o >7cm = MRI scan or surgical evaluation
- Cysts in postmenopausal women
o Raised CA125 = 2WW
o <5cm with normal CA125 = USS every 4-6 months
o Moderate/high RMI = bilateral oophorectomy + staging
- Persistent/enlarging cysts
o Surgical intervention (laparoscopy)
o Ovarian cystectomy
o Oophorectomy
94
Complications of ovarian cysts
- Cysts in postmenopausal women = malignancy
- Ovarian torsion
- Haemorrhage into cyst
- Rupture of cyst with bleeding into peritoneum
- Infection
- Pressure effects = DVT, urinary retention, intestinal obstruction
95
What is Meig's syndrome
- Ovarian fibroma
- Pleural effusion
- Ascites
- Older women
96
Risk factors for ovarian torsion
- Benign tumours
- Pregnancy
- Before menarche
97
Presentation of ovarian torsion
- Sudden onset severe unilateral pelvic pain
- Pain is constant + gets progressively worse
- N+V
- Localised tenderness
- Palpable mass in pelvis
98
Investigations for ovarian torsion
- TV USS “whirlpool sign” = Free fluid in pelvis and oedema of ovary
- Doppler = lack of blood flow
- GS = laparoscopic surgery
99
Management of ovarian torsion
- Emergency laparoscopic surgery
o Untwist (detorsion) and fix in place
o Oophorectomy
- Laparotomy if large ovarian mass/malignancy
100
Complications of ovarian torsion
- Ischaemia necrosis
- Loss of ovary
- Infertility
- Menopause
- Infected necrotic ovary abscess sepsis
- Rupture peritonitis and adhesions
101
Presentation of PCOS
- Oligoovulation or anovulation
o Oligomenorrhoea or amenorrhoea = irregular or absent menstrual periods
o Menorrhagia ± clots
- Hyperandrogenism
o Hirsutism, acne, oily skin, alopecia, obesity
o High LH, high testosterone, normal/low FSH
- Polycystic ovaries on USS = >12 follicles in one/both ovaries or increased ovarian volume >10cm3
- Prolactin normal
102
Investigations for PCOS
- FBC, TFT, HbA1c
- Raised LH
- Raised LH to FSH ratio
- Raised testosterone
- Raised insulin
- Normal or raised oestrogen levels
- Abdo and TV US = 12+ developing follicles in one ovary/ ovarian volume >10cm3
- Screening = OGTT
103
Management of PCOS
- Lifestyle/Reduce complications
o Weight loss, exercise
o Low glycaemic index, calorie-controlled diet
o Smoking cessation
o Antihypertensive medications, Statins
- 2nd line = COCP or IUS (mirena)
- Fertility
o Clomifene +/- metformin
o Ovarian drilling (if BMI normal)
o IVF
- Hirsutism = COCP, metformin, anti-androgens, eflomithine cream, hair removal
- Acne = topical retinoids/Abx
104
Complications of PCOS
- Insulin resistance and diabetes
- Acanthosis nigricans
- CVD, Hypercholesterolaemia, HTN
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems = infertility, miscarriage, GDM
105
Risk factors for PID
- Sexually active, Hx of STIs
- Recent partner change
- Intercourse without barrier contraceptive protection
- Personal Hx of PID
- Gynae surgery
- Termination of pregnancy
- Insertion of IUD
106
Causes of PID
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Mycoplasma genitalium
- Gardnerella vaginalis
107
Presentation of PID
- Lower abdominal pain
- Deep dyspareunia
- Menstrual abnormalities = menorrhagia, dysmenorrhoea or intermenstrual bleeding
- Post-coital bleeding
- Dysuria
- Abnormal vaginal discharge (purulent, unpleasant odour)
- Advanced = Fever, N+V
- Cervical excitation tenderness
- Palpable mass in lower abdomen
108
Investigations for PID
- Pregnancy test
- Swabs = Endocervical and high vaginal
- Urine dip +/- MSU
- Transvaginal/pelvic USS
- Full STI screen (HIV, syphilis etc)
- Laparoscopy + biopsy (GS)
109
Management of PID
- 14 day Abx = IM ceftriaxone 1g single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily
- Contact tracing of all sexual partners from last 6 months
- Safe sex advice Rest and avoid sexual intercourse
110
Complications of PID
- Ectopic pregnancy
- Infertility (1 in 10)
- Tubo-ovarian abscess
- Chronic pelvic pain
- Fitz-Hugh Curtis syndrome
111
Causes of prolactinoma
- Normal pregnancy and breastfeeding
- Pituitary adenomas
- Hypothalamus or pituitary stalk lesions
- Empty sella syndrome
- Hypothyroidism
- Chronic renal failure
- Drugs: phenothiazones, metoclopramide, methyldopa
112
Presentation of prolactinoma
- Amenorrhoea
- Galactorrhoea
- Headache
- Visual field defects (bitemporal hemianopia)
- Diabetes insipidus
- Polydipsia and polyuria
113
Investigations for prolactinoma
- Serum prolactin levels (not that useful in pregnancy)
- CT/MRI imaging of pituitary
114
Management of prolactinoma
- Bromocriptine
o if concern of tumour expansion
o continue through breastfeeding
- Surgery for macroprolactinoma that fail to shrink despite drug therapy (usually delayed until after delivery)
115
Risk factors for urinary incontinence
- Increased age
- Postmenopausal status
- Increase BMI
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions (MS)
- Cognitive impairment and dementia
- Hysterectomy
- FHx
116
Types of urinary incontinence
- Urge incontinence (overactive bladder) Overactivity of detrusor muscle of bladder
- Stress incontinence Weakness of pelvic floor and sphincter muscles
- Mixed incontinence (both urge and stress)
- Overflow incontinence
o Chronic urinary retention due to obstruction to outflow of urine
o Causes = anticholinergic meds, fibroids, pelvic tumours, neurological conditions (MS, diabetic neuropathy, spinal cord injuries)
o More common in men
- Functional incontinence
o Comorbid physical conditions impair patient’s ability to get to bathroom in time
o Cause: dementia, sedating medication, injury
117
Presentation of urge incontinence
o Suddenly feeling the urge to pass urine
o Having to rush to bathroom
o Not arriving before urination occurs
o Conscious about having access to toilet
o May avoid activities or places without easy access
o Significant impact on quality of life, stop work and leisure activities
118
Presentation of stress incontinence
o Allows urine to leak at time of increased pressure on bladder
o E.g. when laughing, coughing or surprised
119
Strength of pelvic muscles grading
Modified oxford grading system
120
Investigations for urinary incontinence
- Bladder diary
o Track fluid intake
o Episodes of urination and incontinence over at least 3 days
o Mix of work and leisure days
- Urine dipstick Rule out infection, microscopic haematuria and other pathology
- Post-void residual bladder volume Measured using bladder scan to assess for incomplete emptying
- Urodynamic testing
o If 1st line medical treatment not working, difficulties urinating, urinary retention, previous surgery or unclear diagnosis
o Cystometry
o Uroflowmetry
o Leak point pressure
o Post-void residual bladder volume
o Video urodynamic testing
121
Management of urge incontinence
o Bladder retraining = 1st line
o Antimuscarinic = oxybutynin (avoid elderly women), tolterodine, darifenacin
o Anticholinergic medication
o Mirabegron
o Invasive procedures = botox, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion
122
Management of stress incontinence
o Avoid caffeine, diuretics and overfilling of bladder
o Avoid excessive or restricted fluid intake
o Weight loss (if appropriate)
o Supervised pelvic floor exercises
o Surgery = tension-free vaginal tapes, autologous sling procedures, colposuspension, intramural urethral bulking
o Duloxetine (SNRI antidepressant) = 2nd line when surgery less preferred
123
Risk factors for pelvic organ prolapse
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopausal status
- Obesity
- Chronic respiratory disease coughing
- Chronic constipation causing straining
- Spina bifida
124
Types of pelvic organ prolapse
- Vault = had hysterectomy and top of vagina descends into vagina
- Rectocele = defect in posterior vaginal wall, allowing rectum to prolapse forwards into vagina
- Cystocele = defect on anterior vaginal wall, allowing bladder to prolapse backwards into vagina
125
Presentation of pelvic organ prolapse
- Feeling of ‘something coming down’ into vagina
- Dragging or heavy sensation in pelvis
- Urinary sx = incontinence, urgency, frequency, weak stream and retention
- Bowl sx = constipation, incontinence, urgency
- Sexual dysfunction = pain, altered sensation and reduced enjoyment
- Worse on straining or bearing down
126
Management of pelvic organ prolapse
- If asymptomatic and mild prolapse = no treatment
- Conservative management
o Physiotherapy
o Weight loss
o Lifestyle changes = reduce caffeine
o Treatment of related symptoms
o Vaginal oestrogen cream
- Vaginal pessaries + oestrogen cream
- Surgery
o Cystocele/cystourethrocele = anterior colporrhapy, colposuspension
o Uterine: hysterectomy, sacrohysteropexy
o Rectocele: posterior colporrhaphy
127
What is adenomyosis
Endometrial tissue inside myometrium
128
Risk factors for adenomyosis
- Multiparous
- Oestrogen
- Trauma
- Inflammation
- Later reproductive years (40-50s) = Hormone-dependent so tends to resolve after menopause
129
Presentation for adenomyosis
- 1/3 asymptomatic
- Dysmenorrhoea
- Menorrhagia
- Dyspareunia
- Irregular bleeding
- Enlarged tender uterus
- Softer uterus than when contains fibroids
130
Investigations for adenomyosis
- Transvaginal USS = 1st line
- Histological exam of uterus after hysterectomy = GS
- MRI = thickening of endo-myometrial zone
131
Management of adenomyosis
- Non-contraceptive Tranexamic acid, Mefenamic acid
- Contraceptive
1. Mirena coil
2. COCP
3. Cyclical oral progestogens
- GnRH analogues
- Endometrial ablation
- Uterine artery embolization
- Hysterectomy
132
Complications for adenomyosis
- Infertility
- Miscarriage
- Preterm birth
- SGA
- Preterm PROM
- Malpresentation
- Need for c-section
- PPH
133
What is endometriosis
Presence of endometrial tissue outside the endometrial cavity which induces chronic inflammatory reaction
134
Risk factors for endometriosis
- Early menarche
- Late menopause
- Delayed childbearing
- Nulliparity
- Vaginal outflow obstruction (imperforate hymen)
- White ethnicity
- Low BMI
- Autoimmune disease
135
Common sites of endometriosis
POD, uterosacral ligaments, ovaries, pelvis, bowel
136
Presentation of endometriosis
- Dysmenorrhoea = painful periods
- Deep dyspareunia = pain during intercourse
- Dyschezia = pain opening bowels
- Dysuria
- Other symptoms Bloating, Lethargy, Low back pain, Rectal bleeding, Subfertility, Anxiety and depression
- Endometrial tissue visible in vagina on speculum examination
- Fixed cervix on bimanual examination
- Tenderness in vagina, cervix and adnexa
- Fixed retroverted uterus
- Tender/nodular uterosacral ligaments
- Palpable rectal nodules
- Enlarged/tender ovaries
137
Investigations for endometriosis
- Pelvic USS = large endometriomas and chocolate ovarian cysts (ground-glass appearance)
- Laparoscopic surgery + biopsy Endometrioma, adhesions, peritoneal deposits
138
Management of endometriosis
- Analgesia = NSAIDs and paracetamol
- Hormonal treatment
o COCP or oral progesterone
o GnRH agonists = Danazol
o Depo-Provera (injection)
o Nexplanon implant
o Mirena coil (progesterone releasing)
- Surgery Ablation, Excision, Hysterectomy
139
What are fibroids
Oestrogen sensitive benign tumours of smooth muscle of uterus
140
Risk factors for fibroids
- later productive years (>35)
- More common in black women
- Obesity
- Early menarche
- FHx
141
Types of fibroids
- Intramural = within myometrium
- Subserosal = just below outer layer of uterus
- Submucosal = just below lining of uterus
- Pedunculated = on a stalk (mobile and prone to torsion)
- Cervical
- Parasitic = detached from uterus and attached to other structures
142
Presentation of fibroids
- Most = Asymptomatic
- Heavy menstrual bleeding
- Intermenstrual/post-coital bleeding
- Prolonged menstruation (>7 days)
- Abdo pain (worse on menstruation)
- Bloating or feeling full in abdomen
- Urinary/bowel symptoms (due to pelvic pressure or fullness)
- Deep dyspareunia
- Subfertility
- Abdo = palpable pelvic mass
- Bimanual exam = enlarged firm non-tender uterus
143
Investigations for fibroids
- Hysteroscopy = submucosal fibroids with HMB
- Pelvic transvaginal USS = larger fibroids
- MRI scanning = before surgical options
- Pregnancy test
144
Management of fibroids
- No treatment necessary if mild symptoms
- Lifestyle advice Weight loss, Reduce red meat
- GnRH analogues (triptorelin) = shrink fibroids before surgery
- <3cm = IUS, COCP, NSAIDs, tranexamic acid
- >3cm = gynae referral
o Sx control = tranexamic acid/mefenamic acid
o Myomectomy
o Hysterectomy (Women who completed family or >45)
- Uterine artery embolization
145
Referral criteria for fibroids
- Compressive symptoms
- Fertility/obstetric problems
- Suspicion of malignancy
- Palpable in abdominal exam or Us/hysteroscopy >12cm
146
Complications of fibroids
- HMB = iron deficiency anaemia
- Reduced fertility
- Pregnancy complications (miscarriage, premature labour, obstructive delivery
- Constipation
- Urinary outflow obstruction and UTIs
- Red degeneration of fibroid
- Torsion of fibroid
- Malignant change
147
Risk factors for endometrial polyps
- Peri/post menopausal
- Obesity
- Tamoxifen
148
Presentation of endometrial polyps
- Intermenstrual bleeding
- Menorrhagia
- Post-coital bleeding
- Subfertility
149
Management of endometrial polyps
- Watchful waiting if small
- GnRH analogues before surgery
- Resection during hysteroscopy
- Send polyp for histological assessment
