Gynaecology Flashcards
What is a cyst?
A fluid-filled sac.
If premenopausal MC benign
If postmenopausal MC malignant
When would an ovarian cyst be considered a PCOS?
Ovarian cysts + the following:
Hyperandrogenism
Polycystic ovaries on USS
Anovulation
Sx for ovarian cyst
Mostly aSx but can present with:
1. Pelvic pain (acute pelvic pain usually occurs if there is ovarian torsion, haemorrhage or rupture)
2. Abdominal fullness - early satiety
3. Palpable pelvic mass
4. Bloating
What are the two types of most common functional ovarian cysts?
- Follicular cysts: MC
Cysts grow on ovaries = called follicles → release oestrogen and progesterone → release egg during ovulation → monthly growing follicle = functional cyst - Corpus luteum cysts:
Doesn’t breakdown during menstrual period + gets filled with fluid - commonly occurs in early pregnancy
Which sx would suggest malignancy in ovarian cysts?
Abdominal distension *
Decreased appetite
Weight loss
Abdominal bloating
Ascites
Urinary Sx
Lymphadenopathy
What are the RF for malignancy of ovarian cysts?
Obesity
Smoking
HRT
Late menopause
Early menarche
Breastfeeding (protective)
Fhx of BCA1or BCA2*
** Increased number of ovulation
What is the tumour marker for ovarian cancer?
CA125 - however it’s not sensitive
What enzyme markers should be measured in all women under 40 due to the possibility of germ cell tumours?
Lactate dehydrogenase
Alpha-fetoprotein
hCG
What investigation is done to diagnose ovarian cyst rupture?
1st line - Transvaginal USS
Definitive - laparoscopy
What are the non-malignant causes of a raise in the tumour marker CA125? (4)
Hint: Think of things that can cause peritoneal inflammation.
Fibroids
PIDs and Adenomyosis
Endometriosis
Menstruation
Pregnancy
Liver disease/ascites
IBD
Describe management for ovarian cysts in premenopausal and postmenopausal women
Premenopausal:
If acute pain consider ovarian torsion
<5 cm = Resolves on it’s own
5-7 cm = Yearly USS
>7 cm = MRI scan to rule out cancer
Postmenopausal:
Raised CA125 = 2 week cancer referral
If <5cm = USS every 4-6 months
What’s Meig’s syndrome and how does it present?
Triad:
Benign ovarian cyst + pleural effusion + ascites
What are factors that reduce the number of ovulations experienced?
Late menarche
Early menopause
Pregnancies
Use of COCP pills
What is ovarian torsion?
When ovaries or fallopian tubes twist on connective tissues that support adnexa (blood supply)
What will most likely cause an ovarian torsion?
Ovarian mass >5cm - benign tumours/cysts
Pregnancies
How can ovarian torsion also happen in younger girl before menarche?
Girls have longer infundibulopelvic ligaments that can twist more easily
Describe the progression of an ovarian torsion and how it’s an emergency.
Twist on ovaries and blood supply → ischaemia → persistence → necrosis of ovaries + loss of function
Sx of ovarian torsion
SUDDEN ONSET SEVERE UNILATERAL PELVIC PAIN
N + V
LOC
Diagnosis of ovarian torsion
1st line - Pelvic USS (whirlpool sign - free fluid and oedema in pelvis)
GS (definitive) - laparoscopic surgery
Tx of ovarian torsion
Detorsion
if severe - oophorectomy (removal of ovary)
What is the main Ddx for ovarian torsion?
Ovarian cyst rupture
What is Pelvic Inflammatory Disease (PID)?
Inflammation and infection of organs surrounding the pelvis which spreads from vagina up to cervix leading to tubular infertility.
Define the following:
- endometritis
- Salpingitis
- Oophoritis
- Parametritis
- Infl. of the endometrium (inner lining of the uterus)
- Infl. of the fallopian tubes
- Infl. of the ovaries
- Infl. of the connective tissue surrounding the uterus.
What are the STI causes and non STI causes for PID?
STI: MC
1. Chlamydia Trachomatis*
2. Neisseria Gonorrhoea
3. Mycoplasma Genitalium
Non STI:
1. Gardnerella Vaginalis
2. H. Influenzae
3. E. Coli
RF for PID
Multiple sexual partners
Non protective sex
Currently have STI
Previous PID’s
Younger age
IUD (e.g. copper coil)
Sx for PID+ examination findings
Bilateral lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (post-coital)
Dysuria
Dyspareunia
Fever
On examination:
Pelvic tenderness
Cervical motion tenderness (during bi-manual examination)
Ix for PID
NAAT swab
Pregnancy test - rule out ectopic pregnancy
Vaginal and cervix swab - Pus cells
ESR and CRP
Tx of PID
IM Ceftriaxone 1 dose 1g
+
Metronidazole 400mg BD 14 days
+
Doxycycline 100 mg BD 14 days
Name 3 complications for PID?
Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)
What is Fitz-Hugh-Curtis Syndrome?
A complication of PID - Inflammation + infx of liver cells → adhesion of liver to peritoneum. Causes RUQ pain.
What is the Rotterdam Criteria for PCOS?
Polycystic ovaries on USS + hyperandrogenism (hirsutism + acne) + anovulation (irregular/absent menstrual cycle)
Sx of PCOS
Oligomenorrhoea/amenorrhoea
Hirsutism
Acne
Obesity
Infertility
Insulin resistance
Acanthosis nigricans
What are different conditions that can cause hirsutism?
Meds (steroids, testosterone)
Cushing’s syndrome
Ovarian and adrenal tumours
How does insulin resistance occur in PCOS?
Insulin = increases androgen levels and suppresses SHBG (sex hormone-binding globulin = binds to androgens)
Therefore, inc. insulin in blood = inc. androgen and decreased SHBG which also further increases androgens+ stops follicle development in ovaries therefore anovulation occurs
Ix for PCOS:
- Blood tests + results
- Other tests
1.
Testosterone ↑
SHBG ↓
LH ↑
FSH normal/low
LH : FSH ↑
Insulin ↑
- 1st line - pelvic USS (not reliable in adolescents)
GS - intravaginal USS: string of pearls appearance, 12 or more developing cysts, ovarian volume > 10 cm³
Conservative management of PCOS
** weight loss - use orlistat for this (lipase inhibitor)
Diet
Stop smoking
Why is there a risk of endometrial cancer in patients with PCOS and how would you manage it?
PCOS → no ovulation → dec. progesterone and inc. oestrogen → endometrial lining proliferate without regular shedding → endometrial hyperplasia (abnormal thickening of endometrium) → inc. cancer risk
Tx: Mirena coil or induce bleeding using cyclical progestogens or COCP - helps with endometrial hyperplasia
How would you manage infertility in patients with PCOS?
Weight loss
Clomiphene + can be taken with metformin
Surgery - Laparoscopic ovarian drilling
How would you manage hirsutism in patients with PCOS?
Weight loss
Co-cyprindiol (COCP) - SE = inc. VTE risk
How would you manage acne in patients with PCOS?
Co-cyprindiol (COCP) - SE = inc. VTE risk
Topical retinoids and antibiotics
Why do overweight girls tend to enter puberty at an earlier age?
Aromatase → enzyme found in adipose tissue (fat) → increases oestrogen creation
Overweight = inc. adipose tissue = inc. enzyme secretion = inc. oestrogen production
What is the process of puberty development in girls?
Breast buds → pubic hair formation → start of menstrual period (aka menarche)
What is lichen sclerosus?
Describe what it is and which parts of the body it affects.
A chronic inflammatory skin condition that presents with itchy, porcelain white patches.
Most common in:
1. Women - inner vulva, labia, perineum, perianal skin
2. Men - foreskin and glans
3. Both - can present in axilla and thighs
Commonly affects females age from 45-60
Causes of lichen sclerosus
Unknown but said to possibly be autoimmune, genetic or even hormonal factors. Also possibly previous trauma.
Difference between lichen sclerosus, lichen simplex and lichen planus.
- Lichen sclerosus = chronic inflammatory skin condition
- Lichen simplex = chronic irritation caused by repeated scratching and itching
- Lichen planus = autoimmune skin condition with shiny, purplish, flat topped raised patches with white striae across surface
Sx of lichen sclerosus
- Itching (vulval itching)
- Shiny, porcelain white, tight, thin, slightly raised patches
- Superficial dyspareunia
- Erosions
- Fissures
Mx of lichen sclerosus
Has no cure
Can use potent topical steroids (e.g. Clobetasol propionate 0.5% dermovate)
Emollients used on a regular basis
Followed up every 3-6 months
Complications of lichen scleorus
Squamous cell carcinoma risk
Sexual dysfunction
Bleeding
What is atrophic vaginitis? What causes it to happen?
Dryness + atrophy of the vaginal mucosa due to low concentrations of osetrogen
Oestrogen = maintains epithelial lining of vagina + urinary tract = thicker, more elastic and produce secretions
Low oestrogen = thinner, dec. elasticity, dry
Most commonly occurs in menopausal women
Sx of atrophic vaginitis
Dryness
Itchy
Superficial dyspareunia
Bleeding (post-coital)
Recurrent UTI
What would examination of the labia + vagina demonstrate?
Thin
Pale
Lack of pubic hair
Dry
Reduced skin folds
Erythema (inflammation)
Tx of atrophic vaginitis
1st step - two week referral for suspected endometrial cancer (if over 55yrs)
Lubricants
Topical oestrogen :
* Estriol pessary
* Estriol cream
* Estradiol tablets
* Estradiol rings
CI for topical oestrogen = breast cancer, angina, VTE