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
- Functional ovarian cysts – cysts that develop as part of the menstrual cycle and are usually harmless and short-lived
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
Not breastfeeding - breastfeeding is 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
What is Asherman’s syndrome? When does it commonly occur?
When adhesions form in the uterus following damage in the uterus.
Usually occurs after:
- pregnancy-related dilatation and curettage procedure (i.e. removing remaining placental tissue after birth)
- Uterine surgery
- Several PID
What does having asherman’s syndrome (adhesions) lead to?
Describe how they have a negative effect on the body.
They form physical obsturction and distort pelvic organs resulting in menstruation abnormalities, infertility and recurrent miscarriages.
Sx of Asherman’s syndrome
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
- Infertility
Ix for Asherman’s syndrome
GS - hysteroscopy
Hysterosalpingography
Sonohysterography
MRI scan
Mx of Asherman’s syndrome
Dissect adhesions during hysteroscopy
What is vulval cancer and what is the most common kind of skin cancer that affects the vulva?
- Definition: Malignant growth that affects skin if vulva (external female genitalia)
- MC: Squamous cell carcinoma
RF of vulval cancer (3)
- Increasing age
- Exposure to HPV
- Cdtns that cause chronic infl. of vulva
Sx of vulval cancer
Lump (lymphadenopathy)
Itching/discomfort in vulval area
Non-healing ulcer
Vulval pain
Vulval skin changes
Irregular bleeding
Describe epidemiology of the following cancers:
* Ovarian cancer
* Vulval cancer
* Cervical cancer
- Older age but can be found in young patients
- > 60 yrs (older)
- 3rd MC cancer worldwide
Tx of vulval cancer?
- If simple - local excision
- In advanced - Radiotherapy (+/- chemotherapy) or radical vulvectomy
- Reconstructive surgery - to maintain vulva structure
What is the MC skin cancer found in cervical cancers?
Squamous cell carcinoma
RF of cervical cancer? (3)
- HPV 16 and 18 infection - MC
- Multiple sexual partners
- Smoking
- Immunosuppression (e.g. HIV)
Sx of cervical cancer
- Vaginal discharge
- Bleeding (postcoital or with micturition/defaecation)
- Vaginal discomfort
- Bowel/urinary changes
- Suprapubic pain
- Abnormal red/white patches on cervix
- Mass felt - PR examination
Ix for cervical cancer
1st line - urgent colposcopy (visualise cervix)
CT abdo/pelvis - cancer staging
Tx of cervical cancer?
Simple:
* Conisation w/free margins (spare fertility)
Advanced:
* Radical trachelectomy (spare fertility)
* Laparoscopic hysterectomy and lymphadenectomy
Invasive:
* Radical (Wertheim’s) hysterectomy
- Conisation - done w/ scalpel, lader, electrosurgical loop as outpatient
- Radical trachelectomy - removal of cervix, upper vagina and pelvic lymph nodes
- Wertheim’s hysterectomy - removal of uterus, primary tumour, pelvic lymph nodes, upper third vagina, utervesical and uterosacral ligaments
Females of what age are asked to do cervical screening and how often do they do it?
Age: 25-64
Every 3 years: 25-49
Every 5 years: 50-64
HPV vaccination is given to boys and girls ages 12-13 yrs to protect against cancers caused by HPV
What is the purpose of cervical screening?
Identify dyskaryotic cells which are pre-cancerous. Detection of HPV
What would be the outcomes of these following results from a cervical screening:
1. Negative HPV
2. Positive HPV but abnormal cytology
3. Positive HPV but negative cytology
- Returned to routine recall
- Colposcopy referral
- Repeat HPV in 12 mths and again in 24 mths if still +ve. If after 24mths still +ve then colposcopy referral
Sx of cervical polyps
Abnormal vaginal bleeding
Discharge
Pain during coitus
However it’s benign and not associated with HPV/cervical cancer.
Define menorrhagia
Excessive blood loss during menstrual period that affects women’s quality of life
Ddx for menorrhagia
- Fibroids
- Adenomyosis
- Endometrial polyps
- Endometrial cancer
Ix for menorrhagia?
FBC, TFTs and Fe
Clotting screem
Trasnvaginal USS - identify underlying cx such as fibroids
Tx of menorrhagia/ dyfunctional uterine bleeding?
- Mirena coil
- Mefenamic acid
- Tranexamic acid
- Hormonal contraception i.e. COCP
What is endometrial cancer?
Malignancy that originates from endometrium (inner uterus lining)
RF for endometrial cancer (4)
- Nulliparity
- Obesity
- Early menarche
- Late menopause
- PCOS
- Oestrogen-only hormone replacement therapy
Sx of endometrial cancer
- Postmenopausal bleeding
- Abnormal vaginal bleeding
- Dyspareunia
- Pelvic pain
- Bloating
- Wgt loss
- Anaemia
Ix for endometrial cancer
Transvaginal USS
Endometrial biopsy
Tx of endometrial cancer
If limited to uterus - hysterectomy with bilateral salpingo-oophorectomy
If spread outside uterus - combination surgery, radio and chemotherapy
What is endometriosis?
When endometrium-like tissue proliferates outside uterine cavity
Sx of endometriosis
- Dysmenorrhoea
- Dyspareunia
- Subfertility
- Cyclical rectal bleeding
- Tender, nodular masses palpable on ovaries or ligaments surrounding uterus
Subfertility = difficulty getting pregnant
Ix of endometriosis
Transvaginal USS - 1st line
Diagnostic laparoscopy - GS (small risk of bowel perforation)
Tx of endometriosis
Medical and surgical
Medical:
* Analgesia (paracetamol/NSAIDs)
* Hormonal (COCP, GnRH agonists)
Surgical:
* Diathermy of lesions
* Ovarian cystectomy
* Adhesiolysis
* Bilateral oophorectomy
- Diathermy of lesions = heat tissue (ablation)
- Ovarian cystectomy = cyst removal from ovary
- Adhesiolysis = cutting the scar tissue through a surgical procedure
- Bilateral oophorectomy = removing both ovaries
What is adenomyosis?
Endometrial tissue inside myometrium.
RF for adenomyosis
MC in later reproductive yrs
Multiparous
Trauma
Sex hormones - sx tend to resolve after menopause
Sx of adenomyosis
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
O/E - enlarged, tender uterus
Ix for adenomyosis
Transvaginal USS - 1st line
Histological examination of uterus after hysterectomy - GS
Tx of adenomyosis
If pt don’t want contraception, sx relief:
* Tranexamic acid (if no associated pain - reduces bleeding)
* Mefenamic acid (if associated pain + bleeding)
If contraception wanted:
* Mirena coil (1st line)
* COCP
Other:
* Endometrial ablation
* Hysterectomy
What are the complications of adenomyosis?
Infertility
Miscarriage
Preterm birth
C-section
PPH
What are fibroids?
Aka uterine leiomyomas. Benign tumours of the smooth muscle of uterus that are oestrogen sensitive (grow in response to oestrogen).
What are the different types of fibroids?
- Intramural - within myometrium, can change shape and distort uterus
- Subserosal - just below outer layer of uterus, grow outwards into abdo cavity
- Submucosal - endometrium
- Pedunculated - on a stalk
Sx of fibroids
Often Asx, but:
Heavy menstrual bleeding
Prolonged menstruation
Abdo pain worse during period
Deep dyspareunia
Bloated
Urinary/bowel sx
O/E - Palpable pelvic mass/enlarged firm non-tender uterus
Ix of fibroids
Hysteroscopy - 1st line
Pelvic USS - if larger fibroids
Tx of fibroids, in the following:
1. If less than 3cm + surgical options
2. If more than 3cm + surgical options
<3cm:
* Mirena coil (1st line)
* Sx mx - NSAIDs and tranexamic acid
* COCP
Surgical:
* Endometrial ablation
* Resection of submucosal fibroids
* Hysterectomy
>3cm:
* Mirena coil (1st line)
* Sx mx - NSAIDs and tranexamic acid
* COCP
* Cyclical progestogens
Surgical:
* Uterine artery embolisation
* Myomectomy
* Hysterectomy
A myomectomy is a procedure to remove uterine fibroids.
What are the complications of fibroids?
Reduced fertility
Urnary outflow obstruction and UTI
Red degenration of fibroid
Fibroid torsion
What is red degenration of fibroids?
Ischaemia, infarction and necrosis of the fibroid due to the disrupted blood supply.
Most likely to occur in fibroids above 5cm during 2nd/3rd trimester of preggo.
How does red degenration of fibroids present?
Sever abdo pain
Low-grade fever
Tachycardia
Vomiting
Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration. Management is supportive, with rest, fluids and analgesia.
What is a molar pregnancy (hydatidiform mole)?
Part of a spectrum of disorders known as gestational trophoblastic disease.
It’s characterised by imbalance in number of chromosomes originating from mother and father during conception.
Highest risk at the extreme ends of the fertility age range, specifically those under 16 years of age and over 45 years of age.
Describe what is meant by the 2 types of molar pregnancies:
1. Complete mole
2. Partial mole
- Formation from a single sperm and an empty egg (no genetic material). Thus sperm replicates to provide normal number of chromosomes.
- Formed from 2 sperm and normal egg. Both maternal/paternal genetic material is present w/ variable evidence of foetal parts
Sx of molar pregnancy?
Vaginal bleeding
Nausea
Hyperemesis gravidarum
Thyrotoxicosis (hCG is closely related to TSH)
Uterus larger than expected size for gestational age (due to excessive growth of trophoblasts and retained blood)
```
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Ix for molar pregnancy
B-hCG levels - significantly higher than normal preggo
Trans-vaginal USS - in complete molar preggo may show ‘snowstorm’ appearance + absence of foetus
Tx of molar pregnancy
Not viable preggo - suction curettage to remove them from uterus
If fertility preservation not concern - hysterectomy
Surveillance - bimonthly serum and urine hCG until levels are normal:
* In partial - hCG done 4 weeks later and discharged if normal
* In complete - monthly repeat hCG sent for atleast 6 mths
Difference between primary and secondary amenorrhoea?
- Primary - when pt has never developed periods
- Secondary - when pt previously had periods but subsequently stopped
Causes of primary amenorrhoea?
- Hypogonadotropic hypogonadism (abnormal hypothalamus or pituitary gland)
- Hypergonadotropic hypogonadism (abnormal gonads)
- Imperforate hymen
Causes of secondary amenorrhoea? (4)
- Pregnancy MC
- Menopause
- Physiological stress
- PCOS
- Medications such as contraceptives
- Excessive prolactin (prolactinoma)
- Cushing’s syndrome
What is intermenstrual bleeding and give examples of causes of it?
Any bleeding that occurs between menstrual periods.
Causes:
* Hormonal contraception
* STI
* Endometrial polyps or cancer
* Cervical polys or cancer
* Vaginal cancer
* Preggo
* Ovulation
Causes of dysmenorrhoea? (3)
- Endometriosis or adenomyosis
- Fibroids
- PID
- Copper coil
- Cancer (cervical or ovarian)
Postcoital bleeding causes? (2)
Remember PCB is a red flag
Cancers!! (cervical, endometrial and vaginal)
Trauma
Atrophic vaginits
Polyps
What is androgen sensitivity syndrome?
Cdtn where cells are unable to respond to androgen hormones due to lack of androgen receptors.
What kind of genetic mutation is androgen insensitivity syndrome?
Extra androgens are converted into oestrogen resulting in female secondary sexual characteristics (testicular feminisation syndrome)
X-linked recessive
Describe pathophysiology of androgen insensitivity syndrome?
- Pts are genetically male
- Absent response to testosterone leads to coversion of additional androgens (testosterone) to oestrogen
- This result in female phenotype externally and pt have normal female external genitalia and breast tissue
- Pts have testes in abdo but don’t develop uterus, upper vagina, cervix, fallopian tubes and ovaries. It also results in lack of pubic hair, facial hair and male type muscle development. They are infertile
Which hormone do testes produce which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes?
Anti-Müllerian hormone
Describe presentation of androgen insensitivity syndrome in infancy and the hormone test results.
Infancy: Inguinal hernia containing testes
Hormone tests:
* Raised LH
* Normal/raised FSH
* Normal/raised testosterone levels (for a male)
* Raised oestrogen levels (for a male)
Mx of androgen insensitivity syndrome
- Bilateral orchidectomy (removal of the testes) - avoid testicular tumours
- Oestrogen therapy
- Vaginal dilators or vaginal surgery - create adequate vaginal length
Generally, patients are raised as female, but this is sensitive and tailored to the individual.
Why do males not develop a uterus?
Due to anti-Mullerian hormone.
Which structure in the fetus does the upper vagina, cdrvix, uterus and fallopian tubes develop from?
Mullerian ducts
What is an imperforate hymen and what complication can it lead to?
When hymen at vagina entrance is fully formed without opening. If not treated can lead to retrograde menstruation leading to endometriosis.
What defines that a women has started menopause and typically at what age does this occur?
Permanent cessation of menstruation - at least 12 mths of amenorrhoea in women not on hormonal contraception.
Age: 45-55 yrs
What is menopause caused by?
Ovarian failure which leads to oestrogen deficiency.
Sx of menopause
Vasomotor: hot flushes, night sweats
Sexual dysfunction: vaginal dryness, dec. libido, dyspareunia
Psychological: depression, anxiety, mood swings, dec. conc.
What Ix are done for menopause?
Also describe the levels of the hormones in menopause.
- Preggo test
- FSH - if 40-45 yrs
Hormones:
* Oestrogen and progesterone = low
* LH and FSH = high
What are the risks associated with having a lack of oestrogen?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Mx of menopause
Combined HRT:
* Oestrogens - oral, transdermal or topical
* Progestogens - oral, transdermal or intrauterine
Non-hormonal:
* Exercise, avoid triggers: spicy foods, caffiene, smoking
* SSRIs
* CBT
* Vaginal moisturisers
Risks of oral HRT = inc. risks of breast cancer, endometrial cancer (if oestrogen given alone), and venous thromboembolism.
Note: oestrogen only HRT is not suitable for woman with a uterus
What are the different types of ovarian cancer?
- Epithelial ovarian tumours - MC
- Germ cell tumours - benign + associated w/ ovarian torsion
- Sex cord stromal tumours - rare
What is a Krukenberg tumour in relation to ovarian cancer?
Metastasis in ovary usually from GI cancer. Has a characteristic “signet-ring” cells on histology.
RF for ovarian cancer
- Older age
- BRCA 1 and 2 genes
- Inc. ovulations - early onset period, late menopause or dec. pregnancies
- Obesity
- Smoking
Protective factors for ovarian cancer?
Dec. number of ovulations in lifetime:
* COCP
* Breastfeeding
* Preggo
Sx of ovarian cancer
- Abdo bloating
- Early satiety
- Appetite loss
- Pelvic pain
- Urinary sx
- Wgt loss
- Ascites
Ovarian mass - may press on obturator nerve and can cause hip or groin pain.
Ix for ovarian cancer?
Blood test: CA-125
Pelvic and abdo USS
Tx for ovarian cancer
Combined surgery and chemotherapy
What are non-malignant causes of raised CA125?
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infx
- Liver disease
- Preggo
