Gynaecology Flashcards
What is the hypothalamic pituitary gonadal axis ?
The hypothalamus releases GnRH which stimulates the anterior pituitary to produce LH and FSH.
These stimulate the development of follicles in the ovaries. The theca granulosa cells secrete oestrogen which has a negative feedback effect on the hypothalamus and anterior pituitary.
What is oestrogen ?
A steroid sex hormone produces by the ovaries in response to LH and FSH. It acts to promote female secondary sexual characteristics.
What does oestrogen stimulate ?
Breast tissue development
Growth and development of the female sex organs at puberty
Blood vessel development in the uterus
Development of the endometrium.
What is progesterone ?
A steroid sex hormone produced by the corpus luteum after ovulation.
When pregnancy occurs progesterone is mainly produced by the placenta.
What are the main functions of progesterone ?
Thickens and maintains the endometrium
Thickens the cervical mucus
Increases the body temperature
At what ages does puberty start in boys and girls ?
8-14 - girls
9-15 - boys
What can cause delayed puberty in girls ?
Low birth weight
Chronic disease
Eating disorders
Athletes
What are the 2 stages of the menstrual cycle ?
Follicular and luteal
What part of the menstrual cycle is the follicular phase ?
Start of the menstruation to the moment of ovulation.
What part of the menstrual cycle is the luteal phase ?
The moment of ovulation to the start of menstruation
What hormone spikes before ovulation ?
LH
What does the corpus luteum secrete ?
High levels of progesterone which maintains the endometrial lining. It also causes the cervical mucus to become thick.
What maintains the corpus luteum ?
HCG
What secretes HCG ?
The syncytiotrophoblasts of the embryo
What happens if there is no fertilisation or production of hCG ?
The corpus luteum degenerates and stops producing oestrogen and progesterone.
This fall causes the endometrium to break down and menstruation to occur.
What is menstruation ?
Involves the superificial and middle layers of the endometrium separating from the basal layer. This tissue is broken down inside the uterus and released the cervix and vagina.
What are some functions of the placenta ?
Respiration
Nutrition
Excretion
Immunity
What is amenorrhoea ?
Refers to a lack of menstrual periods
What are some causes of primary amenorrhoea ?
Abnormal functioning of the hypothalamus or pituitary gland
Abnormal functioning of the gonads
Imperforate hymen
What are some causes of secondary amenorrhoea ?
Pregnancy
Menopause
Physiological stress - excessive exercise, low BMI, chronic disease
PCOS
Medications
Thyroid hormone abnormalities
Cushing’s syndrome
What are the key causes of intermenstrual bleeding ?
Hormonal contraception
Cervical ectropion, polyps or cancer
STI
Endometrial polyps or cancer
Vaginal cancer
Pregnancy
Ovulation
Medications
What are some causes of dysmenorrhoea ?
Primary dysmenorrhoea
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer
What are some causes of Menorrhagia ?
Dysfunctional uterine bleeding
Extremes of reproductive age
Fibroids
Pelvic inflammatory disease
Contraceptives
Anticoagulants
Bleeding disorders
DM or hypothyroidism
PCOS
What are some causes of post-coital bleeding ?
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
What are some differentials for pelvic pain ?
UTI
Dysmenorrhoea
IBS
Ovarian cysts
Endometriosis
Pelvic inflammatory disease
Ectopic pregnancy
Appendicitis
Mittelschmerz
Pelvic adhesions
Ovarian torsion
IBD
What are some causes of vaginal discharge ?
Bacterial vaginosis
Candidiasis
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Polyps
Cervical ectropion
Pregnancy
Malignancy
What are some causes of Pruritus vulvae ?
Irritants
Atrophic vaginitis
Infections - candidiasis
Skin conditions such as eczema
Vulval malignancy
Stress
What is hypogonadism ?
Refers to a lack of sex hormones, oestrogen and testosterone that normally rise before and during puberty.
What is hypogonadotropic hypogonadism ?
Involves deficiency of LH and FSH leading to deficiency of the sex hormones
What can cause hypogonadotropic hypogonadism ?
Hypopituitarism
Damage to the hypothalamus or pituitary
Significant chronic conditions
Excessive exercise or dieting
Constitutional delay in growth and development
Kallman syndrome
What is hypergonadotropic hypogonadism ?
Gonads fail to respond to stimulation from LH or FSH. Without negative feedback LH and FSH rise.
What are some causes of hypergonadotropic hypogonadism ?
Previous damage to the gonads
Congenital absence of ovaries
Tuners syndrome
What is associated with Kallman syndrome ?
Anosmia
What is congenital adrenal hyperplasia ?
Congenial deficiency of the 21-hydroxylase enzyme.
This causes underproduction of cortisol and aldosterone and over production of androgens from birth.
Which inheritance pattern does congenital adrenal hyperplasia follow ?
Autosomal recessive
What are some typical features of congenital adrenal hyperplasia if presenting later in childhood ?
Tall for age
Facial hair
Absent period
Deep voice
Early puberty
What is androgen insensitivity syndrome ?
A condition where the tissues are unable to respond to androgen hormones so typical male sexual characteristics don’t develop.
Resulting in female phenotype
What are the threshold for initiating investigations for amenorrhoea ?
No evidence of pubertal changes in a girl aged 13.
What are some initial investigations for amenorrhoea ?
FBC
U&E’s
Anti-TTG or anti-EMA
What are some hormonal investigations for amenorrhoea ?
FSH and LH
TFT’s
Insulin like growth factor
Prolactin
Testosterone
What imaging can be performed for amenorrhoea ?
X-ray of the wrist
Pelvic USS
MRI of the brain
What is the management option for constitutional delay in growth and development ?
Reassurance and observation
What is the management of hypogonadotropic hypogonadism ?
Pulsatile GnRH
Replacement of sex hormones - COCP
What are some pituitary causes of secondary amenorrhoea ?
Pituitary tumour - prolactinoma
Pituitary failure - trauma, surgery or sheenan’s syndrome
How does high prolactin levels cause amenorrhoea ?
High prolactin levels act on the hypothalamus to prevent the release of GnRH.
Without GnRH there is no release of LH or FSH.
What are some management options for hyperprolactinoemia ?
Bromocriptine
Cabergoline
If amenorrhoea lasts longer than 12 months what should be prescribed ?
Ensure adequate vitamin D and calcium intake
HRT or COCP
What is premenstrual syndrome ?
This describes the physiological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle.
What is the cause of premenstrual syndrome ?
Fluctuation in oestrogen and progesterone hormones during the menstrual cycle.
How does premenstrual syndrome present ?
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Reduced libido
What is the management of premenstrual syndrome ?
General healthy lifestyle changes
COCP
SSRI
CBT
what is classed as excessive menstrual blood loss ?
More than 80mL loss
What are some basic investigations to perform in Menorrhagia ?
Pelvic exam with a speculum and bimanual
FBC
When should an outpatient Hysteroscopy be arranged for Menorrhagia ?
Suspected submucosal fibroids
Suspected endometrial pathology
Persistent intermenstrual bleeding
When should a pelvic and transvaginal USS be arranged in menorrhagia ?
Possible large fibroids
Possible adenomyosis
Examination is difficult to interpret
Hysteroscopy is declined
If a woman doesn’t want contraception what can be offered for Menorrhagia ?
Tranexamic acid
Mefenamic acid
If a woman does want contraception what can be offered for Menorrhagia ?
Mirena coil
COCP
Cyclical oral progestogens
What is endometrial ablation ?
Involves destroying the endometrium.
What are fibroids ?
Benign tumours of the smooth muscle of the uterus.
What is an intramural fibroid ?
Within the myometrium - as they grow the shape changes and distort the uterus
What is a subserosal fibroid ?
Just below the outer layer of the uterus.
These grow outwards and become very large filling the abdominal cavity.
What is a submucosal fibroids ?
Just below the lining of the uterus
What does pedunculated fibroid mean ?
On a stalk
How do fibroids present ?
Can be asymptomatic
Heavy menstrual bleeds
Prolonged menstruation
Abdo pain
Bloating
Urinary or bowel symptoms
Deep Dyspareunia
Reduced fertility
What are some investigations when suspecting fibroids ?
Hysteroscopy
Pelvic USS
MRI scanning
What are the surgical options for smaller fibroids ?
Endometrial ablation
Resection
Hysterectomy
What are some surgical options for larger fibroids ?
Uterine artery embolisation
Myomectomy
Hysterectomy
How is uterine artery embolisation performed ?
Inserts a catheter into an artery usually the femoral artery.
This catheter is then passed through the uterine artery.
Then once in place particles are inserted that cause a blockage in the arterial supply to the fibroid.
What are the complications of fibroids ?
Heavy menstrual bleeding
Reduced fertility
Pregnancy complications
Constipation
Urinary outflow obstruction
Red degeneration of fibroid
Torsion of the fibroid
What is red degeneration of fibroids ?
Refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
More likely to occur in larger fibroids during pregnancy.
How does red degeneration of fibroids present ?
Severe abdominal pain
Low grade fever
Tachycardia
Vomiting
What is the management of red degeneration of fibroids ?
Supportive - rest, fluids and analgesia
What is endometriosis ?
A condition where there is ectopic endometrial tissue outside the uterus.
What is the pathophysiology of the symptoms of endometriosis ?
The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. This sheds and bleeds elsewhere in the body.
This causes irritation and inflammation of the tissues
How does endometriosis present ?
Cyclical abdominal or pelvic pain
Deep Dyspareunia
Dysmenorrhoea
Infertility
Cyclical bleeding
How is a diagnosis of endometriosis made ?
Pelvic USS
Laparoscopic surgery is gold standard
What is the hormonal treatment for endometriosis ?
COCP
POP
Depo
Implant
Mirena coil
GnRH agonists
What are the surgical options for endometriosis ?
Laparoscopic surgery to excise or ablate the endometrial tissue
Hysterectomy
What is adenomyosis ?
Refers to endometrial tissue inside the myometrium
The condition is hormone dependent and symptoms tend to resolve after menopause
How does adenomyosis present ?
Painful periods
Heavy periods
Dyspareunia
May present with infertility
How is a diagnosis of adenomyosis made ?
Transvaginal USS
MRI and trans abdominal USS
Gold standard - histological exam of uterus after a hysterectomy
What is the management of adenomyosis ?
Tranexamic acid if no pain
Mefenamic acid if there is pain
Mirena coil, COCP
Specialist - GnRH analogues, endometrial ablation, uterine artery embolisation, hysterectomy
In pregnancy what is adenomyosis associated with ?
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresention
PPH
What is menopause ?
Retrospective diagnosis made after a woman has had no periods for 12 months - it is defined as a permanent end to menstruation.
What is post menopause ?
The period from 12 months after the final menstrual period onwards
What is perimenopause ?
Refers to the time around menopause where the woman may be experiencing vasomotor symptoms and irregular periods
What is premature menopause ?
Menopause before the age of 40 years
It is as a result of premature ovarian insufficiency.
What are some Perimenopausal symptoms ?
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
What does menopause increase the risk of ?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
What are some management options for menopause ?
No treatment
HRT
Tibolone
Clonidine
CBT
SSRI
Testosterone
Vaginal oestrogen
Vaginal moisturiser
What is premature ovarian insufficiency ?
Defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age.
What is seen on hormonal analysis in premature ovarian analysis ?
Raised LH and FSH levels
Low Oestradiol levels
What are some causes of premature ovarian insufficiency ?
Idiopathic
Iatrogenic
Autoimmune - coeliac, adrenal insufficiency, T1DM or thyroid disease
Genetic - Turner’s syndrome
Infections - mumps, TB
How does premature ovarian insufficiency present ?
Irregular menstrual periods
Lack of menstrual periods
Low oestrogen levels - hot flushes, night sweats and vaginal dryness
How can a diagnosis of premature ovarian insufficiency made ?
Women younger than 40yrs with typical menopausal symptoms plus high FSH
What does premature ovarian insufficiency put you at an increased risk of ?
CVD
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
What is the management of premature ovarian insufficiency ?
HRT until at least the age at which women typically go through menopause
Why is progesterone given in HRT ?
It needs to be given to women with a uterus to prevent endometrial hyperplasia and endometrial cancer secondary to unopposed oestrogen.
What are some non-hormonal treatments for menopausal symptoms ?
Lifestyle changes - diet, weight loss, smoking cessation
CBT
Clonidine
SSRI
Venlafaxine
Gabapentin
What is clonidine ?
It acts as an agonist of alpha-2 adrenergic receptors in the brain.
What are the effects of clonidine ?
Lowers BP
Reduces HR
Helpful for vasomotor symptoms
Helpful for hot flushes
what are the common side effects of clonidine ?
Dry mouth
Headache
Dizziness
Fatigue
What can sudden withdrawal from clonidine cause ?
Rapid increase in BP and agitation
What are the indications for HRT ?
Replacing hormones in premature ovarian insufficiency
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms of low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60
What are the benefits of HRT ?
Improved vasomotor and other symptoms of menopause
Improved quality of life
Reduced risk of osteoporosis and fractures
What are the principle risks of HRT ?
Increased risk of breast cancer
Increased risk of endometrial cancer
Increased risk of VTE
Increased risk of stroke and coronary artery disease
How can some risks of HRT be reduced ?
Risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
Risk of VTE is reduced by using patches
What are the contraindications to HRT ?
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
VTE
Liver disease
Active angina or MI
Pregnancy
What assessments should be made before starting HRT ?
Full history for any contraindications
Family history to assess for oestrogen dependent cancers
Check BMI and BP
Ensure cervical and breast cancer is up to date
How can oestrogen be given for HRT ?
Oral - tablets
Transdermal patches
How can progesterone be given for HRT ?
Cyclical or continuous
How does cyclical progesterone work and when is it given ?
Given for 10-14 days a month
Is used for women who have had a period within the last 12 months
This allows the patients to have a monthly breakthrough bleed
When is continuous progesterone used ?
If a women has not had a period in the last 12 months
How long is continuous progesterone for ?
24 months if under 50
12 months if over 50
How can progesterone be given for HRT ?
Oral - tablets
Transdermal - patches
Intrauterine system - Mirena coil
What is progestin ?
Synthetic progesterone
What is tibolone ?
A synthetic steroid that stimulates oestrogen and progesterone receptors
Used as a form of continuous combined HRT
What is needed for women to be started on tibolone ?
Women need to be more than 12 months without a period ( 24 months if younger than 50 )
How long does it take for HRT to take full effect ?
3-6 months
How long before major surgery should HRT be stopped ?
4 weeks
What are the oestrogenic side effects of HRT ?
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
What are the progestogenic side effects of HRT ?
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
For how long can unscheduled bleeding occur when starting HRT ?
3-6 months
What are the characteristic features of PCOS ?
Multiple ovarian cysts
Infertility
Oligomenorrhoea
Hyperandrogenism
Insulin resistance
What is anovulation ?
Refers to the absence of ovulation
What is oligovulation ?
Irregular infrequent ovulation
What is amenorrhoea ?
Absence of menstrual periods
What is Hirsutism ?
Refers to the growth of thick dark hair often in a male pattern
What criteria is used to make a diagnosis of PCOS ?
Oligovulation
Hyperandrogenism
Polycystic ovaries on USS
How does PCOS present ?
Oligomenorrhoea or amenorrhoea
Infertility
Obesity
Hirsutism
Acne
Hair loss in a male pattern
What are some complications of PCOS ?
Insulin resistance and diabetes
Acanthosis nigricans
CVD
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual probelms
What is acanthosis nigricans ?
Describes thickened rough skin typically found in the axilla and on the elbows.
It has a velvety texture
What can cause Hirsutism ?
PCOS
Medications such as phenytoin, Ciclosporin, corticosteroids, testosterone or anabolic steroids
Ovarian or adrenal tumours
Cushing’s syndrome
Congenital adrenal hyperplasia
What blood tests should be performed for PCOS ?
Testosterone
Sex hormone binding globulin
LH
FSH
Prolactin
TSH
What do hormonal tests usually show in PCOS ?
Raised LH
Raised LH:FSH
Raised testosterone
Raised insulin
Normal or raised oestrogen
What is gold standard for visualising the ovaries ?
Transvaginal USS
What imaging is performed when suspecting PCOS ?
Pelvic USS
How may the follicles be seen in the ovaries in PCOS ?
They are arranged around the periphery of the ovary - giving a string of pearls appearance
What is the screening of choice in patients with PCOS ?
2 hour 75g oral glucose tolerance test
How long after consuming a glucose drink is the plasma glucose measured in a tolerance test ?
2 hours later
What is considered impaired glucose tolerance on a glucose tolerance test?
Plasma glucose at 2 hours of 7.8 - 11.1 mmol/L
What is considered as diabetic after a glucose tolerance test ?
Plasma glucose above 11.1mmol/L at 2 hours
How is PCOS managed ?
Reduce the risk of complications by :
- weight loss
- low glycaemic index
- Exercise
- smoking cessation
- antihypertensives
- statins where indicated
What are some management options for Hirsutism ?
Weight loss
Co-cyprindiol - COCP
Topical eflornithine
What is a cyst ?
Fluid filled sac
When are ovarian cysts most concerning ?
Post-menopause
How can ovarian cysts present ?
Asymptomatic
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvis mass
When may ovarian cysts present with acute pelvic pain ?
Ovarian torsion
Ovarian haemorrhage of the cyst
Rupture of the cyst
What is a follicular cyst ?
The developing follicle fails to rupture or release the egg.
They are harmless and tend to disappear after a few menstrual cycles.
How are follicular cysts seen on USS ?
They have thin walls and no internal structures
What is a corpus luteum cyst ?
It occurs when the corpus luteum fails to break down and instead fills with fluid
How does a corpus luteum cyst present ?
Pelvic discomfort
Pain
delayed menstruation
When are corpus luteum cysts most often seen ?
Early pregnancy
What are the types of functional cysts ?
Follicular cysts
Corpus luteum cysts
What is a serous cystadenoma ?
Benign tumours of the epithelial cells
What is a mucinous cystadenoma and how does it differ from a serous one ?
Benign tumour of the epithelial cells
They can become huge and take up a lot of space in the pelvis and abdomen
What is an endometrioma ?
Lumps of endometrial tissue within the ovary occurring in patients with endometriosis
What is a dermoid cyst of the ovary ?
Benign ovarian tumour - teratoma
germ cell origin and contain various types of tissue
What is a dermoid cyst most commonly associated with ?
Ovarian cysts
What are some sex cord - stromal tumours ?
Sertoli-leydig cell tumours
Granulosa cell tumours
What are some features that may suggest ovarian malignancy ?
Abnormal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
What are some risk factors for ovarian malignancy ?
Age
Post-menopause
Increased number of ovulations
Obesity
HRT
Smoking
Family history and BRCA1/2 gene
What are some factors that reduce the number of ovulations ?
Later onset of periods
Early menopause
Any pregnancies
Use of COCP
What is the tumour marker for ovarian cancer ?
CA125
What tumour markers should be measured if there is a complex ovarian mass in a woman under 40 ( possible germ cell tumour ) ?
LDH
Alpha FP
HCG
What are some causes of raised CA125 ?
Ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
What does the risk of malignancy take into account when estimating the risk of a ovarian mass being malignant ?
Menopausal status
USS findings
CA125 level
If there is a possible ovarian cancer what should be organised ?
2 week wait referral to gynaecological oncology specialist
If there is a possible dermoid cyst what should be organised ?
Referral to gynae for further investigations and consider surgery
How are small simple ovarian cysts managed in premenopausal women ?
Will always resolve within 3 cycles and do not require a follow up scan
How are larger simple ovarian cysts managed in premenopausal women ?
Routine referral to gynae for yearly monitoring
If more than 7cm consider MRI or surgical evaluation
How are cysts in postmenopausal women managed ?
Referral to gynae
If CA125 is raised then 2 week wait
If simple and normal CA125 then 4-6 monthly USS
What is the management of a persistent or enlarging cyst ?
Surgical intervention -
- removing the cyst ( ovarian cystectomy )
- or ovary as well ( oophorectomy )
What are the main complications of ovarian cysts ?
Torsion
Haemorrhage into the cyst
Rupture with bleeding into the peritoneum
What is the triad of Meig’s syndrome ?
Ovarian fibroma
Pleural effusion
Ascites
How is Meig’s syndrome managed ?
Removal of the tumour results in the complete resolution of the effusion and ascites
What is an ovarian torsion ?
A condition where the ovary twists in relation to the surrounding connective tissue, Fallopian tube and blood supply
What is ovarian torsion usually associated with ?
Ovarian mass larger than 5cm such as a cyst or tumour
Why does ovarian torsion occur in young girls ( before menarche ) ?
Girls have a longer infundibulopelvic ligament that can twist more easily
Why is ovarian torsion an emergency ?
Twisting of the blood supply to the ovaries leads to ischaemia and if this persists leads to necrosis. This results in the function of the ovary being lost.
How does ovarian torsion present ?
Sudden onset severe unilateral pelvic pain - constant
Nausea and vomiting
Localised tenderness with a palpable mass
What initial investigation is used when suspecting ovarian torsion ?
Pelvic USS - trans vaginal
What Is seen on USS in ovarian torsion ?
Whirlpool sign - free fluid in the pelvis and abdomen
Oedema of the ovary
How is a definitive diagnosis made of ovarian torsion ?
Laparoscopic surgery
What is the management of ovarian torsion ?
Laparoscopic surgery to either :
- un - twist the ovary and fix it in place ( detorsion )
- remove the affected ovary
If ovarian torsion is untreated and becomes necrotic what can occur ?
It may become infected, develop an abscess and lead to sepsis
What may occur if the ovary ruptures from ovarian torsion ?
May result in peritonitis and adhesions
What is Asherman’s syndrome ?
Where adhesions ( sometimes called synechiae ) form within the uterus following damage to the uterus.
What can cause Asherman’s syndrome ?
Usually occurs after a pregnancy related dilation and curettage procedure
It can also occur due to uterine surgery or several pelvic infections.
What is the pathophysiology of Asherman’s syndrome ?
Endometrial curettage can damage the basal layer of the endometrium. The damaged tissue may heal abnormally causing scar tissue. There may be adhesions binding the uterine walls together or within the endocervix sealing it shut.
What can Asherman’s syndrome result in ?
Menstruation abnormalities
Infertility
Recurrent miscarriages
How does Asherman’s syndrome present ?
Follows recent dilation and curettage and uterine surgery with :
- secondary amenorrhoea
- significantly lighter periods
- dysmenorrhoea
- infertility
What is the gold standard for establishing Asherman’s syndrome ?
Hysteroscopy
How can a diagnosis of intrauterine adhesions be made ?
Hysteroscopy
Hysterosalpingography
Sonohysterography
MRI scan
What is the management of Asherman’s syndrome ?
Dissecting the adhesions during hysteroscopy
What is cervical ectropion ?
Occurs when the columnar epithelium of the endocervix ( the canal of the cervix ) has extended out to the ectocervix ( the outer area of the cervix ).
The cells of the endocervix are more fragile and prone to trauma.
What is the transformation zone of the cervix ?
The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix.
How does cervical ectropion present ?
Asymptomatic
Increased vaginal discharge
Vaginal bleeding
Dyspareunia
What is the management of cervical ectropion ?
Asymptomatic requires no treatment.
What is the management of cervical ectropion if there is the problematic bleeding ?
Cauterisation of the ectropion using silver nitrate
Or
Cold coagulation during colposcopy
What are Nabothian cysts ?
Fluid filled cysts often seen on the surface of the cervix.
Usually up to 1cm
What is the pathophysiology of nabothian cyst ?
The columnar epithelium of the endocervix produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus secreting columnar epithelium, the mucus becomes trapped and forms a cyst.
How does a nabothian cyst present ?
Often found incidentally
How do nabothian cysts look on examination ?
Smooth rounded bumps on the cervix usually near the os and can range from 2mm to 30mm and have a whitish or yellow appearance
What is the management of nabothian cysts ?
No treatment is required and with resolve spontaneously
What is pelvic organ prolapse ?
Refers to the descent of pelvic organs into the vagina. This is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
What is uterine prolapse ?
Where the uterus itself descends into the vagina.
What is vault prolapse ?
This occurs in women that have had a hysterectomy and no longer have a uterus.
The top of the vagina descends into the vagina.
What is a rectocoele ?
They are caused by a defect in the posterior vaginal wall allowing the rectum to prolapse forwards into the vagina.
What is a rectocoele associated with ?
Constipation
What is a cystocoele ?
Caused by a defect in the anterior vaginal wall allowing the bladder to prolapse backwards into the vagina.
What are some risk factors for pelvic organ prolapse ?
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopausal status
Obesity
Chronic resp disease
Chronic constipation
How does pelvic organ prolapse present ?
A feeling of something coming down in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms - incontinence, urgency and frequency
Bowel symptoms - constipation
Sexual dysfunction
How is the severity of uterine prolapse graded ?
Pelvic organ prolapse qualification
What is the conservative management of pelvic organ prolapse ?
Physiotherapy
Weight loss
Lifestyle changes
Vaginal oestrogen cream
What is the medical management of pelvic organ prolapse ?
Vaginal pessaries changed every 4 months
What is the definitive management of pelvic organ prolapse ?
Surgery such as a hysterectomy and mesh repairs
What are some potential complications of pelvic organ prolapse ?
Pain, bleeding, infection, DVT
Damage to bladder or bowel
Recurrence of the prolapse
Altered experience of sex
What are some potential complications of mesh repairs for pelvic organ prolapse ?
Chronic pain
Altered sensation
Dyspareunia
Abnormal bleeding
Urinary or bowel problems
What is urinary incontinence ?
Refers to the loss of control of urination
What is urge incontinence ?
Suddenly feeling the urge to pass urine having to rush to the bathroom and not arriving before urination occurs.
What is stress incontinence ?
Urinary leakage when laughing, coughing or straining.
This is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder.
What is overflow incontinence ?
It occurs when there is chronic urinary retention due to an obstruction to the outflow of urine. This results in the outflow of urine and the incontinence occurs without the urge to pass urine.
What are some risk factors for urinary incontinence ?
Increased age
Postmenopausal status
Increased BMI
Previous pregnancies
Pelvic organ prolapse
Pelvic floor surgery
Cognitive impairment and dementia
Neurological conditions such as MS
What are some modifiable risk factors for urinary incontinence ?
Caffeine consumption
Alcohol consumption
Medications
BMI
What investigations are performed for urinary incontinence ?
Bladder diary
Urine dip
Post void residual bladder volume
Urodynamic testing
How are urodynamic tests performed ?
A thin catheter is inserted into the bladder and another into the rectum. The 2 catheters can measure the pressures in the bladder and rectum for comparison.
What is the management of stress incontinence ?
Avoid caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss
Supervised pelvic floor exercises
Surgery
Duloxetine
What are some surgical options for stress incontinence ?
Tension free vaginal tape
Autologous sling procedures
Colpsosuspension
Intramural urethral bulking
What is the management of urge incontinence ?
Bladder retraining
Anticholinergic medication
Mirabegron
Invasive procedures
What are some Anticholinergic side effects ?
Dry mouth
Dry eyes
Urinary retention
Constipation
Postural hypotension
What is Mirabegron contraindicated in ?
Uncontrolled HTN
What are some invasive options for overactive bladder failing to respond to conservative and medical management ?
Botulinum toxin type A
Percutaneous sacral nerve stimulation
Augmentation cytoplasty
Urinary diversion - urostomy
What is Atrophic vaginitis ?
Refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.
What is the pathophysiology of Atrophic vaginitis ?
As women enter menopause oestrogen levels fall resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation
How does Atrophic vaginitis present ?
Postmenopausal women :
- itching
- dryness
- dyspareunia
- bleeding due to localised inflammation
What will an examination of the labia and vagina look like in atrophic vaginitis?
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
What is the management of Atrophic vaginitis ?
Vaginal lubricants can help with symptoms of dryness
Topical oestrogen - creams, pessaries, tablets and a ring
What are some contraindications of topical oestrogen ?
Breast cancer
Angina
VTE
What is Bartholin’s gland ?
A pair of glands located either side of the posterior part of the vaginal introitus ( opening ).
They produce mucus to help with vaginal lubrication.
When does a Bartholin’s cyst occur ?
When the duct becomes blocked causing the gland to swell and become tender.
What happens if a Bartholin’s cyst becomes infected ?
An abscess forms which is hot, tender and may drain pus.
What is the management of a Bartholin’s cyst ?
Simple treatment - good hygiene, analgesia and warm compress
What is the management of a Bartholin’s abscess ?
ABx
Surgical options - word catheter or marsupialisation
What is the most common pathogen for Bartholin’s abscess ?
E. coli
What is lichen sclerosus ?
A chronic inflammatory skin condition that presents with patches of shiny, porcelain-white skin.
what is most commonly affected by lichen sclerosus ?
Labia, perineum and Perianal skin in women
What conditions is lichen sclerosus associated with ?
T1DM
Alopecia
Hypothyroid
Vitiligo
What age range is most commonly affected by lichen sclerosus ?
45-60
How does lichen sclerosus present ?
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex
Erosions
Fissures
What is the koebner phenomenon ?
Refers to when the signs and symptoms are made worse by friction to the skin.
How does the affected area look in lichen sclerosus ?
Porcelain white in colour
Shiny
Tight
Thin
Slightly raised
What is the management of lichen sclerosus ?
3-6monthly gynae or derm appointment
Potent topical steroids - clobestasol propionate
Emollients
What are some complications of lichen sclerosus ?
Squamous cell carcinoma of the vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings
What is female genital mutilation ( FGM ) ?
Involves surgically changing the genitals of a female for non-medical reasons.
A cultural practice that usually occurs in girls before puberty.
What is type 1 FGM ?
Removal of part or all of the clitoris
What is type 2 FGM ?
Removal of part or all of the clitoris and labia minora ( labia majora may be also removed )
What is type 3 FGM ?
Narrowing or closing the vaginal orifice
What is type 4 FGM ?
All other unnecessary procedures to the female genitalia
What are the key risk factors for FGM ?
Coming from a community that practises FGM
Having relatives affected by FGM
What are some immediate complications of FGM ?
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage or incontinence
What are some long term complications of FGM ?
Vaginal infections - bacterial vaginosis
Pelvic infections
UTI
Dysmenorrhoea
Infertility or pregnancy related complications
Depression or significant psychological issues
What is the management of FGM ?
Educate patients and relatives FGM is illegal in the UK.
Mandatory to report all cases of FGM under 18 to police.
Social services and safeguarding
Paediatrics
De-infibulation - surgical procedure for type 3 FGM ( aims to correct the narrowing or closure of the vaginal orifice )
What develops from the paramesonephric ducts ( Müllerian ducts ) ?
Upper vagina
Cervix
Uterus
Fallopian tubes
What is a bicornuate uterus ?
There are 2 horns to the uterus giving it a heart shaped appearance
What are the typical complications of bicornuate uterus ?
Miscarriage
Premature birth
Malpresentation
What is an imperforate hymen ?
This is where the hymen at the entrance of the vagina is fully formed without an opening
how does an imperforate hymen present ?
Cyclical pelvic pain
Cramping associated with menstruation without bleeding
No menstrual bleeding
What is the treatment of a imperforate hymen ?
Surgical incision to create an opening in the hymen
What are some complications of an untreated imperforate hymen ?
Retrograde menstruation leading to endometriosis
How can a transverse vaginal septae present ?
Difficulties with intercourse or tampon use
If imperforate then cyclical pelvic pain and absent menstrual bleeding
What are some complications of a transverse vaginal septae ?
Infertility
Pregnancy related complications
How is a diagnosis of a transverse vaginal septae made ?
Examination
USS
MRI
What is the management of a transverse vaginal septae ?
Surgical correction
What is vaginal hypoplasia ?
Refers to an abnormally small vagina
What is vaginal agenesis ?
Refers to an absent vagina due to failure of the Müllerian ducts to form properly
What is androgen insensitivity syndrome ?
A condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.
X linked recessive
Genetically male with female secondary sexual characteristics
What is the internal sex organs in androgen insensitivity syndrome ?
Testes in the abdomen or inguinal canal
No female internal sex organs
How does androgen insensitivity syndrome present ?
Infancy with inguinal hernias
Puberty with primary amenorrhoea
Lack of male sexual characteristics
Infertile
What are the results of hormone tests in androgen insensitivity syndrome ?
Raised LH
Normal or raised FSH
Normal or raised testosterone levels ( for males )
Raised oestrogen levels ( for males )
What is the management of androgen insensitivity syndrome ?
Medical input :
Bilateral orchidectomy to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery
Support and counselling - promote psychological, social and sexual wellbeing
What age does cancer of the cervix affect the most ?
Younger women peaking in the reproductive years
What is the most common type of cervical cancer ?
Squamous cell carcinoma
What preventative measures are there for cervical cancer ?
HPV vaccine for 12-13 years
Screening with smear tests are used to screen for precancerous or cancerous changes to the cells of the cervix.
What is HPV ?
A sexually transmitted infection strongly associated with cervical cancer as well as anal, vulval, penile, mouth and throat.
What are the strains of HPV that are associated with cervical cancer ?
Type 16 and 18
What is the management of HPV ?
No treatment for infection as spontaneously resolves within 2 years
How does HPV promote the development of cancer ?
HPV produces E6 and E7 that inhibit tumour suppressor genes -p53 ( E6 ) and pRb ( E7 ) .
What are some risk factors for cervical cancer ?
Factors that increase risk of catching HPV
Later detection of precancerous and cancerous changes
Smoking
HIV
COCP for more than 5 years
Increased number of full term pregnancies
F.H.
Exposure to diethylstilbestrol during full foetal development
What are some risk factors for contracting HPV ?
Early sexual activity
Increased number of sexual partners
Sexual partners with multiple partners
Not using condoms
What are some presenting symptoms of cervical cancer ?
An be asymptomatic
Abnormal vaginal bleeding
Vaginal discharge
Pelvic pain
Dyspareunia
What appearance of the cervix on speculum examination is suggestive of cervical cancer ?
Ulceration
Inflammation
Bleeding
Visible tumour
If there are signs of cervical cancer on speculum exam what should be organised ?
Urgent cancer referral for colposcopy
What is CIN ?
A grading system for the level of dysplasia in the cells of the cervix.
Diagnosed at colposcopy
What is CIN1 ?
Mild dysplasia, affecting 1/3 thickness of the epithelial layer
What is CIN2 ?
Moderate dysplasia affecting 2/3 of the thickness of the epithelial layer and is likely to progress to cancer if left untreated
What is CIN 3 ?
Severe dysplasia very likely to progress to cancer if untreated
How often does cervical smear screening take place ?
Every 3 years 25-49
Every 5 years 50-69
What stains are used during colposcopy ?
Acetic acid and iodine solution
What can be performed during colposcopy to get a tissue sample ?
Punch biopsy
Large loop excision of the transformation zone
What is the treatment for CIN ?
Cone biopsy
What are the main risks of using a cone biopsy ?
Pain
bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
What are the stages of the FIGO system for cervical cancer ?
Stage 1 - confined to the cervix
Stage 2 - invades the uterus or upper third of the vagina
Stage 3 - invades pelvic wall or lower 2/3 of the vagina
Stage 4 - invades the bladder, rectum or beyond the pelvis
What is the management of stage 1-2 cervical cancer ?
Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
What is the management of stage 3-4 cervical cancer ?
Chemotherapy and radiotherapy
What is pelvic exenteration ?
An operation where most or all the pelvic organs are removed - vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum.
Performed in advanced cervical cancer
What do strains 6 and 11 of HPV cause ?
Genital warts
What is endometrial cancer ?
Cancer of the lining of the uterus.
It is oestrogen dependent meaning oestrogen stimulates the growth of endometrial cancer cells
What is the diagnosis of a postmenopausal bleed until proven otherwise ?
Endometrial cancer
What is endometrial hyperplasia ?
A precancerous condition involving thickening of the endometrium.
What is the management of endometrial cancer ?
Intrauterine system
Continuous oral progestogens
What are some situations that increase exposure of unopposed oestrogen ?
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only HRT
No or fewer pregnancies
Obesity
PCOS
Tamoxifen
Why does PCOS lead to increased unopposed oestrogen levels ?
Lack of ovulation.
When ovulation occurs the corpus luteum produces progesterone.
Women with PCOS should be given what for endometrial protection against unopposed oestrogen ?
COCP
Intrauterine system
Cyclical progestogens
Why is obesity a risk factor for endometrial cancer ?
Adipose tissue is a source of oestrogen and is the primary source in postmenopausal women. In women with more adipose tissue there is more oestrogen produced which is unopposed in women who aren’t ovulating.
What are some protective factors for endometrial cancer ?
COCP
Mirena coil
Increased pregnancies
Cigarette smoking
How does endometrial cancer present ?
Postmenopausal bleeding
Postcoital bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
What is the referral criteria for a 2 week cancer wait for endometrial cancer ?
Postmenopausal bleeding ( more than 12 months after the last menstrual period )
What features if present does NICE recommend a transvaginal USS in women over 55 ?
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
What are the investigations for diagnosing endometrial cancer ?
Transvaginal USS for endometrial thickness
Pipelle biopsy
Hysteroscopy + biopsy
How is a pipelle biopsy performed ?
Involves a speculum exam and inserting a thin tube through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that is examined.
What are the stages of endometrial cancer ?
Stage 1 - confined to the uterus
Stage 2 - invades the cervix
Stage 3 - invades the ovaries, fallopian tube, vagina or lymph nodes
Stage 4 - invades the bladder, rectum or beyond the pelvis
What is the management of stage 1 and 2 endometrial cancer ?
Usual - Total abdominal hysterectomy with bilateral salpingo-oophorectomy ( removal of uterus, cervix and adnexa )
Other :
- radical hysterectomy
- radio
-chemo
What is the most common type of ovarian cancer ?
Epithelial cell tumours
What are some subtypes of epithelial cell tumours ?
Serous tumours
Endometriosis carcinomas
Clear cell tumours
Mucinous tumours
What is a Krukenberg tumour ?
Refers to a metastasis in the ovary usually from a GI tract cancer particularly the stomach
What is the characteristic appearance of a krukenberg tumour on histology ?
Signet ring cells
What are some risk factors for ovarian cancer ?
Age
BRCA1 and BRCA2 genes
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
Increased number of ovulations
What are some protective factors of ovarian cancer ?
COCP
Breastfeeding
Pregnancy
What are some symptoms that indicate ovarian cancer ?
Abdominal bloating
Early satiety
Loss of appetite
Pelvic pain
Urinary symptoms
Weight loss
Abdo or pelvic mass
Ascites
Why can an ovarian mass cause hip or groin pain ?
It may press on the obturator nerve as it passes along the pelvis lateral to the ovaries.
When would you refer on a 2 week wait for ovarian cancer after a physical exam ?
Ascites
Pelvic mass ( unless clearly fibroids )
Abdominal mass
What are the initial investigations when suspecting ovarian cancer ?
CA125 blood test
Pelvic USS
What are some further investigations when suspecting ovarian cancer ?
CT scan
Histology
Paracentesis - check for cancer cells in the ascitic fluid
What are the stages of 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 out of the abdomen - distant mets
What is the management of ovarian cancer ?
Combo of Surgery and chemo
What is the most common type of vulval cancer ?
Squamous cell carcinoma
What are some risk factors for vulval cancer ?
Advanced age
Immunosuppression
HPV
Lichen sclerosus
What is VIN ?
A premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer.
What investigation diagnoses VIN ?
A biopsy
What is the management of VIN ?
Watch and wait with close follow up
Wide local excision
Imiquimod cream
Laser ablation
How does a vulval cancer present ?
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
What is seen on examination in vulval cancer ?
Irregular mass
Fungating lesion
Ulceration
Bleeding
What is used to establish the diagnosis and grade of vulval cancer ?
Biopsy of the lesion
Sentinel node biopsy
Ct abdo pelvis
What is the management of vulval cancer ?
Wide local excision
Groin lymph node dissection
Chemo
Radio
