Gynaecology Flashcards
Describe the features of a gynaecological history
- Key details: last menstrual period, gravidity, parity
- Presenting complaint and history
- Focussed questioning of symptoms
- Menstrual history: duration, frequency, volume, pain, age at menarche, menopause
- Contraception: current and previous
- Reproductive plans
- Past gynaecological history
- Abdominal/pelvic surgical history
- Cervical screening history
- Past medical history
- Drug history and allergies
- Brief obstetric history
- Family history: cancer, bleeding disorders
- Social history
What are the common symptoms in a gynaecological history?
- Abdominal and pelvic pain: ectopic pregnancy, ovarian accident, PID
- Post-coital vaginal bleeding: cervical ectropion, cervical cancer, gonorrhoea, chlamydia, vaginitis
- Intermenstrual bleeding: contraception, ovulation, miscarriage, STIs, uterine fibroids, perimenopause, malignancy
- Post-menopausal bleeding: vaginal atrophy, HRT, malignancy
- Abnormal discharge: bacterial vaginosis, chlamydia, gonorrhoea
- Dyspareunia: endometriosis, vaginal atrophy, gonorrhoea, chlamydia
- Vulval skin changes and itching: vaginal atrophy, thrush, gonorrhoea, lichen sclerosus
- Systemic symptoms: fatigue (anaemia), fever (PID), weight loss (malignancy)
What are the names and lengths of the 2 stages of the menstrual cycle?
- Follicular: when the ovum is inside a developing follicle, usually 14 days long but can be more or less which determines the whole cycle length
- Luteal: when the ovum has left the ovary after ovulation, always 14 days long
For the 5 main hormones in the menstrual cycle, list…
- name
- where they are released
- role
- Gonadotrophin releasing hormone (GnRH): released from hypothalamus, causes release of gonadotrophins
- Follicle stimulating hormone (FSH): released from anterior pituitary, stimulates development of follicles
- Luteinising hormone (LH): released from anterior pituitary, causes ovulation
- Oestrogen: released from the granulosa cells of developing follicle + corpus luteum, promotes development of female secondary sex characteristics, develops endometrial lining, thins cervical mucus, causes negative feedback to supress FSH/LH production
- Progesterone: released from corpus luteum + placenta, causes thickening and maintenance of endometrial lining, thickening of cervical mucus
Describe the change in hormone levels during the follicular phase
- FSH: released from the start to develop follicles, slightly spikes before ovulation
- Oestrogen: released from developing follicles so gradually increases, then drops as follicles prepare to release egg
- LH: remains low initially, then spikes before ovulation as oestrogen drops, to initiate ovulation
- Progesterone: low throughout follicular phase as no role
Describe the change in hormone levels during the luteal phase
- Progesterone and oestrogen: increasingly produced by corpus luteum to thicken and maintain endometrial lining, then drop as corpus luteum degenerates causing endometrial lining to breakdown (unless fertilisation occurs)
- FSH and LH: remain low due to high levels of oestrogen and progesterone causing negative feedback to the anterior pituitary
Describe the stages of development of the follicles in the ovaries
- Primordial follicles develop into primary and secondary follicles independent of the menstrual cycle
- At the start of the cycle, FSH stimulates further development of secondary follicles, allowing the production of oestrogen from granulosa cells from a few follicles
- One follicle becomes dominant and its oestrogen inhibits to growth of others, so that this follicle reaches maturity and is known as the Graafian follicle
- After a spike of LH, the Graafian follicle releases the ovum (ovulation), and the remainder of the follicle develops into the corpus luteum to produce progesterone
How do the hormones of the menstrual cycle change if fertilisation does occur?
- The ovum produces human chorionic gonadotrophin (hCG) which maintains the corpus luteum
- This results in the continued production of progesterone, preventing menstruation and maintaining the endometrial lining for the developing foetus
- The placenta takes over the production of progesterone after 5-10 weeks
Define menorrhagia
Excessive menstrual bleeding which interferes with a woman’s physical, social, emotional, and/or material QOL (quantification is highly subjective, but traditionally defined as more than 80ml/duration of more than 7 days)
What are the causes of menorrhagia, and their suggestive features?
- Fibroids: history of pressure symptoms (e.g. urinary frequency), bulky uterus on examination
- Endometrial or cervical polyps: can also cause intermenstrual or post-coital bleeding
- Adenomyosis: associated with dysmenorrhoea, bulky uterus on examination
- Endometriosis: associated with dysmenorrhoea, pelvic pain, dyspareunia, difficulty conceiving
- Coagulation disorders: family history, menorrhagia since menarche, post-partum haemorrhage, surgical/dental bleeding, easing bruising/bleeding
- PCOS: associated weight gain, acne, hirsutism, difficulty conceiving
- Hypothyroidism: associated fatigue, weight gain, cold sensitivity, constipation, depression
- Pregnancy: likely to indicate miscarriage or ectopic pregnancy
- Malignancy: pelvic mass, post-menopausal, weight loss
- Pelvic inflammatory disease: history/symptoms associated with infection
- Iatrogenic causes: medication (NSAIDs, SSRIs, CHC, intrauterine device)
How is menorrhagia assessed?
Ask about nature of bleeding:
- onset (peri-menarcheal, sudden, gradual)
- frequency/pattern (cyclical/non-cyclical)
- temporary association (postcoital, postpartum)
- related symptoms (intermenstrual bleeding, pelvic pain, pressure symptoms)
- signs/symptoms of anaemia (dyspnoea, fatigue, headache, sore tongue)
- impact on quality of life
Menstrual history:
- age or menarche
- gravidity and parity
- normal menstrual cycle (frequency, duration, volumes)
- last menstrual period
Other histories:
- medical conditions and recent procedures
- drug history
- sexual history (current contraception, future plans)
- cervical screening history
What investigations are needed for menorrhagia?
- Examinations: abdominal, bi-manual, speculum (not always needed if no other related symptoms)
- FBC: check for iron-deficiency anaemia
- TFTs: if hypothyroidism is suspected
- Vaginal/cervical swabs: if infection suspected
- Tests for coagulation disorders: e.g. von Willebrand disease)
- Pregnancy test
- Hormonal testing: if PCOS is suspected
- Hysteroscopy: if suspected fibroids, polyps, or other endometrial pathology
- Pelvic ultrasound: if uterus or mass is palpable abdominally
- Transvaginal ultrasound: suspected adenomyosis
What is the management of menorrhagia caused by fibroids <3cm/no identifiable cause, and for large fibroids?
No identified pathology (or fibroids <3cm):
- 1st line = levonorgestrel intrauterine system (Mirena coil)
- Other hormonal options = combined hormonal contraception, cyclical oral progesterone (norethisterone), or progesterone implant/injection (depo)
- Non-hormonal options = tranexamic acid, mefenamic acid (NSIAD)
Specifically for fibroids (3cm or more):
- uterine artery embolisation
- myomectomy
Other surgical treatments (if no longer wish to conceive):
- endometrial ablation
- hysterectomy (partial/total)
Define dysmenorrhoea
Painful cramping, usually in the lower abdomen, which occurs shortly before and/or during menstruation, categorised as…
- primary dysmenorrhoea: occurs in the absence of underlying pelvic pathology, thought to be caused by prostaglandins
- secondary dysmenorrhoea: caused by underlying pelvic pathology (e.g. endometriosis, adenomyosis, fibroids, endometrial polyps, pelvic inflammatory disease)
What are the risk factors for primary dysmenorrhoea?
- Earlier menarche
- Heavy or prolonged menstrual flow
- Nulliparity
- Family history
- Emotional stress
- BMI less than 20
- Smoking
- History of sexual abuse
What are the investigation for dysmenorrhoea?
- Abdominal examination: asses for large fibroids or masses
- Pelvic examination (inc. speculum): except in young women who are not sexually active, and symptoms suggest primary dysmenorrhoea
- Consider other tests to rule out underlying causes: ultrasound (pelvic/transvaginal), high vaginal/endocervical swabs, pregnancy test
What are the clinal features suggestive of primary or secondary dysmenorrhoea?
Primary dysmenorrhoea:
- starts 6-12 moths after menarche
- pain is cramping in nature in lower abdomen, but may radiate to lower back or inner thighs
- starts shortly before menstruation and improves as menses progresses
- non-gynaecological symptoms (e.g. nausea, vomiting, diarrhoea, bloating, headache, emotional symptoms, fatigue, dizziness)
- normal pelvic examination
Secondary dysmenorrhea:
- starts after several years of painless periods
- not consistently related to menstruation, may persist after menstruation, present throughout menstrual cycle, exacerbated by menstruation
- other gynaecological symptoms: dyspareunia, vaginal discharge, menorrhagia, intermenstrual and/or post-coital bleeding
- non-gynaecological symptoms: rectal pain and bleeding (endometriosis)
- abnormal pelvic examination
What is the management of primary dysmenorrhoea?
- Lifestyle changes: stop smoking
- Analgesia: NSAIDs (inhibit prostaglandins), paracetamol
- Hormonal contraception: 3-6 month trial, CHC commonly 1st line, IUS also effective
- Non-pharmacological: local heat application, transcutaneous electrical nerve stimulation
Define infertility
A disorder of the reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sex, classed as…
- primary: when a couple has never conceived
- secondary: when a couple has conceived at least once before (with the same or different partner)
What are the causes of male infertility?
- Testicular failure: cryptorchidism, torsion/trauma, varicocele, low testosterone, genetic/chromosome disorders
- Obstructive azoospermia: congenital structural abnormalities, infections, surgical procedures
- Ejaculatory and erectile dysfunction: premature/delayed/retrograde/painful/anejaculation, haematospermia, many causes of erectile dysfunction
- Abnormal sperm function and quality: abnormal shape and/or movement, can be caused by urogenital infections, anabolic steroids
- Unexplained causes
What are the causes of female infertility?
- Group I ovulation disorders: hypothalamic-pituitary failure such as hypothalamic amenorrhoea (common in low body weight and excessive exercise), and hypogonadotropic hypogonadism (usually congenital)
- Group II ovulation disorders: hypothalamic-pituitary-ovarian axis dysfunction such as hyperprolactinaemic amenorrhoea and PCOS
- Group III ovulation disorders: ovarian failure, characterised by high gonadotrophins, hypogonadism, low oestrogen
- Other ovulatory disorders: thyroid dysfunction, Cushing’s syndrome, congenital adrenal hyperplasia, chronic debilitating disease (uncontrolled diabetes, cancer etc)
- Tubal damage: caused by pelvic inflammatory disease, acute salpingitis, endometriosis, previous tubal surgeries
- Uterine or peritoneal disorders: uterine polyps, adhesions, septae, fibroids, peritoneal endometriosis, adhesions
- Unexplained causes
What are the risk factors for infertility in women?
- Increasing age (lower oocyte number and poorer quality)
- STIs (can damage anatomy)
- Obesity (associated ovulatory dysfunction, and higher risk of pregnancy complications)
- Low body weight (can cause menstrual abnormalities)
- Lifestyle factors (smoking, high stress)
- Occupational and environmental exposures: pesticides, nitrous oxide, metals
- Drugs: NSAIDs, chemotherapy, recreational drugs, metoclopramide, methyldopa, SSRIs
What are the risk factors for infertility in men?
- Age: increasing age may affect sperm motility
- STIs: can damage anatomy
- Obesity: associated erectile dysfunction
- Lifestyle factors: smoking, excessive alcohol intake (harms sperm quality), stress
- Occupational and environmental exposures: pesticides, nitrous oxide, metals
- Tight underwear: elevated scrotal temperature may reduce sperm quality
- Drugs: sulfasalazine, antipsychotics, antidepressants, long-term opiates, 5-alpha reductase inhibitors, recreational drugs
What are the investigations needed for female infertility? (primary and secondary care)
Primary care:
- mid-luteal phase progesterone (1 week before menstruation): to confirm ovulation
- screen for chlamydia
- gonadotrophins (LH/FSH): may identify ovulation disorders
- prolactin: may identify ovulation disorders or pituitary tumour
- thyroid function tests: if thyroid disease is suspected
Secondary care:
- hysterosalpingography: screens for tubal occlusion
- diagnostic laparoscopy: assess tubal and other pelvic abnormalities
What are the investigations needed for male infertility?
- Semen analysis: volume, pH, concentration, sperm count, motility, morphology, vitality
- Screen for chlamydia
- Genetic testing
- Hormone level testing
- Sperm culture
- Imaging of urogenital tract
- Testicular biopsy
When is a referral to secondary care indicated for a couple with infertility?
If the couple has not conceived after 1 year of trying, or sooner if…
In women:
- aged 36 or older
- amenorrhoea or oligomenorrhoea
- previous abdominal/pelvic surgery
- previous STI or PID
- abnormal pelvic exam
- known reason (e.g. prior cancer treatment)
In men:
- previous genital pathology
- previous urogenital surgery
- previous STI
- varicocele
- significant systemic illness
- abnormal genital exam
- 2 abnormal semen analysis results
- known reason (e.g. prior cancer treatment)
What are the lifestyle changes and advice for infertility?
Lifestyle changes:
- weight management
- psychological stress management
- smoking and alcohol cessation
General advice:
- regular sexual intercourse throughout the women’s cycle
- preparation for pregnancy (e.g. pre-conceptual folic acid)
What are the medical treatments of infertility?
- Clomifene (anti-oestrogen drug): effective treatment for anovulation
- Gonadotrophins: for clomifene-resistant anovulation, or in men with low gonadotrophins
- Pulsatile gonadotrophin-releasing hormone: induces ovulation
- Dopamine agonists: used in ovulatory disorders secondary to high prolactin
What are the surgical treatments of infertility?
- Tubal microsurgery in women with minor tubal disease (catheterisation or cannulation)
- Excision/ablation of endometriosis
- Surgical correction in men with obstructive azoospermia
What are the assisted reproduction techniques for infertility?
- Intrauterine insemination (IUI): sperm placed in woman’s uterus, timed with ovulation, maybe with ovary-stimulating hormone drugs
- In vitro fertilisation (IVF): retrieval of one ore more ova, combined with sperm and incubated, then embryo injected into uterus
- Intracytoplasmic sperm injection (ICSI): induvial sperm injected directly into ovum, bypasses natural barriers of fertilisation
- Donor insemination: insemination of donor sperm into woman’s vagina, cervical canal, or uterus
- Oocyte donation: stimulation of donor’s ovaries and collection of ova, then similar process to IVF
Define amenorrhoea
The absence of menstruation during reproductive years, classed as…
- primary amenorrhea: failure to establish menstruation by the time of expected menarche (16, or 14 with no secondary sex characteristics)
- secondary amenorrhoea: cessation of menstruation in women with previous menses (for 3-6 months, after pregnancy ruled out)
Define oligomenorrhoea
Irregular periods, with intervals between menstrual cycles of more than 35 days and/or less than 9 periods per year
* this can be common at the extremes of reproductive age
What are the causes of amenorrhoea?
Physiological causes:
- pregnancy or lactation
- menopause
- constitutional delay
Hypothalamic (reduced GnRH secretion):
- functional disorders (excessive exercise, eating disorders)
- severe chronic conditions (psychiatric disorders, cardiac/renal/liver disease, inflammatory conditions)
- Kallmann syndrome (X-linked recessive disorder, failure of migration of GnRH cells)
Pituitary causes:
- prolactinomas (high levels of prolactin supress GnRH secretion)
- other pituitary tumours (e.g. acromegaly or Cushing’s syndrome, causes gonadotrophin deficiency +/- hyperprolactinaemia)
- destruction of pituitary gland (radiation/injury/autoimmune)
- post-contraception amenorrhoea (long term downregulation of the pituitary gland, most seen with depo)
- Sheehan’s syndrome (pituitary infarction after major obstetric haemorrhage)
Ovarian causes:
- PCOS (more commonly causes oligomenorrhoea)
- Turners syndrome (genetic condition causes amenorrhoea, failure to develop secondary sexual characteristics, infertility)
- Premature ovarian failure (primary ovarian failure before the age of 40 with associated menopausal symptoms)
Genital tract abnormalities:
- Imperforate hymen or transverse vaginal septum (mechanical obstruction)
- Mullerian agenesis (congenital condition leading to agenesis or vagina and uterus)
- ambiguous genitalia
- Asherman’s syndrome (uterine adhesions following dilation and curettage, prevents normal response to oestrogen)
Endocrine disorders:
- hyper/hypothyroidism
- disease of adrenal gland (e.g. congenital adrenal hyperplasia)
- androgen secreting tumours
What investigations are needed for amenorrhoea/oligomenorrhoea?
- Pregnancy test
- Blood tests: TFTs, prolactin, hormones (FSH, LH, oestradiol, progesterone, testosterone), 17 hydroxyprogesterone (CAH)
- Ultrasound: visualise anatomy
- Karyotyping: if suspected genetic abnormality
Describe the hormone levels that are found in the common disorders causing amenorrhoea
- Hypothalamic causes: low GnRH, low/normal FSH/LH, low LH:FSH, low oestrogen, normal/low testosterone, normal/low prolactin
- Prolactinoma: high prolactin, low GnRH, normal/low FSH/LH, low oestradiol
- PCOS: normal FSH, high LH, high LH:FSH, normal/high testosterone, normal/high prolactin
- Premature ovarian failure: high FHS, high LH, low oestrogen, normal prolactin, normal/low testosterone
What is the management for amenorrhoea?
Lifestyle advice:
- if due to functional hypothalamic causes: encourage weight gain, reducing exercise, managing stress
- weight loss, balanced diet and regular exercise in PCOS
Regulating periods:
- contraceptive pill (CHC, POP)
- intrauterine system
Hormone replacement:
- oestrogen (and progesterone if they have a uterus) to treat symptoms of menopause
Osteoporosis prophylaxis:
- DXA scan
- vitamin D and calcium supplements
Treating underlying causes:
- hypothyroidism (levothyroxine)
- hyperthyroidism (carbimazole)
- surgical intervention (e.g. for pituitary tumour)
Improving fertility:
- clomifene (stimulates ovulation)
- metformin (used in PCOS to induce ovulation)
- assisted reproduction techniques
Define uterine fibroids
Benign smooth muscle tumours (leiomyoma) of the uterus, classified according to their position…
- intramural (most common): confined to the myometrium of the uterus
- submucosal: develops immediately underneath endometrium of the uterus, protrudes into the uterine cavity
- subserosal: protrudes into and distorts the serosal (outer) surface of the uterus, may be pedunculated (on a stalk), extends into peritoneal cavity
What are the risk factors for uterine fibroids?
- Increasing age (until menopause)
- Early menarche
- Nulliparity
- Older age at first pregnancy
- Comorbidities (obesity, diabetes, hypertension)
- Black/Asian ethnicity
- Family history
What are the signs/symptoms of uterine fibroids?
- Menorrhagia
- Dysmenorrhoea
- Pelvic/abdominal pain, pressure, or discomfort
- Abdominal bloating
- Urinary symptoms due to pressure (frequency, urgency, increased risk of UTIs)
- Subfertility or infertility
- Firm, enlarged, irregularly shaped non-tender uterus on pelvic examination
What investigations are needed for uterine fibroids?
- Pelvic ultrasound (transabdominal or transvaginal): determine number, size, location
- MRI: rarely required unless malignancy is suspected
- Other investigation based on clinical judgement: FBC to assess iron deficiency anaemia with heavy bleeding
What is the management for uterine fibroids?
- If asymptomatic and small: no treatment needed
- For menorrhagia/dysmenorrhoea: tranexamic acid, hormonal contraceptives, NSIADs
- GnRH analogues (Zoladex): supresses ovulation and induces temporary menopause, useful pre-operatively to reduce fibroid size and lower complications
- Selective progesterone receptor modulators (ulipristal): reduces size of fibroid and menorrhagia, useful pre-operatively or as alternative to surgery
- Surgical: transcervical resection of fibroids (submucosal), myomectomy (preserves uterus), uterine artery embolization, hysterectomy
What are the complications of uterine fibroids?
- Iron deficiency anaemia
- Compression of pelvic organs (incontinence, recurrent UTIs, urinary retention, hydronephrosis)
- Subfertility/infertility
- Complications during pregnancy (miscarriage, red degeneration- fibroid vascular infarction, foetal malpresentation, pre-term delivery)
- Torsion of pedunculated fibroid
Define endometriosis
A chronic condition in which endometrial tissue is located in areas other than the uterus (e.g. in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus, bowel and lung)
What causes endometriosis?
- The exact pathophysiology is unclear, but may be due to retrograde menstruation, where endometrial cells travels backwards through the fallopian tubes and deposit on pelvic organs, or cells may travel distantly through lymphatic or vascular systems
- The symptoms occur as endometrial tissue is sensitive to oestrogen so bleeding occurs from ectopic tissue during menstruation, leading to repeated inflammation, scaring, and adhesions
What are the risk factors for endometriosis?
- Early menarche
- Late menopause
- Delayed childbearing
- Nulliparity
- Family history
- Short menstrual cycles
- Heavy and prolonged bleeding
- Defects in uterus/fallopian tubes
- Vaginal outflow obstruction
- Low BMI
- White ethnicity
- Autoimmune disease
- Smoking
What are the signs/symptoms of endometriosis?
- Dysmenorrhoea
- Pelvic pain (chronic, cyclical or continuous)
- Deep dyspareunia
- Period-related GI symptoms: painful bowel movements
- Period-related urinary symptoms: blood in urine, pain passing urine
- Infertility
- On examination: reduced organ mobility, enlarged uterus, generalised tenderness
What investigations are needed for endometriosis?
- Ultrasound (transabdominal or transvaginal)
- Laparoscopy: gold standard for diagnosis
What is the management of endometriosis?
- Analgesia: NSAIDs and paracetamol
- Hormonal contraceptives (supressing ovulation causes atrophy to endometriosis lesions and reduces symptoms)
- Surgical treatment: laparoscopic excision or ablation, hysterectomy (w/wo oophorectomy)
Describe adenomyosis (define, risk factors, features, management)
- Presence of functional endometrial tissue within the myometrium of the uterus (a variant of endometriosis)
- Risk factors: high parity, previous uterine surgery
- Clinical features: menorrhagia, dysmenorrhoea, symmetrically large and tender uterus o/e
- Management: NSAIDs, hormonal control, uterine artery ablation, hysterectomy
Describe endometrial/cervical polyps (definition, cause, features, investigations, management)
- Benign growths protruding within the uterine cavity or from the inner surface of the cervix, with slight risk of malignant transformation
- Thought to be caused by abnormal response to oestrogen, high risk perimenopausal or postmenopausal, taking hormone therapy, obese
- Clinical features: usually asymptomatic, can have abnormal bleeding (menorrhagia, PCB, IMB, post-menopausal), may be visible on speculum examination
- Investigations: endometrial = US scan, cervical = swab for infection and cervical smear to rule out neoplasm
- Management: watchful waiting, hormonal therapy (for symptoms), surgical removal
Define PCOS
An endocrine disorder characterised by hyperandrogenism, ovulation disorder, and the presence of multiple immature follicles (‘cysts’) within the ovaries
What are the signs/symptoms of PCOS?
- Oligomenorrhoea or amenorrhoea
- Infertility
- Hirsutism and/or acne (hyperandrogenism)
- Chronic pelvic pain
- Obesity
- Acanthosis nigricans
- Male pattern hair loss
- Rotterdam criteria: 2/3 of oligo/anovulation, hyperandrogenism (clinical and/or biochemical), polycystic ovaries on imaging
What causes PCOS?
- Multifactorial: both genetic and environmental factors
- Insulin resistance: hyperinsulinemia supresses the production of sex hormone binding globulin, resulting in higher levels of free circulating androgens
- Excess LH: increased production from the anterior pituitary, stimulating ovarian production of androgens
What investigations are needed for PCOS?
- Testosterone: raised
- SHBG: low
- LH: raised (and raised LH:FSH)
- FSH: normal
- Progesterone (late in cycle): low
- Prolactin: mildly elevated
- TSH: rule out hypothyroidism
- oral glucose tolerance test: check diabetes
- Pelvic ultrasound (not in adolescents, preferably transvaginal): ‘string of pearls’, 12 or more developing follicles, ovarian volume > 10cm3
What is the management of PCOS?
General:
- weight loss
- balanced diet
- exercise
- assess and treat CVD risk
For amenorrhoea/anovulation:
- lack on menstruation causes endometrial hyperplasia and a risk of cancer, so need to regulate bleeding/withdrawal bleeds
- low-dose COC, cyclical progesterone (medroxyprogesterone), or IUD
For infertility:
- clomifene +/- metformin
- ovarian drilling
For hirsutism:
- weight loss
- anti-androgen medication (e.g. cyproterone, spironolactone, finasteride)
- topical eflornithine
For acne:
- COC
- topical creams (retinoid, antibiotics)
Define ovarian cyst
A fluid filled sac within the ovary which are very common in premenopausal women, often physiological due to fluctuating hormone levels during the menstrual cycle
What are some different types of ovarian cysts?
Non-neoplastic:
- functional (follicular, or corpus luteal)
- pathological (endometriosis, PCOS, theca lutein)
Benign neoplastic:
- epithelial (serous cystadenoma, mucinous cystadenoma, Brenner tumour)
- benign germ cell tumour (mature cystic teratoma/dermoid cyst)
- sex cord stromal tumour (fibroma)
What are the risk factors for ovarian cysts?
- Nulliparity
- Early menarche
- Late menopause
- Oestrogen only HRT
- Smoking
- Obesity
- BRCA 1&2 genes
What features are used to calculate the risk of malignancy index for ovarian cysts
RMI = U x M x Ca125
- M (menopause status): premenopausal or postmenopausal
- U (ultrasound finding): solid areas, metastases, ascites, bilateral lesions
- Ca125: tumour marker (also raised in peritoneal cancers, menstruation, pregnancy, endometriosis, PID, fibroids, ascites, pancreatitis)
What are the signs/symptoms of an ovarian cyst?
- Often asymptomatic and incidental
- Dull ache/pain in lower abdomen/back
- Dyspareunia
- Abdominal bloating
- Palpable mass
- Pressure effects (urinary frequency, constipation, varicose veins, oedema
- May present with acute pain from ovarian torsion, haemorrhage, rupture
What investigations are needed for a ovarian cyst?
- Pregnancy test
- FBC: check for signs of infection or haemorrhage
- Ca125: raised in malignancy, very non-specific
- Lactate dehydrogenase, alpha-fetoprotein, hCG (under 40s): germ cell tumour markers
- Urinalysis: if urinary symptoms
- Ultrasound: preferably transvaginal
- CT or MRI: if US not definite
What is the management of an ovarian cyst?
Conservative…
- premenopausal: small (<5cm) simple cysts often resolve after 2-3 menstrual cycles, may be rescanned after 6 weeks
- postmenopausal: if low RMI, and cyst less then 5cm, follow up in 1 year with US and CA125
Surgical…
- appropriate for persistent simple ovarian cysts larger than 5 cm, complex ovarian cysts, or postmenopausal with moderate/high RMI
- preferably laparoscopically (cystectomy/oophorectomy)
What are the risk factors for ovarian cancer?
- Gene mutations (BRCA 1/2)
- Family history of cancer
- Increased number of ovulatory cycles (early menarche, late menopause, nulliparity)
- Use of HRT
- Endometriosis
- Diabetes
- Smoking
- Obesity
- Occupational exposure to asbestos
What clinical features are suspicious of ovarian cancer?
In any woman (particularly over 50), if following symptoms are persistent or frequent…
- Abdominal distension/ascites
- Feeling full (early satiety) or loss of appetite
- Pelvic or abdominal pain
- Increased urinary urgency/frequency
- Weight loss
- Malaise or fatigue
- Change in bowel habit
- Abnormal vaginal bleeding
- GI symptoms
