Gynaecology Flashcards
1
Q
Describe the features of a gynaecological history
A
- 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
2
Q
What are the common symptoms in a gynaecological history?
A
- 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)
3
Q
What are the names and lengths of the 2 stages of the menstrual cycle?
A
- 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
4
Q
For the 5 main hormones in the menstrual cycle, list…
- name
- where they are released
- role
A
- 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
5
Q
Describe the change in hormone levels during the follicular phase
A
- 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
6
Q
Describe the change in hormone levels during the luteal phase
A
- 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
7
Q
Describe the stages of development of the follicles in the ovaries
A
- 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
8
Q
How do the hormones of the menstrual cycle change if fertilisation does occur?
A
- 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
9
Q
Define menorrhagia
A
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)
10
Q
What are the causes of menorrhagia, and their suggestive features?
A
- 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)
11
Q
How is menorrhagia assessed?
A
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
12
Q
What investigations are needed for menorrhagia?
A
- 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
13
Q
What is the management of menorrhagia caused by fibroids <3cm/no identifiable cause, and for large fibroids?
A
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)
14
Q
Define dysmenorrhoea
A
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)
15
Q
What are the risk factors for primary dysmenorrhoea?
A
- Earlier menarche
- Heavy or prolonged menstrual flow
- Nulliparity
- Family history
- Emotional stress
- BMI less than 20
- Smoking
- History of sexual abuse
16
Q
What are the investigation for dysmenorrhoea?
A
- 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
17
Q
What are the clinal features suggestive of primary or secondary dysmenorrhoea?
A
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
18
Q
What is the management of primary dysmenorrhoea?
A
- 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
19
Q
Define infertility
A
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)
20
Q
What are the causes of male infertility?
A
- 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
21
Q
What are the causes of female infertility?
A
- 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
22
Q
What are the risk factors for infertility in women?
A
- 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
23
Q
What are the risk factors for infertility in men?
A
- 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
24
Q
What are the investigations needed for female infertility? (primary and secondary care)
A
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
25
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
26
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)
27
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)
28
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
29
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
30
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
31
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)
32
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
33
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, low FSH/LH)
- 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:
- Mechanical obstruction (imperforate hymen/ haematocolpos, transverse vaginal septum)
- 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
34
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
35
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
- Uterine causes (e.g. Asherman's): normal FSH/LH
- Hypopituitarism: low FSH, LH, TSH, oestrogen
36
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
37
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
38
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
39
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
40
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
41
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
42
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
43
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)
44
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
45
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
46
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
47
What investigations are needed for endometriosis?
- Ultrasound (transabdominal or transvaginal)
- Laparoscopy: gold standard for diagnosis
48
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)
49
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
50
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
51
52
Define PCOS
An endocrine disorder characterised by hyperandrogenism, ovulation disorder, and the presence of multiple immature follicles ('cysts') within the ovaries
53
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
54
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
55
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
56
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)
57
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
58
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)
59
What are the risk factors for ovarian cysts?
- Nulliparity
- Early menarche
- Late menopause
- Oestrogen only HRT
- Smoking
- Obesity
- BRCA 1&2 genes
60
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)
61
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
62
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
63
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)
64
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
65
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
- Hirsutism (testosterone secretion)
- Acute abdomen (ovarian torsion, rupture, or haemorrhage)
- Thyrotoxicosis
- Amenorrhoea
66
Describe the pathology and cause of ovarian cancer
- 95% are epithelial carcinomas (serous or mucinous cystadenocarcinomas)
- Not commonly caused by benign cysts undergoing malignant changes
- Most likely to spread directly within the pelvis and abdomen, but can spread to the lungs and cause pleural effusions
67
What is the management of ovarian cancer?
Surgical:
- staging laparotomy with debulking of tumour, lymph node biopsies
- hysterectomy, bilateral salpingo-oophorectomy
Chemotherapy:
- adjuvant or neoadjuvant
- not needed in early stages or low grade
68
Define ectopic pregnancy
When a fertilised egg implants outside of the uterus, most commonly within the fallopian tube (90%)
69
What are the risk factors for ectopic pregnancy?
- Previous ectopic pregnancy
- Tubal damage (PID, previous STI, sterilisation)
- History of infertility or assisted reproductive technology
- Smoker
- Aged over 35
- Use of IUD/IUS
70
What are the signs/symptoms of ectopic pregnancy?
- PV bleeding
- Abdominal pain (LIF or RIF)
- Shoulder tip pain (typically right)
- Dizziness, hypotension, tachycardia
- Sometime asymptomatic
71
What investigations are needed for ectopic pregnancy?
bHCG:
- determines treatment
USS:
- adnexal mass moving separately to the ovary
- gestational sac or yolk sac
- sometimes foetal heartbeat
- 20% may have a pseudo sac within the uterus
72
What is the conservative management of ectopic pregnancies?
Conservative:
- must be clinically stable and pain free
- have tubal pregnancy <35mm with no heart beat
- hCG < 1000
- return for follow up (hCG must fall by 15% on days 2, 4, and 7 until <20)
73
What is the medical management of ectopic pregnancy?
Medical (methotrexate injection):
- must be clinically stable and pain free
- have tubal pregnancy <35mm with no heart beat
- serum hCG < 1500
- no intrauterine pregnancy
- return for follow up
- hCG monitored on days 4 and 7 (<15% fall = repeat USS and consider repeat MTX), then weekly until negative
- contraindicated in thrombocytopaenia, hepatic/renal dysfunction, immunocompromised, breastfeeding, peptic ulcer disease
- must not get pregnant for 3 months
74
What is the surgical management of ectopic pregnancy?
First line in women who:
- have significant pain
- adnexal mass >35mm
- live ectopic
- hCG >5000
- signs of rupture
- haemodynamic instability
Laparoscopic salpingectomy (first line), or salpingotomy (preserve tube but may need further treatment)
75
Define miscarriage
Spontaneous involuntary loss of a pregnancy at less then 24 weeks gestation, categorised as early (<13 weeks, most common) or late (13-24 weeks)
76
What are the risk factors for miscarriage?
- Maternal age >30-35 (increased chromosomal abnormalities)
- Paternal age >45
- Previous miscarriage
- Obesity or low BMI pre-pregnancy
- Fertility problems or taking longer to conceive
- Maternal or paternal chromosomal abnormalities
- Smoking, alcohol, and illicit drug use
- Uterine surgery or anomalies
- Comorbidities: anti-phospholipid syndrome, coagulopathies, uncontrolled DM, connective tissue disorders
77
What are the causes of a miscarriage?
- Abnormal foetal development
- Uterine abnormality
- Incompetent cervix (2nd trimester)
- Placental failure
- Multiple pregnancy
- Infection
- Conditions (PCOS, antiphospholipid syndrome, inherited thrombophilia, poorly controlled diabetes or thyroid disease)
78
Describe a threatened miscarriage (symptoms, examination, management, prognosis)
- Symptoms: mild bleeding, little or no pain
- Examination: cervical os is closed, viable pregnancy on USS
- Management: if bleeding is mild and stops continue with normal antenatal care, if bleeding heavily or persists admit and observe, if previous miscarriage offer vaginal progesterone
- Roughly half go on to have a complete miscarriage
79
Describe an inevitable miscarriage (symptoms, examination, management, prognosis)
- Symptoms: heavy bleeding, clots, pain
- Examination: cervical os is open, non-viable or viable pregnancy on USS
- Will proceed to incomplete/complete miscarriage
- Management: expectant, medical, or surgical
80
Describe a complete miscarriage (symptoms, examination, management)
- Symptoms: heavy bleeding, passing clots and POC, symptoms may have resolved
- Examination: USS will show an empty uterus (after previously confirmed IUP), endometrial diameter of <15mm
- Usually will require follow-up with bHCG monitoring if no previous IUP confirmed on USS, (decrease of >50% 48 hours later is indicative of early pregnancy loss)
81
Describe incomplete miscarriage (symptoms, examination, management)
- Symptoms: bleeding, passing clots and POC are partially expelled
- Examination: may see POC, USS has mixed echoes within the uterine cavity
- Management: expectant, medical, or surgical
- If no previous IUP seen on USS, will require serial bHCG monitoring to ensure failing IUP
- Need to consider infection risk and need for antibiotics
82
Describe missed miscarriage
- Symptoms: may be none, dark-brown discharge
- Examination: may be diagnosed incidentally on transvaginal scan, uterus is small for dates, requires visualisation of gestation sac, yolk sac and foetal pole, with crown-rump length >7mm with no foetal heart activity (confirmed by 2nd scanner)
- Management: expectant, medical, or surgical management depending on size/gestation
83
Describe a septic miscarriage (symptoms, management)
- Symptoms: bleeding/discharge, pain, uterine tenderness, fevers, rigors, shock
- Management: surgical management, IV antibiotics and fluids
84
Describe the expectant management of a miscarriage (definition, advantages, disadvantages, follow up)
- Conservative management, bleeding and pain should resolve after 7 to 14 days, indicating the miscarriage is complete
- Advantages: can remain at home, no side effects of medication, no surgical risk
- Disadvantages: unpredictable timing, heavy bleeding and pain during passage of POC, chance of being unsuccessful, risk of haemorrhage and infection
- Follow up: pregnancy test after 3 weeks, may need repeat scan
85
Describe the medical management of a miscarriage (definition, advantages, disadvantages, follow up)
- Vaginal or oral misoprostol (prostaglandin analogue, stimulates cervical ripening and myometrial contractions)
- Oral mifepristone first if a missed/inevitable miscarriage
- Advantages: can remain at home, no surgical risk
- Disadvantages: side effects of medication (vomiting, diarrhoea), heaving bleeding and pain during passage of POC, may require emergency surgical intervention
- Follow up with pregnancy test 3 weeks later
86
Describe the surgical management of miscarriage (definition, indication, advantages, disadvantages)
- Vacuum aspiration with LA (<12 weeks), or under GA for suction curettage
- Definite indication: haemodynamically unstable, infected tissue (septic miscarriage), gestational trophoblastic disease
- Advantages: planned procedure (helps with coping), unaware during process
- Disadvantages: anaesthetic risk, risk of infection, uterine perforation, haemorrhage, bowel/bladder damage
87
Describe a molar pregnancy (definition, risk factors, features, investigations, management)
- A type of gestational trophoblastic disease (GTD), and can be complete (sperm fertilises an egg with no chromosomes) or partial (two sperm fertilising an egg)
- Risk of becoming and invasive mole, which is a malignant GTD
- Risk factors: maternal age 20-35, previous GTD, previous miscarriage, use of oral contraceptive pill
- Clinical features: vaginal bleeding and abdominal pain early in pregnancy, symptoms in later pregnancy include hyperemesis, hyperthyroidism, anaemia, large for dates uterus
- Investigations: markedly elevated b-hCG, USS: granular/snowstorm/bunch of grapes appearance, central heterogeneous mass, surrounding cystic areas
- Management: surgical curettage or suction, and histology of POC, chemotherapy if b-hCG fails to fall
88
Define ovarian torsion
When the ovary, and sometimes the fallopian tube twists on its vascular and ligamentous supports, which bocks blood flow to the ovary and is a surgical emergency
89
What are the signs/symptoms of ovarian torsion?
- Severe abdominal pain (often one sided)
- Nausea and vomiting
- Other non-specific symptoms
90
What are the investigations needed for ovarian torsion?
USS: enlarged ovary
91
What is the management of ovarian torsion?
- Urgent laparoscopy
- May require oophorectomy if still necrotic after detorsion
92
Describe ovarian cyst accidents
- Includes rupture, haemorrhage, and torsion
- May present with severe abdominal pain (due to free fluid in the abdomen)
- Cyst rupture and haemorrhage usually occur with functional cysts and are generally self limiting
- Occasionally require laparoscopy if diagnosis is uncertain, or haemodynamically unstable
93
Define pelvic inflammatory disease
Infection of the upper female reproduction system, causing inflammation of the uterus, fallopian tubes, ovaries, and/or peritoneum, most common in sexually active young women
94
What are the causes of pelvic inflammatory disease?
- Bacterial infection (from normal vaginal microbiome, respiratory or enteric pathogens)
- Usually STI (e.g. chlamydia, gonorrhoea, mycoplasma)
- Recent instrumentation of uterus (e.g. termination of pregnancy, IUD insertion, hysteroscopy, assisted reproductive techniques
95
What are the signs/symptoms of pelvic inflammatory disease?
- Pelvic pain
- Dyspareunia
- Dysuria
- IMB/PCB
- Change to vaginal discharge
- Fever
- O/E: cervical motion tenderness, adnexal tenderness, mucopurulent cervical discharge
96
What are the investigations for pelvic inflammatory disease?
- Pregnancy test: rule out ectopic, pregnant women with PID need admission
- High vaginal swabs and endocervical swabs: for STI
- Blood test: raised CRP/ESR, leucocytosis
- Urinalysis: rule out UTI
- USS: rule out other causes
- Laparoscopy: observe gross inflammation + obtain biopsy if needed
97
What is the management of pelvic inflammatory disease?
- 14 day course of antibiotics (single dose of IM ceftriaxone, plus PO metronidazole and doxycycline)
- Contacts also need tracing and treating
- No sex until patient and partners completed treatment
- May need additional pain relief
98
Define pelvic organ prolapse
- Descent of one or more of the pelvic organs including the uterus, bladder, rectum, bowel, or vaginal vault
- Resulting in protrusion of the vaginal walls and/or the uterus
- Accompanied by urinary, bowel, sexual, or pelvic symptoms
99
What are the risk factors for pelvic organ prolapse?
- Raised BMI
- Smoking
- Lack of exercise
- Constipation
- Diabetes
- Increasing age
- Post-menopausal
- Gynaecological surgery or cancer
- Connective tissue diseases (e.g. Ehlers-Danlos)
- Chronic respiratory disease (cough)
- Previous pregnancy (especially aged over 30)
- Assisted vaginal birth
- Occipito-posterior vaginal birth
- Prolonged active second stage
- Injury to anal sphincter during birth
100
Describe the different types of pelvic organ prolapse
- Urethrocele: prolapse of the lower anterior vaginal wall, involving the urethra only
- Cystocele: prolapse of the upper anterior vaginal wall, involving the bladder (often associated with urethra, cystourethrocele)
- Rectocele: prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
- Enterocele: prolapse of the upper posterior wall of the vagina, with the resulting pouch usually containing loops of small bowel
- Apical/uterine/vaginal vault: prolapse of the uterus, cervix, and upper vagina, which can lead to complete inversion
101
How are pelvic organ prolapses graded?
- Stage 0: no prolapse
- Stage 1: more than 1cm above the introitus
- Stage 2: within 1cm proximal or distal to the introitus
- Stage 3: more than 1cm blow the introitus (but less than 2cm)
- Stage 4: complete eversion (procidentia)
102
What are the signs/symptoms of pelvic organ prolapse?
- often asymptomatic and incidental findings
Vaginal:
- sensation of pressure/heaviness/dragging
- seeing/feeling a bulge or protrusion
- difficulty retaining tampons
- spotting (ulceration of the prolapse)
Urinary:
- incontinence, frequency, urgency
- feeling of incomplete bladder emptying
- weak or prolonged urinary stream
- needing to reduce prolapse manually before voiding
Bowel:
- constipation/straining
- urgency of stool
- incontinence of flatus or stool
- incomplete evaluation
- needing to apply manual pressure to the perineum or posterior vaginal wall
- digital evacuation needed to pass stool
Coital difficulty:
- dyspareunia
- loss of vaginal sensation
- vaginal flatus
- loss of arousal
103
What investigations are need for pelvic organ prolapse?
- Speculum examination, asking patient to strain
- Pelvic ultrasound: if a pelvic mass is suspected
- Urodynamic testing: if urinary incontinence
104
What is the conservative management for pelvic organ prolapse?
- Weight loss
- Diet: balanced diet to improve stool consistency
- Caffeine and fluids: reducing caffeine, maintaining adequate fluid intake
- Physical activity
- Pelvic floor muscle exercises
105
Describe the management of pelvic organ prolapse using vaginal pessaries?
- Act as artificial pelvic floor placed in the vagina between the symphysis pubis and sacrum
- Most commonly used is ring pessary, but shelf pessary is most effective for severe prolapses
- Need to be replaced every 6-9 months
- Can be used in combination with oestrogen creams or an oestrogen-releasing ring
106
What are the indications for surgical management of pelvic organ prolapse?
- Failure of conservative treatment
- Voiding problems or obstructed defecation
- Recurrence of prolapse after surgery
- Ulceration
- Irreducible prolapse
- Patient preference
107
Describe the use of surgical management for pelvic organ prolapse
- Restore anatomy
- Improve symptoms
- Return bowel, bladder, sexual function
- Anterior/posterior vaginal wall repair (colporrhaphy), or sacrocolpopexy
108
Define cervical ectropion
Eversion of the endocervix exposing the columnar epithelium onto the ectocervix, thought to be induced by high levels of oestrogen (often seen in pregnancy, adolescence, use of COCP)
109
What are the clinical feature of cervical ectropion?
- Most commonly asymptomatic
- May present with post-coital bleeding, intermenstrual bleeding, or excessive discharge
- On speculum: reddish ring around the external os
110
What is the management of cervical ectropion?
- Triple swabs: to rule out infection
- Cervical smear: to rule out cervical intraepithelial neoplasia
- No treatment needed if asymptomatic
- First line: top any oestrogen containing medication
- If symptoms are persistent: columnar epithelium can be ablated using cryotherapy or electrocautery
111
Define cervical intraepithelial neoplasia
Pre-cancerous changes in the cervix involving atypical dyskaryotic cells, normally asymptomatic and picked up during HPV screening
112
What are the risk factors for cervical intraepithelial neoplasia?
Acquiring HPV infection:
- early first sexual experience
- multiple partners
- history of STIs
- lack of barrier contraception
- immunosuppression
Progression to cervical cancer:
- smoking
- coinfection with other STIs (especially HIV)
- high parity/young age at first birth
- family history
- immunosuppression
- long term use of COCP and steroids
113
How is cervical intraepithelial neoplasia graded?
Histological diagnosis from colposcopy:
- CIN I (mild dysplasia): atypical cells found in the lower third
- CIN II (moderate dysplasia): atypical cells found in the lower two-thirds
- CIN III (severe dysplasia = carcinoma in situ): atypical cells occupy the full thickness of epithelium
114
How is HPV infection prevented?
- Vaccination of girls and boys aged 11-13
- Against stains 6, 11 (to prevent genital warts) and 16 and 18 (to prevent cervical neoplasia)
115
How is HPV and cervical intraepithelial neoplasia detected?
- Cervical smear screening: every 3 years for ages 25-49, every 5 years from 50-65
- Tests for high-risk HPV
- If HPV positive, then test cytology: can be negative, abnormal/dyskaryosis (borderline, low/high grade, invasive carcinoma), or inadequate (obscuring element like blood, insufficient cells, cervix not visualised, taken/labelled incorrectly)
116
When is referral to colposcopy indicated?
- After any smear with abnormal cytology
- After 3 repeated hrHPV positive but cytology negative (each 12 months apart)
- After repeated inadequate results
- If the cervix cannot be visualised, or with cervical stenosis
117
What is the management of cervical intraepithelial neoplasia?
Colposcopy:
- acetic acid stain (abnormal cells turn white)
- iodine stain (abnormal cells are unstained)
- biopsy
Treatment:
- only for high-grade dysplasia (CN II or III)
- large loop excision of the transformation zone (LLETZ)
- other options: cryotherapy, laser or cold coagulation
118
What causes cervical cancer?
- Most are squamous cell carcinomas (remainder are adenocarcinomas from columnar epithelium, or mixed)
- Occurs when cervical intraepithelial neoplasia becomes invasive (breaches the basement membrane)
119
What are the clinical features of cervical cancer?
- Most common symptom: abnormal vaginal bleeding (post-coital, intermenstrual, post-menopausal)
- Other symptoms: abnormal vaginal discharge, dyspareunia, pelvic pain, haematuria, weight loss
- On examination: ulcer or mass on the cervix may be visible or palpable
120
How is cervical cancer staged?
- Stage 0: carcinoma in situ (severe CIN III)
- Stage 1: confined to cervix
- Stage 2: invades into vagina but not pelvic sidewall (lower 1/3)
- Stage 3: invasion of pelvic side wall (lower 1/3 of vagina) or causes ureteric obstruction (hydronephrosis)
- Stage 4: invasion of bladder or rectal mucosa, or distant organs
121
What is the management of cervical cancer?
Surgery:
- stage 1a: radical trachelectomy (removal or cervix and upper vagina, conserving fertility), or laparoscopic hysterectomy
- stage 1b or 2a: radical hysterectomy
- stage 4a or recurrent disease: anterior/posterior/total pelvic exenteration
Radiotherapy:
- combination of external beam therapy and intracavity brachytherapy
- stage 2b or worse, or positive lymph nodes
Chemotherapy:
- can be neoadjuvant, adjuvant, or palliative
- chemoradiotherapy is gold standard in stage 1b to 3
122
What are the benefits and harms of cervical cancer screening?
Benefits:
- early detection of cancer
- reduced mortality of cervical cancer
Harms:
- over diagnosis of HPV and minor changes
- psychological distress
- false reassurance
- pain, discomfort, embarrassment during procedure
123
Describe vulval intraepithelial neoplasia
Atypical cells in the vulval epithelium, divided into histological types:
- usual type VIN: warty, basaloid, or mixed, common in younger women, associated with HPV
- differentiated type VIN: rarer, seen in older women, associated with lichen sclerosis, higher risk of progression to cancer
124
What are the clinical features of vulval intraepithelial neoplasia?
- Pruritis or pain is common
- In usual type VIN: multifocal, red/white/pigmented, plaques/papules/patches
- In differentiated VIN: unifocal lesion, ulcer
125
What is the management of vulval intraepithelial neoplasia?
- Medical: emollients or mild topical steroids
- Surgical excision: relieves symptoms and confirm histology to exclude invasive disease
126
Describe the pathology and cause of vulval cancer
- 90% are squamous cell carcinomas most commonly
- Others include melanoma, basal cell carcinomas, Bartholin's gland carcinoma
- Most common site is labia major (others: clitoris, perineum)
- Can arise from VIN, or de novo
- Spread is most commonly to the superficial and deep inguinal nodes
127
What are the risk factors for vulval cancer?
- HPV infection (multiple sexual partners, early first sexual encounter, smoking, etc.)
- Lichen sclerosis (long term inflammation)
128
What are the clinical features of vulval cancer?
- Pruritis
- Burning
- Soreness
- Bleeding
- Discharge
- Pain
- Lump
- Inguinal lymph node enlargement
129
What is the management of vulval cancer?
- Biopsy for staging
- Wide local excision
- Lymph node biopsy/resection
- Partial/local vulvectomy
- Potential radiotherapy
130
Describe the pathophysiology and cause of endometrial cancer?
Majority are adenocarcinoma, split into:
- type 1 (most common): oestrogen dependent, associated with obesity, low-grade, often has premalignant atypical hyperplasia
- type 2: not oestrogen sensitive, high-grade, more aggressive
131
What are the risk factors for endometrial cancer?
- Obesity and diabetes
- Age >50
- Early menarche
- Late menopause
- Nulliparity
- Unopposed oestrogen HRT
- Tamoxifen
- PCOS
- Hereditary non-polyposis colorectal cancer
132
What are the clinical features of endometrial cancer?
- Postmenopausal bleeding (most common presentation)
- Irregular or intermenstrual bleeding
- Recent onset menorrhagia
- On examination: uterine/adnexal mass, fixed uterus, abdominal distention, vaginal atrophy, cervical lesions
133
What are the investigations needed for endometrial cancer?
- Transvaginal ultrasound: endometrial thickening above 4mm is suspicious
- Hysteroscopy with endometrial biopsy (if high risk, or outpatient biopsy not tolerated)
- MRI or CT for staging
- Raised ca-125 (non-specific)
134
Describe the staging of endometrial cancer
- Stage 1: confined to uterus
- Stage 2: extends to cervix but still confined to uterus
- Stage 3: extends beyond uterus but confined to pelvis (or lymph nodes - pelvic/para-aortic)
- Stage 4: involves bladder, bowel, or distant metastases
135
What is the management for endometrial hyperplasia and cancer?
- Hyperplasia without atypia: Mirena coil with surveillance biopsies
- Atypical hyperplasia: total abdominal hysterectomy (TAH) + bilateral salpingo-oophorectomy (BSO)
- Endometrial cancer: TAH + BSO, radical hysterectomy (if stage 2), additional chemotherapy or radiotherapy (if stage 3 or 4)
136
What are the grounds for termination of pregnancy?
- A: continuation of the pregnancy would involve risk to the life of the pregnant women
- B: termination is necessary to prevent permanent injury to the physical or mental health of the regnant women
- C: pregnancy has not exceeded 24 weeks, and continuation would involve risk to the physical or mental health of the pregnant women
- D: pregnancy has not exceeded 24 weeks, and continuation would involve risk to the physical or mental health of any existing children
- E: substantial risk that the child would suffer from severe physical or mental abnormalities
137
What are the methods of termination of pregnancy?
- Medical: mifepristone (antiprogesterone), plus misoprostol (prostaglandin) 36-48 hours later
- Surgical: suction curettage between 7 and 14 weeks, dilation and evacuation above 14 weeks (with preoperative misoprostol and antibiotic prophylaxis)
- Other management: anti-D prophylaxis for women who are rhesus D negative, screening for STIs, offer contraception
138
What are the complications of termination of pregnancies?
- Infection
- Cervical trauma
- Failure of procedure
- Haemorrhage
- Perforation of uterus
- Psychological distress
139
Define pregnancy of unknown location
When there is a positive b-HCG, but a pregnancy cannot be identified on ultrasound, most likely due to:
- very early intrauterine pregnancy
- miscarriage
- hidden ectopic pregnancy
140
How is a pregnancy of unknown location managed?
- If initial b-HCG is >1500: considered ectopic pregnancy until proven otherwise, diagnostic laparoscopy offered
- If initial b-HCG is <1500 and patient is stable: further bloods taken in 48 hours, viable pregnancy would double, miscarriage would halve
141
Define menopause
- Menopause: permanent cessation of menstruation resulting from loss of ovarian follicular activity causing a decrease in circulating oestrogen, occurring at the median age of 51
- Perimenopause: time beginning with the first features of approaching the menopause, and ending 12 months after the last menstrual period
- Postmenopause: dating from the final menstrual period, determined after 12 months of spontaneous amenorrhoea
- Premature menopause: occurring before the age of 40, sometime due to surgical removal of the ovaries
142
What are the symptoms and consequences of menopause?
Early:
- psychological symptoms (sleep disturbance, mood changes, loss of libido)
- vasomotor symptoms (hot flushes, night sweats
Intermediate:
- menstrual irregularity (longer or shorter cycles)
- urogenital symptoms (dyspareunia, vaginal discomfort/dryness, UTIs, incontinence)
- skin atrophy (thinning of skin, brittle nails, hair loss)
Late:
- osteoporosis (oestrogen deprivation lowering bone density and causing bone fractures)
- cardiovascular disease (coronary heart disease, stroke, peripheral arterial disease)
143
What investigations are used in menopause?
Diagnosis is clinical, and most tests are not helpful
- FSH: raised levels suggests lack of ovarian response, but this varies daily
- Anti-Mullerian hormone: produced by ovarian follicles and low levels indicate ovarian failure
- DEXA scan: to measure bone density
144
What is the treatment of the menopause?
- Lifestyle advice: stop smoking, weight loss, limit alcohol, health diet, regular exercise
Hormone replacement therapy:
- oestrogen alone (only after hysterectomy) or combined with progesterone
- can be used continuously or cyclically,
- preparations include patch, implant, gel, pills
- urogenital symptoms can be treated with vaginal topical oestrogen
145
What are the risks of hormone replacement therapy?
- Endometrial cancer (unopposed non-vaginal oestrogen replacement therapy)
- VTE (oral HRT doubles risk of VTE)
- Gallbladder disease (oral HRT increases risk)
- Stoke (increased risk with oral oestrogen)
- Coronary heart disease (slight risk with combined HRT)
- Breast cancer (slight risk with combined HRT only)
- Ovarian cancer (slight risk with all HRT)
146
What are the contraindications to HRT?
- Past or current breast cancer
- Other oestrogen-sensitive cancers (endometrial, ovarian)
- Undiagnosed uterine bleeding
- Untreated endometrial hyperplasia
- Pregnancy
- Thrombophilia disorder
- Past or current blood clots
147
Define lichen sclerosis
A chronic inflammatory skin disease of the anogenital region affecting postmenopausal or pre-pubescent girls, with a possible autoimmune cause, with the potential to progress to squamous cell carcinoma
148
What are the clinical features of lichen sclerosis?
- Pruritis (often severe and worse at night)
- Pain and discomfort from skin erosions or fissuring
- Dyspareunia
On examination:
- white atrophic patches
- clitoral head fusion
- fusion of labia minora and majora
- posterior fusion resulting in loss of vaginal opening
149
What is the management of lichen sclerosus?
- Biopsy: if uncertain diagnosis, or suspicion of vulval cancer
- Topical steroids (e.g. clobetasol propionate)
- Avoid irritants, minimise contact with urine
150
151
Define a Bartholin's cyst
A fluid filled sac within one of the Bartholin's glands (openings are located at 4 and 8 o'clock of the vaginal orifice), caused y a build up of mucus secretions blocking the duct, which can go on to become infected commonly by STIs, staphylococcus, or E. coli (Bartholin's abscess)
152
What are the risk factors for Bartholin's cyst?
- Nulliparous
- Child bearing age
- Previous Bartholin's cyst
- Sexually active (can be caused by STIs)
- History of vulval surgery
153
What are the clinical features of a Bartholin's cyst?
- Often asymptomatic if small
- Valvular pain (when walking/sitting)
- Superficial dyspareunia
- If cyst spontaneously ruptures: sudden relief of pain
- Bartholin's abscess: acute onset of pain, difficulty passing urine
On examination:
- cyst: soft, fluctuant, non-tender
- abscess: tense, hard, surrounding cellulitis
154
What is the management of a Bartholin's cyst?
- Word catheter: small incision into cyst and catheter inserted for 4-6 weeks to allow epithelialisation of the new opening
- Marsupialisation: vertical incision then eversion of the cyst wall to be sutured open to the vaginal mucosa
- Other management: antibiotics if bacterial infection suspected, conservation measures (warm baths)
155
Define stress incontinence
Involuntary leakage of urine on exertion or effort, during increased intra-abdominal pressure, in the absence of detrusor contraction
156
What are the causes for stress incontinence?
- Pregnancy
- Vaginal delivery (particularly prolonged or forceps delivery)
- Obesity
- Old age (particularly post menopausal)
- Previous hysterectomy
- Co-existent prolapse
- Chronic cough (e.g. COPD, asthma)
157
What are the clinical features of stress incontinence?
History:
- leakage of urine on coughing, sneezing, exercising
- may also have frequency, urgency, or urge incontinence
Examination:
- have also show pelvic organ prolapse
- leakage of urine with coughing
- distended bladder on abdominal palpation
158
What is the management for stress incontinence?
Conservative:
- weight loss
- address causes of chronic cough
- reduce excessive fluid intake
- pelvic floor physiotherapy (for at least 3 months)
Medical:
- duloxetine (SNRI that enhances urethral sphincter smooth muscle activity)
Surgical:
- tension free vaginal tape (TVT, mid urethral sling)
- colposuspension (rarely performed, sutures between paravaginal fascia and pelvic ligaments)
159
Define urge incontinence
Urinary urgency due to an overactive bladder, usually with frequency and nocturia, in the absence of infection or obvious pathology
160
What are the causes of urge incontinence?
- Mostly idiopathic
- Previous pelvic/incontinence
- Neurological conditions (e.g. multiple sclerosis, spina bifida)
161
What are the clinical features of urgency incontinence?
History:
- urgency, frequency, and nocturia, trigged by hearing running water, cold weather etc.
- may also have stress incontinence
- may have history of childhood enuresis
Examination:
- often normal
- may have incidental cystocele
162
What is the management of urge incontinence?
Conservative:
- reduce excessive fluid intake, particularly caffeine
- review drugs that alter bladder function (e.g. diuretics, antipsychotics)
- bladder training
Medical:
- anticholinergics (block muscarinic receptors to supress detrusor smooth muscle contractions, e.g. oxybutynin, solifenacin)
- beta-3 adrenergic receptor agonist (relaxes detrusor smooth muscle e.g. mirabegron)
- intravaginal oestrogens (improves symptoms of vaginal atrophy)
- botulinum toxin A (blocks neurotransmission to make detrusor weaker)
- neuromodulation and sacral nerve stimulation (improves ability to supress detrusor contractions)
Surgery:
- detrusor myomectomy
- augmentation cystoplasty
163
What are some other causes of urinary incontinence (other than stress and urge)?
- Neurological
- Cognitive
- Fistula
- Retention/overflow
164
What are the investigations for urinary incontinence?
- Urinalysis (MSU): rule out infection, renal disease, diabetes
- Frequency volume chart (bladder diary): measuring voided volume, leakage, fluid intake, variation
- Residual urine measurement: in out catheter, or ultrasound
- Questionnaire: improves discussion and disclosure
- Urodynamics: measures pressures to look at detrusor contractions and overactivity
