Gynaecology Flashcards
What is Androgen insensitivity syndrome?
X-linked recessive condition due to end-organ resistance to testosterone
mutation in the androgen receptor gene
causing genotypically male children (46XY) to have a female phenotype
What are the features of Androgen insensitivity syndrome?
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
How is Androgen insensitivity syndrome diagnosed?
buccal smear or chromosomal analysis to reveal 46XY genotype
after puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys
What would hormone results for Androgen insensitivity syndrome show
Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)
How is Androgen insensitivity syndrome managed?
counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy
What is Adenomyosis
endometrial tissue within the myometrium
Who is Adenomyosis more common in
multiparous women towards the end of their reproductive years
It may occur alone, or alongside endometriosis or fibroids.
What conditions tend to resolve after menopause
Adenomyosis endometriosis and fibroids.
How does Adenomyosis present
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
How would Adenomyosis feel on examination
an enlarged and tender uterus.
What is first line investigation for Adenomyosis
Transvaginal ultrasound
MRI and transabdominal ultrasound are alternative investigations
What is the gold standard investigation for Adenomyosis
histological examination of the uterus after a hysterectomy
How is Adenomyosis managed when the woman does not want contraception
Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
How is Adenomyosis managed when contraception is wanted
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
What are other management options of Adenomyosis beside tranexamic acid and contraception
GnRH analogues to induce a menopause-like state
Endometrial ablation
Uterine artery embolisation
Hysterectomy
What conditions are associated with Adenomyosis
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
What is Atrophic Vaginitis
dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
Who does Atrophic Vaginitis occur in
post menopausal
how does Atrophic Vaginitis present
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
how does Atrophic Vaginitis appear on examination
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
how is Atrophic Vaginitis managed
Vaginal lubricants - Sylk, Replens and YES
Topical oestrogen - cream, pessaries, tablets, ring
What is Asherman’s Syndrome
adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus and form physical obstructions and distort the pelvic organ
When does Asherman’s Syndrome occur
typically presents following recent dilatation and curettage, uterine surgery or endometritis
How does Asherman’s Syndrome present
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
sometimes infertility
What is the gold standard investigation for Asherman’s Syndrome
Hysteroscopy
can involve dissection and treatment of the adhesions
Other than Hysteroscopy how else can Asherman’s Syndrome be investigated
Hysterosalpingography - contrast is injected into the uterus and imaged with xrays
Sonohysterography - uterus is filled with fluid & ultrasound
MRI
How is Asherman’s Syndrome managed
dissecting the adhesions during hysteroscopy
reoccurrence is common
why males do not develop a uterus
anti-Mullerian hormone
What structure in a fetus do congenital structural abnormality refer to
Mullerian ducts.
Name 4 congenital structural abnormality
Bicornuate Uterus
Imperforate Hymen
Transverse Vaginal Septae
Vaginal Hypoplasia and Agenesis
What is a Bicornuate Uterus
two “horns” to the uterus, giving the uterus a heart-shaped appearance.
What are typical complications of Bicornuate Uterus
Miscarriage
Premature birth
Malpresentation
What is a Imperforate Hymen
the hymen at the entrance of the vagina is fully formed, without an opening.
causes cyclical pelvic pain and cramping, but without any vaginal bleeding
How is Imperforate Hymen diagnosed and treatmed
diagnosed during a clinical examination. treated with surgical incision
What is a complication of untreated Imperforate Hymen
retrograde menstruation leading to endometriosis.
What is a Transverse Vaginal Septae
a wall forms transversely across the vagina. This septum can either be perforate or imperforate
perforate = still menstruate, but can have difficulty with intercourse or tampon use. imperforate = present similarly to an imperforate hymen
What are complications of transverse Vaginal Septae
infertility and pregnancy-related complications
How is transverse Vaginal Septae diagnosed
examination, ultrasound or MRI.
How is transverse Vaginal Septae treated and what is the complication of treatment
surgical correction
The main complications of surgery are vaginal stenosis and recurrence of the septae.
What is Vaginal hypoplasia
abnormally small vagina
What is Vaginal agenesis
an absent vagina.
What causes Vaginal Hypoplasia and Agenesis
failure of the Mullerian ducts to properly develop
Are ovaries affected in Vaginal Hypoplasia and Agenesis
ovaries are usually unaffected, leading to normal female sex hormones.
The exception to this is with androgen insensitivity syndrome, where there are testes rather than ovaries.
How is Vaginal Hypoplasia and Agenesis managed
use of a vaginal dilator over a prolonged period to create an adequate vaginal size. Alternatively, vaginal surgery may be necessary.
What is cervical cancer
80% are squamous cell carcinoma
adenocarcinoma next most common
strongly associated with human papillomavirus
When are children vax against HPV
12-13
What is used to screen for precancerous and cancerous changes to the cells of cervix
Cervical screening with smear tests
What is the most common cause of cervical cancer
human papillomavirus (HPV)
What other cancers is HPV associated ith
anal, vulval, vaginal, penis, mouth and throat cancers.
What two strains of HPV are responsible for 80% of cervical cancer cases
type 16 and 18
How does HPV promote the development of cancer
HPV produces two proteins (E6 and E7) that inhibit tumour suppressor genes
E6 protein inhibits p53
E7 protein inhibits pRb.
What are rick factors for cervical cancer
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Non-engagement with cervical screening
Smoking
HIV
Combined contraceptive pill >5 years
Increased number of full-term pregnancies
Family history
How does cervical cancer present
often detected asymptomatic
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
How does cervical cancer appear on examination
Ulceration
Inflammation
Bleeding
Visible tumour
How are precursor to squamous cell carcinoma of the cervix graded
Cervical intraepithelial neoplasia (CIN)
how is Cervical intraepithelial neoplasia (CIN) diagosed
colposcopy
What does Cervical intraepithelial neoplasia (CIN) grade
dysplasia (premalignant change)
What does smear results show
dyskaryosis (precancerous changes)
What is CIN 1
mild dysplasia
affecting 1/3 the thickness of the epithelial layer
likely to return to normal without treatment
What is CIN 3
severe dysplasia
very likely to progress to cancer if untreated
sometimes called cervical carcinoma in situ.
What is CIN 2
moderate dysplasia
affecting 2/3 the thickness of the epithelial layer
likely to progress to cancer if untreated
how is cervical cancer screened
cervical smear test
precancerous changes in the epithelial cells of the cervix
how often do you have cervical screen
Every three years aged 25 – 49
Every five years aged 50 – 64
what are cervical smear samples tested for
Tested for high-risk HPV then the cells are examined.
If HPV negative then cell not tested
What women are exceptions to standard cervical screening program
- Women with HIV (annually)
- Women over 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
What other conditions can be identified on a smear test
bacterial vaginosis, candidiasis and trichomoniasis
What happens to women with HPV positive with abnormal cytology smear result
refer for colposcopy
What happens to women with HPV positive with normal cytology smear result
repeat the HPV test after 12 months
What is Colposcopy
Inserting a speculum and using equipment (a colposcope) to magnify the cervix.
stains such as acetic acid and iodine solution can be used to differentiate abnormal areas.
What does Acetic acid do in a colposcopy
causes abnormal cells to appear white
(acetowhite)
Why do abnormal cells turn white with acetic
increased nuclear to cytoplasmic ratio (more nuclear material)
such as cervical intraepithelial neoplasia and cervical cancer cells.
What is Schiller’s iodine test
an iodine solution to stain the cells of the cervix.
Iodine will stain healthy cells a brown colour.
Abnormal areas will not stain.
How are tissue samples collected in colposcopy
punch biopsy or large loop excision of the transformational zone
What is Large Loop Excision of the Transformation Zone (LLETZ)
using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix
Loop Biopsy
local anaesthetic
What is a cone biopsy
treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
surgeon removes a cone-shaped piece of the cervix using a scalpel
general anaesthetic
what are the risks of Cone Biopsy
Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
what are the risks of loop Biopsy
may increase the risk of preterm labour.
bleeding and abnormal discharge
how is cervical cancer staged
International Federation of Gynaecology and Obstetrics (FIGO
What are the stages of cervical cancer (stage 1-4)
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
How is cervical intraepithelial neoplasia and early-stage 1A cervical cancer managed
gold standard = hysterectomy +/- lymph
node clearance
maintain fertility = LLETZ or cone biopsy
with negative margins
How is Stage 1B cervical cancer managed
Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
How is Stage B2 cervical cancer managed
radical hysterectomy with pelvic lymph
node dissection
How is Stage 2 and 3 cervical cancer managed
radiation with concurrent
chemotherapy
if hydronephrosis → nephrostomy
How is Stage 4 cervical cancer managed
radiation and/or chemotherapy
4B = palliative chemotherapy
What monoclonal antibody is used in combo w chemo for metastatic or recurrent cervical cancer
Bevacizumab (Avastin)
What does Bevacizumab (Avastin) target
targets vascular endothelial growth factor A (VEGF-A)
What HPV strain cause genital warts
6 and 11
What is the 5 year survival for stage 1A cervical cancer
98%
What is the 5 year survival for stage 4 cervical cancer
15%
What is menorrhagia
Heavy menstrual bleeding
> 80ml loss
Name 5 causes of menorrhagia
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes and hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- Polycystic ovarian syndrome
Name 5 key history questions to ask a woman presenting with menorrhagia
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
How should menorrhagia be investigated
Pelvic examination with a speculum and bimanual
FBC
Hysteroscopy
Pelvic and transvaginal ultrasound
Swabs
Coag screen
Ferritin
TFT
How is menorrhagia managed when the woman does not want contraception
Tranexamic acid when NO associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
How is menorrhagia managed when the woman wants contraception
- Mirena coil (first line)
- Combined oral contraceptive pill
- Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)
What is the final option for when medical management has failed for menorrhagia
endometrial ablation and hysterectomy.
What is endometrial cancer
Cancer of the endometrium, the lining of the uterus.
80% of cases are adenocarcinoma
What is endometrial cancer dependent on
oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells.
What is the key presenting feature of endometrial cancer
a woman presenting with postmenopausal bleeding
What are risk factors for endometrial cancer
obesity and diabetes
PCOS
tamoxifen
excess oestrogen
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen
what is endometrial hyperplasia
a precancerous condition involving thickening of the endometrium
What percent of cases of endometrial hyperplasia turn into endometrial cancer
5%
Most cases of endometrial hyperplasia will return to normal
Name the 2 types of endometrial hyperplasia
Hyperplasia without atypia
Atypical hyperplasia
How is endometrial hyperplasia without atypia treated
high dose progestogens with repeat sampling in 3-4 months (eg levonorgestrel intra-uterine system)
How is atypical endometrial hyperplasia treated
hysterectomy
How does unopposed oestrogen contribute to endometrial cancer
stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer.
what is unopposed oestrogen
oestrogen without progesterone
Name causes of increased exposure of unopposed oestrogen
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
How does PCOS lead to increased exposure to unopposed oestrogen
lack of ovulation
less likely to form corpus luteum –> what produces progesterone & endometrial lining has more exposure to unopposed oestrogen
What should women with PCOS take for endometrial protection
The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed.
How does obesity contribute to unopposed oestrogen
adipose tissue (fat) is a source of oestrogen
Adipose tissue is the primary source of oestrogen in postmenopausal women
What does adipose fat contain to contribute to unopposed oestrogen and what does it do
aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen
What is tamoxifen oestrogenic effect
anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium.
name two risk factors for endometrial cancer not related to unopposed oestrogen
Type 2 diabetes
Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome
name 4 protective factors against endometrial cancer
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
How may endometrial cancer present
** postmenopausal bleeding **
also
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
What is the referral criteria for a 2 week wait for endometrial cancer
Postmenopausal bleeding (more than 12 months after the last menstrual period)
What is the NICE criteria for referral for a transvaginal ultrasound with suspected endometrial caner
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
What are the three investigations for endometrial cancer
Transvaginal ultrasound for endometrial thickness
hysteroscopy with endometrial biopsy
What is a normal endometrial thickness post menopause
less than 4mm
What is a pipelle biopsy
highly sensitive for endometrial cancer
inserting thin tube (pipelle) through the cervix into the uterus
quicker and less invasive alternative than hysteroscopy
What indicated on investigations are sufficient to demonstrate a very low risk of endometrial cancer and discharge the patient.
a normal transvaginal ultrasound (endometrial thickness < 4mm) and normal pipelle biopsy
How is endometrial cancer staged
International Federation of Gynaecology and Obstetrics (FIGO) staging system
what are the International Federation of Gynaecology and Obstetrics (FIGO) staging system for endometrial cancer
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
How is stage 1&2 endometrial cancer managed
total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
+/- radiotherapy
What is endometriosis
ectopic endometrial tissue outside the uterus
affects 10%
What are chocolate cysts
Endometriomas in the ovaries
What is Endometriomas
lump of endometrial tissue outside the uterus
What is Adenomyosis
endometrial tissue within the myometrium (muscle layer) of the uterus.
What is a theory for the cause of endometriosis
During menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum (retrograde menstruation)
The endometrial tissue then seeds itself around the pelvis and peritoneal cavity.
How does endometriosis present
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods - often before period starts)
Infertility
Cyclical bleeding from other sites, such as haematuria
urinary symptom
painful bowel movements
What can endometriosis in bladder and bowel cause
can lead to blood in the urine or stools.
How does endometriosis present on examination
- Endometrial tissue visible particularly in the posterior fornix
- reduced organ mobility
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
What is the gold standard investigation for endometriosis?
Laparoscopic surgery
definitive diagnosis can be established with a biopsy of the lesions during laparoscopy.
1st = US
other than lapsroscopic surgery how else can endometriosis be investigated
Pelvic ultrasound
may reveal large endometriomas and chocolate cysts
however ultrasound are often unremarkable in patients with endometriosis
What is the body responsible for the staging system for endometriosis
American Society of Reproductive Medicine (ASRM)
what are the endometriosis stages (stage 1-4)
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
What is the initial management of endometriosis
Establishing a diagnosis
Providing a clear explanation
Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
Analgesia as required for pain (NSAIDs and paracetamol first line)
What is the hormonal management of endometriosis
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
What is the surgical management of endometriosis
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
do hormonal therapies improve fertility in endometriosis
Hormonal therapies may improve symptoms but not fertility.
Laparoscopic treatment may improve fertility
how does birth control medication manage endometriosis cyclical pain
stop ovulation and reduce endometrial thickening
outside of uterus where can endometriosis be found
intestinal tract
bladder
heart
lungs
kidney
CNS
how does GnRH agonists manage endometriosis cyclical pain
eg Goserelin
Cyclical pain tends to improve after menopause when the female sex hormones are reduced.
GnRH agonists induce a menopause-like state
Shut down the ovaries temporarily and can be useful in treating pain in many women
How does laproscopic sugery improve endometriosis symptoms
excise or ablate the ectopic endometrial tissue. remove adhesions causing chronic pelvic pain
What is the final surgical option for endometriosis
Hysterectomy and bilateral salpingo-opherectomy
What are fibriods
benign tumours of the smooth muscle of the uterus
What is another name for fibriods
uterine leiomyomas
How many women are affected by fibrioids
40-60% of women in later reproductive years
more common in black women
What hormone are fibroids sensitive to
oestrogen
What are 4 types of fibroids
Intramural
Subserosal
Submucosal
Pedunculated
What are intramural fibroids
within the myometrium (the muscle of the uterus
As they grow, they change the shape and distort the uterus.
What are Subserosal fibroids
just below the outer layer of the uterus
grow outwards and can become very large, filling the abdominal cavity
What are Submucosal fibroids
just below the lining of the uterus (the endometrium)
What are Pedunculated fibroids
on a stalk
How do fibroids present
- Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
- Prolonged menstruation, lasting more than 7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
How do fibroids present one examination
may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
What is the first line investigation for fibroids
transvaginal and transabdominal ultrasound
What is the 1st line medical management for fibroids
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
What is the surgical management for fibroids if fertility desired
- myomectomy
what is the surgical management of fibroids if fertility not desired
Uterine artery embolisation
Hysterectomy
What is Uterine artery embolisation
Inserts a catheter into femoral artery & passed through to the uterine artery under X-ray
Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.
This starves the fibroid of oxygen and causes it to shrink
What is myomectomy
surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery).
only treatment known to potentially improve fertility
What are complications of fibroids
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What is red degeneration of fibroids
ischaemia, infarction and necrosis of the fibroid due to fibroid outgrowing its blood supply
more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy.
How does a woman with red degeneration of fibroids present
pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever
maybe tachycardia and vomiting
What is a hydatiform mole
A type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy
what is a complete mole
when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”).
These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole.
No fetal material will form
What is a partial mole
when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.
The new cell now has three sets of chromosomes. The cell divides and multiplies into a tumour called a partial mole.
some fetal material may form.
What indicates a molar pregnancy vs a normal pregnancy
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
How does molar pregnancy present on ultrasound
“snowstorm appearance” of the pregnanc
How is a molar pregnancy diagnosed
Ultrasound of the pelvis
Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.
How is a molar pregnancy managed
evacuation of the uterus to remove the mole & sent for histological examination
referred to the gestational trophoblastic disease centre
hCG levels monitored
What is the management for a metastatic molar pregnancy
systemic chemotherapy
What is lichen sclerosus
chronic inflammatory skin condition
commonly affecrs the labia perineum and perianal skin
autoimmune condition
what does lichen mean
flat eruption that spreads
how does lichen sclerosus present
45-60 year old woman complaining of vulval itching and skin changes in the vulva
skin tightness
painful sex
erosions
fissures
patches of shiny, “porcelain-white” skin
What is the koebner phenomenon
when the signs and symptoms are made worse by friction to the skin
occurs with lichen sclerosus or psoriasis
How does lichen sclerosus appear
“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques
How is lichen sclerosus managed
cannot be cured, but the symptoms can be effectively controlled.
topical steroids and emollients –> clobetasol propionate 0.05% (dermovate).
What is a critical complication of lichen sclerosus
5% risk of developing squamous cell carcinoma of the vulva.
What conditions is lichen sclerosus associated with
type 1 diabetes, alopecia, hypothyroid and vitiligo.
What is menarche
The age at onset of menstrual bleeding. Mean age is 13 years; typically occurs 2 years after the onset of puberty.
What is menopause
permanent stop to menstruation
How is menopause diagnosed
retrospective diagnosis
made after a woman has had no periods for 12 months
NICE recomends FSH blood test
What is post menopause
the period from 12 months after the final menstrual period onwards.
what is perimenopause
time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods
What is premature menopause
menopause before the age of 40 years
What causes premature menopause
premature ovarian insufficiency
What is cause of menopause
lack of ovarian follicular function,
How do sex hormones change in menopause
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
What are the 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 are the risks of lack of oestrogen
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
How long do women need to use contraception after last menstraul period
<50 = 2 years after last period
>50 = 1 year after last period
What are good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation
What is a UKMEC 2 (the advantages generally outweigh the risks) contraception
combined oral contraceptive pill
What are the two key side effects of the progesterone depot injection
weight gain and reduced bone mineral density (osteoporosis).
How are perimenopausal symptoms managed
- No treatment
- Hormone replacement therapy (HRT)
- Tibolone, a synthetic steroid hormone that acts as continuous combined HRT
- Testosterone
- CBT
- SSRI
What is ovarian cancer
cancer of the ovaries
non specific symptoms
More than 70% of patients with ovarian cancer present after it has spread beyond the pelvis.
What is the most common type of ovarian cancer
Epithelial cell tumours
Name 3 subtypes of epithelial cell tumours
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
what is a teratoma
benign ovarian tumours
arise from germ cells
what markers can germ cell tumors raise
alpha-fetoprotein (α-FP)
human chorionic gonadotrophin (hCG)
What other condition are germ cell tumors associated with
ovarian torsion
Where do Sex Cord-Stromal Tumours arsie from
stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)
benign or malignant
Name two types of Sex Cord-Stromal Tumours
Sertoli–Leydig cell tumours and granulosa cell tumours.
What is a krukenberg tumor
metastasis in the ovary from GI tract cancer
What is the characteristic sign on histology for krukenberg tumor
“signet-ring” cells
What are risk factors for ovarian cancer
- Age (peaks age 60)
- BRCA1 and BRCA2 genes (consider the family history)
- Increased number of ovulations
- Early-onset of periods
- Late menopause
- No pregnancies
- Obesity
- Smoking
- Recurrent use of clomifene
- Tamoxifen
What are protective factors for ovarian cancer
Combined contraceptive pill
Breastfeeding
Pregnancy
(factors that reduce ovulations)
How does ovarian cancer present
non-specific symptoms
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Abdominal or pelvic mass
Urinary symptoms (frequency / urgency)
Weight loss
Ascites
Where can ovarian cancer cause referred pain
may press on the obturator nerve and cause referred hip or groin pain
What is the criteria for two week wait for suspected ovarian cancer
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
What symptoms indicated further investigation before cancer referral in women presenting with symptoms of possible ovarian cancer
women >50
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
What are the initial investigations for ovarian cancer in primary or secondary care
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
What is included in the risk of malignancy index (RMI) for ovarian cancer
Menopausal status
Ultrasound findings
CA125 level
What further investigations can be done in secondary care for ovarian cancer
- CT scan to establish the diagnosis and stage the cancer
- Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
- Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
What tumor marker tests are required for women under 40 with complex ovarian mass and why
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
Lactate dehydrogenase (LDH)
for possible germ cell tumor
what is CA125 a tumor marker for
epithelial cell ovarian cancer
What are non malignant causes for raised CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
What are the stages for ovarian caner
International Federation of Gynaecology and Obstetrics (FIGO) staging system
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 outside the abdomen (distant metastasis)
how is ovarian cancer managed
specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
What is an cyst
fluid-filled sac
What is a functional ovarian cysts
An ovarian cyst that develops due to disruption in the development of follicles or the corpus luteum.
related to the fluctuating hormones of the menstrual cycle
very common in premenopausal
follicular or corpus luteum
At what age are ovarian cysts more concerning
Cysts in postmenopausal women are more concerning for malignancy
How do ovarian cysts present
Most ovarian cysts are asymptomatic
Occasionally, ovarian cysts can cause vague symptoms of:
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
When may ovarian cysts present with acute pain
if there is ovarian torsion, haemorrhage or rupture of the cyst.
What are the most common ovarian cyst
Follicular cysts
What are Follicular cysts
Developing follicle fail to rupture and release the egg (ovulate), the cyst can persist
may produce excess oestrogen
tend to disappear after a few menstrual cycles
What is a Corpus luteum cysts
occur when the corpus luteum fails to break down (involute) and instead fills with fluid.
may produce excess progesterone
often seen in early pregnancy.
Name three other types of ovarian cysts
Serous Cystadenoma
Mucinous Cystadenoma
Endometrioma
Dermoid Cysts / Germ Cell Tumours
Sex Cord-Stromal Tumours
what cysts are benign tumors of epithelial cells
Serous Cystadenoma
Mucinous Cystadenoma
What are endometrioma
lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
What features of ovaian cysts may suggest malignancy
Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
What is the tumor marker for ovarian cancer
CA 125
What is the name of the guidline for managing suspected ovarian cysts
RCOG Green-top guidelines
What is the referral for possible ovarian cancer (complex cysts or raised CA125)
two-week wait referral to a gynaecological oncology specialist.
What is the referral for possible dermoid cysts
referral to a gynaecologist for further investigation and consideration of surgery.
What is the management for premenopausal women with a ovarian cyst <5cm
almost always resolve within three cycles.
A repeat ultrasound should be arranged for 8-12 weeks
What is the management for premenopausal women with a ovarian cyst 5cm to 7cm
Require routine referral to gynaecology and yearly ultrasound monitoring.
What is the management for premenopausal women with a ovarian cyst >7cm
Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
What is the management for cysts in postmenopausal women
benign unlikely in post menopausal women –> any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
How are persistent or enlarging cysts managed
surgical intervention (usually with laparoscopy)
involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
What are the complication of ovarian cysts
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum
What is Meigs syndrome
triad:
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
What is ovarian torsion
ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
What are the RF of ovarian torsion
- ovarian mass >5cm such as cyst or tumor
- pregnancy
- longer infundibulopelvic ligaments
What happens with twisting of the adnexa in ovarian torsion
Twisting of the adnexa and blood supply to the ovary leads to ischaemia
If the torsion persists, necrosis will occur, and the function of that ovary will be lost
How does ovarian torsion present
sudden onset severe unilateral pelvic pain
constant pain
progressive pain
nausea and vomiting
What initial investigation for ovarian torsion
Pelvic ultrasound
Transvaginal is ideal, but transabdominal can be used
What is the ultrasound sign for ovarian torsion
“whirlpool sign”, free fluid in pelvis and oedema of the ovary.
What investigation is used for definitive diagnosis of ovarian torsion
laparoscopic surgery
How is ovarian torsion managed
laparoscopic surgery to
- un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
What is complication of ovarian torsion
loss of function of that ovary
fertility is not typically affected if there is another ovary
What can a necrotic ovarian lead to
become infected, develop an abscess and lead to sepsis.
may rupture, resulting in peritonitis and adhesions.
What are characterisitc features of PCOS
- multiple ovarian cysts
- oligomenorrhea
- hyperandrogenism
- infertility
- insulin resistance.
What is Anovulation
absence of ovulation
What is Oligoovulation
irregular, infrequent ovulation
what is Amenorrhoea
absence of menstrual periods
what is Oligomenorrhoea
irregular, infrequent menstrual periods
what are Androgens
male sex hormones, such as testosterone
What is Hyperandrogenism
effects of high levels of androgens
what is Hirsutism
growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
What is Insulin resistance
lack of response to the hormone insulin, resulting in high blood sugar levels
What criteria is used to making a diagnosis of PCOS
Rotterdam criteria
What is Rotterdam criteria
2/3
infrequent or no ovulation
hyperandrogenism
polycystic ovaries on ultrasound ≥ 12 follicles
What are key features of PCOS presentation
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
What are other features and complications of PCOS
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
What are differential diagnosis of hirsutism
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
What happened when someone is resistant to insulin in PCOS
Pancreas has to produce more insulin to get response
High Insulin =
- promotes the release of androgens
- suppresses sex hormone-binding globulin (SHBG) promoting hyperandrogenism
- halt the development of the follicles in the ovaries, leading to anovulation
What lifestyle management can help reduce insulin resistance
Diet, exercise and weight loss
What blood tests are recommended to diagnose PCOS
Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone
What do hormone blood test typically show for PCOS
Raised luteinising hormone **
Raised LH to FSH ratio (high LH compared with FSH) ***
Raised testosterone
Raised insulin
Normal or raised oestrogen levels
What is the gold standard investigation for visualising the ovaries in PCOS
transvaginal ultrasound
What is the diagnostic criteria for PCOS on ultrasound
either:
- 12 or more developing follicles in one ovary
- Ovarian volume of more than 10cm3
What is the sign on ultrasound for PCOS
“string of pearls” appearance.
What is the screening test of choice for diabetes in patients with PCOS
2-hour 75g oral glucose tolerance test (OGTT).
taking a baseline fasting plasma glucose, giving a 75g glucose drink and then measuring plasma glucose 2 hours later.
What are potential results from oral glucose tolerance test (OGTT)
- Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
- Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
- Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
What is the cut off from impaired glucose tolerance and diabetes
plasma glucose >11.1mmol/l
What medical conditions are associated with PCOS
obesity
type 2 diabetes
hypercholesterolaemia
cardiovascular disease
What are the lifestyle changes used to reduce risk of medical conditions associated with PCOS
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
What are complications of PCOS
Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety
What medication may be used to help weight loss in women with BMI >30 with PCOD
Orlistat - lipase inhibitor
stops the absorption of fat in the intestines.
What are the benefits of weight loss in PCOS
- ovulation and restore fertility and regular menstruation
- improve insulin resistance
- reduce hirsutism
- reduce the risks of associated conditions
why are women with PCOS at increased risk of endometrial cancer
- PCOS ovulate infrequently -> do not produce sufficient progesterone
- do not experience regular menstruation
- endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding
similar to unopposed oestrogen
what is the management for reducing the risk of endometrial hyperplasia and endometrial cancer in women with PCOS
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed with either combined pill or cyclical progestogen
How do women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated
pelvic ultrasound to assess the endometrial thickness
Cyclical progestogens should be used to induce a period prior to the ultrasound scan.
If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
What is the inital step for improving fertility in PCOS
weight loss
When weight loss fails to restore fertility for PCOS what is next step
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)
What is Ovarian drilling
laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy.
can improve the woman’s hormonal profile and result in regular ovulation and fertility.
What must women with PCOD must be screened for in pregnancy
gestational diabetes
oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.
Hwo is hirsutism managed
weight loss
Co-cyprindiol (Dianette) - COCP - anti-androgenic effect
Topical eflornithine
What is a side effect of Co-cyprindiol (Dianette)
venous thromboembolism.
What is 1st line management for acne in PCOS
combined oral contraceptive pill
What are other management options for ance
Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)
What is pelvic inflammatory disease
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix.
It is a significant cause of tubular infertility and chronic pelvic pain.
What is Salpingitis
inflammation of the fallopian tubes
what is Oophoritis
inflammation of the ovaries
What is Parametritis
inflammation of the parametrium, which is the connective tissue around the uterus
What is Peritonitis
inflammation of the peritoneal membrane
What are sexually transmitted causes of PID
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
what are non sexually transmitted causes of PID
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae (a bacteria often associated with respiratory infections)
- Escherichia coli (an enteric bacteria commonly associated with urinary tract infections
What are the risk factors of PID
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
What are the examination findings of PID
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
may have a fever and other signs of sepsis.
How does PID present
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
How is PID investiagted
NAAT swabs for gonorrhoea and chlamydia
NAAT swabs for Mycoplasma genitalium if available
HIV test
Syphilis test
A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
What test should be preformed on sexually active women presenting with lower abdominal pain
pregnancy test to exclude an ectopic pregnancy.
What empirical antibiotics are started for PID to cover gonorrhoea
single dose IM ceftriaxone 1g
What empirical antibiotics are started for PID to cover hlamydia and Mycoplasma genitalium
Doxycycline 100mg twice daily for 14 days
What empirical antibiotics are started for PID to cover anaerobes such as Gardnerella vaginalis
Metronidazole 400mg twice daily for 14 days
What are complications of PID
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis Syndrome
caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
how does Fitz-Hugh-Curtis Syndrome present
right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation
What is Galactorrhoea
breast milk production not associated with pregnancy or breastfeeding.
Breast milk is produced in response to the hormone prolactin
What is prolactinoma
hormone-secreting pituitary tumours secrete excessive prolactin
How does hyperprolactinaemia present
Menstrual irregularities, particularly amenorrhoea (absent periods)
Reduced libido (low sex drive)
Erectile dysfunction (in men)
Gynaecomastia (in men)
What would hormone test show for hyperprolactinaemia
Prolactin suppresses gonadotropin-releasing hormone (GnRH)
reduced LH and FSH release
What conditions is associated with Prolactinomas
multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.
What are thw two types of prolactiomas
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
What are adverse effects of Macroprolactinomas
Headaches
Bitemporal hemianopia (loss of the outer visual fields in both eyes)
how is prolactioma investigated
Serum prolactin
Renal profile (U&Es)
Liver function tests (LFTs)
Thyroid function tests (TFTs)
How is prolactioma diagnosed
MRI scan for pituitary tumors
How are prolactioma symptoms managed
Dopamine agonists (e.g., bromocriptine or cabergoline) –> block prolactin secretion and improve symptoms.
What is the definitive management of prolactiomas
Trans-sphenoidal surgical removal of the pituitary tumour
what is vulval cancer
rare
90% are squamous cell carcinomas.
Less commonly, they can be malignant melanomas.
What are risk factors of vulval cancer
Lichen sclerosus (5% will get vulval cancer)
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
What condition can precede vulval cancer
Vulval intraepithelial neoplasia (VIN)
What Vulval intraepithelial neoplasia (VIN) is associated with HPV
High grade squamous intraepithelial lesion - 35 – 50 years.
What Vulval intraepithelial neoplasia (VIN) is associated with lichen sclerosus
Differentiated VIN (aged 50 – 60 years).
How is Vulval intraepithelial neoplasia (VIN) diagnosed
biopsy
How is Vulval intraepithelial neoplasia (VIN) managed
Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation
How does vulval cancer present
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
How does labia majora appear in vulval cancer
Irregular mass
Fungating lesion
Ulceration
Bleeding
How is vulval cancer diagnses and staged
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)
What system is used to stage vulval cancer
International Federation of Gynaecology and Obstetrics (FIGO)
How is vulval cancer managed
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
what is vaginal cancer
usually secondary to cervical SCC
primary to vaginal carcinoma rare
What is Tanner stage 1
Under 10
No pubic hair
No Breast Development
What is Tanner stage 2
10 – 11
Light and thin pubic hair
Breast buds form behind the areola
What is Tanner stage 3
11 – 13
Course and curly pubic hair
Breast begins to elevate beyond the areola
What is Tanner stage 4
13 – 14
Adult like but not reaching the thigh pubic hair
Areolar mound forms and projects from surrounding breast
What is Tanner stage 5
Above 14
Hair extending to the medial thigh pubic hair
Areolar mounds reduce, and adult breasts form
what are causes of primary amenorrhoea
- gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes (RAISED LH/FSH)
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
what are causes of secondary amenorrhoea
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis*
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions
