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3a Women's Health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What are fibroids?

A

Fibroids AKA uterine leiomyomas = benign tumours of smooth muscle of the uterus
* Affect 40-60% women in later reproductive years - more common in black women
* Fibroids = oestrogen sensitive (they grow in response to oestorgen)

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2
Q

Types of fibroids

What are the 4 types?

A
  • Intramural = within the myometrium - as they grow they change the shape + distort the uterus
  • Subserosal = Just below the outer layer of the uterus - grow large outwards + filling the abdominal cavity
  • Submuscosal = just below the endometrium
  • Pedunculated = on a stalk
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3
Q

How do fibroids present?

A

Symptoms:
* Heavy periods (menorrhagia): particularly submucosal and intramural
* Prolonged menstruation (more than 7 days)
* Pelvic pain (dysmenorrhoea): particularly submucosal + intramural
* Pain during or after sex (dyspareunia)
* Bleeding between peroids (intermenstrual bleeding)
* Due to pelvic pressure or fullness: Urinary frequency or retention + Bloating or constipation

Signs:
* Pelvic examination: firm, enlarged, and irregularly shaped non-tender uterus = characteristic
* Abdominal examination: a central irregular mass may be found in cases of large fibroids
* Reduced fertility

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4
Q

A 43-year-old lady presents to her GP with a 6-month history of worsening menorrhagia. She also reports occasional intermenstrual bleeding. She has been trying to conceive for the last 3 years with no success. Underlying diagnosis?

A

Uterine fibroids

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5
Q

What examination do you do when you suspect uterine fibroids?

A

Abdominal + bimanual examination → a palpable pelvic mass OR an enlarged firm non-tender uterus

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6
Q

Ix for uterine fibroids

A

A combination of a history + abdominal + bimanual examination = usually significantly aid diagnosis.
* Hysteroscopy for submucosal fibroids → presenting with heavy menstrual bleeding
* Ultrasound (transabdominal + transvaginal) - transvaginal = diagnostic
* FBC (anaemia or polycythaemia) - fibroids can also secrete erythropoietin which may cause polycythaemia

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7
Q

What is the medical + surgical management for uterine fibroids less than 3cm?

A

Medical management (same as heavy menstrual bleeding):
* First line: Mirena coil (must be no distrortoin of uetrus)
* Symptomatic management (NSAIDs + tranexamic acid)
* COCP
* Cyclical oral progestogens

Surgical:
* Endometrial abalation
* Resection of submucosal fibroids during hysteroscopy
* Hysterectomy

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8
Q

Medical and surgical management of fibroids more than 3cm (referral to gynaecology)

A

Medical:
* Symptomatic management (NSAIDs + tranexamic acid)
* Mirena coil (depending on the size + shape of the fibroids + uterus
* COCP
* Cyclical oral progestogen

Surgical:
* Uterine artery embolisation
* Myomectomy
* Hysterectomy

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9
Q

What drugs are used to reduce the size of fibroids before surgery?

A

GnRH agonists = goserelin (Zoladex) or leuprorelin (Prostap)

They reduce the amount of oestrogen maintaining the fibroid (used short-term)

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10
Q

What are the surgical options for fibroids?

A
  • Myomectomy → removing the fibroid (laproscopic or laprotomy) - only treatment to improve fertility
  • Endometrial ablation
  • Hysterectomy
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11
Q

Complications of fibroids

A
  • Heavy menstrual bleeding → often with iron deficiency anaemia
  • Reduced fertility
  • Pregnancy complications → miscarriages, premature labour and obstructive delivery
  • Constipation
  • Urinary outflow obstruction + 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%)
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12
Q

What is red degeneration of fibroids?

A

Rapid growth of a fibroid → leading to the outgrowth of its blood supply → causing ischaemia + bleeding - due to surge of sex hormones, particularly during pregnancy

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13
Q

How does red degeneration of fibroids present amd treated?

A
  • Severe abdominal pain
  • Low-grade fever
  • Tachycardia
  • Vomiting

Management: Supportive (rest, fluids, analgesia)

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14
Q

A pregnant woman with a history of fibroids presents with severe abdominal pain and a low-grade fever. Diagnosis?

A

Red degeneration

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15
Q
A
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16
Q

What is Asherman’s syndrome?

A

Asherman’s syndrome = adhesions (aka synechiae) form within the uterus - following damage to the uterus

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17
Q

What is Asherman’s syndrome caused by?

A

After:
* A pregnancy-related dilatation + curettage procedure (e.g. treatment of retained products conception (removing placental tissue left behind after birth))
* Uterine surgery (e.g. myomectomy)
* Several pelvic infections (e.g. endometritis)

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18
Q

Why can endometrial curettage cause Asherman’s syndrome?

A
  • Endometrial curettage (scraping) = can damage the basal layer of the endometrium.
  • This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected.
  • There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut.
  • These adhesions = form physical obstructions → distort the pelvic organs → resulting in** menstruation abnormalities, infertility, recurrant miscarriages**
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19
Q

Are asymptomatic adhesions classified as Asherman’s syndrome?

A

No

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20
Q

A woman that has had recent dilatation + curettage after the birth of her child presents with significantly lighter periods that are painful. Underlying diagnosis?

A

Asherman’s syndrome

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21
Q

Who does Asherman’s syndrome present in and how?

A

Presents following recent (basically anything that can damage the uterus):
* Dilatation + curettage
* Uterine surgery
* Endometritis

Presents with (basically everything works less):
* Secondary amenorrhoea (absent periods)
* Significantly lighter periods
* Dysmenorrhoea (painful periods)
* Maybe infertility

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22
Q

Ix for Asherman’s syndrome

A
  • Gold standard: Hysteroscopy (can involve dissection + treatment of adhesions)
  • Hysterosalpingography (contrast injected + x-rayed)
  • Sonohysterography (uterus filled with fluid + pelvic USS)
  • MRI scan
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23
Q

What is the management for Asherman’s syndrome?

A

Dissecting the adhesions during hysteroscopy

Reoccurrence of the adhesions after treatment is common

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24
Q

What is endometriosis?

A

Where there is ectopic endometrial tissue outside the uterus

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25
Q

What is a lump of endometrial tissue outside of the uterus called?

A

An endometrioma

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26
Q

What is an endometrioma in the ovaries called?

A

‘Chocolate cysts’

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27
Q

What is adenomyosis?

A

Endometrial tissue within the myometrium (of the uterus)

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28
Q

What is the cause of endometriosis?

A

No known cause

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29
Q

What is the main theory that underpins endometriosis?

A

Retrograde menstruation

The endometrial tissue flows backwards through the fallopian tubes and out into the pelvis + peritoneal cavity during menstruation.

The endometrial tissue then seeds itself around the pelvis + peritoneal cavity

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30
Q

What are the other theories behind endometriosis?

A
  • Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue.
  • There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer.
  • Cells outside the uterus somehow change, in a process called metaplasia, from typical cells of that organ into endometrial cells.
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31
Q

Why does cyclical abdominal or pelvic pain occur during menstruation in endometriosis?

A
  • Cells of endometrial tissue outside the uterus = respond to hormones (same way as endometrial lining)
  • During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body.
  • This causes irritation + inflammation of the tissues around the site of endometriosis
  • → results in cyclical, dull, heavy or burning pain
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32
Q

Why can patients with endometriosis present with blood in urine and stools during menstruation?

A

Deposits of endometriosis in the bladder + bowel
(Bleed during period)

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33
Q

Why can adhesions occur in endometriosis?

A
  • Localised bleeding + inflammation = leads to adhesions
  • Inflammation = causes damage → development of scar tissue → binds organs together
  • Adhesions = cause chronic non-cyclical pain → that can be sharp, stabbing, or pulling - with associated nausea
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34
Q

What causes the cyclical and non-cyclical pain in endometriosis?

A
  • Endometriomas → cyclical, dull, heavy or dull burning pain (during menstruation)
  • Adhesions → chronic, non-cyclical pain (sharp, stabbing, pulling) + associated nausea
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35
Q

How can endometriosis lead to reduced fertility?

A

Adhesions around ovaries + fallopian tubes → blocking the release of eggs or kinking the fallopian tubes → obstructing the route to the uterus

Endometriomas in the ovaries = may also damage eggs or prevent effective ovulation

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36
Q

What are the symptoms of endometriosis?

A
  • Cyclical abdominal or pelvic pain
  • Deep dyspareunia (pain on deep sexual intercourse)
  • Dysmenorrhoea (painful periods)
  • Infertility
  • Cyclical bleeding from other sites, such as haematuria

Cyclical symptoms - relating to other areas:
* Urinary symptoms
* Bowel symptoms

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37
Q

What are the signs on examination that you will see for endometriosis?

A
  • Endometrial tissue visible in the vagina on speculum examination - particularly in the posterior fornix
  • A fixed cervix - bimanual examination
  • Tenderness in the vagina, cervix and adnexa
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38
Q

Ix for endometriosis

A
  • Pelvic ultrasound
  • Gold standard: Laproscopic surgery
  • Definitive - biopsy of lesions during laproscopy
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39
Q

What is the staging system for endometriosos?

A

The American Society of Reproductive Medicine (ASRM):
* 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

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40
Q

Management for endometriosis

A

Analgesia: NSAIDs + paracetamol (first line)

Hormonal management:
* Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
* Progesterone only pill
* Mirena coil

Surgical management:
* Laproscopic surgery (excise or ablate the endometrial tissue + remove adhesions (adhesiolysis)
* Hysterectomy + bilateral salpingo-opherectomy

  • Laproscopic treatment → improve fertility
  • Hormonal therapies → improve symptoms
  • GnRH analogues (goserelin): to indice a ‘pseudomenopause’
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41
Q

What is adenomyosis?

A

Adenomyosis = endometrial tissue is inside the myometrium

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42
Q

Who does adenomyosis occur in?

A
  • Older women
  • Multiparous women
  • Occurs alone, or alongside endometriosis or fibroids
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43
Q

Is adenomyosis hormone-dependent?

A

Adenomyosis = hormone-dependent
* Symptoms = resolve after menopause (similary to endometriosis + fibroids)

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44
Q

How does adenomyosis present?

A
  • Asymptomatic (30%)
  • Painful periods (dysmenorrhoea)
  • Heavy periods (menorrhagia)
  • Pain during intercourse (dyspareunia)
  • Infertility or pregnancy-related complications
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45
Q

What will you find on examination of a woman with adenomyosis?

A
  • Enlarged + tender uterus
  • (More soft than a uterus containing fibroids)
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46
Q

Ix for adenomyosis

A

First line: Transvaginal USS
* Alternative: MRI + transabdominal USS where transvaginal USS is not available

Gold standard: Histological examination of uterus after hysterectomy (not suitable)

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47
Q

Mx for adenomyosis (who does not want contraception)

A

Same for heavy menstrual bleeding
* Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
* Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

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48
Q

Mx for adenomyosis
(contraception is wanted or acceptable)

A
  • First line: Mirena coil
  • COCP
  • Cyclical oral progesterons

Progesterone only medications such as the pill, implant or depot injection may also be helpful.

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49
Q

Specialist Mx for adenomyosis

A
  • GnRH analogues → induce a menopause-like state
  • Endometrial ablation
  • Uterine artery embolisation
  • Hysterectomy
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50
Q

Pregnancy complications associated with adenomyosis

A
  • Infertility
  • Miscarriage
  • Preterm birth
  • Small for gestational age
  • Preterm premature rupture of membranes
  • Malpresentation
  • Need for caesarean section
  • Postpartum haemorrhage
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51
Q

Define anovulation

A

Absence of ovulation

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52
Q

Define oligoovulation

A

Irregular, infrequent ovulation

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53
Q

Define amenorrhoea

A

Absence of menstrual periods

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54
Q

Define oligomennorrhoea

A

Irregular, infrequent menstrual periods

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55
Q

Define androgens

A

Male sex hormones (e.g. testosterone)

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56
Q

Define hyperandrogenism

A

Refers to the effects of high levels of androgens

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57
Q

Define hirsutism

A

Refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair

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58
Q

Define insulin resistance

A

Lack of response to insulin - resulting in high blood sugar levels

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59
Q

What is the criteria for diagnosing polycystic ovarian syndrome?

A

Rotterdam Criteria: 2 of the 3
* Oligoovulation or anovulation → presenting with irregular or absent menstrual periods
* Hyperandrogenism → presenting with hirsutism + acne
* Polycystic ovaries on USS (or ovarian volume > 10cm3)

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60
Q

Name the features of polycystic ovarian syndrome

A

Head to toe:
Increased androgens:
* Hair loss in a male pattern
* Acne
* Hirsutism
* Oligomenorrhoea or amenorrhoea
* Infertility

Insulin resistance:
* Obesity (70% patients)
* Acanthosis nigricans (dark velvety patches in creases on neck, groin, armpits)

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61
Q

Complications of polycystic ovarian syndrome

A
  • Insulin resistance and diabetes
  • Acanthosis nigricans
  • Cardiovascular disease
  • Hypercholesterolaemia
  • Endometrial hyperplasia and cancer
  • Obstructive sleep apnoea
  • Depression and anxiety
  • Sexual problems

Acanthosis nigricans = thickened, rough skin - typically found in the axilla + elbows. Has a velvety texture. Occurs with insulin resistance

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62
Q

Differential diagnosis of hirsutism

A
  • Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
  • Ovarian or adrenal tumours → that secrete androgens
  • Cushing’s syndrome
  • Congenital adrenal hyperplasia
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63
Q

Hormonal blood tests that indicate PCOS

A
  • Raised luteinising hormone (LH)
  • Raised LH:FSH
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
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64
Q

Ix for PCOS

A

Gold standard: transvaginal ultrasound (‘string of pearls’)

Hormonal blood tests:
* ↑ LH
* ↑ LH:FSH
* ↑ Testosterone
* ↓FSH
* ↓ SHBG

SHBG = sex hormone-binding globulin

Transabdominal USS = alternative

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65
Q

What is the diagnostic criteria of the transvaginal or pelvic USS - to diagnose PCOS

A

The follicles may be arranged around the periphery of the ovary → giving a “string of pearls” appearance.

The diagnostic criteria are either:

  • 12 or more developing follicles in one ovary
  • Ovarian volume > 10cm3
66
Q

Is a pelvic ultrasound reliable in adolescents in diagnosing PCOS?

A

No!
Transvaginal = gold standard

67
Q

What screening test may be useful for someone diagnosed with PCOS?

A

Oral glucose tolerance test (OGTT)

68
Q

Why is insulin resistance an important part of PCOS?

A

When someone is resistant to insuiln:
* Pancreas produces more insulin → insulin = promotes the release of androgens from the ovaries + adrenal glands
* Therefore → ↑insulin = ↑androgens (e.g. testosterone)

  • Insulin = also suppresses SHBG production from liver
  • SHBG = normally binds to androgens → suppressing their function
  • ↓ SHBG = promotes hyperandrogenism in PCOS
  • ↑ Insulin levels = suppresses follicle development in ovaries → leading to anovulation + multiple partially developed follicles (seen as polycystic ovaries on scan)
69
Q

Mx for PCOS

A

First line: Lifestyle modifications
* Weight loss can restore ovulation + improve insulin resistance + symptoms

Second line:
* Metformin (can help regulate cycles + improve fertilty)
* Oral contraceptive pills (COCP): regulate menstrual cycles, reduce symptoms of hyperandrogenism like acne and hirsutism, and reduce the risk of endometrial cancer
* Clomiphene: used to induce ovulation in women with PCOS who are trying to conceive
* Ovarian drilling: laparoscopic surgical procedure creates multiple holes in the ovaries by diathermy, inducing ovulation and improving fertility

70
Q
A
71
Q

What is the triad for PCOS (Rotterdam criteria)?

A
  • Anovulation
  • Hyperandrogenism
  • Polycystic ovaries on USS
72
Q

Functional ovarian cysts related t the fluctuating hormones of the menstrual cycle are very common in which women?

A

Premenopausal women

73
Q

What is the difference in concern between ovarian cysts in premenopausal and postmenopausal women?

A

The majority of ovarian cysts in:
* Premenopausal women → benign
* Postmenopausal women → malignancy risk → further investigation

74
Q

Why can’t a patient with just multiple ovarian cysts or a ‘string of pearls appearance cannot be diagnosed with PCOS?

A

PCOS diagnosis requires at least 2:
* Anovulation
* Hyperandrogenism
* Polycystic ovaries on ultrasound

75
Q

How do ovarian cysts present?

A
  • Mostly asymptomatic

Vague symptoms of:
* Pelvic pain
* Bloating
* Fullness in the abdomen
* A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

76
Q

When can ovarian cysts present with acute pelvic pain?

A
  • Ovarian torson
  • Haemorrhage
  • Rupture of cyst
77
Q

What are the 2 functional cysts?

A
  • Follicular cysts
  • Corpus luteum cysts
78
Q

What is a follicular cyst?

A

Follicular cyst = functional cyst
Follicular cysts = represent the developing follicle
* Follicle fails to rupture + release the egg → cyst persists

  • Harmless, tend to disappear after a few menstrual cycles
  • Thin walls + no internal structures

Follicular cysts = most common ovarian cyst

79
Q

What are corpus luteum cysts?

A

Corpus luteum cysts = Functional cyst
* Occur when the corpus lutem = fails to break down → then fills with fluid
* Cause pelvic discomfort, pain + delayed menstruation
* Often seen in early pregnancy

80
Q

Name some other ovarian cysts that aren’t functional

A
  • Serous cystadenoma = benign tumours of epithelial cells
  • Mucinous cystadenoma = benign tumours of epithelial cells → HUGE - take up lots of space in the pelvis and admoen
  • Endometrioma = lumps of endometrial tissue within the ovary - occurs in patients with endometriosis, can cause pain + disrupt ovulation
  • Dermoid cysts / Germ Cell Tumours = benign ovarian tumours - = ** ** (come from germ cells), contain various tissue types (e.g. skin, teeth, hair, bone) → associated with ovarian torsion
  • Sex Cord-Stromal Tumours = benign or malignant - They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
81
Q

What are the signs and symptoms that suggest an ovarian cyst is malignant?
(From history and examination)

A

Signs:
* Weight loss
* Ascites
* Lymphadenopathy
* Abdominal bloating

Symptoms:
* Reduced appetite
* Early satiety
* Pain

82
Q

Risk factors for ovarian malignancy

A
  • Age
  • Postmenopause
  • Increased number of ovulations
  • Obesity
  • HRT
  • Smoking
  • Breastfeeding (protective)
  • Familt history of BRCA1 + BRCA2 genes

The number of times a woman has ovulated during her life correlates with her risk of ovarian cancer. More ovulations increases the risk of ovarian cancer - like breast cancer

83
Q

What factros will reduce the number of ovulations
(Protective in breast and ovarian cancer)

A
  • Later onset of periods (menarche)
  • Early menopause
  • Any pregnancies
  • COCP use
84
Q

A premenopausal women is found to have a simple ovarian cyst less than 5cm. Does she need further investigations?

A

No!

85
Q

What is the tumour marker for epithelial cell ovarian cancer?

A

CA125

It contributes to the overall impression of whether an ovarian cyst is related to cancer and forms part of the risk of malignancy index

86
Q

Women over 40 with a complex ovarian mass = require tumour markers for a possible germ cell tumour. What are these?

A
  • Lactate dehydrogenase (LDH)
  • Alpha-fetoprotein (a-FP)
  • Human chorionic gonadotrophin (HCG)
87
Q

Non-malignant causes that may rise CA125

A
  • Endometriosis
  • Fibroids
  • Adenommyosis
  • Pelvic infection
  • Liver disease
  • Pregnancy
88
Q

What estimates the risk of an ovarian mass being malignant?

A

Risk of malignancy index (RMI)
* Menopausal status
* Ultrasound findings
* CA125 level

89
Q

A women has a complex or a raised CA125. What would you do?

Possible ovarian cancer = complex cyst or raised CA125

A

Refer to two-week wait list

90
Q

What 2 findings suggest ovarian cancer?

A
  • Complex cysts
  • Raised CA125
91
Q

Management of simple ovarian cysts in premenopausal women

A
  • Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
  • 5cm to 7cm: Require routine referral to gynaecology + yearly ultrasound monitoring.
  • More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound
92
Q

Management of ovarian cysts in postmenopausal women

A
  • CA125 level (when raised → two-week wait)
  • Simple cysts <5cm + normal CA125 → ultrasound every 4-6 months
93
Q

Managment of persistent or enlarging cysts

A

Surgical intervention (usually with laproscopy)
* Ovarian cystectomy (removal of cyst)
* Oophorectomy (removal of ovary)

94
Q

What are the complications when a woman presents with an ovarian cysts + acute onset pain?

A
  • Torsion
  • Haemorrhage into the cyst
  • Rupture, with bleeding into the peritoneum
95
Q

Triad of Meig’s syndrome

A
  • Ovarian fibroma (benign ovarian tumour)
  • Pleural effusion
  • Ascites

Occurs in older women

Removal of the tumour = results in complete resolution of the effusion + ascites

96
Q

A 60 year old woman presents with a pleual effusion and an ovarian mass. Diagnosis?

A

Meig’s syndrome

97
Q

Define ovarian torsion

A

Ovarian torsion = ovary twists in relation to the surrounding connective tissue, fallopian and blood supply (the adnexa)

98
Q

Why do ovarian torsions occur?

A

Mostly: Ovarian mass (cyst or tumour) >5cm
* Usually benign
* More likely during pregnancy

Before menarche (first period) - with normal ovaries (when girls have longer infundibulopelvic ligaments that can twist more easily)

99
Q

Why is ovarian torsion a medical emergency?

A

Twisting of the adnexa + blood supply to the ovary → ischaemia → necrosis → function loss

100
Q

Presentation of ovarian torsion

A

Symptoms:
* Sudden onset severe unilateral pelvic pain
* Constant pain → progressively worse
* Associated Nausea + vomiting

(Pain = not always severe, it can take a milder + more prolonged course)
(Ovary can untwist intermittenly → causing intermittent pain)

Signs:
* Palpable mass in pelvis (if missing, does not exclude diagnosis)

101
Q
A
102
Q

What does the laproscopic surgical management for ovarian torsion entail?

A
  • Un-twist the ovary and fix it in place (detorsion)
  • Remove the affected ovary (oophorectomy)
103
Q

Complications of ovarian torsion

A
  • Loss of function (the other can compensate) - fertility not typically affected
  • Necrosis → infection → abscess → sepsis
  • Necrosis → infection → rupture → peritonitis + adhesions
104
Q

What is lichen sclerosus?

A

Lichen sclerosus = a chronic inflammatroy skin condition - presents wuth patchy of shiny ‘porcelain-white’ skin

105
Q

Where does lichen sclerosus commonly present?

A

Women:
* Labia
* Perineum
* Perianal skin
* Axilla + thighs

Men:
* Foreskin
* Glans of penis

106
Q

Is lichen sclerosus an autoimmune condition?

A

Lichen sclerosus = autoimmune condition

Associated with other autoimmune conditions:
* Type 1 diabetes
* Alopecia
* Hypothyroid
* Vitiligo

107
Q

Ix for lichen sclerosus

A

Lichen sclerosus → clinical diagnosis

If doubt → vulval biopsy

108
Q

A 55 year old woman presents with vulval itching and skin changes to her vulva (white and shiney). Possible diagnosis?

A

Lichen sclerosus

109
Q

How does lichen sclerosus present?

A

Women aged 45-60 years:
Vulval itching + patches of porcelain-white skin

May be asymptomatic, may present with:
* Itching
* Soreness + pain (worse at night)
* Skin tightness
* Painful sex (superficial dyspareunia)
* Erosions
* Fissures

110
Q

What is the Koebner phenomenon?

A

Koebner phenomenon = when signs + symptoms are made worse by friction to the skin

Occurs with lichen sclerosus - can be made worse by:
* Tight underwear (that rubs the skin)
* Urinary incontinence
* Scratching

111
Q

How does lichen sclerosus present?

A
  • Changes affect the labia, perianal, perineal skin.
  • Asocciated with** fissures, cracks, erosions, haemorrhages** under the skin

Skin appears:
* “Porcelain-white” in colour
* Shiny
* Tight
* Thin
* Slightly raised
* There may be papules or plaques

112
Q

Management of lichen sclerosus

A

Cannot be cured, just controlled effectively

Flares: Potent topical steroids: Clobetasol propionate 0.5% (dermovate) (OD for 4 weeeks)

Maintenance: Emollients

113
Q

What is the main complication of lichen sclerosus?

A

Squamous cell carcinoma of the vulva (5% risk)

Other complications:
* Pain and discomfort
* Sexual dysfunction
* Bleeding
* Narrowing of the vaginal or urethral openings

114
Q

What is androgen insensitivity syndrome?

A
  • Androgen insensitivity syndrome = cells are unable to respond to androgen hormones - due to a lack of androgen receptors
  • X-lined recessive genetic condition → caused by a mutation in the androgen receptor gene on the X chromosome
  • Extra androgens = converted into oestrogen → resulting in female secondary sexual characteristics
  • Genetically male (XY) → phenotypically female (normal female external genitalia + breast tissue)

Androgen insensitivity syndrome = previously known as testicular feminisation syndrome

115
Q

Info: androgen insensitivity syndrome

A
  • Gentically male (XY) →Absent response to testosterone + conversion of additional androgens to oestrogen → female phenotype (normal female external genitalia + breast tissue)
116
Q

What internal reproductive organs do patients with androgen insensitivity syndrome?

A

Testes in the abdomen or inguinal canal
* Testes = produce Mullerian hormone → so no uterus, upper vagina, cervix, fallopian tubes, ovaries

117
Q

How do individuals with androgen insensitivity syndome present?

A
  • Phenotypically female
  • Lack of pubic hair
  • Facial hair
  • Male muscle type development
  • Slightly taller
118
Q

Complications of androgen insensitivity syndrome

A
  • Infertility
  • Increased risk of testicular cancer (unless removed)
119
Q

How does androgen insensitivity syndrome present in infancy and puberty?

A

Infancy: inguinal hernias (containing testes)
Puberty: Primary amenorrheoa

120
Q

What are hormone levels for androgen insensitivity syndrome?

A
  • Raised LH
  • Normal or raised FSH
  • Normal or raised testosterone levels (for a male)
  • Raised oestrogen levels (for a male)

Basically RAISED EVERYTHING

121
Q

Management for androgen insensitivity syndrome

A

MDT: paediatrics, gynaecology, urology, endocrinology, psychology

  • Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
  • Oestrogen therapy
  • Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

Generally, patients are raised female.

122
Q

What is partial androgen insensitivity syndrome?

A

Where there the cells have a partial response to androgens. This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.

123
Q

What is a prolactinoma?

A

A pituitary adenoma
Prolactinomas = benign lactotroph adenomas expressing + secreting prolactin

124
Q

How do women present with a prolactinoma?

A

Amenorrhoea + (infertility) + galactorrhoea

Lower libidio
Temporal hemianopia (if macroadenoma)

125
Q

How do men present with a prolactinoma?

A
  • Erectile dysfunction
  • Hypogonadism (leading to lower libidio)
  • Gynaecomastia (sometimes)
126
Q

Ix for prolactinoma

A
  • Serum prolactin (elevated)
  • Pituitary MRI
  • Computerised visual-field examination (may reveal unilateral or bi-temporal hemianopia)
127
Q

Treatment of prolactinoma

A
  • First line: Dopamine agonist (cabergoline)
    (Results in: prolactin normalisation, symptom improvement, tumour shrinkage)
  • Second line: COCP
  • Third line: Trans-sphenoidal surgery
128
Q

A 40 yr old woman presents with abnormal periods (a lot less than usual), galactorrhoea and is struggling to conceive with her partner. Potential diagnosis?

A

Prolactinoma

Galactorrhoea + amenorrhoea = prolactinoma

129
Q

Adenomyosis info

A

Definition:
* Adenomyosis = presence of endometrial tissue within the myometrium

Who?:
* More common in multiparous women towards the end of their reproductive years

Clinical features:
* Dysmenorrhoea
* Menorrhagia
* Enlarged, BOGGY uterus

Ix:
* First line: Transvaginal ultrasoind
* Alternative: MRI

Management:
* Symptomatic treatment (tranexamic acid to manage menorrhagia)
* GnRH agonists
* Uterine artery embolisation
* Hysterectomy (‘definitive’ treatment)

130
Q

What gynaecological condition is asscociated with an enlarged boggy uterus?

A

Adenomyosis

131
Q

What is primary amenorrhoea and what causes it?

A

Primary amenorrhoea = patient has never developed periods

Causes:
* Hypogonadotrophic hypogonadism (Abnormal functioning of the hypothalamus or pituitary gland)
* Hypergonadotropic hypogonadism (Abnormal functioning of the gonads)
* Imperforate hymen or other structural pathology

132
Q

What is secondary amenorrhoea and causes?

A

Secondary amenorrhoea = patient previously had periods that subsequently stopped

Causes:
* Pregnancy (the most common cause)
* Menopause
* Physiological stress (due to excessive exercise, low body weight, chronic disease or psychosocial factors)
* Polycystic ovarian syndrome
* Medications (e.g. hormonal contraceptives)
* Premature ovarian insufficiency (menopause before 40 years)
* Thyroid hormone abnormalities (hyper or hypothyroid)
* Excessive prolactin (from a prolactinoma)
* Cushing’s syndrome

133
Q

What is abnormal uterine bleeding (irregular menstruation)?

A

Abnormal uterine bleeding refers to irregularities in the menstrual cycle, affecting:
* Frequency
* Duration
* Regularity of cycle length
* Volume of menses

Irregular menstrual periods = indicate anovulation (lack of ovulation) or irregular ovulation

This occurs due to disruption of the normal hormonal levels in the menstrual cycle, or ovarian pathology.

134
Q

Name some causes of irregular menstruation (abnormal uterine bleeding)

A
  • Extremes of reproductive age (early periods or perimenopause)
  • Polycystic ovarian syndrome
  • Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
  • Medications (particularly progesterone only contraception, antidepressants and antipsychotics)
  • Hormonal imbalances (e.g. thyroid abnormalities, Cushing’s syndrome and high prolactin)
135
Q

Name some differential causes for intermenstrual bleeding

A

Intermenstrual bleeding (IMB) = refers to any bleeding that occurs between menstrual periods.
This is a red flag that should make you consider cervical and other cancers, although other causes are more common.

  • Hormonal contraception
  • Cervical ectropion, polyps or cancer
  • STI
  • Endometrial polyps or cancer
  • Vaginal pathology, including cancers
  • Pregnancy
  • Ovulation can cause spotting in some women
  • Medications, such as SSRIs and anticoagulants

Intermenstrual bleeding → think cancer, then polyps

136
Q

Name some differential causes for dysmenorrhoea

A

Dysmenorrhoea = painful periods

  • Primary dysmenorrhoea (no underlying pathology)
  • Endometriosis or adenomyosis
  • Fibroids
  • Pelvic inflammatory disease
  • Copper coil
  • Cervical or ovarian cancer
137
Q

Name some differential causes for menorrhagia

A

Menorrhagia = heavy menstrual bleeding

  • 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
138
Q

Name some differential causes of postcoital bleeding

A

Postcoital bleeding (PCB) = refers to bleeding after sexual intercourse.
This is a red flag that should make you consider cervical and other cancers, although other causes are more common. Often no cause is found. The key causes are:

  • Cervical cancer, ectropion or infection
  • Trauma
  • Atrophic vaginitis
  • Polyps
  • Endometrial cancer
  • Vaginal cancer
139
Q

Differentials for pelvic pain

A

Can be acute or chronic

Urological:
* UTI

GI:
* IBS
* IBD
* Appendicitis

Gynae:
* Dysmenorrhoea (painful periods)
* Ovarian cysts
* Endometriosis
* Mittelschmerz (cyclical pain during ovulation)
* Pelvic adhesions
* Ovarian torsion

140
Q

Differential causes for vaginal discharge

A

Vaginal discharge is a normal physiological finding. Excessive, discoloured or foul-smelling discharge may indicate:

  • Bacterial vaginosis
  • Candidiasis (thrush)
  • Chlamydia
  • Gonorrhoea
  • Trichomonas vaginalis
  • Foreign body
  • Cervical ectropion
  • Polyps
  • Malignancy
  • Pregnancy
  • Ovulation (cyclical)
  • Hormonal contraception
141
Q

Name some differential causes for vaginal itchiness (pruritus vulvae)

A

Pruritus vulvae = refers to itching of the vulva and vagina. There are a large number of causes:

  • Irritants such as soaps, detergents and barrier contraception
  • Atrophic vaginitis
  • Infections such as candidiasis (thrush) and pubic lice
  • ** Skin conditions** such as eczema
  • Vulval malignancy
  • Pregnancy-related vaginal discharge
  • Urinary or faecal incontinence
  • Stress
142
Q

What types of gynaecological bleeding are red flags?

A
  • Intermenstrual bleeding
  • Postcoital bleeding
143
Q

Name 4 causes of postmenstrual bleeding

A

Postmenstrual bleeding = defined as vaginal bleeding occurring after 12 months of amenorrhoea

  • Vaginal atrophy (most common)
  • HRT
  • Endometrial hyperplasia
  • Endometrial cancer
144
Q

What is menopause?

A

Menopause = point at which menstruation stops

Menopause = a retrospective diagnosis, made after a woman has had no periods for 12 months

Women reach menopause at approx. 51 years

145
Q

Define postmenopause

A

Postmenopause = the peroid from 12 months after the final menstrual period onwards

146
Q

Define perimenopause

A

Perimenopause = refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms + irregular periods.

Perimenopause = includes the time leading up to the last menstrual period, and the 12 months afterwards.
This is typically in women older than 45 years.

147
Q

Define premature menopause

A

Premature menopause = menopause before the age of 40 years

Premature menopause = result of premature ovarian insufficiency

148
Q

What is menopaused caused by?

A

Menopause = caused by a lack of ovarian follicular function → resulting in changes in sex hormones associated with the menstrual cycle:

  • Oestrogen + progesterone = low
  • LH + FSH = high (in response to an absence of negative feedback from oestrogen)
149
Q

Physiology of menopause

A
  • Inside the ovaries, the process of primordial follicles maturing into primary + secondary follicles = always occurring, independent of the menstrual cycle

At the start of the menstrual cycle:
* FSH = stimulates further development of the secondary follicles.
* As the follicles grow, the granulosa cells that surround them secrete increasing amounts of oestrogen.
* The process of the menopause = begins with a decline in the development of the ovarian follicles.
* Without the growth of follicles → reduced production of oestrogen.
* Oestrogen = has a negative feedback effect on the pituitary gland → suppressing the quantity of LH + FSH produced

As the level of oestrogen falls in the perimenopausal period → there is an absence of negative feedback on the pituitary gland → increasing levels of LH + FSH

The failing follicular development means ovulation does not occur (= anovulation) → resulting in irregular menstrual cycles
* Without oestrogen → endometrium does not develop → leading to a lack of menstruation (amenorrhoea).
* Lower levels of oestrogen = also cause the perimenopausal symptoms.

150
Q

Name some perimenopausal symptoms

A

A lack of oestrogen in the perimenopausal period leads to symptoms of:

  • Hot flushes
  • Emotional lability or low mood
  • Premenstrual syndrome
  • Irregular periods
  • Joint pains
  • Heavier or lighter periods
  • Vaginal dryness and atrophy
  • Reduced libido
151
Q

What conditions does a lack of oestrogen (menopuase) increase the risk of?

A
  • Cardiovascular disease + stroke
  • Osteoporosis
  • Pelvic organ prolapse
  • Urinary incontinence
152
Q

Diagnosis (possible Ix) for menopause

A
  • Over 45: Perimenopause + menopause diagnosis can be made without Ix

Need FSH blood test to help in diagnosis of:
* Women under 40 years with suspected premature menopause
* Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

153
Q
A
154
Q

Management of perimenopausal symptoms

A

Vasomotor symptoms = likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include:

  • No treatment
  • Hormone replacement therapy (HRT)
  • Tibolone = a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
  • Clonidine = which act as agonists of alpha-adrenergic and imidazoline receptors
  • Cognitive behavioural therapy (CBT)
  • SSRI antidepressants (fluoxetine or citalopram)
  • Testosterone - can be used to treat reduced libido (usually as a gel or cream)
  • Vaginal oestrogen cream or tablets, to help with vaginal dryness + atrophy (can be used alongside systemic HRT)
  • Vaginal moisturisers (Sylk, Replens and YES)
155
Q

Fertility gradually declines after 40 years of age. However, women should still consider themselves fertile. Pregnancy after 40 is associated with increased risks and complications. Women need to use effective contraception for….

A
  • Two years after the last menstrual period in women under 50
  • One year after the last menstrual period in women over 50
156
Q

Can hormonal contraceptives affect the menopause, in terms of when it occurs and how long it lasts?

A

No!
But it can suppress + mask symptoms - which can make diagnosing menopause in women on hormonal contraception more difficult

157
Q

Name some good contraception options (UKMEC 1, meaning no restrictions) for women approaching the menopause

A
  • Barrier methods
  • Mirena or copper coil
  • Progesterone only pill
  • Progesterone implant
  • Progesterone depot injection (under 45 years)
  • Sterilisation
158
Q

At what age can the COCP be used up to?

A

50 years old

The combined oral contraceptive pill is UKMEC 2 (the advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications. Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.

159
Q

What are the 2 key side effects of the progesterone depot injection (e.g. Depo-Proverva)?

A
  • Weight gain
  • Reduced bone mineral density (osteoporosis)

These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

160
Q
A

3a Women's Health (8 decks)

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