Gynaecology Flashcards
What is endometriosis
the presence and growth of tissue similar to endometrium outside the uterus
Give 2 theories for the cause of endometriosis
- retrograde menstruation
- spread of endometrial cells through lymphatic system
Describe the presentation of endometriosis
can be asymptomatic or present with
* cyclical abdominal/ pelvic pain
* deep dyspareunia (pain on deep sex)
* dysmenorrhoea
* reduced fertility
* cyclical urinary/ bowel symptoms - painful stools
Give 3 vaginal examination findings of endometriosis
- tender nodules in the posterior vaginal fornix
- endometrial tissue visible on speculum exam
- fixed cervix on bimanual exam
How is endometriosis diagnosed
- GS: diagnostic laparoscopic surgery +/- biopsy
- transvaginal ultrasound - useful to make/ exclude the diagnosis of an ovarian endometrioma
How is endometriosis managed medically
- Analgesia - NSAIDs and paracetamol
- combined oral contraceptive pill
- progesterone only pill
- gonadotrophin-releasing hormone analogues (eg goserelin)
- Mirena coil
How is endometriosis managed surgically
- laparoscopic surgery to excise or ablate endometrial tissue and remove adhesions
- hysterectomy and bilateral salpingo-oophrectomy
What is the effect of hormonal therapies and laparoscopic treatment on fertility
- laparoscopic treatment may improve fertility
- hormonal therapies may improve symptoms but not fertility
What are fibroids
benign tumours of the smooth muscle of the uterus (myometrium)
aka uterine leiomyomas
Describe the epidemiology of fibroids
- mc in black women
- mc with increasing age during reproductive years
Describe the 3 types of fibroid
- intramural - within the myometrium. As they grow, they change the shape and distort the uterus
- Subserosal - just below the outer layer of the uterus. can be pedunculated (on a stalk)
- submucosal - just below the lining of the uterus
How do fibroids present
typically asymptomatic but can present in several ways:
* heavy menstrual bleeding
* dysmenorrhoea
* bloating
* urinary frequency
* reduced fertility
Describe positive findings of a fibroid on examination
- abdo/ pelvic exam: palpable solid mass
- bimanual: enlarged firm non-tender uterus
How are fibroids diagnosed
- Ultrasound - determine number, size and position
- MRI - considered for greater accuracy or if diagnosis unclear
- hysteroscopy - assess distortion of uterine cavity
How are fibroids managed medically
- Symptomatic: trial NSAIDs and tranexamic acid
- Mirena (levonorgestrel IUS) - 1st line only if uterine cavity is NOT distorted
- COCP
- cyclical oral progestogens
- pre-surgery Tx with GnRH agonist for 1-2m to shrink fibroid
What type of medication may increase the size of fibroids and possibly cause symptoms
hormone replacement therapy
How are fibroids managed radiologically
uterine artery embolization
How are fibroids managed surgically
Laparoscopic:
* Hysterectomy
* Myomectomy (just fibroid) - preservation of fertility
Give 4 complications of fibroids
- torsion of pedunculated fibroids
- red degeneration of fibroid
- malignant change to a leiomyosarcoma
- pregnancy Cx: PPH, prem labour, malpresentations
What is red degeneration of fibroids
refers to ischaemia, infarction, and necrosis of the fibroid due to disrupted blood supply.
During which stages of pregnancy is red degeneration more likely to occur?
more likely to occur during the second and third trimester of pregnancy
Give 2 reasons why red degeneration occurs during pregnancy?
- the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
- kinking in the blood vessels as the uterus changes shape and expands during pregnancy
What are the signs and symptoms of red degeneration?
- severe abdominal pain
- low-grade fever
- tachycardia
- uterine tenderness
- vomiting
How do ovarian cysts present
- most are asymptomatic
- pelvic pain
- bloating
- fullness
What can cause acute pelvic pain in the presence of ovarian cysts?
- ovarian torsion
- haemorrhage
- rupture of the cyst.
What are functional ovarian cysts associated with?
the fluctuating hormones of the menstrual cycle.
Describe 2 types of functional ovarian cysts
only found in premenopausal women
* follicular -persistent enlarged follicle
* corpus luteum - when the corpus luteum fails to break down and instead fills with fluid
Which functional ovarian cyst tends to cause more symptoms
lutein cysts
* pelvic discomfort, pain, delayed menstruation
What are serous cystadenomas
most common benign ovarian epithelial tumour
What are mucinous cystadenomas
Mucinous cystadenomas are benign tumours of epithelial cells that can become very large, occupying significant space in the pelvis and abdomen.
What are dermoid cysts, and what do they contain?
benign ovarian tumours that are teratomas. They originate from germ cells and may contain various tissue types such as skin, teeth, hair, and bone
What are sex cord-stromal tumours, and where do they originate?
rare tumours that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles).
Name two types of benign sex cord-stromal tumours
- Sertoli–Leydig cell tumours
- Fibromas
Which ovarian cyst is particularly associated with ovarian torsion
Dermoid cysts
What are endometriomas, and what causes them?
Endometriomas are ‘chocolate cysts’ that occur in the ovary due to endometriosis, which causes altered blood to accumulate. They can cause pain and disrupt ovulation
Name 3 ovarian masses more commonly seen in premenopausal women
- follicular/ lutein cysts
- dermoid cysts
- endometriomas
How are ovarian cysts investigated
- premenopausal women with a simple ovarian cyst <5cm on USS don’t need further investigations
- Women <40 with a complex ovarian mass require tumour markers for a possible germ cell tumour: LDH, HCG, CA125, alpha-fetoprotein
How are ovarian cysts managed
- <5cm: likely resolve within 3 cycles
- 5-7cm: referral and yearly USS
- > 7cm: consider MRI/ surgical evaluation
- Persistent/ enlarging: laparoscopic ovarian cystectomy
What is the triad for Meig’s syndrome
- ovarian fibroma
- pleural effusion
- ascites
What is adenomyosis
refers to the presence of endometrial tissue within the myometrium
Which women are at a higher risk of adenomyosis?
- multiparous
- later reproductive years (>40)
What are the features of adenomyosis?
- Dysmenorrhoea (painful periods)
- Menorrhagia (heavy menstrual bleeding)
- Enlarged, boggy uterus
What are the recommended investigations for adenomyosis?
- 1st line: transvaginal ultrasound
- MRI as an alternative.
What are the management options for adenomyosis?
- Tranexamic acid for menorrhagia
- Mirena, COCP
- GnRH agonists
- Uterine artery embolization
- Hysterectomy - definitive treatment
What are the key features of polycystic ovarian syndrome (PCOS)?
- Subfertility and infertility
- oligomenorrhoea (irregular) and amenorrhoea (absent)
- Hirsutism (thick dark hair, male pattern) and acne - due to hyperandrogenism (high male sex hormones)
- Obesity
- Acanthosis nigricans (due to insulin resistance)
What is Acanthosis nigricans
thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture
What investigations are recommended to diagnose PCOS and exclude other pathology
- Pelvic transvaginal ultrasound (GS): multiple cysts on the ovaries - string of pearls appearance
Baseline investigations: - Testosterone
- Sex hormone-binding globulin
- Luteinizing hormone
- Follicle-stimulating hormone
- Prolactin
- Thyroid-stimulating hormone
Check for impaired glucose tolerance (OGTT)
What hormonal blood test results are typical in polycystic ovarian syndrome (PCOS)?
- Raised luteinising hormone (LH)
- Raised LH to FSH ratio (high LH compared with FSH)
- Raised testosterone
- Raised insulin
- Normal or raised oestrogen levels
- Sex hormone-binding globulin is normal/ low
What criteria is used to diagnose polycystic ovarian syndrome (PCOS)?
Rotterdam criteria
What are the diagnostic criteria for PCOS according to the Rotterdam criteria?
A diagnosis requires at least two of the three key features:
* Oligoovulation (irregular) or anovulation (absent) - manifested as infrequent or absent menstruation
* Signs of hyperandrogenism - e.g., hirsutism, acne, raised total/ free testosterone
* Polycystic ovaries on ultrasound, defined as:
- Presence of ≥ 20 follicles (measuring 2-9 mm in diameter) in at least one ovary
- and/or Increased ovarian volume > 10 cm³
What are the management options for infertility in PCOS
aim to restore ovulation
* 1st: weight reduction
* Letrozole
* clomifene
* clomifene + metformin
* IVF
* laparoscopic ovarian drilling
How is hirsutism and acne managed in PCOS ?
- COCP - induce monthly bleed
- If there is no response to COC, consider topical eflornithine
- Spironolactone or finasteride under specialist supervision
- discuss hair reduction and removal
- retinoid for acne
Give 4 complications of PCOS
- T2DM
- endometrial cancer/ hyperplasia
- infertility
- CVD
How can risks of obesity, DM and CVD be reduced in PCOS
- Weight loss
- calorie-controlled diet
- Regular exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
What are the options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS
- Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3-4 months with:
- Cyclical progestogens - e.g., medroxyprogesterone acetate 10 mg OD for 14 days
- COCP
What is pelvic organ prolapse
descent of one of the pelvic organs resulting in protrusion on the vaginal walls
What causes pelvic organ prolapse
result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
What are the types of prolapse?
- Cystocele and cystourethrocele
- Rectocele
- Uterine prolapse
- Less common types: urethrocele and enterocele
What causes rectoceles?
Rectoceles occur due to a defect in the posterior vaginal wall, allowing the rectum to protrude forward into the vagina
What causes cystoceles?
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
What are the risk factors for prolapse?
- Increasing age and postmenopausal status
- multiple vaginal deliveries
- Obesity
- Ehlers danlos
- chronic constipation/ cough
What are the common presentations of prolapse?
- dragging or heavy sensation
- Urinary symptoms: incontinence, frequency, and urgency
- constipation
- sexual dysfunction
- may have identified lump themselves - may reduce to enable urine/stool to pass
What instrument allows separate inspection of the anterior and posterior vaginal walls during examination of a prolapse
Sims’ speculum
How is urogenital prolapse managed
- no treatment needed if asymptomatic
- Conservative: pelvic floor exercises, weight loss, lifestyle changes
- Vaginal ring pessaries
- Surgery
What are the surgical options available for prolapse depending on the location
- cystocele - anterior colporrhaphy
- uterine - hysterectomy, sacrohysteropexy
- rectocele - posterior colporrhaphy
What is hyperemesis gravidum
severe form of nausea and vomiting in pregnancy
When is hyperemesis gravidarum most common during pregnancy?
between 8 and 12 weeks of pregnancy but may persist up to 20 weeks.
What criteria does NICE suggest for admitting pregnant women with nausea and vomiting?
- Continued N+V, unable to keep down liquids or oral antiemetics
- Continued N+V with ketonuria and/or weight loss (greater than 5% of body weight) despite oral antiemetics
- Confirmed or suspected comorbidity (e.g., inability to tolerate oral abx for a UTI)
A lower threshold for admission is recommended if the woman has a co-existing condition (e.g., diabetes) that may be adversely affected by n+v
What are the risk factors for nausea and vomiting in pregnancy ?
- Increased levels of beta-hCG
- multiple pregnancies
- trophoblastic disease
- nulliparity
- obesity
- family or personal history of NVP
What are the RCOG guideline criteria for diagnosing hyperemesis gravidarum?
“prolonged” nausea and vomiting in pregnancy (NVP) plus:
* More than 5% weight loss compared to pre-pregnancy weight
* Dehydration
* Electrolyte imbalance
What tool is used to assess the severity of nausea and vomiting in pregnancy (NVP)?
Pregnancy-Unique Quantification of Emesis (PUQE) score.
What are the first line management options for hyperemesis gravidarum
- Antihistamines : oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine
- combination drug - doxylamine/pyridoxine (Vit B6)
What are the second line management options for hyperemesis gravidarum
- D2 receptor antagonist : oral metoclopramide or domperidone
- 5-HT3 receptor antagonist: ondansetron
What are the precautions regarding the use of metoclopramide in treating nausea and vomiting in pregnancy?
Metoclopramide may cause extrapyramidal side effects and should not be used for more than 5 days.
What is a potential concern when using ondansetron in pregnancy?
Ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate.
What are some simple measures for managing nausea and vomiting in pregnancy?
- Rest and avoid triggers (e.g., odours)
- Bland, plain food, particularly in the morning
- Ginger
- P6 (wrist) acupressure
What IV hydration treatment is commonly given to women admitted for nausea and vomiting in pregnancy
generally given normal IV saline with added potassium, as hypokalaemia is common
Give 3 complications of hyperemesis gravidarum
- AKI
- Wernicke’s encephalopathy
- oesophagitis
What is the prevalence of infertility among couples, and what percentage of couples conceive within one year?
- Infertility affects around 1 in 7 couples.
- Approx 84% of couples who have regular sex will conceive within 1 year
When should investigation and referral for infertility be initiated?
- after 12 months of trying to conceive without success.
- can be reduced to 6 months if the woman is older than 35
What are the common causes of infertility and their approximate prevalence?
- Male factor: 30%
- Unexplained: 20%
- Ovulation failure: 20%
- Tubal damage: 15%
- uterine problems: 15%
What general lifestyle advice is recommended for couples trying to conceive?
- woman should take 400 mcg of folic acid daily.
- healthy BMI (20-25)
- Avoid smoking and excessive alcohol.
- Aim for intercourse every 2–3 days.
- Avoid timing intercourse - stress and pressure
What are the key investigations done in primary care for infertility?
- Semen analysis
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle)
- Serum LH and FSH on day 2-5
- anti-mullerian hormone
- chlamydia screen
What is the most accurate marker of ovarian reserve
anti-Mullerian hormone
What are the key investigations done in secondary care for infertility?
- transvaginal USS
- hysterosalpingogram - patency of fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Medical Treatment for Restoring Fertility
- Clomifene - stimulate ovulation
- Gonadotropins - stimulate ovulation in women resistant to clomifene.
- Pulsatile GnRH - Induces ovulation.
- Dopamine Agonists - Used for ovulatory disorders secondary to hyperprolactinemia.
Surgical Treatments for Restoring Fertility
- Tubal Microsurgery: tubal catheterization or cannulation
- Surgical Ablation: Resection of endometriosis plus laparoscopic adhesiolysis
- Surgical Correction of Epididymal Blockage: For men with obstructive azoospermia
What are the key legal frameworks regarding abortion in the UK?
The law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for abortion from 28 weeks gestation to 24 weeks
Under what conditions can an abortion be performed at any time during a pregnancy in the UK?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making them seriously handicapped
What are the legal requirements for obtaining an abortion in the UK?
- Two registered medical practitioners must agree that the abortion is indicated.
- The procedure must be carried out by a registered medical practitioner in an NHS hospital or an approved premises.
How are abortions managed medically
- Mifepristone then misoprostol 48 hours later
- multi-level pregnancy test 2 weeks later to confirm end of pregnancy
What is the role of mifepristone in the medical management of an abortion
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix
What is the role of misoprostol in the medical management of an abortion
- Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them
- Prostaglandins soften the cervix and stimulate uterine contractions
- From 10w gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion
When should anti-D prophylaxis be given to women in the context of abortion?
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation
How are abortions managed surgically
- cervical priming (softening and dilating) with misoprostol +/- mifepristone before procedures
- manual vacuum aspiration
- electric vacuum aspiration
- dilatation and evacuation
- local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation, or general anaesthesia
- an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
What is Androgen Insensitivity Syndrome and how does it affect children?
an X-linked recessive condition caused by end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype externally.
Why do the female internal organs not develop in androgen insensitivity syndrome
the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
Give some 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 managed
- bilateral orchidectomy - reduce risk of testicular cancer
- counselling - generally raised as females but discussed under specialist advice
- oestrogen therapy
