Gynaecology Flashcards
What is polycystic ovarian syndrome: pcos?
ovarian dysfunction
hyperinsulinaemia and high levels of luteinizing hormone.
features of pcos
subfertility and infertility
menstrual disturbance: oligomenorrhoea and amenorrhoea
hirsutism, acne (because of hyperandrogenism)
obesity
acanthasis nigricans (due to insulin resistance)
acne
hair loss in male pattern
how would you investigate pcos?
pelvic ultrasound - multiple cysts on ovaries
transvaginal uss - gold standard.
follicles around periphery of ovary (STRING OF PEARLES)
FSH,LH,PROLACTIN,TSH,TESTOSTEONE,SEX HORMONE BINDING GLOBULIN(SHBG)
raised lh:fsh ratio
prolactin: normal/mildly elvated
testosterone: poss normal/mildly elevated
SHBH - normal to low
raised lh
check for impaired glucose tolerance
what is the diagnostic criteria for pcos?
Rotterdam criteria: 2 of following 3
- infrequent or no ovulation
- clinical/biochemical signs of hyperandrogenism (hirsutism, acne, elevated levels of total/free testosterone)
- polycystic ovaries on uss scan - 12 or more follicles (2-9mm in diameter) in 1 or both ovaries and/or increased ovarian vol over 10cm^3
Management of pcos
weight reduction if poss. - orlistat : lipase inhibitor
combined oral contraceptive if need contraception - regulate her cycle and induce monthly bleed.
hirsutism and acne:
- COC pill. 3rd gen.- fewer androgenic effects or co-cyprindiol (has anti-androgen action) - both have VTE risk.
- if doesnt respond to COC : topical eflornithine
-spironolactone, flutamide, finasteride - specialist supervision
infertilityL
- weight reduction
- poss metformin,clomifene or combo to stimulate ovulation.
- use metformin either with clomifene or alone - esp in obese
-gonadotrophins
which drug poses risk of multiple pregnancies?
clomifene - antioestrogen therapy
how might a oral ccp help regulate cycle and induce monthly bleed?
- occupy hypothalamic oestrogen receptor without activating them.
- interferes with binding of oestradiol
- prevents negative feedback inhibition of FSH secretion.
comps of pcos
insulin resistance and diabetes
acanthosis nigricans
cv disease
hypercholestrolaemia
endometrial hyperplasia and cancer
obstructive sleep apnoea
depression and anxiety
sexual problems.
hirsutism can be caused by?
pcos
meds : phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids
ovarian/adrenal tumours secreting androgens
cushings syndrome
congenital adrenal hyperplasia
how does insulin resistance play in pcos?
insulin resist pt, pancreas produces more insulin.
promotes release of androgens from ovaries and adrenal glands
insulin also suppresses SHBH production by liver. it would normally bind to androgens and suppress the function.
high insulin halt development of follicles in overaies = anovulation. and multiple partially developed follicles - Polycstic ovaries.
screening for pcos
OGTT
2 hr 75g
morning before breakfast.
impaired fasting glucose - 6.1-6.9
impaired glucose tolerance - plasma glucose at 2hrs 7.8-11.1
diabetes - plasma glucose at 2 hours over 11.1
how would you manage acne in pcos?
coc pill - 1st line.
co-cyprindiol antiandrogen effects - risk of vte.
topical adapalene
topical abx - clindamycin 1% with benzoyl peroxide 5%
topical azelaic acid 20%
oral tetracycle abx - lymecycline
how would you manage hirsutism?
weight loss
co-cyprindiol - COC pill - ANTI-ANDROGENIC. - vte risk.
topical eflornithine - facial hirsutism - 6-8 weeks. - will return 2 months after stopping.
other:
laser
electrolysis
spironolactine, finasteride, flutamide (non steroid antiandrogen), cyproterone acetate(antiandrogen and progestin)
i have heard you can do ovarian drilling for infertility in pcos women? explain?
laparoscopic surgery.
multiple holes in ovaries using diathermy/laser.
= regular ovulation and fertility.
when would you check for gestational diabetes?
ogtt before pregnancy and at 24-28 weeks gestation
what is pelvic inflammatory disease?
infection and inflammation of female pelvic organs including uterus falopian tubes ovaries and surrounding peritoneum.
usually due to ascending infection from endocervix
causative organisms of pelvic inflammatory disease
chlamydia trachomatis: MC
neisseria gonorrhoeae - causes more severe PID
mycoplasma genitalium
mycoplasma hominis
can be caused by non sti like:
- gardnerella vaginalis
-haemophilis influenzae
- e coli
features of pelvic inflammatory disease
lower abdo pain
fever
deep dyspareunia
dysuria and menstrual irregularities
vaginal/cervical discharge
cervical excitation
abnormal bleeding - intermenstrual or postcoital
how would you investigate for pelvic inflammatory disease?
pregnancy test - exclude ectopic pregnancy
high vaginal swab - often negative - you can see BV, candidiasis and trichomonas.
micrscope - pus cells from vagina/endocervix. absense of it excludes PID.
inflammatory markers crp esr - high.
screen for chlamydia and gonorrhoea - NAAT swabs and for mycoplasma genitalium if poss.
hiv test
syphilis test
how would you manage pelvic inflammatory disease?
low threshold for tx
1st line : stat IM ceftriaxone 1g (gonorhoea) + 14 days 100mg twice daily oral doxycyline (chla + mycoplasma genitalium) + oral metronidazole400mg 14 days twice daily - avoid fluoroquinolones where poss (cover anaerobes like gardnerella)
2nd line: oral ofloxacin + oral metronidazole
if mild case:
leave in intrauterine contraceptive. - now seen if you remove between outcomes.
potential complications of pelvic inflammatory disease
infertility - 10-20% after single episode
sepsis , abscess
chronic pelvic pain
ectopic pregnancy
perihepatitis (fitz-hugh curtis syndrome) - 10% of cases. - RUQ pain , could confuse with cholecystitis.
talk to me about fitz hugh curtis syndrome
perihepatitis
comp of PID
caused by inflammation and infection of liver capsule (glissons capsule) = adhesions between liver and peritoneum.
bacteria can spread from pelvis via peritoneal cavity, lymphatics or blood.
RUQ pain - referred right shoulder tip pain if diaphragmatic irritation.
laparscopy- visualise
adhesiolysis - treatment of adhesions
what is the connective tissue around the uterus called?
parametrium
what is an ovarian torsion? twist
partial/complete torsion of ovary on its supporting ligaments that may compromise blood supply.
if fallopian tube involved: adnexal (blood supply) torsion
risk factors of ovarian torsion
ovarian mass - 90% of torsion cases (Cyst/tumour)
being of reproductive age -before menarche if girl has longer infundibulopelvic ligaments twist easier.
pregnancy
ovarian hyperstimulation syndrome
features of ovarian torsion
On examination
sudden onset deep-seated colicky abdo pain unilateral. - progressive
vomiting and distress
fever in minority - poss secondary to adnexal necrosis.
occasionally : can be not that severe and ovary can twist and untwist intermittently, causing pain that comes and goes.
on exam: localised tenderness. poss palpable mass in pelvis. - absense of mass doesnt exclude the diagnosis.
investigations for ovarian torsion
pelvic us. preferably transvaginal but transabdominal can be used: free fluid in pelvis/oedema of ovary. or whirlpool sign
doppler studies - lack of blood flow.
vaginal exam: adnexial tenderness
definitive diagnosis: made with laparoscopic surgery
tx of ovarian torsion
laparoscopy - diagnostic and therapeutic:
untwist ovary and fix it in place - detorsion
remove affected ovary- oophorectomy
laparotomy - if large ovarian mass or malignancy
comps of ovarian torsion
loss of function of that ovary. doesnt affect fertility because you have other ovary.
if only functioning one : infertility and menopause
if necrotic ovary not removed: can get infected, develop abscess, sepsis. - could rupture = peritonitis and adhesions.
if i see an ovarian cyst in pre vs post menopausal women what should i be thinking?
pre - benign
post - malignancy
presentation of ovarian cysts
usually asx and found incidentally on pelvic uss scan.
if sx : vague:
pelvic pain
bloating
fullness in abdo
palpable pevlic mass - esp with very large cysts like mucinous cystadenomas
acute pelvic pain if: ovarian torsion, haemorrhage or rupture of cyst
tell me the 2 different types of functional cysts
follicular cysts - when developing follicle fails to rupture and release egg. - dissapear after a few menstrual cycles. - thin walls no internal structures.
corpus luteum cysts - fails to break down fills with fluid. pelvic discomfort pain or delayed menstruation. often seen in early pregnancy
name the other types of ovarian cysts
serous cystadenoma - benign tumour of epithelial cells
mucinous cystadenomia - benign tumour of epithelial cells. can be huge - takeup space in pelvis and abdo
endometrioma - lumps of endometrial tissue in ovary in endometriosis pt. - pain and disrupt ovulation
dermoid cysts - germ cell tumours - benign. teratomas - have skin teeth hair and bone. - associated with ovarian torsion.
sex cord stromal tumours - rare - benign/malignant. come from stroma or sex cords.
features that would suggest ovarian cyst malignancy
abdo bloating
reduce apetite
early satiety
weight loss
urinary sx
pain
ascites
lymphadenopathy
risk factors for ovarian malignancy
age
postmenopause
increased number of ovulations
obesity
hormone replacement therpay
smoking
breastfeeding - protective an so is prenancy and cocpill
fhx and brca1 and brca2 genes
increased ovulation
it is known the number of times a women has ovulated during her life correlates with her risk of ovarian cancer.
what factors reduce the number of ovulations?
later onset of periods- menarche
early menopause
any pregnancies
use of coc pill
what blood tests should you do in ovarian cysts?
premenopasual women with simple ovarian cyst less than 5 cm on USS - no further required
CA125 - tumour marker
women under 40 with complex ovarian mass require tumour markers for poss germ cell tumour
lactate dehydrogenase - ldh
alpha-fetoprotein - a-FP
human chorionic gonadotropin - HCG
what is ca125
causes of raised CA125
tumour marker for epithelial cell ovarian cancer.
not very specific.
endometriosis
fibrosis
adenomyosis
pelvic infection
liver disease
pregnancy
what is the risk of malignancy index
estimates risk of ovarian mass being malignant - takes account of:
menopausal status
uss findings
ca125 level
how would you manage ovarian cysts?
poss ovarian cancer - 2 week wait refer to gynae.
poss dermoid cyst - refer to gynae for surgery
simple ovarian cyst in premenopause:
- less than 5cm: will resolve within 3 cycles.
- 5-7cm : refer to gynae and annual uss.
- 7+cm - MRI or surgery.
postmenopause :
- correlate with ca125 and refer to gynae.
-if raised - 2 week wait.
- simple cyst under 5cm with normal ca125 - uss every 4-6 months.
persistent or enlarging cysts : SURGERY WITH LAPAROSCOPY. could be:
- ovarian cystectomy
- poss remove affected ovary - OOPHORECTOMY
what is meigs syndrome?
occurs in?
triad:
ovarian fibroma - benign ovarian tumour
pleural effusion
ascites
older women
removal of tumour = complete resolution of effusion and ascites.
complications of ovarian cysts - pt it’s acute onset pain think wha?
if pt presents with acute onset pain:
torsion
haemorrhage into cyst
rupture - bleeding into peritoneum
peak incidence of ovarian cancer.
prognosis
pathophysiology of ovarian cancer.
60 yrs old.
poor prognosis - late diagnosis - 80% of women have advanced disease at presentation.
90% epithelial in origin, 70-80% due to serous carcinomas.
- distal end of fallopian tube site of origin of many ovarian cancers.
risk factors of ovarian cancer (OC)
fhx - mutations of BRCA1 or BRCA2 gene
many ovulations: infertility tx increases risk of OC (COC pill reduces risk and so does having loads of pregnancies)
- early menarche
-late menopause
-nulliparity
reccurent use of clomifene
smoking
obesity
clinical features of ovarian cancer: albeit vague
how can ovarian mass cause hip/groin pain.
abdo distension and bloating - abdo/pelvic mass
ascites
abdo and pelvic pain
urinary sx: urgency/frequency
weight loss
early satiety
diarrhoea
loss of apetite
ovarian mass press on obturator nerve - hip/groin pain.
investigations of ovarian cancer
CA125 (over 35 IU/ml) - if raised then USS of abdo and pelvis
pelvic ultrasound
if asx dont do ca125.
diagnostic laparotomy
further ix:
ct - diagnosis and stage the cancer
histology- ct guided biopsy, laparoscopy or laparotomy
paracentesis (ascitic tap) - test for ascitic fluid for cancer cells.
women under 40 with complex ovarian mass require tumour markers for possible germ cell tumour:
- alpha-fetoprotein
-human chorionic gonadotropin
how would you manage ovarian cancer
combo of surgery and platinum based chemo
staging of ovarian cancer
FIGO
stage 1 - confined to ovary
2 - spread past ovary but inside pelvis
3 - spread past pelvis but inside abdo
4 - spread outside abdo
why might you get hip/groin pain with ovarian cancer?
ovarian mass press on obturator nerve.
types of ovarian cancer
epithelial cell tumour - serous tumour MC. endometrioid carcinoma,clear cell , mucinuous or undifferentiated tumours
dermoid cysts/germ cell tumours
sexcord stromal tumour
metastasis - from elsewhere. krukenberg tumour mets from gi cancer (Stomach). SIGNET RING cells on histology
factors that increase the number of ovulations increase the risk of ovarian cancer which include:
early onset of periods
late menopause
no pregnancies
higher number of lifetime ovulations increases the risk of ovarian cancer. factors that stop ovulation and reduce the number of lifetime ovulations reduce the risk which are:
coc pill
breastfeeding
pregnancy
what is prolactin?
primary function
hormone produced by anterior pituitary gland.
stimulate :
- glandular breast tissue development
- breast milk production
what factors stimulate prolactin production
nipple stimulation - suckling by baby
thyrotropin-releasing hormone (TRH) from hypothalamus
elevated oestrogen - during pregnancy
stress
sleep
what hormone inhibits prolactin effects on breast tissue?
progresterone.
prevents breast milk production during pregnancy.
after birth, progesterone levels fall rapid - allow prolactin to carry out its effects.
dopamin - inhibits prolactin secretion
what type of drug can cause prolactin to increase?
side effects
dopamine antagonist - antipsychotic meds
inhibit dopamine receptors
allow prolactin to rise
gyanaecomastia -
galactorrhoea - breast milk production
how does prolactin affect the breast tissue?
mamillary alveoli growth - where breastmilk is made and stored
breastmilk synthesis by epithelial cells of alveoli.
how does prolactin affect testes and ovaries?
prolactin inhibits gonadotropin-releasing hormone by hypothalamus.
inhibits HPA axis.
low GnRH = anterior pituitary produces less LH and FSH resulting in:
- reduced stimulation of testes in men = low testosterone production
- reduced stimulation of ovaries in women = absent ovulation, absent periods
is exclusively breastfeeding enough for contraception?
breastfeeding have high prolactin levels
cause anovulation and amenorrhoea
but just breastfeeding aint enough
causes of hyperprolactinaemia
pregnancy breastfeeding
prolactinomas - prolactin-secreting tumours of pit gland
hypothyroid
meds - dopamin antagonists
pcos
acromegaly: 1/3
stress,exercise,sleep
high prolactin sx
galactorrhoea
menstrual irregularities, amenorrhoea
infertility
reduced libido
ED
gynaecomastia
hypoprolactinaemia - side efects
causes
cant produce breastmild in postpartum.
tumours
surgery
radiotherapy
sheehans syndrome
what is sheehans syndrome
comp of postpartum haemorrhage
drop in circulating blood vol
avascular necrosis of pit gland.
low bp and reduced perfusion of pit gland = ischaemia in pit cells and cell death.
only affects anterior pit gland.
what is a prolactinoma?
classifying pit adenomas
type of pit adenoma - benign tumour of pit gland.
size - microadenoma less than 1cm and macroadenoma over 1cm
hormonal status - secretory/functioning adenoma produces and excess of a particular hormone and a non-secretory/functioning adenoma doesnt produce hormone to excess
features of prolactinoma
excess prolactin in woman - amenorrhoea, infertility, galactorrhoea, osteoporosis.
excess prolactin in men - impotence, loss of libido, galactorrhoea
other sx may be seen with macroadenomas:
- headache
-visual disturbances - bitemporal hemianopia (lateral visual fields) or upper temporal quadrantanopia
- sx and sx of hypopituitarism
how would you diagnose prolactinoma
MRI
how would you manage prolactinoma?
sx pts: dopamine agonist - cabergoline, bromocriptine - inhibit release of prolactin from pit gland
surgery: if cant tolerate or fail to respond to above.
trans-sphenoidal .
what drugs can cause raised prolactin?
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRI, opioids
What is a hydatidiform mole?
2 types
tumour grows like a pregnancy inside uterus.
complete mole - 2 sperm cells fertilise empty ovum with no genetic material. - no fetal material will form.
partial mole - 2 sperm cells + normal ovum at same time. 3 sets of chromosomes. some fetal material will form
hydatidiform mole?
differences from normal pregnancy
behaves like normal pregnancy
periods stop
hormonal changes or pregnancy will occur.
vs normal pregnancy?
- more severe morning sickness
-vaginal bleed
-increased enlargement of uterus
-abnormally high hCG
- thyrotoxicosis ( hCG mimic TSH and stimulate the thyroid to produce excess T3/T4)
would you diagnose hydatidiform mole?
ultrasound of pelvis - snowstorm appearance
histology of mole after evacuation
how would you manage hydatidiform mole?
evacuation of uterus
histology send to confirm.
refer pt to gestational trophoblastic disease centre.
hcg levels monitored until returned to normal.
sometimes mole can metastasise - if so systemic chemo
features of hydatidiform mole
vaginal bleeding
uterus size greater than expected for gestational age
abnormally high serum hCG
US: snow storm - mixed echogenicity
What are fibroids?
who they occur in more?
sensitive to what
4 types
benign tumours of smooth muscle of uterus.
20% white and 50% black women in later productive years
oestrogen sensitive
- intramural - within myometrium (uterus muscle) - grown, change shape of uterus
- subserosal - below outer layer of uterus. grow outwards become very large fill abdo cavity.
- submucosal - below lining of uterus (endometrium)
-pedunculated - on a stalk
how would fibroids present?
rare feature and why?
often asx
heavy menstrual bleeding - MC - can lead to iron def anaemia
prolonged menstruation- longer than 7 days
lower abdo pain- worse during menstruation - cramping
bloating/feeling full in abdo
urinary/bowel sx - frequency due to pelvic pressure or fullness (larger)
subfertility
deep dyspareunia
reduced fertility
rare: polycythaemia - secondary to autonomous production of erythropoietin
what might a abdo and bimanual exam reveal in fibroids?
palpable pelvic mass or enlarged firm non-tender uterus.
how would you investigate fibroids?
hysteroscopy - initial - submucosal fibroids presenting with heavy menstrual bleeding.
pelvic uss - larger fibroids
transvaginal uss
MRI - before surgery - see size shape and blood supply of fibroid
how would you manage fibroids? if less than 3cm
if less than 3cm:
- mirena coil (levonorgestrel intrauterine system) - 1st line - no distortion of uterus and less than 3cm.
- sx mx : nsaids and tranexamic acid
- coc pill
- cyclical oral progesterones or injectale
surgery for smaller fibroids with heavy bleeding:
- endometrial ablation
-resection of submucosal fibroids during hysteroscopy
-hysterectomy
how would you manage fibroids if more than 3cm?
refer to gynae
sx : nsaids and tranexamic acid
mirena coil - depnds on size and shape of fibroids and uterus
COC PILL
cyclical oral progesterones
surgery:
uterine artery embolisation
myomectomy
hysterectomy
before surgery to remove fibroids what might you give the pt?
how it works?
GnRH agonist : goserelin or leuprorelin.
reduce the size of it.
induces menopause like state.(hot flushes, vaginal dryness) and loss of bone mineral density
reduces oestrogen.
what is a myomectomy?
surgery
remove fibroid laparoscopic or laparatomy.
improve fertility in fibroid pts.
what is endometrial ablation?
how does it work?
destroy endometrium.
baloon thermal ablation.
insert baloon into endometrial cavity
fill with high temp fluid.
burns endometrial lining
what is a hysterectomy?
remove uterus and fibroids
laparoscopy , laparotomy or vaginal approach.
may remove ovaries depends on pt preference , risk/benefits
what potential complications are there in fibroids?
heavy menstrual bleed : iron def anaemia
reduced fertility
pregnancy comps: miscarriage, premature labour, obstructive delivery
constipation
urinary outflow obstruction, uti
red degeneration of fibroid
torsion of fibroid - pedunculated more affected
malignant change to a leiomyosarcoma - very RARE
what does it mean by red degeneration of fibroids?
what size of fibroid does it affect more?
sx
mx
ischaemia infarction and necrosis of fibroid.
larger fibroids over 5 cm
2nd and 3rd trimeter of pregnancy.
happens when it gets bigger in pregnancy and outgrows its blood supply and becomes ischemic.
sx:
- severe abdo pai
-low grade fever
-tachy
-often vomiting.
mx:
- supportive
-rest-
-fluids and analgesia
What is endometriosis?
ectopic endometrial tissue outside the uterus.
lump of it = endometrioma - if in ovaries : chocolate cysts.
what does it mean by adenomyosis?
endometrial tissue in myometrium - muscle layer of uterus
aetiology of endometriosis
-genetic?
- during menstruation, endometrial lining flow back through fallopian tubes and out into pelvis and peritoneum - RETROGRADE MENSTRUATION. - tissue then seeds itself around pelvis and peritoneal cavity.
- cells outside uterus undergo metaplasia - from typical cells into endometrial cells
- spread of endometrial cells through lymphatic system
- embryonic cells remain in areas outside uterus during fetus development and later develop into ectopic endometrial tissue
Pathophysiology of endometrial tissue
Pelvic Pain : endometrial tissue sheds and bleeds regardless of whereit is. irritation and inflammation caused. CYCLICAL, DULL HEAVY OR BURNING PAIN.
deposits of endometriosis in bladder or bowel = blood in urine/stools
adhesions: scar tissue binding organs. chronic pain sharp stabbing.
fertility: issues due to blocked/damaged reproductive organs.
when you examine a pt with endometriosis what will be your findings?
endometrial tissue visible in vagina on speculum exam - particularly in posterior fornix (nodularity)
reduced organ mobility,
fixed cervix on bimanual exam
tenderness in vagina, cervix and adnexa
what sx would you see in endometriosis?
can be asx
cyclical abdo or pelvic pain
deep dyspaerunia
dysmenorrhoea
infertility/subfertility
cyclical bleeding from other sites: haematuria
cyclical sx:
- urinary sx - dysuria urgency
- bowel sx - dyschezia (painful bowel movement)
how would you be able to make a diagnosis of endometriosis?
Pelvic Ultrasound : large endometriomas and chocolate cysts. refer to gynae for laparoscopy
laparoscopic surgery : GOLD STANDARD.
definitive with biopsy of lesions during laparoscopy.
surgeon can remove deposits of it and potentially improve sx too.
how do you stage endometriosis?
ASRM
1 - small superficial lesions
2 - mild , deeper lesions than stage 1
3 - deeper lesions - lesions on ovaries and mild adhesions
4- deep and large lesions affect ovaries with extensive adhesions
how would you manage endometriosis?
initial: ice , diagnose, explain, analgesia
hormonal mx before laparoscopy
COC pill
progesterone only pill
medroxyprogesterone acetate injection - depo-provera
nexplanon implant
mirena coil
GnRH agonist
surgical:
- laparoscopic surgery - excise or ablate endometrial tissue and remove adhesions(ahesiolysis)
- hysterectomy and bilateral sapingo-opherectomy - final surgery option. - removing ovaries induces menopause and stops the ectopic endometrial tissue responding to menstrual cycle.
which tx in endometriosis improve fertility and which doesnt?
laparoscopic tx improves it.
hormonal might improve sx but not fertility .
how do these tx options for endometriosis help?
cyclical pain tx with hormonalmeds - stop ovulation and reduce endometrial thickening.
it gets better when menopause happens so you can induce menopause using GnRH agonists like goserelin and leuprorelin
give 2 examples of GnRH agonists and theyre function
side effects of what it induces?
goserelin
leuprorelin
induce menopause. - menopause like state.
shut down ovaries temporarily
side effects of menopause:
hot flushes
night sweats
risk of osteoporosis.
what is endometrial cancer?
mc type
dependent on anything?
rf?
cancer of endometrium- lining of uterus.
mc: adenocarcinoma.
oestrogen dependent cancer.
obesity
diabetes
age
early onset of menstratuion
late menopause
oestrogen only HRT
no/fewer pregnancies (nulliparity)
PCOS
tamoxifen
hereditary non-polyposis colorectal carcinoma
what is endometrial hyperplasia? (endometrial cancer)
2 types
tx
precancerous condition.
thickening of endometrium.
normally go back to normal over time.
2 types:
hyperplasia without atypia
atypical hyperplasia
tx: progesterones:
- intrauterine system - mirena coil
-continuos oral progesterones - medroxyprogesterone or levonorgestrel
name 3 protective factors of endometrial cancer
multiparity
coc pill
smoking
mirena coil
features of endometrial cancer
postmenopausal bleeding
if pre:
menorrhagia or intermenstrual bleeding
pain aint common - signifies extensive disease
vaginal discharge - UNUSUAL
haematuria , anaemia, raised platelet count
how would you manage endometrial cancer?
surgery
localised: total abdo hysterectomy with bilateral salingo-oophorectomy
if high risk: postoperative radiotherapy
if frail elderly: progesterone therapy
how would you investigate for endometrial cancer?
transvaginal uss - endometrial thickness - normal is less than 4mm post-menopause
pipelle biopsy : highly sensitive.
hysteroscopy+ endometrial biopsy
what to use to stage endometrial cancer
FIGO
on average how much blood do women lose during menstruation?
excessive would be?
how would you know its too much?
40ml
80ml
changing pads every1-2 hrs - bleeding lasting more than 7 days and passing large clots.
causes of heavy menstrual bleeding
dysfunctional uterine bleeding - no identifiable cause
extremes of reproductive age
fibroids
endometriosis and adenomyosis
PID
contraceptives esp copper coil
anticoag meds
bleeding disorders - von willebrand
endo - dm and hypothyroid
connective tissue disorders
endometrial hypersplasia/cancer/pcos
pt has heavy bleeding what investigations to do?
pelvic exam with speculum and bimanual - assess for fibroids, ascites, cancers
fbc - iron def anaemia
outpatient hysteroscopy: submucosal fibroids, endometrial pathology, intermenstrual bleeding
pelvic and transvaginal uss : - large fibroids, adenomyosis if hysterescopy declined
swabs - sti hx?
coagulation screen
ferritin
thyroid tests
how would you manage treat heavy menstrual bleeding?
if doesnt want contraception:
tranexamic acid - if no pain - antifibrinolytic - reduces bleeding
below both 1st day of period:
mefenamic acid 500 mg tds - if pain - nsaid or tranexamic acid 500mg tds
if contraception accepted:
- mirena coil - 1st line
- coc pill
- cyclical oral progesterones - norethisterone 5 mg 3 time day from day 5-26. - VTE RISK AND PROGESTERONIC SE.
progesterone only contraception: suppress menstruation. -depo or implant
final option: endometrial ablation and hysterestomy.
what can be used to stop heavy menstrual bleeding?
noresthisterone 5mg tds
short term
MC type of cervical cancer
strong association with which virus.
when do kids gets vaccinated for it?
squamous cell carcinoma
adenocarcinoma
human papillomavirus
12-13
HPV associated with which types of cancers?
2 important types and explain role in cancer.
anal
vulval
vaginal
penis
mouth
throat
type 16 and 18. p53 and pRb - tumour supressor genes. e6 inhibits p53 and e7 for pRb. e6 and e7 inhibits these tunour suppressors
risk factors of cervical cancer
increased risk of catching hpv:
- early sex activity
- increase no. of partners.
-sexual partners who have had more partners
- not using condoms
non-engagement with cervical screenin.
smoking
hiv
coc pill - more than 5 yrs
increased full term pregnancies
fhx
exposure to diethylstilbestrol during fetal development
presentation of cervical cancer
cervical smear for asx women
abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal)
vaginal discharge
pelvic pain
dyspareunia
these sx are non -specific so you exam cervix with speculum.
take swab to exclude infection
what you see on colposcopy for cervical cancer?
ulceration
inflammation
bleeding
visible tumour
what is cervical intraepithelial neoplasia?
how is it diagnosed?
how is it graded?
dysplasia - pre malignant of cervix.
colposcopy
1: mild - 1/3 thickness of epithelial layer affected - go back to normal without tx
2: moderate - 2/3 - likely to progress to cancer if untx.
- severe : very likely to progress to cancer if untx.
another way of CIN III (cervical intraepithelial neoplasia)
cervical carcinoma in situ
how to screen for cervical cancer?
how is it done?
what is the process called?
smear test.
speculum exam and collect cells using brush and put into preservation fluid.
check for precancerous change (dyskaryosis)
called : LIQUID BASED CYTOLOGY
when a smear test is done by liquid based cytology, what is the sample tested for?
high risk HPV. - if negative not examined.
how often do you do cervical screen program
every 3 years aged 25-49
every 5 years 50-64
EXCEPTIONS:
- hiv - screen annually
- over 65 can request.
- previous CIN can require more tess
- immunocomprised
- pregnant women due should wait until 12 weeks post partum
from cytology, ie a cervical smeer what results can come up?
inadequate
normal
borderline changes
low grade dyskaryosis
high grade dyskaryosis - mod/sevee
possible invasive squamous cell carcinoma
possible glandular neoplasia
can clock bv, candiadiasis and trichomonas on smear too
what organisms can be found in women with intrauterine device on smeer?
tx
actinomyces-like organisms.
no tx unless sx.
if sx: remove device.
mx based of cervical smeer results
inadequate - repeat after 3 months min
hpv negative - continue routine screening
hpv positive with normal cytology - repeat hpv test after 12 months
hpv positive with abnormal cytology - refer for colposcopy
what is colposcopy?
insert speculum - then use colposcope to magnify cervix.
use
acetic acid: abnormal cells appear white. - acetwhite! - happens in CIN and cervical cancer cells.
schillers iodine test: iodine to stain cervix cells.
healthy cells : brown. abnormal wont stain
punch biopsy/large loop excision of transformational zone : done to get tissue sample
what is a large loop excision of the transformation zone?
loop biopsy.
local anaesthetic.
loop of wear with electrical current to remove abnormal epithelial tissue on cervix. - cauterise tissue and stop bleeding.
rules for large loop excision >
bleeding and abnormal discharge can occur for several weeks after.
intercourse and tampon use to be avoided.
a consquence of large loop excision of transformation zone?
increase preterm labour risk
what is a cone biopsy?
how its done?
main risks
tx of CIN.
general anaesthic.
cone shaped piece of cervix using scalpel removed. - assess for malignancy
pain,bleeding,infection,scar formation with stenosis of cervix, increased risk of miscarriage and premature labour
staging of cervical cancer
figo
1a: confined to cervix visible my microscopy less than 7mm :
A1: less than 3mm deep
A2: 3-5MM deep
1b: confined to cervix visible clinically larger than 7 mm:
- B1: less than 4cm diameter
-B2: over 4cm
2: extension of tumour beyond cervix but not to pelvic wall:
A- upper2/3 of vagina
B - parametrial involvement
3: - extension of tumour beyond cervix and to pelvic wall
A - lower 1/3 of vagina
B= pelvic side wall.
(if causing hydronephrosis or nonfunctioning kidney its stage 3
4: extension of tumour beyond pelvis or involvement of bladder or rectum.
A: bladder or rectum involved
B - distant sites outside pelvis involved
how would you manage cervical cancer? (1A)
gold: hysterectomy +/- lymph node clearance
if maintain fertility : cone biopsy with negative margins
for A2:
nodal clearance
node evaluation
radical thrachelectomy (poss)
what is pelvic exenteration?
for advanced cervical cancer
remove most pelvic organs:
vagina
cervix
uterus
fallopian tubes
ovaries
bladder
rectum
implications of QoL
what is bevacizumab (avastin?
what is it used for?
what cells does it target?
it treats something else too ? what is it?
monoclonal antibody
used with chemos to treat metastatic or reccurent cervical cancer.
targets vascular endothelial growth factor A - (VEGF-A) - development of new blood vessels.
wet age related macular degeneration
HPV vaccine
when is it given
what is it called
which strains cause genital warts
which strains cause cervical cancer
girls and boys before they have sex.
prevent contracting and spreading it.
GARDASIL - protects on strains 6 11 16 18
6 and 11 - genital warts
16 18 - cervical cancer
if endocervical cells are infected what cells can develop ?
tell me its characteristics?
koilocytes
enlarged nucleus
irregular nuclear membrane contour
nucleus stains darker than normal (hyperchromasia)
perinuclear halo poss
how would you manage stage 1b tumours for cervical cancer?
B1: radiotherapy + chemo
radio: either bachytherapy or external beam
cisplatin - chemo
B2: radical hysterectomy with pelvi lymph node dissection
how would you manage stage 2 and 3 cervical cancer tumours?
radiaiton+ chemo
if hydronephrosis: nephrostomy poss
how would you manage stage 4 cervical cancer tumours?
ridation and or chemo
palliative chemo poss best option
how would you manage cervical cancer recurring disease?
primary surgical tx: chemo or radiation
primary radiation: surgical therapy
complications of cervical cancer tx surgeries?
standard:
bleeding
damage to local structures
infection
anaesthetic risk
cone biopsy and radical trachelectomy: increase risk of preterm birth in future pregnancy.
radical hysterectomy: poss ureteral fistula
complications of radiotherapy
short:
- diarrhoea
- vaginal bleeding
-radiation burns
-pains on micturition
- tired/weak
long term:
- ovarian failure
-fibrosis of bowel skin bladder vagina
- lymphoeda.
how would you treat endometrial cancer?
total abdominal hysterectomy with bilateral salpingo-ooporectomy : TAH and BSO : removal of uterus cervix and adnexa.
other:
radical hysterectomy : remove pelvic lymph nodes surrounding tissues and top of vagina
radio
chemo
progesterone: hormonal tx - slow cancer progression
MC type of vulval cancer
risk factors for it?
squamous cell carcinoma.
less common malignant melanoma
rf:
- age over 75
-immunosuppressed
-hpv 16 and 18
herpes simples virus 2
- lichen sclerosus
what is vulval intraepithelial neoplasia?
2 types
premalignant affecting squamous epithelium of skin .
high grade squamous intraepithelial lesion: associated with HPV - younger women 35-50
differentiated VIN: associated with lichen sclerosus and occurs in older women 5-60
how would you diagnose VIN?
tx
biopsy punch or excisional for histology
hpv testing PCR or in situ hybridisation for high risk HPV DNA
watch and wait
wide local excision
imiquimod cream
5 Fluorouracil : topical chemo agent
laser ablation/wide local excision/partial vulvectomy if extensive.
monitor with colposcopy and biopsy if recurring
how does vulval cancer present_
incidental finding during catheterisation in pt with dementia
vulval lump
ulceration
bleeding
pain
ithcing
lymphadenopathy in groin INGUINAL
what area of the vulva does vulval cancer affect mostÑ
what appearance does it give_
labia majora
irregular mass
fungating lesion
ulceration
bleeding
how would you investigate for vulval cancer_
2 week wait urgent refer
biopsy of lesion
sentinel node biopsy ‘ check lymph node spread
further imagine for staging ‘ CT ABDO AND PELVIS
how do you stage vulval cancer
FIGO
mx of vulval cancer
wide local excision
groin lymph node dissection
chemo
radio
What is atrophic vaginitis?
why?
who does it happen in ?
dryness and atrophy of vaginal mucosa
lack of oestrogen
genitourinar sx of menopause.
occurs in women entering meno
pathophysiology of atrophic vaginitis
epithelial lining of vagina and urinary tract responds to oestrogen by becoming thicker more elastic and producing secretions.
women enters meno
oestrogen levels fall
mucosa: thinner,less elastic dry.
prone to inflam.
vaginal ph change (ph over 4.5)
microbial flora change
how does oestrogen help with atrophic vaginitis?
oestrogen helps maintain healthy connective tissue around pelvic organs
lack of oestrogen contribute to pelvic organ prolapse and stress incontinence.
presentation of atrophic vaginitis
itching
dryness
dyspareunia
bleeding due to localised inflammation
occasional spotting
women comes in with recurrent uti , stress incontinence or pelvic organ prolapse.
what am i thinking?
tx
atrophic vaginitis
tx: topical oestrogen
examination of atrophic vaginitis pt will reveal?
pale mucosa
thin skin
reduced skin folds
erythema and inflammation
dryness
sparse pubic hair
how would you manage atrophic vaginitis?
vaginal lubricants : help dryness - SYLK,REPLENS, YES.
topical oestrogen:
- estriol cream - syringe at night
- estriol pessaries - inset bedtime
- estradiol tabs - vagifem - once day.
- estradiol ring - estring - replace every 3 months
topical oestrogen contraindicatiosn
same as systemic HRT
breast cancer
angina
VTE.
poss long term use: endometrial hyperplasia/cancer.
monitor annually
What is lichen sclerosus?
presenttion : main
where is affects most:
associations:
how to confirm diagnosis?
chronic inflammatory skin condition
porcelain white shiny skin patches
labia, perineum,perianal skin. - axilla/thighs (women)
foreskin and glans (men)
autoimmune
t1dm
alopecia
hypothyroid
vitiligo
vulval biopsy
presentation of lichen sclerosus
45-60 vulval itching and skin changes in vulva. can be asx or:
itching
soreness - pain worse at night
skin tightness
dyspareunia
erosions
fissures
what is the koebner phenomenon?
happens with which condition?
what can make it worse?
signs and symptoms made worse by skin friction.
happens with lichen sclerosus
tight underwear that rubs skin, urinary incontinence and scratching
Appearance of lichen sclerosus
changes affecting labia perianal and perineal skin.
associated fissures cracks erosions or haemorrhages under skin.
porcelain white colour
shiny tight thin
slightly raised
could be papules/pustules
how would you manage lichen sclerosus?
cant be cured.
mx and followed up every 3-6 months.
potential topical steroids - clobetasol propionate (0.05% dermovate) - reduce risk of malignancy.
once a day for 4 weeks.
then reduce every 4 weeks to alternate days then twice weekly.
if flare start again .
30g tube should last 3 months min.
use emoilents too.
2nd line: topical calcineurin inhibitors
topical retinoids
comps of lichen sclerosus
5% risk of getting squamous cell carcinoma of vulva.
pain and discomfort
sex dysfunction
bleeding
narrowing of vaginal or urethral openings
What is Asherman’s Syndrome?
adhesions form in uterus - after damage to uterus.
When might Asherman’s Syndrome occur?
after pregnancy related dilatation and currettage procedure eg in treatment of retained products of contraception.
uterine surgery - mymectomy
pelvic infection - endometritis
how can endometrial curettage (scraping) cause asherman’s syndrome?
what happens when the adhesions are formed?
damage basal layer of endometrium.
damaged tissue might heal abnormal.
scar tissue - adhesions
connecting areas to uterus.
might bind uterine walls together or within endocervix sealing it shut.
form physical obstructions and distort pelvic organs -so you get menstruation abnormalities, infertility and recurrent miscarriages.
presentation of ashermans syndrome
following recent dilatation and curettage, uterine surgery, endometritis with:
- secondary amenorrhoea
-significantly lighter periods - dysmenorrhoea
poss intertility.
how would you diagnose ashermans syndrome?
hysteroscopy - gold : can involve dissection and tx of adhesions
hysterosalpingography - constrast injected into uterus and imaged with xrays
sonohysterography - uterus filled with fluid and a pelvic uss performed
MRI
how would you manage ashermans syndrome?
reacurrance?
dissect adhesions during hysteroscopy.
reoccurance: common
What is Adenomyosis?
more common in ?
endometrial tissue in myometrium - muscle layer of uterus
later reproductive years
several pregnancies.
hormone dependent.
sx resolve after menopause similar to endometriosis and fibroids
presentation of adenomyosis
painful period - dysmenorrhoea
heavy periods - menorrhagia
pain during intercourse (dyspareunia)
1/3 asx
can present with infertility or pregnancy-related comps.
what will examination of adenomyosis show?
ENLARGED AND TENDER UTERUS.
MORE SOFT THAN A UTERUS WITH FIBROIDS.
how would you diagnosis adenomyosis?
transvaginal ultrasound of pelvis : 1st line
MRI and transabdominal uss - alternative if above not suitable.
gold: histological exam of uterus after hysterectomy.
how would you manage adenomyosis?
if women dont want contraception : use these during menstruation for sx relief:
- tranexamic acid - no associated pain
mefenamic acid - if pain
if contra acception:
- mirena - 1st line
-coc pill
- cyclical oral progesterone
progesterone only meds like pill,implant,depot poss good?
others:
endometrial ablation
uterine artery embolisation
hysterectomy
GnRH analogues - induce menopause-like state
what is tranexamic acid?
antifibrinolytic - reduce bleeding
what is mefenamic acid
nsaid - reduce bleeding and pain
in terms of pregnancy what can happen with adenomyosis?
infertility
miscarriage
preterm birth
small for gestational age
preterm premature rupture of membranes
need for c section
postpartum haemorrhage
what is menopause?
when menstruation stops in women.
12 months after last period in women over 50
24 months after last period before 50.
(effective contraception for both)
Symptoms of menopause
change in periods
vasomotor
urogenital
psychological
longer term comps
sx seen in climacteric period are caused by reduced levels of female hormones : oestrogen mainly.
change in periods:
- change in length of menstrual cycles
- dysfunctional uterine bleeding
vasomotor: 80% women. daily and can continue for 5 yrs
- hot flushes
-night sweats
urogenital: 35%
- vaginal dryness and atrophy
- urinary frequency
psychological:
- anxiety + depression - 10%
short term memory impairement
longer term comps:
-osteoporosis
-increased risk of IHD
different terms for menopause condition
menopause - when menstruation stops
post menopause - 12 months after final menstrual period
perimenopause - time around menopause experiencing vasomotor/irregular periods. last period to 12 months after. 45+
premature menopause -before 40. caused by premature ovarian insufficiency
what is menopause caused by?
lack of ovarian follicular function
changes in sex hormones :
oestrogen and progesterone levels are low
LH and FSH are high - in response to absence of negative feedback from oestrogen.
how would you manage perimenopausal sx?
vasomotor sx will resolve after 2-5 yrs without any tx.
mx:
- HRT
-Tibolone - synthetic steroid hormone - continous combined HRT - only after 12 months of amenorrhoea
- CBT
-SSRI eg fluoxetine or citalopram
-testosterone - reduced libido tx - gel/cream
-vaginal oestrogen cream/tablet - dryness and atrophy
vaginal moisturiser - SYLK,REPLENS,YES
- clonidine - agonist of alpha adrenergic and imidazoline receptors
good contraceptive options approaching menopause
barrier methods
mirena/copper coil
progesterone only pill
progesterone implant
progesterone depot injection (under 45)
sterilisation
coc pill : 40-50. containing norethisterone or levonorgestrel in women over 40. - low risk of VTE
side effect of depot - contraception
weight gain
reduced bone mineral density - osteoporosis.
in terms of contraception, when do women need to use it relative to menopause?
2 yrs after last menstrual period in women under 50.
1 yr after last menostrual period in women over 50.
how would you diagnose menopause?
women over 45 with sx - no ix.
FSH blood test to help in:
women under 40 with premature
women 40-45 with menopausal sx or change in menstrual cycle.
lack of oestrogen increases risk of what conditions?
cv disease and stroke
osteoporosis
pelvic organ prolapse
urinary incontinence
HRT RISKS
VTE
stroke - with oral oestrogen hrt
coronary heart disease- combined hrt
breast cancer
ovarian cancer
What is androgen insensitivity syndrome?
genetic
x linked recessive
end organ resistance to testosterone causing genotypically male children (46XY) to have female phenotype.
features of androgen insensitivity syndrome
primary amenorrhoea
little/no axillary and pubic hir
undescended testes causing groin swellings
breast development - testosterone to oestradiol conversion
how would you diagnose androgen insensitivity syndrome?
buccal smear or chromosomal analysis reveal - 46XY genotype
after puberty: testosterone conc high-normal to slightly elevate reference for postpubertal boys
how would you manage androgen insensitivity syndrome?
counselling - raise child female
bilateral orchidectomy - testicular cancer risk bc of undescended testes
vaginal dilators or vaginal surgery - create adequate vaginal length.
oestrogen therapy
if i was to do hormone test for androgen insensitivity syndrome what would come up?
raised lh
normal/raised fsh
normal/raised testosterone levels - male
raised oestrogen levels - male
when and how does androgen insensitivity syndrome present?
in infancy
inguinal hernias containing testes.
or
puberty with primary amenorrhoea.
what is partial androgen insensitivity syndrome?
presentation
cells partial response to androgens.
micropenis
clitoromegaly
bifid scrotum
hyposapdias
diminshed male characteristics
what dont pts with androgen insensitivity have and what do they have?
have testes - in abdo or inguinal cancal
no uterus upper vagina cervix fallopian tube and ovaries.
if androgen insensitivity syndrome why dont female internal organs develop?
testes produce anti-mullerian hormone.
prevents males from getting upper vagina uterus cervix fallopian tubes.
Physiology of menopause
decline in development of ovarian follicles.
reduced oestrogen production.
negative feedback on pituitary gland not happening, so increased levels of LH and FSH.
anovulation
irregular menstrual cycles.
endometrium doesnt develop - amenorrhoea
what is premature ovarian insuffiency?
onset of menopausal sx and high gonadotrophin levels before 40.
causes of premature menopause
idiopathic - mc cause - fhx
bilateral oophorectomy - having hysterectomy with preservation of ovarian has also been shown to advance age of menopause
radio
chemo
infection: mumps
autoimmune
resistant ovary syndrome: due to fsh receptor abnormalities
features of premature ovarian syndrome
climactreric sx: hot flushes , night sweats
infertility
secondary amenorrhoea
raised fsh,lh levels
fsh over 30
elevatred fsh on 2 blood samples 4-6 weeks apart.
low oestradiol : under 100 pmol/L
how would you manage premature ovarian syndrome?
hrt or combined oral contraceptive - until 51 (menopase)
hrt doesnt give contraception in case sponaneous ovarian activity resumes.
Explain the hypothalamic-pituitary gonadal axis in women
hypothalamus releases GnRH
that stimulates anterior pituitary to release lh and fsh
lh and fsh stimulate follicle development in ovaries.
cause theca granulosa cells to secrete oestrogen, which negatively feed back to hypothalamus and AP, reducing LH and FSH levels.
What is oestrogen and what does it stimulate?
steroid sex hormone (17-beta oestradiol is main active version)
- breast tissue development
- growth and development of female sex organs (vulva,vagina,uterus) at puberty
- blood vessel development in uterus
- development of endometrium
What is progesterone and what does it stimulate?
steroid sex hormone produced by corpus luteum after ovulation.
in pregnancy produced by placenta from 10 weeks gestation onwards.
acts on tissues previous stimulated by oestrogen?
- thickens and maintains endometrium
-thickens cervical mucus
-increases body temp
what age does puberty occur in girls, how long does it last and in what sequence do changes occur?also why does low weight delay puberty.
what staging is used
8-14 yrs
4yrs
growth spurt/breast buds, pubic hear, menarche
aromatase found in adipose tissue helps create oestrogen.
more aromatase (Fat) = earlier puberty. low birth weight, chronic disease/ED, athletic hence cause cause delays.
Tanner staging (under 10, no pubic hear or breasts =1 )
2 phases of menstrual cycle
follicular phase - start of menstruation to ovulation - 1st 14 days
luteal phase - ovulation to start of menstruation - final 14 days
what are ovarian follicles?
oocytes are cells that have potential to develop into eggs. surrounded by granulosa cells , forming follicles.
primary follicles are always maturing into primary and secondary follicles.
when they reach secondary, they grow FSH receptors, which when stimulated, cause granulosa cells to secrete oestradiol. (oestrogen)
Describe the follicular phase
Low oestrogen and progesterone causes endometrium shedding and bleeding.
FSH stimulates secondary follicles, causing them to grow, and for surrounding granulosa cells to secrete oestrogen. This reduces LH and FSH production (negative feedback). Rising oestrogen also causes cervical mucus to become more permeable, allowing sperm to penetrate cervix around ovulation.
One follicle will develop more than the rest (dominant follicle) LH spike causes dominant follicle to release an ovum. Ovulation occurs 14 days before end of cycle.
Overall: FSH stimulates oestrogen, which spikes ~day 12. There is an LH spike right before ovulation causing an ovum to release.
Describe luteal phase
The follicle that released the ovum collapses, becoming the corpus luteum. This secretes progesterone, maintaining the endometrial lining. It also causes the cervical mucus to become thick.
If pregnancy: the syncytiotrophoblast of the embryo secretes Human Chorionic Gonadotrophin (HCG), maintaining the corpus luteum.
Without fertilisation the corpus luteum degenerates and stops producing oestrogen and progesterone. This fall causes breakdown of the endometrium and menstruation. The stromal cells in the endometrium release prostaglandins, causing uterus contractions. The fall in Oestrogen and Progesterone causes an increase in LH and FSH, restarting the cycle.
Menstruation marks day 1 of the menstrual cycle.
What is amenorrhoea? Give primary and secondary causes?
failure to establish menstruation at 15 with normal sexual development and 13 without.
Primary
- Gonadal dysgenesis (e.g. Turners)
- Hypogonadotrophic hypogonadism (deficiency of LH and FSH), Hypergonadotrophic hypogonadism (lack of response to LH and FSH by gonads)
- Pregnancy
Secondary - 3-6 months amenorrhoea when previously normal
- Hypothalamic (secondary stress, excessive exercise)
- PCOS
- Thyroid disease
- Hyperprolactinaemia
mc gynae malignancy in developed world
endometrial carcinoma
90% adenocarcinomas
endogenous and exogenous sources of unopposed oestrogen
Endogenous
- Chronic anovulation (e.g. PCOS)
- Aromatisation of androgens
- Granulosa cell tumours
Exogenous unopposed oestrogen
- HRT
- Selective oestrogen receptor modulators (tamoxifen)
How can these cysts rupture, and what is a ruptured ovarian cyst
Can occur spontaneously or in response to physical activity such as vigorous exercise, intercourse, or trauma.
Common emergency characterised by sudden severe lower abdo pain.
presentation of ruptured ovarian cyst
Severe unilateral sharp lower abdo/pelvic pain, radiates to back or thigh.
Rebound tenderness, guarding and rigidity
Haemodynamic instability, caused by intraperitoneal bleeding. (Tachycardia, hypotension, pallor, diaphoresis, syncope)
Fever
Nausea and Vomiting
What cancers are caused by BRCA 1 and 2
BRCA1 - Breast/ovarian (Chromosome 17)
BRCA2 - Breast, Prostate, Ovarian (C13)
Autosomal dominant
What guidelines are used to indicate whether a person is eligible for different types of contraception
The FSRH UKMEC (Faculty of Sexual and Reproductive Healthcare UK Medical Eligibility) Guidelines 2016.
1: No restriction
2: Benefits outweigh risks
3: Risks generally outweigh benefits
4: Unacceptable - Contraindicated
What are the 3 most effective contraceptions
Surgery (sterilisation/vasectomy)
Coils (Copper coil/Mirena coil)
Progesterone only implant
> 99% Under both typical and perfect use
What are some specific risk factors to keep an eye out for when prescribing contraception
Any hormonal contraception - Breast cancer
Any coil - Cervical/endometrial cancer
Copper coil - Wilsons disease
What are some COCP contraindications (UKMEC 4)
Uncontrolled HTN (>160/100)
Migraine with aura
History of VTE or vascular disease/stroke
> 35y AND smoking >15 cigs
Major surgery with immobility
Liver cirrhosis
SLE/antiphospholipid syndrome
Heart disease/ AFib
What are some contraception considerations in over 50s
After the last period keep contraception for 2 years if under 50 and 1 year if over 50
COCP can be used up to 50
Progesterone injection should be stopped <50y due to osteoporosis risk
What does MEN 1 cause and what its pattern of inheritance?
Autosomal dominant
Parathyroid adenoma
Pituitary prolactinoma or acromegaly
Pancreatic endocrine tumours
What does men2a cause
medullary thyroid cancer
pheochromocytoma
primary hyperparathyroidism
what does men 2b cause
medullary thyroid cancer
pheochromocytoma
mucosal neuromas
Risk factors of hyperemesis gravidarum
increased levels of beta-hcg:
- multiple pregnancies
-trophoblastic disease
nulliparity
obesity
fhx personal hx of NVP
SMOKING DECREASED INCIDENCE
TRIAD OF HYPEREMESIS GRAVIDARUM
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
Management of hyperemesis gravidarum
simple:
- rest avoid trigger
-bland plain food in morning
-ginger
- p6 wrist acupressure
1st line:
antihistamine : oral cyclizine or premethazine
phenothiazines: oral prochlorperazine or chlorpromazine.
2nd line:
- oral ondansetron
- oral metoclopramide or domperidone: max 5 days meto bc extrapyramidal se.
admission for iv hydraiton: normal saline with added potasium
oral ondansetron as 2nd line tx of hyperemesis gravidarum - side effect
increased risk of cleft lip/palate.
complications of hyperemesis gravidarum
dehydration
weight loss
electrolyte imbalances
aki
wernickes
oesophagitis, mallory weiss
vte
when to consider admission for hyperemesis gravidarum?
n+ v continued - cant keep liquid or oral antiemetics down
continued n+ v with ketonuria and/or wt loss (over 5%) despite oral antiemetics
comorbidity? like cant tolerate abx for uti
what is ovarian hyperstimulation syndrome?
seen in some infertility tx.
multiple leutinized cysts in ovaries = high oestrogen and progesterone and vegf.
increased membrane permeability and loss of fluid from intravascular compartment.
when is ovarian hyperstimulation syndrome seen?
following gonadotropin or hcg tx.
1/3 of ivf women
classifying ovarian hyperstimulation syndrome?
mild : abdo pain and bloating.
moderate. n+v and uss of ascites. + mild
severe: moderate + clinical ev of ascites.
oliguria.
haematocrit over 45%
hypoproteinemia
critical : severe. thromboembolism.
ards
anuria
tense ascites
