Gynaecology Flashcards
What is the definition of primary amenorrhoea?
Periods have never started, potentially due to:
Delayed puberty e.g. chromosomal abnormality e.g. Turner’s
Absence of a uterus or functional endometrium
Polycystic Ovarian Syndrome
What is the definition of secondary amenorrhoea?
Periods have started but have stopped for over 6 months
Give 3 physiological causes of amenorrhoea
Pregnancy
Lactational Amenorrhoea
Menopause
Give 2 ovarian causes of amenorrhoea
Polycystic Ovarian Syndrome
Premature Menopause
Give 2 iatrogenic causes of amenorrhoea
Hormonal contraceptives e.g. IUS/POP/Depot/COCP
Antipsychotics
Give 3 other non-gynae causes of amenorrhoea
Stress
Low body weight/ eating disorder/ over-exercising
Untreated coeliac disease
What is the definition of menorrhagia?
> 80 mls of menses in ~ 7 days
HOWEVER
Go off what the patient reports as everyone is different and it’s their problem!
Give 6 endometrial causes of menorrhagia
Dysfunctional Uterine Bleeding (most common)
Fibroids
Endometriosis
Adenomyosis
Endometrial Polyp
Endometrial Carcinoma (esp if >45 years old or PMB)
(PID can also cause but doesn’t fit into a category)
Give an iatrogenic causes of menorrhagia
Contraception e.g. IUD or POP
Give 3 systemic causes of menorrhagia
Hypothyroidism
Coagulopathy
Diabetes Mellitus
Give 5 cervical causes of post-coital bleeding
Trauma
Polyps
Ectropion
Carcinoma
Cervicitis
Give 3 other gynae causes of post-coital bleeding
Sexually Transmitted Infections
Pelvic Inflammatory Disease
Pelvic Organ Prolapse
Give 2 physiological causes of inter-menstrual bleeding
Reduction in oestrogen just before ovulation
Pregnancy related e.g. implantation
Give a tubal cause of inter-menstrual bleeding
Ectopic Pregnancy
Give 2 endometrial causes of inter-menstrual bleeding
Polyps
Carcinoma/ Hyperplasia
Give 3 gynae causes of inter-menstrual bleeding
Miscarriage
STIs
PID
Give 4 cervical causes of inter-menstrual bleeding
Trauma
Polyps
Ectropion
Cervicitis
Give an iatrogenic cause of inter-menstrual bleeding
Hormonal contraception e.g. IUCD
Give an ovarian cause of inter-menstrual bleeding
Polycystic Ovarian Syndrome
What are the main causes of post menopausal bleeding? (5)
Endometrial carcinoma/ hyperplasia
Pelvic Organ Prolapse
Polyps (endometrial or cervical)
Atrophic Vaginitis
Ovarian Cysts
What is a fibroid? What are the 4 types?
A leiomyoma
A benign smooth muscle tumour of the uterus
Subserosal (most common), intramural, submucosal, pedunculated
Which group of people are fibroids more common in?
Afro-carribean women, older women or those with a family history
What is the pathophysiology of fibroids?
Oestrogen dependent so can increase in size in response to pregnancy/ COCP/ high oestrogen states
Can also atrophy during the menopause (low oestrogen) or suddenly (red degeneration)
What are 5 symptoms of fibroids?
Menorrhagia (due to ↑ surface area of the uterus) but no PCB or IMB
Sub-fertility e.g. submucosal fibroids may prevent implantation
Abdominal mass +/- irregularly shaped uterus
Urinary frequency (presses on bladder)
Pain (red degeneration)
How do fibroids present on examination?
Enlarged, firm and irregularly shaped uterus
Uterus is NON TENDER
Mass is mobile
Which imaging is diagnostic for fibroids?
Transvaginal and transabdominal ultrasound scan
Refer if any sinister signs
(may do FBC if anaemia)
What is the conservative management of fibroids?
If asymptomatic/incidental finding just watch and wait
What is the medical management of fibroids?
Non-hormonal = Tranexamic acid/NSAIDS
Hormonal =
Mirena IUS if <3cm
POP
Can also use a GnRH analogue to shrink before surgery but not a permanent solution
Can also give HRT just have to council about symptoms
What is the the surgical management of fibroids and the indication to do so?
Fibroid is >3cm in diameter
1) Uterine artery embolisation (painful, long recovery and not if of childbearing age)
UA ablation - also need contraception
2) Myomectomy
3) Hysterectomy (older and/or don’t want to preserve fertility)
What are the complications of fibroids? (4)
Adjacent organ or venous compression
Infertility/problems within pregnancy
Red degeneration
Can calcify
What is red degeneration?
Torsion of a pedunculated fibroid
Cuts off blood supply
Leads to haemorrhagic necrosis
What is the definition of polycystic ovarian syndrome?
Hyperandrogenism + oligomenorrhoea + polycystic ovaries
What is the definition of oligomenorrhoea?
~4-9 menstrual periods per year following regular establishment of menstruation prior to irregularity
leads to anovulatory cycles
In the absence of other PCO causes e.g. Cushing’s
What is the pathophysiology of PCOS?
Ovaries are stimulated to produce excess androgens…
Excess LH production by the anterior pituitary due to ↑ frequency of GnRH pulses
Hyperinsulinaemia
What is the role of obesity in PCOS?
Aromatase enzyme is present in adipose tissue
Aromatase converts testosterone to oestrogen
PCOS = excess androgens and oestrogen = male pattern symptoms and inhibition of FSH so follicle doesn’t mature
Hyperinsulinaemia (see other card)
How does hyperinsulinaemia lead to PCOS?
↑ frequency of GnRH pulses…
↑LH compared to FSH (↑ratio) = ↓ follicle maturation
↑ ovarian androgen production
↓ binding of sex hormone binding globulin (SHBG)
ALSO
upregulaiton of 17 alpha-hydroxylase = ↑ androgen synthesis
What are 3 menstrual symptoms associated with PCOS?
oligomenorrhoea
Amenorrhoea (unless given exogenous hormones)
Hypermenorrhoea (heavy and prolonged)
What are the male pattern symptoms seen with PCOS?
Acne
Hirutism (hairy women)
Andogenic Alopecia (head hair thinning/loss)
What are the metabolic symptoms associated with PCOS?
Central Obesity
Insulin resistance
Which criteria is used to assess PCOS?
Rotterdam criteria: need 2 or 3
Excess androgen activity
Oligoovulation/anovulation/polycystic ovaries
Exclusion of other causes of excess androgens
What are the blood investigations for PCOS?
LH and FSH levels
Free testosterone
Glucose tolerance test and fasting insulin levels (not diagnostic just indicated risk factors and need once a year)
What imaging can be done for PCOS?
Transvaginal ultrasound - 12+ follicles seen ? in periphery/string of pearls appearance
What is the conservative management for PCOS?
- manage weight and obesity related behaviours/conditions
e. g. smoking cessation and diabetes control (↑ insulin sensitivity)
Hair removal
What is the medical management for PCOS?
Hormonal = contraception, either IUS or COCP or a progestogen
Non-hormonal = metformin (↑insulin sensitivity but short term and not licensed)
Anti-androgens/spironolactone for acne (though teratogenic)
How does the COCP help in PCOS?
Regulation of cycle and ↓ risk of endometrial cancer due to ↑ unopposed oestrogen on endometrium
How does a progestogen help in PCOS?
Need to shed the endometrium 4-5 times a year to maintain health and ↓ endometrial cancer risk
What is the definition of pelvic organ prolapse?
Descent of 1+ pelvic organs leading to a protrusion of the vaginal wall +/- uterus. There are usually also urinary/bowel/sexual/local pelvic symptoms
What is the function of the pelvic ligaments? name them
Support the uterus
Pubocervical (pubic symphysis to cervix)
Cardinal (cervix to lateral uterine wall)
Uterosacral (uterus to anterior sacrum)
What are the types of incontinence?
Frequency/Urge
Stress
Mixed
Overflow
What is stress incontinence?
Involuntary leakage when there is an increase in intra-abdominal pressure e.g. due to laughing or coughing o r exercise
What is urge/frequency incontinence?
Urgency symptoms/feeling of needing to go +/- frequency and nocturia but NO URINARY SYMPTOMS
What are the causes of stress incontinence?
↑ pressure = ovarian masses/pressure from superior structures/obesity/chronic cough
Oestrogen deficiency e.g. menopause
Vaginal trauma e.g. childbirth/ surgery
What are the causes of urge incontinence?
Triggers = running water, turning key in door
Pelvic surgery/nerve damage
neurological e.g. MS
What are the bedside investigations for incontinence?
Urinalysis to rule out a UTI
What imaging should be done to investigate incontinence?
1) Cystoscopy if recurrent UTI or haematuria just to check anatomy
2) USS of post void residual volume
3) Urodynamics - looks at storage and voiding of urine
What are the two types of urodynamics?
Uroflowmetry - for voiding difficulties and done in private
Cystometry - fill bladder with saline and measure the pressure when patient gets feeling to void, coughing, straining etc
What are two conservative assessments for urinary incontinence?
Bladder diary - monitor patterns of incontinence and behaviours
QOL questionnaire
What is the conservative management for stress urinary incontinence?
Reduce fluid +/- caffeine +/- alcohol intake
Weight loss
Continence pads
Pelvic floor exercises (v effective if done - refer for 3 months of physio)
What is the conservative management for urge urinary incontinence?
Behaviour therapy e.g. alarm
Electrical stimulation to pudendal nerve
What is the medical management of stress urinary incontinence?
Duloxetine (SNRI so side effects)
What is the medical management of urge urinary incontinence?
Anticholinergics/muscarinics (↑ storage)
Botox (retention is SE)
Oxybutynin (severe SE e.g. dry mouth)
Tolterodine/Solifenacin
What are the types of prolapse?
Cystocele
Rectocele
Enterocele
Vault
Define a cystocele. Which type of incontinence does this lead to?
Weakness in the anterior vaginal wall allowing the bladder to prolapse in
Stress incontinence/ frequent UTIs/ residual urine
Define a rectocele. Which type of incontinence does this lead to?
Weakness in the posterior vaginal wall allowing the rectum to prolapse in
Faecal incontinence/ back ache/ pressure
Define an enterocoele. Which type of incontinence does this lead to?
Weakness in the upper vaginal wall allowing prolapse of the vagina and peritoneal sac +/- bowel or omentum
Backache, faecal incontinence, bleeding
What is a vault prolapse?
Descent of the vagina post hysterectomy +/- cyst/rect/enterocele
How is prolapse graded? (4)
1st degree - uterus is halfway down vag to Introits
2nd degree - uterus is at the level of the Introitus and comes through when straining
3rd degree - uterus is through the introitus and outside
Procidentia - Uterus is outside the vagina
What are the general symptoms of prolapse? (5)
‘something coming down’
Dragging sensation
Dyspareunia
Urinary/Bowel symptoms
Low mood/affecting QOL
What are the risk factors for prolapse? (8)
Non-Modifiable
- Older age
- Asian/hispanic
- Spina Bifida (?)
- Connective Tissue Disorder
- FHx
Modifiable
- Obesity
- Vaginal delivery +/- forceps/trauma/macrosomia/prolonged 2nd stage
- Multiparity
What are the investigations for prolapse?
Very much a clinical diagnosis/examination
Do a bimanual/speculum
What is the conservative management of prolapse?
Symptom and severity dependent
manage risk factors (cough, constipation, weight, stop smoking)
Pelvic floor training
Pessary - Ring is first line and can still shag. Also good for short term relief before surgery
What are the complications of using a pessary?
PV discharge +/- odour
Can cause trauma to walls and fistula formation
What is the surgical management of prolapse?
Only if pessary/previous surgery fails or definitive management is wanted
TVT/colposuspension/hysterectomy
General surgical complications apply
Define endometriosis
The presence of the endometrium outside of the uterus leading to chronic inflammation
Oestrogen driven so get cyclical symptoms and affects women of reproductive age
What is the pathophysiology of endometriosis?
Unknown
1) retrogade menstruation
2) metaplasia of mesothelial cells
3) reduced immunity
What are the risk factors for endometriosis?
1st degree relative also has endometriosis
Early menarche
long flow
short cycles
vaginal obstruction- FGM, hydrocolpos, uterine defects
How does adenomyosis differ to endometriosis?
Adenomyosis is the presence of endometrium within the myometrium
How does endometriosis normally present?
PAIN
S
Q - constant due to adhesion formation
I - SEVERE
T - cyclical, maybe also during ovulation
A - cyclical, worse during periods. Dyspareunia due to uterosacral ligament involvement
R -
S - Bloating, fatigue, constipation, lower back pain
What are some other symptoms of endometriosis?
Subfertility - ?adhesions ?higher prostaglandins
Extrapelvic - LUTS, dyschezia (pain when pooing), cyclical bleeding and epistaxis
How does does endometriosis present on examination?
May be normal
Might have:
Retroverted uterus (v common)
Blue nodules @ pos fornix
Tender @ adnexae
What are the bedside investigations for endometriosis?
Acute exclusion of UTIs etc
What are the blood tests for endometriosis?
Have raised CA-125 although this is of no diagnostic value
What imaging is appropriate for endometriosis?
Transvaginal USS is good if tissue is present at the ovary
Otherwise, MRI allows location to be seen
How is endometriosis diagnosed?
Laparoscopy + biopsy is gold standard
Have to avoid if within 3 months of hormonal treatment
What is the conservative management of endometriosis?
Pain management - hot water bottle, analgesia e.g. NSAIDS (ibuprofen, naproxen, mefenamic acid)
Reassurance and advice - sign post to support groups e.g. endometriosis UK and SHE trust Uk
What is the hormonal medical management of endometriosis?
Contraceptive management wanted =
COCP if under 35 and have no contraindications. do a 3 month trial of a conventional regime then continuous if pain isn’t managed
Progesterone - POP/mirena/IM otherwise
GnRH analogue - creates a pseudo menopause = reduces oestrogen and stops ovulation
What is the non-hormonal management of endometriosis?
Oral progestogen (medroxyprogesterone)
Thins the endometrium and reduces oestrogen levels
What are the problems with using a GnRH analogue for endometriosis?
menopause symptoms
only for 6 months due to cancer risk
pre-IVF?
What is the surgical management of endometriosis?
Laparoscopic ablation/excision of endometriosis (reduces pain, preserves fertility)
Total hysterectomy + bilateral oophrectomy (removes oestrogen driving force but last resort)
What are the complications of endometriosis?
Chocolate cysts (endometrial tissue in ovary. bleeds but blood is trapped so turns brown)
Infertility
Increased risk of ectopic
Non-Hodgkins lymphoma risk
IBD risk
Risk of obstruction
Define pelvic inflammatory disease
Infection of the upper genital tract including the uterus, Fallopian tubes and ovaries
initiated by an infection that ascends from the vagina +/- cervix
What are the most likely causative organisms of PID?
Chlamydia Trachomatis
Neisseria Gonorrhoea
The rest are anaerobes or ascension of bac vag
How can an organism ascend to cause PID?
untreated infection
uterine instrumentation e.g. IUD insertion
Post partum
What are the risk factors for PID?
Under 25 years old
New/multiple sexual partners
No condom use
Low socioeconomic satus
How does PID normally present?
BIG VARIATION
Pain - lower abdominal, usually bilateral/constant, deep dyspareunia, dysmenorrhoea. Cervical excitation and adnexal tenderness o/e
Bleeding - ICB/PMB
Abnormal discharge - increased, ?mucopurulent, change in smell and colour etc
Active chronic infection will be afebrile
What are the bedside investigations for PID?
STI screen (supports but doesn’t diagnose)
Pregnancy Test
Urinalysis
What are the blood tests for PID?
Generic infection markers - FBC, CRP, U&E
LFTs - Fitz-Hugh-Curtis
What imaging can be done for PID?
TVS for ?tubo-ovarian abscess
How can PID be diagnosed?
Gold standard is laparoscopy but not always possible
What is the medical management for PID?
Antibiotics ASAP
Outpatient = Ceftriaxone IM OR Azithromycin PO + Doxycycline for 14 days + metronidazole
Inpatient = Ceftriaxone IV + Doxycycline IV AND PO + metronidazole PO for 14 days
What is the surgical management of PID?
Laparoscopic drainage + adhesiolysis
What is the general management of PID?
Analgesia
Contact tracing
Avoid sex until both have finished treatment and been followed up
What are the complications of PID?
Tubo-ovarian abscess > adhesions > infertility/ectopic
Fitz-Hugh-Curtis - inflammation of Glisson’s capsule + perihepatic adhesions = RUQ pain
Recurrence > chronic inflammation > chronic pelvic pain
Define dysfunctional uterine bleeding
Heavy menstrual bleeding in the absence of pathology
Diagnosis of exclusion and accounts for the majority of cases
What is the pathophysiology of DUB?
Loss of cyclical oestrogen so levels are constantly stable
Endometrium proliferates but doesn’t slough until it outgrows its own blood supply
What are the bedside investigations for DUB?
History
Examination - abdo, pelvis, speculum
What are the blood tests for DUB?
FBC - anaemia
Clotting - ?coagulopathy/Fhx
Coagulation screen
TFT - hypothyroidism
HcG - exclude pregnancy
What is the hormonal medical management of DUB?
1) mirena - suppresses oestrogen and thins endometrium
2) COCP/depot/POP
What is the non-hormonal medical management of DUB?
1) Tranexamic acid
2) Mefanamic acid
What is the MOA of tranexamic acid?
Binds reversibly to lysine receptor on plasminogen
Reduces breakdown of plasminogen to plasmin
Means fibrin isn’t broken down
CI = thromboembolic disease
What is the MOA of mefanamic acid? Contraindications?
NSAID so inhibits COX1 and COX2
Inhibits prostaglandin formation
CI = PUD, IBD, Asthma
Define endometrial cancer
Usually an adenocarcinoma that arises from the endometrium and is oestrogen dependent
Define endometrial hyperplasia
A pre-malignant condition where the endometrium overgrows, potentially due to prolonged and persistent oestrogenic stimulation
What is the overall pathophysiology of endometrial cancer?
Unopposed oestrogen from:
endogenous sources
exogenous sources
genetics
How does unopposed endogenous oestrogen from lower progesterone lead to endometrial cancer? Give examples of sources
Less progesterone
Anovulation e.g. PCOS. Immature follicles mean no corpus luteum to produce progesterone = unopposed oestrogen
Nulliparous - less endogenous progesterone
How does unopposed endogenous oestrogen from ↑oestrogen lead to endometrial cancer? Give examples of sources
Obesity/Associated conditions e.g. T2DM/HTN. Aromatase is present in adipose tissue meaning more testosterone converted to oestrogen
Early menarche/late menopause
How does unopposed exogenous oestrogen from lower progesterone lead to endometrial cancer? Give examples of sources
Tamoxifen (selective oestrigen receptor modulator/partial oestrogen receptor agonist)
HRT - Can only give ERT if no uterus
Give an example of a genetic condition that is also associated with endometrial cancer
Hereditary Non-polyposis Colon Cancer (HNPCC)
What are the symptoms of endometrial cancer?
Post-menopausal Bleeding (red flag if unexplained and after 1 year of amenorrhoea)
Pre-menopausal bleeding - v v heavy and irregular
When should a women with PMB be 2ww?
> 55 and PMB
Consider if <55
What imaging should be done to diagnose endometrial cancer?
Transvaginal ultrasound scan
Hysteroscopy +/- biopsy (outpatient or GA)
What are the TVS findings for endometrial cancer that indicate a hysteroscopy is needed?
Thickness:
> or = to 4mm (not on HRT)
> or = to 5mm (on HRT)
~12mm could be a polyp?
Offer if bleeding and taking tamoxifen
What is the medical management for endometrial hyperplasia?
Progesterone therapy e.g. mirena/POP
longer term benefits e.g. 5 years
What is the medical management for endometrial canceR?
Adjuvant therapy
Chemo - post op stage III and IV
Radio - Reoccurence?
External beam to control bleeding
What is the surgical management for endometrial cancer?
Total abdominal hysterectomy and bilateral salpingoophrectomy
Refer to oncologists too
When are women invited for cervical screening?
25-49 = invited every 3 years via their GP
50-64 = invited every 5 years
Why are women invited for cervical screening?
Screening for dyskaryosis as a way of cancer prevention by checking health of cervix
look for cervix specific low grade abnormal cell changes (dyskaryosis)
Look specifically for HPV 16&18 as are high risk for cervical cancer
How is a cervical smear performed?
Cervix looked at using a speculum
Small brush is used to scrape cells from transformation zone then suspended in a liquid (liquid based cytology)
When are women discharged back to the cervical screening programme?
Low grade dyskaryosis and HPV NEGATIVE
When are women referred to colposcopy from the cervical screening programme?
Low grade dyskaryosis and HPV POSITIVE
High grade (moderate) dyskaryosis
High grade (severe) dyskaryosis
3 inadequate smears in a row
To which groups of people is the HPV vaccine offered to? Which strains does this protect against?
Both girls and boys aged 12-14
MSM up to 45 or HIV +ve
Protects against HPV 16&18 (high risk for cancer) and HPV 6&11 (majority of anogenital warts)
What is the pathophysiology of cervical cancer?
Usually HPV 16&18
Infects epithelium and gains access to basal layer without disrupting the squamous layer
Alters p53 (t. suppressor) and pRB = unregulated growth
Epithelial cells become koilocytes (pre-cancerous)
What are the risk factors for cervical malignancy relating to HPV?
Multiple partners
Not using barrier methods
Early 1st sexual experience
What are the hormonal risk factors for cervical malignancy?
High parity
Long term COCP use
What are 2 other risk factors for cervical malignancy? HPV and hormones already said
Smoking (reduces viral clearance)
Immunosuppression e.g. HIV or transplant
How does cervical cancer normally present?
Bleeding - PCB/PMB/IMB (HMB if advanced)
Abnormal (watery discharge)
Dyspareunia
Cancer symptoms - weight loss/fatigue
Advanced - ureteric obstruction/vesivovaginal fistula/ change in bowels
How does cervical cancer present on colposcopy?
Abnormal cervix on colposcopy and dense uptake of acetic acid
How does cervical cancer present on examination?
Feels rough and hard on bimanual
Irregular mass on speculum
What are the pre and post menopausal investigations of cervical cancer?
Pre = check for STI. Colposcopy and biopsy if negative.
Post = 2ww? colposcopy and biopsy
What is the FIGO staging?
0 = CIN
1 = Just in cervix
2 = Beyond cervix and some in vag
3 = pelvic side wall and lower 1/3 vag
4 = metastases to other organs e.g. bladder
What is the treatment of cervical cancer according to the FIGO staging?
0 = large loop excision of the transformation zone
1 = local excision or hysterectomy + lymphadenectomy
2 = chemoradiotherapy
3 = chemoradiotherapy
4 = palliative care and chemoradio
**important to consider fertility sparing options
Define infertility
No clinical pregnancy within 1 year of regular, unprotected sex
primary = never conceived secondary = conceived before i.e. have had a pregnancy but not necessarily a baby
What is the rule of 1/4 in relation to infertility
Cause is:
25% is idiopathic
25% is tubal factors
25% is ovarian function
25% male factors
What are the tubal factors that may cause infertility?
Adhesion formation
PID/endometriosis/previous surgery
Illegal abortions
What are the ovarian factors that may cause infertility?
THINK HPO
H - rare e.g. ischaemic damage
P - Hypogonadotrophic hypogonadism e.g. neoplasia, trauma OR hyperprolactinaemia (GnRH inhibition)
O - ovarian insufficiency/PCOS/Excess body fat loss/Turners
What are the male factors that may cause infertility?
Sperm problems - production/function/delivery i.e. blockage of vas deferens
What are the specific questions to consider when taking a history about infertilitY?
O&G history
Social Hx
High BMI/pelvic pathology
Undescended testes/ adult mumps/PMH
Which blood tests should be done when investigating infertility?
Female
Hormone profile - Day 2-5 FSH and LH
Mid luteal progesterone - 7 days before period due to start and do again if low as ovulation doesn’t occur each month
Rubella status
?prolactin and TFTs
What imaging should be done when investigating infertility?
Tubal patency test +/- TVS +/- laparoscopy
TVS for uterine abnormalities
What male investigations should be done when investigating infertility?
Semen analysis - maybe do 2 as large variability
STI screen (for both)
What is the conservative management for infertility? (6)
General life advice
Weight loss if high BMI but keep above 19
No smoking/cessation support
No alcohol for women but in safe limits for men
Folic acid 0.4mg per day
Have sex 2-3 times a week but don’t pressure
What is the medical management for infertility?
Ovulation induction using clomifene citrate (anti-oestrogen so increases FSH)
Take 2-6 days of the cycle for 8-12 cycles
Can cause menopausal symptoms
need to monitor ovaries due to hyper stimulation risk
What is the surgical management for infertility?
Can catheterise proximal tubal blocks
IVF but NHS has really specific criteria
What are the main causes of pre-menopausal adnexal masses? (6)
Functional cysts
Cystic Neoplasms
Sex Cord Stromal
Ectopic Pregnancy
Endometrioma/sis
Fallopian tube lesion
What is a functional cyst?
Follicular i.e. hasn’t ruptured or corpus luteum i.e. hasn’t matured
usually dissolves on its own but may cause pain if ruptures
What are the main cystic neoplasms in a pre-menopausal woman?
Germ Cell
Either a benign cystic teratoma or a Dermoid cyst (the one with the teeth)
What is a fallopian tube lesion in relation to adnexal masses?
Hydrosalpinges
The Fallopian tube becomes abnormally dilated, usually due to PID
What are the main causes of adnexal masses in post-menopausal women?
Ovarian fibroma - benign tumour of connective tissue (slow growing and variable size)
Cystic neoplasm
What are the main cystic neoplasms in a post-menopausal woman?
Serous cystadenoma (25% malignant)
Mucinous (the massive ones, 5% malignant)
Endometroid malignant
How do adnexal masses normally present? (4)
Incidental/asymptomatic
Pain - acute if torted/ruptured or chronic if cyclical or dyspareunia
irregular pv bleeding
abdominal swelling/bloating that doesn’t go away when bladder is empty and is dull to percuss
Which blood tests should be done to investigate adnexal masses?
CA-125
<40 = AFP(germ cell tumours), LDH, hCG
What imagine should be done to investigate adnexal masses?
1) TVS on 2WW
2) CT/MRI if big or complex
What special tests can be done to investigate adnexal masses?
Fine needle aspiration and cytology
What is the treatment for adnexal masses in pre-menopausal women?
Try to preserve fertility
<7cm = no surgery
> 7cm and symptoms = lap cystectomy
What is the treatment for adnexal masses in post-menopausal women?
Risk of malignancy index
low risk = CA-125 and repeat TVS every 4 months then stop after 1 year
High risk = bilateral oophrectomy
What is the deal with the irreversible part of sterilisation?
Reversing the procedure is never funded on the NHS
Should be viewed as irreversible even though 3-10% women express regret
Have to document explicitly what you told them and if don’t agree have to hand over to HCP for 2nd opinion
What is the failure rate of females compared to males for sterilisation?
1:200 in women but 1:2000 in men!!!!! WTF!
This failure rate is worse than the mirena!!! Also mirena is a lot less invasive make sure you discuss this!
What are the complications of female sterilisation?
Specific - Increased risk of ectopic pregnancy, damage to surrounding structures, failure
General surgical complications
What are the two types of HRT?
Combined HRT using both oestrogen and progesterone
Oestrogen only HRT (ERT)
What are the two types of combined HRT and when can they be used?
Cyclical - if perimenopausal i.e. still having a period or withdrawal bleed and can see a natural end to periods
Continuous - used if post-menopausal/have had amenorrhoea for over a year OR have been on cyclical for >1year OR <45 OR 2 years since LMP
When can ERT be used?
Only if uterus is NOT PRESENT (due to unopposed oestrogen and endometrial cancer risk)
Or having progesterone from another source e.g. mirena
What are the modes of administration for HRT?
Oral
Transdermal Patch
Topical e.g. oestrogen cream or pessary
What are the benefits and risks of oral HRT?
Benefits - lowest atherogenic risk
Risks - highest VTE risk and undergoes first pass metabolism so not for liver disease
SO
Good for women with high CVD risk but not for high clot risk
What are the benefits and risks of HRT via a transdermal patch?
Benefits - Lowest VTE risk (reduces clotting factor production @ liver)
Risks - skin allergies
SO
Good for women with migraines/diabetes/high VTE risk
When would topical HRT be used?
If urogenital symptoms are most concerning
Has small systemic absorption
When can IUS+oestrogen be used as HRT?
Contraception wanted + bleeding on cyclical
What are the overall risks of HRT?
Breast cancer - highest risk is on combined HRT. Risk increases by 2.3% every year up to 5 years but returns to initial risk after this
Endometrial cancer - ERT is highest risk but mirena can be used to oppose this
Oral preparations = VTE risk
Increased risk CVD
What are the benefits of HRT?
Symptom Relief!
Reduced risk of osteoporosis
Reduced risk of colorectal cancer
What are the contraindications to HRT? (5)
Pregnancy/breastfeeding
Hx breast cancer - offer neither
Hx VTE
Liver disease
Undiagnosed pv bleed
What should be monitored in a woman using HRT? (5)
Blood pressure - stop if >160/100
Breasts - screening attendance
Weight
Pv bleeds
check effect aat 3 months
