Gynaecology Flashcards
1
Q
OVARIAN CANCER
Causes?
A
- Epithelial ovarian tumours
- Germ cell tumours
- sex cord-stromal tumours
- metastatic tumours
2
Q
OVARIAN CANCER
What is the most common cause?
A
Epithelial ovarian tumors (85-90%)
3
Q
OVARIAN CANCER
how will germ cell tumours present and who are they common in?
A
common in women <35 and they present as a rapidly enlarging abdominal mass (often rupture/torsion)
4
Q
OVARIAN CANCER
Risk factors?
A
- Increasing age
- Lifestyle (smoking, obesity, lack of exercise)
- Nulliparous
- early menarche/ late menopause
BRCA1&2
History of:
family
infertility
endometriosis
5
Q
OVARIAN CANCER
Epidemiology
A
1/5th most common cancer in women
incidence rises with age
PEAK 70/80s
6
Q
OVARIAN CANCER
Clinical Presentation
A
- 75% present with advanced disease (3rd/4th stage)
- IBS symptoms in older women
LATER
- abdominal discomfort/bloat/distention
- urinary frequency
- dyspepsia
- fatigue
- weight loss
MASS WITH PAIN
7
Q
OVARIAN CANCER
Ddx?
A
- benign tumour/cyst
- endometriosis
- bowel mass
- peritoneal carcinoma
8
Q
OVARIAN CANCER
Diagnostic tests and results?
A
- Symptoms and age
- Ca125 tumour marker
- USS + CT abdomen
- CXR pleural effusion +lung mets?
9
Q
OVARIAN CANCER
Staging?
A
1- ovaries
2- one or both ovaries with pelvic extension/ implants
3- one or both ovaries with microscopically confirmed peritoneal implants outside pelvis
4- one or both ovaries with distant mets
10
Q
OVARIAN CANCER
Treatment?
A
Abdominal hysterectomy and bilateral salpingo-oopherectomy
Chemo for stage 2-4
Radio for early disease
11
Q
ENDOMETRIAL CANCER
basic scientific definition
A
Cancer of the endometrium arises from the lining of the uterus and is an OESTROGEN DEPENDANT TUMOUR
this can include myometrial sarcoma
12
Q
ENDOMETRIAL CANCER
Risk Factors?
A
- prolonged exposure of unopposed oestrogen
- Nulliparous
- Late menopause
- Obesity
- Diabetes
- Tamoxifen (breast cancer prevention/treatment)
13
Q
ENDOMETRIAL CANCER
What is the most common type of tumour and what are the two different types?
A
80% are adenocarcinomas
Type 1= Oestrogen dependent endometrioid
Type 2= Oestrogen-independent non-endometrioid carcinomas
14
Q
ENDOMETRIAL CANCER
Epidemiology?
A
90% of women with endometrial cancer are over 50
15
Q
ENDOMETRIAL CANCER
Clinical Presentation
A
Post-menopausal bleeding/abnormal uterine bleeding- EARLY SIGN
- heavy/irregular periods in pre-menopausal
16
Q
ENDOMETRIAL CANCER
Diagnostic tests and results?
A
- Transvaginal US scan (TVS- Transvaginal sonography)- endometrial thickness >4mm
- Endometrial pipelle biopsy if over 4mm
- Hysteroscopy
17
Q
ENDOMETRIAL CANCER
Treatment?
A
- Total abdominal/ laparoscopic hysterectomy with bilateral salpingo-oopherectomy with/without lymphadectomy
- post-operative chemotherapy
18
Q
CERVICAL CANCER
Cause?
A
persistent infection with human papillomavirus (HPV)
19
Q
CERVICAL CANCER
What is CIN?
A
Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer.
20
Q
CERVICAL CANCER
Describe the 3 grades of CIN
A
CIN I= lower basal 1/3 of cervical epithelium
CIN II= affects <2/3 of cervical epithelium
CIN III= affects >2/3 of full thickness of epithelium
21
Q
CERVICAL CANCER
who is screened?
A
25-49 every 3 years
50-65 every 5 years
22
Q
CERVICAL CANCER
What is dyskaryosis?
A
Dyskaryosis means abnormal nucleus and refers to the abnormal epithelial cell which may be found in cervical sample. It is graded from low to high grade based on degree of abnormality.
23
Q
CERVICAL CANCER
name the tests/ plan from a :
Borderline/ mild dyskaryosis?
A
Test for HPV
-ve = back to routine
+ve= colposcopy
24
Q
CERVICAL CANCER
name the tests/ plan from a :
moderate dyskaryosis?
A
Urgent colposcopy within 2 weeks. Consistent with CIN II.
25
CERVICAL CANCER
name the tests/ plan from a :
severe dyskaryosis or suspected invasive cancer?
Urgent colposcopy within 2 weeks.
consistent with CIN III
26
CERVICAL CANCER
name the tests/ plan from a :
inadequate smear?
what if they keep being inadequate?
inadequate = repeat smear
consistently inadequate = colposcopy
27
CERVICAL CANCER
Risk factors?
- persistent HPV (high risk is HPV 16&18)
- early intercourse <16yrs
- women with multiple sexual partners
- smoking limits ability to clear HPV
- lower social class
- immunosuppression
- COCP
- non attendance of cervical screening programme
28
CERVICAL CANCER
what are the 3 most common tumours seen?
- bulky ectocervical tumour which fills uppeer vagina
- invasive, bulky tumour that can enlarge to a size that fills lower pelvis
- destructive, invasive tumour that erodes tissues, causing ulceraton and excavation with infected, necrotic cavities
29
CERVICAL CANCER
What % of cancers are found through screening and what is the most common age to get it?
Most common type of tumour?
30% found through screening
most common age is 25-34
70% of tumours are squamous cell
30
CERVICAL CANCER
Clinical presentation?
- Abnormal vaginal bleeding
- Vaginal discharge
- post micturition bleeding
- vaginal discomfort/ urinary symptoms
- Haematuria
- polyuria
- red or white patches on cervix
- pelvic mass
31
CERVICAL CANCER
Ddx?
- cervicitis
- dysfunctional uterine bleeding
- PID
- endometrial cancer
32
CERVICAL CANCER
Diagnostic tests and results?
- Colposcopy with cystoscopy
- Punch biopsy
- bimanual examination (rough and hard cervix)
CT scan for mets +- lymph nodes
PET for staging (FIGO staging)
33
CERVICAL CANCER
treatment?
- Local excision/ hysterectomy
Potential Radio
- Chemo (most common cisplatin)
34
VULVAL CANCER
Cause?
Most common type of tumour?
symptoms?
Tx?
Cause- Vulval intraepithelial neoplasia
Tumour? Squamous (90%)
```
Symptoms?
vulval itch/sore
persistent lump
post-menopausal bleeding
painful urination
```
tx? Surgery/radio
35
VAGINAL CANCER
Cause and epidemiology?
Symptoms and tx?
commonly HPV or due to metastatic spread from cervical/uterine
bleeding & radio.
poor prognosis- 58% 5 yr survival
36
BREAST CANCER
Risk factors?
modifiable and non modifiable lifestyle factors?
Modifiable = weight, exercise, smoking, alcohol
Non-modifiable= age, breast density, menopause age, BRCA 1&2
HRT
37
BREAST CANCER
Clinical features?
Commonly- normal looking breast with small lump 90%
inflammatory- peau d'orange in drawn nipple and lymphatic oedema
Metastatic-bones (pain in hip/fracture presentation)
38
BREAST CANCER
Presenting symptoms?
- Painless lup
- nipple discharge/ in-drawing
- skin tethering
Pain and tenderness uncommon
39
BREAST CANCER
Diagnosis?
TRIPLE ASSESSMENT
Clinical score 1-5
Imaging score 1-5
Biopsy score 1-5
- Mammography
- High resolution US
- Core biopsy
40
BREAST CANCER
What are the tumour markers?
CA 15-3
41
BREAST CANCER
when would you use breast conservation treatment?
small tumour relative to breast size <25%
not allowed if under nipple
pre op chemo and additional radio if this tx is chosen
42
BREAST CANCER
When would you do a mastectomy?
- large tumour relative to breast size
- tumour underneath nipple/ in drawing nipple
- more than one cancer in same breast
- delayed reconstuction
- patient choice
43
BREAST CANCER
40% of breast cancers have axillary disease.
when would you use full-axillary clearance?
what are the complications?
if glands are clinically involved
no need for further surgery
- 10% lymphedema
high complication rate- seromas, arm stiffness, drain, axillary numbness
44
BREAST CANCER
when would you do limited axillary surgery?
what are the benefits of limited surgery.
if glands are clinically normal
- day surgery, no significant complications, no drains, day surgery
45
BREAST CANCER
What are the histological morphology subtypes?
What staging is used?
- Ductal carcinoma 70%
- Lobular 10%
TNM staging
46
BREAST CANCER
if a woman is HER-2 positive what post op treatment must she take?
Trastuzumab
47
BREAST CANCER
All women are ER+ve.
what drugs must be taken post op if they are:
Pre-menopause
post-menopause
Pre= Tamoxifen (inhibits oestrogen receptors on breast cancer cells
Post= Aromatase inhibitors (inhibits aromatase enzyme responsible for conversion of androgens to oestrogen post menopausal)
Anastrozole
48
BREAST CANCER
When would someone have
Radiotherapy?
Chemotherapy?
Radio = when a women has had lumpectomy and aggressive disease after mastectomy
Chemo = aggressive disease and high risk (e.g young age, HER-2 +ve or ER -ve, grade 3, node positve and tumour size)
49
ATROPHIC VAGINITIS
What is it common in and why?
how is it diagnosed?
Common in post-menopausal women due to falling levels of oestrogen.
Diagnosis of exclusion. Rule out pathology first through TVS
50
ATROPHIC VAGINITIS
Causes?
- Natural menopause or oophorectomy
- Anti- oestrogen treatments e.g- Tamoxifen, aromatase inhibitors
- Radio/chemo
- can occur post-partum due to reduced oestrogen levels
51
ATROPHIC VAGINITIS
When oestrogen levels fall what changes are seen to the vaginal mucosa?
- Thinner
- Drier
- Less elastic
- more fragile
52
ATROPHIC VAGINITIS
When oestrogen levels fall what changes are seen to the vaginal epithelium
becomes inflamed contributing to urinary symptoms
53
ATROPHIC VAGINITIS
When oestrogen levels fall this changes vaginal pH,flora and potentially periurethral tissues. Why is this bad?
- changes in vaginal pH/flora may predispose to UTI's or vaginal infections
- if periurethral tissues are affected this may contribute to pelvic laxity and stress incontinence
54
ATROPHIC VAGINITIS
Clinical Symptoms?
- Vaginal dryness
- Burning/itching of vagina
- Dyspareuria
- Vaginal discharge
- Post-meno bleeding
- Urinary symptoms
55
ATROPHIC VAGINITIS
Name some urinary symptoms?
- polyuria
- nocturia
- dysuria
- UTIs
- Stress/urgency incontinence
56
ATROPHIC VAGINITIS
Clinical signs?
- Reduced pubic hair
- Painful vaginal examination
- Lack of vaginal folds
57
ATROPHIC VAGINITIS
Ddx?
- Genital infections
- Uncontrolled diabetes
- Local irritation due to soap/underwear
58
ATROPHIC VAGINITIS
Diagnostic tests and results?
TVS- rule out pathology
| - Investigate if post menopausal bleeding is occuring
59
ATROPHIC VAGINITIS
Treatment?
- Vaginal lubricants and mositurisers
- Vaginal oestrogen
- HRT
60
FIBROIDS
What are they?
What are they stimulated by?
Why may they go through benign degeneration and calcification?
Common benign tumours of the smooth muscle cells of the uterine myometrium
stimulated by O&P
benign calcification may occur due to the centre of larger fibroids not receiving adequate blood supply
61
FIBROIDS
How are they classified?
What are the most common type?
- Intramural
- Submucosal
- Subserosal
Most common is intramural
62
FIBROIDS
What do they following terms mean:
Intramural?
Submucosal?
Subserosal?
Intramural- growing within the endometrium
Submucosal- growing into the uterine cavity (can be pedunculated and may protrude through cervical os)
Subserosal- growing outwards from the uterus. Uterine, cervical, intraligamentous, pedunculated subserous (abdominal)
63
FIBROIDS
Cause?
Acquired genetic change plus effects of hormones and growth factors
64
FIBROIDS
Risk factors?
- Obesity
- Early menarche
- Afro-caribbean
- Aged 30-40
- Family history
- COCP
- Pregnancy
65
FIBROIDS
Epidemiology?
single most common indication for hysterectomy. (clinically apparent in up to 25% of women)
66
FIBROIDS
Clinical presentation?
- Half may be asymptomatic
- Present between 30-50
- Excessive/prolonged heavy periods
Pelvic pain
- Recurrent miscarriage
- Subfertility
67
FIBROIDS
What may be found on examination?
what may menorrhagia cause?
Palpable abdominal mass arising from pelvis
potential iron-deficiency anaemia which may lead to lethargy and pallor
68
FIBROIDS
Ddx?
- Dysfunctional uterine bleeding
- Endometrial polyps, cancer, endometriosis
- PID
- Ovarian tumour
- Pregnancy
69
FIBROIDS
Diagnostic tests an results?
- Pregnancy test
- FBC (anaemia)
- TVUS
MRI if US not definitive
70
FIBROIDS
Medical treatment?
- Tranexamic acid-antifibrinolytic agent
- GnRH agonists
- Ulipristal acetate
71
FIBROIDS
Surgical treatment?
- Myomectomy
| - Hysterectomy (only cure for fibroids) for women who have completed their family
72
FIBROIDS
When would you do a myomectomy?
- excessive enlarged uterine size
- Pressure symptoms present
- Medical management not sufficient to control symptoms
- Fibroids are causing subfertility
73
FIBROIDS
NAme a GnRH agonist and its cons?
- Goserelin
they used to shrink fibroids but then fibroids regrow when discontinued.
Not a long term option as it will start to demineralise bone
74
FIBROIDS
What is ulipristal acetate, what does it do and when is it used?
- Selective progesterone receptor modulator
they shrink fibroids and induce amenorrhoea
used before surgery and for emergency contraception
75
OVARIAN CYSTS
What are the three main types?
- Functional (24%)
- Benign (70%)
- Malignant (6%)`
76
OVARIAN CYSTS
Name some benign neoplastic causes
Benign epithelial neoplastic cysts
Benign neoplastic cystic tumours of germ cell origin
Benign neoplastic solid tumours
(Fibroma <1% malignant)
77
OVARIAN CYSTS
Name some benign fibrous causes
- Adenofibroma
- Teratoma
- brenner tumour
78
OVARIAN CYSTS
What is a brenner tumour
Brenner tumours are a rare subtype of the surface epithelial-stromal tumour group of ovarian neoplasms. majority are benign but some are malignant
79
OVARIAN CYSTS
Risk factors?
- Obesity
- Tamoxifen therapy
- Early menarche
- Infertility
- Dermoid cysts can run in families TERATOMAS
80
OVARIAN CYSTS
Epidemiology?
- Predominantly pre-menopausal
| - benign neoplastic cystic tumours of germ cell origin are most common in young women
81
OVARIAN CYSTS
Clinical presentation?
PAIN
- dull ache in lower abdomen
- lower back pain
- rupture can lead to severe abdo pain + fever
- Dyspareuria
- Irregular vaginal bleeding
82
OVARIAN CYSTS
Examination findings?
What would ascites suggest?
- Swollen abdomen with palpable mass, dull to percussion
Ascites suggests malignancy
83
OVARIAN CYSTS
What may cysts cause?
- Torsion, infarction or haemorrhage which would cause severe pain
84
OVARIAN CYSTS
Complications of rupture?
rupture can cause peritonitis and shock
85
OVARIAN CYSTS
What can hormone secreting tumours cause?
- virilisation
- menstrual irregularities
- post-menopausal bleeding
86
OVARIAN CYSTS
Ddx?
- PCOS
- Endometrioma
- Malignant ovarian tumour
- bowel problems
- PID
87
OVARIAN CYSTS
Diagnostic tests and results?
- Pregnancy test
- FBC for infection/haemorrhage
- TVS/USS
CT/MRI if USS not definitive
Diagnostic laparoscopy
88
OVARIAN CYSTS
What is the tumour marker for Ovarian cancer
CA125
89
OVARIAN CYSTS
For suspected ovarian cancer we do a RISK OF MALIGNANCY INDEX (RMI)
What is this a product of?
Product of USS score, menopausal status and serum CA125 levels
90
OVARIAN CYSTS
in the RMI we do a USS score. What findings add a point to the USS score?
(out of 5)
USS scores 1 point for each of the following:
- Multi ocular cysts
- Solid areas
- Metastases
- Ascites
- Bilateral lesions
91
If you were to find Rokitansky's Protuberance on histopathology what would this mean?
A solid protuberance from a mature dermoid cyst (teratoma)
It often contains calcific, dental, adipose, hair, and/or sebaceous components. This region has the highest propensity to undergo malignant transformation.
92
OVARIAN CYSTS
Treatment?
Small?
Moderate?
Large?
small <50mm = do not require follow up
Moderate 50-70mm = yearly US follow up
Large = consider further MRI imaging
93
OVARIAN CYSTS
Surgical treatment?
Cystectomy
Oopherectomy
Acute onset of symptoms require hospital admission
94
OVARIAN TORSION
Clinical presentation?
Sudden onset deep seated colicky pain
- Iliac fossa pain radiating to loin,groin or back
- potential fever
- Pain may improve after 24hrs and the ovary is dead
95
OVARIAN TORSION
What may US show?
free fluid (oedema) due to venous supply cut off
whirlpool sign (twisting/volvulus)- wrapping of vessels around a central axis which makes it look a bit like a target.
96
OVARIAN TORSION
Diagnostic test?
Laparoscopy
97
What is Mittelschmerz?
Ovulation pain that can last up to 48 hours
usually on one side of the abdomen
98
ENDOMETRIOSIS
What is it?
- Chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity
99
ENDOMETRIOSIS
Where is it most common?
- Pelvic cavity (including ovaries
- Uterosacral ligaments
- Pouch of Douglas
- Recto-sigmoid colon
- Bladder
- Distal ureter
100
ENDOMETRIOSIS
What is Adenomyosis?
The invasion of endometrial tissue into the myometrium
101
ENDOMETRIOSIS
Cause?
- Retrograde menstruation
| - Impaired immunity (retrograde tissue isn't destroyed)
102
ENDOMETRIOSIS
Risk Factors?
- Early menarche
- Late menopause
- Delayed childbearing
- Short menstrual cycles
- Obstruction to vaginal outflow
- Fallopian or uterus defects
- Genetic predisposition
- Alcohol use
- low body weight
103
ENDOMETRIOSIS
What is seen to be protective of endometriosis?
- multiparity
| - COCP
104
ENDOMETRIOSIS
Epidemiology?
Higher prevalence in infertile women 25-40%
exclusive to women of reproductive age
105
ENDOMETRIOSIS
Classic triad of symptoms?
- Dysmenorrhoea
- Deep dyspareuria
- Cyclical or chronic pelvic pain
(chronic/constant inflammation brings pain)
106
ENDOMETRIOSIS
Other symptoms?(other than triad)
- Sub fertility
- Dysuria
- Bloating
- lethargy
- Constipation
- Lower back pain
107
ENDOMETRIOSIS
Ddx?
- PID
- Ectopic pregnancy
- Torsion of ovarian cyst
- Appendicitis
- Primary dysmenorrhoea
- IBS
- uterine fibroids
108
ENDOMETRIOSIS
Diagnostic tests and results?
Gold standard?
gold= Laparoscopy with biopsy
- Bimanual examination
- Transvaginal US
- MRI good for if bowel involved
109
ENDOMETRIOSIS
Whats the classic sign on a bimanual examination?
Fixed, retroverted uterus
110
ENDOMETRIOSIS
Treatment for pain?
NSAIDs/Paracetamol
111
ENDOMETRIOSIS
Medical treatment?
Suppression of ovarian function for at least 6 months:
- COCP
- Medroxyprogesterone acetate (injectable contraception)
- GnRH agonist (Goserelin) for a max of 6 months
112
ENDOMETRIOSIS
Surgical treatment?
Laparoscopic excision or ablation
Hysterectomy with salpingo-oophorectomy (last resort)
113
POLYCYSTIC OVARIAN SYNDROME (PCOS)
What is it?
A syndrome of polycystic ovaries in association with systemic symptoms causing reproductive, metabolic and psychological disturbances
114
PCOS
What is the basic pathophysiology?
Excess androgens produced by theca cells of the ovaries due to either:
1) hyperinsulinaemia
2) Increase of luteinising hormone (LH) levels
115
PCOS
How are excess androgens caused by hyperinsulinaemia?
1) Insulin resistance, weight gain leads to further insulin resistance
2) This leads to increased androgen production and reduced production of sex hormone-binding globulin (SHBG) in the liver
3) Free testosterone subsequently raised
116
PCOS
Why does hyperinsulinaemia cause increased androgen production?
Insulin mimics the action of insulin growth factor 1 (IGF-1), which augments androgen production by the theca cell in response to LH. Since insulin decreases levels of SHBG, the circulating levels of free testosterone are also increased.
117
PCOS
Why may you have raised LH?
- Increase production in the anterior pituitary
| - genetic conditions, like Turner syndrome or Klinefelter syndrome
118
PCOS
Clinical presentation?
(common triad)
- Oligomenorrhoea (less than 9 periods a year)/ Amenorrhoea
- Infertility/ subfertility
- Signs of androgen production (excess testosterone)
119
PCOS
Name some signs of excess androgen production?
- Acne
- Hirsutism (XS hair)
- Deep voice
- Alopecia
- Male pattern balding
- reduced breast size
120
PCOS
Name some signs of insulin resistance
- Acanthosis nigricans
- psychological symptoms (depression, mood swings, anxiety, poor self-esteem)
- Obesity
- Sleep apnoea
121
What is the commonest cause of secondary infertility?
PCOS
122
PCOS ddx?
- thyroid disorder
- cushings
- acromegaly
- medication side effects
- Hyperprolactinaemia
123
PCOS
Diagnostic tests? Triad?
- signs of excess androgen production (acne, hirsutism, decreased breast size)
- oligo/amenorrhoea
- cystic ovaries on US (12 or more on one ovary) - strings of pearls
124
PCOS
Biochemical results?
- Raised testosterone
- Sex hormone binding globulin (SHBG) low
LH levels elevated (1:1 ratio to FSH)
Impaired glucose tolerance (insulin resistance)
125
PCOS
Which hormone is always normal on test?
Prolactin
126
PCOS
What is the Rotterdam Criteria?
Strings of pearls
Hyperandrogenism
Oligomenorrhoea
Prolactin normal
SHOP
127
PCOS
Treatment?
TREAT THE SYMPTOMS
128
PCOS
Treatment of Hirsutism and acne?
Co-cyprindol /Eflornithine
SEVERE Acne= Isotretinoin
129
PCOS
Tx for insulin resitance?
Metformin
130
PCOS
Tx for weight loss?
Lifestyle
Medication =Orlistat
131
PCOS
tx for fertility?
- Letrozole
- Metformin
- Laparoscopic ovarian drilling or gonodotrophins
- Need 4 periods a year to develop lining of the womb
132
What is Menopause?
Permanent cessation of menstruation from loss of follicular activity
133
MENOPAUSE
Symptoms and Consequences of menopause?
- CV disease (cause of death of 1/3 of women)
- Vasomotor symptoms
- Urogenital problems due to oestrogen deficiency
- Osteoporosis
134
MENOPAUSE
Early signs of menopause?
- irregular periods
- vasomotor
- vaginal dryness
- reduced libido
- poor conc and fatigue
- headaches
- joint pain
135
MENOPAUSE
signs of ongoing menopause?
GU symptoms (frequency, urgency, UTIs)
Atrophic vaginitis
PMB
136
MENOPAUSE
Late signs of menopause?
- Osteoporosis
- CVD
- Dementia
137
MENOPAUSE
Name some vasomotor symptoms?
- Hot flushes
- Night sweats
- Palpitations
138
MENOPAUSE
Name some urogenital problems due to oestrogen deficiency
- Dyspareuria
- Dryness
- Frequency, urgency, incontinence
139
MENOPAUSE
Investigations?
- increased FSH suggests fewer oocytes
DEXA scan for bone density estimation and biochemistry for monitoring
140
MENOPAUSE
What is the direct measurement of ovarian reserve?
Anti-mullerian hormone
141
MENOPAUSE
treatment?
HRT
may consist of oestrogen progesterone and tibolone (mixed) to treat symptoms and conserve bone density
142
What are the pros and cons of HRT?
Pros:
- Symptom management
- Osteoporosis prevention
- Colo-rectal cancer prevention
Cons
- Risk breast Ca if combined
- Risk of endometrial Ca if oestrogen only
- Risk of gallbladder disease
143
MENOPAUSE
Treatment for hot flushes and night sweats?
- Progesterone, Clonidine, SSRIs
144
MENOPAUSE
Medical Treatment for Osteoporosis?
1st- Bisphosphonates
2nd - strontium ranelate
3) Teriparatide
4th- denosumab
145
Ddx for Intermenstrual bleeding?
Pregnancy related (ectopic, hydatiform molar, miscarriage)
Fibroids
Endometriosis
Infection (STI)
Cancers (endometrial, cervical)
Iatrogenic (tamoxifen, missed pill, drugs altering clotting e.g. SSRIs, anti-coags, corticosteroids)
146
Post-coital bleeding Ddx?
- Infection
- Cervical/ endometrial polyps
Cervical/endometrial/vagina cancer
- Trauma
147
Pelvic pain Ddx?
Pregnancy related
Appendicitis
PID
ovarian cysts, torsion, fibroids, endometriosis
UTI/ pyelonephritis
Kidney stones
148
What are common symptoms of a:
Ectopic Pregnancy?
USUALLY ACUTE
6-8 weeks of:
- Amneorrhoea
Lower abdominal pain
Later develops vaginal bleeding
Shoulder tip pain
& cervical excitation may be seen
149
What are common symptoms of a:
UTI?
USUALLY ACUTE
Dysuria and frequency
suprapubic burning
150
What are common symptoms of a:
Appendicitis?
USUALLY ACUTE
Pain in abdomen then moves to right iliac fossa
- Tachycardia
- Pyrexia
- Rovsings Sign (press LIF and get more pain in RIF)
151
What are common symptoms of a:
Pelvic Inflammatory Disease?
USUALLY ACUTE
- Pelvic pain
- Fever
- Deep dyspareuria
- Discharge
- Dysuria and menstrual irregularities
- cervical excitation on examination
152
What are common symptoms of a:
Ovarian Torsion?
USUALLY ACUTE
sudden onset unilateral lower abdominal pain (brought on by exercise)
Nausea and vomiting
Unilateral tender adnexal mass on examination
153
What are common symptoms of a:
Miscarriage?
USUALLY ACUTE
Vaginal bleeding
crampy lower abdominal pain
following a period of amenorrhoea
154
What are common symptoms of a:
Endometriosis?
USUALLY CHRONIC
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
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What are common symptoms of a:
IBS?
USUALLY CHRONIC
- bloating, abdo pain, change in bowel habit
- Nausea
156
What are common symptoms of a:
Ovarian cyst?
USUALLY CHRONIC
Unilateral dull ache (could be intermittent or only coital pain)
torsion or rupture = severe abdo pain
large cysts = abdominal swelling or pressure effects on bladder
157
What are common symptoms of a:
Urogenital prolapse?
USUALLY CHRONIC
Older women
Pressure, heaviness 'bearing down'
urinary symptoms : incontinence, frequency, urgency
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Define Menarche?
Last manifestation of puberty following development of secondary sex characteristics by oestrogen
The hypothalamic- pituitary axis is involved as:
GnRH > FSH, LH > ostrogen release from ovaries
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What causes a menstrual cycle?
Hormonal changes causes ovulation and induce endometrial change to prepare for implantation
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MENSTRUAL CYCLE
What happens in day:
1-4?
- hormonal support withdrawn
- endometrial shed
- sometimes painful myometrial contraction
Oestradiol increase causes endometrium to reform and thicken
Positive feedback on LH causes ovulation 36 hours later
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MENSTRUAL CYCLE
What happens in day:
5-13?
GnRH stimulates FSH & LH
LH induces follicular growth which produces oestradiol and
inhibin > suppresses FSH with negative feedback so only one oocyte matures
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MENSTRUAL CYCLE
What happens in day:
14-28?
Follicle that becomes Corpus Luteum, which produces more progesterone than oestradiol causing increased blood supply and cells to enlarge in the endometrium
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What happens if the corpus luteum is not fertilised?
The corpus luteum will collapse if the egg is not fertilised causing oestrogen and progesterone levels to fall.
164
PREMENSTRUAL SYNDROME
What is it?
Premenstrual syndrome describes the emotional and physical symptoms women experience prior to menstruation > ie. in luteal phase
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PREMENSTRUAL SYNDROME
Common symptoms?
- Anxiety
- stress
- fatigue
- mood swings
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PREMENSTRUAL SYNDROME
Management?
Treatment for severe?
- Lifestyle advice, healthy diet, exercise, stress reduction methods, regular sleep
Paracetamol
COCP
SSRIs
for mederate to severe
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MENORRHAGIA
Definition?
Excessive menstrual blood loss (>80mL) within a normal menstrual cycle, interfering with the woman’s physical, emotional and social quality of life.
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MENORRHAGIA
Causes?
Most = no histological problem
30% fibroids
10% polyps
OTHERS
- PID
- Malignancy
- Hypothyroidism
- Von willebrand disease
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MENORRHAGIA
Assessment?
- FBC, TSH/T4, coagulation function
- TVS to assess endometrial thickness and masses
(If >10mm and >40 then endometrial biopsy with hysteroscopy to exclude cancer)
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MENORRHAGIA
Medical management?
1st- IUS e.g Mirena
2nd - Tranexamic acid (antifibrinolytic), NSAIDs or COCP
3rd- Progestogen e.g. depo or GnRH agonist causing amneorrhoea
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MENORRHAGIA
Surgical treatment?
- Endometrial ablation
- resection of fibroids
- Uterine artery embolization
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Post coital bleeding
What is it and what are the likely causes?
What is the assessment?
- Non-menstrual bleeding that occurs immediately after sexual intercourse
Causes :
infection
cervical ectropion, polyps, carcinoma
Assessment - examination and smear
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What is primary amenorrhoea?
if menstruation has not started by the age of 16.
Absence of secondary sexual characteristics by 14 with no menarche.
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what is secondary amneorrhoea
When previously normal menstruation seizes for over 6 months
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AMENORRHOEA
Causes of primary amenorrhoea?
- Turner's Syndrome
- Androgen Insensitivity Syndrome
- Congenital malformations of genital tract
- Congenital adrenal hyperplasia
- IMPERFORATE HYMEN
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What is Oligomenorrhoea?
menstruation occurring every 35days to 6 months
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AMENORRHOEA
Why may a low birth weight cause secondary amenorrhoea?
Low birth weight is linked to increased Ghrelin.
- Ghrelin inhibits hypothalamic - pituitary ovarian axis so therefore GnRH amplitude is altered.
- This decreases the pituitary release of FSH and LH
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AMENORRHOEA
Causes of secondary amenorrhoea?
- Drug induced
- pregnancy (breast-feed)
- Hyperprolactinaemia (inhibits GnRH secretion)
- Hypothyroidism
- Ovarian causes (PCOS)
- Pituitary tumour
- Hypothalamic hypogonadism
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AMENORRHOEA
investigations?
- BhCG (check for pregnancy)
- FSH/LH
- Prolactin
- TFTs
- Testosterone levels
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AMENORRHOEA
What would a low FSH/LH mean?
Hypothalamic pituitary ovarian axis problem
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AMENORRHOEA
What would a high FSH/LH mean?
Premature ovarian failure
182
AMENORRHOEA
Treatment of premature ovarian failure?
this cannot be reversed with HRT
However;
Enough given to control symptoms of oestrogen deficiency + prevent osteoporosis
183
AMENORRHOEA
Treatment of HPO axis malformation?
If mild (stress/exercise) = sufficient activity to stimulate enough oestrogen to produce an endometrium
Severe = GnRH analogues
184
AMENORRHOEA
What would you give to a woman who is wanting fertility now?
Clomifene for mild symptoms
185
Why may someone get Dysmenorrhoea?
high prostaglandin levels in the endometrium
Contraction
Uterine Ischaemia
186
Causes of secondary Dysmenorrhoea?
```
Fibroids
Adenomyosis
Endometriosis
PID
Tumours
```
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GENITOURINARY PROLAPSE
What is it?
descent of one or more of the pelvic organs including:
```
uterus/ vaginal walls
bladder
rectum
small/large bowel
Vaginal vault
```
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GENITOURINARY PROLAPSE
Associated symptoms?
Urinary
Bowel
Sexual
Local pelvic symptoms
189
GENITOURINARY PROLAPSE
Risk factors?
- Increasing age
- Vaginal delivery
- Increasing parity
- High BMI
- Spina bifida and spina bifida occulta (occulta is latin for hidden- closed spina bifida)
- Pelvic mass
- Menopause
- Iatrogenic (pelvic surgery
190
How may a prolapse occur?
pelvic organs losing their structure through muscle trauma, neuropathic injury or stretching
- orientation and shape of pelvic bones have also been implicated
191
What muscles support the pelvic organs?
Levator ani muscles and endopelvic fascia
192
Name the three anterior compartment prolapses
Urethrocele- urethra into vagina
Cystocele- bladder into vagina
Cystourethrocele- both
193
Name the three middle compartment prolapses
Uterine prolapse- into vagina
vaginal vault prolapse - descent of vaginal vault post hysterectomy
Enterocele
194
What is an enterocele?
Herniation of the pouch of Douglas into the vagina
195
What is a posterior compartment prolapse
Rectocele- prolapse of the rectum into the vagina
196
What are the 4 stages of vaginal prolapse
Stage 1 - more than 1cm above the hymen
Stage 2 - within 1cm proximal/distal of the hymen
Stage 3 - more than 1cm below the plane of the hymen but protudes no further than 2cm less than the total length of the vagina
stage 4 - complete eversion of the vagina
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GENITOURINARY PROLAPSE
Symptoms?
- Can be asymptomatic
- Sensation of dragging down, pressure, heaviness
Discomfort
Dyspareuria
198
GENITOURINARY PROLAPSE
anterior Symptoms?
- waterworks related
- incontinence
- frequency
- urgency
199
GENITOURINARY PROLAPSE
Posterior Symptoms?
- Constipation/straining
200
GENITOURINARY PROLAPSE
Diagnostic tests and results?
Sims speculum
Bimanual = exclude pelvic masses
potentially US/MRI
201
GENITOURINARY PROLAPSE
Treatment?
CONSERVATIVE - Reduction of intrabdominal pressure
- weight loss
- stop smoking
- constipation tx
- pelvic floor muscle exercises
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GENITOURINARY PROLAPSE
Surgical tx?
- Hysterectomy
- Colporrhapy (vaginal wall repair)
- Colposuspension (stress incontinence tx)
- Sacrohysteropexy (holds the uterus in place)
- Sacrospinous fixation
203
What is a sacrospinous fixation?
A sacrospinous fixation is an operation to attach the top of the vagina or the cervix (neck of the womb) to a pelvic ligament (sacrospinous ligament) with a stitch. ... The operation is primarily intended to treat prolapse of the uterus (womb) or the vault (top) of the vagina (if you have had a hysterectomy).
204
What is a sacrohysteropexy
Laparoscopic sacrohysteropexy is a surgical procedure to correct uterine prolapse by re-suspending the prolapsed uterus to the anterior longitudinal presacral ligament using a thin strip of polypropylene mesh
205
What is colposuspension?
Colposuspension is an operation to treat stress incontinence (leakage of urine when you exercise, sneeze or strain). We put stitches inside the pelvis through an incision (cut) across your lower abdomen (tummy). The stitches pull up your vagina around the area of the bladder opening.
206
What is a Colporrhaphy
Colporrhaphy is the surgical repair of a defect in the vaginal wall, including a cystocele (when the bladder protrudes into the vagina) and a rectocele (when the rectum protrudes into the vagina)
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INCONTINENCE
What are the two types?
Urgency - overactive bladder (involuntary detrusor muscle bladder contractions)
Stress- Sphincter weakness (detrusor pressure > closing pressure of urethra)
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INCONTINENCE
Symptoms of overactive bladder?
- URGENCY
- Frequency
- Nocturia
- 'Key in door'
- Enuresis
209
INCONTINENCE
Symptoms of stress?`
- coughing
- laughing
- lifting
- exercise
- movement
210
INCONTINENCE
Causes of stress?
- Menopause = low oestrogen = weakening pelvic support
| - radiotherapy, congenital weakness, pelvic surgery
211
INCONTINENCE
Simple assessments?
dipstick/ urinaylsis
- MSU
- urine diary
- residual urine measurement
- ePAQ questionnaire
212
INCONTINENCE
what would you check on Urinalysis?
Nitrates & leukocytes = infection
Haematuria= Glomerulonephritis
Proteinuria = Renal Disease
Glycouria = diabetes
213
INCONTINENCE
What would you check on a frequency volume chart? (urine diary)
- Frequency and quantity of urination
- Frequency and quantity of leakage
- Fluid intake
- Diurnal viariation
214
INCONTINENCE
How do you measure residual urine?
Urine in and out of the catheter
215
INCONTINENCE
What is the ePAQ questionnaire?
Questionnaire to determine the impact on life to determine management plan
216
INCONTINENCE
What questions are involved in the ePAQ questionnaire
Urinary - pain, voiding, stress, overactive bladder
Vaginal- pain, capacity, prolapse
Bowel- IBS, constipation, continence
Sexual- dyspareuria, overall sex life
217
INCONTINENCE
Lifestyle treatment?
- weight loss
- reduce caffiene
- smoking cessation
- avoiding straining
218
INCONTINENCE
Containment treatment?
- Pads and pants
| - catheters
219
INCONTINENCE
Treatment of Stress incontinence?
- pelvic floor muscle training
Duloxetine (SNRI- antidepressant)
220
INCONTINENCE
Surgical treatment of stress incontinence?
- Support urethra
1) Colposuspension
2) Sling
3) TVT (tension free vaginal tape)
restore pressure transmission to urethra
221
INCONTINENCE
Surgical treatment for overactive bladder?
- Bladder Drill
- bypass
- botox
222
INCONTINENCE
Drug treatment for overactive bladder
Anticholinergics
Antimuscarinics
Adrenergic agonist
223
INCONTINENCE
Give examples of some Antimuscarinics
- Oxybutynin
| - Tolterodine
224
INCONTINENCE
What is the nerval innervation of the detrusor
Parasympathetic S2-S4
225
INCONTINENCE
Name an adrenergic agonist and what it does
Mirabegron
relaxes detrusor and increases bladder capacity
226
INCONTINENCE
Name some side effects of Antimuscarinics
- Dry mouth
- Blurred vision
- Drowsiness
- Constipation
- Tachycardia
227
What do FSH and LH bind to on the ovarian follicle?
LH = theca cells
FSH = granulosa cells
228
Where is GnRH produced?
Where are FSH and LH produced?
Hypothalamus
Anterior pituitary
229
When LH and FSH have binding to the various cells, what is produced?
1) Theca cells produce Androstenedione
2) Granulosa cells produce aromatase
3) Aromatase converts Androstenedione into oestrogen
4) oestrogen creates negative feedback to stop producing FSH
5) once oestrogen becomes really high = becomes positive feedback to produce loads of FSH and LH
6) Influx of FSH and LH = release of oocyte
230
What effect does high oestrogen levels have on the endometrium?
1) Thickening of endometrium
2) growth of endometrial glands
3) emergence of spiral arteries to supply the released oocyte
4) make cervical mucus more hospitable for incoming sperm
231
What is the dominant hormone in the luteal phase?
Progesterone - luteinised granulosa and theca cells produce progesterone and inhibin so a negative feedback on FSH/LH and oestrogen
232
What does the corpus luteum become?
Corpus albicans - doesn't produce hormones
low progesterone means spiral arteries collapse and functional layer sloughs off
233
What are the two phases of the uterus in the menstrual cycle?
days 1-14 = Menstrual/ follicular/ proliferative phase
days 15-28 = luteal/ secretory phase
