Gynaecology Flashcards
Ovarian enlargement: management
Management depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Premenopausal women
- a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Postmenopausal women
- by definition physiological cysts are unlikely
- any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
Cysts - can be described as?
The initial imaging modality for suspected ovarian cysts/tumours is ultrasound.
The report will usually report that the cyst is either:
- simple: unilocular, more likely to be physiological or benign
- complex: multilocular, more likely to be malignant
Endometrial hyperplasia - types, features
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types:
- simple
- complex
- simple atypical
- complex atypical
Features:
- abnormal vaginal bleeding e.g. intermenstrual bleeding
Management:
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised
Heavy menstrual bleeding - definition
Heavy menstrual bleeding (also known as menorrhagia) was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive.
The management of menorrhagia now depends on whether a woman needs contraception.
Heavy menstrual bleeding - Ix ?
- a full blood count should be performed in all women
- NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.
Heavy menstrual bleeding- mx ?
- Does not require contraception
- either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
- if no improvement then try other drug whilst awaiting referral - Requires contraception, options include
- intrauterine system (Mirena) should be considered first-line
- combined oral contraceptive pill
- long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
Pelvic inflammatory disease- causative ?
Causative organisms:
- Chlamydia trachomatis
+ the most common cause
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
PID - features ?
Features:
- lower abdominal pain (pain developing over a long duration - not as acute as ectopic for example)
- fever
- deep dyspareunia
- dysuria and menstrual irregularities may occur
- vaginal or cervical discharge (e.g. smelly discharge - that may be a sign of a sexually transmitted infection)
- cervical excitation
PID - Ix, and mx
Investigation
- a pregnancy test should be done to exclude an ectopic pregnancy
- high vaginal swab –these are often negative
- screen for Chlamydia and Gonorrhoea
(endocervical swab specifically a NAATS test )
Management
- oral ofloxacin + oral metronidazole or
intramuscular ceftriaxone + oral doxycycline + oral metronidazole
- RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
PID - complications?
- perihepatitis (Fitz-Hugh Curtis Syndrome)
- -occurs in around 10% of cases
- -it is characterised by right upper quadrant pain and may be confused with cholecystitis
- infertility - the risk may be as high as 10-20% after a single episode
- chronic pelvic pain
- ectopic pregnancy
Amenorrhoea - definiton
Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).
Causes of primary amenorrhoea
- Turner’s syndrome
- testicular feminisation - complete androgen insensitivity syndrome, this is a genetic disorder that makes XY fetuses insensitive (unresponsive) to androgens (male hormones). Instead, they are born looking externally like normal girls
- congenital adrenal hyperplasia
- congenital malformations of the genital tract
Causes of secondary amenorrhoea ?
Secondary amenorrhoea is defined as when menstruation has previously occurred but has now stopped for at least 6 months.
- pregnancy
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS) - hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis* (*hypothyroidism may also cause amenorrhoea)
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
Amenorrhoea - initial investigations?
- exclude pregnancy with urinary or serum bHCG
- gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- prolactin
- androgen levels: raised levels may be seen in PCOS
- oestradiol
- thyroid function tests
Hyperemesis gravidarum
Whilst the majority of women experience nausea (previously termed ‘morning sickness’) during the early stages of pregnancy it can become problematic in a minority of cases. The Royal College of Obstetricians and Gynaecologists (RCOG) now use the term ‘nausea and vomiting of pregnancy’ (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*
*and in very rare cases beyond 20 weeks.
Hyperemesis gravidarum - associations
Associations
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
(Smoking is associated with a DECREASED incidence of hyperemesis)
Referral criteria for nausea and vomiting in pregnancy
NICE Clinical Knowledges Summaries recommend considering admission in the following situations:
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
They also recommend having a lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.
Diagnosis of Hyperemesis gravidarum
The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
Management of Hyperemesis gravidarum
- antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
- ondansetron and metoclopramide may be used second-line
metoclopramide may cause extrapyramidal side effects - ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
-admission may be needed for IV hydration
Complications of Hyperemesis gravidarum?
- Wernicke’s encephalopathy - patients can present with diplopia and ataxia suggestive of this. Therefore supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.
- Mallory-Weiss tear
- central pontine myelinolysis
- acute tubular necrosis
- fetal: small for gestational age, pre-term birth
Endometrial hyperplasia is caused by …
Endometrial hyperplasia is caused by oestrogen which is unopposed by progesterone
Endometrial hyperplasia is associated with:
- Taking oestrogen unopposed by progesterone
- Obesity
- Late menopause
- Early menarche
- Aged over 35-years-old
- Being a current smoker
- Nulliparity
- Tamoxifen (oestrogen unopposed by progesterone)- Tamoxifen is a risk factor due to its pro-oestrogen effect on the uterus and bones. It does also have an anti-oestrogen effect on the breast.
Endometrial hyperplasia - definiton
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle.
- A minority of patients with endometrial hyperplasia may develop endometrial cancer
Endometrial hyperplasia - types
- simple
- complex
- simple atypical
- complex atypical
Endometrial hyperplasia - features ?
Features
- abnormal vaginal bleeding e.g. intermenstrual
Endometrial hyperplasia - mx?
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised
In a young woman taking COCP, with post- coital bleeding - what would be the diagnosis?
cervical ectropion
Cervical ectropion
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
The term cervical erosion is used less commonly now
This may result in the following features
- vaginal discharge
- post-coital bleeding
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of …
an ectopic pregnancy
Ectopic pregnancy - features
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
- lower abdominal pain
- -due to tubal spasm
- -typically the first symptom
- -pain is usually constant and may be unilateral.
- vaginal bleeding
- -usually less than a normal period
- -may be dark brown in colour
- history of recent amenorrhoea
- -typically 6-8 weeks from the start of last period
- -if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
- peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
- dizziness, fainting or syncope may be seen
- symptoms of pregnancy such as breast tenderness may also be reported
(Shoulder tip pain and cervical excitation may be seen)
Ectopic pregnancy - Examination findings
- abdominal tenderness
- cervical excitation (also known as cervical motion tenderness)
- adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
Where the initial serum bHCG level is <1,500 IU per ml, serial bHCG measurements may be required (48 hours apart), what would different results mean?
- Where there is an increase in serum bHCG >63%, the woman is likely to have a developing intrauterine pregnancy.
- Where there is a DECREASE in serum bHCG >50%, the pregnancy is unlikely to continue.
- In the case of unstable serial bHCG measurements, there may be an ectopic pregnancy.
How would a complete miscarriage present?
a complete miscarriage would also present with an empty uterus on transvaginal ultrasound, it is typically associated with heavy blood loss and considerable pain.
In the case of a missed (delayed) miscarriage, what would you find?
a fetus with no cardiac activity will be visible on transvaginal ultrasound.
Urinary incontinence - first-line treatment:
- urge incontinence: bladder retraining
- stress incontinence: pelvic floor muscle training
Urinary incontinence - risk factors and classification
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
Classification
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Urinary incontinence - Initial investigation
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Urinary incontinence - mx ?
Management depends on whether urge or stress UI is the predominant picture.
If urge incontinence is predominant:
- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
- pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
Uterine fibroids- associations, features and diagnosis ?
Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Associations
- more common in Afro-Caribbean women
- rare before puberty, develop in response to oestrogen, don’t tend to progress following menopause
Features
- may be asymptomatic
- menorrhagia
- lower abdominal pain: cramping pains, often during menstruation
bloating
- urinary symptoms, e.g. frequency, may occur with larger fibroids
- subfertility
Diagnosis
- transvaginal ultrasound
Uterine fibroids- mx and complications?
Management
- symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
- other options include tranexamic acid, combined oral contraceptive pill etc
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
- surgery is sometimes needed: myomectomy, hysteroscopic endometrial ablation, hysterectomy
- uterine artery embolization
Complications
- red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
Definitive treatment of Bartholin’s abscess
marsupialisation
Bartholin’s abscess
Bartholin’s glands are a pair of glands located next to the entrance to the vagina. These are normally about the size of a pea, but can become infected and enlarge - forming a Bartholin’s abscess.
- This can be treated by antibiotics,
- by the insertion of a word catheter or
- by a surgical procedure known as marsupialization
Medical management of a miscarriage involves…
giving vaginal misoprostol alone
however, oral misoprostol can alternatively be given if preferred by the patient.
Miscarriage: management - expectant
3 types of management for miscarriage
- Expectant management
- ‘Waiting for a spontaneous miscarriage’
- First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
- If expectant management is unsuccessful then medical or surgical management may be offered
Miscarriage - mx -when is medical or surgical mx better?
- increased risk of haemorrhage
- -she is in the late first trimester
- -if she has coagulopathies or is unable to have a blood transfusion
- previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- evidence of infection
Miscarriage - medical management
‘Using tablets to expedite the miscarriage’
- Vaginal misoprostol
- -Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
- The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
- Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
- Should be given with antiemetics and pain relief
Miscarriage - surgical mx
- ‘Undergoing a surgical procedure under local or general anaesthetic’
- The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
- Vacuum aspiration is done under local anaesthetic as an outpatient
- Surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’
What is a medication for medical management of an ectopic pregnancy ? how does it work?
Methotrexate
(It interferes with DNA synthesis and disrupts cell multiplication thus preventing the pregnancy from developing. )
anti- metabolite therefore is an anti- folic acid
Mx of menorrhagia in a woman with fibroids?
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
PCOS - diagnosis?
It is diagnosed when a patient has at least two of the following:
- polycystic ovary on ultrasound - or increased ovarian volume
- irregular periods (>35 days apart) - wither infrequent or no ovulation (oligomenorrhoea)
- and hirsutism (Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone)
Patients with PCOS have disordered luteinising hormone (LH) production and peripheral insulin resistance, and thus raised levels of LH and insulin. This results in increased androgen production which disrupts folliculogenesis, leading to excess small ovarian follicles, irregular or absent ovulation and hirsutism.
PCOS - complications?
Complications include obesity, type 2 diabetes, subfertility, miscarriage and endometrial cancer.
PCOS - first-line ovulation induction drug used?
Clomifene
As an antioestrogen, it works by blocking oestrogen receptors in the hypothalamus and pituitary and increasing the release of LH and follicle stimulating hormone (FSH), which are inhibited by oestrogen. It is only given on days 2 to 6 of each cycle to initiate follicular maturation. If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.
Polycystic ovarian syndrome: management
Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
- General
- weight reduction if appropriate
- if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below) - Hirsutism and acne
- a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
- if doesn’t respond to COC then topical eflornithine may be tried
- spironolactone, flutamide and finasteride may be used under specialist supervision - Infertility
- weight reduction if appropriate
- the management of infertility in patients with PCOS should be supervised by a specialist.
- research shows clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene.
- metformin is used, either combined with clomifene or alone, particularly in patients who are obese (Metformin can be used as an alternative to clomifene, or in addition to it if it fails to induce ovulation.) It also treats hirsutism and may reduce the risk of gestational diabetes and early miscarriage.
- 2nd line treatments: ovarian diathermy and gonadotrophin induction
- 3rd line: IVF is reserved for cases where neither first nor second-line treatment options have worked.
(*work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion)
What does gonadotropin induction involve?
Used in PCOS - 2nd line infertility treatment
-Gonadotropin induction involves a daily subcutaneous injection of recombinant or purified urinary FSH and/or LH. This stimulates follicular growth and is monitored by ultrasound. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.
PCOS - mx - in someone who doesn’t wish to conceive ?
Treatment options are obviously different for patients not wishing to conceive.
- The combined oral contraceptive pill (COCP) can be used to regulate menstruation, with three to four bleeds necessary every year to protect the endometrium. It also helps to treat hirsutism.
- Likewise, co-cyprindiol treats menstrual irregularity and hirsutism, with the addition of acne.
( Antiandrogens e.g. cyproterone acetate, spironolactone are effective treatments for hirsutism but conception must be avoided. )
PMS? What is it ?
Premenstrual syndrome (PMS) - PMS is defined as a condition which manifests with distressing physical, psychological and behavioural symptoms in the absence of an organic disease. These symptoms regularly occur during the luteal phase of the menstrual cycle and improve at the end of menstruation.
Premenstrual syndrome - common symptoms
Premenstrual syndrome describes the emotional and physical symptoms that women may experience prior to menstruation.
Common symptoms include:
- anxiety
- stress
- fatigue
- mood swings
- irritability
- bloating
- mastalgia
The precise aetiology is unknown, however it is associated with the hormonal changes that occur following ovulation. The absence of PMS before puberty, in pregnancy and after the menopause further support this theory.
Premenstrual syndrome - mx ?
Management of PMS includes:
- lifestyle advice - healthy diet, exercise, reduction in stress levels and regular sleep.
- The combined oral contraceptive pill and selective serotonin re-uptake inhibitors are recommended for moderate to severe symptoms.
Factors that are associated with an increased risk of miscarriage are:
- Increased maternal age
- Smoking in pregnancy
- Consuming alcohol
- Recreational drug use
- High caffeine intake
- Obesity
- Infections and food poisoning
- Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
- Medicines, such as ibuprofen, methotrexate and retinoids
- Unusual shape or structure of womb
- Cervical incompetence
Factors that have not been associated with an increased risk of miscarriage are:
Heavy lifting Bumping your tummy Having sex Air travel Being stressed
Meigs’ syndrome is a…
benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
Most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
The most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
Physiological cysts (functional cysts) types ?
- Follicular cysts
- commonest type of ovarian cyst
- due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- commonly regress after several menstrual cycles - Corpus luteum cyst
- during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
- more likely to present with intraperitoneal bleeding than follicular cysts
Different types of ovarian cysts
Benign ovarian cysts are extremely common. They may be divided into - physiological cysts - benign germ cell tumours - benign epithelial tumours - benign sex cord stromal tumours.
Complex ovarian cysts - e.g, multi-loculated
Ovarian cysts -Benign germ cell tumours?
Dermoid cyst
- also called mature cystic teratomas.
- benign neoplasms derived from multiple germ cell layers
- Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
- most common benign ovarian tumour in woman under the age of 30 years
- median age of diagnosis is 30 years old
- bilateral in 10-20%
- usually asymptomatic. Torsion is more likely than with other ovarian tumours
The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance.
Ovarian cysts - Benign epithelial tumours?
Arise from the ovarian surface epithelium
- Serous cystadenoma
- the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
- bilateral in around 20% - Mucinous cystadenoma
- second most common benign epithelial tumour
- they are typically large and may become massive
- if ruptures may cause pseudomyxoma peritonei
The pain, itching and dyspareunia experienced in atrophic vaginitis is due to…
dryness of the vaginal mucosa
Atrophic vaginitis
Atrophic vaginitis often occurs in women who are post-menopausal women.
- It presents with vaginal dryness, dyspareunia and occasional spotting.
- On examination, the vagina may appear pale and dry.
- Atrophic vaginitis is a diagnosis of exclusion.
- Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS.
- Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
(Oestrogen secreting pessaries are an alternative to topical oestrogen cream)
What is a useful adjunct to topical oestrogen as first-line treatment of atrophic vaginitis?
Lubricants and moisturisers
Dysmenorrhoea - definiton
Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea- features, mx
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
Features
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
Management
- NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
- combined oral contraceptive pills are used second line
What is offered first line for dysmenorrhoea?
NSAIDs e.g. mefenamic acid are offered first-line as they will inhibit prostaglandin synthesis, one of the main causes of dysmenorrhoea pains.
Secondary dysmenorrhoea - what is it ? causes?
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology.
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
Causes include: - endometriosis - adenomyosis - pelvic inflammatory disease intrauterine devices* - fibroids
Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea
Vaginal candidiasis - features, ix, mx
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves.
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV, iatrogenic
Features
- ‘cottage cheese’, non-offensive DISCHARGE
- vulvitis: dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
Investigations
- a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Management
- options include local or oral treatment
- local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
- oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
- if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent vaginal candidiasis
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- compliance with previous treatment should be checked
- confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus
- exclude predisposing factors (see above)
- consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months
Candidial infection (‘thrush’) was precipitated by…
precipitated or exacerbated by recent antibiotic exposure
Vulval carcinoma - risk factors, features
Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
Other than age, risk factors include:
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
Features
- lump or ulcer on the labia majora
- may be associated with itching, irritation
Vulval carcinomas - appearance ?
- commonly ulcerated
- can present on the labium majora
Uterine fibroids are sensitive to …
oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Infertility- causes, basic investigations, key counselling points
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes
- male factor 30%
- unexplained 20%
- ovulation failure 20%
- tubal damage 15%
- other causes 15%
Basic investigations
- semen analysis
- serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
Interpretation of serum progestogen:
< 16 nmol/l - Repeat, if consistently low refer to specialist
16 - 30 nmol/l - Repeat
> 30 nmol/l - Indicates ovulation
Key counselling points
- folic acid
- aim for BMI 20-25
- advise regular sexual intercourse every 2 to 3 days
- smoking/drinking advice
‘For people with unexplained infertility, mild endometriosis or ‘mild male factor infertility’ - what to do?
are having regular unprotected sexual intercourse:
- do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered’.
What makes ectropion more common?
COCP
Ectropions are more common when taking the pill, in pregnancy and during puberty.
Muscarinic antagonists used in urinary incontinence examples ?
oxybutynin
solifenacin
tolterodine
What is the most common cause of pelvic inflammatory disease
Chlamydia trachomatis
Ruptured ovarian cyst- features?
- sudden sharp onset unilateral pelvic pain
- precipitated by intercourse or strenuous activity
Mittelschmerz
Mid cycle pain is very common and is due to the small amount of fluid released during ovulation
Features:
- Usually mid cycle abdominal pain.
- Often sharp onset.
- Little systemic disturbance.
- May have recurrent episodes.
- Usually settles over 24-48 hours.
Ix:
- Full blood count- usually normal. Inflammatory markers are usually normal
- Ultrasound- may show small quantity of free fluid
Tx:
Conservative
Endometriosis- clinical features,
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
Features:
- 25% asymptomatic, in a further
- 25% associated with other pelvic organ pathology.
- Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina.
- Chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
- Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
- Intra-abdominal bleeding may produce localised peritoneal inflammation.
- Recurrent episodes are common.
Ovarian torsion
Features:
- Usually SUDDEN onset of unilateral deep seated colicky lower abdominal pain.
- Onset may coincide with exercise
- Associated with vomiting and distress.
Ix:
- Vaginal examination may reveal unilateral adnexial tenderness.
Ultrasound may show free fluid
- Laparoscopy is usually both diagnostic and therapeutic
Mx:
Laparoscopy
Ectopic gestation
Features:
- Symptoms of pregnancy without evidence of intra uterine gestation.
- Present as an emergency with evidence of rupture or impending rupture.
- Open tubular ruptures may have sudden onset of abdominal pain and circulatory collapse, in other the symptoms may be more prolonged and less marked.
- Small amount of vaginal discharge is common.
- There is usually adnexial tenderness.
Ix:
- Ultrasound showing no intra uterine pregnancy and beta HCG that is elevated
- May show intra abdominal free fluid
Mx:
- Laparoscopy or laparotomy is haemodynamically unstable. A salphingectomy is usually performed.
Pelvic inflammatory disease- features, ix, mx
Features :
- Bilateral lower abdominal pain associated with vaginal discharge.
- Dysuria may also be present
- menstrual irregularities may occur
- deep dyspareunia
- Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort.
- Fever >38C
Ix:
- Full blood count- Leucocytosis
- Pregnancy test negative (Although infection and pregnancy may co-exist)
- Amylase - usually normal or slightly raised
- High vaginal and urethral swabs
Cervical excitation may be found on examination
Mx:
Usually medical management
For all postmenopausal women with atypical endometrial hyperplasia, mx?
A total hysterectomy with bilateral salpingo-oophorectomy
- due to the risk of malignant progression
Cervical cancer
It may be divided into:
- squamous cell cancer (80%)
- adenocarcinoma (20%)
Features
- may be detected during routine cervical cancer screening
- abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- vaginal discharge
Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include:
- smoking
- human immunodeficiency virus
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill
Mechanism of HPV causing cervical cancer
- HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
- E6 inhibits the p53 tumour suppressor gene
- E7 inhibits RB suppressor gene
Hormone replacement therapy- definition?
Hormone replacement therapy (HRT) may be used to replace decreasing oestrogen levels around the perimenopausal period
What type of HRT is recommended in perimenopausal women ?
Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.
Management of cervical cancer stage IA tumours?
- Gold standard of treatment is hysterectomy +/- lymph node clearance
- Nodal clearance for A2 tumours
- For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
- Close follow-up of these patients is advised
- For A2 tumours, node evaluation must be performed
- Radical trachelectomy is also an option for A2
Management of stage IB cervical cancer tumours?
- For B1 tumours: radiotherapy with concurrent chemotherapy is advised
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
- For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of stage II and III cervical cancer tumours?
- Radiation with concurrent chemotherapy
- See above for choice of chemotherapy and radiotherapy
- If hydronephrosis, nephrostomy should be considered
Management of stage IV cervical cancer tumours?
- Radiation and/or chemotherapy is the treatment of choice
- Palliative chemotherapy may be best option for stage IVB
Management of recurrent disease- cervical cancer?
- Primary surgical treatment: offer chemoradiation or radiotherapy
- Primary radiation treatment: offer surgical therapy
Complications of Treatments - cervical cancer ?
Complications of surgery
- Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
- Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies
- Radical hysterectomy may result in a ureteral fistula
Complications of radiotherapy
- Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
- Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
Threatened miscarriage?
- painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
- the bleeding is often less than menstruation
- cervical os is closed
- complicates up to 25% of all pregnancies
Missed (delayed) miscarriage?
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
- when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable miscarriage?
- heavy bleeding with clots and pain
- cervical os is open
Incomplete miscarriage?
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
The risk factors for endometrial cancer are as follows:
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
*the combined oral contraceptive pill and smoking are protective
Endometrial cancer- features , ix, mx
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
Features:
- postmenopausal bleeding is the classic symptom
- premenopausal women may have a change intermenstrual bleeding
- pain and discharge are unusual features
Investigation:
- women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- hysteroscopy with endometrial biopsy
Management:
- localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
