Gynaecology Flashcards
1
Q
What is the difference between primary and secondary amenorrhoea?
A
Primary= when the patient never developed periods Secondary= when the patient previously had periods but they have stopped.
2
Q
Why may a patient be experiencing primary amenorrhoea?
A
Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads
(Hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology
3
Q
What is secondary amenorrhoea due to?
A
Pregnancy
Menopause
Physiological stress (exercise, low body weight, psychosocial)
Polycystic ovarian syndrome
Medications- hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hypo or hyper)
Excessive prolactin- prolactinoma
Cushings
4
Q
What is meant by abnormal uterine bleeding?
A
Irregularities in the menstrual cycle, affecting the frequency, duration, regularity of cycle length and volume of menses.
Irregular menstrual periods indicate either anovulation or irregular ovulation.
5
Q
What is intermenstrual bleeding?
A
Bleeding between menses
6
Q
What are the key causes of intermenstrual bleeding?
A
Hormonal contraception Cervical ectropion, polyps or cancer Sexually transmitted infection Endometrial polyps or cancer Vaginal pathology Pregnancy Ovulation can cause spotting in some women Medications- SSRIs, anticoagulants
7
Q
What are the causes of Dysmenorrhoea?
A
Describes painful periods, causes are: . Primary Dysmenorrhoea (no underlying pathology) . Endometriosis/ adenomyosis . Fibroids . Cervical or ovarian cancer . Pelvic inflammatory disease . Copper coil
8
Q
What is the cause of menorrhagia?
A
Dysfunctional uterine bleeding (cause unknown) Extremes of reproductive age Fibroids Endometriosis/ adenomyosis Pelvic inflammatory disease (infection) Contraceptives- copper cool Anticoagulants Von Willebrand disease Diabetes and hypothyroidism Connective tissue disorders Endometrial hyperplasia or cancer Polycystic ovarian syndrome
9
Q
What could cause postcoital bleeding?
A
Red flag Key causes are: Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
10
Q
What are the causes of pelvic pain?
A
. UTI . Dysmenorrhoea (painful periods) . IBS . Ovarian cysts . Endometriosis . Pelvic inflammatory disease (infection) . Ectopic pregnancy . Appendicitis . Pelvic adhesions . Ovarian torsion . Inflammatory bowel disease
11
Q
What can be the cause of vaginal discharge?
A
Vaginal discharge is actually a normal physiological finding, however excessive, discoloured or foul smelling can indicate the following…
. Bacterial vaginosis . Trichomonas vaginalis . Foreign body . Cervical ectropion . Polyps . Malignancy . Pregnancy . Ovulation (cyclical) . Hormonal contraception
12
Q
What is pruritus vulvae?
A
Itching of the vagina and vulva, causes include... Irritants Atrophic vaginitis Infections- candidiasis (thrush) and public lice Eczema Stress Vulval malignancy Pregnancy related vaginal discharge Urinary or faecal incontinence Stress
13
Q
What is meant by hypogonadism?
A
Lack of sex hormones, oestrogen and testosterone
The lack of sex hormones, is due to one of two reasons…
1) hypogonadotropic hypogonadism- deficiency in LH and FSH
2) hypergonadotropic hypogonadism- a lack of response to LHand FSH by the gonads
14
Q
What is meant by HYPOgonadotropic hypogonadism?
A
Deficiency in LH and FSH leading to deficiency in the sex hormones
LH and FSH= gonadotropins
No Gonadotropins to stimulate the gonads
15
Q
What are the causes of hypogonadotropic hypogonadism?
A
Hypopituitarism
Damage to hypothalamus or pituitary for example: radiotherapy/surgery for cancer
Significant chronic conditions- temporarily delay puberty (CF, IBD)
Excessive exercise or dieting
Constitutional delay in growth and development
Endocrine disorders- GH deficiency, hypothyroidism, Cushing’s, hyperprolactinaemia, Kallman syndrome
16
Q
What is Kallman syndrome?
A
Genetic condition causing hypogonadotropic hypogonadism, it is associated with anosmia.
17
Q
What is hypergonadotropic hypogonadism?
A
Where the gonads fail to respond to stimulation from the gonadotropins, lack of negative feedback therefore leads to high levels of gonadotropins (hypergonadotropic) and low sex hormones (hypogonadism)
18
Q
What are the causes of hypergonadotropic hypogonadism?
A
Previous damage to the gonads (torsion, cancer, infections like mumps)
Congenital absence of the ovaries
Turners syndrome
19
Q
What is congenital adrenal hyperplasia?
A
Congenital deficiency of 21- hydroxylase enzyme, this causes underproduction of cortisol and aldosterone and overproduction of androgens from birth.
20
Q
How does congenital adrenal hyperplasia present?
A
In severe cases, neonates are unwell shortly after birth, with electrolyte disturbances and hypoglycaemia
In mild cases, female patients can present later in childhood or at puberty, with typical features…
. Facial hair, deep voice, primary amenorrhoea, early puberty, tall for their age
21
Q
What is androgen insensitivity syndrome?
A
Occurs in males, tissues are unable to respond to androgens, have female external genitalia but testes In the abdomen or inguinal canal.
22
Q
What bloods should you do when someone is experiencing primary amenorrhoea?
A
FBC and ferritin for anaemia
U and E’s for CKD
Anti TTG or anti EMA for coeliac
Hormonal blood tests;
. FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
. TFTs
. Insulin like growth factor (screening for GH deficiency)
. Prolactin (raised in hyperprolactinaemia)
. Testosterone (raised in PCOS, androgen insensitivity syndrome and congenital adrenal hyperplasia)
. Genetic testing- microarray test to look for genetic conditions such as: turners
. Imaging- X-ray of wrist to assess bone age and diagnosis of constitutional delay
Pelvic US to assess ovaries and other pelvic organs
MRI of the brain to look for pituitary pathologyj
23
Q
How do you treat patients with hypogonadotropic hypogonadism causing primary amenorrhoea ?
A
Pulsatile GnRH
Or replacement sex hormones in the form of COCP if pregnancy not wanted
24
Q
How do you treat a patient with amenorrhoea due to ovarian cause ( PCOS, damage or absence of ovaries?)
A
COCP
25
How does physiological stress lead to secondary amenorrhoea?
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea, this is the hypothalamus responding to situations where the body is not fit for pregnancy!
26
What are the pituitary causes of secondary amenorrhoea?
Pituitary tumours- prolactin secreting prolactinoma
| Pituitary failure- trauma, radiotherapy, surgery, Sheehan syndrome
27
What is the most common cause of hyperprolactinaemia and why does it cause secondary amenorrhoea?
Pituitary adenoma secreting prolactin
28
Patients with amenorrhoea, associated with low oestrogen levels are at risk of osteoporosis, therefore what should they be treated with?
When amenorrhoea lasts more than 12 months...
. Ensure adequate vit D and calcium intake
. HRT/ COCP
29
What is premenstrual syndrome?
Psychological, emotional and physical symptoms which occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.
The symptoms resolve once menstruation begins
30
What is the presentation of premenstrual syndrome?
```
Long list of symptoms, but common ones include...
. Low mood
. Anxiety
. Mood swings
. Irritability
. Bloating
. Fatigue
. Headaches
. Breast pain
. Reduced confidence
. Cognitive impairment
. Clumsiness
. Reduced libido
```
31
How is diagnosis of premenstrual syndrome made?
Symptom diary over two menstrual cycles
32
What is the treatment of PMS?
General healthy lifestyle changes (improving diet, exercise, alcohol, smoking, stress)
SSRIs antidepressants
CBT
COCPs with Drospirenone (yasmin) due to its anti mineralcorticoid effects
33
What should you ask about in a history of heavy menstrual bleeding?
```
age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening
Migraines with or without aura
PMH and past drug history
Smoking and alcohol history
Family history
```
34
How do you assess patients with heavy menstrual bleeding?
If they are at low risk...
Age <45 years old
No inter menstrual bleeding
No risk factors for endometrial cancer
Then you would do history, examination and full blood count and start them in first line treatment
```
If they are at high risk
Age >45 years
Inter menstrual bleeding
Suspected pathology
Risk factors for endometrial cancer
```
Then you would do history, examination, full blood count, ultrasound scan, hysteroscopy and biopsy
35
What investigations should be done if someone is experiencing heavy menstrual bleeding?
Pelvic examination with a speculum and bimanual should be performed, unless straightforward history of HMB and no risk factors/ symptoms
FBC- iron deficiency anaemia
Hysteroscopy if suspected fibroids, endometrial pathology, persistent intermenstrual bleeding.
USS if large fibroids, obesity, adenomyosis is suspected
Consider: swabs, coagulation screen, ferritin if they are clinically anaemic, TFTs
36
How do you treat heavy menstrual bleeding (medical management) ?
Tranexamic acid- when there’s no associated pain
Mefenamic acid- when there’s associated pain (NSAID reduces both bleeding and pain)
Management when contraception is acceptable/ wanted...
1) mirena coil
2) COCP
3) cyclical oral progesterone (norethisterone- however this cannot be used long term!)
Progesterone only contraception can be tried- POP, implant, depo injection
37
What are the surgical options for HMB?
Endometrial ablation and hysterectomy.
38
What are fibroids?
Benign tumours of the smooth muscle of the uterus, they are also called uterine leiomyomas, they are oestrogen sensitive.
39
What are the different types of fibroids you can get?
Intramural (within the myometrium)
Subserosal (just below outer layer of uterus)
Submucosal (just below the endometrium)
Pedunculated (on a stalk)
40
What is the presentation of fibroids?
```
Prolonged menstruation
Abdo pain
Bloating, feeling full in the abdomen
Urinary or bowel symptoms
Deep dyspareunia
Reduced fertility .
```
41
What are the investigations of fibroids?
Hysteroscopy- investigation for fibroids presenting with heavy periods
Pelvic ultrasound- bigger fibroids
MRI scanning -may be considered before surgical options
42
How do you treat fibroids less than 3cm?
This is the same treatment as heavy menstrual bleeding..
. mirena coil (first line)
. Tranexamic acid and NSAIDD
. COCP
. Cyclical oral progestogens
Surgical options for small fibroids include endometrial ablation, resection of submucosal fibroids during hysteroscopy
Hysterectomy
43
How do you treat larger fibroids?
Referral to gynae
Medical management is the same
Surgical options- myomectomy, uterine artery embolisation, hysterectomy
GnRH can be used to reduce the size of fibroids before surgery by reducing the amount of oestrogen needed to maintain fibroids
44
What is the only surgical option known to improve fertility in patients with fibroids?
Myomectomy (removal of the fibroid via. Laparoscopic surgery or laparotomy)
45
What is endometrial ablation?
Used to destroy the endometrium
46
What is hysterectomy?
Removing the uterus and fibroids
47
What are the complications of fibroids?
Heavy menstrual bleeding (often with iron deficiency anaemia)
Reduced fertility
Pregnancy complications- miscarriages, premature labour, obstructive delivery
Constipation
Urinary outflow obstruction and UTI
Red degeneration of fibroids
Torsion of fibroid
Malignant change to a leiomyosarcoma is very rare
48
What is red degeneration of fibroids?
Refers to ISCHAEMIA, infarction and necrosis of the fibroid due to a disrupted blood supply
Usually occurs in larger fibroids (above 5cm) during the second and third trimester of pregnancy
Fibroids grow rapidly in pregnancy outgrowing it’s blood supply and becoming ischaemic, or the expansion and change in the shape of the uterus causing a kinking in blood vessels.
49
How does red degeneration of fibroids present?
Severe abdominal pain, low grade fever, tachycardia, vomiting
50
What is endometriosis?
Ectopic endometrial tissue outside the uterus
51
What is an endometrioma?
A lump of endometrial tissue outside the uterus.
52
What is an adenomyosis?
Endometrial tissue within the myometrium (Muscle layer of the uterus)
53
What is the main symptom of endometriosis?
Pelvic pain, the cells of the endometrial tissue outside the uterus responds to hormones in the same way as endometrial tissue in the uterus. During menstruation as the endometrial tissue in the uterus shreds its lining and bleeds, the same thing happens to endometrial tissue elsewhere in the body
54
What are some complications of fibroids?
Localised bleeding and inflammation can lead to adhesions, inflammation causes damage and development of tissue that binds the organs together.
Adhesions lead to chronic, no cyclical pain, sharp, stabbing or pulling and associated with nausea.
Reduced fertility
55
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites- Haematuria, blood in stools
56
How do you diagnose endometriosis?
Pelvic ultrasound may reveal large endometriosis and chocolate cysts but often unremarkable
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis, definitive diagnose can be established with a biopsy of the lesions during laparoscopy, laparoscopy can allow the surgeon to remove deposits of endometriosis and potentially improve symptoms
57
How would you manage endometriosis?
Pain relief- NSAID and paracetemol
Hormonal options-
COCP (used back without a pill free period if helpful)
POP
Medroxyprogesterone acetate injection (depo provera)
Nexplanon implant
Mirena coil
GnRH agonists
Surgical management- laparoscopic surgery to excise/ablate endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy (removal of uterus)
58
Give examples of GnRH agonists and side effects of these drugs...
They induce a menopause like state (useful in endometriosis where the menopause helps with symptoms)
Goserelin, leuprolerin
Inducing the menopause has side effects- hot flushes, night sweats, risk of osteoporosis
59
What is the presentation of adenomyosis?
Dysmenorrhoea, menorrhagia and dyspareunia
On examination, uterus may be tender and enlarged
60
How do you diagnose adenomyosis?
Trans vagina ultrasound
| MRI and transabdominal ultrasound
61
What are the treatments for adenomyosis?
Depends on symptom, age and plans for pregnancy
When the woman doesn’t 2ant contraception- tranexamic acid and mefenamic acid can be used
If contraception is wanted/ accepted...
. Mirena coil (first line)
. COCP
. Cyclical oral progestogens
62
What complications can you have with adenomyosis and pregnancy?
Infertility, miscarriage, preterm birth, gestational age, malpresentation, postpartum haemorrhage, c section.
63
What is menopause?
Made after a woman has had no periods for 12 months
64
What is postmenopause?
This is from the final menstrual period to 12 months after
65
What is perimenopause?
Time around the menopause, where woman may be experiencing vasomotor symptoms and irregular periods, time leading up to the last menstrual period and the 12 months after.
66
What is premature menopause?
Menopause before the age of 40, it is the result of premature ovarian insufficiency
67
What changes to the sex hormones occur in menopause?
LH and FSH levels are high in response to absence of negative feedback from oestrogen
Oestrogen and progesterone levels are low
68
What are perimenstrual symptoms?
```
These include vaginal atrophy/dryness
Hot flushes
Lack of libido
Emotional liability or low mood
Heavier or lighter periods
Joint pains
Irregular periods
Premenstrual syndrome
```
69
What conditions does a lack of oestrogen increase the risk of?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
70
What investigations could you do for menopause and when would you do them?
FSH levels in blood
In a woman under 40 years with a suspected premature menopause
Woman aged 40-45 with menopausal symptoms or a change in menstrual cycle
71
When can you not give the depot injection?
In over 45 year olds as it reduces bone mineral density.
| It also causes weight gain
72
For how long after the menopause should woman still take contraception for?
If they are under 50 then 2 years after the last menstrual period
If they are over 50 then 1 year after the last menstrual period
73
What is premature ovarian insufficiency?
Menopause before the age of 40
74
For premature ovarian insufficiency, what will hormonal analysis show?
LH and FSH high
| Low oestradiol levels
75
Why is menopause considered hypergonadotropic hypogonadism ?
Under activity of the gonads means there is a lack of negative feedback on the pituitary gland.
76
What are the causes of premature ovarian insufficiency?
Idiopathic
Iatrogenic(chemo, radiotherapy, surgery)
Autoimmune- coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic- positive FH of turners syndrome
Infection- mumps, TB, CMV
77
How does premature ovarian insufficiency present?
Irregular periods
Lack of menstrual periods (secondary amenorrhoea)
Symptoms of low oestrogen symptoms- hot flushes, night sweats, vaginal dryness
78
How do you diagnose premature ovarian insufficiency?
Typical menopausal symptoms plus an elevated FSH
FSH needs to be raised on 2 consecutive samples separated by more than 4 weeks to be able to make a diagnosis, it is more difficult to interpret in women taking hormonal contraception.
79
What are women with premature ovarian failure more at risk from?
Higher risk of multiple conditions relating to the lack of oestrogen
- cardiovascular disease
- stroke
- osteoporosis
- dementia
- Parkinsonism
80
How do you manage premature ovarian insufficiency?
There is still a risk of pregnancy so contraception still required
HRT to reduce the risks associated with low oestrogen and premature menopause
There are two options for the HRT..
. COCP/ traditional HRT
81
Hormone replacement therapy involves using exogenous oestrogen, what should also be used in women who have an uterus?
Progesterone, this is to prevent endometrial hyperplasia and endometrial cancer, secondary to unopposed oestrogen.
82
What HRT should you offer for women who are still having periods?
Cyclical HRT with cyclical progesterone and regular breakthrough bleeds.
83
What non hormonal treatments can be used for menopausal symptoms?
Lifestyle changes- improving diet, exercising, smoking cessation, reduced alcohol, reduced caffeine, reduced stress
CBT
SSRI antidepressants
Clonidine (alpha agonist)
Venlafaxine (antidepressant)
GABApentin
84
Clonidine can be used as a non hormonal treatment for menopausal symptoms, what is this and what does it do?
It is an alpha 2 adrenergic and imidazoline receptor agonist in the brain. It reduces heart rate, also used in antihypertensive medication, helpful for vasomotor symptoms, hot flushes.
Dry mouth, headaches, dizziness, fatigue
Sudden withdrawal can result in rapid increase in blood pressure and agitation
85
What are the risks of HRT?
For women over 50:
Increased risk of breast cancer (however oestrogen only HRT)
Increased risk of endometrial cancer (incept in women without a uterus)
Increased risk of VTE,stroke, CVD (not for oestrogen only)
86
What are the contra indications to HRT?
```
. Undiagnosed abnormal bleeding
. Endometrial hyperplasia or cancer
. Breast cancer
. Uncontrolled hypertension
. Venous thromboembolism
. Liver disease
. Active angina/ MI
. Pregnancy
```
87
What are the options for oestrogen delivery in HRT?
Oral (tablets) or transdermal (patches or gels)
Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, CVD and headaches.
88
When is continuous progesterone used?
When a woman has not had a period in the past
| 24 months if under 50, 12 months is over 50
89
What would giving continuous progesterone cause when a woman is not post menopausal?
Irregular breakthrough bleeding leading to investigations for other underlying causes of bleeding.
90
What are the options for delivering progesterone for endometrial protection?
Oral (tablets)
Transdermal (patches)
Intrauterine system (mirena coil)
Mirena coil is licensed for four years for endometrial protection, after which time it needs replacing.
91
What can occur as a result of mirena coil insertion?
Irregular bleeding and spotting in the first few months after insertion, usually settles with time and women can become amenorrhoeic.
92
What is the difference between progestogens, progesterone, progestin?
Progestogens- chemicals that target and stimulate progesterone receptors
Progesterone- hormone produced naturally in the body
Progestins- synthetic progestogens
93
What are the side effects of HRT?
Oestrogen and progesterone components of HRT cause different side effects...
```
Oestrogenic side effects:
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
```
```
Progestogenic side effects:
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
```
94
What is anovulation?
Absence of ovulation
95
What is oligoovulation?
Irregular infrequent ovulation
96
What is hirsutism?
Growth of thick dark hair, often in a Male pattern
| Androgen dependent hair growth
97
What is the Rotterdam criteria?
This is the criteria for making diagnosis of PCOS
A diagnosis of PCOS requires at least 3 features
1) oligoovulation or anovulation (presenting with absent or irregular menstrual periods)
2) hyperandrogenism characterised by hirsutism and acne
3) polycystic ovaries on ultrasound
98
How do people with polycystic ovaries present?
```
Oligomenorrgoea/ amenorrhoea (irregular or absent menstrual periods)
Infertility
Obesity
Hirsutism
Acne
Hair loss in a Male pattern
```
99
In addition to the presenting symptoms, what else may a woman experience?
```
Insulin resistance and diabetes
Acanthosis nigricans (thickened, rough skin, found in the Axilla and on the elbows, it has a velvety texture)
Cardiovascular disease
Hyper cholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
```
100
What can hirsutism be caused by, other than PCOS?
Medications- phenytoin, corticosteroids, testosterone, anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital, adrenal hyperplasia
101
What is the pathophysiology behind Insulin resistance in PCOS?
When someone is resistant to insulin, the pancreas has to produce more insulin to get a response from the cells of the body
Insulin promotes the release of androgens from the ovaries and adrenal glands
Higher levels of insulin result in higher levels of androgens (such as testosterone), insulin also suppresses sex hormone binding globulin production by the liver, sex hormone binding globulin usually binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS
High insulin levels also contribute to halting the development of follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan)
102
What investigations would you use to diagnose PCOS?
```
Testosterone
Sex hormone binding globulin
Leutinizing hormone
FSH
Prolactin (mildly elevated in PCOS)
TSH
```
These exclude other pathologies that have similar presentations.
103
What would the investigation results show in PCOS?
```
Raised LH
Raised LH:FSH ratio
Raised testosterone
Raised insulin
Normal or raised insulin levels
```
104
What is the gold standard investigation for diagnosing PCOS?
Trans vaginal ultrasound
With the diagnostic criteria being...
12 or more developing follicles in one ovary
An ovarian volume of more than 10cm^3
The follicles May be arranged around the periphery of the ovary, giving a string of pearls appearance
105
How do you screen for diabetes in PCOS?
2 hour 75goral glucose tolerance test performed in the morning prior to having breakfast...
Impaired fasting glucose; fasting glucose of 6.1-6.9mmol/l (before the glucose drink)
Impaired glucose tolerance- plasma glucose at 2 hours of 7.8-11.1mmol/l
Diabetes- plasma glucose at 2 hours above 11.1mmol/l
106
What is an ovarian cyst?
Ovarian cyst is a fluid filled sac. Functional ovarian cysts relate to the fluctuating hormones of the menstrual cycle in pre menopausal women, cysts in pre menopausal are very common, they become concerning post menopausal.
107
How do ovarian cysts present?
Most are asymptomatic
Occasionally they can cause non specific symptoms of:
Pelvic pain
Bloating
Fullness in the abdomen
Palpable pelvic mass
Ovarian cysts May present with acute pelvic pain if their is ovarian torsion, haemorrhage, rupture of the cyst.
108
What is a functional cyst?
Relate to the fluctuating hormones of the menstruated cycle
Follicular cysts- represent the developing follicle, when these fail to rupture and release the egg, the cyst can persist.
Corpus luteum cysts- when the corpus luteum fails to break down and instead fills with fluid, they may cause pelvic discomfort, pain, delayed menstruation, often seen in early pregnancy.
109
What are the two causes of maternal sepsis?
Chorioamnionitis
| Urinary tract infection
110
What is a MEOWS chart?
Maternity early obstretic warning system used in inpatient maternity units
111
What are the signs and symptoms related to chorioamnionitis.
Abdominal pain
Uterine tenderness
Vaginal discharge
112
What are the signs and symptoms related to a urinary tract infection and pregnancy?
```
Dysuria
Urinary frequency
Suprapubic pain/ discomfort
Renal angle pain (pyelonephritis)
Vomiting (pyelonephritis)
```
113
What is an amniotic fluid embolisation?
Amniotic fluid passes into the mothers blood
114
What are the amniotic fluid embolisation risk factors?
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
115
What are the symptoms of amniotic fluid embolisation?
```
Usually around the same time as labour and presents similar to sepsis...
. Shortness of breath
. Hypoxia
. Hypotension
. Coagulopathy
. Haemorrhage
. Tachycardia
. Confusion
. Seizures
. Cardiac arrest
```
116
What is uterine rupture?
Complication of labour where the muscle layer of the uterus (myometrium) ruptures
Incomplete rupture- the myometrium remains intact
Complete- serosa ruptures along with the myometrium and uterus contents are released into the peritoneal cavity
117
What are the risk factors for uterine rupture?
The main risk factor is a previous Caesarean section, the scar on the uterus becomes a point of weakness and may rupture with excessive pressure
Extremely rare to those who are giving birth for the first time
118
What is a uterine inversion?
Rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and into the cervix, turning the uterus inside out.
It is extremely rare.
119
What is a follicular cyst?
They represent the developing follicle, when they fail to rupture and release the egg the cyst will persist. They are harmless and tend to disappear after a few cycles. They have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.
120
What is a corpus luteum cyst?
When the corpus luteum fails to break down and instead fills with fluid (seen in early pregnancy)
121
What symptoms would you get with a corpus luteum cyst?
Pelvic discomfort, pain, delayed menstruation
122
What is a serous cystadenoma?
Tumours of the epithelial cells in the ovary
123
What is a mucinous cyst adenoma?
Tumours of the epithelial cells. They can become huge and and take up a lot of space in the pelvis and the abdomen.
124
What is an endometrioma?
Lumps of endometrial tissue within the ovary, they occur in patients with endometriosis and can cause pain and disrupt ovulation.
125
What is a Dermoid cyst/ germ cell tumour?
Tetaromas
They are benign ovarian tumours, they come from germ cells and may contain various tissue types ie: skin, hair and bone.
Associated with ovarian torsion
126
What are sex cord stromal tumours?
Rare tumours which can be benign or malignant.
They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles), there are several types including Sertoli- leydig Cell tumours and granulosa Cell tumours
127
The key to managing ovarian masses is to determine whether they are malignant or not, what should you enquire about to determine whether they are malignant?
```
abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
```
128
What are the risk factors you need to think about when someone presents with an ovarian mass?
```
Age
Whether they are post menopause
Increase in number of ovulation (early menarche, late menopause)
Obesity
HRT
Smoking
Breastfeeding (this is protective)
Family history/ BRCA1 or BRCA2 genes
```
129
What is an endometrioma?
Lumps of endometrial tissue within the ovary, they occur in patients with endometriosis and can cause pain and disrupt ovulation.
130
What is a Dermoid cyst/ germ cell tumour?
Tetaromas
They are benign ovarian tumours, they come from germ cells and may contain various tissue types ie: skin, hair and bone.
Associated with ovarian torsion
131
What are sex cord stromal tumours?
Rare tumours which can be benign or malignant.
They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles), there are several types including Sertoli- leydig Cell tumours and granulosa Cell tumours
132
The key to managing ovarian masses is to determine whether they are malignant or not, what should you enquire about to determine whether they are malignant?
```
abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
```
133
What are the risk factors you need to think about when someone presents with an ovarian mass?
```
Age
Whether they are post menopause
Increase in number of ovulation (early menarche, late menopause)
Obesity
HRT
Smoking
Breastfeeding (this is protective)
Family history/ BRCA1 or BRCA2 genes
```
134
What blood tests should you consider in someone with an ovarian cyst?
CA-125 is the tumour marker for ovarian cancer and therefore should be tested
Women under 40 years with complex ovarian mass, also require tumour markers for a possible germ cell tumour...
. Lactate dehydrogenase
. alpha fetoprotein
. Human chorionic gonadotropin
135
CA125 is a tumour marker for ovarian cancer, however it is not very specific, what other causes are there for a raised CA-125?
```
Endometriosis
Pregnancy
Fibroids
Adenomyosis
Liver disease
Pelvic infection
```
136
What is the risk of malignancy index for?
This predicts whether an ovarian mass is malignant or not, it takes into account: menopausal status, ultrasound findings, CA125 level
137
How do you treat simple ovarian cysts in premenopausal women?
If less than 5cm then the cyst will always resolve within 3 cycles, they don’t require a follow up scan.
If they are 5-7cm then they require routine referral to gynaecology and yearly ultrasound monitoring
If they are more than 7cm then consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
138
How do you treat ovarian cysts in post menopausal women.?
Treatment depends on the CA-125 level
Simple cysts under 5cm with a normal CA-125 level can be monitored with ultrasound every 4-6 months.
If there is a raised CA-125 then they should have a 2 week wait referral.
139
What is ovarian cystectomy?
Persistent or enlarging ovarian cysts may require surgical intervention (with laparoscopy), the affected ovary may aso be removed- oophorectomy.
140
Complications of an ovarian cyst can often present with acute onset pain, what are the main complications of an ovarian cyst?
. Haemorrhage into the cyst
. Torsion
. Rupture (with bleeding into the peritoneum)
141
What is Meigs syndrome?
Involves a triad of...
Ovarian fibroma
Pleural effusion
Ascites
Typically occurs in older women, removal of the tumour results in complete resolution of effusion and ascites.
142
What is ovarian torsion?
Condition where the ovary twists in relation to the surrounding connective tissue, Fallopian tubes and blood supply (adnexa).
143
How does ovarian torsion normally present?
Sudden onset severe unilateral pelvic pain, pain is constant, gets progressively worse and is associated with N and V.
(Usually)
Can be intermittent as the ovarian twists and untwist sand can also be milder
144
What would you find on examination of ovarian torsion?
Localised tenderness, may be a palpable mass, however the absence of a mass does not exclude the diagnosis.
145
How do you investigate an ovarian torsion?
Pelvic ultrasound
Transvaginal is ideal but trans abdo can also be used.
Ultrasound may show whirlpool sign (free fluid in pelvis and oedema of the ovary) Doppler studies may show a lack of blood flow).
Definitive diagnosis is made by laparoscopic surgery
146
How do you manage ovarian torsion?
Depending on the duration and severity, they will require laparoscopic surgery to either....
1) untwist ovary and fix it in place (detorsion)
2) remove the affected ovary (oophorectomy)
Decision is made by visual inspection of the ovary.
147
What are the complications of ovarian torsion?
Delay in treating the torsion can result in loss of functioning of that ovary, however the other ovary can normally fully compensate
Other complications- necrotic ovary May have became infected, develop an abscess leading to sepsis, could rupture leading to peritonitis and adhesions.
148
What would you see on a pelvic ultrasound of someone with PCOS?
Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either:
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS.
TOM TIP: It is worth remembering the “string of pearls” description for your exams. It may come up in MCQs. It is also worth remembering that an ovarian volume of more than 10cm3 can indicate polycystic ovarian syndrome, even without the presence of cysts.
149
People with PCOS are screened for diabetes, what is the screening test of choice?
2 hour 75g OGTT
Performed in the morning prior to having breakfast
It involves taking a baseline fasting plasma glucose, giving a 75mg glucose drink and then measuring plasma glucose 2 hours lager
150
What results of OGTT would indicate diabetes?
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
151
What is the general management of PCOS?
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia, cardiovascular disease.....
- weight loss
- low glycaemic index calorie controlled diet
- exercise
- smoking cessation
- antihypertensives
- statins where indicated (QRISK >10%)
152
What associated features and complications should patients with PCOS be assessed and ,managed for?
```
Endometrial hyperplasia and cancer
Hirsutism
Infertility
Acne
Obstructive sleep apnoea
Depression and anxiety
```
153
What can be used to aid weight loss in PCOS?
Orlistat
| This is used to help weight loss in women with a BMI >30
154
How does Orlistat work?
It is a lipase inhibitor which stops the absorption of fat in the intestines
155
How can you reduce the risk of endometrial hyperplasia and endometrial cancer in PCOS?
Mirena coil
nducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill
156
How can you manage infertility in PCOS?
Clomifene
Laparoscopic ovarian drilling
IVF
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
Women that become pregnant require screening for gestational diabetes. Screening involves an oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.
157
Are most ovarian cysts benign?
If ovarian cysts occur before menopause then they are likely to be benign, if they occur after then they are likely to be malignant and need further investigation
158
How do ovarian cysts present?
Most are asymptomatic
Cysts can often be found incidentally on US scans
Occasionally they present with vague symptoms...
- pelvic pain
- bloating
- fullness in the abdomen
- palpable pelvic mass
May present with acute pelvic pain if there is an ovarian torsion, haemorrhage or rupture of cyst
159
What is the most common ovarian cyst?
Follicular cysts
These are functional cysts and represent the developing follicle
When the developing follicle fails to rupture and release the egg, the cyst can persist
They are harmless and tend to disappear after a few menstrual cycles
Typically they have thin walls and no internal structures which gives a reassuring appearance on ultrasound
160
When do corpus luteum cysts occur?
When the corpus luteum fails to break down and instead fills with fluid, they may cause pelvic discomfort, pain or delayed menstruation
They are often seen in early pregnancy
161
The key to managing ovarian cysts is to establish whether they are benign or malignant, what features would point to malignancy?
```
Abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
```
162
What risk factors would favour ovarian malignancy?
```
Age
Postmenopause
FHx
BRCA1/2
Smoking
HRT
Nulliparity
Early menarche
Late menopause
```
163
What investigations are done for premenopausal women with a simple ovarian cyst <5cm on ultrasound?
They dont need any further investigation
164
What is the tumour marker for ovarian cancer?
CA125
165
What are the tumour markers for germ cell tumours?
LDH
AFP
HCG
166
Other than ovarian cancer, what are the other csuses of raised Ca125?
```
It is not very sepcific
There are many non malignant causes of a raised Ca125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease pregnancy
```
167
What does the risk of malignancy index take into account?
This estimates the risk of an ovarian mass being malignant, it takes 3 things into account
- Ca125
- menopausal status
- ultrasound findings
168
How are simple ovarian cysts in premenopausal women managed?
<5cm cysts will almost always resolve within 3 cycles, they dont require a follow up scan
5-7cm require routine referall to gynaecology and yearly ultrasound monitoring
>7cm: consider an MRI scan or surgical evaluation as they can be difficult to characterise with Us
169
How are cysts in postmenopausal managed?
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
170
How do you treat cysts which are persistent or enlarging?
Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
171
What are the complications of ovarian cysts?
Torsion
Haemorrhage
Rhpture (bleeding into peritoneum)
172
What is Meigs syndrome?
This involves a triad of
Ovarian fibroma
Pleural effusion
Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.
173
What causes ovarian torsions?
It is usually due to an ovarian mass which is larger than 5cm, such as a cyst or tumour and is more likely to occur during pregnancy
Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
174
Why is ovarian torsion an emergency?
Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.
175
What is the presentation of ovarian torsion?
Sudden onset severe unilateral pelvic pain
The pain is constant and progressively gets worse
The pain is associated with N and V
The pain is not always severe and can sometimes take a milder and more prolonged course
Ocassionally the ovary can twist and untwist intermittently, causing a pain that comes and goes
On examination there will be localised tenderness and there may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis
176
How do you diagnose ovarian torsion?
Pelvic ultrasound is the initial investigation of choice, transvaginal if possible
The transvaginal ultrasound shows whirlpool, free fluid in pelvis and oedema of the ovary
Doppler studies may show a lack of blood flow
Definitive diagnosis is by laparoscopic surgery
177
How do you manage ovarian torsion?
Un twist the ovary and fix it in place- detorsion
Remove the affected ovary- oophorectomy
The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.
178
What are the complications of ovarian torsion?
A delay can result in a loss of function of that ovary, the other ovary can usually compensate so fertility isn’t affected
Where this is the only functioning ovary, loss of function leads to infertility and menopause
Where a necrotic ovary is not removed, it may become infected and develop an abscess leading to sepsis, additionally it may rupture leading to peritonitis and adhesions
179
What is ashermans syndrome?
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
180
What id the presentation of ashermans?
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
181
How do you manage ashermans?
Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common.
182
What is a cervical ectropion, erosion or ectopy?
This occurs when the columnar epithelium of the endocervix has extended out to the ectocervix, the endocervix has columnar epithelium and becomes visible on examination of the cervix using a speculum, the lining has a different appearance to the normal endocervix
The cells of the endocervix are also more fragile and prone to trauma, therefore more likely to bleed with intercourse, this means cervical ectropion often occurs with postcoital bleeding
183
What is cervical ectropion associated with?
Higher oestrogen levels and therefore younger women, COCP, pregnancy
184
What is the zone that can be seen in a cervical ectropion?
Transformation zone
185
What is the presentation of cervical ectropion?
Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests.
Ectropion may present with increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding.
Examination of the cervix will reveal a well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the endocervix. This border is the transformation zone.
186
What is the management of ectropion?
Asymptomatic require no treatment
It only requires treatment if bleeding becomes problematic, it is treated with cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
187
What is atrophic vaginitis?
Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
Atrophic vaginitis can also be referred to as genitorurinary syndrome of menopause, it occurs in women from menopause onwards
188
In atrophic vaginitis, what would you see on examination?
```
Pale mucosa
Think skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
```
189
What is the management of atrophic vaginitis?
Vaginal lubricants- sylk, replens, YES
Topical oestrogen- estriol cream, pessaries, tablets, ring
