Gynaecology Flashcards
Amenorrhoea
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
congenital adrenal hyperplasia
congenital malformations of the genital tract
Secondary amenorrhoea is defined as when menstruation has previously occurred but has now stopped for at least 6 months.
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
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
*hypothyroidism may also cause amenorrhoea
Cervical cancer
Around 50% of cases of cervical cancer occur in women under the age of 45 years, with incidence rates for cervical cancer in the UK are highest in people aged 25-29 years, according to Cancer Research UK. 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
*the strength of this association is sometimes debated but a large study published in the Lancet (2007 Nov 10;370(9599):1609-21) confirmed the link
Cervical cancer screening: interpretation of results
The table below outlines the management of abnormal cervical smears (around 5% of all smears). Cervical intraepithelial neoplasia is abbreviated to CIN
Result
Management
Borderline or mild dyskaryosis
The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis
Consistent with CIN II. Refer for urgent colposcopy (within 2 weeks)
Severe dyskaryosis
Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks**)
Suspected invasive cancer
Refer for urgent colposcopy (within 2 weeks)
Inadequate
Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy
Women who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for ‘test of cure’ repeat cytology in the community.
*high-risk subtypes of HPV such as 16,18 & 33
**please see NHS Cervical Screening Programme link for more details about this recommendation
Source: Clinical Knowledge Summaries - Cervical screening (last revised February 2015)
Offer cervical screening to all women between the ages of 25 years and 64 years.
Age 25 years: first invitation.
Age 25-49 years: screening every 3 years.
Age 50-64 years: screening every 5 years.
Women 65 years of age or older if they have not had a cervical screening test since 50 years of age or a recent cervical cytology sample is abnormal.
Note that:
In Scotland, women aged 20-60 years are invited for screening every 3 years, however this is scheduled to change in 2016 to be consistent with the rest of the UK.
Women who are virgins may choose not to have cervical screening, as their risk of cervical cancer is low.
Women with cervical stenosis should be referred to the colposcopy clinic for consideration of cervical dilatation.
Women with a cervix that cannot be visualised should be referred for colposcopy.
Transgender men who have retained their cervix should be included in the national cervical screening programme unless they have made an informed decision to opt out.
Unscheduled cervical screening is not recommended unless the woman is immunosuppressed, where more frequent screening may be required.
If the woman has symptoms or signs of possible gynaecological cancer urgent referral and assessment of the cervix is required.
Vulval carcinoma
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
Dysmenorrhoea
Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea
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
Secondary dysmenorrhoea
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
Ectopic pregnancy
mplantation 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
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
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
The correct answer here is an ectopic pregnancy, as this is a common presentation for a ruptured ectopic. 7 weeks gestation is a common time for ectopics to become symptomatic, since they have by this point grown large enough to stretch the tubes and therefore cause pain.
A threatened miscarriage means that at the moment, the fetus is viable but the lady may be having some bleeding. A threatened miscarriage would, by definition, be seen on ultrasound scan, thus cannot be the explanation in this case. You cannot diagnose a threatened miscarriage without seeing a viable fetus on ultrasound scan.
When the beta HCG is greater than 1000 it implies that the fetus is large enough to be seen on an ultrasound scan, and therefore the second option here is unlikely.
A complete miscarriage means that the products of conception have all passed, and thus the womb is now empty. Since this lady has only suffered from mild bleeding, it does not sound like she has miscarried yet.
Fibroids can sometimes make it difficult to visualise the inside of the womb, especially if there are many. However, with the modern transvaginal scanners it is becoming more possible to view the gestational sac even if there are fibroids present, and therefore this should never be the presumed cause of an inconclusive scan. Other pathology, especially ectopic pregnancies, should be excluded first.
Endometrial cancer
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
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
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
*the combined oral contraceptive pill and smoking are protective
Endometriosis
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.
Clinical features
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
Investigation
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
Heavy menstrual bleeding: management
Menorrhagia: causes
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures.
Causes
dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
anovulatory cycles: these are more common at the extremes of a women’s reproductive life
uterine fibroids
hypothyroidism
intrauterine devices*
pelvic inflammatory disease
bleeding disorders, e.g. von Willebrand disease
*this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia
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. Prior to the 1990’s many women underwent a hysterectomy to treat heavy periods but since that time the approach has altered radically. The management of menorrhagia now depends on whether a woman needs contraception.
Investigations
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.
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.
Infertility
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
Level Interpretation
< 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
Ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment
Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS
The RCOG uses the following classification of OHSS
Mild
Moderate
Severe
Critical
Abdominal pain
Abdominal bloating
As for mild
Nausea and vomiting
Ultrasound evidence of ascites
As for moderate
Clinical evidence of ascites
Oliguria
Haematocrit > 45%
Hypoproteinaemia
As for severe
Thromboembolism
Acute respiratory distress syndrome
Anuria
Tense ascites
Menopause management
Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.
Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.
The CKS has very thorough and clear guidance on the management of menopause and is summarised below.
The management of menopause can be split into three categories:
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
Management with lifestyle modifications
Hot flushes
regular exercise, weight loss and reduce stress
Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene
Mood
sleep, regular exercise and relaxation
Cognitive symptoms
regular exercise and good sleep hygiene
Management with HRT
Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Roughly 10% of women will have some form of HRT to treat their menopausal symptoms. There is a current drive by NICE to increase this number as they have found that women were previously being undertreated due to worries about increased cancer risk. If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.
If the woman does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch.
Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks:
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.
Management with non-HRT
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
Stopping treatment
For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.
Menopause: premature
Premature menopause may be defined as menopause in a women < 45 years old
Diagnosis
raised FSH and LH - FSH > 40 iu/l
low oestradiol - < 100 pmol/l
Hormone replacement therapy: adverse effects
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side-effects
nausea
breast tenderness
fluid retention and weight gain
Potential complications
increased risk of breast cancer: increased by the addition of a progestogen
increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism: increased by the addition of a progestogen
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Breast cancer
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to duration of use
breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
A 50-year-old woman presents to the GP surgery complaining of night sweats and hot flushes for the last 12 months. Her last period was 18 months ago. She is currently being treated with tamoxifen for the breast cancer. She is not troubled by any other symptom. She would like to have something that helps the hot flushes.
Premature ovarian failure
Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
Causes
idiopathic - the most common cause
chemotherapy
autoimmune
radiation
Features are similar to those of the normal climacteric but the actual presenting problem may differ
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
raised FSH, LH levels
idiopathic: may be family history
surgery: bilateral oophorectomy. Having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
radiotherapy
chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
Menorrhagia causes
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures.
Causes
dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
anovulatory cycles: these are more common at the extremes of a women’s reproductive life
uterine fibroids
hypothyroidism
intrauterine devices*
pelvic inflammatory disease
bleeding disorders, e.g. von Willebrand disease
*this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia
Von Willebrand’s disease is the most common inherited bleeding disorder. The majority of cases are inherited in an autosomal dominant fashion* and characteristically behaves like a platelet disorder i.e. epistaxis and menorrhagia are common whilst haemoarthroses and muscle haematomas are rare
Investigation
prolonged bleeding time
APTT may be prolonged
factor VIII levels may be moderately reduced
defective platelet aggregation with ristocetin
ibroids are benign smooth muscle tumours of the uterus. They are through 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
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
