Gynaecology Flashcards
What is adenomyosis?
endometrial tissue in myometrium
In whom is adenomyosis more common?
multiparous women towards end of reproductive years
Features of adenomyosis:
- dysmenorrhoea
- menorrhagia
- enlarged, boggy uterus
Management of adenomyosis:
- GnRH agonists
- hysterectomy
What is primary amenorrhoea?
failure to start menses by age of 16 years
Causes of primary amenorrhoea:
- Turner’s syndrome
- testicular feminisation
- congenital adrenal hyperplasia
- congenital malformations of genital tract
What is secondary amenorrhoea?
cessation of established regular menstruation for at least 6 months
Causes of secondary amenorrhoea (after excluding pregnancy):
- hypothalamic amenorrhoea (stress, exercise)
- PCOS
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
Initial investigations amenorrhoea:
- exclude pregnancy with urinary or serum bHCG
- gonadotrophins (low - hypothalamic, raised - ovarian)
- prolactin
- androgens (PCOS)
- oestradiol
- thyroid function tests
What is androgen insensitivity syndrome?
- X-linked recessive condition due to end organ resistance to testosterone
- genotypically male children with female phenotype
- complete androgen insensitivity syndrome - new term for testicular feminisation syndrome
Features of androgen insensitivity syndrome:
- primary amenorrhoea
- undescended testes causing groin swellings
- breast development (conversion of testosterone to estradiol)
Diagnosis of androgen insensitivity syndrome:
buccal smear or chromosomal analysis to reveal genotype
Management androgen insensitivity syndrome:
- bilateral orchidectomy (increased risk testicular cancer due to undescended testes)
- oestrogen therapy
What is atrophic vaginitis?
- in post menopausal women
- vaginal dryness, dyspareunia and spotting
- treatment with vaginal lubricants and moisturisers
- or topical oestrogen cream if no help
Main differential diagnoses for bleeding in the first trimester:
- miscarriage
- ectopic pregnancy
- implantation bleeding
- misc: cervical ectropion, vaginitis, trauma, polyps
Symptoms suggestive of ectopic pregnancy:
- positive pregnancy test with following symptoms (refer immediately):
- pain and abdominal tenderness
- pelvic tenderness
- cervical motion tenderness
Management of >= 6 weeks gestation and bleeding:
early pregnancy assessment service
< 6 weeks gestation and bleeding but not pain or risk factors for ectopic pregnancy:
- manage expectantly
- return if bleeding continues or pain
- repeat urine pregnancy test after 7-10 days
- negative pregnancy test - miscarried
Most common types of cervical cancer:
- squamous cell (80%)
- adenocarcinoma (20%)
Features cervical cancer:
- abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- vaginal discharge
Risk factors for cervical cancer:
- HPV (16,18 and 33)
- smoking
- HIV
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- COCP
Mechanism of HPV causing cervical cancer:
- HPV 16 and 18 produce oncogenes E6 and E7 genes respectively
- E6 inhibits p53 tumour suppressor
- E7 inhibits RB suppressor gene
Who is offered a smear test?
- 25-49 years: 3 yearly
- 50-64 years: 5 yearly
- not over 64 (even self referring)
Cervical screening in pregnancy:
delayed until 3 months post partum unless missed screening or previous abnormal
Cervical screening in women who have never been sexually active:
- very low risk
- can opt-out of screening
Types of cervical screening:
- now LBC over Pap
- sample rinsed into preservative fluid rather than smearing onto slide
- LBC reduces rate of inadequate smears and increased sensitivity and specificity
Best time to take cervical smear:
mid cycle
When is cytological examination performed on a cervical screening sample?
if test for hrHPV is positive (if negative, return to normal recall)
Procedure if cervical sample is hrHPV positive:
- examined cystologically
- if cytology abnormal - colposcopy
- if cytology normal repeat test at 12 months
Possible results of colposcopy
- low grade dyskaryosis
- high grade dyskaryosis (moderate)
- high grade dyskaryosis (severe)
- invasive squamous cell carcinoma
- glandular neoplasia
What to do if hrHPV positive but cytology normal and test repeated at 12 months:
- if now hrHPV negative - normal recall
- if positive and cytology still normal - further repeat test 12 months later
- if negative at 24 months - normal recall
- if hrHPV positive at 24 months - colposcopy
What to do if the cervical sample is inadequate:
- repeat within 3 months
- if 2 consecutive inadequate - colposcopy
Negative hrHPV should return to normal recall UNLESS:
- been treated for CIN 1, 2 or 3 invited 6 months after treatment for TOC repeat cervical sample
- untreated CIN1 pathway
- follow up incompletely excised cervical glandular intraepithelial neoplasia/stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- follow up for borderline changes endocervical cells
FIGO stages of cervical cancer:
IA IB II III IV
Cervical cancer stage IA:
- confined to cervix, only visible by microscopy
- less than 7 mm wide
- A1 = <3mm deep
- A2 = 3-5mm deep
Cervical cancer stage IB:
- confined to cervix, clinically visible or larger than 7mm wide
- B1 = <4cm diameter
- B2 = >4cm diameter
Cervical cancer stage II:
- extension of tumour beyond cervix but not to pelvic wall
- A = upper two thirds of vagina
- B = parametrical involvement
Cervical cancer stage III:
-extension of tumour beyond cervix and to pelvic wall
-A = lower third of vagina
-B = pelvic side wall
NB - any tumour causing hydronephrosis or non functioning kidney - stage III
Cervical cancer stage IV:
- extension of tumour beyond pelvis or involvement of bladder or rectum
- A = bladder or rectum
- B = distant sites outside pelvis
Management of cervical cancer stage IA tumours:
- hysterectomy with/without lymph node clearance
- nodal clearance for A2 tumours
- to maintain fertility, cone biopsy with negative margins can be performed
- radical trachelectomy option for A2
Management of cervical cancer stage IB tumours:
- B1: radiotherapy with concurrent chemotherapy
- radiotherapy: brachytherapy or external beam radiotherapy
- cisplatin chemotherapeutic agent
- B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of cervical cancer stage II and III tumours:
- radiation with concurrent chemotherapy
- hydronephrosis: nephrostomy
Management of cervical cancer stage IV tumours:
- radiation/chemotherapy
- palliative chemotherapy may be best for stage IVB
Complications of cervical cancer surgery:
- bleeding, damage, infection etc.
- cone biopsies and radical trachelectomy may increases risk of preterm birth in future pregnancies
- radical hysterectomy may cause ureteral fistula
Complications of radiotherapy in cervical cancer:
- short term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
- long term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
How does cervical ectropion come about?
- ectocervix has transformation zone where stratified squamous epithelium meets columnar epithelium of cervical canal
- elevated oestrogen levels causes larger area of columnar epithelium on ectocervix
- also known as cervical erosion
- can use ablative treatment if troublesome
Features of cervical ectropion:
- vaginal discharge
- post coital bleeding
Features of complete hydatidiform mole:
- vaginal bleeding
- uterus size greater than expected for gestational age
- abnormally high serum hCG
- US: snow storm appearance of mixed echogenicity
Causes of delayed puberty with short stature:
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome
Causes of delayed puberty with normal stature:
- PCOS
- androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome
What is primary dysmenorrhoea?
- no underlying pelvic pathology
- may be caused by excessive endometrial prostaglandin production
Management of primary dysmenorrhoea:
- NSAIDs such as mefenamic acid and ibuprofen in up to 80% of women (inhibit prostaglandin production)
- COCP second line
What is secondary dysmenorrhoea?
- typically develops many years after menarche
- underlying pathology
- 3-4 days before onset of period
- refer all to gynaecology
Causes of secondary dysmenorrhoea:
- endometriosis
- adenomyosis
- PID
- intrauterine devices
- fibroids
Features of ectopic pregnancy:
- lower abdominal pain (due to tubal spasm, first symptoms, unilateral)
- vaginal bleeding (may be dark brown, less than period)
- history of recent amenorrhoea
- peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
- dizziness, fainting, syncope
- breast tenderness
What are some typical examination findings in ectopic pregnancy?
- tenderness
- cervical excitation
- adnexal mass (do not examine due to risk of rupture)
- serum bHCG >1500
Risk factors for ectopic pregnancy:
- damage to tubes (PID, surgery)
- previous ectopic
- endometriosis
- IUCD
- POP
- IVF
Investigation ectopic pregnancy:
- pregnancy test positive
- investigation of choice: transvaginal ultrasound
Expectant management ectopic pregnancy:
- <35mm
- unruptured
- asymptomatic
- no foetal heartbeat
- serum bHCG <1000IU/L
- compatible if another intrauterine pregnancy
- closely monitor patient over 48 hours and if bHCG levels rise again or symptoms manifest intervention is performed
Medical management ectopic pregnancy:
- <35mm
- unruptured
- no significant pain
- no foetal heartbeat
- serum bHCG <1500IU/L
- not suitable if intrauterine pregnancy
- give patient methotrexate and follow up
Surgical management ectopic pregnancy:
- > 35mm
- can be ruptured
- pain
- visible foetal heartbeat
- serum bHCG >1500IU/L
- compatible with another intrauterine pregnancy
- surgical management involves salpingectomy or salpingostomy
Where are most ectopic pregnancies?
- 97% tubal (abortion, absorption or rupture)
- 3% ovary, cervix or peritoneum
Where are ectopic pregnancies more dangerous?
isthmus
In whom is endometrial cancer commonly seen?
- post-menopausal
- 25% before menopause
- good prognosis due to early detection
Risk factors endometrial cancer:
- obestiy
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen
- diabetes mellitus
- tamoxifen
- PCOS
- HNPOC
Features of endometrial cancer:
- postmenopausal bleeding
- premenopausal: change intermenstural bleeding
- pain and discharge
Investigation endometrial cancer:
- women >=55yo postmenopausal bleeding, suspected cancer pathway
- first line investigation in trans vaginal US - normal endometrial thickness has high negative predictive value
- hysteroscopy with endometrial biopsy
Management endometrial cancer:
- localised disease treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
- high risk disease - post operative radiotherapy
- progesterone therapy used in frail elderly women
Clinical features endometriosis:
- chronic pelvic pain
- dysmenorrhoea
- deep dyspareunia
- subfertility
- non-gynaecological: dysuria, urgency, haematuria, dyschezia
- reduced organ mobility, tender modularity in posterior vaginal fornix, visible vaginal endometriosic lesions
Investigation endometriosis:
- laparoscopy
- little role for investigation in primary care
Management endometriosis:
- NSAIDs and/or paracetamol
- hormonal treatments such as COCP or progestogens
Secondary treatments endometriosis:
- GnRH analogues (pseudomenopause)
- surgery: laparoscopic excision and laser treatment of endometriosis ovarian cysts may improve fertility
