Gynaecology Flashcards
What is the first system used for testing for cervical cancer screening
HPV first system
Negative hrHPV results: how to manage- the steps
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Positive hrHPV - cytology is abnormal- what to do
Colposcopy
this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia
Positive hrHPV, cytology is normal
(i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What to do is HPV sample is inadequate
Repeat the sample within 3 months
- If two consecutive inadequate samples then- colposcopy
Risk factors for urinary incontinence
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Classification for urinary incontinence
Overactive bladder (OAB)/urge incontinence: due to destrusor overactivity
- Stress incontinence: leaking small amounts when coughing or laughing
Mixed incontinence: both urge and stress
Overflow incontinence: due to bladder outlet obstruction: due to prostate enlargement
Initial investigation of urinary incontinence
- 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
Management of Urinary continence if urge incontinence is predominant
Bladder retraining - minimum of 6 weeks
Bladder stabilising drugs- antimuscarinics first-line
NICE recommend- oxybutynin- imediate release, tolterodine (immediate release) or darifenacin (once daily)
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management of urinary incontinence is 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
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Risk factors for endometrial cancer
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 of endometrial cancer
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Investigation of endometrial cancer
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 of endometrial cancer
Localised diseas is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
High-risk disease have post-operative radiotherapy
Progestogen therapy used in frail elderly women not suitable for surgery
Side effects of hormone replacement therapy: adverse effects
- Nausea
- Breast tenderness
- Fluid retention and weight gain
Potential complications of HRT - increased risk of breast cancer
Increased risk of breast cancer
Increased by addition of a progestogen
Increased risk of cancer related to the duration of use
Risk of breast cancers begins to decline when HRT is stopped and by 5 years it reaches same level as women never taken HRT
HRT: increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
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
HRT: increased risk of VTE: how?
Increased by the addition of a prostetogen
Transdermal HRT does not appear to increase the risk of VE
Increased risk fo stroke
Increased risk of ischaemic heart disease if taken more than 10 years after menopause
Gold standard investigation of endometriosis
Laparoscopy
Management of the clinical features
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
Secondary treatments of endometriosis
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
Pathophysiology of ovarian cancer
around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
Risk factors of ovarian cancer
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
Clinical features of ovarian cancer
abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea
