Gynaecology: Bleeding Disorders and Cancer Flashcards
Define Post-Menopausal Bleeding?
Vaginal bleeding occurring at least 12 months after the last menstrual period.
What is PMB presumed to be until proven otherwise?
Endometrial Carcinoma.
Apart from Endometrial Carcinoma, what are some alternative diagnoses for PMB?
- Endometrial hyperplasia (with or without Atypia or Polyps)
- Cervical Carcinoma
- Ovarian Carcinoma
- Atrophic Vaginitis (diagnosis of exclusion)
- Cervicitis
- Cervical polyps
- Foreign bodies e.g. Pessaries
What initial investigations should be performed for a woman presenting with PMB?
- Bimanual examination
- Speculum examination
- Cervical smear (if not already performed through national screening programme)
- Transvaginal USS
What does TVS show?
- Endometrial thickness
- Pelvic pathology e.g. fibroids, ovarian cysts
- Fluid in the endometrial cavity (indicates increased risk of malignancy)
When should a patient with PMB go in for an endometrial biopsy and hysteroscopy?
If…
- Endometrial thickness >4/5mm (depends on the literature) OR
- Multiple episodes of PMB
What management options tend to follow a presentation of PMB?
Generally it’ll be either cancer or atrophic vaginitis…
- Cancer: surgical management options, chemotherapy
- AV: Oestrogen cream
What is the most important thing to check when a patient presents reporting PMB?
Is the bleeding actually coming from the vagina, rather than the urethra or rectum
What are the first and second line treatment options for heavy menstrual bleeding?
- Tranexamic acid, PO
- Merina coil
Why is post menopausal bleeding such a concern?
PM women do not menstruate, therefore any bleeding noticed is pathological.
What questions are important to ask in a PMB history?
- Spotting vs Bleeding vs Flooding
- Any concurrent bladder or bowel problems
- Symptoms of cancer
- RFs for cancer
- Cervical smear history
- HPV vaccine history
- Sexually active/protection
What are the most common risk factors for endometrial cancer?
Non-oestrogen related:
- Smoking
- HTN
- Diabetes
Oestrogen related:
- Obesity
- PCOS Leads to many follicles, leads to high oestrogen levels)
- Tamoxifen (stimulates endometrial hyperplasia)
- Lynch syndrome (genetic mutation which increases risk of bowel and endometrial cancer)
Prolonged Oestrogen exposure:
- Nulliparity
- Early menarche
- Late menopause
What are some causes of PMB?
Vaginal:
- Atrophic vaginitis
- Vulvar cancer
- Lichen sclerosis
Cervical:
- Polyps
- Ectropion
- Cancer
Uterus:
- EM cancer
- EM Hyperplasia
- EM polyp
How would you investigate a women with PMB?
Visualise the vagina and cervix with an external exam + speculum.
Examine the uterus with a TVUSS within 2 weeks (urgent pathway).
What is an Ectropion?
- Condition in which the glandular cells of the inner cervix begin to develop outside of the cervix, which should be squamous cells
- Symptoms: clear vaginal discharge, PCB, IMB
- Area looks red and irritated, can be indistinguishable from cancer so should be investigated
- Causes include: random congenital, hormone related (common in puberty), pregnancy, while on oral contraceptives
What are you looking at in the TVUSS of a woman with PMB?
Endometrial thickness, if greater than 4mm (5 in some hospitals), need hysteroscopy and pipelle biopsy
What would a pipelle biopsy show and how are each managed?
EM Hyperplasia w/o Atypia:
- Treat with progesterone
EM Hyperplasia w/ Atypia:
- Hysterectomy (possibly TAH BSO)
EM adenocarcinoma:
- Requires CT CAP for staging
- Staged using FIGO system
- If advanced refer to TAH BSO
- +/- Removal of lymph nodes depending on metastasis
+/- Radiotherapy +/- Chemotherapy (mostly paliative)
What is a TAH BSO?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy.
What is the benefit of TAH BSO over just a hysterectomy?
- Prevents future ovarian cancer + need for intervention
- Prevents development of malignant disease (impossible to tell that early whether or not there are mets in the ovaries).
What are your differentials for Post-Coital Bleeding?
- Infection
- Cancer
- Cervical Ectropion
- Cervical or Endometrial Polyps
- Vaginal atrophic changes
- Sexual abuse or trauma
What are your differentials for Inter-Menstrual Bleeding?
Don’t forget…
- Think of PREGNANCY causes e.g. Ectopic, Gestational Trophoblastic Disease
- Physiological causes (Ovulation, Peri-menopause)
- Medications e.g. SSRIs, anti-coagulants, Tamoxifen, missed COCP
Vaginal causes:
- Adenosis
- Vaginitis
Cervical causes:
- STIs
- Polyps
- Ectropion
Uterine causes:
- Fibroids
- Polyps
- Adenomyosis
- Endometritis
In all cases CANCER
What is the most likely cause of severe cyclical pain?
Endometriosis.
What are the most common causes of Chronic Pelvic Pain?
- PID
- Endometriosis
- Ovarian cyst
What are the differential diagnoses for Heavy Menstrual Bleeding?
Use the Mnemonic; PALM-NOICE
PALM = structural factors:
- Polyps (endometrial or cervical)
- Adenomyosis (look for bulky uterus)
- Leiomyoma (aka Fibroid)
- Malignancy (or hyperplasia)
NOICE = non-structural factors:
- Not classified
- Ovulatory dysfunction (PCOS or Hypothyroidism)
- Iatrogenic
- Coagulopathy
- Endometrial
How is HMB typically managed?
First line:
- Tranexamic acid (esp. if still trying to conceive!), which can cut down bleeding by up to 60%
- Mirena coil.
Alternatively:
- Other hormonal options (POP, implant, Depo, COCP)
- Surgical managements (discussed later)
- GnRH analogues can be used to manage fibroids conservatively
What coagulopathy is most commonly associated with HMB? What history features do you look for?
Von Willebrand’s disease. Look for:
- Heavy bleeding since menarche
- Excessive surgical or dental bleeding
- Bleeding gums
- Easy bruising
- PPH
- Family history
Other coagulopathies linked to HMB include platelet disorders, leukaemia, thrombocytopenia
How is VWD diagnosed?
Von Willebrand antigen, might also look for factor 8 activity
What is considered a normal cycle?
- Length of 24-32 days
- Regularity (although this drops with age)
- N.B: if cycle flits between the normal range e.g. one month is 25 days another is 30, this is still considered regular
- Menstrual blood loss 37-43ml/cycle and mostly in first 48 hours
- However 10% of women lose more than 80ml, 3/4 of whom are anaemic
What factors affect degree of MBL?
- Age, highest in 40s-50s decade
- Genetics
- Parity, more children heavier periods (possibly due to adenomyosis)
What is the difference between menorrhagia and metrorrhagia?
Menorrhagia = HMB
Metrorrhagia = Heavy irregular bleeding
What is Dysfunctional Uterine Bleeding?
Heavy menstrual bleeding with no recognisable pelvic pathology, pregnancy or general bleeding disorders
aka Primary Menorrhagia
How do you clinically assess how heavy someone’s periods are?
Difficult, can’t strictly rely on subjective reporting of heaviness (50% of menorrhagia have normal loss).
Best judge is based on:
- Impact on QoL: staying off work, impact on social life, bleeding through clothing, soiling bed, disrupted sleep
- Anaemia!!!
When is a patient with HMB high vs low risk?
Low risk =
- Below 45
- No IMB
- No risk factors for endometrial cancer (e.g. HTN, diabetes, PCOS, fam history, obesity)
High risk =
- Above 45
- Or IMB
- Or risk factors for Endometrial cancer
- Or Suspected pathology
How do the assessment pathways differ between low and high risk HMB patients?
Low risk are deemed to probably not have any serious underlying pathology, therefore only go for:
- History
- Examination
- FBC
- First line treatment
- Follow up
High risk patients could well have something sinister, therefore also get:
- Pelvic USS
- Possibly Hysteroscopy and Biopsy
- THEN get first line treatment
What are the surgical management options for HMB?
Used for specific conditions e.g.
- Polyps= Hysteroscopic removal of polyps (MYOSURE system)
- Fibroids = Myomectomy or Uterine Artery Ablation
- Endometrial Ablation (NOVASURE- only if family complete!!!)
Can also do a Hysterectomy (definitive management)
How can fibroids/fibroid based HMB be managed?
Medically = GnRH analogues (good but tends to only be temporary)
Surgically = Myomectomy or Uterine Artery Embolization
What is the emergency management of HMB?
HMB can be managed in the short term using:
- Norethisterone 5mg PO TDS, up to 7 days
- GnRH analogues can be given monthly as injections to induce temporary medical menopause
- GnRH analogues are good for stopping heavy periods while anaemia is corrected in preparation for another, more surgical intervention e.g. in fibroids.
Define Oligomenorrhoea?
Infrequent periods. Cycle greater than 35 days in length but still under 6 months in length
Define Amenorrhoea and what are the two types?
Primary:
- No menarche by age 16
Secondary:
- Absent periods for at least 3 months if cycles previously regular
- Absent periods for at least 6 months if previously oligomenorrhoea
What are the main causes of Oligomenorrhoea?
- Constitutional
- Anovulation (so PCOS, Thyroid disease, Prolactinoma, CAH)
What are the physiological causes of amenorrhoea?
- Prepubertal
- Pregnancy
- Menopause
What is Cryptomenorrhoea?
- Menses ae occurring but without external blood flow (e.g. due to imperforate hymen, absent vagina)
- Haematocolpos (blood build up in vagina)
- Haematometra (blood build up in uterus)
What are some pathological causes of PRIMARY amenorrhoea?
- Delayed puberty
- Imperforate hymen
- Absent vagina
- Mullerian agenesis
- Turner’s
- PCOS
- CAH
What are some pathological causes of SECONDARY amenorrhoea?
- Pregnancy
- PCOS
- Premature menopause
- Prolactinoma
- Thyroid disease
- Cushing’s
- Eating disorder
- Exercise induced
- Asherman’s
- Sheehan syndrome
How do you distinguish primary and secondary amenorrhoea?
Primary = never had a period
Secondary = No periods in 6 months or 3 cycles
What is Sheehan’s syndrome?
- Massive PPH
- Hypovolaemia
- Under-perfusion of the pituitary
- Becomes non functional
How can you distinguish between infrequent/absent periods caused by the Hypothalamus/Pituitary vs Ovaries vs Uterus
Blood test for FSH and Oestrogen:
- Hypo or Pit causes have low both
- Ovarian causes have high FSH but low oestrogen
- Uterine causes will have normal bloods
How would you investigate a patient with PRIMARY amenorrhoea?
- History and exam
- Check for normal pubertal developments
- Pregnancy test +/- b-hCG
- TSH
- Prolactin
- LH, FSH
- Pelvic USS if FSH normal
What are the differentials in a patient with primary amenorrhoea with LOW FSH?
Caused by lack of stimulation from pituitary:
- Constitutional delay
- Eating disorder
- Exercise induced amenorrhoea
- Stress induced (common in famine or war victims)
- Chronic illness
What are the differentials in a patient with primary amenorrhoea with HIGH FSH?
If test high FSH, pituitary is working but ovaries are not responding, have to send for karyotyping
- 46XX = primary ovarian failure (or premature menopause)
- 46XO = Turner’s syndrome
What is the next step in the investigation of a patient with primary amenorrhoea with NORMAL FSH?
Require a Pelvic USS, check for presence of uterus.
If present, it’s either:
- imperforate hymen
- vaginal agenesis
- transverse septum
If absent, send for karyotyping, it’s either:
- 46 XX = Mullerian agenesis
- 46 XY = Androgen insensitivity
What are the three important tests for primary amenorrhoea and what do they most commonly indicate?
FSH:
- Low = Pituitary dysfunction (constitutional delay, eating disorder)
- High = Ovarian dysfunction (Primary ovarian failure, Turner’s)
- Normal = something else
Pelvic USS:
- Absent uterus = Genetic conditions = Mullerian agenesis, androgen insensitivity
- Present uterus = imperforate hymen, vaginal agenesis
Karyotyping exists to identify the genetic conditions which can cause amenorrhoea (if necessary) e.g. Turner’s. Mullerian…
How do you investigate a patient with amenorrhoea?
- History and exam
- Pregnancy
- TSH
- Prolactin
- FSH (more diagnostic)
- Pelvic USS (if FSH normal)
How would you interpret FSH results in a patient with secondary amenorrhoea?
If low = Pituitary = eating disorder, exercise or stress induced, chronic illness, Sheehan syndrome.
If high = Ovarian = premature ovarian failure, Turner mosaic
If normal = PCOS/Uterine so need Pelvic USS or Hysteroscopy. Most likely uterine cause is adhesions.
What is PCOS?
- Heterogenous endocrine disorder with unknown aetiology (link to diabetes)
- Clusters in families and accounts for 90% of amenorrhoea cases.
- Usually emerges in adolescence
What are the features of PCOS?
Hyperandrogenism:
- Acne
- Hirsutism (hair growth)
- Obesity
Anovulation:
- Oligo/amenorrhoea
- Infertility
Also commonly get psych issues e.g. depression
What conditions can present similarly to PCOS?
- Hypothyroidism
- Hyperprolactinaemia
- Cushing’s disease
Less closely:
- Simple obesity
- CAH
- Androgen secreting tumour
- Primary ovarian failure
How do you diagnose PCOS?
Rotterdam Criteria- Need 2/3 of…
- Oligomenorrhoea or anovulation
- Clinical and/or biochemical signs of hyperandrogenism (acne, hirsutism, obesity)
- Polycystic ovaries on imaging (12 follicles or more)
What blood tests should be ordered in potential PCOS cases?
To rule out differentials:
- TSH (Hypothyroidism)
- Serum prolactin (Hyperprolactinaemia)
Classic PCOS picture =
- Raised testosterone
- Raised LH
- Normal FSH
- Low Progesterone
- Low Sex Hormone Binding Globulin (SHBG)
Use Test and SHBG to calculate free androgen index (FAI), raised = classic of PCOS
What are the management options for PCOS?
Conservative:
- Weight loss is the primary intervention for PCOS! (especially good if trying to get pregnant)
- Encourage generally healthy lifestyle
- Offer screening for impaired glucose tolerance (diabetic link)
- Ask about mental wellbeing and refer appropriately
Specific management depends on what woman wants
What specific intervention would you offer a woman with PCOS who wants regular periods?
COCP or Cyclical Progestogens
What specific intervention would you offer a woman with PCOS who wants to conceive?
- Reduce BMI below 30
- Folic acid
- Fertility assessment + partner’s semen
- Refer to fertility services
- May require ovulation induction
What specific intervention would you offer a woman with PCOS who wants to manage their acne?
Acne:
- COCP is good for this as well, will cause periods to return
- If not should go under dermatology care for retinoids, antibiotics (nice)
Hirsutism:
- Waxing
- Laser treatment
What are the long term implications of PCOS?
- Higher risk of type 2 diabetes
- CVD
- Obstructive sleep apnoea
- Infertility
- Recurrent miscarriages
- Infertility (normally resolves with treatment)
- Increased chances of complications in pregnancy e.g. pre-eclampsia and diabetes
- Anxiety, depression
How do you define HMB?
Clinically, the definition is 80mls+
In reality its based on symptomatic anaemia and impact on QoL
How does PCOS present (menstruation wise)?
Fluctuation between HMB and Amenorrhoea
What is the most important contraindication of Tranexamic acid?
DVTs and PEs, as its a pro-clotting agent
What are the 5 common interventions for HMB?
1) Tranexamic Acid (for bleeding) +/- Mefenamic Acid (for pain)
2) Hormonal therapy: Mirena, COCP, POP, Depo…
3) Endometrial Ablation (e.g. Novasure)
4) IF Polyp Uterine Artery Embolisation
5) If all else fails, Hysterectomy
How do you take Tranexamic acid?
When the bleeding occurs, 1g, 3 times a day.
What is crucial to check before sending a patient in for endometrial ablation?
- Is there family complete, EA can be sterilising
- Pregnancy is absolutely contraindicated following
- Must have taken an endometrial biopsy, can’t miss cancer.
What is the classic Endometriosis presentation and what is the diagnostic gold standard?
CYCLICAL pain + pain on pooing, intercourse + irregular menstruation
What are the main management options for Endometriosis?
Medical:
- Mefenamic Acid (for pain)
- Mirena, COCP, POP…
(a good option is COCP trycycling, where they take it for 90 days straight)
Surgical:
- Diathermy
- Resection
- Hysterectomy
What is essential to test before performing a hysterectomy for endometriosis?
GnRH analogue test. Puts patients into a pseudo menopausal state which should cure their pain. IF it doesn’t something else is going on and it would be worthwhile to address that before removing the uterus.
What are the most common gynae cancers in the UK?
Uterus and Ovarian and Cervical.
Vulval and Vaginal less common.
What is the respective 10 year survival rates for Uterine, Ovarian and Cervical cancers?
Uterine (78%) and Cervical (63%) quite good.
Ovarian quite poor, 35%.
Which gynae cancers are largely preventable?
Generally, the more common two (Uterine and Ovarian) are not preventable.
The least common three (Cervical, Vulval and Vaginal) are mostly preventable.
At what age does endometrial cancer generally present?
Women aged 64-74, risk rapidly declines after age 80
What are some risk factors and protective factors for endometrial cancer?
RFs:
- Obesity
- Oestrogen exposure (early menarche, late menopause, nulliparity, unopposed oestrogen, tamoxifen)
- PCOS
- Previous breast/ovarian cancer
- BRCA 1/2
- Endometrial polyps
- Diabetes
- Parkinson’s
PFs:
- Continuous HRT
- COCP
- Smoking
- Physical activity
- Coffee
- Tea
How do women with EMB present?
Pre-menopausal:
- Prolonged and frequent bleeding
- IMB
Post-menopausal:
- PMB!!!
- Can see blood stained watery and/or purulent discharge but this is less common.
What is endometrial hyperplasia and how is it managed?
- Pre-malignant endometrial growth
- Can be with or without atypia
How common is cancer progression in EH with atypia?
- 25-50% of the time malignancy co-exists
- 20% develop Ca within 10 years
How do you manage endometrial hyperplasia?
Ideally surgery (TAH BSO). Can use prostagens.
What are the two types of endometrial carcinoma?
T1 = Endometrial Adenocarcinoma (80%)
T2 = Papillary Serous, Clear cell, Carcinosarcoma (20%)
Endometrial Sarcoma is incredibly rare.
Outline the FIGO staging of endometrial cancer?
1 = Limited to myometrium
2 = Cervical spread
3 = Uterine serosa/ ovaries/ tubes/ vagina/ pelvis/ para-aortic lymph notes
4 = Bladder/ bowel/ distant mets
Survival = 80, 60, 40, 20%
How is endometrial cancer investigated and diagnosed?
TV USS: Useful before clinic to measure endometrial thickness in a woman with PMB, 5mm is cut off for risk.
Gold standard = Hysteroscopy w/ Endometrial sampling by Pipelle biopsy
What investigations can be used to look for metastasis in endometrial cancer?
All patients should receive blood tests (FBCs, Us and Es, LFTs)
If seriously concerned about mets risks:
- CT CAP (looks at peritoneum, lungs, bones and brain)
- MRI Pelvis
What is the preferred management of endometrial cancer and what influences this decision?
Surgery (TAH BSO + peritoneal washing) (can be laparoscopic or open)
Stage, grade, age, fitness for surgery, patient preference
85% of patients go for surgery.
What are the main non surgical alternatives for endometrial cancer?
- Long term progestogens therapy with supervision
- Radiotherapy (also given as adjuvant therapy if high risk of recurrence)
What options are available if surgery is counter-indicated, disease is inoperable or too advanced?
- Chemotherapy
- Radiotherapy
- Hormonal therapy (aromatase inhibitors)
- Palliative care
What should be offered to a woman presenting to primary care with PMB?
Referral to one-stop PMB clinic for:
- History and Exam by consultant gynaecologist
- FBC
- TV USS
- Hysteroscopy + Endometrial biopsy
What is the peak age for Ovarian cancer?
70-74 years of age.
How are ovarian tumours classified?
By malignancy status: - Benign - Borderline - Malignant (no pre-malignant stage therefore no screening)
By cell line:
- Surface epithelium (90%) –> Serous, Mucinous, Endometrioid, Clear cell, Brenner tumours
- Germ cells
- Stroma or Sex cord
- Mets, Lymphomas
How do ovarian tumours spread?
Through the peritoneum, therefore normally present with quite advanced disease
What are the most common forms of ovarian cancer?
Epithelial line:
- Serous (can be benign or malignant)
- Mucinous (can be benign or malignant)
Germ cell line:
- Teratoma (benign or very rarely malignant)
What are the risk and protective factors for ovarian cancer?
RFs:
- Obesity
- Oestrogen exposure (nulliparity, early menarche, late menopause, unopposed oestrogen)
- Family history and BRCA 1/2
- Endometriosis
PFs:
- COCP
- Pregnancy
- Breastfeeding
- Hysterectomy
- Oophorectomy
- Sterilisation
How does Ovarian cancer present?
- Non-specific symptoms
- Can be incidental finding
Symptoms:
- Abdominal swelling
- Pain
- Anorexia, N, V, Weight loss
- Vaginal bleeding
- Pressure symptoms on bowel and bladder
What investigations should be ordered for a woman with suspected ovarian cancer?
- Pelvic exam
- USS
- FBC, Us and Es, LFTs
CA125!!!
- Cytology of ascitic tap
- CXR/CT to look for mets
- Can do surgical exploration
Outline the stages of Ovarian cancer?
1 = Limited to ovaries 2 = Spread to pelvic organs 3 = Spread to rest of peritoneal cavity, or omentum, or lymph notes 4 = Lung mets, Liver mets, Distant parenchyma
How is epithelial ovarian cancer managed?
Epithelial cancer (90% of cancers):
- Staging Laparotomy
- TAH + BSO + Debulking
- Chemo: Cisplatin + Paclitaxel
- (if woman is of reproductive age and still wants kids, consider oophorectomy only)
How is non-epithelial ovarian cancer managed?
Non-epithelial tumours:
- Very chemo sensitive
- Often treated with combination of conservative surgery and chemo
What chemo regime is used for Ovarian cancer?
Cisplatin/Carboplatin + Paclitaxel
What should be ordered for a woman presenting with suspected ovarian cancer (e.g. abdo distention, anorexia, change in bowel habit in a woman with risk factors)?
Refer to gynae clinic:
- History and exam with consultant gynaecologist
- Ca125
- Abdominal or Pelvic USS
What women are at greatest risk of cervical cancer?
Bimodal age distribution:
- 30s
- 80s
More common in women of lower SES due to reduced uptake of screening programmes.
What are the RFs and PFs of cervical cancer?
RFs:
- Young age at first intercourse
- Multiple partners
- No barrier contraception
- Smoking
- Long term COCP use
- Immunosuppression
Only recognised PFs are vaccination and compliance to screening programmes
What are the high risk (oncogenic) HPV types?
16 and 18 are the two the vaccine works against, others are rarer e.g. 31, 33, 34, 35…
Produce proteins E6 and E7 which suppresses the p53 tumour suppressor gene.
How common is HPV infection?
Most women will be infected at some point in their life, commonest in teens and early 20s, infection lasts about 8 months.
Cervical cancer should be viewed as a rare complication of a common infection.
What is CIN?
When HPV is not cleared by the body, persists, it causes…
Cervical Intraepithelial Neoplasia, an asymptomatic pre-malignant condition affecting the Transformation Zone. 60% CN1 regresses spontaneously, 30% CN3 progresses to invasive cancer over the next 5-10 years.
How is CIN classified?
Based on degree of infiltration of basement membrane: CN1, CN2, CN3.
Histological diagnosis.
How does Cervical cancer present?
PCB, PMB, IMB, Blood stained vaginal discharge.
50% of cases have had zero smears.
How is Cervical cancer staged?
1 = Confined to cervix
2 = Beyond cervix but not pelvic side wall or lower third of vagina
3 = Pelvic spread, reaches side wall or lower third of vagina
4 = Distant spread or invades adjacent organs
How is Cervical cancer managed?
Depends on stage:
- Micro-invasive carcinoma can be managed conservatively, cone biopsy if concerns about fertility. If family complete, hysterectomy is appropriate
- Stages 1b-2a: Wertheim’s radical hysterectomy OR chemoradiotherapy
- Beyond stage 2a: Chemoradiotherapy
- Post-Op Radiotherapy can be offered
Ideally patients only have one of surgery or CR, both has too many side effects.
What form of hysterectomy is used in cervical cancer?
Wertheim’s
What are the general complications of gynaecologic oncology surgeries?
- Infection
- VTE
- Haemorrhage
- Vesicovaginal fistula
- Bladder dysfunction
- Short vagina
What are some common complications of gynae radiotherapy?
- Vaginal dryness
- Vaginal stenosis
- Radiation cystitis
- Radiation proctitis
- Loss of ovarian function
How frequently is cervical cancer smeared for?
- First invitation at age 25
- 3 yearly between 25 and 50
- 5 yearly between 50 and 65
- After 65 only selected patients
How are the results from a cervical smear interpreted?
Normal = Routine recall
Moderate or Severe Dyskaryosis = Colposcopy + Histology
Borderline or Mild Dyskaryosis = Require HPV test (if negative, routine recall, if positive, Colposcopy + Histology)
What is looked for on colposcopy?
Features suggestive of CIN or invasion:
- Abnormal vascular pattern (mosaicism, punctuation)
- Abnormal staining of the tissue (aceto-white, brown iodine)
How is CIN treated?
Excisional options:
- LLETZ (large loop excision of the transformation zone)
- Cold knife cone
Destructive options:
- Cryocautery
- Diathermy
- Laser vaporisation
Summarise the screening process for cervical cancer?
Smear cytology detects DYSKARYOSIS
–>
Colposcopy, opinion based on visual assessment, treatment or biopsy as directed
–>
Biopsy provides histological diagnosis of CIN 1/2/3/Invasion
How does vulval cancer present?
Ulcerative or raised lesion on vulva.
VIN (premalignant condition) can present as:
- Asymptomatic
- Itching, burning, pain
- Same as CIN mostly resolved but can progress to cancer
How is VIN managed?
Conservatively: Antihistamine for symptom management
Medically: Imiquimod
Surgically: Excision
What are the RFs for vulval cancer?
- HPV
- HSV Type 2
- Smoking
- Immunosuppression
- Chronic vulvar irritation
- Lichen Sclerosus
What type of cancer is vulval cancer?
SCC, normally caused by high rates of skin turnover in an infection (e.g HPV) or a chronic skin disease (e.g. Lichen Sclerosis)
How is vulval cancer managed?
Surgical excision (with anatomical considerations), Radiotherapy, Chemo
