Gynaecology conditions Flashcards
What is a fibroid?
Who are they more commonly seen in?
Benign smooth muscle tumour of uterus
More common in afro-caribbeans
What is the pathogenesis of fibroids?
Poorly understood but growth thought to be stimulated by oestrogen
What are the types of fibroids?
Subserosal - protrude into serial surface of uterus, can be pedunculated
Intramural - most common, confined to myemetrium
Submucosal - Develop immediately beneath endometrium and protrude into uterine cavity
How do fibroids present?
Often asymptomatic
Menorrhagia
Pelvic pain
Bloating/distention
Pressure –> constipation, urinary frequency and urgency
Fertility problems
!!Polycythaemia - due to the fibroids producing erythropoietin!!
How would fibroids present on examination?
Solid mass
Enlarged NON-TENDER uterus may be palpated
How are fibroids investigated?
Transvaginal USS
What are the medical options for fibroid management?
Symptom control:
IUS (mirena), NSAIDs, TXA, COCP
GnRH agonist (goserelin) - pre-op to reduce size Ulipristal (selective progesterone receptor modulator) - reduce fibroid size and help with menorrhagia
What surgical options are there for fibroid management?
Myemectomy - if want to preserve uterus
Hysterectomy
Uterine artery embolisation
What normally happens to fibroids in menopause?
Regress
What complications are associated with fibroids?
Infertility
In pregnancy - miscarriage, fetal malpresentation, IUGR
Red degeneration - haemorrhage into fibroid
How does red degeneration (complication of fibroids) present?
Fever, pain and vomiting
What is endometriosis?
Endometrial tissue located at sites other than the uterine cavity
What are the most common sites for endometriosis to affect?
Lining of pelvis
Uterosacral ligament
Bladder
Ovary
Others include: intestines, Fallopian tubes, ureter, cervix etc.
Can go as far as lungs
What is the pathophysiology of endometriosis?
Retrograde menstruation - endometrial cells travel backwards from the uterus via the fallopian tubes to pelvic organs
Tissue sensitive to oestrogen so bleed during menstruation
Repeated inflammation and scarring lead to adhesions
What is the mean age of endometriosis diagnosis?
25-40yo
How does endometriosis present?
Cyclical pelvic pain beginning the day before menstruation
Dysmenorrhoea + dyspareunia + dysuria + dyschezia (painful bowel motions)
May be subfertility
What are the main risk factors for endometriosis?
Early menarche Short cycle Long bleed time Heavy bleeding Family history
What can be seen on examination in endometriosis?
Fixed retroverted uterus
Uterosacral ligament nodules
General tenderness especially in the posterior vaginal fornix
How is endometriosis investigated? What are the results of these?
Laparoscopy
- Chocolate cysts
- Adhesions
- Peritoneal deposits
Pelvis USS - kissing ovaries can be seen (adhesions)
What are the key differentials for endometriosis?
PID
Ectopic
Fibroids
IBS
How is endometriosis managed?
- NSAIDs +/- paracetamol
- COCP or progesterone’s (POP, injected or IUD)
- GnRH analogues, laser ablation or excision.
What is adenomyosis?
Functional endometrial tissue within myometrium of uterus
How does adenomyosis present?
Menorrhagia
Dysmenorrhoea - progress from cyclical to daily
Deep dyspareunia
Irregular bleeding
Who does adenomyosis affect?
Multiparous women at end of their reproductive life
Associated with fibroids
What is the pathophysiology of adenomyosis?
Thought to occur when endometrial connective and supportive tissue allowed to interact with myometrium after damage (childbirth, c-section, surgery)
Can occur anywhere but most often posterior uterine wall
Tissue responsive to hormones
How is adenomyosis diagnosed?
Histological diagnosis after hysterectomy
How is adenomyosis investigated? What do they show?
Transvaginal USS
- globular uterine configuration
- Poorly defined endometrial-myometrial interface
- anterior-posterior myometrium asymmetry
Hysteroscopic biopsy
MRI - thickening of endo-myometrial junction zone
What is observed on examination of a lady with adenomyosis?
Enlarged, tender, boggy uterus
How is adenomyosis managed curatively?
Hysterectomy
What is the medical management for adenomyosis?
Similar to endometriosis
- NSAIDs
- COCP
- Progesterone - oral, IUS, depot
- GnRH agonist
- Aromatase inhibitors
What surgical option is there for adenomyosis apart from hysterectomy?
Uterine artery embolisation
- stop blood supply to adenomyosis causing it to shrink
What is a cervical polyp?
Benign growths due to hyperplasia of the endocervical epithelium
They arise from the inner surface of the cervix
What age is peak incidence of cervical polyps?
50-60 years old
How do cervical polyps present?
Generally asymptomatic and picked up on cervical screening
Can cause abnormal vaginal bleeding:
- Menorrhagia
- Post-coital
- Intermenstrual
- Post-menopausal
How are cervical polyps diagnosed?
Histological examination after removal May also do: - Swab for infection - Cervical smear - CIN - USS if symptoms persist after removal ?endometrial polyp
How are cervical polyps managed?
Removal - small risk of malignant transformation
Can be done in primary care - twist polypectomy forceps
Larger/hard to access need diathermy in colposcopy clinic
What is cervical ectropion?
Who it is common in?
Eversion of the endocervix - metaplasia of stratified squamous (ectocervix) to glandular simple columnar (endocervix)
Common in teenagers, pregnancy and those on COCP
What causes the metaplasia seen in ectropion?
High oestrogen levels
How does cervical ectropion present?
Commonly asymptomatic
Discharge - increased glandular tissue
Post-coital bleeding - fine blood vessels in epithelium
How is cervical ectropion investigated?
Rule out more sinister diagnosis:
- Swabs - infection
- Smear - CIN
- Biopsy - if lesions seen
How does a cervical ectropion appear on examination?
Ring of reddish tissue around external os
How are cervical ectropion’s managed?
Stop any oestrogen containing medication
Cryotherapy can be used
What happens in PCOS?
Excess androgen production and multiple immature follicles (cysts) in the ovaries
What happens to the hormones in PCOS?
Increased frequency of GnRH pulses = increased LH = ovarian production of androgens
Insulin resistance means increased insulin secretion = suppression of sex hormone binding globulin = more free circulating androgens
Free circulating androgens suppress LH surge so follicles develop in ovaries but maturation arrest at early stage so remain visible as cysts in ovaries
How does PCOS present?
Oligo/amenorrhoea Infertility Chronic pelvic pain Acne Male pattern baldness Hirsutism Obesity Depression Acanthosis nigricans
What are the main risk factors for PCOS?
Diabetes
Family history
What are the main differentials for PCOS?
Hypothyroidism
Hyperprolactinaemia
Cushing’s
What is the Rotterdam criteria for PCOS?
Need 2/3 for diagnosis:
>=12 cysts or ovarian volume >10cm3
Oligo/anovulation
Clinical or biochemical signs of hyperandrogenism
What hormones would be raised in PCOS?
Testosterone
LH
LH:FSH
What hormones would be low in PCOS?
Sex Hormone Binding Globulin
Progesterone
How is amenorrhoea in PCOS managed? Why is this done?
COCP to induce at least 3 bleeds per year
Anovulatory cycles due to unopposed oestrogen lead to endometrial hyperplasia which can become malignant so bleeding must be induced
How is weight controlled in PCOS?
Orlistate - can improve insulin resistance
How is hirsutism in PCOS managed?
- COCP or co-cyprindiol
- Eflornithine topical cream
- Antiandrogens - spironolactone, finasteride
How is infertility in PCOS managed? (2 drugs)
What are the risks of on of these drugs?
Clomifene - associated with multiple pregnancy, ovarian hyper stimulation syndrome and ovarian cancer
Metformin - particularly good in obese patients
Where are the bartholin’s glands located?
Deep to posterior aspect of labia majora
Also called greater vestibular glands
Where do the bartholin’s glands open?
Either side of vaginal orifice
Within vestibule - 4 o clock and 8 o clock
Just below hymenal ring
What is the function of the bartholin’s glands?
Secrete mucus to lubricate vagina
What is the pathophysiology of a bartholin’s cyst?
Build up of mucus secretions can cause duct of gland to become blocked - cyst develop
Cyst can become infected and if untreated develop into abscess
What organisms can infect a bartholin’s cyst?
Usually aerobic
E.Coli, MRSA and STI’s most common
Who gets bartholin’s cysts?
Nulliparous women of reproductive age
How do bartholin’s cysts present?
Often asymptomatic
Vulval pain on sitting or walking
Superficial dyspareunia
Soft fluctuant and non tender mass
How do bartholin’s abscesses present?
Acute onset of pain
Difficulty passing urine
Hard mass and surrounding cellulitis
How are bartholin’s cysts diagnosed?
Clinical diagnosis
If >40yo a biopsy should be done - exclude vulval malignancy
If signs of STI - swab
How are bartholin’s cysts managed?
Warm bath - aid spontaneous rupture in small asymptomatic cysts
NO SIMPLE INCISION AND DRAINAGE - reaccumulate
Either word catheter or marsupialisation
Describe the use of word catheters for bartholin’s cysts
Catheter inserted into cyst and left in place for 4-6 weeks
Done under local anaesthetic
Risks - recurrence, dyspareunia, scarring
Describe how marsupialisation is used for bartholin’s cysts
Incision into cyst allow drainage. Cyst wall everted and sutured to vaginal mucosa
General anaesthesia
Risks - hameatoma, dyspareunia
What is lichen sclerosis?
Chronic inflammatory skin disease which has the potential to progress to squamous cell carcinoma
What is the epidemiology of lichen sclerosis?
Bimodal incidence - prepubescent girls and post-menopausal women
What is the pathophysiology of lichen sclerosis?
Atrophy of the epidermis - thin stratified squamous epithelium
Band-like infiltrate of chronic inflammatory cells beneath epithelial layer
How would you investigate lichen sclerosis?
Biopsy
Only needed if suspicious of vulval cancer or not responding to treatment
How does lichen sclerosis present?
White atrophic patches on skin - anogenital region
!!Itching!!
Skin may fissure/erode - pain
Dyspareunia
What would be seen on examination of a woman with lichen sclerosis?
White well defined lesions Evidence of adhesions and/or scarring: - clitoral hood fusion - fusion of labia minora to labia majora - posterior fusion - loss of vaginal opening
What are the main differentials for lichen sclerosis?
Vitiligo
Vulval cancer
Candida
How would you manage lichen sclerosis?
Topical steroids and emollients- clobetasol propionate
Why is follow up important for lichen sclerosis?
Risk of developing squamous cell carcinoma (2-5% lifetime risk)
What are the types of ovarian cyst?
Simple - fluid only
Complex - can vary but may be irregular, solid, have septations or a vascular supply
What is a dermoid cyst?
Also called mature teratoma or benign germ cell
Lined with epithelial tissue - hair, teeth, fat etc.
Most likely to torsion
What is an endometrioma?
“chocolate cysts” seen in patients with endometriosis
Blood in cyst
What type of cyst is a follicular cyst? What causes it?
Commonest type of functional cyst/physiological
Non-rupture of dominant follicle or failure of atresia of non-dominant follicle
What type of cyst is a corpus luteal cyst? What causes it? What complication can it lead to?
Functional cyst/physiological
Corpus luteum doesn’t break down, can fill with blood or fluid and become cyst
Can cause intra-peritoneal bleeding
What are the types of benign epithelial cyst? Which is most common? Describe them?
Either mucinous cystadenoma or serous cystadenoma
Serous is most common
Mucinous - very large, can rupture and cause rare type of peritoneal cancer, common 20-40yo
Serous - bear resemblance to serous carcinoma, common 40-50yo
How do ovarian cysts present?
Asymptomatic mostly - found incidentally
Dull ache in lower abdomen + back ache
Dyspareunia
Pressure effects on bladder
Acute events - torsion or rupture
How do ovarian cysts present acutely?
Torsion - severe abdominal pain and fever
Rupture - peritonitis and shock
What are the risk factors for ovarian cysts?
Obesity
Tamoxifen
Early menarche
What investigations are requested for an ovarian cyst?
Transvaginal USS
- Biopsy
- Fine needle aspiration (second line as risk of spillage and malignancy spread)
CA125 not needed in premenopausal women
LDH, AFP, Beta HCG should be measured if <40yo
What complications are associated with ovarian cysts?
Torsion
Rupture
Haemorrhage
Infertility - surgical management
How are simple cysts in pre-menopausal women managed?
Malignancy unlikely - watchful waiting
Most disappear within 3 menstrual cycles
How are larger cysts in pre-menopausal women managed?
> 5cm, complex or concern for malignancy
Surgical removal - cystectomy or oophorectomy
How are cysts managed in post menopausal women?
Risk of malignancy index (RMI) based
RMI <25 - 1yr follow up USS and CA125 (<5cm)
RMI 25-250 - bilateral oophorectomy and if malignancy found then staging req. (with completion of surgery)
RMI > 250 - Referral for staging laparotomy
How would an ovarian torsion present?
Often acute onset pain with exercise
N&V
What would an USS of a tortioned ovary show?
whirpool sign free fluid (due to venous/lymph obstruction leading to transudate from the ovary leaking out)
What constitutes a complex cyst?
solid mass within cyst
multi-loculated
