Gynaecology - General Flashcards
What are the four UKMEC classes?
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages > disadvantages
UKMEC 3: disadvantages > advantages
UKMEC 4: represents an unacceptable health risk
Give examples of UKMEC 3 conditions for the COCP
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Changes in 2016 – breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
Give examples of UKMEC 4 conditions for the COCP
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding + < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Which are the three systems used to classify POP (pelvic organ prolapse)
• POP-Q system [pelvic organ prolapse quantification, NICE recommended, most comprehensive and widely used according to RCOS] (measures different anatomical landmarks in relation to the hymen)
o Positions are recorded as coordinates relative to the physiological position of the pelvic organs as seen in the picture below. The hymen is used as a reference point
o Distal to hymen is a +ve number, proximal is a -ve number
o Stage 0 – no prolapse
o Stage 1 – >1cm above hymen
o Stage 2 – within 1cm proximal or distal to the plane of the hymen
o Stage 3 – >1cm below the plane of the hymen but protrudes no further than 2cm less than the total length of the vagina
o Stage 4 – complete eversion of the vagina
• Shaw’s (most commonly used, looks at extent of descent of prolapse)
o 1st degree – descent to the introitus
o 2nd degree – extends to the introitus but descends past the introitus on straining
o 3rd degree – prolapse descends through the introitus
• Baden-Walker or Beecham classification systems
o 1st degree – cervix is visible when the perineum is depressed – prolapse is contained within the vagina
o 2nd degree – cervix prolapsed through the introitus with the fundus remaining in the pelvis
o 3rd degree – procidentia (complete prolapse) – entire uterus is outside the introitus
Which are the different types of pelvic organ prolapse? POP
Anterior compartment prolapse
• Urethrocele
o Prolapse of the urethra into the vagina
o Frequently associated with urinary stress incontinence
• Cystocele
o Prolapse of the bladder into the anterior vaginal wall
o Isolated cystocele Rarely causes incontinence, usually leads to few or no symptoms
o Large cystocele urinary frequency, frequent UTI, pressure sensation/mass at the introitus
• Cystourethrocele – prolapse of both urethra and bladder
Middle compartment prolapse
• Uterine prolapse – scent of the uterus into the vagina
• Vaginal vault prolapse
o Descent of the vaginal vault post-hysterectomy
o Often associated with cystocele, rectocele, enterocele
o With complete inversion – the urethra, bladder, distal ureters may be included resulting in varying degrees of retention + distal ureteric obstruction
Posterior compartment prolapse
• Enterocele
o Prolapse of the upper posterior vaginal wall containing loops of small bowel (small intestine and perineum are involved)
o Herniation of the pouch of Douglas (incl. small intestine/omentum) into the vagina
o Small enteroceles are usually asymptomatic
o Can occur following pelvic surgery
o The neck of the hernial sac is usually sufficiently wide to make strangulation very rare
o Can be difficult to differentiate clinically from a rectocele
A cough impulse can be felt in enterocele on combined rectal + vaginal examination
• Rectocele – prolapse of the anterior wall of the rectum into the lower posterior vaginal wall
RF for POP (pelvic organ prolapse)
• Weakening of the support structure
o Direct muscle trauma
o Neuropathic injury
o Disruption or stretching
• Confirmed RF o Increasing age o Vaginal delivery o Increasing parity o Obesity o Previous hysterectomy
• Possible RF o Prolonged 2nd stage of labour (>2h)– levator ani dysfunction o Increased birth weight o Pregnancy o Use of forceps o Age <25 at first delivery o Shape of pelvis o FHx of prolapse o Constipation o Connective tissue disorders – Marfan’s, Ehlers-Danlos syndrome o Occupations involving heavy lifting
Aetiology and RF for USI
Aetiology
• Pelvic floor weakness
• Incompetent intrinsic sphincter
RF • Age • Women o Pregnancy o Parity o Vaginal delivery, forceps use, heavier birth weight Can cause anatomical or neuromuscular injury Can damage the pelvic floor muscles o DM o Oral oestrogen therapy o High BMI o UTI o Vaginal hysterectomy
RF for OAB (overactive bladder syndrome)
- Prevalence increases with age
- PD
- Spinal cord injury
- Diabetic neuropathy
- MS
- Dementia
- Stroke
Causes
Idiopathic
Neurogenic
Urogynaecology history cribsheet
Urogynaecology history cribsheet
Introduction
Name, Age
PC: Can you tell me what’s brought you into hospital today?
HPC:
Timeline: when it started, has it worsened recently?
Urge Urinary incontinence Urinary frequency: 8 times normal Urinary urgency Urinary incontinence Nocturia: 1 time a night is normal
How often do you go for a wee in the daytime?
Do you ever feel like you need to rush to the toilet?
If yes, how often does that happen in the day? (50%/100%)
Do you ever have accidents when you can’t get to the toilet in time?
If yes, how often and how much (drops/large amounts)
Do you go to the toilet at nighttime? How often?
Stress Urinary Incontinence
Do you leak urine when you cough or sneeze?
Do you leak urine when you lift heavy objects/grandchildren?
Do you leak urine when you stand?
How much urine comes out?
UTI
Ask about symptoms of UTIs
Ask about diagnosis with urine dipstick or MC+S
Ask about ABx treatment, how often, which ABx
Prolapse
Are you aware of a prolapse/lump/heaviness in the vagina?
Does the lump come to the entrance of the vagina?
Does the lump come out of the vagina?
Do you have to put the lump back in the vagina with your fingers to help empty your bladder or bowels?
- Ask if sexually active, if affects UI/UTI’s
- Ask about bowel function
- Ask about postmenopausal bleeding
What is PID (pelvic inflammatory disease)?
- Infection of the upper female genital tract (uterus, fallopian tubes, ovaries)
- Usually results from ascending infection from the cervix
- Serious and common complication of STIs (esp. chlamydia + gonorrhoea)
• Pelvic infections are often polymicrobial
o Genital mycoplasmas, endogenous vaginal flora (actnomycetes), aerobic streptococci
o M. TB + STIs e.g. Chlamydia trachomatis (most common), Neisseria gonorrhoea
• Most common STI – chlamydia
• Incidence of gonorrhoea is increasing – it is becoming a more common cause of PID
• Other organisms – those associated with bacterial vaginosis (Gardnerella vaginalis, mycoplasma hominis, mobiluncus)
RF for PID (pelvic inflammatory disease)?
- RF for acquiring STIs
- IUCD inserted in the previous 20 days
- Termination of pregnancy
Complications of PID pelvic inflammatory disease
- PID can damage the fallopian tubes and tissues in and near the uterus and ovaries
- Delaying treatment by 2-3 days increases the risk of infertility
- Untreated PID- infertility, ectopic pregnancy, tubo-ovarian abscess formation, chronic pelvic pain, perihepatitis (Fitz-Hugh Curtis syndrome) – RUQ pain, reactive arthritis
• In pregnancy - in preterm delivery, maternal and fetal morbidity
• Neonatal
o Perinatal transmission of C. trachomatis or N. gonorrhoea can cause ophthalmia neonatorum
o Chlamydial pneumonitis
DDx of PID pelvic inflammatory disease
- Ectopic pregnancy
- Appendicitis (N+V seen more often than PID),
- Other causes of dyspareunia – e.g. endometriosis
Bartholin’s cysts definition and aetiology
- Pair of glands, each about the size of a pea, whose secretions maintain the moisture of the vestibular surface of the vagina
- Damage or infection of the ostium of the duct causes blockage + a cyst occurs that may become infected
Causative organisms
• Aerobic organisms are the usual pathogens – E. coli is the most common
• STIs can also be cultured
• Staphylococcus or GBS
Define endometriosis
• Chronic oestrogen-dependent condition
• Characterised by growth of endometrial tissue in sites other than the uterine cavity
o Most commonly the pelvic cavity (incl. the ovaries)
o The uterosacral ligaments
o The pouch of Douglas
o The rectosigmoid colon
o The bladder
o The distal ureter
o Rarer sites – umbilicus, scar sites (following C-section, laparoscopy), pleura, pericardium, CNS
Define adenomyosis
• Adenomyosis = invasion of myometrium (muscular outer layer of the uterus) by endometrial tissue
o Age 40-50
o Heavy menstrual bleeding
o Dysmenorrhoea
o Dyspareunia
o Sometimes bowel/bladder change due to bulk effect (pressure symptoms)
o Diffusely large uterus on bimanual examination
o Pelvic USS – enlarge uterus, globular or asymmetrical, myometrial cysts, Venetian blind sign
Endometriosis aetiology and risk factors
- RETROGRADE MENSTRUATION
- Lymphatic/circulatory dissemination
- Metaplasia – cells in the pelvic + abdominal area change into endometrial-type cells
- Genetic predisposition
- Environmental factors
- Immune dysfunction
Risk factors (remember endometriosis is a chronic oestrogen dependent condition)
• Obstruction to vaginal outflow – hydrocolpos, female genital mutilation, defects in uterus or fallopian tubes
• Early menarche/late menopause
• Late first sexual encounter
• Delayed childbearing
• Nulliparity
• Genetic factors – first degree relatives
• Other RF – white ethnicity, low BMI, smoking
Complications of endometriosis + differentia diagnosis
Complications • Increased risk of clear cell of the endometrium low grade serous ovarian cancer endometroid invasive carcinoma of the ovary
• Infertility
o Moderate to severe endometriosis can cause tubal damage
o Lesser degrees of endometriosis – subfertility, increased risk of ectopic pregnancy
- Adhesion formation
- Increased risk of IBD
Differential diagnosis
• PID, ectopic pregnancy, torsion of an ovarian cyst, primary dysmenorrhoea, uterine fibroids
• UTI
• Appendicitis, IBS
Define fibroids
- Common benign monoclonal tumours of the smooth muscle cells of the uterine myometrium containing a large amount of extracellular matrix with disordered collagen
- Multiple, single-cell seedlings distributed throughout the uterine wall - These then increase in size very slowly over many years, stimulated by oestrogens and progestogens As fibroid grows, central areas may not receive adequate blood supply benign degeneration often followed by calcification
• Hormone dependent
o Contain lots of oestrogen and progesterone receptors
o Enlarge in pregnancy (oestrogen)
o Shrink in menopause
• Classified according to their position within the uterine wall
Types of fibroids
https: //laparoscopysurgeries.com/wp-content/uploads/2018/07/Fibroids-Imagae-1200x900.jpg
https: //www.google.com/search?q=wall+of+uterus+histology&sxsrf=APq-WBvJrb3KRZ2w_Lo9cwnSYVjONDovlw:1648037806490&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjZvKCgm9z2AhUXhf0HHQ3eB74Q_AUoAXoECAEQAw&cshid=1648037871293217&biw=1280&bih=577&dpr=1.5#imgrc=qXrJI8OoAKyiXM
Submucosal (endometrum)
Intramural (myometrium) - most common type of fibroid
Subserosal (perimetrium)
The uterus has three layers: mucosa (endometrium), muscularis (myometrium) and serosa/adventitia (perimetrium)
https://www.nhs.uk/conditions/fibroids/
Fibroid risk factors and protective factors
• Most common non-cancerous tumours in women of childbearing age
• Risk – BONE o Black women o Obesity o Nulliparity o Expecting (pregnancy), early menarche
• Protective factors – SECM o Smoking o Exercise o COCP o Multiparity
• Usually present between 30-50 years old
Fibroids ddx
- Uterine Sarcoma – abdominal pain, abnormal bleeding
- Dysfunctional uterine bleeding
- Endometriosis
- Endometrial polyps, endometrial cancer
- Ovarian tumour
- Tubo-ovarian abscess
- Chronic PID
- Pelvic masses
- Pregnancy
Complications of fibroids
- Iron deficiency anaemia
- Bladder frequency, constipation ( increased pelvic pressure)
- Ureteral obstruction – hydronephrosis
- Hyaline degeneration (asymptomatic)
- Torsion of pendunculated fibroid
• Infertility
o Narrowing of the isthmic portion of the fallopian tube
o Interference with implantation – submucosal fibroids
o Only caused by submucosal fibroids
• In pregnancy o Recurrent miscarriage o Foetal malpresentation o IUGR o Premature labour o PPH o Hydronephrosis o Red degeneration – fever, pain, vomiting (Mx – conservative – resolve in 4-7 days)
Cervical polyp definition
- Normal epithelium of the cervix is endocervix (columnar) - transformation zone - ectocervix (squamous)
- Benign neoplasms of the cervix
- Smooth, fingerlike growths on the cervix that appear red or purple
- Most common in women in their 40s and 50s who have had more than one child
- Also common during pregnancy – may occur due to an increase in the hormone oestrogen
• Can be endocervical or ectocervical
o Endocervical – arise from the cervical glands, most common type of cervical polyp
Overgrowth of endocervical columnar epithelium
single/multiple, cherry red lesions, pedunculated lesion on a stalk of varying length
o Ectocervical – arise from the outer surface layer of cells on the cervix
- Premenopausal women are more likely to have endocervical polyps
- Postmenopausal women are more likely to have ectocervical polyps
• Formation may be linked to
o Increased levels of oestrogen
o Chronic inflammation of the cervix, vagina or uterus
o Clogged blood vessels
What is a cervical ectropion?
- Normal epithelium of the cervix is endocervix (columnar) - transformation zone - ectocervix (squamous)
- Ectropion = ectocervical migration of columnar epithelium (Speculum – red outer cervix due to shift of transformation zone)
• Linked to oestrogen exposure – pregnancy, COCP
What is an endometrial polyp?
• Proliferation of benign endometrial stroma and glandular elements, protruding into endometrial cavity
Difference between fibroids and polyps
Fibroids - benign proliferation of the myometrium
Polyps - benign proliferation of the endometrium
Complications of polyps
• Occasionally polyps may grow big enough to obstruct the external os – infertility
• Surgery to remove polyps
o Vagally stimulated bradycardia – may need treatment with atropine
o Haemorrhage – may require cautery for haemostasis
Define
Perimenopause
Menopause
Postmenopause
Menopausal women
Perimenopause – the time in which a woman has irregular cycles of ovulation + menstruation leading up to menopause and continuing until 12 months after her final period
Also known as menopausal transition or climacteric
Accompanied by an increased risk of new + recurrent depression
Menopause
a biological stage in a woman’s life that occurs when she stops menstruating and reaches the end of her natural reproductive life
defined as having occurred when a woman has not had a period for 12 consecutive months
Can only be defined with certainty after 12 months’ spontaneous amenorrhoea (need to ask about this specifically in history to establish if women are menopausal or not)
Postmenopause – the time after menopause has occurred starting when a woman has not had a period for 12 consecutive months
Menopausal women – includes women in perimenopause and postmenopause
Define
Early menopause
Premature ovarian insufficiency (POI)
Early menopause – women who go through menopause between 40-45 years
Premature ovarian insufficiency (POI) – women under 40
Syndrome characterised by amenorrhoea, elevated gonadotrophins and oestrogen deficiency
NICE POI definition – diagnose POI in women aged under 40 years based on
Menopausal symptoms incl. no or infrequent periods (taking into account whether the woman has a uterus)
Elevated FSH levels on 2 blood samples taken 4-6 weeks apart
How can menopause be induced?
• Menopause can also be induced by
surgical removal of the ovaries
iatrogenic ablation of ovarian function
by chemotherapy, radiotherapy
treatment with GnRH analoguesPhysiological changes during menopause
- The changes associated with menopause occur when the ovaries stop producing maturing eggs and secreting oestrogen and progesterone
- Natural phenomenon which occurs in all women when their finite number of ovarian follicles becomes depleted
- As a result, oestrogen and progesterone hormone levels fall
- LH + FSH increase in response
Menopause associated diseases
• CVD – coronary artery disease, stroke, PAD
• Osteoporosis
o Loss of ovarian oestrogens associated with declines in BMD
o Low oesteogen levels associated with an increased risk of both hip + vertebral fractures in older women – this association is independent of age + body weight
• Urogenital atrophy
• Redistribution of body fat
o Tends to be distributed around the abdomen with age
• AD
Risks in early menopausal women
All women with an early menopause have an increased risk of osteoporosis, cardiovascular disease and dementia if they are not given HRT appropriately
RF for atrophic vaginitis
- Natural menopause or oophorectomy
- Anti-oestrogenic treatments e.g. tamoxifen, aromatase inhibitors
- Radiotherapy or chemotherapy
- Can also occur postpartum or with breast feeding due to reduced oestrogen levels
DDx for atrophic vaginitis
• Genital infections
o Bacterial vaginosis, trichomonas, candidiasis, endometritis
o May co-exist (atrophic vaginitis predisposes the vagina to bacterial infection)
o Trichomonas + bacterial vaginosis give a more alkaline result on pH testing
- Uncontrolled DM may cause vaginal or urinary symptoms
- Local irritation due to soap, panty liners, spermicides, condoms, biological washing powder, tight fitting clothes
What is Asherman’s syndrome?
- Cervical stenosis and cervical or intrauterine adhesions/scarring or synechiae
- Bonding of scar tissue that lines the walls of the uterus, this decreases the volume of the uterine cavity
- In many cases the front and back walls of the uterus stick to one another, in other cases adhesions occur in a small portion of the uterus
- The extent of the adhesions defines whether a case is mild, moderate or severe
- Adhesions can be thin or thick, spotty in location or confluent
• Synonyms
o Intrauterine synechiae
o Uterine synechiae
o Intrauterine adhesions (IUA)
Asherman’s syndrome complications
- Infertility
- Recurrent miscarriage
- Menstrual disturbance
- Abnormal placentation
- IUGR
- Placenta accreta
- Hematometra
• Endometriosis
o Either due to complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus due to adhesions – menses are either retained in the uterus (hematometra) or flow into the abdominal cavity causing endometriosis
• Endometrial cancer
o Risk is not higher than in the general population
o Patients might miss warning signs (excessive uterine bleeding)
o Therefore pelvic ultrasound is a routine part of their annual gynaecologic visit
Asherman’s syndrome ddx
• Primary amenorrhoea
o Absence of menstruation by the age of 15 or 3 years after the first signs of breast development
o Abnormal GnRH level
o Incomplete/underdeveloped external genitalia and breasts, ovarian deficiency, underactive pituitary
• Endometriosis
o Inability to shed the tissue build-up of the uterus before menstruation
o Lower back or thigh pain, excessive pain during menstrual cycle
o Can cause Asherman’s syndrome
• PID
o Infection of the fallopian tubes, cervix, uterus, ovaries
o Transmitted by sexual intercourse, childbirth, abortion
• PCOS
o Absent/abnormal menstruation
o Sterility
o Mild signs of secondary sex characteristics – hirsutism, acne
o Obesity
o 3 diagnostic criteria – hyperandrogenism, ovulatory dysfunction, polycystic ovaries on US
List RF for Asherman’s syndrome
• Trauma to the endometrial lining forms adhesions
o D+C - missed/incomplete miscarriage, RPC, elective abortion
o Sometimes also after other pelvic surgeries – C-section, surgery to remove fibroids/polyps
• Factors that trigger inflammation in the uterus
o Endometriosis
o Sporadic inflammation of the uterus
• Infection
o Genital TB
o Schistosomiasis
• Can affect
o 1.5% of women undergoing hysterosalpingogram (HSG)
o 5-39% of women with recurrent miscarriage
o Up to 40% of patients who have undergone D+C for RCT (retained products of conception) of incomplete abortion
Define early vs late miscarriage
How common is it?
Loss of pregnancy before 24 weeks of gestation
Early - <12 weeks
Late – 13-24 weeks
Bleeding after 24 weeks is antepartum haemorrhage
Common – 1 in 5 pregnancies
• 85% of spontaneous miscarriages occur in the 1st trimester
What are the 5 different types of miscarriage?
Threatened Inevitable Missed (delayed/late) miscarriage Incomplete miscarriage Complete miscarriage
