Gynaecology - Investigations Flashcards
POP (pelvic organ prolapse) investigations
• Examination
o Abdominal examination
o Examine patient with them in both standing + left lateral position
o Ask the woman to strain + observe both whilst standing + supine
o Sim’s speculum – inserted along the posterior vaginal wall to assess the anterior wall + vaginal vault + vice versa – ask pt to strain
o Bivalve speculum – to identify the cervix or the vaginal vault
Ask pt to strain
Slowly remove speculum
Look for the degree of descent of the vaginal apex
o If prolapse protrudes beyond the hymen
Ulceration and hypertrophy of the cervix or vaginal mucosa with concomitant bleeding
o Rectal examination if there are bowel symptoms
For urinary symptoms • Urine dip • Speculum examination • Bladder diary (3 days) • Residual volume • Urodynamics • Cystoscopy • Renal USS
• Dx is usually clinical + based on hx + examination
o Speculum – grade and severity
• For urinary symptoms o Urine dip – Urinalysis +/- MSU o Post-void residual volume testing using a catheter or bladder USS o Urodynamic investigations o Urea and Creatinine o Renal USS
• For bowel symptoms
o Anal manometry
o Defecography
o Endo-anal USS – to look for an anal sphincter defect if faecal incontinence is present)
• USS or MRI
USI urinary stress incontinence investigations
• A full obstetric history should be taken in women
• Examination (speculum)
o Digital assessment of pelvic floor muscle contraction (Kegel exercises)
o Bimanual/vaginal examination to assess for the presence of prolapse
o Ask patient to cough (Valsalva) during exam to check for fluid leakage
o Look for signs of vaginal atrophy
o Perform an abdominal/pelvic/neurological examination
• Bladder diaries – 1st line
o Minimum of 3 days
• Urine dipstick testing (+/-MSU) – 1st line
o Look for blood, glucose, protein, leukocytes, nitrites
o Rule out UTI or DM
• Urodynamic studies – 2nd line
o Multi-channel cystometry, ambulatory urodynamics, video urodynamics
o After you start conservative treatment but before surgery for urinary incontinence
o Multi-channel filling + voiding cystometry should not be performed in women in whom pure stress or stress-predominant mixed urinary incontinence is identified by hx or examination
o Multichannel filling and voiding cystometry before surgery for stress urinary incontinence if
Urge-predominant mixed urinary incontinence or urinary incontinence in which type is unclear
Symptoms suggestive of voiding dysfunction
Anterior or apical prolapse / cystocele
Hx of previous surgery for stress urinary incontinence
o Consider ambulatory urodynamis/videourodynamics if dx remains unclear after conventional urodynamics
Other ix:
• Renal function tests
• Assessment of residual urine
o Post-void residual volume using a bladder scan
o Measure in women who have symptoms suggesting voiding dysfunction or recurrent UTI
o Can also be assessed using catheterisation
• Symptom scoring + QOL
o Use a validated urinary incontinence-specific symptom + WOL questionnaire when therapies are being evaluated
• Cystoscopy
OAB overactive bladder syndrome investigations
• Dx made from the symptoms
• Speculum examination
o Exclude pelvic organ prolapse
o Assess ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercises)
o Ask patient to cough (Valsalva) during exam to check for fluid leakage
• Urine dipstick + MSU – 1st line
o Rule out UTI or DM
• Bladder diaries – 1st line
o Minimum of 3 days
• Urodynamic studies – 2nd line
o To confirm the diagnosis
o Show involuntary contraction of the bladder during filling
o Multichannel cystometry
3 pressures measured from inside rectum + urethra
Bladder pressure = detrusor + IAP (intraabdominal pressure)
Detrusor = bladder – IAP
o Urinary flow rate
Men can hold 400ml and void at a rate of 10-15ml/s
Women can hold 500ml and void at a rate of 15-20ml/s
• Depending on presentation
o USS of the renal tract + cystoscopy
o Ix to consider differential dx – blood tests for renal function, electrolytes, calcium, fasting glucose
PID (pelvic inflammatory disease) investigations
- Start Abx before swabs if you suspect PID
- Pregnancy test – rule out ectopic pregnancy
• Triple swabs (2 x EC, 1x HVS)
o Cervical swabs for chlamydia + gonorrhoea
o A positive result supports dx of PID, a negative result does not exclude PID
• Speculum – look for signs of inflammation/discharge
• Bimanual – cervical excitation, adnexal masses (tubo-ovarian abscess)
o If tubo-ovarian abscess, confirm with TVUSS
- raised ESR, CRP
- If febrile – blood cultures, FBC, CRP
- Endometrial biopsy + USS
• Laparoscopy
o Direct visualisation of the fallopian tubes – the best single diagnostic test
o Invasive procedure + not appropriate in routine clinical practice
- Urinalysis to exclude UTI
- USS to exclude other conditions
Bartholin’s cysts ix
• Swab from the contents of the cyst (often organisms are skin commensals)
• If >40
o Biopsy to rule out carcinoma of the vulva
o A number of types of malignancy can present in this way
o Carcinoma of the Bartholin’s gland – 5% of vulval carcinoma
Endometriosis ix
• Acute setting bloods urinalysis + MC+S cervical swabs βHCG – helpful in excluding important differentials
• TVUSS can be used to:
o Investigate suspected endometriosis
o Make and to exclude the diagnosis of an ovarian endometrioma
o Identify deep endometriosis involving the bowel, bladder or ureter
o Association to clear cell + endometroid ovarian carcinoma
o If TVUSS not acceptable. consider a transabdominal USS
• Laparoscopy – the only reliable diagnostic test, gold standard
o Can be used to diagnose endometriosis if clinical suspicion remains or symptoms persist, even if USS was normal
o Active lesions = red vesicles or puncuae marks on peritoneum
o Less active endometriosis = white scars/brown spots
o Consider taking a biopsy to: a) confirm the dx, b) exclude malignancy (if an endometrioma is treated but not excised)
o Small risk of major complications – bowel perforation
o For women with suspected deep endometriosis involving bowel/bladder/ureter – consider a pelvic US or MRI before an operative laparoscopy
• Abdominal and pelvic examination for women with ?endometriosis – bimanual + speculum examination
o Identify abdominal masses + pelvic signs –
decreased organ mobility + enlargement
Tender nodularity in the posterior vaginal fornix
Visible vaginal endometriotic lesions
Fixed retroverted uterus (ectopic tissue on utero-sacral ligament)
o If pelvic examination not appropriate, offer abdominal examination to exclude abdominal masses
• Pelvic MRI
o Should not be used as the primary ix for dx
o Should be used to assess the extent of deep endometriosis involving the bowel, bladder, ureter before diagnostic/surgical laparoscopy
o Pelvic MRI before operative laparoscopy
• AFS (american fertility society) /ASRM (american society for reproductive medicine) – classification system that classifies endometriosis as minimal (stage I), mild (stage II), moderate (Stage III)
Fibroids investigations
- Abdominal examination
- Pregnancy test
- FBC (anaemia), iron studies
• Pelvic USS
o To exclude other causes of a pelvic mass
o To confirm presence + size of fibroids
o To exclude complications (e.g. urinary tract obstruction causing hydronephrosis)
o TVUSS is more accurate
- MRI – if USS is not definitive + myomectomy is being considered
- Submucous fibroids – saline infusion US
- Leiomyosarcoma – LDH, LDH isoenzyme 3, gadolinium enhanced MRI
- Abnormal uterine bleeding – Endometrial sampling (Pipelle)
- Hysteroscopy with biopsies
Cervical ectropion investigations
Speculum – red outer cervix due to shift of transformation zone Then colposcopy (1st line) to visualise suspicious area
Endometrial polyp investigations
o Pelvic US/TVUSS – 1st line ix – endometrial thickening
o OPH (outpatient hysteroscopy)
o SIS (saline infusion sonography)
OPH + SIS are the most accurate
Menopause ix
• Clinical dx, investigations not usually recommended
• Pregnancy test
• Laboratory tests not required in the following otherwise healthy women >45 with menopausal symptoms
o Perimenopause = vasomotor symptoms + irregular periods
o Menopause = women who have not had a period for at least 12 months and are not using hormonal contraception
o Menopause in women without uterus = based on symptoms
Investigations undertaken in some women with menopausal symptoms
• FSH levels
o Two levels are required 2 or 6 weeks apart
o Considered FSH testing to dx menopause only
In women aged 40-45 years with menopausal symptoms incl. a change in their menstrual cycle (? early menopause)
In women aged <40 years in whom POI is suspected (?POI)
Women >50 years who are amenorrhoeic and taking the POP/have an implant or a Mirena fitted who wish to consider stopping contraception
• >30 nmol/L, continue contraception for 1 year and then stop (there is no need to repeat this test)
• <30 nmol/L, continue with contraception and recheck FSH after 1 year.
o No need for the FSH level to be tested in most women
o Do not use FSH to dx menopause in women using COCP and progestogen contraception or high-dose progestogen
o A raised FSH it not diagnostic for the menopause – a high level will just indicate a lack of ovarian response at a point in time
• To rule out alternative dx – TFT, Blood glucose, prolactin, TVUSS (endometrial/ovarian cancer- bleeding = endometrial, no bleeding and mass = ovarian)
- Blood cholesterol and triglycerides – consider if the woman has any CV RF
- Cervical screening and mammograms – ensure the woman is up to date
- A pelvic scan – for women with atypical symptoms
- Tests that should not be used to dx perimenopause or menopause in women >45 years = anti-mullerian hormone, inhibin A or B, estradiol, antral follicle count, ovarian volume
Atrophic vaginitis ix
• May not be necessary if the dx is clear
• May be needed to exclude other problems
o Postmenopausal bleeding that requires investigation
o Infection – if there is discharge or bleeding
o Other causes of recurrent UTI
o Screen for diabetes may be considered
• Other ix
o Vaginal pH testing
Sample from mid-vagina, not the posterior fornix
Result: more alkaline in atrophic vaginitis
o Vaginal cytology
Lack of maturation of the vaginal epithelium (typical of atrophic vaginitis)
Asherman’s syndrome ix
• Hysteroscopy
o Gold standard
o Direct visualisation of the uterus
o Most reliable method for diagnosis
• Saline hysterosonography
• TVUS
o Subendothelial linear striations
o Boggy uterus
• Hysterosalpingogram
o Injection of a contrasting fluid into the uterus in order for an X-ray imaging to be generated
o Allows for the imaging of the uterine cavity shape which may be abnormal in the presence of intrauterine adhesions
Describe these findings in the 5 types of miscarriage + septic miscarriage
Threatened Inevitable Missed (delayed/late) miscarriage Incomplete miscarriage Complete miscarriage \+ Septic miscarriage
Bleeding Pain Os TVUSS state of pregnancy Fetal heartbeat=viability
Threatened Bleeding Yes Pain No Os Closed TVUSS state of pregnancy Present Fetal heartbeat=viability Present 25-50% progress to c complete miscarriage associated with a risk of subsequent preterm delivery
Inevitable Bleeding Yes (heavy, clots) Pain Yes Os Open TVUSS state of pregnancy Present, may be lower in the uterus Fetal heartbeat=viability No Progresses to (in)complete
Missed (delayed/late) Bleeding Normally asymptomatic Pain Normally asymptomatic Os Closed TVUSS state of pregnancy Present Fetal heartbeat=viability No other: CRL >7mm GS >25mm uterus is small for dates pregnancy test can remain positive for several days/weeks but early pregnancy symptoms may have decreased or stopped hx of threatened miscarriage + persistent dark-brown discharge
Incomplete miscarriage Bleeding Yes Pain Yes Os Open TVUSS state of pregnancy RPOC Fetal heartbeat=viability No
Complete miscarriage Bleeding resolved Pain resolved Os closed TVUSS state of pregnancy empty Fetal heartbeat=viability No
Septic miscarriage Bleeding light bleeding Pain yes Os slightly open TVUSS state of pregnancy RPCO Fetal heartbeat=viability No occurs with incomplete miscarriage signs of infection (temperature, foul smelling discharge, tachy, abdo pain)
Miscarriage ix
• Pregnancy test –> speculum (inspect Os) –> TVUS (FH (Foetal heartrate) –> CRL (Crown-rump length) /foetal pole or GS (Gestational sac) / YS (Yolk sac)
o Speculum – quantity + location of bleeding, os open/closed, can remove any products
o Abdo exam – exclude ectopic (=unilateral tenderness, cervical excitation, adnexal mass) (do not perform a PV exam if suspecting an ectopic - might rupture)
• TVUS
o Dating pregnancies using USS
<14 weeks –> CRL
A foetal pole may not be seen until 9 weeks
>14 weeks –> AC, HC, FL
o Need GS + YS to be a viable IUP – otherwise PUL
o Process of TVUS
If there is no visible heartbeat – second scan should be performed at minimum of 7 or 14 days
Look for FH –> foetal poles (either crown or rump) or CRL –> if not foetal pole, look for GS
Miscarriage [cannot be diagnosed as miscarriage on 1 USS alone – get 2nd opinion/re-scan] if
• No FH + CRL >7mm
• GS >25mm + no foetus
PUV (pregnancy of unknown viability) –> TVUS in 7 days if
• No FH + CRL <7mm
• GS <25mm + no foetus
• Serum hcg
o Can help exclude an ectopic pregnancy in women with a complete miscarriage or PUL
o Serial tests are required – they should complement clinical assessment and not replace it
o Two tests are taken 48 h apart
>63% increase – ongoing pregnancy
>50% decrease – pregnancy is unlikely to continue
Consider rare causes of raised hcg – gestational trophoblastic disease, cranial gem cell tumour
• RMC (recurrent miscarriage) o Cytogenic analysis of products of conception o Pelvic USS (structural abnormalities) o Anti-phospholipid antibodies o Anticardiolipin antibodies o Screen for BV (bacterial vaginosis)
gestational trophoblastic disease ix
• URINE AND BLOOD LEVELS OF β-hcg
o Molar pregnancy
Blood βhcg grossly elevated – will be very high for gestation
Βhcg similar to TSH - low TSH, high T4
o Malignancy
Persistently raised βhcg or rising after ERCP (evacuation of retained products of conception)
FBC, LFTs (mets)
o Urine pregnancy test should be performed in all cases of persistent or irregular vaginal bleeding >8 weeks after a pregnancy event
o Women with persistent abnormal vaginal bleeding after a non-molar pregnancy should undergo a pregnancy test to exclude persistent GTN
o Women who receive care for a miscarriage should be recommended to do a urine pregnancy test 3 weeks after miscarriage
o Women who undergo medical abortions should be recommended to do a urine pregnancy test 3 weeks after the procedure
o Used as a biomarker
o Bhcg May be of value in diagnosing molar pregnancies but are far more important in disease follow-up
• HISTOLOGY
o To make a definitive diagnosis
o The diagnosis of complete mole, partial mole, atypical PSN, PSTT, ETT require histological confirmation
o The diagnosis of GTN does not require histological confirmation
o All products of conception from a non-viable pregnancy/miscarriages obtained from medical or surgical treatment should undergo histological examination to exclude trophoblastic disease/neoplasia if no fetal parts are identified at any stage of the pregnancy
o No need to routinely send products of conception for histological assessment after TOP, provided foetal parts have been identified on prior US
o All forms of GTD have distinctive morphological features, depending on which tissues they are derived from
• PELVIC USS
o USS in the first trimester may not be reliable
o Second trimester
o Complete mole: Snowstorm appearance Cluster of grapes No foetal parts Heterogeneous mass with not fetal development Theca-lutein ovarian cysts
o Incomplete mole
No snowstorm/cluster of grapes
Foetal parts
o Malignancy
Snowstorm, vesicles or cysts
• STAGING ix where metastatic disease is suspected
o Doppler pelvic USS for local pelvic spread + vascularity
o CXR or lung CT – lung metastases
o Liver/Intra-abdominal masses CT – CT CAP
o MRI scan – brain mets
Staging - FIGO staging system
Disease risk - FIGO staging for GTD
https://www.obgproject.com/wp-content/uploads/2018/06/thumbnail.jpg
gestational trophoblastic disease staging
FIGO
o Stage I – disease confined to the uterus
o Stage II – extends outside the uterus but is limited to the genital structures (adnexa, vagina, broad ligament)
o Stage III – extends to the lungs +/- genital tract involvement
o Stage IV – all other metastatic sites
PCOS ix
• Raised LH
• FSH normal
• Raised LH:FSH ratio (>2)
o These 3 parameters are not part of the diagnostic criteria and may be normal
o Oral contraceptive pills affect levels
o Helps to exclude premature ovarian insufficiency (LH + FSH both raised) + hypogonadotropic hypogonadism (LH + FSH reduced)
• Total testosterone – normal to slightly raised
o If total testosterone is >5 nmol/L, exclude androgen-secreting tumours and CAH
• Free testosterone – may be raised
• SHBG – normal to low
o Can be used to calculate the free androgen index = (100 x total testosterone)/SHBG
• Free androgen index – normal or elevated
o Can be used as an alternative to measuring free testosterone if this is not locally available
• Transvaginal/pelvic USS
o Pearl necklace sign
o Characteristic ovaries (the average volume is 3x that of normal ovaries)
o Increased ovarian volume >10mL in either or both ovaries
o 12 or more follicles in each ovary (measuring 2-9 mm)
and/or
• Tests to exclude other causes –
TFT
17-hydroxyprogesterone levels (CAH, excludes 21-hydroxylase deficiency)
prolactin (hyperprolactinaemia)
DHEA-S + free androgen index (androgen-secreting tumours)
24-h urinary cortisol (Cushing’s syndrome)
• Fasting glucose, OGTT – to assess insulin resistance/diabetes
o Look for impaired glucose tolerance/type 2 DM – fasting glucose
(N - <6.1
impaired fasting glucose – 6.1-6.9
diabetes >7)
HbA1c (>6.5%, >48mm)
if either of these are abnormal, do an OGTT
• Assess CV risk, incl. lipid levels
o Fasting lipid profile – raised total cholesterol, LDL, triglycerides, low HDL – dyslipidaemia often observes in PCOS
Subfertility investigations - history
• Ask about general health – weight, smoking, drinking, recreational drugs
• Ask about sexual history
o Frequency of coitus (ideally 2-3x/7)
o Any prolonged/recurrent absences of one of the partners
o Potential physical problems – inadequate penetration or dyspareunia
• PMH
o Previous treatment for malignancy – chemo (sterility), radiotherapy and surgery (may be relevant if they involved the pelvic region)
o Systemic disease (may interfere with the HPA axis)
Autoimmune disease – rheumatoid disease, SLE, APL
CKD
Poorly controlled DM
Anorexia nervosa – can cause anovulation amenorrhoea
• Medication and drug history
o Phenothiazines + older typical antipsychotics + metoclopramide – can increase levels of prolactin
o NSAID use is associate with luteinised unruptured follicles
o Immunosuppressants
Subfertility investigations - examination
Examination
• Increased androgen levels
o Hirsutism
o Acne
o Male pattern alopecia with slight bitemporal recession
o Pubic hairline may extend up towards the umbilicus in a typical male pattern
• Abdominal examination must precede bimanual pelvic examination
o Very easy to miss a large mass e.g. big ovarian cyst
• Gynaecological examination
o May indicate undisclosed sexual difficulties e.g. vaginismus
• Bimanual examination
o Adnexal mass from an ovary of tubo-ovarian mass
o Tenderness suggesting PID or endometriosis
o Presence of uterine fibroids
Subfertility investigations - primary care
• Mid-luteal progesterone level – to assess + confirm ovulation
o If low, may need repeating as ovulation does not occur every month
o Blood test is taken 7 days before the anticipated period (i.e. on day 21 of a 28 day cycle)
o If POI you cannot do this – there are no periods to base the measurement off
<16 nmol/l - repeat, if consistently low refer to a specialist
16-30 nmol/l - repeat
>30 nmol/l - indicated ovulation
• FSH + LH – should be measured if there is menstrual irregularity
o High levels – may suggest poor ovarian function
o A comparatively high LH level relative to FSH – can occur in PCOS
• Test for rubella status
o If susceptible to rubella – vaccinate + advise not to become pregnant for at least one month following vaccination
Subfertility investigations - secondary care
• TUBAL PATENCY – tubal damage is estimated to account for 20% of infertility in women
o Hysterosalpingogram (HSG) or hysterosalpingo-contrast USS For women who are not known to have comorbidities (e.g. PID, ectopic pregnancy, endometriosis)
o Laparoscopy and dye test
For women who have comorbidities
o Prior to undergoing uterine instrumentation, offer women screening for Chlamydia trachomatis + treat appropriately
o Prophylactic antibiotics should be considered before uterine instrumentation if screening has not been undertaken
• OVARIAN RESERVE TESTING
o Woman’s age should be used as an initial predictor of her overall chance of success through natural conception or with IVF
o One of the following measures should be used (measured around Day 3 of the menstrual cycle) to predict the likely ovarian response to gonadotrophin stimulation in IVF
Total antral follicle count (TVUS)
• <4 – low response
• >16 – high response
Anti-Mullerian hormone – will be low in infertility
• <5.4 pmol/L – low response
• >25.0 pmol/L – high response
FSH – will be high in infertility – inaccurate during the luteal phase as it is being suppressed by progesterone
• >8.9 IU/L – low response
• <4 IU/L – high response
o People undergoing IVF should be offered screening for (if positive – offer specialist advice + counselling + appropriate clinical management)
HIV
Hep B
Hep C
Subfertility ix
• Semen analysis
• Blood hormone profile
o Look at early follicular phase FSH, LH and oestradiol levels (day 2-3)
o AMH – assesses ovarian reserve
Independent of the menstrual cycle
Produced by granulosa cells and does not change in response to gonadotrophins – it is the most successful biomarker of ovarian reserve
o Mid-luteal progesterone – used to confirm ovulation
o If irregular menstrual cycle – TFTs, prolactin, testosterone
• Ovarian reserve testing
• Regularity of menstrual cycles
o Ask about frequency + regularity of menstrual cycles
o Regular monthly menstrual cycles – women are likely ovulating
o Mid-luteal progesterone level
o If prolonged irregular menstrual cycles - blood test for serum progesterone (Conducted later in the cycle e.g. day 28 of a 35-day cycle, Repeated weekly thereafter until the next menstrual cycle starts) + blood test for serum gonadotrophins (FSH, LH)
• Prolactin measurement
o Should only be offered to women who have an ovulatory disorder, galactorrhoea or a pituitary tumour
• Investigation of suspected tubal + uterine abnormalities
o Not known to comorbidities – Hysterosalpingography (HSG) or hysterosalpingo-contrast-ultrasonography – screens for tubal occlusion
o Comorbidities – laparoscopy + dye (so that tubal + pelvic pathology can be assessed at the same time)
o Should not be offered hysteroscopy unless clinically indicated
• Testing for viral status
o People undergoing IVF should be offered testing for HIV, Hep B, Hep C
• Susceptibility to rubella
• Screening for Chlamydia trachomatis
o Before undergoing uterine instrumentation women should be offered screening for Chlamydia trachomatis
o Prophylactic antibiotics should be considered before uterine instrumentation if screening has not been undertaken
• TVUS o Assessment of pelvic anatomy o Identify pathology o Antral follicle count (important parameter of ovarian reserve) <4 = poor response 16+ = good response
When to refer the woman earlier for infertility ix in secondary care
• An earlier referral for specialist consultation should be offered when
o Woman is >36 y/o
o There is a known cause of infertility
o There is hx of predisposing factors for infertility
o Ix show there is apparently no chance of pregnancy with expectant management
Semen analysis reference values
Semen volume pH sperm concentration total sperm number total motility (progressive motility + non-progressive motility) vitality sperm morphology (normal forms)
Further ix if… are…
o If the result of semen analysis is abnormal
o If gross spermatozoa deficiency (azoospermia or severe oligozoospermia) has been detected
o Reference values
Semen volume – >1.5 ml
pH - >7.2
sperm concentration – >15 million spermatozoa per ml
total sperm number - >39 million spermatozoa per ejaculate or more
total motility (progressive motility + non-progressive motility) - >40% motile, >32% progressively motile
vitality - >58% live spermatozoa
sperm morphology (normal forms) >4%
o If the result of semen analysis is abnormal –> repeat confirmatory test 3 months after the initial analysis (allow time for the cycle of spermatozoa formation to be completed)
o If gross spermatozoa deficiency (azoospermia or severe oligozoospermia) –> repeat test should be undertaken asap
Endometrial hyperplasia ix
• Diagnosis requires histological examination of the endometrial tissue
• TVUS to diagnose endometrial hyperplasia
o <4mm – endometrial cancer unlikely
o >4mm – hysteroscopy +/- biopsy
• Diagnostic hysteroscopy + biopsy
Endometrial cancer ix
• TVUS
o First-line for women with PMB
o The mean endometrial thickness in postmenopausal women is much thinner than in premenopausal women
o <4mm – endometrial cancer unlikely
o >4mm – hysteroscopy +/- biopsy
o Malignant and benign endometrial patterns can often be determined by TVUS which can help diagnosis
• Hysteroscopy +/- Biopsy
o In OP under LA
o Preferred diagnostic technique to detect polyps + other benign lesions
o High diagnostic accuracy for – endometrial cancer, polyps, submucous myomas
o Moderate diagnostic accuracy for – endometrial hyperplasia
• Other
o Many women will also have CXR and blood tests (FBC, LFTS)
• Staging o TAH + BSO - primary treatment + staging o FIGO staging I – limited to uterus II – spread to cervix III – spread adjacent IV – distant spread
• Lynch syndrome testing for women with endometrial cancer
o All women diagnosed with endometrial cancer should be offered testing for lynch syndrome
o The inherited condition Lynch syndrome increases the risk of certain types of cancer incl. endometrial and colorectal cancer
FIGO endometrial cancer staging
I – limited to uterus
II – spread to cervix
III – spread adjacent
IV – distant spread
https://geekymedics.com/wp-content/uploads/2014/01/endometrial-cancer-staging.jpg
Ovarian cancer ix in primary care
• Ca125 o >35 IU/ml --> 2WW referral + TVUS of the abdomen + pelvis o Normal (<35 IU/ml) or high Ca125 but normal US --> assess carefully other clinical causes of her symptoms + ix if appropriate, safety net – return to GP if symptoms become more frequent and/or persistent
o CA125 raised in
>80% epithelial ovarian cancers
Also raised in pregnancy, endometriosis, alcoholic liver disease
o Should be the only tumour marker used for primary evaluation – allows the risk of malignancy index of ovarian cysts in postmenopausal women to be calculated
Ovarian cancer ix in secondary care
• Ca 125 – 1st line
• TVUS – 1st line – ordered by gynaecology, not GP – characterise
o Size
o Consistency
o Bilateral or not
o Presence of solid elements
o Presence of ascites
o Extraovarian disease – peritoneal thickening, omental deposits
• Risk malignancy Index 1 – 1st line
o To assess likelihood of malignancy
If >250 (NICE) or >200 (SIGN, RCOG) – high risk, CT abdomen pelvis, refer to a specialised multidisciplinary team
<25 – low risk
• Imaging – staging
o TVUS abdomen pelvis – first imaging test in secondary care for suspected ovarian cancer
o If US, CA125 + clinical status suggest ovarian cancer –> CT abdomen pelvis
o Do not use MRI
• Biopsy
o Percutaneous image-guided biopsy
o Laparoscopic biopsy – if percutaneous image-guided biopsy is not feasible/has not produced an adequate sample
o (if offering cytotoxic chemotherapy to women with suspected advanced ovarian cancer, first obtain a confirmed tissue diagnosis by histology (or by cytology if histology is not appropriate) in all but exceptional cases)
• If <40 y/o
o Exclude endodermal sinus tumours – AFP
o Identify women who may have dysgerminomas, embryonal carcinomas or choriocarcinomas –βhcg
o LDH, AFP, hCG – should all be measured in all women <40 with a complex ovarian mass - ?germ cell tumours
Ovarian cancer staging
FIGO
Stage I - limited to ovaries
Stage II - Limited to pelvis
Stage III - Limited to abdomen
Stage IV - outside abdominal cavity
https: //miro.medium.com/max/842/1*JjBWhX3bd8p6YLhdjsTkQw.png
https: //www.researchgate.net/profile/Athina-Tsili/publication/266126977/figure/tbl1/AS:668226933510156@1536329124256/FIGO-staging-of-ovarian-cancer.png (+ look at notes)
When to investigate for ovarian cancer in primary care?
When to refer?
• Tests in primary care to be carried out if the woman (esp. >50) reports having ay of the following symptoms on a persistent or frequent basis, particularly >12 times per month
o Persistent abdominal distension – “bloating”
o Early satiety +/or loss of appetite
o Pelvic or abdominal pain
o Increased UU and/or frequency
o Unexplained weight loss, fatigue, changes in bowel habit
• Appropriate tests for ovarian cancer in any woman >50 who has experienced symptoms within the previous 12 months that suggest IBS –> IBS rarely presents for the first time in women of this age
REFERAL
• Ca125
o >35 IU/ml –> 2WW referral + TVUS of the abdomen + pelvis
• Urgent referral (2WW) to a gynaecological cancer service if physical examination identified: a) ascites and/or pelvic/abdominal mass
Risk of malignancy index calculation
o Score = US score x menopausal score x CA125 level in IU/ml
US score = the number of the following findings on scan
• Multilocular cyst
• Solid areas
• Bilateral lesions
• Ascites
• Intra-abdominal metastases
• U=O (US score = 0), U=1 (US score 1), U=3 (US score 2-5)
Menopausal status
• 1=pre-menopausal
• 3=postmenopausal
• Assessing response to chemotherapy + monitoring efficacy of treatment + monitoring for recurrence in ovarian cancer
o CA 125
o (Imaging) – CT scan
Ovarian cysts ix in premenopausal women
- Pregnancy test
- Germ cell tumours - raised AFP, raised βHCG
• Physical examination
o Abdominal + vaginal examination
o Presence/absence of local lymphadenopathy
o Evaluation of mass tenderness, mobility, nodularity, ascites
• Acute presentation - ?accident to the ovarian cyst (torsion, rupture, haemorrhage)
• TVUS>TAUS
o Single most effective way of evaluating an ovarian mass
o Can be used to estimate accurately the risk of malignancy in premenopausal women without a ca125
o Simple - manage depending on size
50-70mm yearly TVUS <50mm no f/u, likely to be physiological
o Complex (<40y/o) - LDH, AFP, bHCG levels – should all be measured in all women <40 with a complex ovarian mass - ?germ cell tumours
• Bloods
o Ca125 - Does not need to be done in premenopausal women who have had an US dx of a simple ovarian cyst made
Can be raised in numerous conditions e.g. fibroids, endometriosis, adenomyosis, pelvic infection
If it’s raised – serial monitoring – rapidly rising levels are more likely to be associated with malignancy
<200 units/ml – exclude/treat the common differential diagnoses
>200 units/ml – discussion with the gynaecological oncologist
o <40 – LDH, AFP, hCG – should all be measured in all women <40 with a complex ovarian mass - ?germ cell tumours
Exclude endodermal sinus tumours – AFP
Identify women who may have dysgerminomas, embryonal carcinomas or choriocarcinomas –βhcg
• Risk of malignancy index (RMI)
o To estimate the risk of malignancy
o Essential in the assessment of an ovarian mass
o However results may not be applicable to the premenopausal group –
• Refer if (American college of obstetric and gynaecologists + society of obstetricians and gynaecologists)
o Ca125 >200 units/ml
o Evidence of abdominal/distant mets
o First degree relative with breast/ovarian cancer
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Tumour markers
ca125 ca19-9 cea inhibin AFP HER2 LDH bHCG
ca125 - serous epithelial ovarian cancer
ca19-9 - mucinous epithelial ovarian cancer
pancreatic cancer
cea - bowel cancer
inhibin - granulosa cell tumours
AFP
liver cancer
endodermal yolk sac tumour
teratoma
HER2 breast cancer (receptor)
LDH
Dysgerminoma
bHCG
Dysgermioma
choriocarcinoma
Ovarian cysts ix in postmenopausal women
• Full physical examination
o BMI
o Abdominal examination to detect ascites + characterise any palpable mass - Evaluation of mass tenderness, mobility, nodularity, ascites
o Vaginal examination
o Presence/absence of local lymphadenopathy
• Ca125
o Should not be used in isolation to determine if the cyst is malignant – a normal value does not exclude ovarian cancer
o Monitoring ca125 levels may be helpful – rapidly rising levels more likely to be associated with malignancy than high levels which remain static
o Main use of ca125 – assessing response over time to treatment for malignancy
o >35 IU/ml -2WW referral + TVUS of the abdomen + pelvis
o Normal (<35 IU/ml) or high Ca125 but normal US - assess carefully other clinical causes of her symptoms + ix if appropriate, safety net – return to GP if symptoms become more frequent and/or persistent
• TVUS
o First line imaging ix
o Single most effective way of evaluating ovarian cysts in postmenopausal women
o Transabdominal US should not be used in isolation – only to provide supplementary information to the TVUS (e.g. when an ovarian cyst is large or beyond the field of view of TVUS)
o Simple or complex - use CA-125 level - RMI calculation
• MRI
o Second line
o Used if TVUS is inconclusive
• CT abdomen and pelvis
o If malignant disease is suspected based on the US findings and tumour markers
• Risk malignancy Index 1
o To assess likelihood of malignancy
If >250 (NICE) or >200 (SIGN, RCOG) – high risk, CT abdomen pelvis, refer to a specialised multidisciplinary team –
<25 – low risk
- FBC – infection, haemorrhage
- Urinalysis – if there are urinary symptoms
- CT/MRI – only required if US results are not definitive or if intra-abdominal pathology is suspected
- Diagnostic laparoscopy
- FNA + cytology to confirm that the cyst is benign
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Elevated ca125 ddx
Ovarian cancer Endometriosis uterine fibroids menstruation pregnancy benign ovarian neoplasms >80% epithelial ovarian cancers
Alcoholic liver disease
Diverticulitis
Liver cirrhosis
other malignancies (pancreatic, breast, liver, lung)
Sonographic evidence (US) dx
Beads on a string
Snowstorm appearance
Whirpool sign
Hypoechoic mass
Chronic salpingitis/Hydrosalpinx
mural nodules appearing as ‘beads’ and the relatively-thin wall appearing as ‘string’.
Complete hydatidiform mole/molar pregnancy
Ovarian torsion
https://www.youtube.com/watch?v=5x3FhvWgqJs
Fibroid
Liachen sclerosus ix
- Diagnosis is usually made clinically by clinical appearance
- Lesions should be well documented for follow up purposes – diagrams + photography
• Other investigations
o Biopsy
Indicated only when there is diagnostic uncertainty or suspected malignancy (coexistent vulval intraepithelial neoplasia (VIN)/SCC suspicion)
Should be considered when presentation is atypical e.g. young adult women, extragenital lesions, pigmented lesions, development of raised lesions
Essential if lesions do not respond to initial course of steroid treatment
Findings – thinned epidermis with sub-epidermal hyalinization and deeper inflammatory infiltrate
o Blood tests
If there are clinical features to suggest an AI disorder– autoantibody screen
if symptoms present – autoimmune screen, TFTs
Ix/ considerations before TOP
Considerations before TOP
• Counselling/support
o Verbal advice + written information
o Additional support/counselling if needed (evidence of coercion, poor social support, psychiatric history)
• Blood tests
o Hb
o Blood group + antibodies
o If clinically indicated – HIV, HBV, HCV, haemoglobinopathies
• USS – to give accurate gestation + identify already non-viable and occasional ectopic pregnancies
• Prevention of infection – screen for lower genital tract infections e.g. Chlamydia (with treatment + contact tracing if +ve)
