Gynaecology Part 3 Flashcards
What are the 4 main types of ovarian tumours:
- surface derived
- germ cell
- sex cord-stromal
- metastasis
What is the most common type of ovarian tumour?
surface derived
Name all the surface derived tumours:
- serous cystadenoma
- serous cystadenocarcinoma
- mucinous cystadenoma
- mucinous cystadenocarcinoma
- brenner tumour
What is a serous cystadenoma?
- benign
- most common benign ovarian tumour
- often bilateral
- cysts lined by ciliated cells (similar to fallopian tube)
What is a serous cystadenocarcinoma?
- malignant
- often bilateral psammoma bodies (collection of calcium)
What is a mucinous cystadenoma?
- benign
- cysts lined by mucous secreting epithelium (similar to endocervix)
What is a mucinous cystadenocarcinoma?
-malignant
-may be associated with pseudomyxoma peritonei
(mucinous tumour of appendix more common cause)
What is a Brenner tumour?
- benign
- contain Walthard cell rests (benign cluster of epithelial cells)
- similar to transitional cell epithelium
- coffee bean nuclei
In whom are germ cell tumours more common?
adolescent girls
What are the germ cell ovarian tumours?
- teratoma
- dysgerminoma
- yolk sac tumour
- choriocarcinoma
What is a teratoma?
- mature teratoma (dermoid cysts) is most common - benign
- immature teratoma - malignant
- combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
What is a dysgerminoma?
- malignant
- most common malignant germ cell tumour
- similar histologically to testicular seminoma
- associated with Turner’s
- typically secrete hCG and LDH
What is a yolk sac tumour?
- malignant
- secrete AFP
- Schiller-Duval bodies on histology are pathognomonic
What is a choriocarcinoma?
- malignant
- rare (part of gestational trophoblastic disease)
- typically increased hCG
- often early haematogenous spread to lungs
What are the sex cord-stromal ovarian tumours?
- granulosa cell tumour
- sertoli Leydig cell tumour
- fibroma
What is a granulosa cell tumour?
- malignant
- produces oestrogen - precocious puberty in children or endometrial hyperplasia in adults
- Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
What is a Sertoli-Leydig cell tumour?
- benign
- produces androgens - masculinising
- associated with Peutz-Jegher syndrome
What is a fibroma?
- benign
- associated with Meig’s syndrome (ascites, pleural effusion)
- solid tumour - bundles of spindle shaped fibroblasts
- typically around menopause
- pulling sensation in pelvis
What is the ovarian metastatic tumour?
- Krukenberg tumour
- malignant
- metastases from gastrointestinal tumour resulting in mucin-secreting signet ring cell adenocarcinoma
What happens in the early follicular phase?
- increased in GnRH pulse frequency
- this increase FSH and LH release
- stimulation and development of multiple ovarian follicles
- one will become dominant ovulatory follicle
What happens mid-follicular phase?
- FSH gradually stimulates estradiol production
- estradiol produces negative feedback on hypothalamus and pituitary to decrease FSH and LH concentrations
What happens in the luteal phase?
- switch from negative to positive feedback of estradiol
- surge of LH secretion
- follicular rupture and ovulation
Three main categories of anovulation:
- Class I: hypogonadotrophic hypogonadal anovulation - hypothalamic amenorrhoea
- Class II: normogonadotrophic normoestrogenic anovulation - PCOS (80%)
- Class III: hypergonadotrophic normoestrogenic anovulation - premature ovarian insufficiency (requires IVF with donor oocytes)
Forms of ovulation induction:
- exercise and weight loss (first line for PCOS)
- Letrozole
- Clomiphene citrate
- gonadotropin therapy
How does Letrozole work as an ovulation inducer?
- first line PCOS
- reduces ADRs on endometrial and cervical mucous compared to clomiphene citrate and higher live birth rate
- aromatase inhibitor - reduces negative feedback by oestrogen’s in pituitary so increased FSH
- high rate of mono follicular development
- some fatigue and dizziness possible
How does clompihene citrate work as an ovulation inducer?
- SERM
- acts on hypothalamus to block negative feedback of oestrogens
- increase in GnRH pulse frequency etc.
- ADR: hot flushes, abdominal distention, pain, n&v
How does gonadotropin therapy work as an ovulation inducer?
- used mostly for women with class I ovulatory dysfunction
- risk of multi follicular development and multiple pregnancy, OHSS
- IV infusion of GnRH
What is the main life-threatening complication of ovulation induction?
- ovarian hyperstimulation syndrome
- multiple cystic spaces and increase in permeability of capillaries
- shift of fluid from intra to extravascular space
- hypovolaemic shock, acute renal failure, VTE
Management OHSS:
- fluid and electrolyte replacement
- anti-coagulation therapy
- abdominal ascitic paracentesis
- pregnancy termination
What is PID?
- infection and inflammation of female pelvic organs
- includes uterus, fallopian tubes, ovaries and surrounding peritoneum
- usually from ascending infection form endocervic
What organisms typically cause PID?
- Chlamydia trachomatis (most common)
- Neisseria gonorrhoea
- mycoplasma genitalium
- mycoplasma hominis
Features of PID:
- lower abdo pain
- fever
- deep dyspareunia
- dysuria and menstrual irregularities
- vaginal or cervical discharge
- cervical excitation
Investigations in PID:
- pregnancy test to exclude ectopic
- high vaginal swab (often negative)
- screen for Chlamydia and Gonorrhoea
Management of PID:
oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxycycline + oral metronidazole
Complications of PID:
- perihepatitis (Fitz Hugh Curtis)
- infertility
- chronic pelvic pain
- ectopic pregnancy
Acute causes of pelvic pain:
- ectopic
- UTI
- appendicitis
- PID
- ovarian torsion
- miscarriage
Chronic causes of pelvic pain:
- endometriosis
- IBS
- ovarian cyst
- urogenital prolapse
What type of pain is experienced with ovarian cysts?
- unilateral dull ache intermittent or during intercourse
- torsion or rupture may lead to severe abdominal pain
- large cysts may cause abdominal swelling or pressure effects on bladder
Symptoms with urogenital prolapse:
- older women
- sensation or pressure, heaviness, bearing down
- urinary symptoms: incontinence, frequency, urgency
Features of PCOS:
- subfertility and infertility
- menstrual disturbances : oligomenorrhoea and amenorrhoea
- hirsutism, acne (due to hyperandrogenism)
- obesity
- acanthosis nigricans
Investigations PCOS:
- pelvic ultrasound: multipel cysts on ovaries
- FSH, LH, prolactin, TSH, testosterone (raised LH:FSH)
- check for impaired glucose tolerance
General management of PCOS:
- weight reduction
- COCP
Management of hirsutism and acne in PCOS:
- COCP for hirsutism
- third generation COCP has fewer androgenic effects or co-cyprindiol has anti-androgenic action
- topical eflornithine
- spirinolactone, flutamide, finasteride
Management of infertility in PCOS:
- weight reduction
- clomifene most effective
- metformin with or without clomifene
- gonadotrophins
What causes postcoital bleeding?
- no pathology 50%
- cervical ectropion (33%) - more common with COCP
- cervicitis
- cervical cancer
- polyps
- trauma
All the different causes of postmenopausal bleeding:
- vaginal atrophy
- HRT
- endometrial hyperplasia
- endometrial cancer
- cervical cancer
- ovarian cancer
- vaginal cancer
- uncommon: trauma, vulval cancer, bleeding disorders
Most common cause of postmenopausal bleeding:
- vaginal atrophy
- thinning, drying and inflammation of walls due to reduction in oestrogen
Risk factors of endometrial hyperplasia leading to postmenopausal bleeding:
- obesity
- unopposed oestrogen use
- tamoxifen use
- PCOS
- diabetes
Investigations post-menopausal bleeding:
- > 55yo should be investigated within 2 weeks by US for endometrial cancer
- vaginal and full abdominal examination
- urine dipstick (haematuria or infection), FBC (anaemia or bleeding disorder, CA-125
- cancer pathway referral: transvaginal US - asses endometrial thickness, should be <5mm
- endometrial biopsy for definitive diagnosis (hysteroscopy or aspiration)
- imaging in secondary (CT, MRI)
What is premature ovarian failure?
onset of menopausal symptoms and elevated gonadotrophin levels before 40yo
Causes of premature ovarian failure?
- idiopathic (most common, family history)
- bilateral oophorectomy
- radiotherapy
- chemotherapy
- infection e.g. mumps
- autoimmune disorders
- resistant ovary syndrome: due to FSH receptor abnormalities
Features of premature ovarian failure:
- climacteric symptoms: hot flushes, night sweats
- infertility
- secondary amenorrhoea
- raised FSH, LH levels
- low oestradiol
Management of mild PMS:
regular frequent, small, balanced meals rich in complex carbohydrates
Management of moderate PMS:
- new generation COCP
- Yasmin
Management of severe PMS:
SSRI taken continuously or during luteal phase
Causes of recurrent miscarriage:
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes/thyroid, PCOS
- uterine abnormality e.g. uterine septum
- parental chromosomal abnormalities
- smoking
What defines recurrent miscarriage?
3 or more consecutive spontaneous abortions
How should semen analysis be performed?
- after min 3 days and max 5 days of abstinence
- deliver to lab within 1 hour
Normal semen analysis results:
- volume >1.5ml
- pH >7.2
- sperm concentration >15 million/ml
- morphology >4% normal forms
- motility >32% progressive motility
- vitality >58% live spermatozoa
Legal points around termination of pregnancy:
- 2 registered medical practitioners must sign legal document
- 1 in an emergency
- only registered medical practitioner
How does gestation affect method of pregnancy termination:
- less than 9 weeks: mifepristone followed 48 hours later by prostaglandins to stimulate uterine contractions
- less than 13 weeks: surgical dilation and suction of uterine contents
- more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion
Upper limit of abortion:
24 weeks (unless to save life, extreme abnormality or serious physical or mental injury)
Risk factors urinary incontinence:
- advancing age
- previous pregnancy and childbirth
- high BMI
- hysterectomy
- family history
Classification of urinary incontinence:
- overactive bladder (OAV)/urge incontinence - detrusor overactivity
- stress incontinence: small amounts leaking when coughing or laughing
- mixed incontinence: urge and stress
- overflow incontinence: bladder outlet obstruction e.g. due to prostate enlargement
Initial investigations urinary incontinence:
- bladder diaries for min 3 days
- vaginal exam to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
- urine dipstick and culture
- urodynamic studies
Management urinary incontinence:
-bladder retraining (min 6 weeks)
-bladder stabilising drugs: anti-muscarinics
oxybutinin - immediate release (avoid in older women), tolterodine - immediate, or darifenacin (once daily)
-mirabegron (useful if concern about anticholinergic side effects in elderly)
If stress incontinence is predominant, what management options are there?
- pelvic muscle training (8 contractions 3 times per day for 3 months)
- surgical procedures e.g. retropubic mid-urethral tape
- duloxetine - combined noradrenaline and serotonin reuptake inhibitor - increased synaptic concentration pudendal nerve
Causes of vaginal discharge:
- Candida
- trichomonas vaginalis
- vaginosis
- gonorrhoea
- chlamydia
- ectropion
- foreign body
- cervical cancer
What are the typical features of candida?
- cottage cheese discharge
- vulvitis
- itch
What are the typical features of trichomonas vaginalis?
- offensive, yellow/green, frothy discharge
- vulvovaginitis
- strawberry cervix
What are the typical features of bacterial vaginosis?
- offensive
- thin
- white/grey
- fishy discharge
Types of urogenital prolapse:
- cystocele, cystourethrocele
- rectocele
- uterine prolapse
- less common: urethrocele, enterocoele (herniation of pouch of Douglas, including small intestine into vagina)
Risk factors of urogenital prolapse:
- increasing age
- multiparity, vaginal deliveries
- obesity
- spina bifida
Presentation of urogenital prolapse:
- sensation of pressure, heaviness, bearing down
- urinary symptoms: incontinence, frequency, urgency
Management of urogenital prolapse:
- asymptomatic and mild prolapse then no treatment
- conservative: weight loss, pelvic floor muscle exercises
- ring pessary
- surgery
Surgical options urogenital prolapse:
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
What are fibroids?
benign smooth muscle tumours of uterus
Associations of uterine fibroids:
- more common Afro-Caribbean women
- rare before puberty, develop in response to oestrogen
Features of uterine fibroids:
- asymptomatic
- menorrhagia - iron-deficiency anaemia
- lower abdominal pain: cramping, often during menstruation
- bloating
- urinary symptoms e.g. frequency, may occur with larger fibroids
- subfertility
- rare: polycythaemia secondary to autonomous production of erythropoietin
Diagnosis of uterine fibroids:
transvaginal ultrasound
Management of uterine fibroids:
- asymptomatic: no treatment
- menorrhagia: levonorgestrel intrauterine system, NSAIDs e.g. mefenamic acid, tranexamic acid, COCP, oral progestogen, injectable progestogen
- treatment to shrink/remove fibroids
What treatments to shrink/remove fibroids are there:
- GnRH agonists reduce size as short term treatment
- ulipristal acetate but serious liver toxicity possible
- myomectomy
- hyesteroscopic endometrial ablation
- hysterectomy
- uterine artery embolisation
Complications of uterine fibroids:
- subfertility
- iron deficiency anaemia
- red degeneration - haemorrhage into tumour. commonly occurs during pregnancy
Risk factors vaginal candidiasis:
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV
Features vaginal candidiasis:
- cottage cheese, non offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions
Investigation vaginal candidiasis:
high vaginal swab is not routinely indicated if clinical features are consistent with candidiasis
Management of vaginal candidiasis:
- local: clotrimazole pessary e.g. clotrimazole 500mg PV stat
- oral: itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
- only local treatments if pregnant (oral contra)
What is defined as recurrent vaginal candidiasis and how is it diagnosed? Treatment?
- 4 or more episodes per year
- check compliance with previous treatment
- confirm with high vaginal swab for microscopy and culture, consider blood glucose test to exclude diabetes
- exclude diff diagnoses such as lichen sclerosus
- consider use of induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
What type of cancer are vulval carcinomas?
- 80% squamous cell carcinomas
- most in over 65yo
Risk factors vulval carcinoma:
- HPV infection
- vulval intraepithelial neoplasia (VIN)
- immunosuppression
- lichen sclerosis
Features of vulval carcinoma:
- lump or ulcer on the labia majora
- may be associated with itching, irritation
