Gynaecology Pt. 2

Question 1

What are some infective causes of vaginal discharge?

Answer 1

• Bacteria vaginosis
• Vulvovaginal candidiasis
• Trichomoniasis

Question 2

What is bacterial vaginosis?

Answer 2

• MOST COMMON cause of abnormal vaginal discharge
• Occurs in 5-50% of women worldwide
• Definitive cause is not known but thought to be associated with depletion of lactobacilli dominant in the healthy vaginal flora
• Vaginal pH will also rise > 4.5
• Presence of vaginal epithelial biofilm consisting of Gardnerella vaginalis has also been described

Question 3

What are risk factors of having bacterial vaginosis?

Answer 3

• Douching
• Afro-Caribbean
• Smoking
• Having a new sexual partner
• Receiving oral sex

Question 4

What are symptoms of bacterial vaginosis?

Answer 4

• Offensive vaginal discharge (‘fishy’ odour)

- Homogenous off-white vaginal discharge with a high pH

Question 5

How is bacterial vaginosis diagnosed?

Answer 5

• Evaluation of Gram-stain of vaginal discharge using validated method (e.g. Hay-Ison, Nugent or Amsels criteria)

Question 6

What conditions are associated with bacterial vaginosis?

Answer 6

• PID
• Posthysterectomy vaginal cuff cellulitis
• Pregnancy: preterm birth, rupture of membrane and miscarriage
• Increased risk of HIV acquisition

Question 7

What is the management of bacterial vaginosis?

Answer 7

• Oral or intravaginal treatment with metronidazole or clindamycin
• Advice: vaginal douching and excessive genital washing should be avoided

Question 8

What is vulvovaginal candidiasis?

Answer 8

• When Candida yeast (usually C. albicans) causes vulval and vaginal inflammation
• The vagina is colonised by Candida sp. in up to 20% of women in their reproductive years and 40% of pregnant women
• Usually ASYMPTOMATIC

Question 9

What are the symptoms of vulvovaginal candidiasis?

Answer 9

• Itching
• Irritation
• White, curdy vaginal discharge
• Erythema, oedema and fissuring of the vulva and vagina (on examination)
• NOTE: symptoms may be more frequent and persistent if diabetic, immunocompromised or pregnant

Question 10

How is vulvovaginal candidiasis diagnosed?

Answer 10

• Bacterial swab for microscopy and culture

Question 11

What is the management of vulvovaginal candidiasis?

Answer 11

• Prescribe antifungal treatment
  
  • Most women: intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole) or an oral antifungal (fluconazole, itraconazole)
  • Women > 60 years: oral antifungals may be more acceptable because of ease of administration
  • Girls aged 12-15 years: consider prescribing topical clotrimazole 1% or 2% applied 2-3 times per day (do NOT prescribe intravaginal or oral antifungal)
  • Breastfeeding women: intravaginal clotrimazole or oral fluconazole
  • If vulval symptoms: topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
  • NOTE: intravaginal clotrimazole (Canesten), oral fluconazole and topical clotrimazole can be purchased OTC
• Advice
  
  • Return if symptoms have not resolved in 7-14 days
  • Avoid predisposing factors:
    
    • Washing and cleaning the vulval area with soap or shower gels , wiped and feminine hygiene products
    • Cleaning the vulval area more than once per day
    • Washing underwear in biological washing powder and using fabric conditioners
    • Vaginal douching
    • Wearing tight-fitting and/or non-absorbent clothing
  • Wash the vulval area with a soap substitute - used externally and not more than once per day
  • Use simple emollient to moisturise vulval area
  • Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms
• Do NOT routinely treat asymptomatic sexual partner
  
  • Male partner could get candida balanitis

Question 12

What is Trichomoniasis?

Answer 12

• Vaginal and urethral infection caused by flagellate protozoan Trichomonas vaginalis (TV)
• TV is sexually-transmitted, therefore, simultaneous treatment of current and recent sexual partners is required

Question 13

What are the symptoms of Trichomoniasis?

Answer 13

• Vaginal discharge with a variable appearance
• Symptoms of vulvo-vaginitis
• Asymptomatic infection is seen in up to 50% of women and their male partners

Question 14

How is trichomoniasis diagnosed?

Answer 14

• Testing is required if symptomatic
• NAAT (nucleic acid amplification test) on vaginal or endocervical swab or urine
• Some test swill also be able to detect N. gonorrhoea or Chlamydia trachomatis on the same swab (ideally vulvovaginal swab)
• Microscopy and culture as well as POCT (point of care test) are available but have lower sensitivity

Question 15

How is trichomoniasis managed?

Answer 15

• Metronidazole

Question 16

What are causes of cervicitis and pelvic inflammatory disease?

Answer 16

• Gonorrhoea

- Chlamydia

Question 17

What is Gonorrhoea?

Answer 17

• Caused by Nerisseria gonorrhoea (Gram-negative intracellular diplococcus)
• Simultaneous treatment of current and previous sexual partners is required
• Ascending infection may result in PID
• Rarely, it can lead to haematogenous spread causing disseminated gonococcal infection with a purpuric non-blanching rash and/or arthralgia (usually monoarticular in a weight-bearing joint)
• Ophthalmic infection can occur due to inoculation from infected genital secretions
• Neonatal infection may occur when the mother has endocervical infection a the time of delivery

Question 18

What are the symptoms of Gonorrhoea?

Answer 18

• Endocervical infection is ASYMPTOMATIC in up to 50%
• Altered vaginal discharge (MOST COMMON)
• Lower abdominal pain
• Rectal infection (through transmucosal spread or receptive anal sex)
• Pharyngeal infection (through receptive oral sex)
• This is nearly always asymptomatic
• Examination is often normal (cervicitis with or without mucopurulent discharge may be seen)

Question 19

How is Gonorrhoea diagnosed?

Answer 19

• Required if symptomatic of if the woman has another STI
• NAAT is the gold standard
• If N. gonorrhoea is identified, a sample should be obtained for culture and sensitivity (because there is widespread resistance)
• Screening for other STIs (particularly chlamydia) is important because dual infection is common

Question 20

How is Gonorrhoea managed?

Answer 20

• Ceftriaxone IM

Question 21

How is dual infection (gonorrhoea and chlamydia) managed?

Answer 21

• Parenteral 3rd generation cephalosporin (e.g. ceftriaxone) + azithromycin

Question 22

What is Chlamydia?

Answer 22

• MOST COMMON bacterial STI
• Women < 25 years are most frequently affected
• Caused by Chlamydia trachomatis
• Often asymptomatic
• May cause subclinical PID and complications
• Screening programmes have been developed for the highest risk age group
• Examination is often NORMAL
• Cervicitis with mucopurulent discharge may be observed
• Neonates born to mothers with cervical chlamydia infection may develop conjunctivitis
• Reactive arthritis is a complication but is more common in men

Question 23

What are the risk factors of chlamydia?

Answer 23

• New sexual partner
• Altered vaginal discharge
• Intermenstrual or post-coital bleeding
• Abdominal pain

Question 24

How is chlamydia diagnosed?

Answer 24

• NAAT (some test N. gonorrhoea simultaneously)

- Best specimen is a vulvovaginal swab that may be self-taken

Question 25

What is the management of chlamydia?

Answer 25

• Azithromycin or doxycycline are equally effective

- Simultaneous treatment of current and recent sexual partners

Question 26

What is Pelvic Inflammatory Disease?

Answer 26

• Occurs when there is ascending infection from the endocervix to the higher reproductive tract
• Recognised complication of chlamydia
• Occurs less frequently with gonorrhoea
• Other implicated organisms include Mycoplasma genitalium and vaginal microflora

Question 27

What are the symptoms of PID?

Answer 27

• Lower bilateral abdominal pain
• Dyspareunia
• Altered vaginal discharge
• Abnormal vaginal bleeding (intermenstrual or post-coital)

Question 28

What are the signs of PID?

Answer 28

• Lower abdominal and cervical motion tenderness

- Cervicitis

Question 29

What are the investigations for PID?

Answer 29

• Testing for all STIs
• Exclusion of pregnancy
• Laparoscopy may reveal scarring and adhesions between structures in the pelvis and the development of hydrosalpinges

Question 30

What is the management of PID?

Answer 30

• IMPORTANT: if an IUD is in situ, consider removal although the risk of pregnancy if there has been unprotected sex in the last week should be considered
• Macrolide (e.g. azithromycin) OR tetracycline (e.g. doxycycline) AND metronidazole with a parenteral 3rd generation cephalosporin
• Sexual partners require screening and empirical treatment (usually azithromycin)
• Provide women with information regarding possible sequelae

Question 31

What are genital herpes?

Answer 31

• TWO types:
  
  • HSV1 (orolabial herpes)
  • HSV2 (genital herpes
• The virus establishes latency in the local sensory ganglia and may reactive leading to viral shedding with or without symptoms
• Primary infection = first infection
• Most initial infections are asymptomatic (but can still be infectious)
• Recurrence rates are higher with HSV2
• Recurrence rates reduce in frequency with time
• Neonatal herpes is devastating and has a mortality of up to 30% and lifelong neurological morbidity in 70%
• C-section is recommended for women with first-acquisition genital herpes in the 3rd trimester

Question 32

What are the symptoms of genital herpes?

Answer 32

• Genital pain
• Dysuria
• Multiple superficial tender ulcers with regional lymphadenopathy

Question 33

How are genital herpes diagnosed?

Answer 33

• Detection of the virus from the genital lesions by gently taking a swab
• PCR is the test of choice
• Type-specific serology (for IgG and IgM to HSV1 and 2) can be useful to establish whether the infection is primary, non-primary or recurrence

Question 34

How is genital herpes managed?

Answer 34

• Aciclovir (or valaciclovir)
  
  • Safe in pregnancy
• Most effective if given as soon as possible after symptoms begin
• Important information for patients: lifelong nature of infection, asymptomatic shedding, risk to sexual partners, need for disclosure, effectiveness of condoms and antivirals in limiting transmission

Question 35

What are genital warts?

Answer 35

• Benign epithelial tumours caused by HPV infection
• Over 100 genotypes
• Types 6 and 11 cause 90% of genital warts
• Majority of cases are subclinical
• Types 16 and 18 are also spread through sexual contact but cause anogenital dysplasia and cancer rather than warts
• HPV vaccination is available in a bivalent (16 and 18) and quadrivalent (6, 13, 16 and 18) form
• VERY RARELY, infants born to mothers with HPV may develop respiratory papillomatosis (however, C-section should not be recommended)

Question 36

How is genital warts diagnosed?

Answer 36

• Clinical examination

Question 37

How are genital warts managed?

Answer 37

• Ablation with liquid nitrogen (cryotherapy)
• Surgical techniques
• Patient-applied topical therapies (e.g. podophyllotoxin-containing preparation, imiquimod)
• Treatment is optional because the lesions are benign

Question 38

What is syphilis?

Answer 38

• Caused by Treponema pallidum
• Spread through direct contact with secretions from infective lesions or via transplacental passage of bacteria during pregnancy
• If untreated, it can relapse and remit leading to complications later on
• Infectivity declines with time
• Treatment with penicillin-based regimens are curative (but reinfection is possible)
• More common in homosexual men

Question 39

How is syphilis infection classified?

Answer 39

• Acquired or congenital

- Late or early

Question 40

What is acquired early syphilis?

Answer 40

• First manifestation is the chancre at the site of exposure
• This is a single genital lesion
  
  • NOTE: this is sometimes seen in other sites (e.g. oral cavity)
• The lesion is typically painless, indurated and exudes serous fluid containing T. pallidum
• Regional lymphadenopathy
• This will resolve over a few weeks
• Relapse may occur for up to 2 years (time limit for ‘early’ infection)

Question 41

What is secondary syphilis?

Answer 41

• Widespread erythematous rash typically including the palms and soles
• Can result in alopecia, oral and genital mucous lesions and raised lesions usually in the anogential region called condylomata lata
• Typically resolves spontaneously as the immune response controls the infection

Question 42

What are complications of syphilis?

Answer 42

• Meningitis
• 8th nerve palsy leading to deafness or tinnitus
• Ophthalmic involvement (uveitis)

Question 43

What are the late complications of syphilis?

Answer 43

• Gummatous lesions (granulomatous, locally destructive lesions typically affecting the skin and bone)
• Cardiovascular involvement (usually affecting ascending aorta, resulting in aortic valve incompetence)
• Neurological involvement
  
  • Meningo-vascular disease
  • Tabes dorsalis
  • Progressive dementing illness
  • General paresis

Question 44

How is syphilis diagnosed?

Answer 44

• Serology
• Direct detection of T. pallidum from infectious lesions (usually dark field microscopy or PCR)
• Non-treponemal serological tests
  
  • Rapid plasma reagin (RPR)
  • Venereal Disease Reference Laboratory (VDRL)
  • These show rising titres during acute, active infection that drop with time/following treatment
  • It is useful for monitoring treatment
  • May be false negative in early infection
  • May be false positive in other physiological or diseases states (e.g. pregnancy, rheumatological conditions)
• May require confirmation using other treponemal tests, such as:
  
  • Enzyme or chemiluminescence immnuoassays (EIA/CLIA)
  • Treponema pallidum particle or haemagglutination assay (TPPA/TPHA)
  • These may also be negative in early disease
  • Should be repeated 4-6 weeks later if the diagnosis is still suspected

Question 45

What is the management of syphilis?

Answer 45

• Curative
• Depot preparations of penicillin
• Different regimes for different stages of infection
• Simultaneous treatment of current sexual partners is required
• If the time of infection is unknown, tracing and testing previous partners is important

Question 46

What are the gynaecological complications in HIV-positive Women?

Answer 46

• More likely to have infection with HPV 16 or 18
• Higher incidence of CIN and high-grade squamous intraepithelial lesion (HSIL)
• Because of this, annual cervical cytology is recommended

Question 47

Describe contraception and preconception management in HIV-positive women

Answer 47

• Most antiretrovirals interact with hormonal contraceptives (reduced efficacy of the contraceptive)
• Dynamic HIV drug interaction website (University of Liverpool) provides accurate information on specific drug interactions
• Health of HIV-positive woman and partner should be optimised prior to attempting pregnancy
• Transmission between the partners is extremely low when the positive partner has an undetectable viral load
• Fertility assessment of both partners is good practice
• STI screens should be done for both partners

Question 48

What is urge incontinence?

Answer 48

• involuntary leakage accompanied by or immediately preceded by urgency

Question 49

What is stress incontinence?

Answer 49

• involuntary leakage on effort, exertion, sneezing or coughing

Question 50

What are different types of urine voiding symptoms?

Answer 50

• Slow stream: perception of reduced urine flow
• Spitting or spraying: where the stream or urine is not a single flow
• Intermittent stream: urine flow that stops and starts
• Hesitancy: difficulty in initiating micturition resulting in a delay in the onset of voiding
• Terminal dribble: a prolonged final part of micturition, where the flow has slowed to a trickle or dribble

Question 51

Describe the micturition cycle

Answer 51

• As bladder capacity is reached, sensory signals from stretch receptors in the bladder wall send the sensation of bladder filling
• Voluntary delay of micturition until socially convenient is achieved by cortical inhibition of the spinal voiding reflex arc
• Before voiding, this inhibition is removed leading to relaxation of the pelvic floor muscles and urethral sphincters
• The detrusor muscle is innervated by muscarinic cholinergic nerves of the parasympathetic nervous system (leading to contraction)
• The urethral sphincter is innervated by noradrenergic neurones of the sympathetic nervous system (causing sphincter contraction) and somatic fibres (for voluntary contraction and relaxation) from the pudendal nerves

Question 52

What does the urethral sphincter mechanism consist of in women?

Answer 52

• Internal sphincter - smooth muscle
• External sphincter - striated muscle
• In premenopausal women, the urethral epithelium has a rich blood supply and contributes to continence by acting as a seal

Question 53

What is stress incontinence suggestive of?

Answer 53

• An incompetent urethral sphincter

Question 54

What is urethral sphincter weakness mainly due to?

Answer 54

• Hypermobility
• Pelvic floor and ligaments cannot retain the urethra in position and it falls through the urogenital hiatus during increases in abdominal pressure
• Leads to loss of intra-abdominal pressure transmission to the urethra leading to leakage of urine

Question 55

What is intrinsic sphincter deficiency?

Answer 55

• Less common
• Occurs when urethral closure pressure is low without urethral mobility
• Caused by weakness of the sphincter muscles and loss of cushioning seal effect in the urethra

Question 56

What urethral sphincter problems can childbirth lead to?

Answer 56

• Stretching/damage of the pudendal nerves
• Overstretching of the pelvic floor muscles
• Direct muscle damage can result in loss of pelvic floor support (and urethral hypermobility)

Question 57

What are the risk factors for stress incontinence?

Answer 57

• Multiparity
• Forceps delivery
• Perineal trauma
• Long labour
• Epidural analgesia
• Birthweight > 4 kg
• Increasing age
• Postmenopause
• Obesity
• Connective tissue disease
• Chronic cough (e.g. bronchiectasis)
• Doxazocin (alpha blocker)

Question 58

What is detrusor overactivity?

Answer 58

• Characterised by involuntary detrusor contractions during the filling phase of micturition
• Women will often complain of symptoms of an overactive bladder but may not be incontinent unless urethral sphincter function is compromised or detrusor contractions are of very high pressure
• Detrusor overactivity may be due to differences in sensory and interstitial nerves in the bladder wall and differences in neurotransmitters

Question 59

What are modifiable risk factors of detrusor overactivity?

Answer 59

• Obesity
• Smoking
• Continence surgery carries a 5-10% risk of new detrusor overactivity
• Childhood bedwetting

Question 60

What should be included in the history for incontinence?

Answer 60

• Detailed history to determine whether they are symptoms of stress or urge incontinence
• If there are mixed symptoms, assess which ones are predominant
• Measures of severity
  
  • Number of episodes per day of frequency, urgency and leakage
  • Are continence pads needed?
  • If so, how many and what size?
  • Does the patient need to change underwear or outer clothes because of leakage?
  • Changes in behaviour to accommodate for this issue?
    
    • E.g. reduced fluid intake, limiting social activities
  • Associated symptoms
    
    • Prolapse
    • Faecal incontinence
    • Sexual difficulties
  • Past medical history for predisposing factors (e.g. previous surgery, medical conditions)
    
    • Red flags: haematuria, rectal bleeding, significant pain

Question 61

What’s included in the examination for incontinence?

Answer 61

• General examination
• Abdominal and pelvic examination
• Visible leakage during coughing or Valsalva
• Ability of the patient to contract and hold the contraction of pelvic floor muscles is essential

Question 62

How is incontinence investigated?

Answer 62

• MSU
• Bladder diary (usually about 3 days)
  
  • Record amount, type and frequency of drinks taken
  • Record timing, frequency and volume of voids
• Pad test
  
  • Patient wears a pre-weighed sanitary pad for a variable length of time (e.g. 1 hour in clinic or 24 hours at home) whilst performing provocation tests (e.g. handwashing, climbing stairs, coughing)
  • The change in weight is a measure of the amount of urine lost
• Pelvic or renal ultrasound if there are symptoms of pelvic pain , pelvic mass, haematuria, bladder pain or recurrent UTI
• Discuss with the MDT (gynaecologist, urologist, continence nurse, physiotherapist and maybe medicine for the elderly consultant)

Question 63

What are the elements of conservative management for incontinence?

Answer 63

• Advice about fluid balance
• Reduction of caffeine intake
• Bladder retraining
• Pelvic floor muscle exercise

Question 64

Describe the management of fluid balance for urine incontinence

Answer 64

• (avoid excessive intake > 2.5 litres)
• NOTE: however, reducing fluid intake can result in an increased sensation of urgency due to the more concentrated urine
• Women should be encouraged to drink 1.5-2.5 L of water per day
• Avoid caffeinated drinks and artificially sweetened or carbonated drinks

Question 65

Describe pelvic floor muscle exercises to help urine incontinence

Answer 65

• The woman contracts the pelvic floor muscles by direct coaching whilst being examined vaginally to ensure correct identification of the levator muscle complex
• Programmes are developed to increase the duration of the hold of the contraction and to increase the number of contractions that can be performed consecutively
• This builds strength and endurance
• This measure can lead to cure in over 50% and improvement in 75% or more
• Adherence is a barrier to success
• Pelvic floor exercises work for both incontinence and overactive bladder

Question 66

What does bladder retraining involve?

Answer 66

• Involved re-educating the patient (and her bladder) to increase the interval between voids to re-establish normal frequency
• The urgency and fear of leakage associated with overactive bladder leads to the woman wanting to void whenever they are aware of bladder filling sensations
• Bladder retraining involves teaching the woman about normal bladder sensation, rate of urine production and normal bladder capacity (350-500 mL)
• The woman should be encouraged to delay voiding for several minutes after when she would normally void
• This should be done in a step-wise fashion
• NOTE: obesity is associated with increased risk and severity of incontinence

Question 67

What are common urodynamic diagnoses?

Answer 67

• Detrusor Overactivity: presence of a detrusor contraction, with or without sensation, during the filling phase of urodynamics
• Detrusor Overactivity Incontinence: leakage from the urethra in associated with a detrusor contraction and increase in bladder pressure
• Urodynamic Stress Incontinence: leakage from the urethra in association with a rise in abdominal pressure (e.g. coughing) without a detrusor contraction (a sign of urethral sphincter weakness)
• Mixed Incontinence: presence of both urodynamic stress incontinence and detrusor overactivity

Question 68

How does urodynamic testing work?

Answer 68

• A fine pressure catheter is placed in the bladder through the urethra, and a second catheter is inserted into the rectum
• The bladder is filled with warm saline whilst pressure recordings are made with the patient sitting on a commode that records leakage
• Detrusor pressure = bladder pressure - abdominal pressure
• During the filling of the bladder, the patient is asked to declare the onset of bladder filling sensation, a strong desire to void and the onset of urgency
• When urgency is reported, filling is stopped and the patient performs various actions to provoke leakage (e.g. coughing, star jumps) before voiding
• Urodynamic testing is reserved for patients who fail to improve with conservative measures
• IMPORTANT: the relationships between urinary symptoms and urodynamic diagnoses is not strong

Question 69

What is the medical treatment for incontinence?

Answer 69

• Anticholinergic medications are the mainstay because parasympathetic nerves stimulate the detrusor muscle to contract
• Inhibition of acetylcholine action at the muscarinic receptor also leads to reduced perceived sensations of bladder filling
• Anticholinergic Medications
  
  • Oxybutynin: 2.5-5 mg up to TDS
    
    • 1st choice recommended by NICE
    • Modified preparations of 5 mg OD increasing weekly by 5 mg up to 20 mg daily
  • Propiverine: 15 mg 1-3/day
  • Trospium: 20 mg BD
  • Tolterodine: 2 mg BD
  • Fesoterodine: 4 mg OD (max 8 mg OD)
  • Solifenacin: 5 mg OD (max 10 mg OD)
  • Darifenacin: 7.5 mg OD
• All anticholinergics have similar efficacy
• Mirabegron is a new beta-3 adrenergic agonist that enhances detrusor relaxation
  
  • Can be used for overactive bladder
• Topical vaginal oestrogen can help improve bladder sensation and urgency in post-menopausal women
• Duloxetine is occasionally used for incontinence
  
  • It is an SNRI
  • It increases sympathetic output to the urethral sphincter thereby increasing sphincter tone
  • Nausea if a common side-effect

Question 70

What are the side effects of anticholinergic medications for incontinence?

Answer 70

• Dry mouth
• Constipation
• Blurred vision

Question 71

What is the surgical treatment for stress incontinence?

Answer 71

• Surgery is a highly effective treatment option
  
  • Best surgical options:
    
    • Synthetic midurethral tape procedure
      
      • Cure rate for stress incontinence of 80-85%
      • This rate persists for 10+ years
      • Complications
        
        • Voiding difficulty (usually short term)
        • Bladder perforation during the procedure
        • Onset of new OAB symptoms after surgery
    • Burch colposuspension
      
      • Older procedure
      • Cure rate for stress incontinence of 80-85%
      • Similar complications
      • Added complication is a long-term risk of posterior vaginal prolapse
    • Periurethral injections to bulk up the bladder neck and coat the urethral mucosa (e.g. macroplastique)
      
      • Usually used for women deemed unfit for general anaesthesia
      • Lower cure rates than colposuspension and midurethral tape

Question 72

What is the surgical management of detrusor overactivity?

Answer 72

• Surgery may be second-line
• Botulinum toxin is a highly effective treatment
• It works by preventing release of neurotransmitter vesicles from the motor end-plate and causes flaccid paralysis in the muscle
• It can be injected at multiple points within the bladder to abolish the involuntary detrusor contractions that cause symptoms
• Achieves continence rates > 40%
• Can lead to voiding difficulty
• It does, nonetheless, provide a higher degree of social independence to patient

Question 73

What are the symptoms of prolapse?

Answer 73

• Sensation of vaginal bulge, heaviness or visible protrusion at or beyond the introitus
• Lower abdominal/back pain
• Dragging discomfort relieved by lying or sitting
• Difficulty voiding urine
• Difficulty emptying bowels
• Sensation of incomplete emptying or bladder or rectum
  
  • NOTE: patients may need to support or reduce the prolapse with their fingers to be able to void or evacuate stool completely (referred to as digitation)
• Urinary or faecal incontinence
• Difficulty achieving penetration during sex
• Pain/discomfort during sex
• Loss of sensation or difficulty achieving orgasm due to vaginal or introital laxity
• Vaginal bleeding (exclude endometrial cancer)

Question 74

What are the risk factors for prolapse?

Answer 74

• Childbirth

- Thinning of the puborectalis muscle

Question 75

What is a uterovaginal prolapse caused by?

Answer 75

• Uterovaginal prolapse is caused by failure of the interaction between the levator ani muscles and the ligaments and fascia that support the pelvic organs

Question 76

What are the three levels of supporting ligaments and fascia that support the uterus, vagina and other organs?

Answer 76

• Level 1 (Apical)
  
  • Uterosacral ligaments attach the cervix to the sacrum
  • This is important in supporting the vaginal walls
  • DEFECTS in level 1 can lead to descent of the uterus within the vagina
  • It is important to reattach the uterosacral ligaments during hysterectomy to prevent vaginal vault prolapse
• Level 2
  
  • Provided by the fascia around the vagina (anterior, posterior, pubocervical (between the vagina and bladder) or rectovaginal (between vagina and rectum) fascia)
  • The fascial sheets fuse at the vaginal edge and are attached to the pelvic side wall (during with the obturator internus fascia)
  • The fascial attachments result in the vagina lying as a flattened tube at rest
  • DEFECTS in level 2 result in prolapse of the vaginal wall into the vaginal lumen (anterior or posterior vaginal prolapse)
  • The bladder or rectum will also prolapse behind the vaginal wall due to the fascial attachment
• Level 3
  
  • Provided by the fascia of the posterior vagina (attached to the caudal end of the perineal body)
  • The perineal body is the mass of tissue that is torn or cut during childbirth
  • It is the point of attachment of the posterior vaginal fascia, fibres of levator ani and transverse perineal muscles
  • DEFECTS of the perineal body cause development of lower posterior vaginal wall prolapse
  • However, loss of the perineal body increases the size of the vaginal opening and predisposes to anterior vaginal prolapse as well

Question 77

What should be asked in a history of prolapse?

Answer 77

• Specific questions should be asked about sexual discomfort and difficulty achieving orgasm
• If the woman is NOT sexually active, it should be explored whether this is because of anxieties or embarrassment of the appearance of the genitalia/loss of perceived attractiveness

Question 78

How is a potential prolapse examined?

Answer 78

• Lithotomy position with Sims speculum
• Three Stages of Descent
  
  • Stage 1: prolapse does NOT reach the hymen
  • Stage 2: prolapse reaches the hymen
  • Stage 3: prolapse is mostly or wholly outside the hymen
    
    • NOTE: when the uterus prolapses wholly outside, it is called procidentia
• A note should also be made about whether the prolapse occurs when the patient is straining or at rest and whether traction is applied
• Assess whether the perineal body is intact or has been attenuated (resulting in enlarged vaginal opening)
• If the woman has additional indirect symptoms (e.g. issues with bladder and bowel function) it would be appropriate to arrange urodynamic assessment or functional tests of the lower bowel (e.g. endoanal ultrasound to check for anal sphincter defects (rectal manometry, flexisig, defaecating proctogram)
• An MDT approach is essential

Question 79

What is a vaginal prolapse of the anterior vagina called?

Answer 79

• Cystocele - if in the upper half of the vagina

- Urethrocele - if in the lower half of the vagina

Question 80

What is a vaginal prolapse of the posterior vagina called?

Answer 80

• Enterocele - if in the upper third of the vagina

- Rectocele - if in the lower two-thirds of the vagina

Question 81

What is conservative treatment for prolapse?

Answer 81

• Pelvic floor exercises (unlikely to be useful if prolapse is beyond the vaginal introitus)
• Supportive vaginal pessaries
  • Ring pessaries are usually tried first
  • There is a range of options
  • Usually replaced every 6 months
  • Complications are uncommon
  • Sexual intercourse is theoretically possible with a well-placed ring pessary but not with others
  • Some patients can be taught to insert and remove their pessaries if they would like to remain sexually active

Question 82

Describe surgery for pelvic organ prolapse

Answer 82

• Principles for Prolapse Surgery
  
  • Remove/reduce the vaginal bulge
  • Restore the ligament/tissue supports to the apex, anterior and posterior vagina
  • Replace associated organs win their correct positions
  • Retain sufficient vaginal length and width to allow intercourse
  • Restore the perineal body
  • Correct or prevent urinary incontinence
  • Correct or prevent faecal incontinence
  • Correct obstructed defecation
• Usually performed through the vagina to restore the ligamentous tissue support to the apex, anterior and posterior vagina and to repair the perineal body
• The vaginal route can also be used for posthysterectomy vaginal vault prolapse to attach the vaginal vault to the right sacrospinous ligament
• An abdominal approach to perform a sacrocolpopexy is also possible

Question 83

What are the differential diagnoses of a pelvic mass? (Gynaecological)

Answer 83

• Benign or malignant ovarian cyst
• Ovarian torsion
• Para-ovarian cyst
• Ectopic pregnancy
• Hydrosalpinx
• Pyosalpinx
• Tubo-ovarian abscess
• Tubal malignancy
• Pregnancy
• Fibroids
• Uterine malignancy

Question 84

What are the differential diagnoses of a pelvic mass? (Gastrointestinal)

Answer 84

• Small or large bowel obstruction
• Diverticular/appendicular abscess
• Intussusception
• Malignancy

Question 85

What are the differential diagnoses of a pelvic mass? (Urological)

Answer 85

• Hydronephrosis
• Pelvic kidney
• Renal/bladder malignancy

Question 86

What are the other differential diagnoses of a pelvic mass? (Besides gynae, gastro and uro)

Answer 86

• Pelvic lymphocele
• Peritoneal cyst
• Psoas muscle abscess
• Lymphoma
• Neuroblastoma
• Aortic aneurysm

Question 87

Which demographics are function cysts, germ cell tumours and benign epithelial tumours more common in?

Answer 87

• Functional cysts are common in young girls, adolescents and women in their reproductive years
• Germ cell tumours occur more commonly in young women
• Benign epithelial tumours are more common in older and post-menopausal women
• Acute pain may represent torsion of a cyst or rupture/haemorrhage into it

Question 88

What is ovarian torsion?

Answer 88

• Refers to rotation of the vascular pedicle supplying the ovary, which compresses and cuts its blood supply
• This is more likely if the ovary is enlarged (e.g. when a cyst is present)
• Up to 15% of dermoid cysts present acutely with torsion

Question 89

What are the presenting symptoms of ovarian torsion?

Answer 89

• Acute onset lower abdominal pain

- Nausea and vomiting

Question 90

How is ovarian torsion diagnosed?

Answer 90

• Pelvic USS with Doppler measurement of blood flow may be useful
• Torsion of a normal ovary is VERY unlikely

Question 91

What is the management of ovarian torsion?

Answer 91

• Untwist the ovary and its attached pedicle
• Removal of the ovarian cyst
• If surgery is not prompt enough, removal of a necrotic ovary may be necessary
• Decision to operate should be based on clinical findings with TVUSS support

Question 92

How is ovarian torsion investigated?

Answer 92

• 1st line for women with a suspected pelvic mass or pelvic pain = USS
  
  • Transvaginal - better resolution
  • Transabdominal - recommended in women who have never been sexually active
• CT and MRI can further characterise the ovarian cyst
• Pregnancy test - exclude pregnancy
• Inflammatory markers - if appendicitis or tubo-ovarian abscess are differentials

Question 93

What are functional ovarian cysts?

Answer 93

• Includes:
  
  • Follicular cysts
  • Corpus luteal cysts
  • Theca luteal cysts
• Risk of functional ovarian cysts is REDUCED by the COCP
• Diagnosis is made when the cyst measures > 3 cm (normal ovulatory follicles may reach 2.5 cm)
• Tend to appear as simple unilocular cysts on USS

Question 94

What is the management of asymptomatic functional ovarian cysts?

Answer 94

• Reassurance and repeat USS to check resolution or non-enlargement before discharge

Question 95

What is the management of symptomatic functional ovarian cysts?

Answer 95

• Laparoscopic cystectomy

Question 96

What are corpus luteal cysts?

Answer 96

• Cysts that occur following ovulation

- May present with PAIN due to rupture or haemorrhage (usually late in the menstrual cycle)

Question 97

What is the management of corpus luteal cysts?

Answer 97

• Expectant (with analgesia)
• Occasionally, surgery is necessary if there has been significant bleeding to wash out the pelvis and perform an ovarian cystectomy

Question 98

What are theca luteal cysts?

Answer 98

• Cysts associated with pregnancy (especially multiple pregnancy)
• Often bilateral
• May be diagnosed incidentally on ultrasound
• Usually resolve spontaneously during pregnancy

Question 99

What are inflammatory ovarian cysts?

Answer 99

• Cysts ssually associated with pelvic inflammatory disease (PID)
• Can involve the tubes, ovaries and bowel
• Inflammatory markers are an important part of the investigations
• Patients may have endometriomas
  
  • Sometimes referred to as ‘chocolate cysts’ due to the presence of altered blood within the ovary
  • Characteristic ground glass appearance on USS

Question 100

What is the treatment of inflammatory ovarian cysts?

Answer 100

• Antibiotics
• Surgical drainage
• Surgical excision
  
  • NOTE: definitive surgery is usually deferred until after the acute infection has resolved

Question 101

What are germ cell tumours?

Answer 101

• MOST COMMON ovarian tumours in young women (20-40 years)
• Most common form of benign germ cell tumour: mature dermoid cyst (cystic teratoma)
  
  • Contains fully differentiated tissue types from all three germ cell layers
  • Up to 10% are bilateral
  • Low risk of malignant transformation
• Usually diagnosed with pelvic USS
• MRI may be useful

Question 102

What is the management of germ cell tumours?

Answer 102

• Usually ovarian cystectomy is needed (spontaneous resolution is unlikely)
• Surgery is particularly necessary if:
  
  • Symptomatic
  • 5+ cm diameter
  • Enlarging
• Surgery prevents torsion and allows histological analysis

Question 103

What are epithelial tumours?

Answer 103

• Benign epithelial tumours increase in frequency with age
• MOST COMMON in perimenopausal women
• Most common type: serous cystadenoma
  
  • Usually unilocular and unilateral
• Mucinous cystadenomas are large, multiloculated cysts that are bilateral in 10% of cases
• Brenner tumours are small tumours usually found incidentally in the ovary
  
  • Contain urothelial-like epithelium
  • Rarely secretes oestrogen

Question 104

What are sex cord stromal tumours?

Answer 104

• MOST COMMON type: ovarian fibromas
  
  • Solid ovarian tumours composed of stromal cells
• Tend to occur in older women
• Usually presents with torsion
• May, occasionally, present with Meig syndrome (pleural effusion, ascites and ovarian fibroma)
• The pleural effusion usually resolves after removal of the ovarian fibroma

Question 105

What are thecomas?

Answer 105

• Benign oestrogen-secreting tumours
• Often present after menopause
• Can cause features of excess oestrogen (e.g. postmenopausal bleeding)
• Can induce an endometrial carcinoma

Question 106

What are some other ovarian cysts?

Answer 106

• Fimbrial cyst
• Paratubal cyst
• Paraovarian cysts of Morgani

Question 107

What is endometriosis?

Answer 107

• Endometrial tissue lying outside the uterine cavity
• Usually found in the pelvic
• Commonly located on the peritoneum lining the pelvic side walls, pouch of Douglas, uterosacral ligaments and bladder
• When endometrial tissue is implanted into the ovary, an endometrioma forms
  
  • This may contain old, altered blood giving it a chocolate cyst appearance
• Rarely, endometriosis an be found in the umbilicus, abdominal scars and pleural cavity
• Endometriotic tissue responds to hormonal changes
• Repeated episodes of bleeding and healing lead to fibrosis and adhesion formation between pelvic organs, leading to pain and infertility
• Adenomyosis is often seen with endometriosis
  
  • Islands of endometrial tissue are found deep within the myometrium

Question 108

What is the incidence of endometriosis?

Answer 108

• 5-10% of women of reproductive age
• Found in 1/3 of women undergoing diagnostic laparoscopy for pelvic pain or infertility
• It is oestrogen-dependent so it resolves after menopause or when treatment induces a pseudomenopause

Question 109

What is the aetiology of endometriosis?

Answer 109

• Sampson’s Implantation Theory
  
  • Retrograde menstrual regurgitation of viable endometrial glands along patent Fallopian tubes and subsequent implantation on the pelvic peritoneal surface causes endometriosis
• Meyer’s Coelomic Metaplasia Theory
  
  • Coelomic epithelium transformation refers to the de-differentiation of peritoneal cells linng the Mullerian duct back to their primitive origin (which then become endometrial cells)
• Some genetic and ethnic influences (more common in oriental women, less common in Afro-Caribbean women)
• Rarely, endometrial tissue can embolise through the vascular and lymphatic system and deposit in distant sites (e.g. pleural cavity)

Question 110

What are general clinical features of endometriosis?

Answer 110

• Severe cyclical non-colicky pelvic pain
• Occurs around the time of menstruation (may occur a few days before menses starts until the end of menses)
• May be associated with heavy menstrual loss
• Severe fatigue
• NOTE: there is a lack of correlation between the extent of disease and the intensity of symptoms
• Deep dyspareunia and pain on defecation (dyschezia) are key indicators of the presence of endometriosis deep within the pouch of Douglas
• Endometriosis at distant sites can cause bizarre symptoms (e.g. cyclical epistaxis, cyclical rectal bleeding)

Question 111

What are symptoms of endometriosis? (Female Reproductive Tract)

Answer 111

• Dysmenorrhoea
• Lower abdominal and pelvic pain
• Dyspareunia
• Rupture/torsion of endometrioma
• Low back pain
• Infertility

Question 112

What are symptoms of endometriosis? (Urinary Tract)

Answer 112

• Cyclical haematuria/dysuria

- Loin/flank pain (ureteric obstruction)

Question 113

What are symptoms of endometriosis? (GI Tract)

Answer 113

• Dyschezia (pain on defecation)
• Cyclical rectal bleeding
• Obstruction

Question 114

What are symptoms of endometriosis? (Surgical Scars/Umbilicus)

Answer 114

• Cyclical pain, swelling and bleeding

Question 115

What are symptoms of endometriosis? (Lung)

Answer 115

• Cyclical haemoptysis

- Haemopneumothorax

Question 116

How is endometriosis diagnosed?

Answer 116

• Physical Examination
• Ultrasound
• MRI
• Laparoscopy
• Biomarkers

Question 117

What is seen in the physical examination of endometriosis?

Answer 117

• A normal vaginal examination does NOT rule out endometriosis
• Findings suggestive of endometriosis:
  • Thickening or nodularity of the uterosacral ligaments
  • Tenderness in the pouch of Douglas
  • Adnexal mass
  • Fixed retroverted uterus

Question 118

What is seen on ultrasound and MRI for endometriosis?

Answer 118

Ultrasound
- TVUSS can diagnose endometriosis involving the ovaries (e.g. endometriomas)

• It is less useful for diagnosing smaller lesions
• TVUSS may be useful for rectal disease
• Negative scans do NOT exclude endometriosis

MRI
- Can detect lesions > 5 mm

Question 119

What is seen on laparoscopy for endometriosis?

Answer 119

• Traditional method of diagnosis
• Based on the accuracy of visual diagnosis of endometriotic lesions (experience-dependent)
• Appearances of endometriotic lesions:
  
  • Red
  • Puckered, black matchstick
  • White fibrous
• Laparoscopy allows lesions to be biopsied for histological confirmation
• Allows concurrent surgical diathermy and /or excision and staging of the disease
• Patency of the Fallopian tubes can also be assessed

Question 120

What biomarkers are used for endometriosis?

Answer 120

• CA125 has been explored as a biomarker for endometriosis

- Currently too inaccurate for clinical use

Question 121

How does endometriosis affect fertility?

Answer 121

• 30-40% of patients with endometriosis complain of difficulty conceiving
• It is not fully understood why endometriosis can lead to subfertility
• Medical treatment of endometriosis does NOT improve fertility and should NOT be given to patients wishing to conceive
• On the other hand, surgical ablation/excision of minimal and mild endometriosis does improve fertility
• It is uncertain whether surgical treatment of endometriomas increases pregnancy rates (because it may damage ovarian tissue)
• Currently thought that endometriomas should be left alone prior to IVF unless they are symptomatic or reduce access for egg collection

Question 122

What are some principles for endometriosis management?

Answer 122

• Analgesics and hormonal ovarian suppression can be effective for treating pelvic pain associated with endometriosis
• Medical treatment of presumed endometriosis can be started if the clinical examination/TVUSS are normal without the need for invasive laparoscopy
  
  • If no symptom relief is achieved after 3-6 months, a laparoscopy should be considered
• Co-existing additional diseases such as IBS and constipation (seen in up to 80% of cases) should also be treated
• Endometriosis is known to recur throughout reproductive life so it is impossible to guarantee complete cure
• Treatment should be based on the age, symptoms, extent of disease and desire to have children

Question 123

What is medical therapy for endometriosis?

Answer 123

• Analgesics
  
  • NSAIDs are useful for reducing severity of dysmenorrhoea and pelvic pain
  • Codeine/opiates should be AVOIDED because it could worsen co-existing IBS
• Combined OCP
  
  • If pregnancy and contra-indications are absent, the COCP should be considered
  • It reduces endometriosis-associated dyspareunia, dysmenorrhoea and non-menstrual pain
  • It also provides cycle control and contraception
  • It can be taken for 21 days with a 7 day pill-free break but it may be more effective at alleviating symptoms if tricycled (3 packets taken back to back)
  • It can also be taken without a break to induce amenorrhoea
  • If this achieves symptomatic relief, it can be continued for several years until pregnancy is intended
  • If ineffective, consider treatment for co-existing conditions (e.g. IBS) and changing the medical management
• Progestogens
  
  • Used to induce amenorrhoea in those with contraindications for the COCP
  • The depot-medroxyprogesterone acetate and levonorgestrel IUS are particularly effective for providing long-term therapeutic effect (particularly after surgery)
• GnRH Agonists
  
  • Effective at relieving the severity and symptoms of endometriosis
  • Usually administered as slow-release depot formulations (lasting 1 month or more)
  • It should NOT be used for > 6 months because of the risk of osteoporosis
  • Also available as multiple, daily-administered intranasal sprays
• Other hormonal agents
  
  • Ovarian suppressive agents (e.g. danazol, gestrinone) are no longer used
  • Current research is exploring aromatase inhibitors for endometriosis

Question 124

Describe surgical treatment for endometriosis

Answer 124

• Fertility Sparing Surgery
  
  • Most operations can be achieved laparoscopically
  • Endometriotic chocolate cysts should have their inner cyst lining excised to reduce recurrence
    
    • However, this could result in damage to ovarian tissue
    • So, if the patient is also receiving fertility treatment, only drainage should be considered
  • Deposits of superficial peritoneal endometriosis can be easily ablated or excised during laparoscopy using diathermy or laser energy
  • Specialist surgery may be needed if the endometriosis has caused extensive adhesions or involved other organs
  • Risk of recurrence following surgery is as high as 30% so long-term medical therapy is often necessary and started straight after surgery
• Hysterectomy and Oophrectomy
  
  • Hysterectomy with removal of the ovaries and all visible endometriosis lesions should be considered in women who have completed their family and failed to respond to conservative treatments
  • The woman should be informed that hysterectomy will NOT necessarily cure the symptoms or the disease
  • Oestrogen-only HRT can be started immediately after surgery once the patient is mobile
  • Some surgeons may prefer deferring HRT until about 6 months after surgery to prevent activation of any residual disease
  • Combined HRT can also be used if reactivation of new or residual disease is suspected

Question 125

What is chronic pelvic pain?

Answer 125

• Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, NOT occurring exclusively with menstruation (dysmenorrhoea) or intercourse (dyspareunia) and not associated with pregnancy

Question 126

What is the incidence of chronic pelvic pain?

Answer 126

• 20% of all outpatient appointments in gynaecological secondary care
• Very COMMON
• Prevalence of 10-20%

Question 127

What is aetiology of chronic pelvic pain?

Answer 127

• Gynaecological
  
  • Endometriosis and adenomyosis
  • Adhesions including chronic PID
  • Uterine fibroids
  • Ovarian cysts
• Central and Peripheral Nervous System
  
  • Modified pain perception (e.g. visceral hyperalgesia and neuropathic pain)
• Gastrointestinal
  
  • IBS
  • Constipation
  • IBD
  • Coeliac disease
• Urological
  
  • Bladder pain syndrome (pain, pressure or discomfort related to the bladder along with at least one other urinary symptoms (e.g. urgency or frequency) in the absence of other pathology)
  • Recurrent UTI
  • Urinary tract calculi
• Musculoskeletal
  
  • Degenerative joint disease
  • Spondylolisthesis
• Nerve Entrapment
• Psychological and Social Issues
  
  • Depression, anxiety and sleep disorders
  • Physical and sexual abuse

Question 128

What are the investigations for chronic pelvic pain?

Answer 128

• History should explore:
  
  • Pattern or pain
  • Association with other problems (e.g. psychological, bladder and bowel)
  • Effect of movement and posture
• Examination: abdominal and pelvic to look for areas of tenderness or masses
• Genital Tract Swab
  
  • All sexually active women should be offered screening for STIs
  • PID can cause chronic pelvic pain
• Pelvic USS
  
  • Conducted if pelvic mass is suspected
  • Potential diagnoses include ovarian cysts, endometriomas, hydrosalpinges, tubo-ovarian abscess or uterine pathology (adenomyosis, fibroids)
• MRI
  
  • Conducted if further assessment of pelvic masses is needed or there is suspected deep infiltrating endometriosis
• Laparoscopy (GOLD standard but most invasive)
  
  • If pelvic masses, endometriosis or adhesions are suspected
  • Potential diagnoses include superficial/deep infiltrating endometriosis, abdominopelvic adhesions and pelvic masses

Question 129

What is the management of chronic pelvic pain?

Answer 129

• General health advice is important (diet, hydration, exercise and sexual health)
• Analgesia (NSAIDs, opiates and paracetamol)
• If clinical examination and USS are normal in a woman with cyclical CPP, a therapeutic trial of hormonal treatment to suppress ovarian function for 3-6 months should be conducted before diagnostic laparoscopy
• Hormonal treatments
  
  • COCP
  • LNG-IUS
  • Systemic progestogens
  • GnRH analogues
• Structural pathology can be treated surgically (e.g. removal of adnexal masses)
• Referral to relevant specialist if the cause of CPP is thought to be non-gynaecological
• If pain persists, referral to a pain management team may be considered

Question 130

Describe the Uterine cervix

Answer 130

• The cervix is the cylindrical lower extremity of the uterus
• Consists mainly of collagen fibres
• The vaginal part of the cervix (ectocervix) is lined by thick non-keratinised stratified squamous epithelium and has a pink appearance
• The external os is visible in the centre of the ectocervix as a dark circular or slit-like area
• It is the opening to the endocervical canal
• The endocervical canal is lined by simple columnar epithelium
• The point at which the simple columnar epithelium of the endocervical canal changes to the stratified squamous epithelium of the ectocervix is called the squamocolumnar junction

Question 131

What is cervical ectropion?

Answer 131

• Cervical ectropion is a condition in women of reproductive age, where the columnar epithelium is visible on the ectocervix as a round, red area surrounding the external cervical os (this is NORMAL)
• Ectropion normally develops under the influence of the THREE Ps:
  
  • Puberty
  • Pill
  • Pregnancy
• A large cervical ectropion may be fragile leading to intermenstrual and postcoital bleeding
• Some women may complain of an excessive, clear, odourless mucus-type discharge

Question 132

What is the management of cervical ectropion?

Answer 132

• Changing from oestrogen-based hormonal contraceptives can reduce symptoms
• Cervical ablation (cryocautery done as an outpatient)
• Cervical and lower genital tract swabs should be taken to exclude STI
• A smear should also be taken to exclude cervical premalignancy/malignancy

Question 133

What are nabothian follicles?

Answer 133

• When the columnar glands within the transformation zone become sealed over, forming small, mucous-filled cysts visible on the ectocervix
• They have NO pathological significance
• NO treatment is required
• Very large ones may need drainage

Question 134

What are cervical polyps?

Answer 134

• Benign tumours arising from the endocervical epithelium
• May be seen as smooth, reddish protrusions
• Usually asymptomatic
• May be detected incidentally on routine cervical smear
• Can cause vaginal discharge, IMB and PCB
• Easily removed by avulsion with polyp forceps as an outpatient

Question 135

What is cervical stenosis?

Answer 135

• Pathological narrowing of the endocervical canal
• Usually iatrogenic (caused by surgery)
  
  • E.g. cone biopsy, loop diathermy and endometrial ablation
• Entrapment of blood within the uterus (haematometra) causes cyclical dysmenorrhoea with no associated menstrual bleeding

Question 136

What is the management of cervical stenosis?

Answer 136

• Surgical dilatation of the cervix under ultrasound or hysteroscopic guidance

Question 137

What are endometrial polyps?

Answer 137

• Focal endometrial outgrowths containing a variable amount of glands, stroma and blood vessels (so have a varying appearance)
• May be asymptomatic
• Can cause abnormal uterine bleeding (HMB, IMB and PMB)
• Can adversely impact fertility
• COMMON - seen in 10-20% of women with AUB and 10% of women with subfertility
• Polyps tend to be insensitive to cyclical hormonal changes (so can cause unscheduled vaginal bleeding)
• 10-25% of symptomatic endometrial polyps contain hyperplastic foci and 1% are malignant
• Endometrial polyps may be
  
  • Pedunculated or sessile
  • Single or multiple
  • Vary in size (0.5-4 cm)

Question 138

What are the risk factors of endometrial polyps?

Answer 138

• Obesity
• Late menopause
• Tamoxifen
• HRT

Question 139

What investigations are done for endometrial polyps?

Answer 139

• TVUSS
• Outpatient hysteroscopy (OPH) and saline infusion sonography (SIS) are the most accurate
  • These tests involve distending the uterine cavity

Question 140

What is the management of endometrial polyps?

Answer 140

• Some small polyps may resolve spontaneously
• Polypectomy recommended to alleviate AUB symptoms, optimise fertility and exclude hyperplasia/cancer
  • Can be performed as a day-case under general anaesthesia
  • Can also be performed as an outpatient with or without local anaesthesia
  • A hysteroscope is used to visualise the polyp and small instruments are used to remove the polyp

Question 141

What is Asherman’s syndrome?

Answer 141

• Fibrosis and adhesion formation within the endometrial cavity following irreversible damage of the single layer thick basal endometrium (does not allow normal regeneration or the endometrium)
• This results in:
  
  • Reduced/absent menstrual shedding
  • Subfertility
• Conservative and less traumatic surgical approaches to managing retained products of conception

Question 142

What are the causes of Asherman’s syndrome?

Answer 142

• Surgical breakdown of intrauterine adhesions (adhesiolysis)
• NOTE: this risks further uterine trauma

Question 143

What are fibroids?

Answer 143

• Benign tumour of the uterine smooth muscle (leiomyoma)
• Macroscopically looks like a well-demarcated, firm, whorled tumour
• Found in 40% of women
  
  • More common in nulliparous, obese and African women
• Often multiple, and can considerably increase the size of the uterus

Question 144

How are fibroids classified?

Answer 144

• Based on location relative to uterine wall
  
  • Submucous
  • Cervical
  • Intramural
  • Subserosal
• Rarely, they can arise outside the uterus (e.g. broad ligament)

Question 145

What are the symptoms of fibroids?

Answer 145

• Most are small and asymptomatic
• Heavy menstrual bleeding and intermenstrual bleeding
• Reproductive failure
• Subfertility
• Recurrent pregnancy loss
• Bulk effects on adjacent structures in the pelvis
• Pressure and pain
• Bladder and bowel dysfunction
• Abdominal distension

Question 146

What is the natural history of fibroids?

Answer 146

• Fibroids are oestrogen-dependent so they can enlarge during pregnancy (due to hyper-oestrogenic state)
• They tend to shrink after menopause
• THREE forms of degeneration (due to outgrowing its blood supply) of a fibroid:
  
  • Red
    
    • Haemorrhage and necrosis occurs within the fibroid typically presenting in the mid-second trimester pregnancy with acute pain
  • Hyaline
    
    • Asymptomatic softening and liquefaction of the fibroid
  • Cystic
    
    • Asymptomatic central necrosis leaving cystic spaces at the centre
    • Degenerative changes can initiate calcium deposition leading to calcification
    • Very rarely, malignant or sarcomatous degeneration can occur
    • Suspicion is greatest in the postmenopausal period when there is rapidly increasing size of the fibroid

Question 147

What are the clinical features of fibroids?

Answer 147

• VAST MAJORITY are asymptomatic
• Examination Findings
  
  • General: signs of anaemia
  • Abdominal: visible and/or palpable abdominal mass arising from the pelvis
  • Bimanual: enlarged, firm, smooth or irregular non-tender uterus
• Menstrual disturbance
• Pressure/bulk symptoms
  
  • Urinary frequency
  • Infertility
• Pain is UNUSUAL except for
  
  • Red degeneration
  • Torsion of pedunculated fibroid

Question 148

How do fibroids relate to Subfertility?

Answer 148

• May result from mechanical distortion or occlusion of the Fallopian tubes
• An endometrial cavity that is distorted by submucous fibroids may prevent implantation
  
  • Removal of submucosal fibroids can enhance fertility and improve outcomes for assisted reproductive techniques
• Removal of other types of fibroids risks hysterectomy (1%) so surgical removal should be carefully considered
• Risk of miscarriage is NOT increased once pregnancy is established
• In late pregnancy, fibroids could cause an abnormal lie
• After delivery, PPH may occur due to inefficient uterine contraction

Question 149

What investigations are done for fibroids?

Answer 149

• Often a clinical diagnosis
• FBC - check for anaemia
• Ultrasound (MAINSTAY)
  
  • TVUSS
    
    • Good for detecting submucous fibroids and small intramural fibroids
  • TAUSS
    
    • Good for detecting larger intramural and subserosal fibroids and excluding hydronephrosis secondary to pressure from fibroids on ureters
  • Saline Infusion Sonography (SIS)
    
    • Good for detecting and locating submucosal fibroids and endometrial polyps
• MRI may be used to demarcate morphology, size and location of fibroids
  
  • Useful for monitoring treatment response
  • Should be performed before uterine artery embolisation
• Hysteroscopy
  
  • Good for detecting submucosal fibroids and endometrial polyps
  • Good for planning subsequent hysteroscopic surgical treatment
  • Surgical hysteroscopy can remove polyps, adhesions and submucosal fibroids

Question 150

How is the management of fibroids split up into?

Answer 150

• Medical Treatment
• Surgical Treatment
• Radiological Treatment

Question 151

What is the medical management of fibroids?

Answer 151

• Conservative management if asymptomatic fibroids
• Main treatments for HMB
  
  • LNG-IUS
  • Tranexamic acid
  • Mefenamic acid
  • COCP
  • May be ineffective in the presence of submucous fibroid or an enlarged uterus that is palpable abdominally
• Injectable GnRH Agonist
  
  • Only effective medical treatment
  • Induces a menopausal state (shuts down ovarian oestradiol production)
  • Poorly tolerated because of severe menopausal symptoms
• Ulipristal Acetate (selective progesterone receptor modulator)
  
  • As effective as GnRH agonists in reducing fibroid volume and alleviating HMB symptoms
  • Not yet widely accepted into clinical practice
  • Does NOT induce a menopausal state
  • Can be taken orally
• NOTE: neither of the above options are long-term - fibroids regrow as soon as ovarian function returns

Question 152

What is the surgical management of fibroids?

Answer 152

• Depends on presenting complains and patient’s preferences regarding menstrual function and fertility
• Minimally invasive hysteroscopic surgery can be used to remove submucous fibroids and fibroid polyps (which relieved HMB symptoms)
• If the patient has a bulky fibroid uterus causing pressure symptoms or where HMB is refractory to medical interventions, there are THREE options:
  
  • Myomectomy
    
    • Preferred if preservation of fertility is required
    • Can be done laparoscopically (power morcellation is used to shrink the fibroids for removal)
    • There is a small but significant risk of uncontrolled life-threatening bleeding during myomectomy which may require a hysterectomy
  • Surgical removal of fibroids with uterine conservation
  • Hysterectomy
• Hysterectomy and myomectomy could be preceded by GnRH agonist pre-treatment for 3 months to reduce the bulk and vascularity of the fibroids
  
  • This can facilitate a suprapubic incision and vaginal hysterectomy rather than midline abdominal incision and abdominal hysterectomy
  • This is associated with quicker recovery and fewer complications

Question 153

What is the radiological management of fibroids?

Answer 153

• Uterine artery embolisation
  
  • Involves embolisation of both uterine arteries under radiological guidance
  • A cannula is passed through the femoral artery into the uterine artery
  • Embolisation induces infarction and degeneration of fibroids leading to a reduction in fibroid volume of around 50%
  • Patients usually require admission to deal with the pain associated with uterine artery occlusion (opiate analgesia)
  • Complications: fever, infection, fibroid expulsion, potential ovarian failure
  • Adequate counselling is important because the effect on reproductive function are uncertain
  • 1/3 of women require further medical, radiological or surgical treatment within 5 years
  • As effective as myomectomy for alleviating fibroid-related HMB and pressure symptoms

Question 154

What is adenomyosis?

Answer 154

• Disorder in which endometrial glands and stroma are found deep within the myometrium
• It can only definitively be diagnosed following histopathological examination of a hysterectomy specimen
• The ectopic endometrium responds to cyclical hormonal changes resulting in bleeding within the myometrium
• This manifests as:
  
  • Increasingly severe secondary dysmenorrhoea (pain through menses)
  • Uterine enlargement
  • HMB
• Women are usually multiparous and diagnosed in their late 30s/early 40s

Question 155

What are the investigations for adenomyosis?

Answer 155

• Examination: bulky and sometimes tender ‘boggy’ uterus
• Ultrasound may show haemorrhage-filled, distended endometrial glands
  
  • May show an irregular nodular development (similar to fibroids)
• MRI: BEST INVESTIGATION
  
  • Provides excellent resolution images

Question 156

What is the management of adenomyosis?

Answer 156

• Any treatment that induces amenorrhoea will render the ectopic endometrium quiescent (thereby relieving pain and excessive bleeding)
• So, use of progestin-containing long-acting reversible contraceptives (LARCs) should be considered
  
  • E.g. LNG-IUS, DepoProvero, short-term GnRH agonists
• HOWEVER, symptoms return rapidly on ceasing treatment
• Hysterectomy is the only definitive treatment

Question 157

What are the differential diagnosis of vulva complaints?

Answer 157

• Vulval Pruritis
  
  • Infections (e.g. candidiasis, TV)
  • Skin conditions (e.g. lichen sclerosis, eczema, VIN)
  • Contact dermatitis
• Vulval Pain
  
  • Infections (e.g. candidiasis)
  • Skin conditions (e.g. lichen sclerosis, eczema, VIN)
  • Vulvodynia (chronic vulval pain with no identifiable cause)
  • Bartholin gland infection
• Superficial Dyspareunia
  
  • Skin conditions (e.g. lichen sclerosis leading to vulval splitting)
  • Vulvodynia
  • Vulval fissures
  • Skin bridges of the vulva

Question 158

How do you assess vulval conditions?

Answer 158

• Full history and examination (potentially with vaginal swabs/biopsies)
• Ask about general skin problems (general skin disorders like eczema and psoriasis can affect the vulva)
• Discuss current methods of skin care (e.g. scented products can worsen symptoms)
• Impact of symptoms on sexual functioning

Question 159

What are the most common presenting symptoms of vulval itching and discomfort?

Answer 159

• Itching
• Discomfort
• Pain
• Discharge
• Dyspareunia
• Affect all ages, in particular, postmenopausal women
• Support group: Vulval Pain Society
• Itching can lead to nocturnal involuntary itching
• This can lead to dysuria as the urine burns the excoriated vulval skin

Question 160

How is reduction in allergens useful in vulva conditions?

Answer 160

• Vulval dermatitis is strongly associated with a history of atopy
• Therefore, allergen exposure should be reduced in all patients presenting with symptoms of vulval pruritus
• Discourage women from washing with soaps or detergents that disrupt the bacterial balance of the vagina (water is a better alternative)
• Encourage cotton underwear and washing clothing with an unperfumed washing powder/fabric conditioner
• Sanitary pads may cause vulval dermatitis (so changing to unbleached, organic pads (moon cup))

Question 161

Describe recurrent use of antifungals and vulva pruritus

Answer 161

• Some women will regularly be prescribed or receive OTC antifungals (e.g. clotrimazole cream and pessaries)
• It may soothe initial symptoms but can cause a hypersensitivity reaction that worsens symptoms
• Vulval and vaginal candidiasis is COMMON in women of reproductive age
• It is uncommon in prepubescent and postmenopausal women
  
  • These women, therefore, should be checked for other causes of itching
  • Diabetes should be considered as a cause of recurrent thrush
• Candidal infection should be treated with:
  
  • 150 mg clotrimazole nightly over 3 consecutive nights
  • 2nd line: oral fluconazole
• NOTE: in menstruating women, thrush is more common postmenstrually due to changes in vaginal pH
• There is no need to treat partners unless they are symptomatic

Question 162

How does ferritin affect vulva pruritus?

Answer 162

• 5% of women with vulval pruritus have low ferritin

- Correction of this will improve symptoms

Question 163

Describe biopsy in vulva disease

Answer 163

• Should only be performed if there is concern regarding MALIGNANCY
• If diffuse leukoplakia or erythema treatment with steroids and emollients is recommended
  
  • If symptoms do NOT resolve, biopsy should be considered
• Done by Keyes punch biopsy which can be done under local anaesthetic in clinic
• Biopsies should also be carried out for pigmented lesions, raised or indurated areas and persistent ulcers

Question 164

What is Lichen Planus?

Answer 164

• Autoimmune disorder affecting 1-2% of the population (particularly > 40 years) affecting the skin, genitalia and oral and GI mucosa

Question 165

What are the symptoms of lichen planus?

Answer 165

• Pruritus
• Superficial dyspareunia
• Lesions in the mouth (reticular-like cobwebs)
  
  • Oral inspection is important
• Longitudinal ridging of the nailbeds
• Genital lesions
  
  • Longitudinal, annular, ulcerative, hyperpigmented or bullous
  • May cause vaginal stenosis and sexual dysfunction

Question 166

What is the management of lichen planus?

Answer 166

• High-dose topical steroids

- If vaginal stenosis, dilatation with manual measures should be attempted in the first instance

Question 167

What is lichen sclerosus?

Answer 167

• Destructive inflammatory skin condition that affects mainly the anogenital area of women.
• Believed to be autoimmune (many patients have other autoimmune conditions (e.g. thyroid disease and pernicious anaemia))
• Results in hyalinisation of the skin
• Leads to fragility and white parchment paper appearance of the skin and loss of vulval anatomy
• Associated with vulval cancer

Question 168

What are the symptoms of lichen sclerosus?

Answer 168

• Itching
• Soreness (usually due to scratching)
• Hypopigmentation
• Loss of anatomy
• Vaginal stenosis and cracking (particularly at posterior fourchette)

Question 169

What is the management of lichen sclerosus?

Answer 169

• Good skin care
• Strong steroid ointments (e.g. clobetasol proprionate for 3 months)
• Biopsy is indicated if the condition does not resolve with treatment

Question 170

What are vulval cysts?

Answer 170

Types

• Bartholin’s cyst
• Skene gland cyst
• Mucous inclusion cyst
• Can cause a lump with or without vulval discomfort
• Bartholin’s cysts can become infected causing a Bartholin’s abscess
  
  • These usually present acutely
  • May require incision and drainage
    
    • Outpatient drainage is possible
    • May be accompanied by insertion of a tiny catheter to maintain patency for several weeks
• May be managed by marsupialisation of the cyst
  
  • Involves suturing the internal aspect of the cyst to the outside of the cyst to prevent the cyst from reforming
  • Usually done under general or spinal anaesthesia

Question 171

What is vulvodynia?

Answer 171

• A condition of pain of the vulva often described as a burning pain, occurring in the absence of skin disease of infection
• It is a neuropathic pain syndrome
• Classification
  
  • Anatomical site (generalised, localised or clitoral)
  • Provoked or unprovoked
• Can occur at any age
• Support: Vulval Pain Society
• Neuromodulators (e.g. amitrytiline) can be useful in some women
• Some may benefit from perineal massage
• Oils may provide a barrier to precipitating factors (e.g. allergens, chafing)
• Provide support to regain their sex lives

Question 172

What is dyspareunia?

Answer 172

• Pain during or after sexual intercourse
  
  • Superficial: affecting the vagina, clitoris or labia
  • Deep: pain within the pelvis
• Epidemiology
  
  • 10 - 20% prevalence
• Risk Factors
  
  • FGM
  • Suspected PID
  • Endometriosis
  • Peri/postmenopausal
  • Depression and anxiety
  • History of sexual assault

Question 173

What should be asked in a history for dyspareunia?

Answer 173

• Nature and onset of pain
• Relationship to intercourse
• Associated chronic pelvic pain symptoms
• Reproductive and past medical history
• Psychosexual history

Question 174

Describe the examination of dyspareunia

Answer 174

• Nature and onset of pain
• Relationship to intercourse
• Associated chronic pelvic pain symptoms
• Reproductive and past medical history
• Psychosexual history

Question 175

How are superficial and deep dyspareunia investigated?

Answer 175

• Superficial: consider biopsy of lower genital tract lesions or swabs
• Deep: consider TVUSS, swabs and laparoscopy

Question 176

What is the treatment for dyspareunia?

Answer 176

• Superficial: treat any identifiable cause

- Deep: treat as for chronic pelvic pain

Question 177

What is psychosexual dysfunction?

Answer 177

• Primary: sexual difficulties where there may be psychosomatic pain
• Secondary: sexual difficulties resulting from pain or emotional issues

Question 178

What is vaginismus and non-consummation?

Answer 178

• DEFINITION: involuntary contraction of vaginal muscles during vaginal examination
• Often leads to non-consummation and can cause considerable distress (fertility, relationship issues)
• Traditionally, doctors and sex therapists used vaginal dilators to widen the opening but these rarely translate into sexual activity
• There are various psychological influences (e.g. mentioning that you are using the ‘small speculum’ can reinforce the idea within the patient’s mind)
• Encourage self-exploration at home with perineal massage and stretching of the vagina with fingers
• Explore the patient’s anxieties and consider whether surgery is the best option

Question 179

What is FGM?

Answer 179

• DEFINITION: any procedure involving partial or total removal of the external genitalia and/or injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons
• Can lead to physical, sexual and psychosexual issues
• May even lead to renal failure due to urinary obstruction/infection
• There is a legal obligation in the UK to document all cases and report all cases in minors through the safeguarding team
• FGM in minors is considered child sexual abuse and social services and the police should be involved
• There has been an increase in the number of patients requesting cosmetic surgery for their vaginas
• Resource: The Great Wall of Vagina (hundreds of plaster casts of vulvas by a British artist)

Question 180

What are the four degrees of FGM?

Answer 180

• Type 1: clitoroidectomy - excision of the clitoral hood with or without removal of the clitoris
• Type 2: excision of the clitoris and partial or total removal of the labia minora
• Type 3: excision of part of all of the external genitalia (clitoris, labia minora and majora) and stitching/narrowing the vagina (infibulation)
• Type 4: piercing the clitoris, cauterisation, cutting the vagina, inserting corrosive substances. Also includes any plastic surgery procedures done as an adult

Question 181

What is de-infibulation?

Answer 181

• Reversal of infibulation
• Ideally should be identified pre-conceptually
• Should be performed with adequate analgesia to avoid flashbacks of FGM
• Incision is made along the vulval incision scar
• Women should receive prior urinary infection screening and given appropriate antibiotics
• Access to specialist services and support groups is necessary

Question 182

What is the classification of primary ovarian tumours?

Answer 182

• Epithelial (80%)
  
  • High-grade serous
  • Endometrioid
  • Clear cell
  • Mucinous
  • Low-grade serous
• Sex cord stromal
  
  • Granulosa cell
  • Sertoli-Leydig
  • Gynandroblastoma
• Germ cell
  
  • Dysgerminoma
  • Endodermal sinus (yolk sac)
  • Teratoma
  • Choriocarcinoma
  • Mixed

Question 183

What are types of secondary ovarian tumours?

Answer 183

• Secondary ovarian tumours (Krukenberg tumours) can come from
  
  • Colon
  • Stomach
  • Breast

Question 184

What are epithelial tumours?

Answer 184

• Can be benign, malignant or borderline
• 10% are classified as borderline ovarian tumours (BOTs) - well differentiated with some features of malignancy but do NOT invade the basement membrane
  
  • Most are serous tumours
  • BOTs can spread to other abdominopelvic structures but do not tend to recur following initial surgery
• High-grade serous carcinoma accounts for 75% of all epithelial ovarian cancers
  
  • Mucinous and endometrioid account for 10%
  • Clear cell carcinoma is less common
  • High-grade serous is characterised by psammoma bodies (concentric rings of calcification)
• Mucinous carcinomas are generally LARGE, multiloculated tumours associated with pseudomyxoma peritoneii
• Endometrioid carcinomas have a similar histological appearance to endometrial cancer and are associated with endometriosis in 10% of cases and endometrial cancer in 10-15%
  
  • Associated with better survival
• Clear cell carcinoma can also arise from endometriosis

Question 185

What are the aetiology and risk factors of high-grade pelvic serous carcinoma?

Answer 185

• Often present with advanced disease so it is difficult to establish the anatomical site of origin
• There may be a Fallopian tube precursor lesion called serous tubal intraepithelial carcinoma (STIC)
• These are characterised by p53 mutations in the secretory cells of the distal Fallopian tube
• 30% of high-grade pelvic serous cancers have BRCA mutations

Question 186

What are the aetiology and risk factors of Endometrioid, mucinous, clear cell, borderline and low-grade serous ovarian carcinomas?

Answer 186

• Inclusion cysts of the ovarian surface epithelium and endometriosis can give rise to tumours
• Endometriosis-associated ovarian cancers are usually endometrioid or clear cell

Question 187

What increases the risk of ovarian cancer?

Answer 187

• Nulliparity
• IUD
• Endometriosis
• Cigarette smoking (mucinous only)
• Obesity

Question 188

What decreases the risk of ovarian cancer?

Answer 188

• Multiparity
• COCP
• Tubal ligation
• Salpingectomy
• Hysterectomy

Question 189

Describe the genetic factors for ovarian cancer

Answer 189

• 10-15% of women with ovarian cancer have a hereditary predisposition
• Increased risk associated with:
  
  • BRCA1 and BRCA2
  • Lynch syndrome
• Lifetime risk for general population = 1 in 70
• Risk if 1 family member is affected = 1 in 20
• BRCA accounts for 90% of hereditary cancers
  
  • BRCA 1 = 80%
  • BRCA 2 = 15%
• Lynch syndrome is hereditary non-polyposis colorectal cancer (HNPCC) and is associated with endometrial cancer and a 10% lifetime risk of ovarian cancer

Question 190

What is the prevention for ovarian cancer?

Answer 190

• Women who are positive for BRCA mutation are offered prophylactic bilateral salpingo-oophorectomy (BSO) when they have completed their families
• This reduces the risk of ovarian cancer by 90%
• Ovarian cancer tends to occur at a younger age in people with BRCA mutation (1 = 30s, 2 = 40s)
• Bilateral salpingectomy with delayed oophorectomy may be a new, improved option based on the theory that BRCA-associated ovarian cancer originate in the Fallopian tube
  
  • Delayed oophorectomy offsets the morbidity associated with surgical menopause
• Tubal ligation and hysterectomy can also reduce ovarian cancer risk
• COCP reduces ovarian cancer risk by up to 50% in both BRCA mutation carriers and women at average risk of ovarian cancer

Question 191

What is the screening for ovarian cancer?

Answer 191

• Screening with TVUSS and CA125 has not been shown to improve survival in women with a familial predisposition to ovarian cancer
• This is because BRCA-associated ovarian cancers develop rapidly

Question 192

What are the clinical features for ovarian cancer?

Answer 192

• Often non-specific and vague
• MOST COMMON SYMPTOMS
  
  • Increased abdominal girth/bloating
  • Persistent pelvic pain and abdominal pain
  • Difficulty eating and feeling full quickly
• Other symptoms
  
  • Change in bowel habit
  • Urinary symptoms
  • Back ache
  • Irregular bleeding
  • Fatigue

Question 193

What is seen on examination for ovarian cancer?

Answer 193

• May reveal fixed, hard mass arising from the pelvis
• Differential diagnosis for pelvic mass
  
  • Non-epithelial ovarian cancer
  • Tubo-ovarian abscess
  • Endometriomas
  • Fibroids
• NOTE: ascites is highly suggestive of ovarian cancer
• Chest examination for pleural fluid
• Neck and groin should be examined for enlarged nodes

Question 194

How is ovarian cancer diagnosed?

Answer 194

• TVUSS is the initial imaging modality of choice
• Characterise in terms of:
  
  • Size
  • Consistency
  • Presence of solid elements
  • Bilaterality
  • Presence of ascites
  • Extraovarian disease (peritoneal thickening and omental deposits)
• Tumour Markers
  
  • CA125 is also commonly raised in pregnancy, endometriosis and alcoholic liver disease
  • CA125 is raised in 80% of epithelial ovarian cancers
• Risk of Malignant Index (RMI) can be calculated from menopausal status, pelvic ultrasound features and CA125 to triage pelvic masses
• Pelvic pathology at intermediate or high risk malignancy should receive CT and/or MRI
  
  • CT is particularly useful for extrapelvic disease and staging
  • MRI helps determine operability
  • Other investigations: CXR, ECG, FBC, U&E, LFT
• If there is gross ascites or pleural effusion, paracentesis or pleural aspiration may be required
• Biopsy is needed before chemotherapy can be given (ultrasound or CT-guided)

Question 195

Describe FIGO staging

Answer 195

• It can spread directly to the peritoneum and other organs
• It can spread via the lymphatics to the pelvic and para-aortic nodes

Question 196

What is the surgical management of ovarian cancer?

Answer 196

• Aims to stage the disease and remove all visible tumour
• Most important prognostic factor is NO residual disease following laparotomy
• Vertical incision is required to gain access
• Total abdominal hysterectomy and BSO performed along with omentectomy
• Ascites and peritoneal washings should be sampled
• Further debulking may be required (e.g. resection of bowel, peritoneal stripping, splenectomy)
• Lymph node resection is important
• Young women with early-stage epithelial ovarian cancer may want fertility-sparing surgery
• Fertility-sparing surgery may also be considered in patients with borderline tumours if fertility is an issue
• If surgery is deemed unsuitable, chemotherapy may be offered
• ‘Second look’ surgery is a planned laparotomy at the end of chemotherapy
• This aims to assess for residual disease
• After surgery, the MDT should discuss the need for chemotherapy

Question 197

How does chemotherapy treat ovarian cancer?

Answer 197

• Can be given as primary treatment, an adjunct following surgery or for relapse of disease
• 1st line: combination of a platinum compound with paclitaxel
• Most are given as an outpatient, 3 weeks apart for 6 cycles
• Platinum compounds
  
  • Most effective in ovarian cancer
  • Cause cross-linkage of DNA stands leading to cell cycle arrest
  • Carboplatin is the main platinum compound used as it is less nephrotoxic and causes less nausea than cisplatin
  • Does of carboplatin is calculated using the GFR
• Paclitaxel
  
  • Causes microtubular damage
  • Prevents replication and cell division
  • Pre-emptive steroids are given to reduce hypersensitivity reactions and reduces side-effects (e.g. peripheral neuropathy, neutropaenia and myalgia)
  • Causes total loss of body hair
• Bevacizumab
  
  • Monoclonal antibody against VEGF
  • Inhibits angiogenesis
  • Not routinely prescribed in ovarian cancer due to cost
  • Available for the treatment of recurrent disease
• Patients will undergo a CT scan following completion of chemotherapy to assess response to treatment
• Follow-up includes clinical examination and CA125 measurement
  
  • CA125 tends to rise prior to the onset of clinical evidence of disease recurrence
  • When disease recurs, treatment is largely palliative

Question 198

What is the prognosis of ovarian cancer?

Answer 198

• Depends on stage, volume of disease following surgery and histological grade
• 5-year survival = 46% (stage 1 = 90%; stage 3 = 30%

Question 199

What are primary peritoneal carcinomas?

Answer 199

• High-grade serous carcinoma
• Histologically same as tumours coming from the Fallopian tubes and ovaries
• Criteria for Diagnosis:
  
  • Normal sized or slightly bulky ovaries
  • More extraovarian disease than ovarian disease
  • Low volume peritoneal disease
• Natural history, prognosis and treatment are the same as for other high-grave pelvic carcinomas

Question 200

What are sex cord stromal tumours?

Answer 200

• 10% of all ovarian tumours
• Low malignant potential and good prognosis
• Morbidity may arise from oestrogen-producing (granuloa, theca, Sertoli) and androgen-producing (Sertoli-Leydig, steroid cell)
• This can result in precocious puberty, abnormal menstrual bleeding and an increased risk of endometrial cancer
• Granulosa cell tumours are the most common type of sex cord stromal tumour

Question 201

What are the clinical features of sex cord stromal tumours?

Answer 201

• Manifestations of hormone production
  
  • Irregular menstrual bleeding
  • Postemenopausal bleeding
  • Precocious puberty
• Granulosa cell tumours may present with:
  
  • Large pelvic mass
  • Pain due to torsion/haemorrhage
  • May produce inhibin which can be used to follow-up surveillance
• Sertoli-leydig cell tumours produce androgens and may present with:
  
  • Pelvic mass
  • Signs of virilisation (amenorrhoea, deep voice, hirsutism)
  • Can produce renin leading to hypertension
• Most sex cord stromal tumours present as unilateral ovarian masses

Question 202

What is the management of sex cord stromal tumours?

Answer 202

• Based on age and wish to preserve fertility
• If YOUNG, unilateral salpingo-oophorectomy, endometrial sampling and staging is sufficient
• In OLDER patients, full surgical staging is recommended
• Granulosa cell tumours can recur after many years so requires long-term follow-up
• Surgery is the mainstay of treatment (no effective chemotherapy)

Question 203

What are germ cell tumours?

Answer 203

• Occur mainly in YOUNG women
• Account for 10% of ovarian tumours
• Dysgerminomas are 50% of germ cell tumours
  
  • Bilateral in 20%
  • Occasionally secrete hCG
• Endodermal sinus yolk sac tumour is the SECOND most common (15%)
  
  • Secrete alpha-fetoprotein
  • Large solid mass
  • Often causes acute symptoms with torsion or rupture
  • Spreads late, usually to the lungs
• Immature teratomas are 15-20% of malignant germ cell tumours
  
  • Mature or immature depending on the grade of neural tissue present
  • Occasionally there is malignant transformation of a cell type within the mature teratoma (usually squamous cell carcinoma)
• Non-gestational choriocarcinoma is a VERY RARE type of tumour that usually occurs in young girls (irregular bleeding, high hCG)

Question 204

What are the presenting symptoms of germ cell tumours?

Answer 204

• Pelvic mass
• 10% present acutely with torsion or haemorrhage
• 70% will be stage 1

Question 205

What are clinical features and investigations of germ cell tumours?

Answer 205

• Young women presenting with a pelvic mass that is rapidly growing
• Tumour markers
• MRI to assess morphology
• CT to check liver and lymph nodes
• CXR for pulmonary metastases

Question 206

What is the management of germ cell tumours?

Answer 206

• Fertility-sparing treatment may be preferred (because most women are of reproductive age)
• Exploratory laparotomy to remove the tumour and assess contralateral spread to other ovary
• Careful inspection of the abdominal cavity is required with peritoneal biopsies and sampling of any enlarged pelvic or para-aortic nodes
• Postoperative chemotherapy depends on stage
  
  • Most common regime = bleomycin, etoposide and cisplatin (BEP)
  • Given as 3-4 treatments 3 weeks apart
  • 90% cure rates
• If recurrence, 90% will present within the first year of diagnosis and salvage chemotherapy has good success rates