Gynaecology (Quesmed) Flashcards
What is Atrophic Vaginitis?
The Inflammation and Thinning of Genital Tissue due to a fall in Oestrogen levels so it is most common after Menopause
What are the 9 features of Atrophic Vaginitis?
4 things getting smaller/ 3 painful things/ 1 discharge and 1 UTI
Thinning of Vaginal Mucosae
Loss of Vaginal Rugae (folds)
Loss of Pubic Hair
Narrowed Introitus
Vaginal dryness or Itching
Dyspareunia
Post-Coital BLEEDING
Vaginal Discharge
Urinary Symptoms
If Atrophic Vaginitis is suspected, what other conditions should be suspected based on 5 symptoms?
Postmenopausal bleeding- Malignancy, Endometrial Hyperplasia
Genital Itching/ Discharge- STI, Vulvovaginal Candidiasis (fungal infection of vagina), skin conditions such as Lichen Sclerosis, Lichen Planus, Diabetes
Narrowed Introitus- Female Genital Mutilation
Urinary Symptoms- UTI, Bladder Dysfunctions, Pelvic Floor Dysfunction, Cystitis
Dyspareunia- Malignancy, Vaginismus
What 4 investigations should be ordered in Atrophic Vaginitis?
Clinical Examination- including Speculum Examination if Tolerated, looking for Vaginal signs of Atrophy
Transvaginal Ultrasound and Endometrial Biopsy may be necessary to exclude Endometrial Cancer
Infection screen if there is Itching or Discharge
Biopsy of any abnormal Skin Lesions
What are the 3 treatment options for Atrophic Vaginitis?
Hormonal Treatment- Systemic hormone-replacement therapy (Oral or Transdermal), Topical Oestrogen Preparations
Non-hormonal Treatment- Lubricants which provide short-term improvement to Vaginal Dryness- this can Alleviate Symptoms such as Dyspareunia, Moisturisers can also be used
Also Transvaginal Laser Therapy but not enough evidence so not done
What are Bartholin’s Glands? And what are the 2 pathologies of these glands?
They are glands within the Vestibule, lateral to the Introitus and function to secrete a Lubricating Fluid
Bartholin’s Gland Cyst- When the duct from the gland becomes blocked resulting in a Palpable Swelling and Pain at the site of the Bartholin’s Gland
Bartholin’s Gland Abscess- When a Cyst becomes infected, resulting in extreme Pain, Lymphadenopathy, Erythema and (rarely) Systemic Upset
What is the 4 step management of a Bartholin’s Gland Cyst?
Incision and Drainage under local Anaesthetic
Antibiotics in Abscess
Salt Water Baths to relieve pain
Surgery if Recurrent
What is Primary Amenorrhoea?
It is the failure of Menstrual Periods to start by 15 years of age in a female with normal growth and secondary sexual characteristics
This may also be diagnosed at age 13 if the girl has Absent Pubertal Maturation and Absent Menses
What are the 5 causes of Primary Amenorrhoea?
A Constitutional Delay in Puberty
Chromosomal or Genetic Abnormality such as Turner Syndrome (45XO), Kallman Syndrome and Androgen Sensitivity
Disruption of the Hypothalamic or Pituitary Glands- Anorexia or Eating Disorders, Excessive Exercise, Extreme Physical or Psychological Stress
Structural Abnormalities of the Genetic Tract (Imperforate Hymen (which blocks the vaginal tract), Uterine Agenesis (the uterus does not develop))
Pregnancy
What cell type of Cancer is Cervical Cancer?
A Squamous Cell Carcinoma associated with HPV
What are the 4 risk factors for Cervical Cancer?
HPV 16 and 18
Multiple Sexual Partners
Smoking
Immunosuppression
What are the 8 signs of Cervical Cancer? (Although most of the cases are picked up Asymptomatically or through Cervical Screening)
Vaginal Discharge
Vaginal Bleeding (Either Post-Coital or with Micturition or Defaecation)
Urinary or Bowel Habit Change
Vaginal Discharge
Suprapubic Pain
Mass felt on PR Exam
Pelvic Bulkiness on PV Exam
Abnormal White/Red patches on the Cervix
What 2 investigations should be ordered if Cervical Cancer is suspected?
First line investigation is Colposcopy (allows for Visualisation and Biopsy of the Cervix)
CT Chest/ Abdomen/ Pelvis to Stage the Cancer
What is the 5 step management of Cervical Cancer?
For very small cancers in Stage 1A- they are Conised with Free Margins if aiming to retain Fertility. Conisation is done with a Scalpel (Cold-Knife), Laser or Electrosurgical Loop in Outpatients
Radical Trachelectomy is done for slightly more Advanced, but still Early-stage Cancers where the aim is to preserve Fertility. This is the removal of the Cervix, Upper Vagina and Pelvic Lymph Nodes
If Remaining Fertile is not an aim, Laparoscopic Hysterectomy and Lymphadenectomy is offered for Early-stage Cancers
For Invasive, Infiltrating, Early Metastatic Cancers, Radical (Wertheim’s) Hysterectomy can be performed, which involves the removal of the Uterus, Primary Tumour, Pelvic Lymph Nodes and the Upper Third of the Vagina and Uterovesical and Uterosacral Ligaments
If the cancer has spread outside the Cervix and Uterus, Surgical Management won’t be curative. These are treated with Radiotherapy and/or Chemotherapy
How often is Cervical Cancer Screening done?
For 24-49 year old women, every 3 years
Then every 5 years
What is the purpose of Cervical Cancer Screening?
To identify Dyskaryotic Cells which are Pre-cancerous- allowing management before Invasive Cancer can develop
The results from the Smear decide what is the next best step of patient care
What happens if a patient has positive HPV?
They have Cytological Testing and if they have Abnormal results, they are divided into:
- Borderline
- Mild Dyskaryosis
- Moderate Dyskaryosis
- Severe Dyskaryosis
Anybody with Abnormal Cytology should be referred to Colposcopy
Anybody with Positive HPV but Normal Cytology should have repeat HPV Testing in 12 months and again at 24 months if they are still Positive. If they are still positive at 24 months, they should be referred to Colposcopy
In some cases, the sample may be Inadequate so the Smear Test should be repeated. If it is still not Adequate for the next 2 samples, they should be Referred for Colposcopy
What happens if a patient is negative for HPV following a screening?
They are returned to their routine recall
What are the 7 Absolute (UKMEC 4) Contraindications to the Oral Contraceptive Pill?
Known or suspected pregnancy
Smoker over the age of 35 who smokes>15 cigarettes
Obesity
Breast Feeding< 6 weeks post partum
Family History of Thrombosis before 45 years old
Breast Cancer or some kind of Cancer within last few years
BRCA genes
What are the UKMEC 3 (Disadvantages> Advantages) (5), UKMEC 2 (Advantages> Disadvantages) for the Oral Contraceptive Pill (2)?
Breast feeding> 6 weeks post partum
Previous arterial or venous clots
Continued use after heart attack/ stroke
Migraines with Aura
Active Disease of Liver/ Gallbladder
Initiation after current or past history of MI or Stroke
Multiple risk factors for Arterial Cardiovascular Disease
What 3 investigations should be ordered in Dysmenorrhoea?
Rule out an STI
Examination of Abdominal Tenderness/ Mass, Bimanual Examination for Cervical Tenderness
Pelvic Ultrasound if Investigations suggest pathology (Fibroids, Endometriosis)
What 7 treatments can be given for Dysmenorrhoea?
NSAIDs (Ibuprofen, Mefenamic Acid)
Tranexamic Acid
Combined Oral Contraceptive Pill
Progestogen-only Pill
Levonorgestrel-releasing Intrauterine System (Mirena)
Contraceptive Injection (Depo Provera)
Contraceptive Implant (Nexplanon)
What are the 7 risk factors for Ectopic Pregnancy?
Pelvic Inflammatory Disease
Genital Infection (Gonorrhoea)
Pelvic Surgery
Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine (e.g. Mirena) in situ
Assisted reproduction e.g. IVF
Previous Ectopic Pregnancy
Endometriosis
What are the 6 clinical features of Ectopic Pregnancy?
Pelvic Pain, which may be unilateral to the side of the ectopic
Shoulder Tip Pain, if the ectopic bleeds, the blood can irritate the diaphragm
Abnormal vaginal bleeding e.g. Missed Period or Intermenstrual Bleeding
Haemodynamic Instability caused by blood loss if ectopic ruptures
Abdominal examination reveals unilateral tenderness
Cervical tenderness (Chandelier sign) on Bimanual Examination
What is the main differential for Ectopic Pregnancy?
Miscarriage is the main differential, but in an ectopic pregnancy, the pain is often the first and dominant symptom and the vaginal bleeding is often minor compared to miscarriage
What 2 investigations should be ordered in an Ectopic Pregnancy?
A Pregnancy Test
Transvaginal Ultrasound to locate the pregnancy
There are 3 management options for an Ectopic Pregnancy, what is the Conservative Pathway? (2)
If the patient has minimal/ no symptoms
Do repeat B-hCG tests and if the levels are not falling at a satisfactory rate, then active management is advised
What is the medical management of an Ectopic Pregnancy? (3)
One-off dose of Methotrexate
The criteria for Methotrexate treatment (3) (low hCG level, ability to attend follow up, adherence to avoiding pregnancy for a period following treatment)
If the initial dose does not work, then a second dose or surgical management may be necessary
What is the surgical management of an Ectopic Pregnancy?
4 Criteria for Surgical Management
- Significant amount of pain
- Adnexal mass of 35mm or more
- B-hCG levels are 5000IU or more
- Ultrasound identifies a foetal heartbeat
Surgical Management- Salpingectomy (fallopian tube containing the Ectopic Pregnancy is removed)- if they only have one Fallopian Tube and wish to remain fertile then a Salpingotomy can be done
The risk with Salpingotomy is that sometimes not all of the tissue is removed, so B-hCG measurements are done to make sure no trophoblastic tissue is left
What are the 6 risk factors for Endometrial Cancer?
Late Menopause
Early Menarche
Obesity
Nulliparity
Oestrogen-only hormone replacement therapy
Polycystic Ovary Syndrome
What are the 8 features of Endometrial Cancer?
Postmenopausal bleeding
Abnormal Vaginal bleeding (Intermenstrual bleeding)
Dyspareunia
Pelvic Pain
Abdominal discomfort/ bloating
Weight loss
Anaemia
Enlarged Uterus on Bimanual Pelvic Examination, or this may be normal as the gross uterus size may be unchanged
What 2 investigations should be ordered in Endometrial Cancer?
Transvaginal ultrasound to look for the abnormal thickening of the endometrium
Biopsy of the endometrium
What is the 3 step management of Endometrial Cancer?
Depends on the stage
Limited to uterus- Hysterectomy with Bilateral Salpingo-Oophorectomy is curative
Spread outside the uterus- Surgery, Radiotherapy and Chemotherapy
What are the 5 features of Endometriosis?
Dysmenorrhoea
Dyspareunia
Subfertility
Pelvic Examination may reveal Tender, Nodular masses on the ovaries or the ligaments surrounding the uterus
Rarely, Endometrial tissue can grow outside the female reproductive system, such as the Bowel- which leads to Cyclical Rectal Bleeding
What are the main differentials for Endometriosis? (4)
(Other causes of Dysmenorrhoea)
Primary Dysmenorrhoea
Uterine Conditions (fibroids, adenomyosis)
Adhesions
Pelvic Inflammatory Disease
What 2 investigations should be ordered in Endometriosis?
Trans-vaginal Ultrasound (which is usually normal)- sometimes can identify an Ovarian Endometrioma (cyst made of Endometrial Tissue)
Diagnostic Laparoscopy is Gold-Standard but it carries complications (Bowel Perforation)- so it is not First Line
What is the Medical Management of Endometriosis (2)?
Analgesia (Paracetamol or NSAIDs)
Hormonal Therapy (3)
- Combined Oral Contraceptive Pill
- Medroxyprogesterone Acetate
- Gonadotrophin-releasing Hormone Agonists
What is the Surgical Management of Endometriosis (5)?
Diathermy of Lesions
Ovarian Cystectomy (for Endometriomas (cysts in the ovaries))
Adhesiolysis
Bilateral Oophorectomy (sometimes with Hysterectomy)
(For managing Infertility, menstrual suppression would be unsuitable, so ablation or surgery is more appropriate)
What is the presentation of Fibroids?
Often Asymptomatic
When symptoms occur, they involve menstrual dysfunction in the form of Menorrhagia and Dysmenorrhoea
If large enough, the fibroids may distort the Uterine Cavity and interfere with Fertility
If large, the fibroids may be palpable on abdominal examination such as a suprapubic mass. Pelvic examination may reveal and irregularly enlarged uterus
What are the differentials for Fibroids?
(Other causes of Menorrhagia and Dysmenorrhoea)
Endometrial Polyps
Endometriosis
What 3 investigations should be ordered if Fibroids are suspected?
Transvaginal Ultrasound (used to assess size and location of fibroids)
MRI is used if Ultrasound is not detailed enough to assess the fibroid for surgery
If there is any doubt over the diagnosis, a Biopsy may be taken to differentiate the fibroid from other differentials such as Endometrial Cancer
What warrants Non-surgical management of Fibroids and what are the 5 treatment options?
If <3cm with no Uterine Distortion
- NSAIDs
- Anti-fibrinolytics
- Combined Hormonal Contraception
- Levonorgestrel-releasing intrauterine system (Mirena)
- Mirena is first-line, however other treatments may be selected depending on the patient’s wishes to remain fertile
What is the Surgical management of Fibroids? (4)
Myomectomy (generally Fertility-sparing)
Ablation involves Laser or Radiofrequency (generates heat) to induce Necrosis of the Fibroid, so the dead vessels no longer bleed
Uterine Artery Embolisation may provide a targeted degeneration of the Fibroid and may also preserve Fertility
Hysterectomy involves removing the Uterus- Effective but does not preserve Fertility
What are the 7 types of Genital Prolapse?
Anterior Vaginal Wall
- Cystocele= bladder (may lead to stress incontinence)
- Urethrocele= urethra
- Cystourethrocele= both bladder and urethra
Posterior Vaginal Wall
- Enterocele= Small intestine
- Rectocele= Rectum
Apical Vaginal Wall
- Uterine Prolapse= Uterus
- Vaginal vault Prolapse= Roof of Vagina (common after a hysterectomy)
What two hormones does Hormone Replacement Therapy comprise of?
Oestrogens- function to overcome oestrogen deficiency- Oral, Transdermal or Topically (Intravaginal Creams, Gels and Pessaries for Urogenital Symptoms only)
Progestogens- for Endometrial protection from unopposed systemic Oestrogens. Oral, Transdermal or Intrauterine (via Mirena)
What are the two regimes for HRT?
Cyclically- for perimenopausal women who are still having menstrual periods
Continuous- if postmenopausal
What are the 3 benefits of HRT?
Relief of Vasomotor Symptoms
Relief of Urogenital Symptoms
Reduced risk of Osteoporosis
What are the 3 risks of HRT?
Increased risk of Breast Cancer
Increased risk of Endometrial Cancer if Oestrogen is given alone
Increased risk of Venous Thromboembolism
What are the chances for a couple to conceive a child within 1 year and what 3 factors influence this?
80% if
- woman is under 40 years old
- they do not use contraception
- they have regular intercourse
What 7 factors affect natural fertility?
Age
Obesity
Smoking
Alcohol
Drugs
Tight fitting underwear (males)
Anabolic Steroid use
What are the Genetic (2), Endocrine (6), Tubal Abnormalities (2), Uterine Abnormalities (3), Cervical Abnormalities (1), Testicular Disorders (4) and Ejaculatory Disorders (2) that can result in Infertility?
Genetic-
- Turner’s (XO)
- Kleinfelter’s (XXY)
Endocrine-
- Polycystic Ovary Syndrome
- Pituitary tumours
- Sheehan’s Syndrome (Pituitary Infarction as a result of Haemorrhagic Shock during Labour)
- Hyperprolactinaemia
- Cushing’s Syndrome
- Premature Ovarian Failure
Tubal-
- Congenital Anatomical Abnormalities
- Adhesions following Pelvic Inflammatory Disease- secondary to Chlamydia or Gonorrhoea
Uterine-
- Bicornate Uterus
- Fibroids
- Asherman’s Syndrome (Adhesions of Uterus)
Cervical -
- Cervical Damage- after Biopsy or LLETZ
Testicular Disorders-
- Cryptorchidism
- Varicocele
- Testicular Cancer
- Congenital Testicular Defects
Ejaculatory-
- Obstruction of Ejaculatory System (congenital or acquired)
- Disorders of Ejaculation (retrograde or premature ejaculation)
What are the 4 features of an Intra Uterine Device?
Device can stay in for up to 10 years. When it is removed, fertility returns to normal
Not suitable for women with current pelvic infection or a distorted uterus. Women with a repeat history of STIs are also unsuitable for this
If fitted after 40, the device can stay until the woman has her menopause. They need to be taught how to check if their device is in the right place
Contraindications- unexplained bleeding and an abnormal cervix
What are some facts about IUDs being used as Emergency Contraception? (5)
It is the Most Effective form of Emergency Contraception
It can be used for up to 120 hours after the Unprotected Sex has occurred or after the earliest expected date of Ovulation
It is not recommended to be used within 28 days after giving birth
Some women may experience Spotting and Period Type Pains
Women should visit the doctor 3-4 weeks later to check that they are not pregnant and discuss future contraception
What 5 investigations should be ordered if the patient has irregular menstrual bleeding?
Pelvic Examination (Speculum +/- smear test)
Pregnancy Test
Pelvic Ultrasound (if the examination findings are suggestive (such as fibroids)
Cervical Biopsy if the smear is abnormal +/- abnormal findings on examination
Endometrial biopsy if Endometrial Pathology is suspected
If pathology is ruled out as a cause for Irregular Periods, what is the 4 step management?
Combined Oral Contraceptive Pills- to regulate Menstrual Cycle
Mirena Intrauterine system- to reduce Overall Bleeding
Norethisterone- taken on cycle days 5-26to prevent bleeding
Progestogens- to reduce Amenorrhoea but can not be used long term (like Medroxyprogesterone acetate)
What are the features of Lichen Sclerosus?
White patches which may scar around anal and genital areas
Pain may occur when the area is irritated during Urination or Sexual Intercourse
What is the 3 step management of Lichen Sclerosus
Topical Steroids
Avoidance of Soaps in the Affected Areas
Emollients to relieve Dryness and Itchiness
What are the 3 categories of symptoms for Menopause?
Vasomotor (hot flushes, night sweats)
Sexual Dysfunction (vaginal dryness, reduced libido, problems with orgasm, dyspareunia)
Psychological (depression, anxiety, mood swings, lethargy, reduced concentration)
When are women considered fertile?
They are fertile for at least 2 years after their last menstrual period if they are <50 years old, and for 1 year after their last menstrual period if they are >50 years old
In general, they are no longer fertile after the age of 55
How is Menopause managed?
HRT
or
Non Hormonal Management (5)-
- Lifestyle measures (regular exercise, weight loss (if overweight), clothing alterations, stress reduction and avoiding triggers (spicy food, caffeine, smoking), good sleep hygeine)
- SSRIs or SNRIs
- Clonidine (alpha-2 adrenergic receptor agonist)
- Cognitive Behavioural Therapy
- Vaginal Moisturisers
What is Menorrhagia?
Blood loss during a period, to the point where a woman’s quality of life is affected
What are the 4 Systemic (non Local) causes of Menorrhagia?
Bleeding disorders
Hypothyroidism
Liver and Kidney Disease
Obesity
What 4 investigations should be ordered in Menorrhagia?
FBC to eliminate Iron Deficiency Anaemia
Clotting studies if bleeding elsewhere
Transvaginal Ultrasound- to look for things like Fibroids/ Endometrial Polyps
Other tests for Endocrine Diseases (TFTs) should only be done if indicated
What is the 5 step management plan for Menorrhagia?
Mirena Coil
Mefenamic Acid
Tranexamic Acid
Hormonal contraception (COCP)
If it is refractory- Endometrial Ablation or Hysterectomy
What are the 3 Foetal Pathology causes and 6 Maternal Pathology causes of Miscarriage?
Foetal-
- Genetic Disorder
- Abnormal Development
- Placental Failure
Maternal-
- Poorly controlled Diabetes
- Anti-Phospholipid Syndrome
- Poorly controlled Thyroid Disease
- Cervical Incompetence
- Uterine Abnormality
- Polycystic Ovary Syndrome
What are the 3 features of a Miscarriage?
Vaginal Bleeding
Pain- Worse than usual pain of period
Vaginal tissue loss
What is the timeframe for a Miscarriage?
Loss of pregnancy prior to 24 weeks Gestation
What is the main differential for a Miscarriage?
Vaginal bleeding prior to 24 weeks of Gestation= Ectopic Pregnancy (but in Ectopic, the pain is the presenting complaint and the bleeding is minimal)
What are the 4 types of Miscarriage?
Threatened Miscarriage
- Mild symptoms of bleeding and Foetus is retained within the Uterus, as the Cervical OS is closed. so there is the Threat of a Miscarriage but it is Not Certain. There is Little or No Pain. Ultrasound reveals that the foetus is present Intrauterine
Inevitable Miscarriage
- Heavy bleeding and pain, where the foetus is Intrauterine BUT the Cervical OS is open. Hence it is inevitable. Ultrasound reveals that the foetus is present Intrauterine
Complete Miscarriage
- There was an Intrauterine Pregnancy which has now fully miscarried, with all products of conception expelled, and the Uterus is now Empty. The OS is usually closed. The patient may have been alerted to the miscarriage by the pain and bleeding
Missed Miscarriage
- Uterus still contains Foetal Tissue but the Foetus is no longer Alive. This is called Missed as the woman does not realise it. the Cervical OS is closed
What 2 investigations should be ordered in a suspected Miscarriage?
Transvaginal Ultrasound to establish whether there are Any Foetal Components and whether a Foetal Heartbeat can be detected
When these are Not present- serial hCG measurements may be indicated. Serial Serum hCG measurements 48 hours apart can give an indication of the location and prognosis of the pregnancy
- if the levels fall then it suggests that the foetus will not develop or there has been a miscarriage
- if there is only a slight increase or a plateau in hCG, then this indicates an Ectopic Pregnancy
- normal increase in hCG suggests the foetus is growing normally but does not exclude Ectopic Pregnancy
What is the management of Miscarriage?
Miscarriage can not be stopped or prevented
Expectant management- waiting for contents to be expelled naturally
Medical management- Misoprolol
Surgical management- Dilatation and Curettage
If the woman is Rhesus Negative, they may require anti-D prophylaxis
What should be investigated in Recurrent Miscarriages?
Blood tests (Antiphospholipid Antibodies, Thrombophilia Screens)
Cytogenetic Analysis of Products of Conception (if abnormal then the Parents should be Karyotyped)
Pelvic Ultrasound (to identify Uterine Abnormalities)
What are the 7 OPTIONS for managing a Recurrent Miscarriage? (treating the cause)
Genetic Disorder- refer to Clinical Geneticist for Genetic Counselling. Options include continuing pregnancy attempts with a Prenatal Diagnosis or using a Donor Egg/Sperm
Uterine Structure Abnormality- Surgically treat this
Cervical Incompetence- Regular Ultrasound monitoring of the Cervix. May use Cervical Cerclage
Polycystic Ovary Syndrome- pathophysiology is not fully understood
Antiphospholipid Syndrome- Heparin or Low-dose Aspirin
Thrombophilia- Heparin
Diabetes- improves Glycaemic Control
What are the 3 types of Ovarian Cancer?
Epithelial Ovarian Cancer
- Originate from the Epithelium- which lines the Fimbria of the Fallopian Tubes/ Ovaries
- Epithelial tumours are partly cystic and the cysts can contain fluid
- The initial metastatic spread involves the Peritoneal Cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm
Germ Cell Tumour
- Originate from the Germ Cells in the Embryonic Gonad
-These tumours grow rapidly and spread via the lymphatic route
- Germ cell tumours most commonly arise in Young Women, which is atypical for most cases of Ovarian Cancer
- Tumour markers for this type of cancer include AFP and sometimes B-hCG
Sex Cord
Sex Cord Stromal Tumours
- Originate from the Connective Tissue
- They are rare (<5% of Ovarian Tumours). They are less aggressive than Epithelial Tumours
- Ovarian Cancer can be secondary to cancer elsewhere. Krukenberg Tumour= a “signet ring” subtype of tumour (usually from the GI System) which spreads to the Ovaries
What are the 6 Risk Factors and 4 Protective Factors against Ovarian Cancer?
Old Age
Smoking
Greater number of Ovulations (Early Menarche and Late Menopause)
Obesity
HRT
BRCA1 and 2 genes
Parity
Breastfeeding
Early Menopause
COCP
What are the 4 clinical features of Ovarian Cancer?
Symptoms develop late in the course of cancer and involve Abdominal Discomfort, Bloating, Early Satiety, Urinary Frequency or Change in Bowel Habit
The cancer can produce vascular growth factors which Increase Vessel Permeability, leading to Ascites in Late Disease
Other symptoms of Late Disease include Back, Pelvic and Abdominal Pain
There may be a Palpable Mass where the cancer is growing
What are the main differentials for Ovarian Cancer?
GI Conditions (like IBS)
Other causes of masses (Fibroids, Ovarian Cysts, other cancers (Bladder, Endometrial))
What are the 2 Initial and 3 Further Tests that should be ordered in Ovarian Cancer?
CA125
Pelvic and Abdominal Ultrasound
(These two are used to calculate the Risk of Malignancy Index)
CT Scans for Staging
AFP and B-hCG for Young Women who have Germ Cell Tumours
Laparotomy for Tissue Biopsy
What is the Staging for Ovarian Cancer?
Stage I (limited to the ovaries):
Stage IA: limited to one ovary, the capsule is intact
Stage IB: limited to both ovaries, capsules intact.
Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.
Stage II involving one or both ovaries with pelvic extension and/or implants:
Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings
Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings
Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.
Stage III involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:
Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)
Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm
Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.
Stage IV ovarian cancer is tumour involving one or both ovaries with distant metastasis.
What are the management options for Ovarian Cancer?
Surgery
- If Early Disease, surgery can include the removal of the Uterus, Ovaries, Fallopian Tubes and Infracolic Omenectomy
- If Advanced Disease, debulking surgery can be performed
Chemotherapy
- Adjuvant Chemotherapy in Combination with Surgery
- Intraperitoneal Chemotherapy may be performed at the time of operation
What are the symptoms of an Ovarian Cyst Rupture?
Can be Asymptomatic
Otherwise, Acute Unilateral Pain or Intra-peritoneal Haemorrhage with Haemodynamic Compromise
What are the differentials for an Ovarian Cyst Rupture
Ovarian Torsion and Ectopic Pregnancy
GI causes such as Appendicitis can also be considered
What investigations should be ordered if an Ovarian Cyst Rupture?
Pregnancy Test to exclude an Ectopic Pregnancy
Diagnostic Laparoscopy may be needed in an Unstable patient
What is the management of an Ovarian Cyst Rupture?
Mainly Conservative but may require Surgery
What is Overactive Bladder Syndrome?
It results from Detrusor Muscle Hyperactivity
It manifests as Urinary Urgency, Nocturia and Incontinence
What 3 investigations should be ordered in Overactive Bladder Syndrome?
Urinalysis with or without Culture to rule out a potential Infection
Frequency/ Volume Charts
Urodynamics
What are the 5 management options for Overactive Bladder Syndrome?
Behavioural Modification- reduce Oral Fluid Intake, avoid things like Caffeine and Alcohol which are diuretics
Bladder Retraining- to Increase the Interval between Voids and suppress the Urinary Urge
Anticholinergic Drugs (Oxybutynin, Solifenacin)
Vaginal Oestrogens if Urogenital Atrophy is a likely Contributory Factor
Botulism Toxin- which is used for Refractory Cases
Which pathogen most commonly causes Pelvic Inflammatory Disease?
39% of cases are caused by Chlamydia and 14% are caused by Gonorrhoea
What are the 7 signs and symptoms of Pelvic Inflammatory Disease?
Bilateral Abdominal Pain
Discharge
Post-Coital Bleeding
Adnexal Tenderness
Cervical Motion Tenderness on Bimanual Examination
Fever
(10% have RUQ pain due to inflammation of Liver, secondary to the PID (known as Fitz Hugh Curtis Syndrome)- LFTs are normal but Abdominal Ultrasound should be done to exclude Gallstones anyway)
What 5 investigations should be ordered in Pelvic Inflammatory Disease?
Pelvic Examination
Pregnancy Test
Swabs for Gonorrhoea and Chlamydia
Bloods
Transvaginal Ultrasound
What is the management of Pelvic Inflammatory Disease?
Ofloxacin and Metronidazole
Analgesia may be required
If ANY woman presents with bilateral lower abdominal pain with adnexal tenderness should be treated for PID
What are the 8 signs of Polycystic Ovary Syndrome?
Subfertility
Hirsuitism
Acne
Mood Swings/ Depression/ Anxiety
Obesity
Male Pattern Baldness
Oligomenorrhoea
Acanthosis Nigricans (secondary to Insulin Resistance)
What 9 investigations should be ordered in Polycystic Ovary Syndrome?
LH:FSH ratio>2 (can also help exclude Menopause where the ratio is normal)
Total Testosterone- normal or high
Fasting/ Oral Glucose Tolerance Tests (helps to diagnose Insulin Resistance which is seen in POS)
Transabdominal and Transvaginal Ultrasound to see the cysts themselves
Other Pathologies-
TFTs- for Thyroid function
17-Hydroxyprogesterone Levels- for CAH
Prolactin- for Hyperprolactinaemia
DHEA-S and Free Androgen Index (Androgen Secreting Tumours)
24 hour Urinary Cortisol (for Cushing’s)
According to the Rotterdam Diagnostic Criteria, 2 out of 3 signs warrant the diagnosis of Polycystic Ovary Syndrome. What are these Signs?
Polycystic Ovaries (>12 on Imaging or Ovarian Volume >10 cubic cm)
Oligo/anovulation
Clinical or Biochemical Features of Hyperandrogenism
What is the management of Polycystic Ovary Syndrome?
General Advice (2), Not wishing to Conceive (3), Wishing to Conceive (4)
General Advice-
- Weight Loss and Exercise Control
- Education about Increased Cardiovascular, Diabetes and Endometrial Cancer risks
Not Wishing to Conceive-
- Co-cyprindrol- Used for Reducing Hirsutism and Inducing Regular Menstruation
- Metformin- Used for Reducing Hirsutism and Inducing Regular Menstruation AND Acne
- COCP- Reduces Irregular Bleeding and protects against Endometrial Cancer
Wishing to Conceive-
- Clomiphene- Induces Ovulation and Improves Conception Rates
- Metformin- Can be used with or without Clomiphene to Increase the chances of pregnancy
- Ovarian Drilling- 2nd Line Laparoscopic Surgical Procedure- used to damage the Hormone-producing cells of the Ovary
- Gonadotrophins- can induce Ovulation if Clomiphene and Metformin have failed
What are the 5 differential diagnoses for Post-Coital Bleeding?
Cervical Ectropion- Often Asymptomatic
Endocervical and Cervical Polyps- Often Asymptomatic but may have Vaginal bleeding, Intermenstrual bleeding or Menorrhagia. Diagnosed via Speculum Examination
Cervical Cancer- can cause Post-Coital Bleeding as well as bleeding at other times such as Urination. There will also be Urinary Symptoms and Vaginal Discomfort
STIs- Discharge and Pelvic Pain will be seen
Atrophic Vaginitis- Most common cause of Post-coital bleeding in Postmenopausal women
What are the 4 causes of Post-Menopausal Bleeding?
(Suspect Cancer and refer them to Gynaecology if they present with this for TV Ultrasound and Biopsy)
Endometrial Cancer- this is often the Only Symptom
Vaginal Atrophy- It can cause Pruritus, Dyspareunia and Vaginal Discharge
Cyclical Combined HRT- it is common to experience Breakthrough Bleeding when on HRT
Bleeding Disorders- if there is frequent bleeding elsewhere/ family history
What is Pre-Menstrual Syndrome?
Psychological, Behavioural and Physical Symptoms that occur in the Luteal Phase of the Menstrual Cycle
What are the 5 Pharmacological and 5 Non-Pharmacological Management approaches to Pre-Menstrual Syndrome?
Pharmacological-
- COCP
- Danazol
- Transdermal Oestrogen
- GnRH Analogues (to induce a Menopausal State)
- Antidepressants (SSRIs and SNRIs)
Non-Pharmacological-
- Dietary modifications (Reduce Fat, Sugar, Caffeine and Increase Fibre, Fruit and aim for more Frequent Snacks)
- Increasing Exercise
- Vitamin Supplementation (for Vitamin B supplementation)
- Stress Induction (Relaxation)
- CBT
What is a pregnancy of unknown origin and what are the 3 causes of it?
A positive pregnancy test but negative ultrasound
- Early Viable or Failing Intrauterine Pregnancy
- Complete Miscarriage
- Ectopic Pregnancy
What 2 Investigations should be ordered in a pregnancy of unknown origin (3,1)?
Serial Serum B-hCGs 48 hours apart
- If the levels fall- Foetus will NOT develop or there is a Miscarriage
- Slight increase or Plateau- Ectopic Pregnancy
- Normal increase- Foetus is growing normally but does NOT exclude Ectopic
Transvaginal Ultrasound- as foetus may be too small to identify in early days of Gestation
What is Premature Ovarian Insufficiency and what are the 3 signs?
Menopause in a women under 60 years old
- Vasomotor- Hot Flushes and Night Sweats
- Sexual Dysfunction- Vaginal Dryness, Reduced Libido, Problems with Orgasm, Dyspareunia
- Psychological- Depression, Anxiety, Mood Swings, Lethargy, Reduced Concentration
How is Premature Ovarian Insufficiency diagnosed and managed
Diagnosed- Reduced FSH levels indicate Menopause. The levels should be repeated at least once to exclude Anomalies
Management- HRT until the normal age of Menopause unless the risks outweigh the benefits
What is Primary Amenorrhoea? And what are the 5 causes of it?
It is the failure of Menstrual Periods to start by the time the female is 15 years old if they have Normal Growth and Secondary Sexual Characteristics
It may be diagnosed at 13 years old if there is no Pubertal Maturation and No Menses
- Constitutional Delay in Puberty
- Chromosomal or Genetic Abnormalities such as Turner’s Syndrome (45 XO), Kallmann Syndrome and Androgen Insensitivity
- Disruption of the functioning of the Hypothalamus and the Pituitary Glands due to: Anorexia, Excessive Exercise, Extreme Physical or Psychological Stress
- Structural Abnormalities of the Genital Tract such as: an Imperforate Hymen obstructing Menstrual Flow (leading to Haematocolpos), Uterine Agenesis
- Pregnancy
What are the 3 main causes of Right Iliac Fossa pain?
GI Causes- (5) Acute Appendicitis, Mesenteric Adenitis, Inflamed Meckel’s Diverticulum, Diverticulitis (although this is more common on the left) and Inflammatory Bowel Disease (Crohn’s)
Gynaecological Causes- (5) Ectopic Pregnancy, Ovarian Torsion, Ovarian Cyst Growth, Ovarian Cyst Rupture, Pelvic Inflammatory Disease
Urological Causes- (2) Pyelonephritis, Ureteric Colic
What is Secondary Amenorrhoea and what are the 9 causes of it?
The absence of periods in a woman who had previously had them for 6 months or more
- Pregnancy (most common cause)
- Breastfeeding
- Menopause
- Pituitary Gland Pathology (Sheehan Syndrome or Hyperprolactinaemia)
- Hypothyroidism or Hyperthyroidism
- Physical Stress, Excess Exercise and Weight Loss
-PCOS
- Intrauterine Adhesions causing Outflow Tract Obstruction (Asherman’s Syndrome)
-Drug Induced Amenorrhoea (Contraceptive Use)
What is Vasa Praevia and what are the 3 signs?
It is a condition where the Foetal Vessels run near to or across the internal Cervical os
These vessels are likely to rupture in Vasa Praevia during the rupture of membranes as the vessels are UNSUPPORTED by the Umbilical cord or Placental tissue. This can lead to Foetal Haemorrhage or Foetal Death
- Painless Vaginal Bleeding
- Rupture of Membranes
- Foetal Bradycardia (or resulting Foetal Death)
How is Vasa Praevia diagnosed and managed?
Transabdominal or Transvaginal Ultrasonography and most cases can now be diagnosed Antenatally
It is managed through Elective Caesarean Section prior to the Rupture of the Membranes. This is usually arranged at 35-36 weeks gestation. If the mother ruptures her membranes or goes into labour then Emergency Caesarean Section should be started asap
What type of cancer are Vulvar Cancer and what are the 4 signs of Vulvar Cancer?
Squamous Cell Carcinoma
- Vulval Pain
- Itching
- Non-healing Ulcer
- Lump with or without Lymphadenopathy
What is the diagnosis and management of Vulvar Cancer?
Examination of the vulvar can raise suspicion if there is a lump or Ulceration
After Inspection, the diagnosis can be confirmed with a Biopsy
Management- The main treatment option is Surgery. In simple cases of primary vulvar cancer, Radical/ Wide Local Excision can be used. If it is a multi-focal disease, then Radical Vulvectomy is preferred
If advanced, Radiotherapy is used with or without Chemotherapy
