O&G Flashcards
What are the risk factors for vaginal candidiasis?
Diabetes mellitus,
Antibiotics, steroids
Pregnancy
Immunosuppression: HIV
What is the first line management for vaginal candidasis?
Single dose oral fuconazole 150 mg
OR clotrimazole 500 mg intravaginal pessary is first line is contraindicated
What is the first line management for endometriosis if analgesia is ineffective?
Combined oral contraceptive pill or progestogens
What is the gold standard investigation for diagnosing endometriosis?
Laparoscopy
What is the fasting glucose diagnosis threshold for gestational diabetes mellitus?
> 5.6 mmol/L
How long does the progestogen-only pill take to become effective?
48 hours
What muscarinic antagonist is prescribed to manage urgency incontinence, despite bladder retraining?
Oxybutynin, tolterodine
What is the endocrine complication associated with severe PPH?
Sheehan’s syndrome
Which drug is prescribed to manage infertility in PCOS?
Clomifene
When is folic acid advised in pregnancy?
From conception to the 12th week
What threshold of fasting blood glucose indicates insulin administration?
> 7 mmol/L
When are OGTT investigations performed for screening gestational diabetes in a patient with a previous GDM?
Immediately, and at 24-28 weeks.
When is breast feeding an absolute contraindication to COCP use (UKMEC 4)?
<6w post partum
What should be administered to a rhesus-negative mother undergoing surgical removal of an ectopic pregnancy?
Anti-D immunoglobulin
At what stage should a serum progesterone level be measured for assessing ovulation?
7 days prior to the expected next period
First line investigation for pregnancy exposure to varicella zoster (with uncertain background)?
IgG VZ antibodies (<100 = high risk)
Define Asherman’s syndrome
Intrauterine adhesions/scar tissue resulting in dysfunctional endometrium - typically followers dilation and curettage.
Which thromboprophylaxis should be prescribed in high risk pregnant women?
Low molecular weight heparin
What is the management for positive group B strep in pregnancy?
Intrapartum IV benzylpenicillin
First line SSRI in postpartum depression
Sertraline (not fluoxetine)
What is the management for breech position at 36w?
External cephalic version
What is the first line non-hormonal management for menorrhagia?
Tranexamic acid
What is the management for Premenstrual dysphoric disorder?
Sertraline
What is the second line management for stress incontinence after a trial of pelvic floor muscle training (3 months)?
Duloxetine
Tamoxifen increases which type of cancer?
Endometrial cancer - behaves as an oestrogen receptor agonist on endometrial cells.
When is an anomaly scan performed?
18 - 20+6 weeks
What drug is prescribed to ripen the cervix during induction of labour (Bishop Score <7)?
Vaginal prostaglandin
What is the complication of cholestastic disease of pregnancy?
Stillbirth
What are the risk factors for cord prolapse?
- Rupture of membranes – high outward flow of amniotic fluid Carries the umbilical cord.
- Preterm gestational age
- Second twin
- Low birth weight
- Low lying placentation (placental praevia).
- Pelvic deformities
- Uterine malformations
- Multiparity
- Polyhydramnios
- Long umbilical cord
What is the largest risk factor for cord prolapse?
- Rupture of membranes
What is cord prolapse?
Overt prolapse – Cord slips ahead of the foetal presenting part and prolapses into cervical canal, vagina or beyond – Obstetric emergency – vulnerable to complete occlusion (compression of all three vessels), or partial occlusion (compression of umbilical vein) or vasospasm of the umbilical artery.
What obstetric interventions can result in a cord prolapse?
Obstetric interventions account for ~50% of cord prolapse: Iatrogenic rupture of membranes, cervical ripening with a balloon catheter, induction of labour, amnioinfusion, manual rotation of the foetal head.
What foetal presentation is associated with cord prolapse?
Severe prolonged foetal bradycardia
Moderate to severe variable decelerations
Risk of foetal hypoxia
What is the antepartum diagnosis of cord prolapse?
Ultrasound - demonstrates that the umbilical cord is interposed between the presenting part of the foetus and the internal cervical os.
+ Colour flow Doppler studies
What is the emergency management option for cord prolapse?
Emergency caesarean section
- Keep cord warm and wet – minimal handing (handling causes vasospasm) – urinary catheter.
In cord compression, what position is recommended for the mother?
Left lateral position
Knee-chest position
What is the knee-chest position for the management of cord prolapse?
Using gravity to draw the foetus away from the pelvis to reduce cord compression.
What is the main cause of atrophic vaginitis?
Menopause
What is the main presenting features associated with atrophic vaginitis?
- Vulvovaginal dryness
- Decreased vaginal lubrication during sexual activity.
- Dyspareunia – vulvar or vaginal pain
- Vaginal bleeding e.g., postcoital, labial fissures
- Decreased arousal, orgasm, or sexual desire
- Vulvovaginal burning, irritation or itching.
- Levator spasm
- Vaginal discharge (leukorrhea or yellow and malodorous)
- Urinary tract symptoms (e.g., urinary frequency, urinary urgency, dysuria, urethral discomfort, haematuria, recent UTIs).
- Urethral prolapse.
What are the examination features associated with atrophic vaginitis?
- Labia minora resorption of fusion
- Tissue fragility
- Loss of hymenal remnants
- Prominence of urethral meatus
- Loss of vaginal rugae, vulvovaginal pallor/erythema/decreased elasticity and abnormal discharge.
What is the 1st line treatment for atrophic vaginitis?
Non-hormonal vaginal moisturisers and lubricants
What is the 2nd line treatment option for atrophic vaginitis?
Vaginal oestrogen therapy
What is the normal microbiome of the vagina?
Lactobacillus
What does Lactobacillus produce?
Hydrogen peroxide and lactic acid
Which bacteria is implicated in the pathogenesis of bacterial vaginosis?
Gardnerella vaginalis
What type of bacteria is Gardnerella vaginalis?
Anaerobic gram-negative rod
What are the risk factors associated with BV?
- Sexually active + concurrent STIs
- Use of douches, deodorant, and vaginal washes
- Menstruation and semen – associated with alkaline vaginal pH.
- Copper intrauterine devices
- Smoking.
What happens to the vaginal pH in BV?
> 4.5
What are the protective factors associated with BV?
use of hormonal contraception
consistent condom use
Circumcised partner
What is the classical presentation of BV?
- Vaginal discharge
o Off-white, thin, and homogenous discharge coating the walls of the vagina and vestibule.
o Malodorous – ‘fishy smell’ (noticeable post-coital and during menses).
No itching or soreness.
What are the four investigations for diagnosing BV?
Vaginal swab
pH test - >4.5
Positive white-amine test
Sample for gram-staining and microscopy
What microscopy findings are observed in bacterial vaginosis?
Clue cells on saline wet mount
stippled vaginal epithelial cells >20%
Which criteria is commonly used to diagnose BV?
Amsel’s criteria
What are the four parameters of Amsel’s criteria?
- Homogenous, thin, grayish-white discharge coating the vaginal walls.
- Vaginal pH >4.5
- Positive whiff-amine test
- Clue cells on saline wet mount
Only need 3 out of the 4
What is the 1st line ABx for BV?
Oral metronidazole 400 mg BD for 5-7 days.
If oral metronidazole is not tolerated in BV, what is the alternative option?
Intravaginal metronidazole 0.75% gel OD for 5 days or intravaginal clindamycin OD for 7 days.
What are the complications associated with BV during pregnancy?
Late miscarriage, preterm birth, PROM and postpartum endometritis.
What is the cause of Trichomonas Vaginalis?
Protozoan trichomonas vaginlias
What are the risk factors of Trichomonas Vaginalis?
Sexually active women <25 years (>1 partner in the last 12 months + history of STI)
What clinical presentation differentiates between TV and BV?
Vulval itching and soreness
What type of vaginal discharge is seen in Trichomonas Vaginalis?
Frothy and yellow-green malodorous discharge
What is the clinical presentation of Trichomonas Vaginalis?
Asymptomatic in ~50% of women
* Vaginal discharge
o Frothy, and yellow-green, malodours discharge (in 10-30% of affected women).
* Vulval itching and soreness.
* Dysuria
* Offensive odour
* Lower abdominal pain
* Vaginal pH >4.5
* Dyspareunia
On examination of the vulva and cervix, what characteristic features are seen?
Strawberry Cervix
A strawberry cervix is associated with what pathology?
Trichomonas Vaginalis
If Trichomonas Vaginalis is suspected what is the management referral?
Refer to the GUM clinic for confirmed diagnosis
What type of swab is recommended for Trichomonas Vaginalis?
High vaginal swab from the posterior fornix
+ STI tests for chlamydia, gonorrhoea, HIV and syphillis
What is the diagnostic test for Trichomonas Vaginalis?
Microscopy of a wet mount slide - revealing motile trophozoites
What is the first-line antibiotic for the management of Trichomonas Vaginalis?
Metronidazole 400-500 mg BD for 5-7 days OR single 2 g dose of metronidazole.
Is a STAT dose prescribed in Trichomonas Vaginalis during pregnancy?
No, offer 5-7 400 mg prescription of metronidazole
What advice is given to women with Trichomonas Vaginalis?
Sexual abstinence for at least 1 week and for partners to complete treatment + contact tracing.
What are perinatal complications associated with Trichomonas Vaginalis?
Preterm delivery
Low birthweight infant
What type of bacteria is chlamydia?
An obligate intracellular gram-negative bacterium
What is uncomplicated Chlamydia ?
Has not ascended to the upper genital tract
What does ascending Chlamydia cause?
Pelvic inflammatory disease
Which is the most common infected anatomic site for Chlamydia ?
Cervix
What is the clinical presentation associated with Chlamydia ?
Cervix is the most commonly infected anatomic site:
* Cervicitis
* Dysuria-pyruria syndrome due to urethritis
* Cervical discharge
- Cloudy or yellow discharge
- Mucopurulent
* Friable cervix
- Cervix bleeds easily with friction from a polyester swab.
* Abnormal vaginal bleeding
- Postcoital or intermenstrual bleeding.
* Vaginal discharge (increased)
* Dyspareunia
* Abdominal tenderness and pelvic pain.
What are the symptoms of lymphogranuloma venereum?
Tenesmus
Anorectal discharge
Diarrhoea
Altered bowel habit
What is the first-line investigation for Chlamydia?
Vulvovaginal or endocervical swab or first-catch urine
NAAT positive
What is the antibiotic of choice for the management of Chlamydia ?
Doxycycline
What is the starting dose for doxycycline for Chlamydia ?
100 mg BD for 7 days
Which ABx for Chlamydia is contraindicated in pregnancy?
Doxycycline
Direct microscopy in Chlamydia reveals what?
Neutrophils - in non-gonococcal urethritis
What Abx is recommended in pregnant women with Chlamydia ?
Azithromycin 1 g single dose or 500 mg OD for 2 days
oR
Erythromycin 500 mg QDS for 7 days or amoxicillin
What is the second line ABx for Chlamydia ?
Azithromycin
When is the test of cure performed for Chlamydia ?
5 weeks (and avoid sexual intercourse until treatment has completed)
How far back should contact tracing go for Chlamydia ?
6 months
What are the complications associated with Chlamydia ?
Pelvic inflammatory disease
Endometritis
Increased incidence of ectopic pregnancy
Infertility
Reactive arthritis
Fitz-Hugh Curtis Syndrome (perihepatitis)
When does annual screening for Chlamydia begin in sexually active women?
<25 years of age
What type of bacteria is Gonorrhoea?
Gram-negative intracellular coccus
What are the risk factors for Gonorrhoea ?
Age 15-24 years, black ancestry, current or history of STI, multiple sexual partners, inconsistent condom use, MSM.
What are the presenting features of cervicitis in Gonorrhoea?
o ~70% are asymptomatic.
o Vaginal pruritus
o Mucopurulent discharge
o Examination – cervix is friable.
What are the clinical features associated with Gonorrhoea?
- Cervicitis
o ~70% are asymptomatic.
o Vaginal pruritus
o Mucopurulent discharge
o Examination – cervix is friable. - Urethritis
- Lower abdominal pain (~25%)
- Dyspareunia – Ascending infection Pelvic inflammatory disease.
- Dysuria
What does a bimanual examination assess for?
Perform bimanual examination for cervical motion tenderness, uterine tenderness, and adnexal tenderness.
What is the first-line investigation for suspected Gonorrhoea ?
Vulvovaginal swab for nucleic acid amplification testing (NAAT)
What is the antibiotic of choice for antimicrobial susceptible Gonorrhoea ?
Ciprofloxacin 500 mg Oral - Stat
What is the first -line antibiotic for the management of Gonorrhoea ?
Ceftriaxone 1g single dose IM
When is a test of cure performed in Gonorrhoea ?
1 week follow-up (avoid sex for 7 days and initiate contact tracing)
What are the complications associated with Gonorrhoea infections in women?
Pelvic inflammatory disease - chronic pelvic pain, tubal infertility, or ectopic pregnancy
Fitz-Hugh Curtis Syndrome
Disseminated - septic arthritis, polyarthralgia, tenosynovitis, petechial skin lesions and meningitis
What are the pregnancy complications of Gonorrhoea ?
- Pregnancy complications:
o Spontaneous abortion
o Premature labour
o Premature rupture of foetal membranes
o Perinatal mortality
o Gonococcal conjunctivitis in the newborn (vertical transmission).
Define Pelvic Inflammatory Disease
PID -Infection of the upper genital tract in sexually active young women, ascending from the vagina and endocervix.
What are the two most common pathogens implicated in the pathology of pelvic inflammatory disease?
Neisseria gonorrhoeae and chlamydia trachomatis (most common)
What are the risk factors associated with predisposing PID?
Sexual activity, African ancestry, multiple partners, history of current or previous STI, 15 to 25 years, previous PID, inconsistent barrier contraception, vaginal douching, IUCD 4-6 week insertion.
What is the clinical presentation of pelvic inflammatory diseae?
- Lower abdominal pain
o Cardinal presenting symptom – bilateral <2 weeks duration. - Mucopurulent cervical or vaginal discharge
- Fever
- Deep dyspareunia
- Secondary dysmenorrhoea
- Intermenstrual, postcoital or heavy menstrual bleeding – secondary to associated cervicitis and endometritis.
- RUQ pain/right shoulder pain due to perihepatitis (Fitz-Hughs Curtis Syndrome)
o Inflammation of the liver capsule and peritoneal surfaces of the anterior RUQ. - Nausea and vomiting - ~50% + fever.
What is the clinical presentation of Fitz-Hugh Curtis Syndrome?
RUQ pain/right shoulder pain due to perihepatitis
What are the diagnostic criteria for pelvic inflammatory disease on bimanual examination (/3)?
- Uterine tenderness
- Cervical motion tenderness
- Adnexal tenderness - a sensitive marker for endometritis
What are the first-line investigations for pelvic inflammatory disease?
Perform a urine pregnancy test to exclude ectopic pregnancy
Triple Swabs (high vaginal swabs x2 + endocervical) - NAAT testing
On a wet mount vaginal smear, what is revealed in PID?
Pus cells
What imaging modality is used to detect for tubo-ovarian abscess secondary to PID?
TVUSS
What are the three criterions for admission in patient with PID?
- Pregnant or ectopic pregnancy is suspected.
- Adnexal mass, tubo-ovarian abscess, or pelvic peritonitis
- Pyrexia (>38C, or suspected sepsis/systemically unwell).
What are the three outpatient antibiotics prescribed to patients with PID?
- Ceftriaxone 1 g - Single IM dose
- Oral doxycycline 100 mg BD for 14 days
- Oral metronidazole 400 mg BD for 14 days
What is the advice pertaining to IUD/Copper coils in patients with PID?
For moderate symptoms - remain in situ
Severe -Removed
What is the alternative antibiotic regimen for pelvic inflammatory disease?
- Oral ofloxacin 400 bd
- Oral metronidazole 400 mg BD for 14 days
When should patients with PID be followed-up post ABx management?
Within 72 hours
What is the antibiotic regiment for a patient with PID and is pyrexic or oral Tx has failed?
IV cefoxitin and doxycycline (offer post-IV ceftriaxone)
OR
2nd line: IV clindamycin and gentamicin
Why are patients followed-up 72 hours after PID antibiotic therapy?
To assess for compliance with ABx and adjust regimen if necessary
if no improvement - admit for IV antibiotics
When should a follow-up be arranged to ensure for resolution of PID?
2-4 weeks
What is the antibiotic prescribed to a partner within 6 months of disease onset in contact tracing?
Doxycycline for 7 days
What are the complications associated with PID?
- Ectopic pregnancy – Absolute risk – 1%.
- Pelvic peritonitis and sepsis
- Tubo-ovarian abscess – Fever, systemic illness, and severe pelvic pain Increased risk of rupture.
- Perihepatitis – Pleuritic RUQ pain, and right shoulder pain.
- Tubal factor infertility - caused by scarring and adhesions.
What is Cervical intraepithelial neoplasia (CIN)?
A pre-malignant condition referring to dysplastic change to the squamous epithelium of the ectocervix
What type of cells lines the ectocervix?
squamous epithelium.
What type of cells line the endocervix?
glandular epithelium (columnar)
What does Cervical intraepithelial neoplasia (CIN) stage 1 refer to?
A low-grade lesion - atypical cellular changes in the lower 1/3 of the epithelium
What does Cervical intraepithelial neoplasia (CIN) stage 2 refer to?
High-grade lesion - moderately atypical cellular changes confined to the basal 2/3rd of the epithelium (moderate dysplasia)
What does Cervical intraepithelial neoplasia (CIN) stage 3 refer to?
- CIN3 – Severe dysplasia – Carcinoma in situ – Atypical cell extend throughout the full thickness of the epithelium with minimal differentiation and maturation on the surface – Extending to upper 1/3 of epithelium Risk of stage Ia1 FIGO.
What are the four main dysplastic epithelial changes observed in CIN?
Dysplastic epithelial changes:
1. Increased nuclear to cytoplasmic ratio
2. Abnormal nuclear shape – poikilocytosis
3. Increased nuclear size, and nuclear density
4. Decreased cytoplasm.
Which HPV is carcinogenic for CIN?
HPV 16 and 18
When is the national vaccination for HPV adminstered?
For girls and boys aged 12-13 years old.
What HPV subtypes are vaccinated against?
HPV subtypes 6, 11, 16 and 18
When does cervical screening begin?
Age - 25 years
How frequent is cervical cancer screening for 25 to 49 year olds?
Every 3 years
How frequent is cervical cancer screening for 50-65 year olds?
Every 5 years
How frequent should you screen a patient for cervical cancer with a positive HPV/HIV status?
Every year
If there is an inadequate cervical smear, when should the next one be?
In 3 months
How many inadequate cervical smears warrants a colposcopy?
3
When should a cervical smear be conduced postpartum?
3 months post partum
For borderline/mild dyskaryosis on cervical smear, what is the next-step investigation?
HPV testing - followed by colposcopy if positive
For Moderate to severe dyskaryosis/CN II/III, what is the next step investigation?
Urgent colposcopy
What does dyskaryosis refer to?
Abnormal nuclei
What is the first line management for CIN I?
Repeat smear in 12 months
What is the first line surgical intervention for CIN?
Large loop excision of the transformation zone (LLETZ)
What is Large loop excision of the transformation zone (LLETZ)?
Removal of abnormal cells using a thin wire loop, heated by an electric current, under LA
What are the side effects associated with Large loop excision of the transformation zone (LLETZ)?
Cervical stenosis
Cervical incontinence
Pyometra
Smear follow-up difficulties
Bleeding for 3-5 days
No sex for 4 weeks
What obstetric risks are associated with Large loop excision of the transformation zone (LLETZ)?
Mid-trimester miscarriage
What is a cone biopsy?
Used less frequently and under a GA – Performed if a large area of tissue needs to be removed + Increased risk of preterm birth.
What obstetric risk is associated with a cone biopsy?
Preterm delivery
When should a follow-up test of cure be performed following an LLETZ?
6 months - with smear and HPV testing
If negative - routine recall
If positive - repeat colposcopy
If hysterectomy for CIN , what type of smear is performed at 6m and 18m?
Vault smear
Where does cervical cancer originate from (anatomy)?
Transformation zone
What are the risk factors for cervical cancer?
- Risk factors: HPV-related, oral contraceptive use, intrauterine device, cigarette smoking and low socioeconomic status.
Which HPV subtypes predispose patients to developing cervical cancer?
HPV types 16 and 18
What is the median age of diagnosis for cervical cancer?
50 years
What is the most common histological type of cervical cancer?
Squamous cell carcinoma (80%)
Adenocarcinoma (20%)
What is the clinical presentation of cervical cancer?
- Abnormal vaginal bleeding
- Postcoital bleeding
- Postmenopausal bleeding and not taking HRT.
o Increased in heaviness, duration of bleeding, or irregular bleeding if taking HRT. - Pelvic or back pain
- Dyspareunia
- Cervical mass/+bleeding on vaginal examination.
What is the first line step for a patient with suspected cervical cancer (cervical mass on examination)?
Urgent 2ww referral for colposcopy (all women with pm bleeding)
What urgent investigations are performed for cervical cancer?
Urgent colposcopy and MRI
What are the diagnostic changes observed in cervical cancer?
Abnormal vascularity
White change with acetic acid
Visible exophytic lesions
What change is observed with acetic acid in cervical cancer?
White change
What staging system is used to classify cervical cancer?
FIGO
What is FIGO stage I for cervical cancer?
Carcinoma is confined to the cervix
What is FIGO stage II for cervical cancer?
Carcinoma invades beyond the uterus, but NOT into the lower third vagina
What is FIGO stage III for cervical cancer?
Carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or para-aortic lymph nodes.
What is FIGO stage 4 for cervical cancer?
Carcinoma has extended beyond the true pelvis or biopsy-proven involvement of the mucosa of the bladder or rectum to distant organs.
What is the management for StageIA1 (micro invasive disease) cervical cancer?
Loop electrosurgical excision and conization.
If a woman does not want to preserve fertility, what is the management for cervical IA1?
Simple hysterectomy
What stage IA2-IB2 (early) disease, what is the first-line surgical approach (<4 cm)?
Radical hysterectomy (resection of the cervix, uterus, parametria, and cuff of upper vagina) AND bilateral salpingectomy (if fertility-sparing surgery is appropriate in low-risk disease)
Consider Wertheim’s for bilateral oophorectomy with bilateral pelvic lymphadenopathy
For stage IA2-IB2 tumours measuring >4 cm, what is the first-line management for cervical cancer?
Consider adjuvant chemotherapy or radiotherapy
For <4cm cervical tumours desiring fertility, what is the first line surgical management (Stage IA2-IB2)?
Radica trachelectomy
What are the surgical risks associated with radical trachelectomy?
o Bladder dysfunction (atony) -Common
o Sexual dysfunction
o Lymphoedema
May require intermittent self-catheterisation
What is the first-line management for IB3-IVA locally advanced disesae?
Chemoradiation - external beam radiotherapy
Intracavity radiotherapy
What is the preferred chemotherapy drug for cervical cancer?
Cisplatin
What are the risks associated with radiotherapy?
o Lethargy, fatigue
o Skin erythema
o Urgency
o Dyspareunia/vaginal stenosis
o Infertility
o Dysuria
o Diarrhoea/Malabsorption
o Incontinence.
Cystitis like symptoms
Malabsorption and mucous diarrrhoea
Radiotherapy induced menopause
What is type 1 endometrial cancer?
(SEM)
Secretory
Endometrioid
Mucinous carcinoma
What type of cancers is type 1 endometrial cancer?
Oestrogen-driven, affecting young patients and is low-grade
What are the two most common mutations implicated in endometrial cancer?
PTEN and P13KCA
What are the 2 main subtypes of type II endometrial cancer?
SC
Uterine papillary serous carcinoma
Clear cel carcinoma
What is the main mutation associated with serous carcinoma?
p53
What classification system is used for endometrial cancer?
FIGO
What is the most common histological subtype of endometrial cancer?
Adenocarcinoma
What is the peak incidence of endometrial cancer?
60-70 years
What is the main aetiology driving the development of endometrial cancer?
Long-term exposure to increased unopposed oestrogen
What are the risk factors of endometrial cancer?
Chronic anovulation
Obesity
Lynch Syndrome
Early menarche, late menopause
Tamoxifen
TD2M, PCOS
What are the protective factors of endometrial cancer?
Oestrogen-progestin or Progestin-only contraceptives (protective against oestrogen-driven carcinomas (Grades 1-2)).
Which clinical feature warrants further referral for suspected endometrial cancer?
Abnormal uterine bleeding
Post-menopausal bleeding warrants what?
2ww referral to gynaecologist
What are the clinical features of endometrial cancer?
- Abnormal uterine bleeding (75-90% of cases).
o Post-menopausal bleeding (Urgent 2w referral to gynaecologist)
o Intermenstrual bleeding (Frequent, heavy, or prolonged >7 days).
On examination (bimanual), what is observed in endometrial cancer?
Uterine mass, fixed uterus, or adnexal mass indicating extra-uterine disease – as detected by a bimanual examination.
* Associated with bulky uterus.
What is the first line investigation for suspected endometrial cancer?
Pelvic transvaginal ultrasound
What is normal endometrial thickness
<4 mm
What level of endometrial thickness is highly sensitive for endometrial cancer?
> 5 mm
What is the definitive diagnostic investigation for confirming endometrial cancer?
Outpatient hysteroscopy
with endometrial biopsy
What is the management for stage 1 endometrial cancer?
Total abdominal hysterectomy and bilateral salpingo-oophorectomy and peritoneal washings.
What is the surgical management for stage 2+ endometrial cancer?
- Radical hysterectomy (including cervix)
- Radiotherapy adjunct.
What hormonal therapy is available for young women desiring for conception with endometrial cancer?
High dose oral and intrauterine progestins (LNG-IUS)
What are the common sites of endometriosis?
Pelvis, on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas.
What is the definition of endometriosis?
Endometriosis is characterised by the growth of endometrium-like tissue outside the uterus.
What are the risk factors associated with endometriosis?
Early menarche, late menopause, delayed childbearing, nulliparity, FHx, white ethnicity, high BMI, vaginal outflow obstruction, smoking, and autoimmune disease (Oestrogen driven).
What are the protective factors of endometriosis?
Fruit/veg; multiparity, Omega 3, prolonged lactation/breastfeeding.
Which ovarian cancer is associated with endometriosis?
Clear cell ovarian carcinoma
What is Sampson’s theory?
Retrograde menstruation and implantation may be the cause.
What is the coleomic metaplasia of multipotent cells?
Endometriosis originates from the metaplasia of multipotent cells present in the mesothelial lining of the visceral and abdominal peritoneum.
What are the three types of endometriosis?
- Endometrioma (ovarian cysts)
- Superficial peritoneal lesions (located on the pelvic organ or peritoneum)
- Deep infiltrative endometriosis.
What is the clinical presentation of endometriosis?
- Chronic pelvic pain
o Minimum of 6 months of cyclical or continuous pain. - Period-related pain (dysmenorrhoea)
o Affecting daily activities and QoL. - Deep pain during or after sexual intercourse (dyspareunia) – due to adhesions present in fixed uterus.
- Period-related or cyclical gastrointestinal symptoms – painful bowel movements.
- Period-related or cyclical urinary symptoms – blood in urine or dysuria.
- Infertility
- Fatigue
- Associated with depression and anxiety.
N.B: No menorrhagia – differentiates this from fibroids.
On examination, what are the characteristic features associated with endometriosis?
Pelvic mass, reduced organ mobility, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions
A fixed retroverted uterus in endometriosis is suggestive of what?
Ectopic tissue on uterosacral ligament
What is the first-line investigation for suspected endometriosis?
TVUSS
What is the diagnostic investigation for endometriosis?
Laparoscopic visualisation of the pelvis.
Red vesicles or punctuate marks on the peritoneum in endometriosis is indicative of what?
Active lesions
What is the first line pain relief management for endometriosis?
Short trial of paracetamol or NSAIDs (3 months)
What adjunctive medication to pain killers can be prescribed as first-line non-hormonal medication in endometriosis?
Tranexamic acid
What is the first-line hormonal management for endometriosis?
Combined oral contraceptive pill, or progestogen (depot-provera or Mirena coil)
How long should hormonal treatment should be prescribed as a first line trial?
3 months
How does the COCP work in the management of endometriosis?
- COCP provides cycle control and contraception whilst alleviating symptoms of endometriosis.
- Continue until pregnancy required.
- Progesterone – used to induce amenorrhea in those where COCP is contraindicated
What is the preferred surgical intervention for mild endometriosis?
Laparoscopic ablation
What is the radical surgical option for endometriosis?
- Hysterectomy with BSO
For patients with endometriosis desiring conception, what is the surgical management?
Laparoscopic ablation + endometrioma cystectomy
What is the pre-operative management prescribed to patients undergoing surgery for endometriosis?
GnRH analogues (e.g., leuprorelin)
What side effects are associated with using GnRh analogues?
pseudo-menopause
Menopause-like side effects: hot flushes, night sweats
What co-existing conditions are associated with endometriosis?
IBS and constipation in up to 80%
What are the complications associated with endometriosis?
Subfertility
Recurrence
Adhesions
Ovarian failure post-operatively
Predisposition to autoimmune disease + mental health issues
Increased risk of miscarriage, ectopic pregnancy, and placenta praevia
Name the two layers of endometrial hyperplasia?
Functional - glands and stroma
Basal - regenerates the functional layer after each menstrual cycle
What are the risk factors of endometrial hyperplasia?
Prolonged exposure to oestrogen
In which phase during the menstrual cycle is associated with oestrogen stimulating growth of endometrial glands?
Proliferative phase
Which ratio is raised in endometrial hyperplasia?
High gland: stroma ratio
What are the risk factors for endometrial hyperplasia?
Obesity
Granulosa cel tumours
PCOS
Early menarche
Late menopause
Nulliparity
Drugs - oestrogen-only hormone replacement therapy , tamoxifen
Mutations - PTEN, lynch syndrome and HNPCC
Why does obesity cause endometrial hyperplasia?
Adipose tissue converts androgens to oestrogen
Why do granulosa-cell tumours increase the risk of endometrial hyperplasia?
Oestrogen secreting tumours
Why do cystic follicles increase the risk of endometrial hyperplasia?
Secretes oestrogen
Chronic anovulation and no progesterone-secreting luteal bodies
Which breast cancer drug increases the risk of endometrial hyperplasia (and why?)
Tamoxifen
- Blocks oestrogen receptors + stimulates oestrogen receptors.
What is the presentation of endometrial hyperplasia?
- Menorrhagia – heavy or prolonged menstrual bleeding
- Metrorrhagia
- Amenorrhea
What is the first line of investigation for suspected endometrial hyperplasia?
Transvaginal ultrasound
What is the threshold for prompting 2nd line investigations for endometrial hyperplasia?
> 4 mm
What is the gold-standard investigation for endometrial hyperplasia?
Outpatient hysteroscopy with a pipelle biopsy
What is simple endometrial hyperplasia?
Normal stroma : gland ratio
What is complex hyperplasia?
Increased gland : stroma ratio (large and hyperchromatic nucleus)
Associated with nuclear atypia
What is the risk of developing endometrial cancer in patients with hyperplasia with nuclear atypia?
30%
What is the management for EH without atypia (simple)?
Reversal of risk factors:
1. Weight loss
2. Correcting PCOS
3. Progesterone medications
4. Hysterectomy – surgical removal of uterus
Endometrial surveillance every week 6 monthseverse risk factors.
Treatment option: Oral progesterone
How frequent should endometrial surveillance be in a patient with EH without atypia?
Every 6 months
2 negative biopsies - discharge
What is the first line medical management for EH without atypia?
Oral progesterone - continuous
What is the fertility non-sparing treatment option for EH with atypia?
Total hysterectomy + BSO if post-menopausal
What is the fertility-sparing treatment option for EH with atypia?
2nd line: Oral progestogens, routine surveillance with biopsies
How many consecutive negative biopsies are required for discharge in a patient with EH?
2
Define a uterine fibroid
A benign smooth muscle tumour of the uterus - leiomyoma - monoclonal proliferation of smooth muscle cells and fibroblasts
What are the risk factors associated with fibroids?
- Afro-Caribbean Ethnicity – affects females during pregnancy and pre-menopausal women (oestrogen exposure).
- Nulliparity
- Breastfeeding
- Late menopause and early menarche
-Hypertension - Hereditary leiomyomatosis and renal papillary cell carcinoma syndrome (Reed’s Syndrome)
- Oestrogen and progesterone – Fibroids upregulate ER receptors and produce aromatase activity– mitogenic effect.
o Oestrogen – IGF-1, EGFR, TGF-B1
o Progesterone – EGF, TGF-B1/3
What are the protective factors associated with uterine fibroids?
Smoking
Multiparity
COCP
What are the four types of fibroids?
Subserosal
Intramural
Submucosal fibroid
Pedunculated fibroids
Where do subserosal fibroids develop?
Develop in the wall of the uterus.
Where do intramural fibroids develop?
From myometrial cells at the perimetrium | can detach from uterus.
Where do submucosal fibroids develop?
From myometrial cells below the endometrium.
What are pedunculated fibroids?
Can grow into the cavity of the uterus.
What is red-generation in regards to fibroids?
Coagulative necrosis in pregnancy , cystic change
What is the presentation of fibroids?
- Abnormal uterine bleeding – iron deficiency anaemia
o Heavy menstrual bleeding - Abdominal pain – pressure on pelvic organs.
o Pelvic pain, pressure, discomfort, abdominal discomfort, bloating, back pain - Bowel and bladder compressive symptoms
o Urinary symptoms – frequency, urgency, urinary incontinence, or retention, UTIs.
o Bowel symptoms – Bloating, constipation, and/or painful defecation. - Infertility and increased risk of miscarriage.
o Associated with submucosal and intramural fibroids. - Pregnancy – Foetal malpresentation, preterm labour and postpartum haemorrhage.
On bimanual examination, what are the positive findings associated with fibroids?
Firm, enlarged, and irregularly shaped non-tender uterus
What is the first line investigation for fibroids?
Transvaginal ultrasound - to assess size and location
What are the differential diagnoses for fibroids?
Ovarian cancer, endometrial cancer (not associated with pelvic mass), endometrial polyps, adenomyosis, endometriosis, ectopic pregnancy or urinary retention.
For fibroids <3 cm in size, what is the first line management?
IUS - Mirena coil
For fibroids >3 cm, what is the first-line medical management?
1 - Hormonal - COCP or cyclical oral progestogens
OR
1 - (Non-contraceptive - fertility required)
- Transexamic acid and mefenamic aicid
What medication is used to manage pain associated with fibroids?
Mefenamic acid / NSADIs
Mefenamic is contraindicated in what disorder?
IBD
What class of drug is Transexamic acid ?
Antifibrinolytic - 1 TDS
Transexamic acid is contraindicated in what?
Renal impairment, thrombotic disease
What is the non-fertility-sparing definitive surgical option for fibroid treatment?
Hysterectomy
If surgery is not tolerated or unsuitable, what alternative approach is indicated for the management of fibroids?
Uterine artery embolisation
How does uterine artery embolisation work?
Catheter reduces blood flow to fibroids – atrophy.
What class of drug is ulipristal?
Selective progesterone receptor modulator
What medication is prescribed pre-operatively to shrink fibroids?
GnRH analogues
What are the side effects associated with the use of GnRH analogues?
Chemical menopause - Hot flushes, sweating, vaginal dryness, osteoporosis
What are the four criteria indicating specialist referral in fibroids?
- An uncertain diagnosis
- Severe heavy menstrual bleeding or compressive symptoms
- Confirmed fibroids measuring >3 cm or suspected submucosal fibroids.
- Suspected fertility or obstetric issues.
Describe the pathophysiology of cervical ectropion
Migration of endocervix columnar cells from the transformation zone to the ectocervix
What type of cells line the endocervix?
Columnar cells
What histopathological change occurs in cervical ectropion?
Metaplastic change of squamous to columnar cells
What are the symptoms of cervical ectropion?
Intermenstrual bleeding, post-coital bleeding, and increased discharge (most common identifiable cause of post-coital bleeding).
What are the risk factors associated with cervical ectropion?
Linked to oestrogen - pregnancy and COCP
What is the management of cervical ectropion?
Reassurance, cauterisation, cryotherapy.
Definition of cervical polyps
Overgrowth of endocervical columnar epithelium - benig and solitary
What is the diagnostic investigation for endometrial polyps?
1st line = TVUSS
Gold-standard - outpatient hysteroscopy and saline - infusion sonography
What is the surgical management for symptomatic endometrial polyps?
Polypectomy
What is the latin name of anogenital warts?
Condylomata acuminate
What is the common site of anogenital warts?
Vaginal introitus
What HPV subtypes are indicated in the development of anogenital warts?
HPV subtypes 6 and 11
What are the high risk HVP subtypes?
16 and 18
What is the presentation of genital warts?
- Pain
- Arises if the lesions become friable or are irritated due to local trauma.
- Urinary symptoms – Terminal haematuria or abnormal stream of urine – can indicate lesions in the distal urethra and meatus.
- Bleeding – Due to local trauma (e.g., underwear).
- Warts – Pedunculated/or pigmented.
o Appearance – Cauliflower growths of varying size, small popular, keratotic, flat papules/plaques.
Flesh-coloured, whitish, hyperpigmented, or erythematous.
<10 mm in diameter – can coalesce in large plaques.
What is the characteristic appearance of genital warts?
Cauliflower growths
What is the management for genital warts?
Referral to sexual health specialist
What is the first line management for genital warts (non-keratainised)?
Topical podophyllotoxin
What is the first line of management for keratinisied external genital and perianal warts?
Imiquimod
What is the surgical management for keratinisied genital warts?
Ablative methods (cryotherapy, excisions, and electrocautery)
What is type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
What is type II FGM?
Partial or total removal of the clitoris and the labia minora (with or without excision of the labia majora)
What is type III FGM?
Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora with or without the clitoris (Infibulation).
What is type IV FGM?
Type IV: Other harmful procedures – pricking, piercing, incising, scraping and cauterisation.
What clinical features are associated with FGM?
Presentation:
* Constant pain,
* Dyspareunia
* Bleeding, cysts, abscesses
* Incontinence
* Depression, flashbacks, self-harm.
What is the management for FGM?
Deinfibulation
* Offered to those unable to have sex, pass urine or pregnant women at risk during delivery.
* Analgesia to avoid flashbacks.
What is the management for a patient <18 years presenting with FGM?
Report to the police and social services
What is the management for a patient >18 years presenting with FGM?
No obligatory duty to report Offer Deinfibulation.
What are the complications associated with FGM?
Repeated infections Infertility, life threatening complications during labour, childbirth.
What is the diagnosis of the following presentation :
Distressing emotional and physical symptoms during the luteal phase of the menstrual cycle (in the absence of disease).
* Only occurs in the presence of ovulatory menstrual cycles – not prior to puberty, during pregnancy or menopause.
Premenstrual Syndrome
What are the clinical features associated with PMS?
- Mood swings
- Anergia
- Breast tenderness
- Anxiety
- Changes in appetite
- Headache
- Disturbed sleep
- Poor concentration
- Bloating
What is the first line investigation for suspected PMS?
Symptom diary - minimum over 2 cycles
What is the first line management for moderate PMS?
COCP - yasmin - paracetamol or NSAIDs
consider CBT
What is severe PMS?
Premenstrual dysphoric disorder (Withdrawal from activities, prevent normal functioning)
What is the first line management for severe PMS?
Sertraline
What are the three classifications of ovarian tumours?
- Epithelial surface derived tumours
- Germ cell tumours
- Sex-cord stromal tissues
What are the risk factors associated with ovarian tumours?
Increased ovulation - nulliparity, early menarche, and late menopause
Which genes are implicated in increasing the risk of ovarian tumours?
BRCA1/2, MSH2, MLH1
What genetic syndrome is associated with increasing ovarian tumour development?
Lynch Syndrome
Which mutations are associated with Lynch syndrome?
MSH2 and MLH1
Which type of ovarian tumour is the most common?
Epithelial
Which type of ovarian tumour is most common in postmenopausal women?
Epithelial ovarian tumour
What are the most common epithelial tumours?
Serous cystadenoma
Mucinous cystadenoma
What are malignant serous epithelial ovarian tumours associated with on histology?
Psammoma body
Definition of Psammoma body?
Plaques with calcium and cellular deposits
What are mucinous cystadenomas?
Associated with mucous filled cysts (ovarian epithelial tumour)
What complication are malignant mucinous epithelial ovarian tumours associated with?
pseudomyxoma peritonei.
What is pseudomyxoma peritonei?
Mucinous material collecting within the peritoneal cavity
Name the four types of epithelial ovarian tumours?
- Serous cystadenoma
- Mucinous cystadenoma
- Endometrioid
- Transitional cell
Name the characteristic cysts associated with endometrioid tumours?
Chocolate cysts
What are Brenner tumours?
Transitional ovarian tumours - coffee bean nuclei
What histological finding (nuclei) is found in Brenner tumours?
Coffee Bean Nuclei
What is the presentation of ovarian tumours?
- Abdominal distension
- Bloating
- Abdominal/pelvic pain
- Ascites
- Abdominal mass
- Bowel obstruction
- Dyspareunia
- Sister-Mary Joseph Nodule – Metastasise to the umbilicus.
What are the common benign ovarian tumours associated in women <30 years of age?
Teratoma
What are common types of germ cell ovarian tumours?
Teratoma (dermoid cyst)
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
Which type of ovarian tumour is associated with thyroid tissue?
Struma-Ovarri Tumour - causes hyperthyroidism
(Associated with mature cystic teratoma)
What is the most common germ cell tumour associated in children?
Yolk Sac tumour
What types of bodies are associated with yolk ovarian tumours?
Schiller–Duval Bodies
What are Schiller–Duval Bodies?
Rings of cells around a central blood vessel.
What cell do choriocarcinoma derive from?
Syncytiotrophoblast cells
What do choriocarcinoma secrete?
Beta-hcg
Which type of germ-cell ovarian cancer is most malignant?
Dysgerminoma
what are the four common sex-cord stromal ovarian cancers?
- Fibroma - no endocrine function
- Thecoma - Oestrogen
- Granulosa cell tumour - Oestrogen
- Sertoli-Leydig cell tumour - androgens variable
Which cell does LH stimulate?
Theca cells
What do theca cells produce?
Androgens
What effect does FSH have?
Oestradiol production via stimulating aromatase activity
Call-Exner bodies are associated with which type of Sex-cord stromal ovarian cancer?
Granulosa-theca cell cancer
What are the hallmark features associated with granulosa-theca cell cancer?
Granulosa-theca cell – Most common malignant stromal tumour
* Oestradiol overproduction
o Uterine bleeding
o Breast tenderness
o Early puberty
Fluid pockets -Call-Exner bodies
What is Meigs syndrome?
Tumour causing transudative fluid accumulation - pleural effusion and ascites.
What histological finding is associated with Sertoli-Leydig cells?
Reinke Crystals - Pink crystals
What first-line tumour marker should be performed in a patient with suspected ovarian cancer?
Serum CA-125
What is the diagnostic threshold for serum CA-125 in ovarian cancer?
> 35 IU/L
What is the next-step investigation following a raised CA-125 in suspected ovarian cancer?
Refer to 2WW for ovarian cancer - urgent TVUSS and pelvic/abdominal US scan
What factors can cause an falsely raised CA-125?
Pregnancy, endometriosis, and alcoholic liver disease, heart failure
Which risk index is used to determine the risk associated with ovarian tumours?
Risk of Malignancy Index (RMI)
What are the three parameters included in the RMI?
- Menopausal status
- USS features – Ultrasound abdomen and pelvis
- CA125
A threshold RMI score of what is considered high-risk for ovarian cancer?
> 250 IU/L
What type of neoadjuvant chemotherapy is administered in ovarian cancer?
Platinum-based compounds with paciltaxel
What are the common platinum-based chemotherapy compounds implicated in the management of ovarian cancer?
Carboplatin
What are the three chemotherapy and immunotherapy agents indicated in the management of ovarian cancer?
Carboplatin
Paciltaxel
Bevacizumab
What is the mechanism of action of carboplatin in the management of ovarian cancer?
Cross-linkage of DNA leading to cell cycle arrest
How does Paclitaxel work in the management of ovarian cancer?
Microtubular damage resulting in cell division inhibition
What are the side effects associated with the use of Paclitaxel in ovarian cancer?
Loss of body hair
What medication is given to reduce hypersensitivity reactions and side effects associated with Paclitaxel?
Steroids
What is the definitive surgical approach for ovarian cancer?
Laparotomy (TAH + BSO omentectomy + extra debulking)
Define ovarian torsion:
Ovarian torsion – refers to complete or partial rotation of the ovary on its ligamentous supports Common gynaecological emergencies.
Which ligament suspends the ovary?
Suspensory ligament
Which ovarian ligaments are implicated in the pathogenesis of ovarian tumours (name 2)?
Utero-ovarian ligament
infundibulopelvic ligament
Which ovary (right or left) is most likely affected by ovarian torsion?
Right due to longer utero-ovarian ligament
What is adnexal torsion?
Fallopian tube + ovarian twisting
What are the risk factors for ovarian torsion?
Ovarian cysts, tumours
Long ovarian ligaments
Pregnancy
Tubal ligation
What is the presentation/clinical features of ovarian torsion?
- Pelvic pain (acute onset)
o Diffuse and localised/ipsilateral
o Colicky, stabbing and cramping (1–3-day history). - Abdominal tenderness (right illiac fossa)
- Nausea + vomiting
- Ovarian mass
- Fever
What first-line investigation should be performed in a patient presenting with features of ovarian torsion?
Urine hCG test to exclude for pregnancy
What is the first line diagnostic investigation for a patient with suspected ovarian torsion?
Ultrasound with Doppler
What sign is demonstrated by an ultrasound with Doppler in ovarian torsion?
Whirlpool sign
What is the diagnostic test for confirming ovarian torsion?
Diagnostic laparoscopy + perform detorsion
What is the therapeutic management to alleviate ovarian torsion?
laparoscopic detorsion
What is the management of ovarian torsion with a viable adnexa without pathology?
- Oophoropexy – fix the ovary to the pelvic sidewall or round ligament (Limit range of motion).
a. Indicated: Contralateral ovary is absent or repeated torsion.
Management of ovarian torsion for a viable adnexa with pathology?
Perform a cystectomy if ovarian torsion is a result of a simple or dermoid cyst
Perform oophorectomy in postmenopausal women
Perform salpingectomy if the fallopian tube is adherent to the ovary or the patient has completed childbearing.
What is the surgical management indicated for a patient with a non-viable adnexa in ovarian torsion?
- Oophorectomy or salpingectomy
What are the four types of urinary incontinence?
- Stress
- Urge
- Mixed
- Overflow
What is stress incontinence?
Leakage on effort or exertion e.g., sneezing or coughing.
What is urgency incontinence?
a. Involuntary leakage accompanied by a sudden desire to pass urine which is difficult to defer – Part of overactive bladder syndrome.
What is an overactive bladder?
Urinary urgency associated with increased frequency + nocturia.
c. Associated with involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle – OVERACTIVITY.
What is mixed urinary incontinence?
a. Both stress and urgency incontinence – involuntary leakage is associated with both urgency and physical stress (exertion, effort, sneezing, or coughing).
What are the causes of urgency urinary incontinence?
Idiopathic | Parkinson’s disease, MS or pelvic injury.
What is overflow urinary incontinence?
a. Detrusor underactivity or bladder outlet obstruction - Urine leakage.
What medications are associated with causing overflow urinary incontinence?
ACEi, antidepressants, antihistamines, antimuscarinic, AP, beta-adrenergic agonists, opioids, sedatives.
What are the risk factors associated with urinary incontinence?
- Older age (50-70 years)
- Obesity – Pressure on pelvic tissue and stretching/weakening of muscles and nerves.
- Constipation – weaken pelvic floor muscles.
- Pregnancy and vaginal delivery – Weakened pelvic floor muscles and connective tissue + damage to pudenal and pelvic nerve.
- Deficiency in supporting tissue – Hysterectomy, prolapse, lack of oestrogen at the menopause (oestrogen maintains urethral seal).
- FHx, smoking (chronic cough), drugs (ACEi)
What is the first line set of investigations indicated in a patient presenting with urinary incontinence?
- Urine dipstick to exclude UTI + DM
- Bladder diary (min 3 days)
- Speculum examination to exclude pelvic organ prolapse
What is the minimum time period for a bladder diary?
3 days
What testing is indicated in a patient presenting with mixed urinary incontinence?
Urodynamic studies (assessment of 3 pressures)
Which type of exercises is used to assess the contraction of the pelvic floor?
Kegel exercise
During the pelvic examination what manoeuvre should be performed to assess for fluid eakage?
Ask patient to cough (Valsalva) during exam to check for fluid leakage.
What grading system is used to assess for urinary incontinence?
Oxford Grading System
What postpartum complication is associated with incontinence?
Vesicovaginal fistula
What is the first line management indicated for stress urinary incontinence?
3-month trial of supervised pelvic floor muscle training
What lifestyle advice is provided to patients with stress urinary incontinence?
Lifestyle advice on: Caffeine intake, fluid intake, weight loss (<30 BMI), smoking cessation.
What is the second line management for stress urinary incontinence (medical)?
Duloxetine
What is the first line management for urgency incontinence?
Bladder training for 6 weeks
What is the second line of management following bladder training for urgency incontinence?
Oxybutynin
What class of drug is oxybutynin?
Antimuscarinic
What are the adverse effects associated with oxybutynin ?
Dry mouth and constipation
What is the referral criteria for patients presenting with overflow urinary incontinence?
- Aged >45 years AND
- Unexplained visible haematuria without UTI.
- Or >60 with unexplained non-visible haematuria + dysuria + raised WCC.
What is the definition of menorrhagia (mL)?
> 80 mL of blood and duration of more than 7 days
What are the common causes of Menorrhagia ?
o Uterine fibroids, endometrial polyps
o Ovarian, cervical, or endometrial cancer.
o Endometriosis and adenomyosis.
o PCOS
o Pelvic inflammatory disease
o Systemic disorders: Coagulation disorder, hypothyroidism, T2DM, hyperprolactinaemia.
What is the first line blood test indicated for investigating Menorrhagia ?
FBC - assess for IDA
+ Pregnancy test
Test for coagulation disorders
What IX (imaging) for Menorrhagia ?
TVUSS
What are the two cancer referral criteria for Menorrhagia ?
Pelvic mass + unexplained bleeding or weight loss
Women aged >55 years with postmenopausal bleeding
What is the first line management for Menorrhagia (with no identified pathology, + fibroids <3 cm)?
Levonorgestrel intrauterine system (LNG-IUS)
What is the non-hormonal management for menorrhagia?
Tranexamic acid 1g TDS or NSAID | Mefenamic acid 500 mg TDS.
What are the three lines of hormonal management options for menorrhagia?
1st line - IUS
2nd line: COCP
3rd line - Long-acting progestogens e.g., depo-provera
Which emergency contraception is administered within the first 72 hours of UPSI?
Levonorgestrel
Mechanism of action for Levonorgestrel?
Inhibits ovulation and implantation
What singe dose is prescribed for Levonorgestrel as emergency contraception?
1.5 mg
What dose is prescribed for Levonorgestrel indicated for UPSI (BMI >26)?
Double dose
When can Ulipristal be prescribed?
Within 5 days (120 hours) of unprotected sexual intercourse
What is the mechanism of action for Ulipristal ?
Selective progesterone receptor modulator (EllaOne) - inhibits ovulation
What dose of Ulipristal is prescribed as emergency contraception?
30 mg oral dose
What is the contraindication for Ulipristal as emeregency contraception?
Asthma
What is the preferred emergency contraception?
Intrauterine Device - copper coil
When must the IUD be inserted to be an effective mode of emergency contraception?
Within 5 days or up to day 19.
When must a pregnancy test be performed following emergency contraception?
3 weeks after UPSI
What is the mode of action of the Copper IUD as emergency contraception?
Prevents implantation of fertilized ovum, toxic to sperm and eggs.
What is the most common type of vulval cancer?
Squamous cell carcinomas
What are the risk factors for vulval cancer?
o Advanced age (>75 years)
o Immunosuppression
o HPV infection (Type 16)
o Lichen sclerosus.
~5% with lichen sclerosus develop vulval cancer.
What is the premalignant condition prior to the development of vulval cancer?
Vulval Intraepithelial Neoplasia
A high-grade squamous intra-epithelial lesion (VIN) is associated with what?
HPV infection
What is the diagnostic investigation to confirm Vulval Intraepithelial Neoplasia?
Biopsy (+ sentinel node biopsy)
What is the management for VIN?
Watch-and-wait; wide local excision, imiquimod cream, laser ablation
Which anatomical site is commonly affected by vulval cancer?
Labia majora
For suspected vulval cancer, what is the confirmatory diganostic test?
Biopsy + sentinel lymph node biopsy
CT
What is the first line surgical management for vulval cancer?
Vulvectomy + bilateral inguinal lymphadenopathy
For stage 1a vulval cancer what is the surgical management?
Wide local excision
What is the surgical management for stage >1a vulval cancer?
Radical vulvectomy
What is the definition of adenomyosis?
The presence of endometrial tissue inside the myometrium - more common in later reproductive years
What is the presentation of Adenomyosis?
- Dysmenorrhoea (Painful periods)
- Menorrhagia
- Dyspareunia
What are the examination findings for adenomyosis?
An enlarged, boggy and tender uterus
What is the first line of investigation for suspected adenomyosis?
Transvaginal ultrasound
On ultrasound what distinct appearance is demonstrated?
‘Venetian blind appearance’* Heterogenous myometrium:
o Streaky shadowing
o Asymmetric myometrial thickness
o Myometrial cysts
What is the gold-standard investigation for confirming adenomyosis?
Outpatient hysteroscopy with histological examination (biopsy)
What is the first line of medical management for a patient with adenomyosis?
Tranexamic acid - reduce bleeding
Mefenamic acid - reduce pain
For when contraception is desired, what is the first line medical management for adenomyosis?
Mirena coil
COCP
Cyclical oral progestogens
What is the definitive management for adenomyosis?
- Hysterectomy - causes infertility
What is the fertility-sparing surgical management for adenomyosis?
Uterine artery embolisation
What is the time period for infertility to be defined as, in a woman <35 years of age?
12 months of unsusccesful conception despite active sexual intercourse
What is the most common cause of infertility in a woman?
Ovulation and tubal problems - 40%
Idiopathic - 20 %
Uterine problems - 10 %
(Male factor infertility (sperm motility) - 30%)
What is the lifestyle advice indicated for a patient presenting with infertility?
- Folate supplementation – 400 mcg Daily
- Healthy BMI
- Smoking cessation and alcohol discontinuation
- Reduce stress.
- Regular intercourse 2-3 days (avoid timing intercourse).
Why is timed intercourse not recommended in the management for infertility?
Timed intercourse – coincide with ovulation – can lead to stress and pressure.
What does a raised FSH indicate in a patient presenting with infertility?
Poor ovarian reserve - consider AMH
Which is an accurate marker of ovarian reserve and is released by granulosa cells?
Anti-Mullerian Hormone
Which is the recommended investigation performed in a patient presenting with infertility?
Serum progesterone on day 21 (7 days before the end of the cycle)
A raised LH in a female presenting with infertility suggests what diagnosis?
Polycystic ovarian syndrome
What are the two outpatient diagnostic investigations for a patient with infertility?
- Hysterosalpingogram
. * Laparoscopy and Dye Test
How does a Hysterosalpingogram work in the diagnosis of infertility?
Patency of the fallopian tubes
o Tubal cannulation under X-ray guidance – to increase tubal patency (Contrast guided).
Reveals tubal obstruction if there is discontinuous dye flow.
What dye is used in a
Laparoscopy and Dye Test?
Methylene blue - injected into the uterus to assess for tubal obstruction
Which anti-oestrogen drug is prescribed to support fertility?
o Clomifine
What drug class is prescribed to stimulate ovulation in clomifene-resistant patients?
Gonadotrophins
Define Asherman’s syndrome
Asherman syndrome is characterised as intrauterine adhesions/synechiae occurring when scar tissue forms inside the uterus/cervix.
Which surgical procedure is implicated in perpetuating Asherman’s syndrome?
Dilation and curettage for ToP or incomplete miscarriage or for retained products of conception
What are the three main aetiological causes for Asherman’s?
- Post-operative (Dilation and curettage).
- Pelvic infection (Endometritis)
- Myomectomy
What is the presentation of Asherman’s Syndrome?
- Secondary amenorrhoea (Menstrual flow is obstructed due to adhesions near or within the cervix)
- Significantly lighter periods
- Dysmenorrhoea
What is the gold-standard investigation for Asherman’s syndrome?
Hysteroscopy
What is the management Asherman’s syndrome?
Hysteroscopy - Dissection of the adhesions
What are the complications associated with Asherman’s syndrome?
- Repetitive pregnancy loss/abortions.
- Infertility
- Abnormal placentation
What is the common position of a Bartholin’s cyst (Clock face)?
4 and 8 o clock
What is a Bartholin’s gland?
Bartholin’s glands reside on either side of the posterior part of the vaginal introitus – pea-sized and non-palpable.
* Produce mucous and support vaginal lubrication.
Definition of a Bartholin’s cyst?
Unilateral, asymptomatic blockage of the Bartholin gland (2-4 cm in diameter); filled with non-purulent fluid that contains staphylococcus, streptococcus, and E. coli.
What are the risk factors for Bartholin’s cyst?
- Nulliparous
- Previous Bartholin’s cyst
- Sexually active (STIs)
What is the presentation of Bartholin’s Cyst?
- Tenderness with activities – waking, sitting, standing or sexual intercourse.
- Vaginal bleeding/discharge or STIs
- Unilateral labial swelling is often asymptomatic/painless.
- Infected – Abscess with cardinal signs of infection, fever, dyspareunia.
What are the three symptoms associated with a Bartholin’s abscess?
Hot
Tender
Purulent
What is the conservative approach for a Bartholin’s cyst?
Good hygiene, analgesia and warm compress
Spontaneous drainage - Sitz baths and analgesia
What is the definitive management for a Bartholin’s cyst?
Words Catheter
What is the management for a Bartholin’s abscess?
Incision and drainage
Marsupialisation
What is the characteristic appearance of lichen sclerosus?
Patches of shiny ‘porcelain-white’ skin affecting the labia, perineum and perianal area.
What are the autoimmune risk factors for lichen sclerosus?
T1DM, alopecia, hypothyroid, and vitiligo
What is the presentation of lichen slcerosus?
- 45-60 years complaining of vulval itching and skin changes.
- Itching
- Soreness
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
- Dysuria
What is the Koebner phenomenon in Lichen Sclerosus?
Refers to when symptoms are worsened by friction to the skin.
What is the topical management for lichen sclerosus?
High potency steroids (Clobetasol propionate) for 3 months
What is the 2nd line management for lichen sclerosus?
Topical calcineurin inhibitors and imiquimod
What is the complication associated with lichen sclerosus?
Vulval squamous cell carcinoma
What is an imperforate hymen?
- An imperforate hymen = does not spontaneously rupture during neonatal development (presents with obstructive symptoms of the female genital and urinary tract).
The Wolffian duct forms what?
Vas deferens in men
What is the presentation of an imperforate hymen?
Patients remain asymptomatic until menarche.
* Cyclic abdominal pain – menstrual blood that expands the vaginal canal and uterus with resultant hematometra.
- Cramping pain
* Amenorrhoea
On examination what feature is observed in an imperforate hymen?
Haematocolpos
What is a Haematocolpos ?
Haematocolpos – accumulation of menstrual blood in the vaginal or uterine cavities Pelvic mass identified on physical exam (blue, bulging perineal mass).
What is the definitive management for an imperforate hymen?
- Hymenectomy using cruciate or annular incisions.
- Hymenectomy using electrocautery.
- Carbon dioxide laser treatment
What is the main complication associated with an uncorrected imperforate hymen?
Endometriosis as a result of retrograde menstruation
What are the two types of physiological ovarian cysts?
Follicular
Luteal
What is the most common type of ovarian cyst in postmenopausal women?
Graafian follicle cyst
What is a follicular cyst?
Failure to rupture during ovulation - follicular cysts form due to inadequate LH surge or excessive FSH simulation
Which cells line follicular cysts?
Granulosa cells
How long do corpus luteal cysts last?
14 days
What hormone do corpus luteal cysts secrete?
Progesterone
When do corpus luteal cysts typically occur?
In the first trimester of pregnancy
Corpus luteal cysts are lined by what type of cells?
Luteal cells
Which type of cyst is formed as a result of overstimulation in elevated Hcg levels?
Theca luteal cysts
What are the complications associated with follicular and corpus luteal cysts?
Transformation into a haemorrhagic cyst
What complication is associated with mucinous cystadenoma cysts?
Pseudomyxoma peritonei
Struma ovarri tumours are associated with which type of cyst?
Dermoid cysts - mature cystic teratomas
What term describes multiple white shiny masses that protrude out of dermoid cysts?
Rokitansky protuberances
What is the presentation of an ovarian cyst rupture?
Lower abdominal pain - sudden acute - nausea + vomiting
What is the first line investigation for a patient presenting with a neoplastic ovarian cyst?
Serum CA-125 to exclude for malignancy
Beta-hCG to exclude for pregnancy
What is the management for an asymptomatic <10 mm ovarian cyst?
Serial monitoring with TVUSS - spontaneous resolution
What are the indications for surgical cyst removal?
Ovarian torson
Adnexal mass
Acute abdominal pain
Suspected malignancy i
What is a cystocele?
Bladder prolapse – herniation and descent of the bladder through the anterior wall of the vagina.
What risk factors are associated with cystocele?
- Risk factors:
- Obesity – BMI >25
- Increasing age
- Parity
- Increased intra-abdominal pressure.
- Pelvic surgery
- Instrumental, prolonged or traumatic delivery
- Chronic respiratory disease-causing coughing
- Chronic constipation causing straining
What is the presentation of a cystocele?
- Vaginal pressure – bulging sensation
- Urinary symptoms
- Stress incontinence, frequency, and urgency associated with an overactive bladder.
- Sexual dysfunction
- Dyspareunia
- Urinary incontinence during intercourse, obstruction, and dryness.
What questionnaire is used to assess for pelvic prolapse related symptoms?
Pelvic floor impact questionnaire (PFIQ)
What position is recommended for examining cystocele?
dorsal lithotomy position and diagnosed using the POPQ
What staging scale is used to assess for cystocele?
POPQ
