O+g For GUM Flashcards
What is Mayer-Rokitansky-Kuster-Hauser syndrome
Müllerian agenesis - absent / rudimentary uterus + upper vagina.
Primary amenorrhea after normal pubertal development.
What age defines precocious puberty
Before 8 in F
Before 9 in M
2 categories of precocious puberty
Central (gonadotropin dependent - 75% cause unknown.)
Peripheral (always pathological)
Causes of central precocious puberty
75% unknown
25% due to CNS malformation or brain tumour
Causes of peripheral precocious puberty
Always pathological
Oestrogen secretion - e.g. Hormone producing tumour, exogenous ingestion
Age definition of delayed puberty
No secondary sexual characteristics
by age 13 In girls
14 in boys
Due to - hypogonadotrophic hypogonadism
- hypergonadotrophic hypogonadism
What causes hypogonadotrophic hypogonadism
Constitutional Anorexia nervosa Excessive exercise Diabetes Renal failure (Pituitary tumour, kalman's syndrome) - rare
What causes hypergonadotrophic hypogonadism
Turner syndrome
XX gonadal dysgenesis
Premature ovarian failure
Following chemo or radio therapy for child cancers.
What does gonadotropin releasing hormone do
Controls pituitary hormone secretion
GnRH secreted in a pulsatile way to stimulate LH and FSH
GnRH at constant high dose reduces LH and FSH secretion.
What is the effect of oestrogen on LH
Low oestrogen inhibits LH production.
High oestrogen increases LH production.
Effect of progesterone on LH and FSH
Low progesterone levels increase LH and FSH productions.
High progesterone levels decrease LH and FSH productions.
Causes of heavy menstrual bleeding
Fibroids Endometrial polyps Coagulation disorders PID thyroid disease Drug tx - warfarin Copper coil Endometrial ca Cervical ca
Management of heavy menstrual bleeding
Mefenamic acid (NSAID) Tranexamic acid Mirena coil COCP Norethisterone - taken from day 6 to 26 GnRH agonists - short term Endometrial ablation Hysterectomy
Causes of dysmenorrhea
Idiopathic Endometriosis Adenomyosis PID Cervical stenosis Haematometra
Diagnosis of endometriosis
laparoscopy - gold standard
often clinically suspected and managed without laparoscopic confirmation
Management options for endometriosis
COCP - continuous is best
IUS - Mirena / Levosert
Surgical laser ablation, diathermy or excision
Complication of endometriosis
Pain - dysmenorrhoea / dyaparunia
Adhesions
‘Chocolate’ ovarian cysts = endometriomas
possible increased risk of Infertility
What is adenomyosis
Ectopic endometrial tissue within myometrium
Management of dysmenorrhea
NSAIDS - ibruprofen, mefenamic acid COCP IUS - Mirena / Levosert Exercise Heat packs GnRH anaologues - short term only ?Low fat diet nay help
Causes of dyspareunia
PID Endometriosis Ovarian cysts STIs - CT most common cause Vaginal atrophy / lack of lubrication UTIs Thrush / vulvovaginitis / genital skin conditions / HSV (superficial dyspareunia)
Define primary amenorrhea
Failure to menstruate by age 16
Define secondary amenorrhea
Absence of menstruation for >6m that isn’t due to pregnancy, lactation or menopause
Causes of secondary amenorrhea
Obesity BMI <18.5 Excessive exercise Severe anxiety Pituitary tumour Chemotherapy Antipsychotic drugs Thyroid overactivity PCOS POI Ashermans syndrome
Causes of primary amenorrhea
Anatomical - cervical stenosis - imperforate hymen - Müllerian agenesis - transverse vaginal septum Hypothalamic-pituitary dysfunction - Anorexia - Chronic illness - excessive exercise - head injury Ovarian failure - Turners syndrome - POF - chemotherapy - pelvic irradiation Hypothyroidism Hyperthyroidism
Investigation of amenorrhea
Pregnancy test
Blood - LH, FSH - if premature menopause suspected
Prolactin level
TFT
USS of ovaries
Hysteroscopy if ashermans / cervical stenosis
Clinical manifestations of PCOS
Menstrual irregularity - oligomenorrhoea / amenorrhea Hirsutism Subfertility Recurrent miscarriage (50%) Obesity High LH insulin resistance Acanthosis nigricans
Diagnosis of PCOS
2 or more of:
- amenorrhea / oligomenorrhoea
- hyperandrogenism
- polycystic ovaries on USS
Management of PCOS
COCP - for endometrial protection, cycle regulation and contraception
OR Cyclical oral progesterone - for endometrial protection
Metformin
Clomiphene
Weight reduction
Exercise
Management of hirsutism
Eflornithine cream Cyproterone acetate (Dianette) Metformin GnRH analogues Laser / electrolysis
Causes of post menopausal bleeding
Atrophic vaginitis - 60% Endometrial polyps - 12% Endometrial hyperplasia - 10% Endometrial carcinoma - 10% Hormonal effects - 7% Cervical carcinoma - <1%
Investigation of post menopausal bleeding
TV USS of endometrial thickness (<3mm)
Endometrial biopsy
Hysteroscopy (+curettage of polyps)
Management of atrophic vaginitis
Topical oestrogen cream Oestrogen pessaries Oestrogen ring pessaries Vaginal moisturisers - daily use Vaginal lubricants for SI
Management of simple or complex endometrial hyperplasia (without atypia)
Oral progesterone
Mirena (NOT Levosert)
Usually regresses with progestogen treatment - needs monitoring
How can we explain endometrial hyperplasia to a patient
Endometrial hyperplasia is when the endometrium, the lining of the womb, becomes too thick.
It is not cancer, but in some cases if we leave it it could become cancer of the lining of the womb (uterus)
Management of atypical endometrial hyperplasia
Total abdominal hysterectomy - risk of progression to malignancy
Management of endometrial cancer
Total abdominal hysterectomy + BSO + washing +/- adjuvant therapy
Management of pre-menstrual syndrome
Stress reduction Exercise Alcohol and caffeine reduction COCP / oestrogen patches / IUS SSRIs CBT GnRH analogues - short term GnRH analogues - long term with add back HRT continuous combined Hysterectomy + BSO
Causes of cervical excitation
Ectopic pregnancy
PID
gonorrhoea / CT
Drugs for heavy menstrual bleeding
Mefenamic acid Tranexamic acid Norethisterone day 15 or 19 - 26 Levornagesterel IUD Danazol
How frequent should HIV +Ve women have cervical smears?
Yearly.
Despite CD4 count
What is the recommended frequency of cervical smears for women aged 25-49?
3 yearly
What is the recommended frequency of cervical smears for women aged 50-64?
5 yearly
What is Sheehan syndrome
Intrapartum pituitary haemorrhage
Does smoking affect the menopause?
yes - earlier
Define postmenopausal bleeding
PV bleeding occurring at least 12 months after the cessation of menstruation
Causes of postmenopausal bleeding include
Vaginal atrophy Endometrial carcinoma Endometrial hyperplasia Cervical cancer Ovarian cancer Liver cirrhosis
A retroverted uterus may be associated with what symptoms
none
Backache
dyspareunia
Characteristics of lichen sclerosis
Thickened skin and accentuated markings of the vulva
Itching and pain
What is the malignant potential of lichen sclerosis in %
Potential of squamous cell carcinoma of the vulva in 2 - 5%
Treatment of lichen sclerosis
Topical steroids emollient
Avoid irritants, heat and allergens
What may koilocites on a cervical smear suggest
HPV
Possible presentation of antiphospholipid syndrome
Recurrent miscarriage Arterial or venous thrombosis Livedo reticularis rash Stroke Adrenal haemorrhage Migraine Myelitis Myocardial infarction Multi-infarct dementia
Antibodies found in antiphospholipid syndrome
Anti-cardiolipin antibodies
What happens to CIN on colposcopy when acetic acid and iodine are applied
Aceto-white change
Failure of iodine staining
Persistent gestational trophoblastic disease occurs in what percentage of molar pregnancies?
0.5 - 15%
treatment = surgery + methotrexate
or dactinomycin and etoposide
what proportion of VIN would progress to invasive cancer if left untreated
> 80%
how much of the endometrium does a pipelle biopsy sample?
4%
risk factors for cervical cancer
smoking
multiple sexual partners
immunosuppression
COCP use
risk factors for ovarian cancer
1st degree relative with ovarian cancer known BRCA1 or 2 gene age >63 obesity early menarche <12yo nulliparous first child when aged >30 menopause later than age 50 previous fertility drug use
What is the RMI formulae
risk of malignancy index
RMI = (ultrasound score x menopausal status) / CA125
What ultrasound features score 1 point when calculating the RMI score for ovarian cancer
Ultrasound features - 1 point for each of:
- multi-locular cysts
- solid areas
- metastasis
- acsites
- bilateral lesions
Then for RMI calculation use the following numbers
0 if scored 0
1 if scored 1
3 if scored 2-5
What susceptibility does the BRCA1 gene confer for breast cancer and ovarian cancer
BRCA1
= 83% risk of breast cancer
= 63% risk of ovarian cancer
What may endometrial hyperplasia be associated with
obesity anovulation unopposed exogenous estrogens tamoxifen oestrogen secreting tumours
What risk factors are associated with endometrial hyperplasia?
Increasing age White race Nulliparous Older age at menopause Early menarche Diabetes mellitus, PCOS gallbladder disease thyroid disease Obesity Cigarette smoking Family history of ovarian, colon, or uterine cancer
Lynch II syndrome is a familial predisposition to what
non-polyposis colon cancer
endometrial cancer
ovarian cancer
Common signs of ectopic pregnancy (3)
and other less common signs (9)
common - pelvic tenderness / adnexal tenderness / abdominal tenderness
less common - cervical motion tenderness / rebound tendernesss / peritonitis / abdo distension
pallor / tachycardia >100 / Hypotension BP <100/60 / postural hypotension / shock or collapse
How may women with an ectopic pregnancy have no risk factors
1 in 3
Who would be referred to Early pregnancy Assessment unit and how urgent
Immediate / ED if - UPT +Ve and pain on examination or cervical motion tenderness
Non-urgernt referral if - UPT +ve and one of:
- reports pain but not found on examination
- pregnancy >6 weeks + bleeding
- pregnancy unknown gestation + bleeding
RCOG recommended management of a F with +ve UPT <6/40 with bleeding but no pain
expectant management
repeat UPT in 7-10 days
A negative UPT at that point would suggest complete miscarriage
advise return if bleeding worsens or develops pain
management in EPAU if CRL on TV USS <7mm and no FH
perform a second scan in a MINIMUM of 7 days before diagnosing miscarriage
management in EPAU if CRL on TV USS >/=7mm and no FH
Second opinion re presence of FH to confirm diagnosis of miscarriage
OR - repeat USS in 7/7
Steps for confirming viability on an EPAU TV scan
Look for FH
if no FH measure CRL if fetal pole seen
if no fetal pole measure the gestational sac diameter
management in EPAU if no FH but CRL measured by TA scan only
Record CRL
repeat scan in 14 days before making diagnosis of miscarriage
management in EPAU if TV USS shows mean sac diameter <25mm and no fetal pole
repeat scan in 7/7
Symptoms of ectopic pregnancy
- common (3)
- less common (7)
common
- abdo or pelvic pain
- amenorrhoea / +ve UPT
- PV bleeding +/- clots
less common
- breast tenderness
- GI symptoms
- Dizziness / fainting
- shoulder tip pain
- urinary symptoms
- passage of tissue
- rectal pressure / pain on defecation
What are the cervical screening guidelines in Scotland
Changed to the same as rest of UK
i.e. 25 - 49 years = 3 yearly
50 - 64 years = 5 yearly
Until June 2016 was 20 - 60 years old - 3 yearly
Karyotype and phenotype of Androgen Insensitivity Syndome
and inheritance pattern
Karyotype = 46 XY Pheonotype = female inheritance = X-linked recessive
Pathophysiology of androgen insensitivity syndrome and result
46XY
failure of normal masculinisation of male genitals
Due to complete or partial insensitivity of the androgen receptor
Normal androgen synthesis and levels
What age and frequency is breast cancer screening offered?
50 - 71 = 3 yearly
>71 on request
Presentation of triple X
47 XXX
Female
1 : 1000 female births
Neuromotor or developmental delay
Immature behaviour
Reduced IQ
tall stature
what may annovulation be associated with
contracpetion Drugs stress / depression excess exercise excess weight loss chronic renal failure PCOS Cushings asthma
Normal range of oestradiol
oestradiol = 130 - 830 pmol/l
Normal range of LH
LH = 1 - 10 mU/l
Normal range of FSH
FSH = 1 - 10 mU/l
Normal range of prolactin
Prolactin = 50 - 450 mU/l
Normal range of testosterone in women
normal testosterone level in women - <3pmol/l
Azoospermia and a normal FSH is consistent with what diagnosis
Obstructive cause of male subfertility
- congenital absence of the vas
- varicoceles
- tubal blockage secondary to infection or trauma
Azoospermia and a raised FSH is consistent with what diagnosis
testicular failure
what signs or symptoms would merit admission for OHSS
tachypnoea / SOB hypotension tense ascites oliguria electrolyte imbalances intractable vomiting
long term risks of premature ovarian insufficiency
subfertility cardiovascular disease risk decreased BMD / risk of osteoporosis reduced cognitive function decreased verbal fluency impaired memory possible increased risk of Alzheimers
What is the age cut off for diagnosis of premature ovarian insufficiency
40 yo
what are possible autoimmune causes of premature ovarian insufficiency
addisons pernicious anaemia hashimotos ITP Rheumatoid arthritis with vitiligo bushings myaasthenia gravis
Effects of metformin when used in treatment of PCOS
Decrease insulin secretion improved insulin sensitivity increased conception rate decrease androgen levels decrease hepatic gluconeogenesis NOT effective for weight loss
What is the role of FSH in men
Stimulates the formation of sperm in the testes
How many days does spermatogenesis take?
70 - 80 days
What is type 1 FGM
Partial or total removal of the clitoris
Or in rare cases removal of the just the clitoral prepuce
What is type 2 FGM
Partial or total removal of the clitoris and labia minora
with or without excision of the labia majora
What is type 3 FGM
Infibulation
Narrowing of the vaginal opening by creating a covering seal
cutting + repositioning the inner or outer labia
+/- removal of the clitoris
What is type 4 FGM
All other harmful procedures to the female genitalia for non-medical purposes
e.g.
pricking, piercing, incising, scraping, cauterising
Short term consequences of FGM
Haemorrhage infection urinary retention sepsis death tetanus gangrene transmission of HIV / Hepatitis
long term consequences of FGM
recurrent UTI painful menstruation psychological problems Sexual difficulties pregnancy complications subfertility Cysts Keloid scarring
At what age are women first invited for cervical screening
24.5 years
to ensure women can be screened for the first time by their 25th birthday
In what circumstances may women have a cervical smear taken at age 65+
Invitation as required for women who have had recent abnormal tests.
Women who have not had an adequate screening test reported since age 50 may be screened on request
what can be done for women who do not want cervical screening
Voluntary withdrawal from the programme by written request.
Reasons for voluntary withdrawal may include:
• women at low risk of cervical cancer. e.g. never had intimate contact with another male or female
• A physical or learning disability of a nature that makes taking a sample very difficult or distressing, who do not wish to receive further invitations
• women who may not benefit from screening. e.g. terminally ill
• women unable to give an adequate sample – e.g. FGM - alternative options such as gynaecological referral should be discussed
• women who do not want to participate at any point
Medical reasons for ceasing a womans invitation for cervical smears
Women should be ceased from the programme where they do not have a cervix due to:
• total hysterectomy (women with a subtotal hysterectomy remain at risk and should remain in the programme)
• congenital absence of the cervix
• being a male-to-female transsexual
• having undergone a radical trachelectomy for cervical cancer
• after radiotherapy for cervical, bladder, rectal and other pelvic cancers - difficult to accurately report samples - provide with gynaecological follow-up instead
Management of a patient where cervical stenosis is preventing adequate cervical screening smears
Refer for colposcopy examination AND Consider cervical dilatation OR Consider hysterectomy - if a history of high- grade dyskaryosis or cervical glandular intraepithelial neoplasia (CGIN)
If neither options are appropriate or acceptable then discuss voluntary withdrawal from the screening programme.
What is the HPV triage protocol for cervical screening
HR-HPV triage protocol
= cervical samples reported as borderline / low-grade dyskaryosis
given a HR-HPV test
IF
HPV positive - referred to colposcopy
HR-HPV negative - returned to routine recall
IF high-grade dyskaryosis or worse - referred straight to colposcopy without a HR-HPV test
What is the HPV test of cure protocol fro cervical screening
After treatment for all grades of CIN
women are invited for screening at 6 months
IF sample is negative / borderline / low-grade dyskaryosis then do HR-HPV test.
IF the HPV test is negative - recall in 3 years (irrespective of age) and return to routine recall if that test is negative.
IF the HR-HPV test is positive - referr back to colposcopy.
IF cytology is high-grade dyskaryosis or worse - refer straight to colposcopy without an HR-HPV test
What is Primary HR-HPV testing
Cervical screening algorithm - introduced 2019
Smear sample is taken as usual
Tested for HR-HPV first
if HR-HPV +ve then perform cytology
Women who are:
- HPV negative = returned to the routine screening programme
- HPV positive = cytology performed AND referred to colposcopy OR rescreened in 12 months
Why is the primary HR-HPV testing algorithm for cervical screening superior to cytology primary testing?
Primary HR-HPV testing = higher sensitivity for high grade cervical intraepithelial neoplasia (CIN) than primary cytology.
Lower false negative rate
When should cervical screening be delayed ?
A cervical sample should not be taken (unless you think the woman will not re-attend), if the woman:
- Is menstruating.
- Is less than 12 weeks postnatal.
- Is less 12 weeks after a termination of pregnancy, or miscarriage.
- Has a vaginal discharge or pelvic infection — treat the infection and take the sample on another occasion.
- If the woman is pregnant
Should women who are immunosuppressed be offered more frequent cervical screening?
- HIV positive - offer annually + colpscopy at HIV diagnosis
- Kidney failure requiring dialysis (any disease with a high chance of needing organ transplantation) - offer AT diagnosis
- Patients about to undergo organ transplantation - offer within 1 year BEOFRE transplantation
- Patients starting cytotoxic drugs for rheumatological disorders - offer at START of treatment if the screening history is incomplete
There is NO indication for increased surveillance in women taking:
- Post-transplantation immunosuppressive drugs after the 1st year
- Cytotoxic chemotherapy for non-genital cancers.
- Long-term biologic agents.
- Oestrogen antagonists (such as tamoxifen).
Stages of CIN
CIN1 — one-third of the thickness of the surface layer of the cervix is affected
CIN2 — two-thirds of the thickness of the surface layer of the cervix is affected.
CIN3 — sometimes called high-grade or severe dysplasia or stage 0 cervical carcinoma in situ.
The full thickness of the surface layer is affected
Causes of a cervical cytology result being inadequate
cervix was not fully visualized.
Sample was taken in an inappropriate manner (e.g. using an unapproved device)
Sample contains insufficient cells.
Sample contains an obscuring element (e.g. lubricant / inflammation / blood).
Is incorrectly labelled
Management of a patient with actinomyces-like organisms (ALOs) reported present on the cervical cytology result
If patent has no IUD/ IUS - No follow up is required.
If patient has an IUD / IUS is in situ and is asymptomatic - it does not need to be removed.
If patient has an IUD / IUS is in situ and is symptomatic
e.g. pelvic pain / deep dyspareunia / ntermenstrual bleeding / vaginal discharge / dysuria / significant pelvic tenderness
= consider removing device after excluding STIs +/- treating for PID
When should a referral to colposcopy be made on the basis of consecutive inadequate cervical screening samples
After 3 consecutive inadequate samples
