O&G:Gynae Flashcards
What are fibroids also known as?
Uterine leiomyoma
What are fibroids?
Benign tumours of the myometrium
What are risk factors for fibroids?
- more common near the menopause
- early puberty
- afrocarribbean descent
- family history
What are protective factors for fibroids?
Parous women
Late puberty
Previous taking of COCP or injectable progesterone
Histology of fibroids
Smooth muscle and fibrous elements present
‘Whorled’ appearance in transverse section
Monoclonal origin
How are fibroids related to hormones?
Oestrogen (and probs progesterone) sensitive
- in pregnancy, equally likely to grow/shrink/stay the same
- in menopause, regress and calcify due to reduction in circulating oestrogen.
- HRT may cause growth
What are the possible sites for fibroids?
Intramural
Subserosal
Submucosal
Clinical features of fibroids
- asymptomatic 50%
- menorrhagia 30%
- intermenstrual bleeding
- pressure effects: frequency/urgency (bladder), hydronephrosis (ureter), infertility (tubal ostia)
- sub fertility: blocked tubal ostia, prevention of implantation, dysmenorrhea
Complications of fibroids
Painful if:
- torsion (bedunculated fibroid)
- degeneration (red, avascular necrosis)
- malignancy (more likely if pain, rapid growth, growth post menopausal + poor response to GnRH)
What are the pregnancy complications with fibroids?
- premature labour
- malpresentation
- PPH
- transverse lie
- obstructed labour
- red degeneration
Investigations of fibroids?
Abdo/bimanual pelvic exam
- solid mass arising from pelvis and continuous with uterus
- multiple small fibroids give: irregular ‘knobbly’ enlargement of uterus
TVUS/TAUS
MRI/laparoscopy if needed
Hysteroscopy to assess disortion of uterine cavity
FBC
- decrease if heavy bleeding
- increase as fibroids can secrete erythropoietin
What is the Mx for fibroids?
Asymptomatic + slow growing = none
Fibroids <3cm assoc with heavy bleeding
- TXA, NSAIDs, progesterone injections
- IUS or COCP
Fibroids >3cm assoc with heavy bleeding
- ulipristal acetate (progesterone-receptor modulator)
- GnRH agonists (induce temporary menopausal state, max 6month use)
- Mifepristone (anti progesterone - shrinks fibroids)
What are the SE of mifepristone?
Vasomotor Sx
Endometrial hyperplasia
What are the SE of GnRH agonists?
Bone density loss
What are the surgical Mx options for fibroids?
Hysteroscopic surgery Myomectomy Hysterectomy Uterine artery embolisation Myolysis
What are serous cystadenomas?
Papillary growths which may be so prolific the cyst looks solid
Get them aged 40-50yrs old
What are mucinous cystadeonmas?
Mucin filled and can become huge
20-40 yrs
What are teratomas?
Arising from germ cells
Young, premenstrual women
Can contain hair + teeth
What are benign solid tumours?
Fibromas
- can cause Meig’s syndrome: ascites + right pleural effusion
Thecomas
- secrete oestrogen and androgens
Adenofibromas
What are functional cysts?
Only in menstruating women (risk factor is early menarche)
Made up of:
- follicular cysts - persistently enlarged cysts
- leutien cysts - persistently enlarged corpora lutea
What are chocolate cysts?
Endometriomas caused by endometriosis
Accumulation of blood in the ovary (Dark-brown cyst)
What are symptoms of ovarian cysts?
- asymptomatic
- ache/pain of abdo + lower back
- dysparenuina
- large cysts have pressure effects
> bladder: urgency
> veins: oedema and varicostes - large cysts can cause abdo distension (dull to percuss)
What are complications of cysts?
Rupture
- fever, severe abdo pain, peritonitis, shock
Torsion
- fever, severe abdo pain
Hamorrhage + infarction
Pseudomyxome peritone: in mucinous cyst adenomas, mucinous cells disseminate and clog up pelvic viscera
How do you investigate cysts?
USS CT/MRI Laparoscopy + fine needle aspirate CA125 (rule out cancer) Pregnancy test (rule out pregnancy) Urinalysis (rule out infection)
Why is torsion an emergency?
blood supply cut off which leads to ischaemia, infarction and necrosis
What is polycystic ovarian syndrome?
Characteristic US appearance of multiple (>12), small (2-8mm) follicles in an enlarged ovary (>10ml volume)
What is the triad of PCOS?
- Polycystic ovaries on US
- Irregular periods
- Hirsutism
Pathophys of PCOS?
Affected women have raised LH and insulin which leads to raised ovarian androgen (testosterone) production.
Increased insulin causes increased adrenal androgen production + hepatic SHBG production = lots of free floating androgen
What is the effect of free floating androgens in PCOS?
Increased intra ovarian androgens lead to
- PCO
- Irregular/absent ovulation
Increased peripheral androgens lead to
- Hirsutism
What are clinical features of PCOS?
Obese Acne Excess body hair Oligo/amenorrhea Miscarriage
What is diagnostic criteria for PCOS?
2 or more of:
- PCO
- Irregular periods (>5 weeks apart)
- Hirsutism (clinical or biochemical)
Investigations for PCOS?
Bloods
- FSH: raised in ovarian failure, decreased in hypothalamic disease, normal in PCOS
- Prolactin: normal in PCOS, used to exclude prolactinaemia
- TSH: normal in PCOS
- Serum tesosterone: raised
- LH: raised but not diagnostic
TVUS
- shows PCO
Fasting lipids + glucose
- screen for complications (T2DM, Gestational diabetes + endometrial cancer)
What is the Mx for PCOS?
- Obese patients: lose weight
- COCP: regulates menstruation and treats hirsutism
- Clomifene or tamoxifen: oestrogen receptor modulators to regulate hormones and lead to ovulation
- Metformin: treats hirsutism
- Ovarian diathermy: regulates ovulation for years
- Ovulation induction with gonadotrophins
What is adenomyosis?
The presence of ectopic endometrial tissue and underlying stromatolites within the myometrium
What is the hormone relationship with adenomyosis?
Oestrogen dependent. Endometrium grows into the myometrium, pockets of menstrual blood can be seen n the myometrium if severe.
What are the symptoms of adenomyosis?
- Asymptomatic
- Painful, regular, heavy menstruation
What are the signs of adenomyosis?
Mildly enlarged, tender uterus
How do you diagnose adenomyosis?
MRI
Histology on hysterectomy
Treatment of adenomyosis?
Medical: Progesterone IUS, COCP +/- NSAIDs or a GNRH agonist trial.
Surgical: Hysterectomy.
What is a intrauterine polyp?
Small benign tumours that grow into uterine cavities, usually endometrial in origin, sometimes submucosal fibroid origin.
Pathophysiology of polyps?
They arise a result of disordered cycles of apoptosis and regrowth of the endometrium. The fibrous tissue core is covered by columnar epithelium.
What is the clinical presentation of polyps?
- Asymptomatic
- Menorrhagia
- IMB
- Occasional prolapses through cervix
Diagnosis of polyps?
- Ultrasound
- Hysteroscopy
Management of polyps?
- Resection w/ cutting diathermy
- Avulsion
What are congenital uterine abnormalities?
Result from differing degrees of failure of fusion of mullerian ducts at about 9 weeks. Increased risk of renal abnormalities.
What are the pregnancy complications of congenital uterine abnormalities?
- Malpresentaion
- Transverse lie
- Preterm labour
- Retained placenta
- Recurrent miscarriage
Management of congenital uterine abnormalities?
- Surgical
- Hysteroscopy for simple septa
- Redimentary horns removed
What is endometriosis?
Presence of endometrium like tissue found outside the uterus, usually within the peritoneal cavity.
What is the hormonal affect in endometriosis?
Oestrogen dependent
Regresses during pregnancy and after menopasue
Bleeds at menstruation
Common sites for endometriosis?
- Pouch of douglas (uterosacral ligament)
- On/behind ovaries
What are the causes of endometriosis?
Most common:
- Retrograde menstruation (sampsons theory)
Other:
- Extra-peritoneal endometriosis (eg. umbilical scar) Halbans theory. + embolisation
- Metaplasia
What are the clinical features of endometriosis?
- Asymptomatic
- Chronic pelvic pain –> constant or cyclic
- Severe dysmenorrhoea
- Dysparaeunia
- Dysuria
- Infertility
- Dyschezia –> during menses
- Acute pain, when there is rupture of choco cyst
Who does endometriosis normally affect?
Young, low parity women
Why is pouch of douglas affected in endometriosis?
Has endometrium tissue, is damaged on sex, causing dyspareunia.
Signs of severe disease in endometriosis?
- Cyclical haematuria
- Rectal bleeding
- Umbilicus bleeding
What do you see on scan for endometrioma?
- Blue cyst
What is frozen pelvis?
When all pelvic organs are immoblised by adhesions, due to pelvic inflammation and progressive fibrosis due to endometriosis.
What are the investigations of endometriosis?
Gold standard: Laparoscopy and biopsy Vaginal exam: - tenderness - thickening behind uterus or in adnexa - nodules in posterior vaginal fornix or uterosacral ligament - rectovaginal nodules - fixed retroverted uterus (2dary to adhesions) USS: - to visualise chocolate cysts MRI: - if adenomyosis suspected
When is laparoscopy indicated in endometriosis?
When there is NSAID resistant lower abdo pain
Pain is causing days off work ad hospitalisation.
Pain and infertility
Treatment of endometriosis?
Medical: - COCP - Medroxyprogesterone acetate - GnRH analogues - Levenorgesterone releasing IUD - Donazol - Aromatase inhibitors Surgery: - Lesions are destroyed on laparoscopy if consented - Disection of adhesions - Hysterectomy - Salpingoopherectomy
What treatment aboloshises cyclicity?
COCP (triphasic, fixed dose) GnRH analogues (60-90min pulses)
What treatment causes glandular atrophy?
Oral progesterone
Depot provera
Mirena
Risks of GnRh?
Prolonged treatment necessary
HRT add-back therapy to prevent BMD decrease and prevent menpause sx.
What is the most common genital tract cancer?
Endometrial cancer
- prevalence highest at age 60yrs
- only 15% occurs pre-menopausal
- <1% in women <35 yrs
What are the different types of endometrial cancer?
1) Adenocarcinoma of columnar endometrial gland cells (>90%)
2) Adenosquamous CA (poorer prognosis, most common of the rest)
3) Endometrial hyperplasia (pre-malignant condition)
What are the risk factors for endometrial cancer?
Exogenous oestrogen
- unopposed oestrogen therapy
- tamoxifen (oestrogen antagonistic breast, but agonist in pros-menopausal uterus)
Endogenous oestrogen excess
- PCOS with prolonged amenorrhea
- obesity
- nulliparity
- late menopause
- ovarian granuloma cell tumours (secrete oestrogen)
Other:
- T2DM
- Lynch type II syndrome
- HNPCC
- Pelvic irradiation
What is a protective factor for endometrial cancer?
COCP
What are the symptoms for endometrial cancer?
- Postmenopausal bleeding ***
- If premenopausal: irregular bleeding/IMB, sometimes recent onset menorrhagia
What are the signs of endometrial cancer?
- Atrophic vaginitis
- Abnormal columnar cells on cervical smear
- Pelvis: often normal
How do you investigate endometrial cancer?
TVUS Endometrial biopsy Pipelle/hysteroscopic biopsy + histology MRI (if spread suspected or high risk biopsy) CXR (exclude rare pulmonary spread)
What are the indications for endometrial biopsy if suspecting endometrial cancer?
Endometrium >4mm thick on TVUS if postmenopausal
Endometrium >10mm thick on TVUS if premenopausal
What are some causes of PMB?
Endometrial cancer Endometrial hyperplasia Cervical carcinoma Atrophic vaginitis Cervical polyps Ovarian carcinoma Cervicitis
What is the Mx for endometrial cancer?
Stage 1: hysterectomy + bilateralsalpingoopherectomy
Stage 2:
- radical hysterectomy with system pelvic node clearance
- alternative: hysterectomy + adjuvant therapy
Stage 3/4: maximum bulking surgery, combo chemo, radio + surgery
What are the indications for radiotherapy in endometrial cancer?
- High risk for extrauterine disease (poor grade, deep myocetrial/cervical stroll spread)
- Proven extrauterine disease
- Inoperable/recurrent disease
- Palliation for Sx (e.g bleeding)
- Surgery not poss (e.g. meds CI)
Describe the stages of endometrial cancer
Stage 1: lesions confined to uterus
1a: <1/2 of myometrial invasion
1b: >1/2 of myocetrial invasion
Stage 2: as above but in cervix swell
(Cevrical stromal invasion, but not beyond uterus)
Stage 3: tumour invades through uterus
3a: invades serosa or adnexa
3b: vaginal and/or parametrial involvement
3ci: pelvic node involvement
3cii: para-aortic involvement
Stage 4: further spread
4a: in bowel or bladder
4b: distant mets
Where is the most common site for endometrial cancer recurrence?
At the vaginal vault (in first 3 years)
- treated with vaginal vault radiotherapy
What is haematometra?
Menstrual blood accumulating in the uterus because of the outflow obstruction.
What causes haematometra?
- Cervical canal usually occluded by fibrosis after endometrial resection, cone biopsy or carcinoma
- Congenital abnormalities (e.g. imperforate hymen or blind rudimentary uterine horn) present in adolescence as primary amenorrhoea
What is endometritis?
Infection of the uterus but commonly spreads to the pelvis if left untreated
What causes endometritis?
- instrumentation of the uterus
- complication of pregnancy
Therefore is common after c-section and miscarriage.
What organisms can cause endometritis?
Chlamydia, gonococcus, e.coli, staphylococci, clostridia
What are the clinical features of endometritis?
persistent, heavy vaginal bleeding + pain
(+maybe fever initially)
> tender uterus
cervical os = open
What are the Ix for endometritis?
Vaginal + cervical swabs
FBC
Pelvic US
What is the Tx of endometritis?
Broad-spec Abx
What are the different uterine sarcomas?
1) Leiomyosarcomas
2) Endometrial stromal tumours
3) Mixed mullein tumours
What are leiomyosarcomas?
Malignant fibroids (rapid painful enlargement of a fibroid)
What are endometrial stromal tumours?
Tumours of the storm beneath the endometrium
- vary histologically from benign nodules to malignant sarcoma
Most common in perimenopausal women
What are mixed mullein tumours?
Derived from embryological elements of the uterus
More common in older age
Present with: irregular/IMB or rapid painful enlargement of a fibroid
Tx: hysterectomy
What can cause carcinoma of the vulva?
- Lichen sclerosis
- Vulval intraepithelial neoplasia (VIN)
What is vulval intraepithelial neoplasia?
Premalignant disease assoc with HPV.
- pruitus + pain
- benefits from emollients + topical steroids
- Gold standard: local surgical excision + histology to exclude cancer
What are the types of vuval cancer?
Squamous cell carcinoma (95%)
Malignant melanoma
Bartholin’s gland
Paget’s disease
What are the Sx of vuval cancer?
- vulval itching + soreness
- ulcer/mass on labia major/clitoris
- dysuria
- bleeding
- discharge
How is vulval cancer diagnosed?
Biopsy
What is the Tx for vulval cancer?
Stage 1a: wide, local excision
Other stages: wide local excision + groin lymphadenectomy
Radiotherapy Neo-adjuvantely
What cancer is usually secondary to malignancy of cervix, endometrium or vulva?
Carcinoma of the vagina
Describe primary vaginal carcinomas?
Affect older women
Squamous cell carcinoma
Bleeding, discharge + mass/ulcer
Intravaginal radiotherapy
Describe clear cell adenocarcinomas?
Secondary to DES exposure in utero
Presents in late teenage years
Good prognosis post surgery + radio
Describe the epidemiology of ovarian cancer?
- Presents late due to vague Sx (5yr survival <35%)
- Lifetime risk: 1 in 48
- 80% in >50yrs old
- Highest incidence: 80-84 years old
What are the risk factors for ovarian cancer?
Increased risk with no. of ovulations:
- early menarche + late menopause
- nullparity
- HRT
Gene mutation: BRCA 1 + 2, HNPCC
- benign cysts can undergo malignant change
What are the various types of epithelial tumours in ovarian cancer?
Epithelial tumours account for 90% of ovarian cancer
- Serous cystadenocarcinomas (40-60years)
- Endometrial carcinoma (50-60years)
- Mucinous cystadenocarcinomas (30-50 years)
- Clear cell carcinoma (40-80years)
What are the various types of germ cell tumours in ovarian cancer?
- Dysgerminomas
- Teratomas
These arise from primitive germ cells of the embryonic gland
Women <35yrs
No Sx, more curable
What are protective factors for ovarian cancer?
- Pregnancy
- Lactation
- COCP
What are the Sx of ovarian cancer?
- Asymptomatic/vague initial Sx
- Abdo distension/bloating
- Early satiety
- Loss of appetite
- Pelvic/abdo pain
- Urgency/frequency
What are the signs of ovarian cancer?
Ascites
Abdo/pelvic mass
Cachexia (weakness + wasting of body due to severe illness)
What are the Ix for ovarian cancer?
CA125: test this in any older woman with IBS-like Sx
- if it is raised then do an USS
Detected mass? > urgent referral
Describe the staging of ovarian cancer
Stage 1: confined to the ovary
Stage 2: confined to the pelvis
Stage 3: confined to the abdomen
Stage 4: extra-abdominal disease
How do you work out the risk of malignancy index (RMI) in ovarian cancer?
USS findings (1 or 3)x menopausal status(1or3) x CA 125
USS findings get
- 1 point for 1 finding
- 3 points for 3-5 findings
findings: multi ocular cysts, solid areas, mets, ascites, bilateral lesions
Menopausal status:
Premenopausal: 1 point
Postmenopausal: 3 points
RMI of 250 or more needs MDT + CT for staging
If a 70 year old woman with a solid cystic adnexal mass of 8cm with ascites and a CA125 of 400 came into the clinic, what would her RMI be?
Postmenopausal: 3
>1 abnormal feature of cyst on USS: 3
3x3x400 (CA125 score) = 3600
= needs referral to gynaecologist oncologist
What is the surgical treatment for ovarian cancer?
- Midline laparotomy for full view of pelvis then remove everything cancerous
- Total hysterectomy, sapling-oopherectomy, partial omentectomy + peritoneal + lymph node samples
What treatment is there for ovarian cancer patients who cannot have surgery?
Chemo
How do you manage ovarian cancer patients following tx?
Repeat CA125s + repeat Its
Prognosis is improving but is not great so palliative care is important
When are the peaks of incidence in cervical carcinoma?
30s and 80s
Majority: 25-49 yrs
What is the cause of cervical carcinoma?
HPV
What are the types of cervical carcinoma?
Squamous cell carcinoma (70%)
Mixed pattern (15%)
Adenocarcinoma (15%) –> from columnar epithelium + worse prognosis
What are the risk factor for cervical carcinoma?
- early age intercourse (<16yrs)
- multiple sexual partners
- STDs
- cigarette smoking
- previous CIN
- multiparty
- OCP usage
- other genital tract neoplasia
How can cervical carcinoma spread?
Lymph
- pelvic nodes = early feature
Direct invasion
- parametric, vagina, pelvic side wall, uterus, bladder, rectum, ovary (rare)
Blood
- occurs late
What are the symptoms of cervical carcinoma?
Early:
- post-coital bleeding
- offensive vaginal discharge
- IMP or PMB
Late:
Involvement of ureters, bladder, rectum + nerves
- uraemia, haematuria, rectal bleeding + pain
- Leg oedema, pain, hydronephrosis (leads to CKD + pelvic wall involvement)
How do you investigate cervical carcinoma?
Colposcopy to biopsy tumour Staging: - vaginal/rectal exam - cystoscopy - MRI (size, spread, lymph node involvement) - CT with contrast
What is the staging of cervical carcinoma?
Stage 1: lesions confined to the cervix
1ai: diagnosed only by microscope, invasion <3mm in depth and lateral spread <7mm
1aii: diagnosed with microscope, invasion >3m and <5mm with lateral spread <7mm
1bi: clinical visible lesion or greater than 1aii, <4cm in greatest dimension
1bii: clinically visible lesion, >4cm in greatest dimension
Stage 2: invasion into vagina, but not the pelvic side wall
2ai: involvement of upper 2/3rds vagina, without parametrial invasion, <4cm in greatest dimension
2aii: >4cm in greatest dimension
2b: invasion of parametrium
Stage 3: invasion of lower vagina or pelvic wall, or causing ureteric obstruction
Stage 4: invasion of bladder or rectal mucosa, or beyond the true pelvis
What factors suggest a poor prognosis with cervical carcinoma?
LN involvement Advanced clinical stage Large primary tumour Poorly differentiated tumour Early recurrence
What is the management for cervical carcinoma?
Stage 1ai: cone biopsy, hysterectomy (older women)
Stage 1aii - 2a: surgery, chemo or radio
- pelvic LN dissected + tested laparoscopically
If neg = surgery
If pos = chemo/radio
What is Wetheim’s hysterectomy?
The surgery for cervical carcinoma which involves pelvic node clearance, hysterectomy tommy, removal of parametric/upper 1/3rd of vagina. Ovaries are left only in young women with squamous carcinoma.
What is radical trachelectomy?
Alternative surgery for cervical carcinoma. Remove 80% of cervix and upper vagina, insertion of cervical suture to prevent preterm. Women want to conserve fertility.
What is the Tx for stage 2b> cervical carcinoma?
Chemo/radio (platinum agents e.g. cisplatin)
Combo of internal beam radio + brachytherapy
Palliative radio for bone pain/haemorrhage
What is menstruation?
Monthly bleeding from reproductive tract induced by hormonal changes of the menstrual cycle.
What is the menstrual cycle?
The time from the start of a period to the start of the next.
What is normal amount of blood loss during menstruation?
60-80ml
How long is an average menstrual cycle?
21-35 days (28 days)
How many days do you usually lose blood during menstruation?
2-8 days (5 days)
What is abnormal uterine bleeding?
Any menstrual bleeding from the uterus that is either abnormal in volume, regularity, timing or is non-menstrual.
What is menorrhagia?
Excessive menstrual blood loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material QoL.
Blood loss> 80ml
- ask about flooding and large clots as measurement
Why is it 80ml of blood that is classified as excessive menstrual loss?
Max amount women on a normal diet can lose per cycle without becoming iron deficient.
What are the causes of menorrhagia?
Systemic:
- hypothyroidism
- coagulopathy
- diabetes
- obesity
Local:
- polys
- carcinoma
- fibroids
- adenomyosis
Treatment-related:
- IUD
- Anti-coags
How do you investigate menorrhagia?
- Examination: pelvis + bianual
- Menstrual charting
- FBC (assess effect of blood loss)
- Exclude systemic causes: coag + thyroid function
- Exclude organic causes: TVUS, Endometrial biopsy
- TVUS (endometrial thickness, exclude uterine fibroid/ovarian mass, detects larger intrauterine polyp)
What are indications for biopsy in menorrhagia?
- endometrial thickness
- abnormal bleeding resulting in acute …?
- suspected polyps- prior to endometrial ablation/diathermy
- before insertion of IUS if cycle irregular
- IMB
- > 40 with recent onset menorrhagia
What is the medical treatment for menorrhagia?
1st line: IUS (not copper coil) 2nd line: - antifibrinolytics (tranexamic acid) - NSAIDs (mefenamic acid) - COCP 3rd line: progesterones + GnRH analogues
What is the surgical treatment for menorrhagia?
Endometrial ablation (remove endometrium(
Hysterectomy (last resort)
Uterine artery embolisation
What is amenorrhoea?
The absence of menstruation
Difference between primary and secondary amenorrhoea?
Primary: menstruation has not started by the age of 16 years
Secondary: previously normal menstruation that stops for >6months
What is oligomenorrhoea?
Infrequent periods (>every 35 days for 6 months)
What are the causes of amenorrhoea?
Physiological
- constitutional delay
- drugs
Pathological
- anorexia nervosa
- psychological
- athleticism
- PCOS
- hyperprolactinaemia
- thyroid issues
- adrenal tumours
- adrenal hyperplasia
- turner’s syndrome
- premature ovarian failure
- imperforate hymen/transverse vaginal septum
Investigations for amenorrhoea
- pregnancy test
- FSH/LH levels
- prolactin levels
- thyroid function
- total testosterone + sex-hormone binding globulin level
- pelvic US (if PCOS)
Why should prolactin levels be measured at least twice in amenorrhoea?
Can be temporarily high due to stress, eating, recent breast exams.
What is primary dysmenorrhoea?
Cramping/pain in lower abdo just before or during period.
- usually coincides with start of menstruation and improves as menses progresses
- due to contraction and uterine ischaemia
What are some non-gynae Sx of dysmenorrhoea?
N+V
Migraine
Bloating
Emotional
What are clinical features of primary dysmenorrhoea?
Normal pelvic examination
Assoc with high prostaglandin levels in endometrium
What is the Mx of primary dysmenorrhoea?
NSAIDs or COCP
Local application of heat (e.g. hot water bottle)
TENS (set to high freq)
Reassurance
What is secondary dysmenorrhoea?
painful periods often preceding (and relived by) onset of menstruation
What are some assoc features of secondary dysmenorrhoea?
Deep dyspareunia
Menorrhagia
Irregular menstruation
What Ix are done for secondary dysmenorrhea?
Examination
Swabs (if STI risk)
Pelvic US
Pelvic laparoscopy
Causes of secondary dysmenorrhoea?
Fibroids Adenomyosis Endometriosis PID Ovarian tumours
What are the causes of irregular menstruation + intermenstrual bleeding?
Anovulatory cycles
- early/late reproductive years
Pelvic pathology
- fibroids
- polyps
- adenomyosis
- ovarian cysts
- chronic pelvic infection
- malignant: ovarian, cervical, endometrial
What Ix are there for irregular menstruation + intermenstrual bleeding?
FBC (blood loss) Cervical smear TFT/clotting FSH/LH USS of uterine cavity (>35yrs) Endometrial biopsy
What is the Tx for irregular menstruation + intermenstrual bleeding?
1st line: IUS or COCP
2nd line: Progesterone, HRT
Surgical
- treat underlying cause (e.g. polyp)
- menorrhagia tx
What is post-coital bleeding?
Vaginal bleeding following intercourse that is not menstrual loss.
- except for 1st intercourse this is always abnormal and cervical carcinoma must be excluded.
What are causes of PCB?
Cervical carcinoma Cervical ectropion Cervical polyps Cervicitis Vaginitis
When is cervix most likely to bleed?
When it is not covered by healthy squamous epithelium?
What is the Mx for PCB?
Smear
Colposcopy
What is the menopause?
The permanent cessation of menstruation resulting from loss of ovarian follicular activity.
- diagnosed after 12 consecutive months of amenorrhoea (or onset of Sx if hysterectomy)
- average age: 51 years
What is perimenopause?
Time beginning with first features of approaching menopause (e.g. vasomotor sx + menstrual irregularity) and ends 12 months after the last period.
What is premature menopause?
Menopause <40 years old. Usually no cause but may be:
- post bilateral oophorectomy
- infection
- autoimmune disordes
- chemo
- ovarian dysgeneis
- metabolic diseases
What are the short term vasomotor symptoms of the menopause?
Hot flushes
Night sweats > sleep disturbance (tired + irritable)
Usually lasts <5yrs
Is sue to fluctuations in oestrogen levels
What are the medium term urogenital problems of menopause?
- urethral mucosal/vaginal atrophy
- urinary problems: frequency, nocturne, incontience, recurrent infection, increase in vaginal pH
- dyspareunia, itching, burning, dryness, cessation of sexual activity
What are some general symptoms of menopause?
- mood change/irritability
- loss of memory/concentration
- headaches, dry+itchy skin, joint pain
- loss of confidence, lack of energy
What are some long term symptoms of menopause?
Osteoporosis
- decreased risk if you take oestrogen
CVD
- adverse changes in lipid
Dementia
- increased prevalence with early menopause
When should you investigate for the menopause?
- <40 years (premature menopause0
- consider in ages 40-45years
- > 45 years with atypical symptoms
How to investigate menopause?
FSH: gives estimate of ovarian reserve
- high levels = low oocytes
- measure between days 2-5
AMH (anti-mullerian hormone) is produced in granuloma cells of natural/pre-natural follies: gives direct measurement of ovarian reserve
- can measure any day as it is stable throughout cycle
TFTs Catecholamine - increased in phaeochromocytoma/carcinoid syndrome LH Oestradiol Progesterone DEXA
What is the aim of menopausal treatment?
To relieve Sx
What is the tx for menopause?
HRT
- Oestrogen: if hysterectomy
- Oestrogen + progesterone: if no hysterectomy as this decreases risk of endometrial cancer
How does a combine oestrogen + progesterone treatment help reduce risk of endometrial cancer in menopausal tx?
Progesterone counteracts the proliferative effect of oestrogen. If you didn’t have it then the uterus would hyperplase and lead to neoplasia.
What are the routes to give oestrogen?
Oral
Transdermal (best)
Subcutaneous
What are the routes to give progesterone?
Oral
Transdermal
IUS
How long should you have menopause treatment for?
up to 5 years
or up to age 51 in premature menopause
Talk about the breast cancer risk with menopause treatment?
Only an increased risk of breast caner with oestrogen and progesterone therapy
STOP HRT if develop breast cancer
- do not offer HRT routinely if they have Hx of breast cancer
- can still give to people with family Hx of breast cancer
Talk about the VTE risk with menopause treatment?
Only increase risk if using oral HRT because it does 1st pass metabolism= increased clotting factor production in liver.
Transdermal is better as it gives a constant level (esp good for migraines, epilepsy + crohns)
Talk about the CVD risk with menopause treatment?
No solid evidence
HRT can reduce plaques if started before they have formed however it can destabilise already formed plaques
- do not give to >60 years without careful consideration
Talk about the stroke risk with menopause treatment?
Risk increased on oral HRT
Talk about the T2DM risk with menopause treatment?
No assoc risk
How often is mirena replaced if used in HRT?
Every 4 years
Who should have transdermal HRT tx?
Everyone but esp:
- gastric upset (e.g. crohns)
- need for steady absorption (migraine, epilepsy)
- perceived increased risk of VTE
- older women
- HTN
- patient choice
What is premature ovarian insufficiency (POI) aka?
Premature menopause (<40yrs)
What are some causes of POI?
- mostly idiopathic
- chromosomal abnormalities
- FSH receptor gene polymorphisms
- inhibin B mutations
- iatrogenic: surgery, chemo/radio
- enzyme deficiencies
- autoimmune disease
- infections: mumps, TB, malaria
How do you diagnose POI?
FSH 25iu/l on 2 samples >4weeks apart
AND
4months of amenorrhoea
How do you treat POI?
Oestrogen replaement - HRT preferred - COCP (increased risk of VTE) Fertility - donor egg - surrogacy Androgen replacement - testosterone gel
Why is it recommended to give HRT until menopause in POI patients?
To try and rebalance the deficiency to protect from stuff like decreased BMD which is likely to happen earlier on
Do you still need contraception during (premature) menopause?
Contraception required as fertile for:
- 2 years if menopause <50
- 1 year if menopause >50
What are some non-hormonal treatments for POI?
Alpha-adrenergic receptor agonists
- clonidine (for hot flushes)
SSRI
- fluoxetine, paroxetine, citalopram, sertraline
SNRI
- venlafaxine
Anti-epileptics
- gabapentin
What does sertraline CI with?
Tamoxifen
Why should you gradually stop clonidine?
It is an anti-hypertensive so needs to be gradually topped to avoid rebound HTN.
What are some causes of irregular menstrual bleeding?
Benign: idiopathic, anovulatory cycles, fibroids, PID, polyps, endometriosis, adenomyosis
Malignant: Endometrial carcinoma, cervical carcinoma
Systemic: Thyroid or clotting abnormalities
Investigations in irregular menstrual bleeding?
- FBC, TFTs,
- Pregnancy test
- Cervical smear
- USS (biopsy if abnormal)
Management of irregular menstrual bleeding?
If <35: IUS, COCP or NSAIDS/TXA if wanting to conceive
If >35: Pelvic USS +/- biopsy first. IUS/COCP or NSAIDS/TXA. HRT if perimenopausal
If postmenopausal bleeding: urgent pelvic uss, biopsy if endometrium >4mm or bleeding
If PCB: Cervical smear + colposcopy. consider cryotherapy
What is androgen insensitivity syndrome?
AIS occurs when a male has cell receptor insensitivity to androgens, which are converted peripherally to oestrogens. The indiviudal appears to be female: the diagnosis is only uncovered when ‘she’ presents with amenorrhoea. The uterus is absent and rudimentary testes are present. These are removed because of risk of malignant change and oestrogen replacement therapy is started.
What is Lichen Sclerosis?
Lichen Sclerosis is thought to be an autoimmune disorder. Elastic tissue turns to collagen (usually after middle age or before puberty).
What are the signs of Lichen Sclerosis?
- Bruised, red, purpuric areas
- Bullae, erosions, ulcerations
- Vulva gradually becomes white, flat and shiny.
- May be an hourglass shape around vulva and anus.
- intensely itchy
Treatment of lichen sclerosis?
- Clobetasol propionate cream
- If steroid resistant use Tacrolimus.
What are hydatidiform moles?
Type of gestational trophoblastic disease in womb. Tumours consisting of proliferating chorionic villi which have swollen and degenerated. Derived from chorion, it makes lots of hCG, giving rise to exaggerated pregnancy symptoms and strongly positive pregnancy tests.
What makes hydatidiform moles more likely to occur?
- Extremes of childbearing age
- After previous mole
- Asian women
Signs of hydatidiform moles?
- Early pregnancy failure eg. failed miscarriage or signs on USS
- Bleeding may be heavy
- Molar tissue may look like frogspawn
- Rarer: Severe morning sickness or 1st trimester pre-eclampsiai.
What would USS scan show for hydatidiform moles?
‘Snowstorm effect’.
Treatment of hydatitiform moles?
- Molar tissue is removed from the soft, easily perforated uterus by gentle suction.
- Send to histo to confirm dx
- Give anti D if rhesus -ve
- Avoid pregnancy for 6months until hCg normal
Possible complications of hydatidiform moles?
- Choriocarcinoma.
- Or metastisization to lung, vagina, brain, liver and skin
Describe characteristics of atrophic vaginitis?
- Clear/blood stained discharge
- Watery consistency
- No odour
- No itch
- TReatment is with topical oestrogen
What is pelvic inflammatory disease?
Sexually transmitted upper genital tract infection due to:
- Ascending endocervical infection
- Sexual factors
- No barrier contraception
- Multiple partners
- Descending abdominal infection
- eg appendicitis
Common causes of PID?
- Chlamydia (often asymptomatic)
- Gonorrhoea
- Anaerobes
Clinical presentation of PID?
- Constant or intermittent pelvic pain
- Deep dyspareunia
- Bleeding: irregular periods, intermenstrual beeding, post-coital bleeding
- Discharge (due to concurrent vaginal infection)
- Uncommonly fever
On examination of PID?
- Cervical motion pain
- Adnexal tenderness
Investigations for PID?
- Endocervical swabs - for chlamydia and gonorrhoea testing
- Increased WCC and CRP
- USS to exclude abcesses and cysts
- Laparoscopy with fimbrial biopsy and culture
Treatment of PID?
IM Ceftriaxone followed by Doxycycline or Metronidazole.
Complications of PID?
Early: Abcess or pyosalpinx Late: - Tubal obstruction - Subfertility - Chronic PID - Chronic pelvic pain - Ectopic pregnancy
What is chronic PID?
Persisting infection as a result of non/inadequate treatment of acute PID, leading to:
- Dense pelvic adhesions
- Fallopian tube obstruction
Symptoms of chronic PID?
- Chronic pelvic pain
- Dysmenorrhoea
- Deep dyspareunia
- Heavy and irregular menstruation
- Chronic vaginal discharge
- Subfertility
On exam of chronic PID?
Abdominal and adnexal tenderness
Fixed retroverted uterus
Investigations for chronic PID?
- TVUS - fluid collection in fallopian tube, surrounding adhesions
- Laparoscopy would reveal adhesions
Treatment of chronic PID?
- Analgesia and abx (only if active infection)
- Adhesiolysis
- Salpingectomy
Where are the vagina and uterus derived from?
Mullerian duct system and urogenital sinus.
What are some genital abnormalities?
- Vaginal septae: common, easily missed
- Duplication of cervix and/or uterus: May only present when woman has coil in but becomes pregnant in the other uterus
-Bicornuate uterus: partially divided uterus
-Unicornuate uterus: one side has dailed to develop.
Bicornuate and unicornuate uterus presents with recurrent miscarriage, difficulties in labour.
-Imperforate hymen
What is imperforate hymen?
When the membrane at the mouth of the vagina where the mullerian and urogenital systems fuse is imperforate.
Signs of imperforate hymen?
There is primary amenorrhoea, with history of monthly lower abdo pain and swelling, adn the membrane bulging under the pressure of dammed up menstrual blood (haematocolpos)
Treatment of imperforate hymen?
Cruciate incision in the membrane.
What is turners syndrome?
45 X0 monosymy in 40-60%
Signs of turners:
Newborn: Lymphoedema of hands and feet, cardiac and renal abnormalities (coarc of aorta, absent kidney)
Infancy: Short stature, webbed neck, behavioural difficulties, recurrent otitis media, hearing loss
Adolescence: gonadal dysgenesis (streak ovary) results in absent or incomplete puberty, amenorrhoea, impaired growth.
Treatment of turners?
Recombinant human growth hormone used to treat short stature.
Supplemental oestrogen initiates puberty and stops osteoporosis.
What is Ashermans syndrome?
an acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix
What are the commonest pituitary tumours seen in pregnancy?
Prolactinomas
Clinical features of prolactinoma?
- Amenorrhoea
- Galactorrhoea
- Headache
- Visual field defects (bitemporal hemianopia)
- Diabetes Insipidues
What is the effect of pregnancy on the prolactinoma?
They could increase in size in pregnancy and cause symptoms. Highest risk is in 3rd trimester with macroprolactinomas. Pregnancy should be delayed until tumour shrinkage has occurred wtih drug therapy.
What is the effect of the prolactinoma on pregnancy?
High prolactin levels lead to infertility. Most cases have no complications in pregnancy.
Management of prolactinoma?
- Outside pregnancy: Dopamine receptor agonists eg Cabergoline and Bromocriptine reduce prolactin levels, these should be stopped upon confirmation of pregnancy
- If sx of tumour expansion do CT or MRI
Causes of hyperprolactinaemia?
- Normal pregnancy and breastfeeding
- Pituitary adenomas
- Hypothalamus or pituitary stalk lesions
- Empty sella syndrome
- Hypothyroidism
- Chronic renal failure
- Drugs; phhenothiazine, metoclopramide, methyldopa.
