OB-GYN Revision 13 Flashcards
A diagnosis of PCOS requires at least two of: [3]
Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound
Describe the presentation of ovarian cysts [5]
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.
Occasionally, ovarian cysts can cause vague symptoms of:
* Pelvic pain
* Bloating
* Fullness in the abdomen
* Pain during sex
* A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
* Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst
Describe the difference between follicular and corpus luteums cysts [2]
Follicular cysts
- represent the developing follicle.
- When these fail to rupture and release the egg, the cyst can persist.
- Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles.
- Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.
Corpus luteum cysts
- occur when the corpus luteum fails to break down and instead fills with fluid.
- They may cause pelvic discomfort, pain or delayed menstruation.
- They are often seen in early pregnancy.
Give a basic overview of the follicular and luteal phase of an average cycle with regards to structures created in the ovaries [2]
First two weeks of average 28 day cycle, the ovaries go through the follicular phase:
- couple of follicles become the dominant follicle that releases an ovum in ovulation
- the rest degress and die off
- the follicles secrete oestrogen - which inhibits FSH
At ovulation the oocyte is released into the fallopian tube and luteal phase begins (remaining 2 weeks of 28 day cycle):
- corpus luteum (remnant of ovarian follicle) makes progesterone, which inhibits LH
- if fertilisation occurs the corpus luteum continues to make progesterone until the placenta forms.
- If no fertilisation, then becomes fibrotic and becomes the corpus albicans
Describe what theca lutein cysts are [1] and when they occur [2]
Caused by overstimulation of hCG during pregnancy
- stimulates growth in follicular theca cells
- occur in high hCG: multiple pregnancy; trophoblastic disease
NB: Theca cells are essential for female reproduction being the source of androgens that are precursors for follicular oestrogen synthesis
Describe what is meant by a Dermoid Cysts / Germ Cell Tumours [1]
What pathology are they particularly associated with? [1]
These are benign ovarian tumours.
They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone.
They are particularly associated with ovarian torsion.
Which type of tumours are the most common type in young women? [1]
Mature cystic teratomas
What are the two types of serous and mucinous cysts? [2]
Serous or Mucinous cystadenomas
Serous or Mucinous cystadenocarcinomas
Which investigations would you conduct for ?ovarian cysts [2]
Blood tests:
- If premenopausal w simple cyst < 5cm on US - none
- CA125 helps determine if cyst is related to cancer
- If under 40 and complex cysts - need tumour markers (AFP; LDH; HCG)
Abdominal Ultrasounds:
* simple: unilocular, more likely to be physiological or benign
* complex: multilocular, more likely to be malignant
As per RCOG how do you monitor cysts if:
o If pre-menopausal + asymptomatic simple cyst < 5 cm [1]
o If 5-7 cm –> [1]
o If > 7 cm –> [1]
o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> [1]
o If post-menopausal –> [2]
o If pre-menopausal + asymptomatic simple cyst < 5 cm –> no follow-up
o If 5-7 cm: - repeat USS in 1 year, and if growing –> refer
o If > 7 cm –> refer
o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> refer
o If post-menopausal –> CA-125, and if normal + asymptomatic simple cyst < 5 cm –> repeat USS in 4-6 months
What would be the referral protocol if:
- postmenopausal, raised CA125
- Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral.
- Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
Describe what is meant by Meig’s syndrome [3]
- Meig’s syndrome involves a triad of:
- Ovarian fibroma (a type of benign ovarian tumour)
- Pleural effusion
- Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.
Describe the examination results of ovarian torsion [2]
On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.
Describe why you should still suspect ovarian torsion in younger girls [1]
Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
Describe the diagnosis and management of ovarian torsion [3]
Diagnosis:
Pelvic US:
- Transvaginal is 1st choice, but transabdominal can also be used
- “whirlpool sign”: free fluid in pelvis and oedema of the ovary.
- Doppler studies may show a lack of blood flow
- The definitive diagnosis is made with laparoscopic surgery.
Management:
Laparoscopic surgery to either:
* Un-twist the ovary and fix it in place (detorsion)
* Remove the affected ovary (oophorectomy)
It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.
What are these other conditions? [2]
Lichen simplex
- chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
Lichen planus
- an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
What are the 4 types of FGM? [4]
Type 1: Removal of part or all of the clitoris
Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
Type 3: Narrowing or closing the vaginal orifice (infibulation).
Type 4: All other unnecessary procedures to the female genitalia.
Describe what is meant by a transverse vaginal space [1]
Transverse vaginal septae is caused by an error in development, where a septum (wall) forms transversely across the vagina.
This septum can either be perforate (with a hole) or imperforate (completely sealed).
- Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use.
- Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation
Define Asherman’s syndrome [1]
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
Describe the presentation of nabothian cysts [2]
Nabothian cysts appear as smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.
TOM TIP: It is worth becoming familiar with photographs of nabothian cysts. They are relatively common. They can have a raised and discoloured appearance, creating concern when you first see them. With practice, you will be able to identify them correctly, and the woman can be reassured. Getting a senior opinion if there is any doubt creates a feedback loop that helps you confirm your impression and build your confidence in making the correct diagnosis.
Describe what a cervical ectropian is [2]
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal
- Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
Describe what is meant by a vault prolapse [1]
When does it occur? [1]
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus.
The top of the vagina (the vault) descends into the vagina.
Define rectocele [1]
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
What are the 4 grades of uterine prolapse? [4]
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
