Obs and Gynae Flashcards
Define primary amenorrhoea
Not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development
What is hypogonadism?
Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise before and during puberty. A lack of these hormones causes a delay in puberty.
What are the two types of hypogonadism?
Hypogonadotropic hypogonadism: a deficiency of LH and FSH
Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
Give three causes of hypogonadotropic hypogonadism.
Hypopituitarism (under production of pituitary hormones)
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome
Give three causes of hypergonadotropic hypogonadism
Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)
What causes congenital adrenal hyperplasia?
Congenital adrenal hyperplasia is caused by a congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth.
What is the pattern in congenital adrenal hyperplasia?
It is a genetic condition inherited in an autosomal recessive pattern.
How does congenital adrenal hyperplasia present?
In severe cases, the neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. In mild cases, female patients can present later in childhood or at puberty with typical features:
Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
What is androgen insensitivity syndrome?
Androgen insensitivity syndrome is a condition where the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop.
How does androgen insensitivity syndrome present?
It results in a female phenotype, other than the internal pelvic organs. Patients have normal female external genitalia and breast tissue. Internally there are testes in the abdomen or inguinal canal, and an absent uterus, upper vagina, fallopian tubes and ovaries. Primary amenorrhoea
How do we investigate primary amenorrhoea?
Initial investigations assess for underlying medical conditions:
Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal blood tests assess for hormonal abnormalities:
FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
Thyroid function tests
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia
Genetic testing with a microarray test to assess for underlying genetic conditions:
Turner’s syndrome (XO)
Imaging can be useful:
Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
Pelvic ultrasound to assess the ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome
How do we manage hypogonadotropic hypogonadism?
Pulsatile GnRH can be used to induce ovulation and menstruation. This has the potential to induce fertility. Alternatively, where pregnancy is not wanted, replacement sex hormones in the form of the combined contraceptive pill may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency.
Define secondary amenorrhoea
Secondary amenorrhea is defined as no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.
Give three causes of secondary amenorrhoea
Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
Give three stresses that could lead to secondary amenorrhoea
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example:
Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress
Give two pituitary causes of secondary amenorrhoea
Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
How does high prolactin impact GnRH release, and what does this lead to?
High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism. Only 30% of women with a high prolactin level will have galactorrhea (breast milk production and secretion).
How do we investigate secondary amenorrhoea?
Detailed history and examination to assess for potential causes
Hormonal blood tests
Ultrasound of the pelvis to diagnose polycystic ovarian syndrome
Which hormone tests would we use in secondary amenorrhoea?
Beta human chorionic gonadotropin (HCG) urine or blood tests are required to diagnose or rule out pregnancy.
Luteinising hormone and follicle-stimulating hormone:
High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome
Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour.
Thyroid stimulating hormone (TSH) can screen for thyroid pathology. This is followed by T3 and T4 when the TSH is abnormal.
Raise TSH and low T3 and T4 indicate hypothyroidism
Low TSH and raised T3 and T4 indicate hyperthyroidism
Raise testosterone indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.
How do we reduce risk of endometrial cancer in PCOS patients?
Women with polycystic ovarian syndrome require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed.
What is premenstrual syndrome?
Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation. These symptoms can be distressing and significantly impact quality of life.
Give five symptoms of PMS
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
How do we manage PMS in primary care?
General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP)
SSRI antidepressants
Cognitive behavioural therapy (CBT)
How do we diagnose PMS?
Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation.
Which COCP is recommended first-line in PMS?
RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone (less breast swelling, water retention and bloating)
What is normal and excessive blood loss during menstruation?
On average, women lose 40 ml of blood during menstruation. Excessive menstrual blood loss involves more than an 80 ml loss.
How do we diagnose heavy menstrual bleeding?
The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. Heavy menstrual periods can have a significant impact on quality of life.
Give three causes of heavy menstrual bleeding
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
How do we investigate HMB?
Pelvic examination with a speculum and bimanual should be performed, mainly to assess for fibroids, ascites and cancers.
Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.
When should outpatient hysteroscopy be arranged for investigation of HMB?
Suspected submucosal fibroids
Suspected endometrial pathology, such as endometrial hyperplasia or cancer
Persistent intermenstrual bleeding
When should pelvic and tvs us be arranged for investigation of HMB?
Possible large fibroids (palpable pelvic mass)
Possible adenomyosis (associated pelvic pain or tenderness on examination)
Examination is difficult to interpret (e.g. obesity)
Hysteroscopy is declined
How do we treat HMB in a patient who does not want ocntraception?
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
How do we treat HMB in a pt who wants contraception?
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)
Progesterone only contraception may also be tried, as it can suppress menstruation. This could be the progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant).
How do we treat HMB when medical management hasn’t worked?
The final options when medical management has failed are endometrial ablation and hysterectomy.
Endometrial ablation involves destroying the endometrium. The first generation of ablative techniques involved a hysteroscopy and direct destruction of the endometrium. This has been replaced by second generation, non-hysteroscopic techniques that are safer and faster. A typical example of one of these techniques involves passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining. This is called balloon thermal ablation.
What are fibroids?
Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas. Oestrogen sensitive
How do we investigate fibroids?
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
Pelvic ultrasound is the investigation of choice for larger fibroids.
MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
How do we manage fibroids?
For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding:
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
More than 3cm = referral to gynaecology
Give three surgical options for larger fibroids
Uterine artery embolisation
Myomectomy (surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.)
Hysterectomy
What might we give to reduce the size of fibroids before surgery?
GnRH agonists, such as goserelin or leuprorelin. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
What is red degeneration of fibroids?
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
When is red degeneration of fibroids most likely to occur?
Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
How does red degeneration of fibroids present? How do we manage it?
Severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
How does endometriosis present?
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria
There can also be cyclical symptoms relating to other areas affected by the endometriosis:
Urinary symptoms
Bowel symptoms
How do we diagnose endometriosis?
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
What is endometriosis?
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma.
Why do we use COCP in the treatment of endometriosis?
Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.
What is adenomyosis?
Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall.
How does adenomyosis present?
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
How do we investigate adenomyosis?
Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
How do we manage adenomyosis?
Same as HMB
How do we diagnose menopause
Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation.
What is perimenopause?
Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
What is premature menopause?
Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
What causes the menopause?
Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
What are the perimenopausal symptoms?
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
Which conditions does a lack of oestrogen increase the risk of?
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Give two side effects of the progesterone depot injection
Weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.
Define premature ovarian insufficiency
Premature ovarian insufficiency is defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.
What will hormonal analysis in premature ovarian insufficiency show?
Premature ovarian insufficiency is characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show:
Raised LH and FSH levels (gonadotropins)
Low oestradiol levels
How does premature ovarian insufficiency present?
Premature ovarian insufficiency presents with irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness.
How do we diagnose primary ovarian insufficiency?
NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in women younger than 40 years with typical menopausal symptoms plus elevated FSH.
The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.
How do we manage primary ovarian insufficiency?
Management involves hormone replacement therapy (HRT) until at least the age at which women typically go through menopause. HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required.
How do we reduce VTE risk in pts taking HRT?
There may be an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches).
What must you prescribe as HRT for a woman with a uterus?
Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT.
What must you prescribe as HRT for a woman still having periods?
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.
What should you prescribe as HRT for a woman with a uterus and more than 12 months without periods?
Continuous combined HRT
What is clonidine? What is it used for?
Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
Give three side effects of clonidine
Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.
Give four indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
Give four risks of HRT
Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
Increased risk of endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
Give the oestrogenic SEs of HRT
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
Give the progestogenic SEs of HRT
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
What is the best way of delivering oestrogen as HRT?
Patches, due to the reduced risk of VTE
What’s the best way of delivering progesterone as HRT?
IUD, e.g. the Mirena coil
What is oligoovulation?
irregular, infrequent ovulation
What is oligomenorrhoea?
Irregular, infrequent menstrual periods
What are androgens?
Male sex hormones, e.g. testosterone
What is hirtuism?
The growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
What are the Rotterdam criteria?
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Give two symptoms of PCOS not in the Rotterdam criteria
Infertility
Obesity
Hair loss in a male pattern
Insulin resistance
Where do you see acanthosis nigricans?
Insulin resistance
Give four causes of hirtuism.
Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
What do hormonal blood tests show in PCOS?
Raised luteinising hormone **
Raised LH to FSH ratio (high LH compared with FSH) **
Raised testosterone
Raised insulin
Normal or raised oestrogen levels
How does a polycystic ovary present on TVS?
The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.
What are the diagnostic criteria for PCOS on TVS?
The diagnostic criteria are either:
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
What is an impaired fasting glucose =?
7mmol/l or higher
What is an impaired glucose tolerance?
Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
How do we diagnose diabetes using an oral glucose tolerance test?
Plasma glucose at 2hrs above 11.1mmol/l
What is the best way to manage PCOS?
Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.
Why are women with PCOS more likely to develop endometrial cancer?
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
How do we manage the risk of endometrial cancer in PCOS?
Options for reducing the risk of endometrial hyperplasia and endometrial cancer are:
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill
When do we assess female patients endometrial thickness?
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
How do we manage acne in PCOS?
The combined oral contraceptive pill is first-line for acne in PCOS. Co-cyprindiol may be the best option as it has anti-androgen effects; however, there is a significantly increased risk of venous thromboembolism. Also treat hirtuism.
What is a tumour marker for ovarian cancer?
CA125
Give the tumour markers for possible germ cell tumours (? ovarian ca in under 40 y.o.)
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
What is the risk of malignancy index?
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
What is Meig’s syndrome? How is it managed?
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.
How does ovarian torsion present?
The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting.
The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.
What is seen O/E with ovarian torsion?
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.
How do we diagnose ovarian torsion?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow.
Laparoscopic surgery
What is Asherman’s syndrome?
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
How does Asherman’s syndrome present?
Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with:
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
It may also present with infertility.
How do we diagnose Asherman’s syndrome?
There are several options for establishing a diagnosis of intrauterine adhesions:
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan
What is cervical ectropion?
Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.
How does cervical ectropion present?
Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests.
Ectropion may present with increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding.
How do we manage cervical ectropion?
Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
How do nabothian cysts present?
Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis.
How do we manage nabothian cysts?
Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously.
If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.
What is a vault prolapse?
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 vagin
What is a rectocele? How does it present?
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.
How does pelvic organ prolapse present?
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
How do we manage pelvic organ prolapse?
Conservative management
Vaginal pessary
Surgery
How does urge incontinence present?
The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
What causes urge incontinence?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder.
What causes stress incontinence?
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles
What is overflow incontinence?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine.
What is the post-void residual bladder volume used to identify?
Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
What is atrophic vaginitis?
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. It occurs in women entering the menopause
How does atrophic vaginitis present?
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
How do we manage atrophic vaginitis?
Vaginal lubricants can help symptoms of dryness.
Topical oestrogen can make a big difference in symptoms. Options include:
Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months
What are the Bartholin’s glands?
The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
How do we manage Bartholin’s cysts?
Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).
How do we manage Bartholin’s abscesses?
A Bartholin’s abscess will require antibiotics. A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. E. coli is the most common cause. Send specific swabs for chlamydia and gonorrhoea.
What is lichen sclerosus?
An autoimmune condition, a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.
What is lichen simplex?
Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
What is Lichen planus?
Lichen planus is 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.
How does Lichen sclerosus present?
The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
What is the Koebner phenomenon?
The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.
How do we manage lichen sclerosus’/
Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist.
Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.
Emollients
Give the main complication of lichen sclerosus
The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.
Who must we inform when we see a patient with FGM?
The police if the patient is under 18
Why don’t the female internal organs develop in androgen insensitivity syndrome?
The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
What is the common presentation for androgen insensitivity syndrome?
Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.
How do we manage androgen insensitivity syndrome?
Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
What develops from the Mullerian ducts?
The upper vagina, cervix, uterus and fallopian tubes
Who is given the HPV vaccine? What is it for?
HPV type 16 and 18, as they are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine.
Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer and genital warts.
How does HPV promote the development of cancer?
P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
What increases risk of catching HPV?
Increased risk of catching HPV occurs with:
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Non-engagement with cervical screening is a significant risk factor. Many cases of cervical cancer are preventable with early detection and treatment of precancerous changes.
How does cervical cancer present?
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
How does cervical cancer present OE?
Ulceration
Inflammation
Bleeding
Visible tumour
What is cervical intraepithelial neoplasia?
Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are:
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
Describe the cervical screening program
Every three years aged 25 – 49
Every five years aged 50 – 64
What is the most common endometrial cancer?
Adenocarcinoma
What is endometrial cancer?
Endometrial cancer is cancer of the endometrium, the lining of the uterus
What does PCOS lead to increased risk of endometrial cancer
Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation. Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg. It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle). Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum. Without developing a corpus luteum during the menstrual cycle, progesterone is not produced, and the endometrial lining has more exposure to unopposed oestrogen.
Why is obesity a risk factor for endometrial cancer?
Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen. Adipose tissue is the primary source of oestrogen in postmenopausal women. Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen. Androgens are produced mainly by the adrenal glands. In women with more adipose tissue, and therefore more aromatase enzyme, more of these androgens are converted to oestrogen. This extra oestrogen is unopposed in women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.
How does endometrial cancer present?
The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding.
How would you manage a 55 F patient presenting with unexplained vaginal discharge and haematuria?
Transvaginal ultrasound
Which biopsy do we use to diagnose endometrial cancer?
A pipelle biopsy can be taken in the outpatient clinic. It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer. Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.
How do we manage endometrial cancer?
The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
How does ovarian cancer present?
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
How do we investigate ovarian cancer?
The initial investigations in primary or secondary care are:
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
What is the risk of malignancy index?
Menopausal status
Ultrasound findings
CA125 level
What is the most common form of vulval cancer?
Around 90% are squamous cell carcinomas.
What is VIN?
Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).
