Obs + gynae Flashcards
Ectropion overview
(previously cervical ectopy, cervical erosion or abrasion)
Under the influence of oestrogen the columnar epithelium of the endocervix is displayed beyond the os.
Dx: It is seen on examination as a red ring around the os and is so common.
Cause/epidemiology: It is most commonly seen in teenagers, during pregnancy and in women on combined oral contraception (COC).
Presentation: asymptomatic (occasionally, bleeding or excessive discharge)
Mx:
Cervical smear (Pap smear) for all.
Stopping any oestrogen-containing contraceptive
If asymptomatic»_space; conservative management. Over time, vaginal acidity promotes metaplasia to squamous epithelium.
4. If there are symptoms»_space; treatment options:
Diathermy, Cryotherapy, Laser Treatment, Microwave therapy
Bartholin’s cyst/abscess
Background:
Common in ages 20-30 in roughly 3% of women
Most common in women of childbearing age
If they present after age 40 must consider a malignant cause (although rare)
Pathology:
Two small glands located slightly posteriorly at both sides of the vaginal introitus (vaginal opening), secreting mucus to lubricate the vagina
Normally cannot be palpated and pea sized
Damage or infection of the ostium of the duct causes a blockage or cyst, which can become infected resulting in an abscess
Aetiology:
abscess - Infection, most commonly E. coli, gonorrhoea or chlamydia
Bartholin’s cyst risk factors and presentation
Risk factors:
STI
Ages 20-30
Presentation:
Typically unilateral presentation
Small cyst - soft painless lump, may be fluctuant
Large cyst - uncomfortable when mobilising, sitting and dyspareunia
Abscess - erythematous, hot to touch, hard, tender mass arising over 1-2 days
Bartholin’s cyst diagnosis and management
Diagnosis:
Swab from contents of cyst/abscess
STI screening
+/- biopsy (women >40 should have excisional biopsy to rule out carcinoma)
Management:
Small and asymptomatic - warm compresses, good hygiene
Large and uncomfortable/abscess:
Sitz baths (warm baths helping drain abscess)
Antibiotics and analgesia
Surgical incision and drainage (avoided if possible as increases risk of recurrence)
Marsupialisation (incision and drainage under general anaesthetic and sides of abscess are sutured open for continuous drainage preventing recurrence
Word catheter (bartholin’s gland balloon - tube with balloon on the end, incision and drainage, word catheter inserted into abscess space and inflated <3ml under local anaesthetic) insertion for a few weeks to epithelialize new tract
Imperforate hymen overview
Hymen is the membrane at the mouth of the vagina where the Mullerian and urogenital systems fuse
The normal hymen has multiple variations of perforation, including an imperforate hymen
Aetiology:
Normal anatomical variation of fusion of the mullerian and urogenital systems during development
Presentation:
Apparent/false primary amenorrhea
History of monthly abdominal pain and swelling
Membrane bulging under pressure of hematocolpos (build up of menstrual blood)
Possible complication - hematometra and hematosalpinx (rare) blood builds up reaching uterus and ovaries
Investigation/diagnosis:
Genital examination
USS to assess for hematometra/hematocolpos
Management:
Relieved by cruciate incision into the hymen forming opening/perforation
Vaginal Genesis or atresia
Agenesis - Vagina and uterus are absent but ovaries are present (rare)
Atresia - lower portion of the vagina consists of fibrous tissue with a well differentiated uterus (rare)
Transverse vaginal septa overview
Background:
Relatively common, often missed on examination
Pathology:
Can be single or multiple, in the upper, mid or lower vagina
Can be patent or perforated
Aetiology:
Congenital anomaly during development
Presentation:
Transverse connective tissue within the vaginal canal
Investigation/diagnosis:
Vaginal examination
Management:
Surgery if needed
Cervical/uterus duplication overview
Background:
Common - duplication of uterus or cervix
Rare - condition present with primary amenorrhoea
Pathology:
Duplication of the cervix and/or uterus
Bi-cornuate uterus - partially divided
Unicornuate uterus - one side of uterus has failed to develop
Aetiology:
Congenital anomaly
Presentation:
May be missed on examination
Varies depending on duplications/divisions
Two asymptomatic smaller uteri/cervix
Recurrent miscarriage (particularly second trimester)
Labour difficulties
Based on type - dysmenorrhoea, haematometra, recurrent miscarriage, pregnancy and labour complications
Fertility usually not affected
Investigation/diagnosis:
MRI
3D USS
Hysterosalpingogram (HSG)
Management:
referral to gynaecology
Female genital mutilation background and risk factors
Background:
Partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons
In the UK the majority of affected women are from Somalia, Kenya, Eritrea, Ethiopia, Yemen
It is also common in Mali, Guinea and Egypt
Estimated around 137,000 females in the UK have been affected
Around 60,000 girls under age 15 are at risk of FGM in the UK (2015)
Risk factors:
Coming from a community that practices FGM
Family history of FGM
FGM classification
type I - Partial or total removal of clitoral glands (external and visible part of clitoris, very sensitive) and/or prepuce
type II - Partial or total removal of the clitoral glans and labia minora (inner folds of vulva) +/- labia majora
type III - AKA infibulation - narrowing of the vaginal opening through the creation of a covering seal. Seal is formed via cutting and repositioning the labia minora or majora sometimes with stitching. +/- removal of the clitoral prepuce and glans (type I FGM)
type IV - Includes all other harmful procedures to female genitalia for non-medical purposes (pricking, piercing, incising, scraping and cauterising the genital area
FGM complications
Immediate - death, shock, pain, haemorrhage, infection, adjacent organ damage, acute urinary retention
Long term reproductive - AIDS, HIV, blood borne disease, problems with pregnancy and childbirth, psychological and psychiatric problems
Long term pelvic organ complications - failure to heal, recurrent UTI, renal/bladder calculus formation, urethral obstruction/urinary retention, pelvic infections, abscesses, menstrual abnormalities and infertility, sexual dysfunction (VERY COMMON), fistulae
FGM investigations and management
Investigation/diagnosis:
FGM guidelines from the royal college of obs and gynae (RCOG) state every pregnant women must be asked if she has been cut and all those attending maternity, family planning, gynae, urology clinics should be routinely asked aboout FGM
Genital assessment
Must record:
If they have FGM
If there is a family history of FGM
If an FGM related procedure has been carried out on a woman
Management:
As of 2015, all FGM in girls under 18 must be reported to the police. Should also contact social services and safeguarding, paediatrics, specialist gynae/FGM services and counselling
In those >18 a risk assessment is used to determine if police/social services should be contacted: includes risk to other family members. (Gov.uk website)
Record grade of mutilation after consent for genital assessment
Refer to MDT for psychological and educational support (FGM clinic)
Infection, adjacent organ damage, fistulae to be managed PRN
Deinfibulation should be offered after a full assessment by an FGM specialist if: Intercourse problem Micturition problem Delivery problem Patients wish
Reinfibulation (performed after childbirth to re-close the vaginal orifice) is illegal
cervical cytology and NHS screening
NHS cervical screening programme (NHSCSP) aims to reduce incidence of and mortality from cervical cancers through a systematic quality assured population-based screening programme for eligible women
Testing:
Training is needed to ensure clinicians are competent to visualise the cervix and take a sample from the whole transformation zone
HPV triage and liquid based cytology that looks for abnormal cells
Primary high risk HPV (HR-HPV) testing now takes precedence
Reduction in inadequate tests and improved sensitivity compared to Papanicolaeou (PAP) smears
Cervical/LBC brush:
Enables simultaneous collection of endocervical, ectocervical and transformation zone cells with single device
Hairs are flexible so mucosal surface is well sampled but not damaged
Criteria for cervical screening and reasons to delay screening
Criteria for screening in the UK:
Screening for all women (transgender men or non-binary who have retained a cervix included) before between the ages of 24.5-64 years
Invitation sent to those aged 24.5 to ensure they can be screened before age 25
Screening from ages 25-49 every 3 years
Screening form ages 50-64 every 5 years
65< invited if: a recent cervical cytology sample is abnormal or they have not had cervical screening since age 50 and they request one
Delayed screening:
Avoid if:
Menstruating
<12 weeks postnatal
<12 weeks after pregnancy termination
Has vaginal discharge or pelvic infection - treat first
If pregnant (seek specialist advice if they have had a recent abnormality)
Those with any sexual contact/sexual orientation are at risk and should be screened
Women should be ceased from the programme where they no longer have a cervix or have undergone pelvic radiotherapy (they should have vault cytology)
Voluntary withdrawal: Must be done in writing
Reasons include
Low risk of cervical cancer (no sexual contact)
Physical or learning disability making process difficult or distressing
Terminally ill/will not benefit from screening
Unable to give adequate samples - FGM (gynae referral instead)
Those who do not want to participate (must be made aware of the risks)
HPV overview and vaccines available
Very common sexually transmitted virus
Most infectious are transient, usually the immune system clears the virus
If it persists, can cause genetic mutation predisposing to carcinogenic changes (responsible for 99% of cervical cancers)
13 high risk strains - 16 and 18 account for 80%
Vaccination programme from ages 12-13 both sexes
High negative predictive value of HR-HPV test raises prospect that HPV can become primary screening at more regular intervals
Vaccines:
Gardasil: protects against 4 types of HPV (6, 11, 16 and 18)
Gardasil 9: prevents infection from the same 4 strains plus 5 additional cancer causing types (31, 33, 45, 52 and 58)
Cervarix: discontinued, vaccinated against types 16 and 18
Liquid based cytology sampling, results and actions
Inadequate:
Sample taken but cervix not fully visualised
Taken inappropriately (using unapproved devices etc.)
Contains insufficient cells
Contains obscuring elements (lubricant, inflammation, blood etc.)
Incorrectly labelled
Samples must be repeated after 3 months (time taken for cells to regrow)
Two consecutive inadequate samples warrant referral to colposcopy to exclude invasive cancer
Results:
Negative: no abnormality detected
Abnormal:
Borderline changes in squamous or endocervical cells (cells seen with abnormal nuclei) - 1
Low grade dyskaryosis (abnormal nuclei and cell morphology) - usually CIN1. 1
High grade dyskaryosis (moderate) - usually CIN2. 2
High grade dyskaryosis (severe) - usually CIN3. 2
Invasive squamous cell carcinoma. 2
Glandular neoplasia. 2
1 - Colposcopy in 6 weeks
2 - Colposcopy in 2 weeks (2WW)
Colposcopy
Those who are HPV positive/present with abnormal cytology are referred to colposcopy allowing direct observation using a colposcope and staining of the cervix for either a punch biopsy or excisional treatment.
Acetic acid is applied to the cervix using cotton wool ball or spray to show cell changes by turning them white
Schiller’s iodine test uses iodine solution to stain normal cervical tissue dark brown. Cell changes may not stain
Excisional biopsy may be recommended for:
Most of endocervix is replaced with high grade abnormality
Low grade colposcopy change associated with high grade dyskaryosis (severe) or worse
Lesion extends into the canal - sufficient canal must be removed with endocervical extension of abnormality
Cervical intraepithelial neoplasia (CIN)
Premalignant lesion detected by colposcopy
Three stages dependent on how deep cell changes go into the OUTER surface of the cervix
CIN1: ⅓ thickness of the surface layer of the cervix is affected
CIN2: ⅔ 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. Full thickness of surface layer is affected
Left untreated, CIN2 or 3 (CIN2+) may progress to cervical cancer
Usually for all three grades only a small part of the cervix has abnormal changes
Cervical glandular intraepithelial neoplasia (CGIN)
Changes to the glandular cells that line the INSIDES of the cervix
Without treatment these cells can develop into adenocarcinoma
CGIN is less common than CIN but treated similarly
CIN and CGIN management
Large loop excision of the transformation zone (LLETZ)
Needle excision of transformation zone (NETZ/SWETZ)
Cone biopsy
Laser therapy ablation
Cold coagulation (thermoablation)
Cryotherapy
follow up spec exams on case by case basis and smear usually 1 year after treatments.
Invasive cancer - triage onto 2 week pathway for additional treatments
Large loop excision of transformation zone (LLETZ) and needle excision of transformation zone (NETZ/SWETZ) therapy
LLETZ
Uses a thin wire loop with an electrical current to remove the affected area of the cervix
Most common treatment for abnormal cells
Usually requires local anaesthetic although general can be requested
Risks of bleeding, change in vaginal discharge, cervical stenosis, premature birth or late miscarriage
NETZ
Straight wire excision of the transformation zone (SWETZ) and NETZ are similar to LLETZ but a thin wire is strength rather than looped
Treatment usually reserved for cell changes INSIDE the cervical canal (CGIN)
Cone biopsy treatment
Minor operation to remove a cone shaped piece of tissue of the cervix
Carried out under general anaesthesia usually taking about 15 minutes but may need overnight stay depending on complications
Usually use a medical “plug” tampon to help stop any initial bleeding
Advise to avoid menstruation tampons, sexual intercourse or contact and swimming for at least 4 weeks
Abnormal vaginal bleeding terminology
Polymenorrhea: frequent periods within the calendar month (<21 day interval between 2 consecutive periods)
Oligomenorrhea: less frequent periods or delayed periods >35 days
Dysmenorrhoea: pain before and with periods lasting 1-3 days from onset of bleeding
Menorrhagia: heavy menstrual bleeding and usually for longer duration >7 days
Intermenstrual bleeding: vaginal bleeding (other than postcoital) at any time during the menstrual cycle other than normal menses. May indicate underlying cervical/uterine pathology such as fibroids, endometriosis or cancers
Postcoital bleeding: non-menstrual bleeding occurring immediately after sexual intercourse. Following vaginal sex, may indicate cervical pathology or PID
Dyspareunia
Pain during or after sexual intercourse, can affect men but more common in women
Can be superficial (localised to vulva or vaginal entrance) while deep pain is often inside the vagina or lower pelvis
Causes are vaginal or genital infections, vaginal dryness, menopause (atrophic vaginitis), vigorous activity
Menorrhagia
Background:
Excessive (heavy) menstrual blood loss occurring regularly (every 24-35 days) interfering with a women’s physical, emotional, social and material quality of life
The average blood loss during menses is 30-40mL, 90% of women have losses <80mL
Excessive blood loss is classified at >80mL and/or a duration of >7 days - direct measurement is accurate but difficult to undertake in clinical practice
It is also defined as the need to change a menstrual product every 1-2 hours, passage of clots >2.54cm and/or “very heavy” periods as reported by women
Can occur alone or in combination with associated symptoms
One of the most common causes of referral to gynaecologist, especially in women aged 30-49
Up to 25% of women suffer at least one episode of dysfunctional uterine bleeding during reproductive years and around 20% will have a hysterectomy before age 60 to alleviate heavy bleeding
Pathology:
As the corpus luteum regresses the concentrations of oestrogen and progesterone decrease. At their lowest concentrations, spiral arteries collapse and the functional endometrial layer of the uterus “sloughs off” for menstruation
Bleeding occurs for an average of 5 days (>7 days menorrhagia)
Menorrhagia cause and presentation
Aetiology:
50% idiopathic (dysfunctional uterine bleeding)
Uterine and ovarian pathologies - fibroids, endometriosis, adenomyosis, PID and infection, endometrial polyps or hyperplasia, PCOS
Systemic diseases - coagulation disorders (willebrand disease), hypothyroidism, diabetes, hyperprolactinaemia, liver/renal disease
Iatrogenic - anticoagulant, chemotherapy, herbal supplements (ginseng, ginkgo, soya), IUD
Presentation:
Heavy bleeding during menstruation
Associated symptoms of underlying cause (dysmenorrhoea, pelvic pain, vaginal discharge, postcoital bleeding, menstrual irregularity)
Complications - iron deficiency anaemia (⅔ cases), increased risk of endometrial pathology, negative impacts on psychosocial, emotional or material quality of life
Menorrhagia investigations and diagnosis
Investigation/diagnosis:
No associated symptoms - consider pharmacological treatment without examination
Associated symptoms - genital examination
FBC (iron def. anaemia)
Hysteroscopy/pelvic USS/transvaginal USS - Suspected fibrous, polyps, endometrial pathology
Vaginal or cervical swab - infection
TFTs
Coagulation studies/genetic testing - coagulation disorders
Management:
Provide information and reassurance of natural variability of menstrual blood loss and information of possible treatments (NHS on heavy periods - https://www.nhs.uk/conditions/heavy-periods/)
Idiopathic/fibroids <3cm or adenomyosis -
LNG-IUS first line
2nd line Tranexamic acid or NSAIDs (non-hormonal) or combined oral contraceptive/cyclical oral progesterone (hormonal) prescription
Progesterone only contraception may suppress menstruation
Fibroids >3cm diameter -
Tranexamic acid and/or NSAIDs, advise to continue for as long as is beneficial
LNG-IUS, CHC or cyclical oral progesterone 2nd line
Uterine artery embolisation
Surgery (myomectomy, hysterectomy, 2nd generation endometrial ablation)
Vaginal concern history taking
Nature of bleeding and impact on quality of life
Age - first year after menarche and perimenopause are associated with irregular cycles and anovulatory bleeding
Cervical screening history, previous abnormal results and treatments
Details of normal cycles (length, frequency, intermenstrual bleeding, postcoital bleeding, pains between periods, vaginal discharge, dyspareunia, pain in rectum, days of menses and variation from normal pattern)
Sexual history (current contraception, future family plans, partners, STI screening, type of sex, pain with sex/associated symptoms)
Medical history (endometriosis, family history of coagulation disorders, PID, willebrand disease, comorbidities
Drug history including previous menorrhagia treatments
Smoking history
Obstetric history
Related symptoms (intermenstrual bleeding, pelvic pain, pressure symptoms)
Referrals:
Urgent - ascites and/or pelvic/abdominal mass + weight loss using 2WW pathway, no weight loss - 4 week wait referral
Compressive symptoms from large fibroids (dyspareunia, pelvic pain, discomfort, constipation, urinary symptoms)
Iron deficiency anaemia failed to respond to treatment and other causes excluded (2WW)
Menorrhagia has not improved despite treatment
menorrhagia management advise on treatment
- levonorgestrel-releasing IUS - warn of changes in bleeding pattern, particularly first few cycles maybe >6 months and it is advisable to wait at least 6 cycles to see benefits of treatment*
- uterine artery embolisation - cannulating femoral artery and identifying uterine arteries to inject embolic agents to impair blood supply to fibroids. May potentially allow them to retain fertility*
- myomectomy - inform it may potentially allow retained fertility and may increase pregnancy rate compared to UAE in women with fibroids*
- hysterectomy - can be vaginal, abdominal or laparoscopic. May include removal or preservation of ovaries/cervix. Should be informed of risk of haemorrhage, organ damage, loss of ovarian function/menopause. Should discuss the psychological impact, alternative surgery, expectations, complications, further treatments needed, bladder function, impact on fertility*
- endometrial ablation - destroys endometrial lining and superficial myometrium of uterus (muscle). Inform them to avoid subsequent pregnancy (must be on effective contraception)*
dysmenorrhoea
Background:
Painful cramping, usually in the lower abdomen occurring shortly before and/or during menstruation (pain lasting >3 days from period onset)
Can be primary (alone) occurring in young females with no pelvic pathology, 90% of women at reproductive age report this
Secondary occurring in association with pelvic pathology, less common
Childbirth reduces dysmenorrhoea and severity diminishes with age
Pathology:
Thought to be from an excess/imbalance of prostaglandins and leukotrienes in the menstrual fluids producing vasoconstriction in uterine vessels
This causes uterine contractions causing pain and may also be responsible for diarrhoea, nausea, headache, light-headedness
dysmenorrhea aetiology and risk factors
Aetiology:
Primary: thought to be caused by prostaglandin production during menstruation (from progesterone drop) stimulating uterine myometrial contractions leading to decreased blood flow, uterine hypoxia and pain
Secondary: Pelvic disorders (endometriosis, fibroids, PID, ovarian cancer, IUD)
Risk factors: Longer duration of menses Early menarche Smoking Alcohol Obesity Depression or poor social support networks Risk factors for more severe symptoms: Earlier age of menarche Menorrhagia Nulliparity Family history
Presentation for dysmenorrhea
Painful cramping, usually in the lower abdomen occurring shortly before and/or during menstruation
Primary - often begins with onset of ovulatory cycles, six months-1 year after menarche in absence of underlying pathology. Pain with onset of period lasting 24-72 hours. Often associated with non-pelvic symptoms such as N+V, dizziness, headaches, lower back pain, emotional symptoms
Secondary - more likely years after menarche, associated dyspareunia, pelvic pain, evidence of underlying pathology (fibroids, endometriosis, PID, adhesions, developmental abnormalities. May be present with associated symptoms such as dyspareunia, vaginal discharge, rectal pain, bleeding, postcoital bleeding etc.
Cu-IUCD recent application can cause dysmenorrhoea
Dysmenorrhea investigations
History taking - exclude secondary causes
Clinical diagnosis
Abdominal and vaginal examination if sexually active
Speculum exam
High vaginal swab, STI screening
Cervical smear
Pelvic USS for masses or uterine enlargement
Transvaginal USS
Dysmenorrhea management
Information and reassurance of normal variation of menses cycles (NHS on period pains or women’s health concerns www.womens-health-concern.org)
Primary often improves with age, parity and use of oral contraceptives
Lifestyle changes - smoking cessation and local heat application, tea (regular, camomile or mint), abdominal/back massages, lying supine. Dietary supplements and herbal remedies can be tried but have insufficient evidence (calcium, Mg, thiamine, ginger, fish oil, toki-shakuyaku-san), acupuncture and acupressure
Primary:
NSAIDs/paracetamol
3-6 months trial of hormonal contraceptive (COC)/oral progestins (desogestrel), parenteral (Depo-Provera) or LNG-IUS
Combination of NSAIDs and contraceptive if ineffective alone
Transcutaneous electrical nerve stimulation (TENS)
Surgery - laparoscopic uterine nerve ablation (LUNA) for severe cases or hysterectomy
Secondary:
Refer for red flags:
Ascites and/or pelvic/abdominal mass
Abnormal cervix
Persistent intermenstrual or postcoital bleeding without associated features of PID (pelvic pain, deep dyspareunia, abnormal vaginal/cervical discharge)
USS suggestive of cancer
Investigation/management of underlying cause
Endometriosis
Background:
One of the most common gynae disorders in women of reproductive age (2nd after fibroids)
Affects approx 10% of women in the UK however variance of clinical presentation means prevalence is not well known
Infertility affects 30% of sufferers
Pathology:
Chronic oestrogen-dependent condition characterised by growth of endometrial tissue in sites other than the uterine cavity, most commonly the pelvic cavity (including ovaries), uterosacral ligaments, pouch of douglas, rectosigmoid colon, bladder and distal ureter
Other sites are rarely involved but include umbilicus, scar sites, pleura, pericardium and CNS
Cause and risk factors for endometriosis
Idiopathic but may be a result of a combination of:
Retrograde menstruation (cells flow backwards from uterine cavity through fallopian tubes implanting in pelvic organs
Lymphatic or circulatory dissemination (may travel to distant sites via lymphatic/blood system)
Genetic predisposition
Metaplasia (cells in pelvic/abdo area change into endometrial type cells)
Environmental factors (toxins)
Immune dysfunction
Risk factors: Early menarche Late menopause Later first sexual encounter Delayed childbearing Nulliparity Obstruction of vaginal outflow - FGM, hypercolpos etc. Family history Caucasian ethnicity Low BMI Smoking
Endometriosis presentation and investigations
Presentation:
Dysmenorrhoea
Dysparenuia
Cyclical or chronic pelvic pain
Subfertility
Other - bloating, lethargy, low back pain, cyclic rectal bleeding, asymptomatic
Complications - risk of ovarian cancer, infertility, adhesions, IBD
Investigation/diagnosis: Laparoscopy GOLD STANDARD Transvaginal USS MRI to assess extent/severity CA 125, FBC, urinalysis and microscopy, cervical swabs, beta-HCG to exclude differentials acutely
Endometriosis Management and referrals
Management:
Based on nature, severity and future fertility plans
Suppression of ovarian function for at least 6 months via COC, medroxyprogesterone acetate, GnRH agonists
Levonorgestrel IUS effective after 3 years of use
Surgery - removing infiltrating lesions, ovarian cystectomy, adhesiolysis and bilateral oophorectomy +/- hysterectomy
Uterine artery embolisation for adenomyosis - short/medium term relief
Pain management (NSAIDs, paracetamol, danazol, GnRH agonists for 3-6 months) and clinical psychology referrals
AVOID medical treatment for women trying to conceive
Referral:
Severe, persistent or recurrent symptoms
Pelvic signs of endometriosis
Initial management not effective/not tolerated or CI
adenomyosis pathology, cause and risk factors
Background:
Occurs in around 10% of women
Pathology:
The invasion of myometrium by endometrial tissue causing inflammation, pain, formation of adhesions, enlargement of uterine wall and can lead to chronic pelvic pain, dyspareunia and infertility
Aetiology:
Not well understood but thought to have a multifactorial cause (hormones, trauma, inflammation)
Risk factors:
Later reproductive years
Multiparous women (multiple pregnancies)
Presentation of adenomyosis
Dysmenorrhoea
Menorrhagia
Dyspareunia
Infertility or pregnancy related complications
⅓ are asymptomatic
Associated with - infertility, miscarriage, preterm birth, small for gestational age, malpresentation, C section and postpartum haemorrhage
Adenomyosis investigation and management
Investigation:
Bimanual exam - enlarged, tender uterus, feels softer than fibroids
Transvaginal USS first line
MRI/transabdominal USS
Histological exam (GOLD STANDARD after a hysterectomy)
Management:
Symptoms tend to resolve after menopause as the condition is hormone dependent
Does not want contraception: Tranexamic acid (no associated pain) Mefenamic acid (with associated pain)
Contraceptive:
Mirena coil first line
COC
cyclical oral progesterone
Premenstrual symptoms PMS
Background:
Most common type is called Core PMDs (premenstrual disorders), must have no other underlying cause to be found
Premenstrual dysmorphic disorder (PMDD): a severe form of PMS, occurring when a woman suffers from at least 5 out of 11 distinct psychological premenstrual symptoms, one of which must include mood
Variants of PMD: do not meet PMD criteria:
Premenstrual exacerbation of underlying disorder (Diabetes, depression, migraine)
Non-ovulatory PMDs (symptoms result from ovarian activity other than ovulation)
Progesterone-induced PMD (symptoms result from exogenous progesterone administration like HRT, COC etc.)
PMDs with absent menstruation (symptoms arise from continued ovarian activity even though menstruation has been suppressed (hysterectomy, ablation, LNG-IUS etc.)
Pathology:
Symptoms are present during the luteal phase and resolve as menstruation begins, then followed by a symptom free week
Aetiology:
Hormonal changes during the luteal phase of the menstrual cycle
PMS presentation
Core PMDs: timing starts 1-2 weeks before menstruation, symptoms are nonspecific and recur in ovulatory cycles
Symptoms can be severe enough to affect daily functioning or interfere with work, school performance or interpersonal relationships
Psychological - Irritability, labile affect/mood swings, anxiety, lassitude (lack of energy), fatigue, low mood, changes in appetite, sex drive, sleep disturbance
Physical - breast tenderness/pain, joint pain, muscle pain, back pain, abdominal swelling or bloating, headaches/migraines, skin disorders (acne), swelling of extremities, weight gain
Symptoms vary in severity from person to person and time to time
Investigation/diagnosis:
Clinical diagnosis and exclusion of other possible causes
Daily symptoms diary for 2 or 3 cycles and review (daily record of severity of problems)
PMS management
Inconclusive symptoms diary - refer to hospital secondary care
Lifestyle advice - diet, exercise, stress reduction, vitamin and dietary supplements
Pain management (NSAIDs)
Moderate PMS - new COC (Yasmin)
Severe PMS - SSRI (sertraline 50-100mg OD) for 3 months- 1 year continuously or during luteal phase or CBT
Spironolactone may be used to treat physical symptoms - breast swelling, water retention and bloating
Review after 2 months to assess treatment effectiveness
Vaginitis
Background:
Bacterial vaginosis - change in normal bacteria - overgrowth of other organisms
Atrophic vaginitis/genitourinary syndrome of menopause - very common in postmenopausal women due to decreasing oestrogen
Pathology:
Inflammation of the vagina that can result in discharge, itching and pain
Usually caused by an imbalance of normal vaginal bacteria or infection
Reduced oestrogen levels especially after menopause (increases vaginal dryness) and some skin disorders may also cause
Atrophic - Epithelial lining and mucus thickens in response to oestrogen, when oestrogen is lower the cells are more prone to inflammation and there are changes in vaginal pH and microbial flora contributing to local infections.
vaginitis causes and presentation
Aetiology/risk factors:
Most common cause is bacterial vaginosis
Yeast infection (candida albicans)
Trichomoniasis (commonly transmitted via sexual intercourse)
Atrophic vaginitis
Menopausal changes in oestrogen
Presentation:
Bacterial vaginosis - 50% asymptomatic, foul/fishy-smelling vaginal discharge
Atrophic - dry vagina, burning/itching vagina/vulva, dyspareunia, vaginal discharge (white/yellow), postcoital bleeding
Vaginitis investigation and management
Investigation/diagnosis:
Genital exam
Speculum exam - atrophic will show pale mucosa, think skin, reduced skin folds, erythema and inflammation, dryness and sparse pubic hair
Management:
BV - non-pregnant women with asymptomatic BV usually need no treatment. For symptomatic/pregnant women oral metronidazole is 1st line or intravaginal metronidazole gel/clindamycin cream alternatives
Atrophic - lubricants (short relief) such as Sylk, Replens and YES. Topical vaginal oestrogen (long term use) such as oestriol cream (syringe application at night time), oestriol pessaries (nighttime), tablets (vagifem) taken OD, vaginal ring (Estring) replaced every three months
Contraindications for topical oestrogens - breast cancer, angina, venous thromboembolism, women should be monitored at least annually with a view of stopping treatment whenever possible
Cervicitis, causes and risk factors
Background:
Can be acute onset (usually severe) or chronic lasting months+
Pathology:
Irritation or infection of the cervix
Aetiology:
Gonorrhoea, chlamydia
Herpes
HPV
Risk factors:
Previous STI
Multiple/new change in sexual partner
Unprotected sex
Cervicitis presentation, Ix and management
Presentation: Purulent discharge Pelvic pain Intermenstrual and postcoital bleeding Urinary symptoms
Investigation/diagnosis:
Cervical smear +/- biopsy (cytology)
Cervical and vaginal swabs (culture)
Management:
Antibiotics for specific identified organism (doxycycline chlamydia, ceftriaxone gonorrhea)
Superficial lesions - cervical cautery (outpatient procedure) via electrocautery or cryosurgery for chronic cases
Deep lesions - deeper cauterisation or conisation under general anaesthesia
Fibroids
Background:
Very common, affecting 40-60% of women in later reproductive years and in black women
Types:
Intramural: within the myometrium (the muscle of the uterus). As they grow they change shape and distort the uterus
Subserosal: just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity
Submucosal: just below the endometrium
Pedunculated: on a stalk
Pathology:
Benign tumours of the smooth muscle in the uterus (uterine leiomyomas)
They are oestrogen sensitive and grow in response to high concentrations
aetiology:
unknown but thought to be related to genes increasing uterine growth
Fibroids risk factors and presentation
Risk factors:
Later reproductive years
Black ethnicity
Presentation: Often asymptomatic Menorrhagia is most common symptoms Abdominal pain, worse around menses Bloating or feeling full in abdomen Urinary or bowel symptoms due to pelvic pressure of fullness Deep dyspareunia Reduced fertility Palpable pelvic masses or enlarged non-tender uterus on abdominal or bimanual exam
Fibroid complications
Menorrhagia and iron deficiency anaemia
Reduced fertility
Constipation
Urinary outflow obstruction and UTIs
Red degeneration of fibroid
Torsion of fibrosis (usually pedunculated)
Malignant change to a leiomyosarcoma (<1% very rare)
Fibroid investigations
Abdominal exam Bimanual exam Hysteroscopy (submucosal fibroids with menorrhagia) Pelvic USS MRI (before surgery)
Management of fibroids
Fibroids <3cm/no uterine distortion: Mirena coil first line NSAIDs COC or cyclical oral progestogens Endometrial ablation, resection (during hysteroscopy) or hysterectomy for severe small
fibroids/menorrhagia
>3cm fibroids/uterine distension:
NSAIDs and tranexamic acid
Mirena coil (depending on size, shape and type)
COC or cyclical oral progestogens
Surgery: uterine artery embolisation, myomectomy, hysterectomy (may use GnRH agonists like Goserelin or leuproelin to reduce fibroid size before surgery)
Red degeneration of fibroids:
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
More likely in larger fibroids (>5cm) during 2nd or 3rd trimester of pregnancy
May occur if a fibroid rapidly enlarges during pregnancy, outgrowing blood supply causing ischaemia
Or due to kinking in blood vessels as the uterus changes shape and size during pregnancy
Presents with severe abdominal pain, low grade fever, tachycardia, vomiting
Management is supportive with rest, fluids and analgesia
TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
Normal pregnancy overview
Full-term lasts 40 weeks
Preterm/early labour is <37 weeks
Consists of 3 trimesters (Tri 1 - weeks 1-12; tri 2 - weeks 13-27 and tri 3 - weeks 28-40)
Age of viability - infants born very early are not considered to be viable until after 24 weeks gestation (less survival chance)
Antepartum haemorrhage (APH), bleeding during pregnancy during 1st 24 weeks can end in miscarriage
Obstetric terminologies
Gravidity: defined as the number of times that a woman has been pregnant (e.g. gravida 2 or G2)
Parity: the number of times that she has given birth to a foetus with gestational age of >24 weeks, regardless of if the child was born alive or stillborn (Para 2 or P2)
Nulliparous women: (nullip) has not previously given birth >24 weeks gestation
Primigravida: first pregnancy (Primi)
Multiparous: patient who has given birth after 24 weeks gestation two or more times regardless of outcome
Primiparous: technically refers to patient that has never given birth after 24 weeks gestation
Gestational age: duration of pregnancy starting from date of last menstrual period
Last menstrual period: date of first day of their last (most recent) period
E.g. G2 P0 - pregnant twice, no births. G1 P1 - one pregnancy and birth
Gestational age is described in weeks and days e.g. 5+0 = 5 wks since LMP, 13+6 = 13 wks 6 days gestational age
Prenatal/antenatal care
Regular forms of check-ups for pregnant women by a midwife or specialist doctor to prevent and treat potential health problems throughout the course of pregnancy
During follow ups women are encouraged to follow healthy lifestyle for the benefit of her and the baby
Provides health promotion, risk reduction and disease prevention
WHO - All women should have 8 contacts with a health provider
Screening and diagnosis helps to reduce: Maternal death Miscarriages Birth defects Low birth weight Neonatal infections
Uncomplicated pregnancy/routine care
Health promotion and identifying those at risk
Screening for haematological conditions - anaemia, thalassaemia
Screening for foetal abnormalities (NHS programme)
Screening for infections
Screening for clinical conditions (gestational diabetes, HTN)
Assessment of foetal growth and well-being
Appointments:
Managed by midwives, GPs and obstetricians
10 appointments (nullipara) 7 appointment (parous)
Each appointment is different depending on stage of gestation
Advise on supplements - vit D 10mcg OD, folic acid 400mcg OD
Lifestyle advice - smoking cessation, diet, exercise
Key pregnancy appointment and milestones
Gestational age:
<10 weeks
Booking clinic
Offer baseline assessments, lifestyle advice and plan pregnancy (booking bloods, risk assessments)
Gestational age:
10-13+6
Dating scan
Accurate gestational age is calculated from the crown rump length (CRL), confirmed intrauterine pregnancy, check development and multiple pregnancies identified
Gestational age:
16 weeks
Antenatal appointment
Discuss results and plan future appointments
Gestational age:
18-20+6
Anomaly scan
USS to identify 11 specific rare anomalies, heart conditions etc.
Gestational age:
25, 28, 31, 34, 36, 38, 40, 41, 42 wks
Antenatal appointments
Monitor pregnancy and discuss future plans
First pregnancy appointment
10 wks pregnant
Given a green book documenting pregnancy progress
Initial assessment of weight, BMI, BP, urinalysis for proteinuria
Identify those at risk and additional care needed with current/past medical history, discuss FGM, domestic violence
Lifestyle advice on diet, alcohol, smoking, exercises, education on what to expect at each stage, screening tests, antenatal classes, breastfeeding classes, mental health discussion.
Discussion or offering screening tests for blood group and Rh status, anaemia screening, IDA, sickle cell, thalassaemia (family history questionnaire) also offered HIV, Hep B and syphilis.
Offer foetal screening for chromosomal abnormalities (down’s, edward’s, pataus’s syndrome) and screening for other anomalies by USS at 18-20 wks
12 week pregnancy appointment
Checking how many weeks in pregnancy, calculating due date (estimated delivery date (EDD))
Number of foetus’
Confirm intrauterine pregnancy
Check foetal development
Detect some health conditions such as spina bifida
Mid-pregnancy anomaly scan (20 weeks)
Scan looks in detail at the bones, heart, brain , spinal cord, face, kidneys and abdomen of the baby
Allows screening for 11 rare conditions: Anencephaly Open spina bifida Diaphragmatic hernia Gastroschisis Serious cardiac abnormalities Bilateral renal agenesis Lethal skeletal dysplasia Edwards syndrome (T18) Plateau syndrome (T13)
Edwards syndrome presentation
Congenital heart defects growth retardation dysmorphic features facial clefts spina bifida severe developmental delay
Down’s syndrome screening
Combination of USS and blood tests taken over weeks 11-14
USS screening showing nuchal translucency (thickness of back of neck) Downs is indicated if thickness >6mm
Serum screening - blood sample from mother for protein markers PAPP-A (lower result = higher risk) and beta-HCG (higher result = high risk)
These combined between 10-14 weeks of pregnancy are the “combined test”
Triple test performed between weeks 14-20 weeks involving blood tests only (beta-HCG high, alpha-fetoprotein low and serum oestriol lower indicate a higher risk)
Quadruple test between 14-20 weeks is identical to the triple test but also looks at maternal inhibin-A (higher = greater risk)
Results are a statistical chance and sometimes classed as “increased chance” or “low chance”. When risk is greater than 1 in 150 women are offered amniocentesis (USS guided aspiration of amniotic fluids later in pregnancy) or chorionic villus sampling (USS guided biopsy of placental tissue done before 15 weeks gestation).
Involves sampling foetal cells for karyotyping to confirm diagnosis
Non-invasive prenatal testing is a new maternal blood test looking for DNA fragments from placental tissue, not a definitive test but gives a good indication, can be used for women with high risk (1 in 150)
Additional test for Edwards’ syndrome (trisomy 18) and Pataus’ syndrome (trisomy 13) offered at 18-20 weeks
Screening for gestational diabetes
Gestational diabetes (24-28 weeks), develops in 2 or 3rd trimester due to hormonal and other lifestyle risk factors. May develop symptoms of hyperglycemia Screening test - oral glucose tolerance test (OGTT) - 2 hours
NICE recommends test should be offered if:
BMI >30
Given birth to large babies previously
Previous gestational diabetes
Family history of diabetes
Family origin of south asia, black caribbean or middle eastern
Gestational diabetes management and complications overview
Management:
Usually improves with diet and exercise
tablets/insulin therapy may be needed to help control diabetes if lifestyle changes are ineffective
Monitoring and interventions during pregnancy and labour
Complications:
Macrosomia (big baby) may make birth complicated/difficult
Polyhydramnios - too much amniotic fluid around the baby in the womb
Type 2 DM long term
HTN in pregnancy screening
BP and urinalysis regularly throughout pregnancy
Can have HTN pre-pregnancy or diagnosed within the first 20 weeks (chronic HTN)
New onset occurring in second half of pregnancy (gestational HTN) or new HTN with features of multi-organ involvement (Pre-eclampsia)
Additional milestones for complicated pregnancies
Higher risk pregnancies need more app.
Oral glucose tolerance test (gest. diabetes)
anti-D injections in Rh -ve women at weeks 28 and 34
USS at 32 weeks for women with placenta praevia on anomaly scan
Serial growths scans are offered to increased risk of fetal growth restriction
Routine antenatal discussions and vaccines
Discuss plans for pregnancy and delivery
Symphysis-fundal height measured from 24 weeks onwards
Fetal presentation assessment from 36 weeks onwards
Urine dipstick for proteinuria and BP (pre-eclampsia)
Urine for microscopy and culture for asymptomatic bacteriuria
Vaccines: Whooping cough (pertussis) from 16 weeks gestation Influenza in autumn or winter when available
General pregnancy lifestyle advise
Folic acid 400mcg before pregnancy to 12 weeks (reduced neural tube defects)
Vitamin D supplements (10mcg/400 IU daily)
AVOID vitamin A, liver or pate (teratogenic in high doses)
AVOID alcohol (miscarriage, small for gestation, preterm birth, foetal alcohol syndrome, risk is greatest within first 3 months of pregnancy)
AVOID smoking (foetal growth restriction, miscarriage, stillbirth, preterm labour, placetal abruption, pre-eclampsia, cleft palate/lip, sudden infant death syndrome (SIDS)
AVOID unpasteurised dairy or blue cheese (risk of listeriosis)
AVOID undercooked or raw poultry (salmonella)
Continue moderate exercise but AVOID contact sports
Sex is safe
Flying increases the risk of VTE. RCOG advises flying is generally ok in uncomplicated pregnancy up until 37 weeks (single pregnancy) or 32 weeks (twins). After 28 weeks most airlines ask for a note from a healthcare professional to state it’s going well with no additional risks
Place car seatbelts above/below bump NOT across
fetal alcohol syndrome overview
refers to certain characteristics that can occur in children of mothers that consumed alcohol during pregnancy.
The features include: Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy
Vulval neoplasms
Background:
Primary malignancy is very rare (1% UK cancers)
Usually starts as a premalignant lesion - VIN
Benign neoplasms (lipoma etc.) are less common
90% are SCC
10% are BCC, adenocarcinomas (glandular cells - Paget’s disease of vulva, bartholin’s cancer), sarcomas and melanomas
Labia majora are most common site - 50%, labia minora in 20% cases and the clitoris and bartholin’s glands are less commonly involved
5 year survival rate is >80%
Pathology:
Mutated cells proliferate forming undifferentiated/partially differentiated mass of cells - tumour
Usually spreads slowly, locally (vagina, urethra, anus) then metastasises to the groin lymph nodes, then pelvic lymph nodes
Aetiology:
Cellular mutation, environmental factors
vulval neoplasm risk factors
> 60 (70% cases)
Smoking
HIV/immunodeficiencies
HPV - especially 16, 18 (50% of SCC are in relation to HPV infection)
Vulvar intraepithelial neoplasia (VIN) - premalignant state
Lichen sclerosus (4% risk which may not be reduced with treatment)
Paget’s disease of the vulva (adenocarcinoma in situ) has risk of invasive cancer
Atypical mole - malignant melanoma
vulval neoplasms presentation
Vulval lump Ulceration with bleeding Bleeding or blood stained discharge Wart-like lesion in postmenopausal women Suspicious lesions - chronic, insufficient response to treatments Vulval pruritus and pain/tenderness Burning while urinating 75% on labia majora Presentation is often delayed Melanoma - dark brown lesions (ABCDE rule)
vulval neoplasm investigation and staging
Investigation/diagnosis:
Vaginal examination - look for spread to local or lymph node areas
Biopsy (punch or excisional) +/- vulvoscopy for subclinical lesions
Staging - cystoscopy, proctoscopy, CXR, MRI
Grading of non-invasive cancers:
Low grade squamous intraepithelial lesions (LSIL): equivalent to anogenital warts, treated with podophyllotoxin or imiquimod creams, cryotherapy or surgical excision
High grade squamous intraepithelial lesions (HGIL): topical treatment, ablation, wide local excision, skinning vulvectomy
TNM staging for Invasive vulvar cancer:
stage I - <2cm local lesion, no lymph node or distant metastases
stage II - invasion into lower 1/3 urethra, vagina and/or anus with no lymph or distant metastases
stage III - above but with lymph node metastases
stage IV - any form of vulval neoplasm with distant metastases
vulval cancer management
2WW referral for women with UNEXPLAINED vulval lump, vulval ulceration or bleeding
Pruritus or pain without suspected vulvar cancer - treat suspected cause, watch and wait, refer any persistent symptoms to gynae (2WW or routine depending on presentation)
Radical or wide local resection of cancer
Advanced - sentinel lymph node biopsy (SLNB) or groin node dissection, radiotherapy +/- chemotherapy
Reconstructive surgery after resection
Women with uncomplicated lichen sclerosus do NOT need routine hospital based follow up but must be informed of risk of cancer
vulval intraepithelial neoplasia (VIN) overview
Background:
Premalignant lesions
May start independently or as a transformation of already existing vulval disorders (lichen sclerosus, squamous cell hyperplasia)
Pathology:
VIN 1: ⅓ thickness dysplasia
VIN 2: ⅔ thickness dysplasia
VIN 3: full thickness dysplasia
Presentation:
Most pruritus
Asymptomatic
White, grey, red or raised patches of skin
Indurated, ulcerated nodules
White, multifocal pearly lesions in peri-clitoridian and labia regions
Investigation/diagnosis:
Vaginal examination
Biopsy (multiple for large lesions)
Management: Laser therapy Wide local excision Imiquimod cream (Zyclara, Aldara) Lifelong follow up - close association with HPV infection and risk of recurrence
vaginal neoplasms
Background:
Rare
80% of vaginal carcinoma is metastatic spread from the cervix, endometrium or ovary
Primary malignancy are SCC mostly and adenocarcinomas (melanoma and sarcoma are very rare)
SCC 85% cases - Upper posterior vaginal wall, postmenopausal women
Adenocarcinoma - peak incidence 17-21 years
Vaginal intraepithelial neoplasia (VAIN) is associated with other genital neoplasia (CIN, VIN) etc so should always be examined for this too
Pathology:
Cancerous cell proliferation and growth to form tumours
SCC usually spreads superficially within the vaginal wall and later invades the paravaginal tissues (bladder or rectum) and then parametria. Distant metastases most often to the lungs and liver
Adenocarcinoma - more pulmonary metastases and supraclavicular, pelvic node involvement
Aetiology:
Genetic, environmental multifactoral cell changes
vaginal neoplasms risk factors and presentation
Risk factors:
HIV (have more VIL)
HPV
Vaginal intraepithelial lesions
Presentation:
SCC - ulcerative or exophytic lesions. Some Bleeding
Adenocarcinoma - bleeding
vaginal neoplasms investigation and staging
Investigation/diagnosis:
Colposcopy - screen for other neoplasia
Multiple biopsies (vaginal, cervical, endometrial)
CT, PET, CXR, cystoscopy, sigmoidoscopy for staging
Staging FIGO system:
Stage O: SCC in situ, usually multifocal and at vaginal vault
Stage I: limited to vaginal wall mucosa
Stage II: subvaginal tissue not not pelvic wall
Stage III: extends to the pelvic wall
Stage IV: extends beyond true pelvis or involves the bladder/rectal mucosa
Stage IVA: spread to adjacent organs (bladder/rectum)
Stage IVB: spread to distant organs
vaginal neoplasm management
2WW referral for women with unexplained palpable mass in or at entrance to the vagina
Dependent on stage
Carbon dioxide laser - safe and effective in premalignant condition
Surgery and radiotherapy - early stages of disease (stage I and II some cases may need a radical hysterectomy with removal of upper vagina)
Radiation therapy - advanced stages
pelvic organ prolapse
Background:
Can be classified according to compartment affected
Anterior vaginal wall prolapse - cystocele, urethrocele (most common)
Posterior vaginal wall prolapse - rectocele, enterocele (prolapse of bowel into top part of vagina)
Prolapse of the cervix or uterus
Apical prolapse - Prolapse of the uterus or vaginal vault (least common)
Prolapse of the vaginal vault (occurs after hysterectomy)
40-60% of parous women experience prolapse
Several types may coexist in the same patient
Pathology:
Falling, slipping or downward displacement of pelvic organ(s) or structure beyond its normal confines
Caused by weakness of the supporting structures (levator ani muscles and endopelvic fascia) allowing pelvic organs (bladder, rectum, uterus, vaginal vault etc.) to sag into the vagina
pelvic organ prolapse cause and risk factors
Aetiology: Congenital weakness (rare) Childbirth Menopausal atrophy (coughing and straining exacerbating condition) Likely a multifactorial cause
Risk factors: Increasing age Obesity Increasing parity Vaginal delivery Previous hysterectomy
pelvic organ prolapse presentation and investigation
Presentation:
Based on type, may cause urinary, bowel, sexual, local pelvic symptoms
Vaginal symptoms - common in all types - sensation of heaviness, fullness, bulging, difficulty retaining tampons, spotting (ulceration)
Urinary symptoms - incontinence, frequency, urgency, tenesmus, weak/prolonged stream, need to manually reduce/change position prolapse before voiding/to completely void
Coital difficulty - dyspareunia, loss of sensation, flatus, loss of arousal, change in body image
Bowel symptoms - constipation, urgency, incontinence, flatus, tenesmus, needing to apply digital pressure or digital evacuation
Investigation/diagnosis: Clinical diagnosis Vaginal examination Bimanual examination In standing and LLD positions, Sims’ speculum - ask to strain/cough
pelvic organ prolapse management
Conservative:
Regularly assess for symptoms and complications until treatment is needed
Lifestyle - decrease weight, avoid heavy lifting, prevent constipation, smoking cessation, pelvic floor exercises (Kegel’s for supervised 16 week course of training, continue if beneficial)
Topical oestrogen: For postmenopausal women with vaginal atrophy Estriol cream 0.1% twice weekly Oestrogen releasing ring Estradiol vaginal tablets
Vaginal pessary:
Silicone or plastic ring shaped device into the vagina to provide support and relieve pressure on bowel or bladder (FIRST LINE usually)
Can be used short term prior to surgery or long term if surgery is not wanted or CI
Should be removed and changed every 6 months to avoid complications
Common types: ring, Gellihorn, Doughnut pessaries
Treat vaginal atrophy BEFORE fitting
May affect sexual intercourse
Complications: bleeding, discharge, difficulty removing, expulsion
CI: active pelvic infection, ulceration, silicone allergy
Surgery:
Failure or other treatments, presence of voiding/bowel symptoms, recurrence of prolapse after surgery, ulceration, irreducible, or preferred treatment
Choice based on if they’re sexually active, family plans, general fitness, past hysterectomy, nature of prolapse
Can be abdominal or transvaginal surgery
Surgery indicated for POP-Q stage 2+
Needs follow ups annually for 5 years
cystocele overview
Prolapse of the bladder into the vagina (anterior wall prolapse)
Presentation:
Small isolated cystocele - asymptomatic/few symptoms
Larger - frequency, recurrent UTI, sensation of pressure, mass
Investigation/diagnosis: Vaginal examination Standing and Sim’s speculum exam - ask to strain/cough Urinalysis and MSU Urodynamic studies Urea and creatinine Renal USS
Management: conservative (lifestyle) vaginal pessaries topical Oestrogens Surgery - anterior colporrhaphy + Mesh reinforcement
rectocele overview
Prolapse of the rectum into the vagina (posterior wall prolapse)
Presentation:
Asymptomatic
Splinting (applying digital pressure to perineum or posterior vaginal wall to defecate)
Digital rectal evacuation
Investigation/diagnosis:
Vaginal examination
Standing and Sim’s speculum exam - ask to strain/cough
Anal manometry
Defecography
Endo-anal USS (if fecal incontinence to assess anal sphincter)
Management: conservative vaginal pessaries topical Oestrogens Surgery - posterior colporrhaphy + mesh reinforcement
history taking for breast complaint
Examination:
Ask them to remove clothes from the waist up, including bra, go behind curtain for privacy
Use paper towel to cover self up while waiting
History taking:
When did you notice it?
Is it painful?
When was the last menstrual period? Could you be pregnant? Is the condition premenstrual?
Are you currently breastfeeding?
Does the lump size change?
Have you noticed nipple changes? Discharge, inverted?
Changes to the colour of the skin?
Any trauma to the breast? (haematoma)
Any previous breast lumps or diagnoses?
History of breast surgeries? Scarring, fibrosis, much more difficult to feel a lump
Family history of breast cancer?
Taking any regular medications? Allergies?
fibroadenosis
Background:
More common in women of childbearing age, can occur unilaterally or bilaterally
More than 50% of women have fibroadenosis/fibrocystic disease at some point in their lives
Do not increase the risk of cancers
Pathology:
Fibrosis: similar to scar tissue
Cyst - fluid filled sacs
Aetiology:
Usually as a result of hormonal changes during menstrual cycle
fibroadenosis presentation, Ix and Mx
Presentation:
COC, HRT and pregnancy can make the lump tender/worse
Fibrosis - feels rubbery, firm, hard to touch
Cysts - >2.5cm, can become tender before periods, mobile, smooth, fluctuant lumps
Much more common to be bilateral
Investigation/diagnosis: Breast examination (ask them where they felt it to help locate)
Management:
Reassurance and education as to cyclical nature
Supportive bra
NSAIDs, review of contraceptive (if it is impacting them significantly)
If after 3 months and impacts on quality of life - refer to specialist team for further management
Larger cysts - needle aspiration or local excision
fibroadenoma
Background: Common in puberty and younger girls AKA the breast mice - small and mobile 25% self-resolve Simple fibroadenomas - 1-3cm size Complex - can be >5cm Other types - giant and juvenile
Pathology:
Benign tumour developed from a lobule within the breast tissue forming a solid lump
Aetiology:
Unknown aetiology - thought to be an increased sensitivity to oestrogens causing growth
fibroadenoma presentation, Ix and Mx
Presentation:
Lump developing from lobule (usually <3cm)
Smooth, rubbery textured unilateral lump (raisen like)
Highly mobile
Common in puberty
Hormone dependent, regress after menopause
Usually painless but can cause pain/deformity
Investigation/diagnosis:
Breast examination
Mammography/USS
Excisional biopsy (not needed if <25 YO with confirmed diagnosis)
Management:
Asymptomatic, simple fibroadenomas - no treatment needed and no follow-ups (should report/have all new fibroadenomas checked individually)
Symptomatic - usually removed surgically or by vacuum-assisted mammotome (GA or LA)
lipoma in breast overview
Background:
Benign breast lesions
Painless, fatty lump caused by overgrowth of adipose cells
Pathology:
Benign mesenchymal tumours composed of mature adipose tissue
Aetiology:
Multifactoral
Presentation: Soft and doughy Slow growing Up t0 20cm size Painless most often
Investigation/diagnosis:
Breast examination
Mammography/USS
Management:
Refer to 2WW if diagnosis is uncertain
Diagnosis certain and asymptomatic - leave alone
Diagnosis uncertain - imaging +/- surgical intervention
Patient symptomatic - surgically removal
mastitis
Background:
Painful, inflammatory condition which can be accompanied by an infection
It is not clinically possible to differentiate between infected and non-infected mastitis
Pathology:
Non-infectious - milk stasis irritated breast tissue causing inflammation
Infectious - milk stasis leads to infection, spreading through breast tissue causing inflammation
Aetiology:
Lactating women - milk stasis usually primary cause
Soft tissue infection via break in skin integrity
Risk factors:
Breastfeeding (weaning baby off breast milk or within first few weeks of starting especially)
Smoking - damage to ducts in breast
mastitis presentation, ix and mx
Typically develops within first few weeks of breastfeeding
Very tender breast
Red, swollen breast sometimes with hard areas
Can present with fever and general malaise
Investigation/diagnosis:
Clinical
Breast exam
Management:
Antibiotics (flucloxacillin soft tissue infection)
NSAIDs
Continue breastfeeding/expression of milk if possible to avoid milk stasis
breast abscess overview
Collection of pus within the breast tissue
Aetiology:
Can be complication of mastitis (infected mastitis)
Soft tissue infection - commonly staphylococcus aureus and strep pyogenes
Presentation: Extremely painful May be visible on skin surface Can present as very tender lump May be very afebrile and unwell (fever, tachycardia, hypotensive)
Investigation/diagnosis:
Clinical
Breast exam
Culture of fluid
Management:
Refer urgently for diagnostic USS, drainage (USS guided needle aspiration/surgical drainage)
Antibiotics (IV if needed)
Advise lactating women to try to continue breastfeeding or express if too painful to avoid milk stasis
breast carcinoma
Background:
Most common form is ductal carcinoma in situ (DCIS) for invasive and non-invasive types
Most types are invasive, inflammatory carcinoma only occurs in a minority of cases
Approximately 4-6% of breast cancers are metastatic when diagnosed
Second most common cause of death from cancer in the UK
Pathology:
Cancerous mass
Aetiology:
Multifactoral
breast carcinoma risk factors
Previous breast cancer Family history Genetics - BRCA1, 2 and TP53 mutations Nulliparity or giving birth after 30 Early menarche and late menopause Radiation to chest Western style diet Obesity Alcohol HRT COC Breast augmentation does NOT increase the risk but can make diagnosis difficult
breast carcinoma presentation
Lump/craggy feeling lumps (walnut consistency), bumpy, hard, no defined borders, less mobile
Nipple changes, discharge - bloody discharge in intraductal carcinoma
Skin dimpling
Skin changes
Breast pain
breast carcinoma Ix and staging
Breast examination
Mammograms >30 years OR USS <30 years
Biopsy (FNA)
TNM Staging - CXR, CT, bloods (LFTs), PET, bone scans
staging:
N0-N3: no lymph node - metastases to one+ lymph nodes
M0-M1: no distant metastases - distant metastasis
breast carcinoma management
Management:
Stop systemic HRT, offer counselling about early menopause risk and fertility preservation
Surgery
Radiotherapy (can be preoperative to shrink large tumours)
Chemotherapy
Hormone therapy
Biological agents
Follow up - no screening needed for total mastectomy, yearly mammography for 5 years in those with early BC, after 5 years frequency based on risk for individuals. All patients should have care plans with contact details, treatment review dates, surveillance dates, safety netting advice and support service details
NICE breast referral guidelines
NICE 2WW referral guidelines for breast lumps:
30+ with unexplained breast lump with/without pain
Skin changes suggestive of breast cancer
50+ with any of the following:
Discharge from nipple
Retraction of nipple
Other changes of concern
Consider non-urgent referral in those aged <30 with an unexplained breast lump with/without pain
inflammatory breast carcinoma overview
Background:
Poor prognosis, 50% 5 year survival rate with lymph node involvement
50% 2 year survival with metastatic rate
More common in younger population
Pathology:
Rapidly growing, painful mass causing enlargement of the breast and overlying skin to become erythematous and hot
May have diffuse infiltration of tumour
Aetiology:
Multifactoral
Risk factors:
As for breast carcinoma
Presentation: NOT TENDER Red, swollen breast Hot and firm to touch Ridges/thickening of skin Pitted skin like orange peel Lump in breast Discharge from nipple Inverted nipple
Investigation/diagnosis and management:
as for breast carcinoma
breast self examination guide
look for: thick mass indentation skin sores or rashes erythema or heat new fluid dimpling bump growing vein retracted nipple new shape/size orange peel skin (textured) hidden lumps pain in breast or armpit all of the time swelling in the armpits or around the collar bone
breast cancer radiotherapy advice/info
- anyone receiving radiotherapy for breast cancer receives targeted radiotherapy just to the breast tissue
- does not cause any pain or discomfort
- patient must not move at all
- teats 2% of the lungs - possibly may get lung fibrosis (small amount) as complication
- 2 week treatment everyday OR every 4 days go in for treatment
- often causes fatigue
- big lump of vaseline like substance put on top of directed breast (BOLUS) and used to bring therapy away from the lung closer to the skin - causes a burn in shape of bolus (square red mark on chest)
- large masses may need radiotherapy before surgery to shrink the tumour - needs a two week gap between radiotherapy and surgery
fungating breast cancer
extensive breast cancer with fungal growths
usually problematic and very high risk to remove due to extensive blood supply - needs radio +/- chemo to shrink the tumour and then remove more safely
male breast cancer overview
Background:
Rare (1% all breast cancers)
Prognosis largely depends on staging
Staging identical to female breast cancer
Most common type is infiltrating ductal carcinoma
Pathology:
Cancerous mass
Aetiology:
Multifactoral
Risk factors: Increasing age BRCA1, 2 genes Elevated oestrogen (gynaecomastia) Prior radiation Family history of breast cancer
Presentation: Painless or tender lump, hard knot, thickening of breast/chest area Change in size/shape of breast Dimpling, puckering, redness of skin Itchy, scaly, sore rash Inverted nipple Nipple discharge
Investigation/diagnosis:
Breast examination
Mammography or USS
Tissue biopsy (FNA)
Management:
Surgery (radical mastectomy or simple mastectomy)
Hormone therapy (tamoxifen)
Radiotherapy +/- chemotherapy
Gynaecomastia
Background:
Can occur from neonates to elderly
⅓ of men experience in their lifetime
Most commonly ages 50-69
Breast cancer only detected in 1% of male breast enlargement
Common in puberty and old age and is most often entirely reversible
Pseudogynecomastia - breast enlargement mainly due to excess adipose tissue formation
Pathology:
Benign proliferation of male breast glandular tissue, resulting from a relative decrease in androgen effect/increase in oestrogen effect
May be associated with chronic liver disease/drug induced due to altered oestradiol/testosterone ratio
Aetiology/risk factors: Obesity Oestrogen surge (neonates) Puberty Drop in testosterone in old age Medication - oestrogens, digoxin, metronidazole, ketoconazole, spironolactone, chemotherapy, GnRH, anabolic steroids, antiretrovirals etc. Alcohol Illicit drugs - cannabis Chronic liver disease
Gynaecomastia presentation and red flags
Presentation:
Mass around >2cm size, firm
Palpable, subareolar gland and ductal breast tissue
Evidence of palmar erythema, bruising, spider naevi, hepatosplenomegaly (liver disease)
Red flags: Unilateral enlargement Hard or irregular breast tissue Rapidly enlarging Recent onset Fixed mass Nipple or skin abnormalities Painful breast Axillary LAP
gynaecomastia Ix and Mx
Investigation/diagnosis: Breast exam Bloods - eGFR, LFTs, TFTs, hormone profile USS/mammography CXR for suspected lung lesions Biopsy (FNA)
Management:
Refer if any red flags on 2WW pathway
Neonates - leave, reassurance and education
Reassurance, education, Diet and lifestyle advice (weight loss, alcohol decrease)
Surgery (exceptional case funding)
Drugs to reduce oestrogen
causes of retracted nipples
Injury to breast, surgery
Breast cancer
Breast infections (mastitis)
Rapid and substantial weight loss
galactorrhea
Background:
Lactation can begin during second trimester and can continue up to 2 years post-breastfeeding in pregnancy
Can also be idiopathic hyperprolactinemia - elevated prolactin levels with absence of underlying cause, usually self limiting and benign
Prolactinomas - pituitary gland tumour, most common between ages 20-40
Pathology:
Milk production from breasts in response to the hormone prolactin (produced in anterior pituitary, breast and prostate)
Dopamine blocks prolactin secretion
Aetiology: Pregnancy Idiopathic hyperprolactinemia Prolactinomas Drugs - contraceptives, SSRIs, antipsychotics, methyldopa, digoxin, spironolactone etc. Endocrine disorders - hypothyroid, acromegaly, Cushing’s, PCOS Liver failure CKD
Risk factors:
Prolactinomas are associated with MEN1 syndrome
galactorrhea presentation, Ix and mx
Presentation:
Idiopathic hyperprolactinemia - galactorrhoea
Prolactinomas - gynaecomastia, sexual dysfunction, amenorrhea, infertility, bitemporal hemianopia, galactorrhea
Investigation/diagnosis:
Pregnancy test
Medication review
Cranial nerve exam (bitemporal hemianopia)
Bloods - hormone profile, LFTs, TFTs, eGFR
Management:
Prolactinomas - bromocriptine (dopamine agonist) and surgery to remove tumour
Idiopathic hyperprolactinemia - bromocriptine to reduce prolactin concentration
Identify and treat underlying cause
menopause
Background:
Women periods cease for >12 months and are no longer able to become pregnant naturally
Permanent end to menstruation
On average occurs at age 51 although this varies significantly
Menopause is the point at which menstruation ceases
Postmenopase - period from 12 months after final menstrual period onwards
Perimenopause - time around the menopause, women often experience vasomotor symptoms, irregular periods etc. and are typically >45 YO
Premature menopause - menopause before age 40.
Pathology:
Primordial follicles mature into primary and secondary follicles within the ovaries, meaning the numbers deplete throughout our lifetime.
Without the growth of follicles there is reduced production of oestrogen
As oestrogen declines in perimenopausal period there is an absence of negative feedback on the pituitary gland, therefore increased levels of LH and FSH
The failing follicular development results in anovulation, irregular menstrual cycles and amenorrhoea (due to endometrium not developing)
Lowered oestrogen also causes perimenopausal symptoms
Aetiology:
Premature - premature ovarian insufficiency
natural decline in primordial follicles via ovulation during reproductive years
perimenopause/menopasue presentation
7 dwarfs of menopause: Sleepy Bitchy Itchy Psycho Forgetful Sweaty Bloaty
Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido
postmenopause - absence of menses for >12 months
risks associated with oestrogen decline
CVD and stroke increase
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
menopause Ix and management
Investigation/diagnosis:
Clinical (Perimenopause and menopause diagnosis can be made in women >45 with typical symptoms without performing investigations)
NICE guidelines state to use FSH blood test to aid diagnosis in women <40 with suspected premature menopause and women aged 40-45 with menopausal symptoms or change in their menstrual cycle
Management:
Vasomotor symptoms are likely to resolve after around 2-5 years without treatment
HRT
Tibolone (synthetic steroid hormone can only be used 12 months after menopause)
Clonidine (alpha adrenergic agonist and imidazoline receptor agonist)
CBT
SSRIs (fluoxetine or citalopram)
Testosterone (for reduced libido) usually cream or gel
Vaginal oestrogen cream/tablets for vaginal dryness or atrophy (can be used alongside systemic HRT)
Vaginal moisturisers (Sylk, Replens and YES)
