Obs & gynae Flashcards
What is pelvic organ prolapse?
Descent of pelvic organs into the vagina
Why does pelvic organ prolapse occur?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum, and bladder
What is a uterine prolapse?
When the uterus descends into the vagina
What is a vault prolapse?
–> Occurs in women who have had a hysterectomy and no longer have a uterus, the top of the vagina (the vault) descends into the vagina
What is a rectocele?
rectum prolapses forwards into the vagina
What are rectoceles caused by?
–> defects in the posterior vaginal wall
–> associated with constipation
What is the pathophysiology of a rectocele?
–> Can develop faecal loading in the part of the rectum that has prolapsed into the vagina
–> faecal loading leads to 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 its anatomical position and aloowing them to open their bowels
What is the presentation of a rectocele?
–> Constipation (faecal loading)
–> urinary retention ( due to urethral compression
–> palpable lump in posterior wall of vagina
What is a cystocele?
–> bladder prolapses backwards into the anterior vagina
What are cystoceles caused by?
–> defect in the anterior vaginal wall
What is prolapse of the urethra into the vagina called?
urethrocele
What is prolapse of the bladder and the urethra into the vagina called?
–> cystourethrocele
What are the risk factors for pelvic organ prolapse?
–> Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:
–>Multiple vaginal deliveries
–> Instrumental, prolonged or traumatic delivery
–> Advanced age and postmenopause status
–> Obesity
–> Chronic respiratory disease causing coughing
–> Chronic constipation causing straining
What is the presentation of pelvic organ prolapse?
–> 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
–> Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down.
What is a Sim’s speculum and how can it be used to examine for pelvic organ prolapse?
–> u-shaped, single bladed speculum thats used to support either the anterior or the posterior wall of the vagina whilst the others are examined
Which system is used to grade the severity of a pelvic organ prolapse?
Pelvic organ prolpase quantification system ( POP-Q)
How can a uterine prolaspe be graded?
POP-Q system
Grade 0 –> normal
Grade 1 –> lowest part is more than 1cm above the introitus
grade 2 –> lowest part within 1 cm of the introitus (above or below)
Grade 3 –> lowest part is more than 1cm below the introitus but not fully descended
Grade 4 –> full descent with eversion of the vagina
What is uterine procidentia
Pelvic organ prolapse extedning beyond the introitus
What is the management of pelvic organ prolapse
–> Conservative management -
–> Vaginal pessary
–> Surgery
What is the conservative management of pelvic organ prolapse?
–> mild symptoms/ do not tolerate surgery or pessary/
–> Physio (pelvic floor excercises)
–> weight loss
–> lifestyle changes (for asociated stress incontience such as redcued caffeine intake and pads)
–> treatment of related symptoms
–> vaginal oestrogen cream
How can vaginal pessaries be used to treat pelvic organ prolapse?
–> inserted into the vagina to provide extra support to the pelvic organs
–> Ring (sits below the uterus and holds it up)
–> shelf or Gellhorn - flat disk with a stem, sits below the uterus with the stem pointing downwards
–> Cube pessaries
–> Donut
–> hodge - rectangular - hook around the posterior aspect of the cervix and the other extends into the vagina
–> can be changed and cleaned
–> Oestrogen crema can help with irritation of the vaginal wall
What is the surgical treatment for pelvic organ prolapse?
–> definitive option - anterior/posterior colporrhaphy
–> hysterectomy option
–> NICE recommends that Mesh repairs should not be carried out
What are the complications of pelvic organ prolpase surgery?
–> Pain, bleeding, infection, DVT and risk of anaesthetic
–> Damage to the bladder or bowel
–> Recurrence of the prolapse
Altered experience of sex
What is urinary incontinence?
Loss of control of urination
What are the two types or urinary incontinence?
–> urge incontinence
–> Stress incontinence
identifying which one determines the management
What is urge incontinence caused by?
overactivtiy of the detrusor muscle of the bladder
–> also known as overactive bladder
What is the typical description of urge incontinence?
–> Suddenly feeling the urge to pass urine
–> rushing to the bathroom and not arriving before urination occurs
–> women always concious about going places with access to a toilet, impact on quality of life
What is stress incontinence due to?
–> Weakness of the pelvic floor muscles and the sphincter muscles ( the contents of the pelvis are held by a sling of muscles)
–> allows urine to leak at times of increased bladder pressure
–> such as laughing, coughing or when suprised
What is overflow incontinence?
–> occurs when there is chronic urinary retention due to obstruction to the outflow of urine
–> leads to overflow of urine without the urge to pass urine
what are the potential causes of overflow incontinence?
anticholinergic medication
–> fibroids
–> pelvic tumours
–> neurological conditions (MS, DN, spinal cord injuries)
–> more common in males
What are the risk factors for urinary incontinence?
–> Increased age
–> Postmenopausal status
–> Increase BMI
–> Previous pregnancies and —–> vaginal deliveries
–> Pelvic organ prolapse
–> Pelvic floor surgery
–> Neurological conditions, such as multiple sclerosis
–> Cognitive impairment and dementia
Which modifiable risk factors can attribute to urinary incontinence?
–> Caffeine consumption
–> Alcohol consumption
–> medications
–> BMI
How can the severity be assesed of urinary incontinence through the history
Frequency of urination
Frequency of incontinence
Nightime urination
Use of pads and change of clothing
What should the examination for urinary incontinence include?
–> assess pelvic tone
–> examine for pelvic organ prolapse
–> atrophic vagintiis
–> urethral diverticulum
–> pelvic mass
–> strength of pelvic muscle contractions - bimanual examination - squeeze against fingers - modified oxford grading system
–> ask patient to cough and watch for leackage
What are the investigations for urinary incontinence?
–> bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
–> Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology.
–> Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
–> Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
Describe how urodynamic tests take place and what are the different types?
–> need to stop taking anticholinergic medication and bladder medication around five days before
–> thin catheter placed in the bladder and other in the rectum
–> measures the pressures and compares
–> cystometry - measures the detrusor muscle contraction and pressure
–> uroflowmetry - measures the flow rate
–> post-void residual volume
What is the management of stress incontinence?
–> Avoiding caffeine, diuretics and overfilling of the bladder
–> Avoid excessive or restricted fluid intake
–> Weight loss (if appropriate)
–> Supervised pelvic floor exercises for at least three months before considering surgery
–> Surgery (Tension free vaginal tape and autologus sling procedures, last line - artifical urinary sphincter - pump in labia that inflates cuff around urethra
–> Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
What is the management of urge incontinence?
–> Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
–> Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin ( have anticholinergic effects which include dry mouth, dry eyes, urinary retention, constipation and worsening of dementia)
–> Mirabegron is an alternative to anticholinergic medications - contraindicated in uncontrolled hypertension
Invasive procedures where medical treatment fails
–> Botulinum toxin type A injection into the bladder wall
–> Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
–> Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
–> Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
What structure in the fetus does the female reproductive system come form?
paramesonephric ducts (Mullerian ducts)
Why do males not develop a uterus?
produce anti-mullerian hormone
What is a bicornuate uterus?
Congenital malformation of the uterus where there is two horns in the uterus giving the uterus a heart shape
Can be picked up on pelvic ultrasound scan
What are the typical complications of a bicornuate uterus?
–> miscarriage
–> premature birth
–> malpresentation
What is an imperforate hymen?
–> congenital abnormality where the hymen at the entrance of the vagina is fully formed without an opening
What is the presentation of an imperforate hymen?
–> MAy be discovered when girls start to menstruate
–> menses is sealed in the vagina
–> cyclical pelvic pain and cramping
–> without vaginal bleeding
What is the management of an imperforate hymen?
Surgical excision to create an opening
What are the complications if an imperforate hymen is not diagnosed?
–> retrograde menstruation (mesntrual blood backflowing into the fallopian tubes and the ovaries
–> endometriosis
What is transverse vaginal septae?
–> error in development where a septum (wall) forms transversely across the vagina
–> can either be perforate or imperforate
What is the presentation of transverse vaginal septae
–> when perforate, girls can still menstruate, but can have difficult intercourse or tampon use
–> When imperforate presents as cyclical pelvic pain and cramps without menstruation
What are the complications of transverse vaginal septae?
–> infertility
–> pregnancy-related complications
What are the investigations and management of transverse vaginal septae?
–> diagnosis by examination, ultrasound or MRI
–> Surgical correction - complications - vaginal stenosis or recurrence
What is vaginal hypoplasia?
Abnormally small vagina
What is vaginal agenesis?
–> absent vagina
–> these occur due to failure of the mullerian ducts to develop properly and may be associated with an absent uterus and cervix
What is the management of vaginal hypoplasia?
–> using a vaginal dilator over a prolonged period to create an adequate vaginal size, alternativley vaginal surgery
What is androgen insenstivity syndrome?
Cells are unable to respond to androgen hormones, due to a lack of androgen receptors
X-linked recessive condition - caused by a mutation in the androgen receptor gene on the X chromosome
What is the pathophysiology of androgen insensitivity syndrome?
Lack of androgen receptors through mutations in the androgen receptor gene on the X chromosome
Leads to extra androgens converted into oestrogen, resulting in female secondary sexual characterisitics - previously known as testicular feminisation syndrome
What is the presentation of complete androgen insensitivity syndrome?
–> Patients are genetically male, with XY sex chromosomes
–> absent response to testosterone and the conversion of extra testosterone leads to the conversion of extra into oestrogen
–> results in femle phenotype externally
–> male sexual characteristics do not develop and patients have normal female external genitalia and breast tissue
–> tests in the abdomen or inguinal canal
–> absence of female reproductive system as the testes prodcue anti-mullerian hormone - only lower vagina
–> insensitivity to androgens leads to lack of pubic hari and, facial hari and male muscle development , slightly taller than average female and infertile with an increased risk of testicular cancer due to testes in abdo
What will be the presetation of partial androgen insentivity syndrome?
–> micropenis
–> clitomegaly
–> bifid scrotum
–> hypospadius
–> diminished male characterisitics
What is the presentation of androgen insensitivity syndrome?
–> often presents in infanct with inguinal hernias containing testes
–> can present in puberty with primary amenorrhoea
–> Hormone tests - Raised LH/ normal or raised FSH/ normal or raised testosterone levels (for a male)/ raised oestrogen levels (for a male)
What is the management of androgen insensitivty syndrome?
–> MDT approach - paediatrics/ gynae/ urology/ endocrinolgist/ clinical psychologist
–> bilateral orchidectomy- to avoid testicular tumours
–> oestrogen therapy
–> vaginal dilators or vaginal surgery to create an adequate vaginal length
Which hormones do girls have relativley little of before puberty?
GnRH, LH, FSH, oestrogen and progesterone
What happens to the levels of GnRH, LH, FSH, oestrogen and progesterone in puberty?
they increase leading to female secondary sexual characteristics, the onset of the menstrual cycle and the ability to conceive children
When does puberty start in girls and boys?
–>8-14 in girls
–> 9-15 in boys
–> takes around 4 years from start to finish
–> girls have pubertal growth spurt earlier in puberty than boys
Why are overweight children more likley to enter puberty at an earlier age?
Aromatase is an enzyme found in adipose tissue, important in the creation of oestrogen
In which girls may there be delayed puberty?
–> low birth weight
–> chronic disease
–> eating disorders
–> athletes
How does puberty start in girls?
–> development of breast buds
–> followed by pubic hair
–> onset of menstrual periods
–> first episode of menstruation is called menarche
–> menstrual cycles begin around two years from the start of puberty
Which staging system can be used to determine the stage of pubertal development for girls?
Tanner staging
Age, pubic hair and breast development
What are the hormonal changes during puberty for girls?
–> GH increases initially - causes a growth spurt during the initial phases of puberty
–> hypothalamus starts to secrete GnRH, first during sleep and then throughout the day in later stages
–> GnRH causes the releases of FSH and LH from the pituitary gland
–> FSH and LH cause the ovaries to make oestrogen and progesterone.
–> FSH levels plateau about a year before menarche
–> LH levels continue to rise and spike just before they induce menarche
What is menopause?
–> Retrospective diagnosis, made after a women has no periods for 12 months
–> defined as a permanent end to to mesntruation
On average when do women experience the menopause
51 years- can vary significantly
What is postmenopause?
Describes the period of 12 months after the final menstrual period onwards
What is perimenopause?
refers to the time around menopause when the women is experiencing vasomotor symptoms and irregular periods.
–> includes the time leading up to the last menstrual period, and the 12 months afterwards, typically in women older than 45
What is premature menopause?
Menopause before the age of 40 years
- Result of premature ovarian insufficiency
What is menopause caused by?
Lack of ovarian follicular function = Changes in the sex hormones associated with the menstrual cycle
What are the sex hormone changes seen in menopause?
Low = Oestrogen and Progesterone
High = LH and FSH in response to an absence of negative feedback from the oestrogen
What is the physiology of menopause?
Usually:
–> In ovaries, primordial follicles mature into primary and secondary follicles
–> At the start of the menstrual cycle FSH stimulates the further development of the secondary follicles
–> As the follicles grow the granulosa cells that surround them secrete increasing amounts of oestrogen
In menopause:
–> menopause begins when there is a decline in the development of the ovarian follicles
–> without the growth of the follicles there is reduced production of oestrogen
–> As the levels of oestrogen fall in the perimenopausal period there is an absence of negative feedback on the pituitary gland and increasing levels of LH and FSH
–> failing follicular development means that ovulation dosent occur, leading to irregular periods
–> without oestrogen the endometrium dosent develop and this leads to amenorrhoea and low levels of oestrogen cause the perimenopausal symptoms
What are 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
What are the risks of a lack of oestrogen in menopause?
- Cardiovascular disease and stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
How is the diagnosis of menopause made?
Women over 45 (Typically around 51 for menopause) Done clinically w/ 12+ months amenorrhea
Can use FSH if….
- Women under 40 years with suspected premature menopause
- Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
Pregnancy over 40 is often associated with….
increased risks and complications
How long do women have to use effective contraception for after their last menstrual cycle?
Under 50? 2 years
Over 50? 1 Year
What are some good contraceptive options UKMEC 1 - no restrictions ) for women approaching menopause?
- Barrier methods
- Mirena or copper coil
- Progesterone-only pill
- Progesterone implant
- Progesterone depot injection (under 45 years)
- Sterilisation
In whom should the combined oral contraceptive pill be used in (UKMEC 2) ?
Aged over 40 and up to 50 years
–> as the benefits usually outweigh the risks
–> Consider combined oral contraceptive pill in women over 40 years containing norethisterone or levonorgestrel in women over 40 due to low risk of venous thromboembolism
What are two complications of the progesterone depot injection (Depo-provera)
Weight gain
Osteoporosis
- Reduced bone mineral density means it is unsuitable for women over 45
What is the management of perimenopausal symptoms?
Vasomotor symptoms = Self Limiting <5 years
HRT
- Tibolone - a synthetic steroid hormone that acts as continuous combined HRT
- Clonidine - agonist of alpha-adrenergic and imidazoline receptors
CBT/ SSRI (fluoxetine or citalopram)
Testosterone (decreased libido)
Vaginal oestrogen/Moisturisers (vaginal dryness and atrophy)
What is adenomyosis?
Endometrial tissue inside the myometrium (muscle layer of the uterus)
–> condition is hormone dependent and usually gets better after menopause, similar to endometriosis and fibroids
In whom is adenomyosis more common?
Multiple Pregnancies
Unopposed Oestrogen
What is the presentation of adenomyosis?
- Dysmenorrhoea
- Menorrhagia
- Dyspaerunia
- Infertility/ pregnancy-related complications
- Maybe Asymptomatic
Examination = Enlarged and tender uterus, feels more soft than an uterus with fibroids (Boggy)
How can the diagnosis of adenomyosis be made?
1) TV USS
2) MRI and transabdominal ultrasound
Gold) perform a histological examination of the uterus after a hysterectomy
What is the management of adenomyosis?
No Contraception?
Tranexamic acid (Menorrhagia)
Mefenamic acid (Dysmenorrhea)
NSAID - reduced bleeding and pain
Contraception?
1) Mirena coil / COCP/ COP
- Progesterone only meds such as the pill or depot may be useful
Others
GnRH analogues to induce a menopause-like state
Endometrial ablation
Uterine artery embolisation
Myomectomy/ Hysterctomy
Which pregnancy complications are associated with adenomyosis?
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
What is Ashermans syndrome?
Adhesions
Adhesions form within the uterus following uterus damage
When does Ashermans syndrome normally occur?
- After a pregnancy
- Dilatation and curettage procedure ( scraping retained products of conception
- Uterine surgery (myomectomy) or
- Several pelvic infections/ PID
What is the pathophysiology of Asherman’s syndrome?
1) Damaged endometrial base layer
2) Abnormal healing w/ scar tissue adhesions
3) Scar tissue may produces unwanted connections/ blockades (does not respond to oestrogen)
Result
Physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages
What is the presentation of Ashermans syndrome?
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea - painful periods
- Infertility
How is the diagnosis of Ashermans syndrome made?
Gold = Hysteroscopy
Other
- 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 the management of Asherman syndrome?
Dissecting adhesions during the hysteroscopy
- Reoccurence of the adhesions after treatment is common
What is Lichen Scelorus?
Chronic inflammatory skin condition that presents with patches of white shiny porcelain-white skin
- Affects the labia, perineum, and perianal skin in the skin
- Autoimmune condition associated with type 1 diabetes, alopecia, hypothyroid and vitiligo
how can lichen scelrosus be diagnosed?
Clinical diagnosis
Can confirm w/ Vulval Biopsy
What does Lichen refer to?
Flat eruption that spreads
What is Lichen simplex?
Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin
- Presents with excoriations, plaques, scaling and thickened skin
What is Lichen planus?
Autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
What is the presentation of lichen sclerous?
- Vulval Itching and Skin changes
- Soreness and pain possibly worse at night
- Skin tightness
- Superficial dyspareunia
- Erosions and Fissures
- Koebner Phenomenon
Koebner Phenomenon
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.
What is the appearance of Lichens Scelrosus?
Labia/ Perianal/Perineal Changes
- Fissures/ Cracks/ Erosions
“Porcelain-white” in colour
Shiny Thin Tight Skin
Slightly Raised
- Papules or plaques
What is the management of Lichens sclerosis?
1st) Clobetasol propionate 0.05% (dermovate)
- control symptoms and reduce risk of malignancy
2) Regular emollient use
What are the complications of Lichens sclerosis?
5% Risk of Vulval Small Cell Carcinoma
Other complications include:
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
What is atrophic vaginitis?
Low Oestrogen = Vaginal Mucosa Dryness and Thinning
Px = Genitourinary symptom of menopause
What is the pathophysiology of atrophic vaginitis?
–> Epithelial lining of the vagina and urinary tracct responds to oestrogen by becoming thicker, more elastic and producing more secretions
–> menopause, oestrogen levels fall and mucosa becomes thinner, less elastic and more dry, tissues prone to inflammation
–> changes the vaginal pH and microbial flora that can contribute to localised infections
–> oestrogen helps maitain healthy connective tissue around the pelvic organs and a lack of oestrogen can contribute to POP and stress incontinence
What is the presentation of atrophic vaginitis?
–> presents in postmenopausal women with symptoms of
–> itching
–> dryness
–> dyspareunia - painful sex
–> bleeding due to localised inflammation
–> recurrent urinary tract infections, stress incontinece or POP
What would the examination reveal for atrophic vaginitis?
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
what type of cancer can vulval cancer be?
–> 90% squamous cell carcinomas
–> less commonly they can be malignant melanomas
What are the risk factors for squamous cell carcinomas?
–> advanced age
–> immunosuppression
–> HPV - humanpapilloma virus infection
–> lichen sclerosus - 5% of women with lichen sclerosus get vulval cancer
What is vulval intraepithelial neoplasia?
–> Premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
What is a high-grade squamous intraepithelial lesion?
–> Type of vulval intraepithelial neoplasia
–> associated with HPV infections that typically occur in younger women aged 35-50 years
What is differentiated vulval intraepithelial neoplasia?
–> alternate type of VIN and associated with lichen sclerosis and typically occurs in older women 50-60
How do you diagnose vulval intraepithelial neoplasia?
biopsy
What are the treatment options for vulval intraepithelial neoplasia?
–> Watch and wait with close followup
–> Wide local excision (surgery) to remove the lesion
–> Imiquimod cream
–> Laser ablation
What is the presentation of vulval cancer?
–> may be an incidental finding in older women, for example, during catheterisation in a patient with dementia.
–> Vulval lump
–> Ulceration
–> Bleeding
–> Pain
–> Itching
–> Lymphadenopathy in the groin
Vulval cancer most frequently affects the labia majora, giving an appearance of:
–> Irregular mass
–> Fungating lesion
–> Ulceration
–> Bleeding
What are the investigations for vulval cancer?
–> 2ww referral
–> Biopsy of the lesion and sentinel node biopsy - lymph node spread
–> Further staging imaging such as CT of the abdomen and pelvis
which system is used to stage vulval cancer?
International Federation of Gynecology and Obstetrics - FIGO system
What is the management of vulval cancer?
–> wide local excision to remove the cancer
–> groin lymph node dissection
–> chemotherapy
–> radiotherapy
cervical cancer normally affects which type of women?
–> younger women
–> peaking in reproductive years
What type of cancer can cervical cancer be?
–> 80% are squamous cell carcinoma
–> Adenocarcinoma next most common
–> Small cell cancer rare
Which virus is cervical cancer strongly associated with?
HPV - human papillomavirus
what is HPV infection associated with?
anal, vulval, vaginal, penis, mouth and throat cancers
–> sexually transmitted infection
How does HPV infection increase the risk for cancer development?
HPV inhibits the tumour suppressor genes
What are the risk factors for cervical cancer?
Increased risk of catching HPV
–> early sexual activity
–> Increased number of sexual partners
–> Sexual partners who have had more partners
–> Not using condoms
Non-engagement with cervical screening
–> Most cases are preventable with early detection and treatment
Other risk factors
–> smoking
–> HIV
–> combined oral contraceptive
–> Increased number of full-term pregnancies
–> family history
–> Exposure to diethylstilbesterol during fetal development
What is the presentation of cervical cancer?
–> may be detected during cervical smears in asymptomatic women
–> abnormal vaginal bleeding - intermenstrual/postcoital/post-menopausal bleeding
–> vaginal discharge
–> pelvic pain
–> dyspareunia - pain or discomfort with sex
–> ulceration/inflammation.bleeding or visible tumour in the cervix
What is cervical intraepithelial neoplasia?
grading system for the level if dysplasia (premalignant change) in the cells of the cervix
How is cervical intraepithelial neoplasia diagnosed?
through colposcopy
How is cervical intraepithelial neoplasia staged?
–> 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.
How is cervical cancer screened?
–> smear test
–> aims to pick up precancerous changes (dyskaryosis)
–> liquid-based cytology- brush into a preservation fluid
–> initially tested for high-risk HPV before the cells are examined, if the sameple is negative the cells arn’t examined and the women returned to the routine screening programme
How often should smears be carried out?
Every three years aged 25 – 49
Every five years aged 50 – 64
What are the exceptions in the smear programme?
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
What cytology results could you get from a smear test?
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
How should smear results be managed?
–> Inadequate sample – repeat the smear after at least three months
–> HPV negative – continue routine screening
–> HPV positive with normal cytology – repeat the HPV test after 12 months
–> HPV positive with abnormal cytology – refer for colposcopy
What is a colposcopy?
Involves inserting a speculum and a colposcope to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail.
During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas.
A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.
What is a large loop excision of the transition zone?
also known as loop biopsy
–> loop of wire with diathermy to removal abnormal tissue of the cervix
–> may result in pre-term labour
What is a cone biopsy of the cervix and what is it used for?
–> Treatment for cervical intraepithelial neoplasia and very early-stage cervical cancer
–> General anesthetic - surgeon removes a cone-shaped piece of the uterus - sent to histology
–> increased risk of misscarriage, premature labour, pain, bleeding, infection, and scar formation with stenosis of the cervix
Which staging system is used to stage cervical cancer?
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer:
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
What is the management of cervical cancer?
–> Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
–> Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
–> Stage 2B – 4A: Chemotherapy and radiotherapy
–> Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy, and palliative care
–> Pelvic exenteration - may be used in advanced cervical cancer - removal of most or all of the pelvic organs including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder, and rectum
Bevacizumab - is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer
targets vascular endothelial growth factor a
When does the HPV vaccine need to be given to girls?
–> before they become sexually active
Which strains of HPV does the HPV vaccine protect against?
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
A woman presenting with postmenopausal bleeding has what until proven?
–> endometerial cancer
What is the pathophysiology of endometrial cancer?
Endometrial cancer is cancer of the endometrium, the lining of the uterus. Around 80% of cases are adenocarcinoma. It is an oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells.
What is endometrial hyperplasia?
–> precancerous condition involving the thickening of the endometrium
–> most cases of endometrial hyperplasia will return to normal overtime
What are the two types of endometrial hyperplasia?
–> hyperplasia without atypia
–> atypical hyperplasia
How can endometrial hyperplasia be treated?
progestogens
–> intrauterine system - mirena coil
–> continued oral progestogens - levonorgestrel
What are the risk factors for endometrial cancer?
–> Patient’s exposure to unopposed oestrogen, refers to oestrogen without progesterone
Situations where there is an increased unopposed oestrogen
–> increased age
–> earlier onset of menstruation
–> late menopause
–> oestrogen-only HRT
–> no or fewer pregnancies
–> obesity
–> polycystic ovarian syndrome
–> tamoxifen
–> diabetes
Why might polycystic ovarian syndrome lead to increased exposure to unopposed oestrogen - endometrial cancer?
–> After ovulation, corpus luteum forms in the ovaries from the ruptured follicle that released the egg
–> Corpus luteum produced progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (second half)
–> PCOS - less likely to ovulate and form a corpus luteum, progesterone not produced
–> endometrial lining has more exsposure to unopposed oestrogen
For endometrial protection what should women take that have PCOS?
–> combined oral contraceptive pill
–> an intrauterine system (mirena coil)
–> cyclical progestogens
Why is obesity a risk factor for endometrial cancer?
–> 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.
What are the protective factors in endometrial cancer?
–> Combined contraceptive pill
–> Mirena coil
–> Increased pregnancies
–> Cigarette smoking
Smoking appears to be protective against endometrial cancer in postmenopausal women by being anti-oestrogenic. Interestingly, it is not protective against other oestrogen dependent cancers, such as breast cancer (where it increases the risk).
what is the presentation of endometrial cancer?
The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding.
Endometrial cancer may also present with:
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
what are the referral criteria for endometrial cancer?
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
What are the investigations for endometrial cancer?
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
How is endometrial cancer staged?
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer:
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
What is the management of 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).
Other treatment options depending on the individual presentation include:
A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Why does ovarian cancer normally present later?
–> non- specific symptoms resulting in a worse prognosis
–> more than 70% of women present with ovarian cancer once it has spread beyond the pelvis
What are the different types of ovarian cancer?
Epithelial cell tumours
Dermoid cysts/ germ cell tumours
Sex cord-stromal tumours
metastasis
What are epithelial cell tumours (ovarian cancer)
–> tumours arising from the epithelial cells of the ovary
–> most common type
–> subtypes include - serous tumours (most common)/ endometrioid carcinomas/ clear cell tumours/ mucinous tumours/ undifferentiated tumours
What are dermoid cysts/germ cell tumours (ovarian cancer)
–> benign ovarian tumours - teratomas, they come from germ cells
–> may contain various tissue types such as skin, hair, teetch, bone
–> associated with ovarian torsion.
–> germ cell tumours may cause a raised alpha-fetoprotein and hCG
What are sex cord-stromal tumours?
–> rare tumours that can be benign or malignant - arise from stroma (connective tissue) or sex cords (emryonic structure assocaited with follicles)
–> several types such as sertoli-leydig tumours and granulosa cell tumours
What are Krukenburg tumours?
–> metastasis in the ovary usually from gastrointestinal tract cancer paritcularly the stomach
What are the risk factors for ovarian cancer?
–> Age (peaks age 60)
–> BRCA1 and BRCA2 genes (consider the family history)
–> Increased number of ovulations
–> Obesity
–> Smoking
–> Recurrent use of clomifene (inferitlity treatment which causes ovulation)
Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:
–>Early-onset of periods
–> Late menopause
–> No pregnancies
What are the protective factors for ovarian cancer?
Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk:
Combined contraceptive pill
Breastfeeding
Pregnancy
What is the presentation of ovarian cancer?
Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include:
–> 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.
Which 3 physical examination signs should prompt a 2ww referral for ovarian cancer?
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
which blood test can be done in women presenting with signs of ovarian cancer?
CA-125 - cancer antigen 125
What investigations should be carried out for ovarian cancer?
initial investigations in primary or secondary care are:
–> CA125 blood test (>35 IU/mL is significant)
–> Pelvic ultrasound
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
Further investigations in secondary care include:
–> CT scan to establish the diagnosis and stage the cancer
–> Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
–> Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
–> Alpha-fetoprotein (α-FP)
–> Human chorionic gonadotropin (HCG)
What are the other causes of a raised CA-125?
–> Endometriosis
–> Fibroids
–> Adenomyosis
–> Pelvic infection
–> Liver disease
–> Pregnancy
How is ovarian cancer staged?
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is:
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
How is ovarian cancer managed?
Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
What is endometriosis?
–> where there is ectopic endometrial tissue outside the uterus
What is the term given to a lump of endometrial tissue outisde the utreus?
endometrioma
What is the term given to endometriomas in the ovaries?
Chocolate cysts
What are the aetiology theroies for endomatriosis?
–> genetic component
–> retrograde menstruation - where ther endometrial lining flows back out into the pelvis and peritoneum
–> embryonic cells destined to become endometrial tissue may remian outside the uterus
–> may be spread of endometrial cells through the lympahtic system similar to cancer
–> Cells outside the uterus someohow change - metaplasia
What is the pathophysiology of endometriosis?
–> endometrial tissue respond to hormones same as in uterus
–> during menstruation the endometrial tissue sheds and bleeds
–> with endometriosis this bleeding causes irritation and inflammation of the tissues around the site of endometriosis
–> results in cyclical, dull, heavy or burning pain during menstruation
–> deposits of endometriosis in the bladder or the bowel can lead to blood in the urine or stool
–> localised inflammation and bleeding can lead to adhesions, causes scar tissue - adhesions and binds the organs together
–> adhesions lead to chronic - non-cyclical pain that can be sharp, stabbing or pulling and associted with nausea
–> inferitlity due to adhesions blocking egg release and chcoloate cysts damaging eggs
What is the presentation of endometriosis?
–> 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
Examination may reveal:
–> Endometrial tissue visible in the vagina on speculum examination, –> particularly in the posterior fornix
–> A fixed cervix on bimanual examination
–> Tenderness in the vagina, cervix and adnexa
How is the diangosis of endometriosis made?
Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.
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 the management of endometriosis?
Initial management involves:
–>Establishing a diagnosis
–> Providing a clear explanation
–> Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
–> Analgesia as required for pain (NSAIDs and paracetamol first line)
Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy - 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.
The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore, another treatment option for endometriosis is to induce a menopause-like state using GnRH agonists. Examples of GnRH agonists are goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
Surgical management options:
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
What are prolactinomas?
type of pituitary adenoma, a benign tumor of the pituitary gland
How can pituitary adenomas be classified?
–> Size - microadenoma < 1cm and macroadenoma is > 1cm
–> Hormonal status - secretory/ functioning adenoma produces an excess of a particular hormone and non-secretory adenoma does not produce a hormone to excess
What is the most common type of pituitary adenoma and what does it produce?
–> prolactinomas are the most common
–> produce prolactin
What is the presentation of prolactinomas?
excess prolactin in women
–> amenorrhoea
–> infertility
–> galactorrhoea
–> osteoporosis
excess prolactin in men
–> impotence
–> loss of libido
–> galactorrhoea
other symptoms may be seen with macroadenomas
–> headache.
–> visual disturbances (classically, a bitemporal hemianopia (lateral visual fields) or upper temporal quadrantanopia)
symptoms and signs of hypopituitarism
What are the investigations for prolactinomas?
MRI
What is the management of prolactinomas?
–> symptomatic - dopamine agonists e.g cabergoline or bromocriptine which inhibits the release of prolactin from the pituitary gland
–> surgery is performed for patients who cant tolerate or fail to respond to the medical therapy - trans-sphenoidal approach
What are fibroids?
benign tumors of the smooth muscle of the uterus - also called uterine leiomyomas
–> very common
–> more common in black women
–> oestrogen sensitive
What are the different types of fibroids?
–> Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
–> Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
–> Submucosal means just below the lining of the uterus (the endometrium).
–> Pedunculated means on a stalk.
What is the presentation of fibroids?
Fibroids are often asymptomatic. They can present in several ways:
–> Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
–> Prolonged menstruation, lasting more than 7 days
–> Abdominal pain, worse during menstruation
–> Bloating or feeling full in the abdomen
–> Urinary or bowel symptoms due to pelvic pressure or fullness
–> Deep dyspareunia (pain during intercourse)
–> Reduced fertility
–> Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Which investigations should be done for 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.
What is the management for 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
Surgical options for managing smaller fibroids with heavy menstrual bleeding are:
–> Endometrial ablation
–> Resection of submucosal fibroids during hysteroscopy
–> Hysterectomy
For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are:
–> Symptomatic management with NSAIDs and tranexamic acid
–> Mirena coil – depending on the size and shape of the fibroids and uterus
–> Combined oral contraceptive
–> Cyclical oral progestogens
Surgical options for larger fibroids are:
–> Uterine artery embolisation - causes fibroid shrinkage
–> Myomectomy - can improve fertility
–> Hysterectomy
–> GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. 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 are the complications of fibroids?
–> Heavy menstrual bleeding, often with iron deficiency anaemia
–> Reduced fertility
–> Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
–> Constipation
–> Urinary outflow obstruction and urinary tract infections
–> Red degeneration of the fibroid
–> Torsion of the fibroid, usually affecting pedunculated fibroids
–> Malignant change to a leiomyosarcoma is very rare (<1%)
What is red degeneration+ of fibroids?
–> ischemia, infarction and necrosis of the fibroid due to disrupted blood supply.
–> 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.
–> Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia
What is pelvic inflammatory disease?
–> infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum
What are the causes of pelvic inflammatory disease?
–> ascending infection from the endocervix
–> chlamydia trachomatis
–> Neisseria gonorrhoea
–> mycoplasma genitalium
What are the features of pelvic inflammatory disease?
–> lower abdominal pain
–> fever
–> deep dyspareunia
–> Dysuria and menstrual irregularities may occur
–> vaginal or cervical discharge
–> cervical excitation
What are the investigations for pelvic inflammatory disease?
–> a pregnancy test should be done to exclude an ectopic pregnancy
–> high vaginal swab -these are often negative
–> screen for Chlamydia and Gonorrhoea
What is the management of pelvic inflammatory disease?
–> Due to the difficulty in making an accurate diagnosis and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
–> oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
–> RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in
What are the complications for pelvic inflammatory disease?
–> Perihepatitis (Fitz-Hugh Curtis Syndrome) - occurs in around 10% of cases/ it is characterised by right upper quadrant pain and may be confused with cholecystitis
–> Infertility - the risk may be as high as 10-20% after a single episode
–> Chronic pelvic pain
–> ectopic pregnancy
What are functional ovarian cysts?
–> cysts related to fluctuating hormones of the menstrual cycle
–> very common in premenopausal women (benign)
Ovarian cysts in postmenopausal women suggest…
Malignancy
What can the appearance of multiple ovarian cysts be described as?
String of pearls
What is the presentation of ovarian cysts?
–> Most are asymptomatic
–> vague pelvic pain
–> vague bloating
–> vague fullness in the abdomen
–> a palpable pelvic mass (large cysts - mucinous cystadenomas)
When might ovarian cysts present with acute pelvic pain?
–> ovarian torsion
–> haemorrhage
–> rupture of the cyst
What are the two types of functional ovarian cysts?
–> follicular cysts - when the developing follicle fails to rupture and release the egg/ most common/ harmless and disappear after a few menstrual cycles/thin-walled and no internal structures.
–> corpus luteum cysts - corpus luteum fails to break down and instead fills with fluid/ causes pelvic pain or delayed menstruation/ often in early pregnancy
What are the other 5 types of ovarian cysts?
–> Serous cystadenoma - benign tumour from epithelial cells
–> Mucinous cystadenoma - benign tumour from epithelial - can be huge
–> Endometrioma - lumps of endometrial tissue in the ovary - only in endometriosis - causes pain and disrupts ovulation
–> Dermoid/germ cell tumours - benign tumours - teratomas (come from germ cells) can contain various tissues (hair, skin, teeth and bone) associated with ovarian torsion
–> Sex cord-stromal tumours - rare - benign or malignant - from stroma (connective tissue) or sex cords (embryonic structures associated with follicles. - includes Sertoli-Leydig cell tumours and granulosa cell tumours
What are the risk factors for ovarian malignancy?
–> Age
–> Postmenopause
–> Increased number of ovulations
–> Obesity
–> Hormone replacement therapy
–> Smoking
–> Breastfeeding (protective)
–> Family history and BRCA1 and BRCA2 genes
Which factors can reduce the number of ovulations that occur?
Later onset of periods (menarche)
Early menopause
Any pregnancies
Use of the combined contraceptive pill
What are the investigations for ovarian cysts?
–> Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
–> blood test - CA125
–> women under 40 with complex ovarian mass require tumour markers for possible germ cell tumour: Lactate dehydrogenase/ alpha-fetoprotein/ HCG
–> Risk of malignancy index: menopausal status/ USS findings/ CA125 level
What can be the causes of a raised CA125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
What is the management of ovarian cysts?
–> Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist.
–> Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery.
–> Simple ovarian cysts in premenopausal women can be managed based on their size: < 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. / 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring/ More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
What are the potential complications of ovarian cysts?
Torsion
Hemorrhage into the cyst
Rupture, with bleeding into the peritoneum
What is Meigs syndrome?
Meig’s syndrome involves a triad of:
–> Ovarian fibroma (a type of benign ovarian tumor)
–> Pleural effusion
–> Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
What is ovarian torsion?
Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
Why does ovarian torsion normally happen?
–> Usually due to an ovarian mass larger than 5cm such as cyst or tumour
—> more likely with benign tumours and more likely to occur during pregnancy
What is ovarian torsion a medical emergency?
Twisting of the adnexa and blood supply to the ovary leads to ischemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.
What is the presentation of ovarian torsion?
–> Sudden onset severe unilateral pelvic pain
–> Nausea and vomiting
–> localised tenderness
–> palpable mass in the pelvis
–> can be intermittent pain if the ovary and untwist spontaneously
How is the diagnosis of ovarian torsion made?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show a “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow.
The definitive diagnosis is made with laparoscopic surgery
What is the management of ovarian torsion?
–> may require laparoscopic surgery
–> Untwist the ovary and fix in it place (detorsion)
–> Remove the affected ovary (oophorectomy)
What are the complications of ovarian torsion?
–> A delay in treating ovarian torsion can lead to loss of function.
Other ovaries can compensate so fertility is not affected
–> When necrotic ovary is removed it can become affected developing an abscess and this can lead to sepsis, it can also rupture resulting in peritonitis and adhesions
What is PCOS?
–> Common condition causing metabolic and reproductive problems in women
–> Characteristic features of multiple ovarian cysts/ oligomenorrhoea/ hyperandrogenism and insulin resistance
Which criteria can be used to diagnose PCOS?
Rotterdam criteria
–> at least 2 out of 3 features
–> Oligoovulation or anovulation - presenting with irregular or absent menstrual periods
–> hyperandrogenism - hirsutisim and acne
–> polycystic ovaries on ultrasound
What is the presentation of PCOS?
–> Triad of - anovulation (oligomenorrhoea/amenorrhoea) / hyperandrogenism ( Hirsutism and acne)/ Polycystic ovaries on ultrasound
–> infertility
–> Hair loss in a male pattern
–> insulin resistance and diabetes
–> acanthosis nigricans (insulin resistance)
–> endometrial hyperplasia and cancer
–> cardiovascular disease
–> hypercholesterolemia
–> obstructive sleep apnoea
–> depression and anxiety
–> sexual problems
What are the differential diagnosis for hirsutism?
–> Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone, and anabolic steroids
–> Ovarian or adrenal tumors that secrete androgens
–> Cushing’s syndrome
–> Congenital adrenal hyperplasia
What is the pathophysiology of insulin resistance in PCOS?
Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
Diet, exercise and weight loss help reduce insulin resistance.
What are the investigations for PCOS?
BLOODS
–> testosterone
–> Sex hormone-binding globulin
–> LH
–> FSH
–> Prolactin - might be slightly elevated
–> TSH
–> Raised LH
–> Raised LH: FSH ratio
–> Raised testosterone
–> raised insulin
–> normal or raised oestrogen levels
–> TVU - the follicles may be arranged around the periphery of the ovary giving a string of pearls appearance - 12 or more developing follicles in one ovary or a ovarian volume >10cm3
–> Diabetes - 2hr OGTT
–> Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
–> Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
–> Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
What is the general management of PCOS?
reduce the risks associated with obesity, type 2 diabetes, hypercholesterolemia, and cardiovascular disease. These risks can be reduced by:
Weight loss - significant management - can improve insulin resistance, reduce the risks of associated conditions and reduce hirsutism - orlistat for bmi >30 - lipase inhibitor stops fat absorption.
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
Patients should be assessed and managed for the associated features and complications, such as:
Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety
What risk factors do women with PCOS have for endometrial cancer?
Women with polycystic ovarian syndrome have several risk factors for endometrial cancer:
Obesity
Diabetes
Insulin resistance
Amenorrhoea
What is the reason why women with PCOS are at risk fo endometrial cancer?
–> Normally corpus luteum secretes progesterone
–> PCOS - anovulation - less progesterone - more unopposed oestrogen
–> Continuous oestrogen leads to endometrial lining proliferation without regular shedding as there’s no progesterone
–> similar to unopposed oestrogen in women on HRT - leads to endometrial hyperplasia
What are the options available for investigation for at-risk PCOS patients for endometrial hyperplasia/cancer?
–> pelvic ultrasound scan if extended gaps in periods or abnormal bleeding, cyclical progestogens are given to induce period before scan - if >10mm referred for biopsy
–> 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
How can infertility be managed for PCOS patients?
–> Weight loss to help restore regular ovulation
–> Clomifene
–> laparoscopic ovarian drilling
–> IVF
–> if pregnant require OGTT at 24-28 weeks gestation
How can hirsutism be managed in PCOS patients?
–> Weight loss
–> Co-cyprinidiol is a COCP licensed for the treatment of hirsutism and acne - anti-androgenic effect. Increased risk of VTE so only 3 months of use allowed
–> topical eflornithine
–> electrolysis
–> Laser hair removal
–> Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
–> Finasteride (5α-reductase inhibitor that decreases testosterone production)
–> Flutamide (non-steroidal anti-androgen)
–> Cyproterone acetate (anti-androgen and progestin)
