Obs + Gynae - Gynaecology Flashcards
Name a common cause of heavy menstrual bleeding
- Uterine fibroids
- Uterine polyps
- Adenomyosis
- Endometriosis
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes and hypothyroidism)
- PCOS
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
Name a pharmacological treatment and a surgical treatment for Fibroids
Pharmacological: LNG-IUS Mirena, NSAID, Antifibrinolytic (Tranexamic acid), CHC, GnRH agonist (Triptorelin), Progesterone receptor inhibitor (Mifepristone), Aromatase inhibitor (Letrozole), Ulipristal acetate
Surgical: Myomectomy, Laparoscopic resection, Endometrial ablation, Uterine artery embolisation, Hysterectomy
Benign tumours of myometrium (whorls of SMCs with collagen)
Uterine fibroids
Name a cause of abnormal bleeding during menstruation
Blood coagulation disorders (VW disease, ITP), Reproductive tract diseases (ectopic, malignancy, endometritis, fibroids, lesions), Hypothyroidism, Cirrhosis (ALSO rapid weight change, stress, medication)
Fibroids are what type of tumour, in what cell and where in the uterus?
Benign monoclonal tumour of smooth muscle cells of the uterine myometrium
Are most fibroids intramural, submucosal or subserosal?
Intramural
Name an investigation for Fibroids
FBC (Fe), Pelvic USS or TVUS, MRI, Endometrial sampling, Hysteroscopy, Pregnancy test may be indicated
Name a type of ovarian cyst
Functional cyst (Follicular cysts + Corpus lute cysts), Dermoid Cyst, Cystadenoma, Endometrioma
Name 2 common features for these causes of chronic pelvic pain: Endometriosis IBS Ovarian Cyst Urogenital prolapse
- Endometriosis - Chronic pelvic pain; Dysmenorrhoea; Deep dyspareunia; Subfertility
- IBS - abdominal pain, bloating and change in bowel habit (lethargy, nausea, backache and bladder symptoms may also be present)
- Ovarian Cyst - Unilateral dull ache which may be intermittent or only occur during intercourse (Dyspareunia); Torsion or rupture may lead to severe abdominal pain; Large cysts may cause abdominal swelling
- Urogenital prolapse - (older women) Sensation of pressure, heaviness, ‘bearing-down’; Urinary symptoms: incontinence, frequency, urgency
Name 2 common features for these causes of acute pelvic pain: Ectopic pregnancy UTI Appendicitis PID Ovarian torsion Miscarriage
- Ectopic pregnancy - amenorrhoea with lower abdominal pain and later develops vaginal bleeding (can see shoulder tip pain and cervical excitation)
- UTI - Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis, haematuria
- Appendicitis - Pain in the central abdomen before localising to the right iliac fossa; Anorexia common; Tachycardia; low-grade pyrexia; Rovsing’s sign
- PID - Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria (menstrual irregularities and cervical excitation may occur)
- Ovarian torsion - sudden onset unilateral lower abdominal pain (Onset may coincide with exercise); N+V common; Unilateral, tender adnexal mass
- Miscarriage - Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Name a treatment for polycystic ovarian syndrome
normalise weight/Tamoxifen (or Clomifene)/Metformin/Laparoscopic ovarian drilling
Name a treatment for tubal disease
tubal catheterisation/adhesiolysis/salpingostomy
Name:
a. ) the Gonadotrophin-releasing hormones and where they are produced
b. ) the Gonadotrophin hormones and where they are produced
c. ) the ovarian hormones that the Gonadotrophins control
a. ) LHRH and FSHRH from Hypothalamus
b. ) LH and FSH from anterior pituitary
c. ) Oestrogen and Progesterone
a. ) During the follicular phase, a rise in FSH stimulates development of several…, while a rise in LH mid-cycle triggers the release of the…
b. ) During the luteal phase, levels of … and … decrease, the ruptured … closes and forms a …, which produces …
a. ) several follicles (on the surface of the ovary); ovum (ovulation)
b. ) LH and FSH, follicle, corpus luteum, progesterone
Name a hormonal treatment for Dysmenorrhoea
Combined Hormonal Contraception (CHC), Oral progesterone-only contraception (Cerazette), Depo-medroxyprogesterone acetate (Depo-Provera®),Levonorgestrel-containing intrauterine system (LNG-IUS; Mirena®)
Name a surgical treatment of dysmenorrhoea
Laparoscopic uterine nerve ablation (LUNA) or Hysterectomy
What is the most often used pharmalogical treatment for pain due to dysmenorrhoea because of its low incidence of side effects?
Ibuprofen
What is the average menstrual blood loss and what would be considered excessive?
Average = 30-40ml; Excessive ≥80ml
What is the first-line pharmacological treatment of Menorrhagia?
LNG-IUS-Mirena (left in situ for 12 months)
Name a surgical treatment for Menorrhagia
Endometrial ablation, Uterine artery embolisation, Hysterectomy
Name 2 risk factors for developing Cervical cancer
Persistence of HPV infection, Heterosexual, Multiple sex partners, Smoking, Immunosuppression, COCP
Name a diagnostic investigation for cervical cancer
Colposcopy, Cone biopsy, CT/MRI/PET pelvis
How might cervical cancer be treated
Surgery (cervicectomy/hysterectomy), radiotherapy (external beam therapy and intracavity brachytherapy), chemotherapy (Cisplatin-based) (adjuvant, concurrent with radiation or palliative)
Most endometrial carcinomas are what type?
Adenocarcinomas
Most cervical malignancies are what type?
Squamous cell carcinoma
Name 3 risk factors for developing endometrial cancer
(Unopposed oestrogen)
- Nulliparous
- Late menopause
- Obesity
- Endometrial hyperplasia
- Polycystic ovary syndrome (POS)
- Diabetes Mellitus
- Hereditary nonpolyposis colon cancer (HNPCC)
- Tamoxifen
- Earlier onset of menstruation
- Oestrogen HRT,
Name an investigation for endometrial malignancy
Trans-vaginal ultrasound (TVUS), Endometrial biopsy, Hysteroscopy
Ovulation occurs around what day of menstrual cycle?
14
Mid-luteal phase is usually how many days before the end of the menstrual cycle?
7 days
What is the commonest type of ovarian cyst?
Follicular cyst
What is the other name for a dermoid cyst?
mature cystic teratomas
What is the most common benign ovarian tumour in woman under the age of 30 years?
Dermoid cyst
Normal length of menstrual cycle
21-35 days
The medical condition in which endometrial tissue lies outside the endometrial cavity
Endometriosis
The medical condition in which ectopic endometrial tissue lies within the myometrium
Adenomyosis
Benign localised growths of endometrium (fibrous tissue covered by columnar epithelium)
Uterine polyps
Uterine bleeding that occurs between clearly defined cyclic and predictable menses
Intermenstrual bleeding
Investigation of menorrhagia (3 marks)
FBC / Coagulation / TFT / TVS / Hysteroscopy / Endometrial biopsy
Name a primary management and a secondary management for abnormal menstrual bleeding
- Primary: Levonorgestrel/Antifibrinolytics (Tranexamic acid)/NSAID (Mefenamic acid)/ Progestogens/COCP/POOP/Danazol
- Secondary: Endometrial ablation/Hysterectomy/Uterine artery emobilastion/Myomectomy
What are the 4 WHO categories of FGM?
1 - Clitoridectomy
2 - Excision (removal of clitoris + labia)
3 - Infibulation (narrowing of vaginal orifice + covering seal)
4 - Other harmful procedures. (pricking, piercing, incising, scraping, cauterisation)
unopposed oestrogen increases risk of which cancer?
Endometrial cancer
How are stage 2-4 ovarian cancers primarily treated?
chemotherapy, radiotherapy, hormone therapy or surgical excision
Surgical excision
Symptoms of Endometriosis
+ Signs on examination
- 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 urinary/bowel symptoms due to the endometriosis affecting these areas)
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
What is the first-line antibiotic for PID?
Ceftriaxone 1g IM (followed by Doxycycline + Metronidazole)
Name a risk factor for PID
- <25 y.o.
- Early age of first coitus
- Multiple sexual partners
- Recent new partner (within 3 months)
- History of STI
- Termination of pregnancy
- Use of IUD within the past 4–6 weeks
- Hysterosalpingography
- IVF
Name 2 complications of PID
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Perihepatitis (Fitz-Hugh Curtis syndrome - RUQ pain)
- Tubo-ovarian abscess
- Reactive arthritis
- Sepsis
- Abscess
Name an investigation for PID
- pregnancy test to exclude ectopic
- Cervical NAAT swabs (for chlamydia and gonorrhoea)
- Endocervical NAAT swabs (for C. trachomatis and N. gonorrhoeae)
- HIV test
- Syphilis test
- Endometrial biopsy and ultrasound scanning
- Urinalysis and urine culture to exclude urinary tract infection
- A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
- A microscope can be used to look for pus cells on swabs from the vagina or endocervix to exclude PID
- Inflammatory markers (CRP and ESR) are raised in PID
Features of PID
+ examination findings?
- Bilateral lower abdo pain
- Deep dyspareunia
- Abnormal vaginal bleeding (postcoital, intermenstrual or menorrhagia)
- Vaginal or cervical discharge that is purulent
- Fever above 38°C
- Dysuria
Examination:
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
a general term for infection of the upper female genital tract, including the uterus, Fallopian tubes, and ovaries
Pelvic inflammatory disease
Name a treatment for premenstrual syndrome
Cognitive behavioural therapy, SSRIs, COCP, Oestrogen
Name a mental symptom and a physical symptom of premenstrual syndrome
Mental: irritability, tiredness, aggression or anger, low mood, anxiety, loss of confidence, changes to sleep, appetite and libido
Physical: breast swelling and/or pain, abdominal bloating, swelling of the feet or hands, weight gain, headaches
Name a few things that can indicate a molar pregnancy versus a normal pregnancy
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
Ultrasound of the pelvis shows what characteristic in the presence of a Hydatidiform mole?
‘Snowstorm appearance’
What is the management of a Hydatidiform Mole?
- evacuation of the uterus to remove the mole
- products of conception need to be sent for histological examination to confirm a molar pregnancy
- Patients should be referred to the gestational trophoblastic disease centre for management and follow up
- hCG levels are monitored until they return to normal
Features of cervical ectropion
- Vaginal discharge
- Post-coital bleeding
- Dyspareunia
Cervical ectropion is associated with higher oestrogen levels, and therefore, is more common with which three demographics?
younger women, the combined contraceptive pill and pregnancy
Treatment of cervical ectropion causing problematic bleeding
cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
Cervical cancer screening: if two consecutive inadequate samples, what is the next step?
Refer to colposcopy
Which ligament might be longer than usual causing ovarian torsion in younger girls before menarche (the first period)?
infundibulopelvic ligament
What can happen if ovarian torsion / twisting of the adnexa and blood supply persists?
(+ what might happen if a necrotic ovary is not removed?)
Ischaemia of the ovary eventually leading to necrosis
(If necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions)
What is the main presenting feature of ovarian torsion?
sudden onset severe unilateral pelvic pain
The pain is constant, gets progressively worse and is associated with nausea and vomiting
What is the investigation of choice for ovarian torsion and how is definitive diagnosis made?
Investigation - Ultrasound
Diagnosis - Laparoscopic surgery
Where and how does Lichen Sclerosus skin usually present?
- Patches of shiny, “porcelain-white” skin.
- Commonly affects labia, perineum and perianal skin in women.
- It can affect the axilla and thighs.
- It can also affect men, typically on the foreskin and glans of the penis.
Lichen sclerosis is associated with which other autoimmune conditions?
type 1 diabetes, alopecia, hypothyroid and vitiligo.
What investigation can confirm the diagnosis in women with Lichen Sclerosis?
Vulval biopsy
Features of Lichen Sclerosus
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
What is first line treatment for Lichen Sclerosis?
- Potent topical steroids (clobetasol propionate 0.05% (dermovate)) to control the symptoms of the condition and also seem to reduce the risk of malignancy. Once a day for four weeks, then gradually reduced in frequency every four weeks to alternate days, then twice weekly.
Emollients should be used regularly, both with steroids initially and then as part of maintenance.
The critical complication of Lichen Sclerosis to remember is a 5% risk of developing what condition?
squamous cell carcinoma of the vulva.
Cervical cancer is strongly associated with what virus?
HPV
When are children vaccinated against certain strains of HPV to reduce the risk of cervical cancer?
12-13 years
How is HPV transmitted?
HPV is primarily a sexually transmitted infection.
Which strains of HPV are responsible for 70% of cervical cancers?
Strains 16 and 18
Which two proteins does HPV produce and which tumour suppressor genes are inhibited by these proteins?
- HPV produces E6 and E7
- They inhibit the tumour suppressor genes: pRb and p53
Name a risk factor for catching HPV
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
What are 4 presenting symptoms that should make you consider cervical cancer as a differential?
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
How often is a smear performed as part of the cervical screening program for women (and transgender men that still have a cervix)?
Every three years aged 25 – 49
Every five years aged 50 – 64
What group of women are screened annually as part of the cervical screening program instead of every 3 or 5 years?
Women with HIV
How long should pregnant women wait until they can have cervical smear?
until 12 weeks post-partum
When should the cervical smear be repeated if there is an inadequate sample?
repeat the smear after at least three months
When should the smear be repeated for the following results?
- Inadequate sample
- HPV negative
- HPV positive with normal cytology
- HPV positive with abnormal cytology
- 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
How might cervical cancer cells present when stained with acetic acid and iodine solution?
- Acetic acid - Acetowhite
- Schiller’s iodine test - healthy cells stain brown. Abnormal areas will not stain.
A cone biopsy is a treatment for what condition?
+ risk factors?
cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer
(a cone-shaped piece of the cervix is removed using a scalpel)
Risks involve: Pain, Bleeding, Infection, Scar formation with stenosis, Increased risk of miscarriage and premature labour)
What staging system is used to stage cervical cancer?
+ what are the 4 stages?
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
Which monoclonal antibody may be used in combination with chemotherapy in the treatment of metastatic or recurrent cervical cancer?
Bevacizumab (Avastin)
(targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels. Therefore, it reduces the development of new blood vessels)
Management of cervical cancers? (Stage 1a, 1b-2a, 2b-4a, 4b)
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
What does LLETZ stand for?
large loop excision of the transformation zone
What is the current HPV vaccine called?
Gardasil
What do HPV strains 6 and 11 cause?
Genital warts
Which hormone stimulates the growth of endometrial cancer cells?
Oestrogen
Which precancerous condition involves thickening of the endometrium?
(+ what are the 2 treatments?)
Endometrial Hyperplasia
treated by a specialist using progestogens, with either:
- Intrauterine system (e.g. Mirena coil)
- Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
For endometrial protection, women with PCOS should have one of which three treatment options?
- The combined contraceptive pill
- An intrauterine system (e.g. Mirena coil)
- Cyclical progestogens to induce a withdrawal bleed.
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 converts androgens such as testosterone into oestrogen.
- Androgens are produced mainly by the adrenal glands. - more adipose tissue = more aromatase enzyme = more of these androgens 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.)
Why is Diabetes a risk factor for endometrial cancer?
Increased production of insulin.
( - Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer.
- PCOS is also associated with insulin resistance and increased insulin production.
- Insulin resistance further adds to the risk of endometrial cancer in women with PCOS.)
Name a protective factor against endometrial cancer
- Combined contraceptive pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
What is the number one presenting feature of endometrial cancer?
Postmenopausal bleeding (more than 12 months after LMP)
How might endometrial cancer present?
- Postmenopausal bleeding
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Raised platelet count
NICE recommends referral for a transvaginal ultrasound for endometrial cancer in women over 55 years with which 2 symptoms ?
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia or elevated glucose levels
Which are three investigations to remember for diagnosing and excluding 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
What does a Pipelle biopsy involve?
It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer.
Treatment for endometrial cancer
The usual treatment for stage 1 and 2 endometrial cancer is
- 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:
- 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
Name a type of ovarian cancer
Epithelial Cell Tumours such as:
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
Dermoid Cysts / Germ Cell Tumours
(benign ovarian tumours - aka teratomas, meaning they come from the germ cells + contain various tissue types, such as skin, teeth, hair and bone)
(associated with ovarian torsion)
(Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG))
Sex Cord-Stromal Tumours
(rare tumours, benign or malignant)
(arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles))
(eg. Sertoli–Leydig cell tumours and granulosa cell tumours)
What is a Krukenberg tumour?
+ characteristic feature on histology?
metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
(characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy)
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
What are the 3 main protective factors for ovarian cancer?
Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk:
- Combined contraceptive pill
- Breastfeeding
- Pregnancy
Ovarian cancer can present with non-specific symptoms
What are some symptoms that may indicate ovarian cancer?
- 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
Refer directly on a 2-week-wait ovarian cancer referral if a physical examination reveals one of what 3 signs?
Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass
2 initial investigations for ovarian cancer
- CA125 blood test (>35 IU/mL is significant)
- Pelvic ultrasound
Name a condition which might result in raised CA125
- Ovarian cancer (obviously)
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
Most vulval malignancies are what type?
squamous cell carcinoma
Risk factors for vulval cancer
- Advanced age (particularly over 75 years)
- Immunosuppression
- Human papillomavirus (HPV) infection
- Lichen sclerosus
What is the premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer?
(+ diagnosis + treatment options?)
Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
A biopsy is required to diagnose VIN.
Treatment options include:
- Watch and wait with close followup
- Wide local excision (surgery) to remove the lesion
- Imiquimod cream
- Laser ablation
Potential symptoms of vulval cancer
- 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
Diagnosis + management of vulval cancer
Establishing the diagnosis and staging involves:
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
Management depends on the stage, and may involve:
- Wide local excision to remove the cancer
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
Does fetal material form in a partial or a complete molar pregnancy?
Partial mole
Molar pregnancy behaves like a normal pregnancy. Periods stop and the hormonal changes of pregnancy will occur.
What few things indicate a molar pregnancy rather than a normal pregnancy?
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
What is a chocolate cyst?
Endometriomas in the ovaries are often called “chocolate cysts”
What condition causes the endometrial lining to flow backwards, through the fallopian tubes and out into the pelvis and peritoneum?
retrograde menstruation
endometrial tissue then seeds itself around the pelvis and peritoneal cavity
What is the cause of the chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with endometriosis?
Adhesions due to localised bleeding / inflammation
What complication can arise from endometriosis and what is the treatment?
Infertility secondary to endometriosis can be treated with surgery. The aim is to remove as much of the endometriosis as possible, treat adhesions and return the anatomy to normal. This improves fertility in some but not all women with endometriosis.
2 investigations of Endometriosis
- Laparoscopic surgery is gold standard.
(Definitive diagnosis => biopsy of the lesions during laparoscopy)
(Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms. - Pelvic ultrasound may reveal large endometriomas and chocolate cysts.
(suspected endometriosis need referral to a gynaecologist for laparoscopy)
Management of Endometriosis
+ which treatment may improve fertility?
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:
- 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 (Triprotrelin)
(stop ovulation and reduce endometrial thickening!)
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!)
Adenomyosis usually presents with which 3 classic symptoms?
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
(It may also present with infertility or pregnancy-related complications. Around a third of patients are asymptomatic)
Diagnosis of Adenomyosis
- Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
- MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
- Histological examination of the uterus after a hysterectomy is gold standard. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.
Management of Adenomyosis
If contraception not wanted; treatment can be used during menstruation for symptomatic relief, with:
- Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Management when contraception is wanted or acceptable:
- Mirena coil (first line)
- Combined oral contraceptive pill
- Cyclical oral progestogens
- Progesterone only medications such as the pill, implant or depot injection may also be helpful.
Other options are that may be considered by a specialist include:
- GnRH analogues to induce a menopause-like state
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
Adenomyosis is associated with which conditions?
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
Polymenorrhoea = bleeding at intervals of how long?
Less than 21 days
Name a cause of Menorrhagia
- Fibroids.
- Endometrial polyps.
- Endometriosis.
- Adenomyosis.
- Endometritis.
- Pelvic inflammatory disease (PID).
- Endometrial hyperplasia or endometrial carcinoma
- Systemic disease can include hypothyroidism, liver or kidney disease, obesity and bleeding disorders - eg, von Willebrand’s disease.
Management of Menorrhagia
- LNG-IUS should be considered as the first-line treatment.
Pharmacological:
- non-hormonal (tranexamic acid or a nonsteroidal anti-inflammatory drug) or hormonal (combined hormonal contraception or cyclical oral progestogens).
(If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, refer to a specialist)
- Secondary care treatment options include uterine artery embolization, and surgery (myomectomy, hysterectomy, or second-generation endometrial ablation).
Androgen insensitivity syndrome is inherited in what inheritance pattern?
X-linked recessive
Are patients with androgen insensitivity syndrome genetically male or female?
genetically male
(with XY sex chromosome. However, absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue)
Features of androgen insensitivity syndrome
+ results of hormone tests?
- lack of pubic hair, facial hair and male type muscle development.
- Patients tend to be slightly taller than female average.
- Patients are infertile, and there is increased risk of testicular cancer unless the testes are removed
- Often presents in infancy with inguinal hernias containing testes.
- Alternatively, it presents at puberty with primary amenorrhoea.
The results of hormone tests are:
- Raised LH
- Normal or raised FSH
- Normal or raised testosterone levels (for a male)
- Raised oestrogen levels (for a male)
(partial androgen insensitivity => cells have a partial response to androgens. Presents with ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics)
Medical / surgical management of androgen insensitivity syndrome
- Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
- Oestrogen therapy
- Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
Menopause is a retrospective diagnosis, made after a woman has had no periods for how long?
12 months
Premature menopause is menopause before what age?
+ what is usually the cause?
40 years and it is the result of premature ovarian insufficiency.
Which hormones are high/low in menopause?
- Oestrogen and progesterone levels are low
- LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
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
A lack of oestrogen due to menopause increases the risk of which conditions?
- Cardiovascular disease and stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
Management of perimenopausal symptoms
- Barrier methods
- Mirena or copper coil
- Progesterone only pill
- Progesterone implant
- Progesterone depot injection (under 45 years)
- Sterilisation
- Combined oral contraceptive pill (COCP) is UKMEC 2 (the advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications. Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options)
TIP: It is worth making a note and remembering two key side effects of the progesterone depot injection (e.g. Depo-Provera): weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.
Atrophic vaginitis is also known as what?
genitourinary syndrome of menopause
Features of Atrophic Vaginitis
on examination?
- Itching
- Dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding due to localised inflammation
(consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse)
Examination: Pale mucosa, Thin skin, Reduced skin folds, Erythema and inflammation, Dryness, Sparse pubic hair
Management of atrophic vaginitis
Vaginal lubricants help symptoms of dryness (eg. Sylk, Replens and YES)
Topical oestrogen can make a big difference in symptoms. Options include:
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
- Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism
What age is puberty considered precocious in boys and in girls?
before 8 (girls), before 9 (boys)
How long does puberty take (start to finish)?
about 4 years
Do overweight children tend to start puberty earlier or later?
Earlier
(Aromatase is an enzyme found in adipose (fat) tissue, that is important in the creation of oestrogen. Therefore, the more adipose tissue present, the higher the quantity of the enzyme responsible for oestrogen creation. There may be delayed puberty in girls with low birth weight, chronic disease or eating disorders, or athletes)
The stage of pubertal development can be determined using what scale?
(+ what are the 5 stages?)
Tanner staging scale
(Stage 1 - under 10yo, no pubic hair, no breast bud)
(Stage 2 - 10-11yo, light and thin pubic, breast buds behind areola)
(Stage 3 - 11-13yo, coarse and curly pubic, breast elevates beyond areola)
(Stage 4 - 13-14yo, Adult-like pubic not on thigh, areolar mound)
(Stage 5 - >14yo, Hair on medial thigh, Areolar mounds reduce + breasts form)
At what age / in whom are intrauterine (endometrial) polyps most common?
40-50 years and when oestrogen. levels are high.
In postmenopausal women, they are found in patients on Tamoxifen for breast carcinoma.
What is the most common feature of endometrial polyps and how are they treated?
Abnormal bleeding + resection with diathermy or avulsion
What criteria are used for making a diagnosis of polycystic ovarian syndrome.
(+ diagnosis requires at least two of which three key features?)
Rotterdam criteria
3 key features:
- Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
- Hyperandrogenism, characterised by hirsutism and acne
- Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
TIP: remember the triad of anovulation, hyperandrogenism and polycystic ovaries on ultrasound. Only having one of three features does not meet criteria for a diagnosis. 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.
Features of Polycystic Ovarian Syndrome
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism
- Acne
- Hair loss in a male pattern
Other Features include:
- Insulin resistance and diabetes
- Acanthosis nigricans (thickened, rough skin, typically found in the axilla and on the elbows)
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
Investigation of Polycystic Ovarian Syndrome
+ screening test of choice for diabetes in patients with PCOS? / what would be the results?
Blood tests:
- Testosterone (raised)
- Sex hormone-binding globulin
- Luteinizing hormone (raised LH and LH:FSH ratio)
- Follicle-stimulating hormone
- Prolactin (may be mildly elevated in PCOS)
- Thyroid-stimulating hormone
- Insulin (raised)
- Normal or raised oestrogen
Imaging:
- Pelvic ultrasound is required when suspecting PCOS
- Transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either:
(Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS)
TIP: It is worth remembering the “string of pearls” description for your exams. It is worth remembering that ovarian volume of more than 10cm3 can indicate polycystic ovarian syndrome, even without the presence of cysts.
Diabetes:
- The screening test of choice for diabetes in patients with PCOS is a 2-hour 75g oral glucose tolerance test (OGTT)
(performed in the morning prior to having breakfast)
(Take a baseline fasting plasma glucose, giving a 75g glucose drink and measure plasma glucose 2 hours later.)
The results are:
- 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 characteristic feature/appearance of PCOS on TVUS?
‘String of pearls’ appearance
Ovarian volume of more than how much can indicate polycystic ovarian syndrome, even without the presence of cysts?
10cm3
PCOS management under the subheadings:
- General
- Risk of cancer
- Infertility
- Hirsutism
- Acne
General
(reduce risks associated with obesity, T2DM, hypercholesterolaemia and cardio disease)
- Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism.
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
(Orlistat (lipase inhibitor) stops absorption of fat in intestines + may be used to help weight loss if BMI>30)
Cancer risk
(Women with PCOS do not ovulate regularly, and therefore do not produce sufficient progesterone)
- Mirena coil
- Inducing a withdrawal bleed with either Cyclical progestogens or Combined oral contraceptive pill
Infertility
- Clomifene
- Laparoscopic ovarian drilling
- In vitro fertilisation (IVF)
- Metformin and letrozole may also help restore ovulation
Hirsutism
- Weight loss
- Co-cyprindiol (Dianette) is a COCP licensed for hirsutism but has increased risk of VTE!
- 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)
Acne
- COCP (Co-cyprindiol)
- Topical adapalene (a retinoid)
- Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
- Topical azelaic acid 20%
- Oral tetracycline antibiotics (e.g. lymecycline)
What hormone does the corpus luteum release after ovulation?
Progesterone
What may be used to induce a period prior to an ultrasound scan for oligo-/amenorrhoea?
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
How might Hirsutism be managed in PCOS?
- Weight loss
- Co-cyprindiol (Dianette) is a COCP licensed for hirsutism but has increased risk of VTE!
- 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)
How might infertility be managed in PCOS?
- Weight loss
- Clomifene
- Laparoscopic ovarian drilling
- In vitro fertilisation (IVF)
- Metformin and letrozole may also help restore ovulation
What COCP might be used for PCOS and what is the increased risk associated?
Co-cyprindiol (Dianette) is a COCP licensed for hirsutism but has increased risk of VTE!
The upper vagina, cervix, uterus and fallopian tubes develop from what embryonic structure?
paramesonephric ducts (Mullerian ducts)
In a male fetus, what suppresses the growth of the paramesonephric ducts, causing them to disappear?
anti-Mullerian hormone
Name a congenital structural abnormality of the female organs
- Bicornuate Uterus
- Imperforate Hymen
- Transverse Vaginal Septae
- Vaginal Hypoplasia and Agenesis
Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with which characteristic 3 features?
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
(It may also present with infertility)
What is the cause of Asherman’s syndrome and how is it diagnosed?
Intrauterine adhesions
Diagnosis
- Hysteroscopy is gold standard and can involve dissection and treatment of the adhesions
- Hysterosalpingography (contrast injected into uterus and x-rayed)
- Sonohysterography (uterus is filled with fluid and a pelvic ultrasound is performed)
- MRI scan
What is the parametrium?
Connective tissue which connects the uterus to other tissues in the pelvis (The uterine artery and ovarian ligament are located in the parametrium)
Most cases of PID are caused by which STI’s?
+ Which other bacteria might cause it more rarely?
STI’s:
- Neisseria gonorrhoeae (tends to produce more severe PID)
- Chlamydia trachomatis
- Mycoplasma genitalium
Non-STI:
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae
- E. coli
What is Fitz-Hugh-Curtis syndrome?
+ features and treatment?
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
Management of PID
- refer to GUM for management and contact tracing
- Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications
- A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
- Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
- Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
(If there are signs of sepsis or the patient is pregnant, admit to hospital for IV antibiotics. If a pelvic abscess develops, this may need drainage by interventional radiology or surgery)
What are two key side effects of the progesterone depot injection (e.g. Depo-Provera)?
weight gain and reduced bone mineral density (osteoporosis).
What is Meig’s syndrome?
+ 3 classic features?
Meigs syndrome is the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor.
(Ovarian fibromas constitute the majority of the benign tumors seen in Meigs syndrome)
Three features of Meig’s syndrome are:
- a benign ovarian tumour
- ascites
- pleural effusion
For patients with uterine fibroids, what drugs may reduce the size of the fibroid but are typically useful for short-term treatment?
GnRH agonists (Leuprolide/Triptorelin)
Premature ovarian failure is defined as: The onset of menopausal symptoms and elevated gonadotrophin levels before what age?
40 years
What is thrush also known as?
Vaginal candidiasis
what type of discharge is pathognomonic of thrush?
‘Cottage-cheese’ like discharge
Which one of the following is the most common cause of recurrent first trimester spontaneous miscarriage?
PCOS / Hyperprolactinaemia / Antiphospholipid syndrome
Antiphospholipid syndrome
Where in the Fallopian tube is an ectopic most likely to be found?
Ampulla
Free pelvic fluid with whirlpool sign on USS?
Ovarian torsion
What is the management of atypical endometrial hyperplasia for all postmenopausal women due to the risk of malignant progression?
total hysterectomy with bilateral salpingo-oophorectomy
What is the only effective treatment for large fibroids causing problems with fertility?
myomectomy
Staging of Ovarian Cancer (4 stages)?
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
No. 1 Investigation for Endometriosis
Laparoscopic visualisation of pelvis
