OnG year 5 Impeys Flashcards
What is the average age of menarche?
13 years
what are the different phases of the menstrual cycle?
Day 1-4: menstruation
day 5-13: proliferative phase
day 14-28: luteal/secretory phase
Define abnormal uterine bleeding
any variation from the normal menstrual cycle. Includes: changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss
Define amenorrhea
No bleeding in a 6 month interval
What is the normal frequency and duration of periods?
24-38 days, with 3-8 days of bleeding
What is the subjective and objective defintion of menorrhagia?
Subjective: bleeding interferes with woman’s physcial, emotional, social and material quality of life.
Objective: >80mL blood loss = maximum amount a woman can lose eating a normal diet without becoming iron defecient
what are the most common pathologies causing heavy menstrual bleeding? + rest?
fibroids- 30%
Polyps- 10 %
thyroid disease, haemostatic disorders such as von willebrand’s disease and anti- coagulant therapy
What are the investigations required for a patient presenting with dismenorrhagia?
Haemoglobin + FBC: assess the effect of blood loss
Coagulation + thyroid: if history is suggesive of a problem
TVUS: to exclude local structural causes ( saline US improves visualisation of fibroids and polyps.)
what is the normal range of endometrium thickness in premenopausal women?
4mm(follicular phase) - 16mm(luteal phase)
What are the risk factors of endometrial cancer?
Obesity diabetes nulliparity history of PCOS family history of HNPCC) hereditary non polyposis colorectal cancer
What investigations should be considered for endometrial cancer?
Pipelle in OP
hysteroscopy in IP
How is HMB managed?
IUS- NICE first line if not trying to concieve. 2nd = COCP. 3rd= POP, GnRH agonists- limited to 6 months
Tranexamic acid or NSAIDS (mefenamic acid reduces prostaglandin synthesis) if trying to concieve
Then consider surgical management- Polyp removal endometrial ablation techniques transcervical resection of fibroids Myomectomy Uterine artery embolisation Hysteroscopy
When should endometrial biopsy be considered?
Age > 40 years
HMB with IMB
risk factors for endometrial cancer present
HMB unresponsive to medical treatment
US shows polyp or focal endometrial thickening
If abnormal uterine bleeding has led to acute admission
Which pelvic pathology can use irregular bleeding or IMB?
Non malignant causes: fibroids, polyps, adenomyosis, ovarian cysts and chronic pelvic infection
Malignant causes: endometrial, ovarian + cervical cancer
What are the investigations for irregular bleeding or IMB?
FBC + Hb: assess effect of blood loss
cervical smear taken if required to rule our malignancy
US for >35 with irregular or IMB or if medical treatment has failed for younger women
Endometrial biopsy if the endometrium is thickened, especially if women is over 40.
What is the management for IMB or irregular bleeding?
COCP makes cycle regular. IUS lightens period. - 1st line
Progestogens in high dose cause amenorrhoea
HRT may regulate erratic uterne bleeding during perimenopause
Surgery: cervical polyps can be avulsed.
Define primary and secondary amenorrhoea.
Primary amenorrhoea = menstruation hasn’t started by age of 16, may be after delayed puberty- no secondary sexual characeristics by 14 years.
Secondary amenorrhoea = previously normal menstruation ceases for 3 months
What are the most common cause of oligomenorrhoea and secondary amenorrhoea? + other causes
PCOS, premature menopause (1/100), hyperprolactinaemia
What causes hypothalamic hypogonadism and how does it cause amenorrhoea?
Causes: psychological stress, low weight/anorexia, excessive exercise
Leads to reduced GnRH and therefore FSH, LH and oestrodial are reduced.
Oestrogen replacement required if prolonged
How is hyperprolactinaemia managed?
Bromocriptine, cabergoline, transsphenoidal surgery
How does hypothyroidsim lead to amenorrhoea?
Hypothyroidism leads to raised prolactin levels
What are some congenital causes of amenorrhoea?
congenital adrenal hyperplasia, Turner’s syndrome, imperforate hymen, transverse vaginal septum
What are structural causes causes secondary amenorrhoea?
Cervical stenosis, asherman’s syndrome- caused by excessive curettage during ERPC.
What are the causes of postcoital bleeding?
Think Cervix! cervial carcinoma cervial ectropion cervical polyps cervicitis, vaginitis
How is postcoital bleeding managed?
Cervix inspected using a speculum, smear taken and if polyp present it is avulsed. Ectropion can be frozen with cyrotherapy. If smear is abnormal, colposcopy is undertaken to exclude a malignant cause.
define dysmenorrhoea?
Painful menstruation associated with high prostagalandin levels in the endometrium and due to contraction and uterine ischaemia
define primary dysmenorrhoea
when no organic cause is found, associated with onset of menstruation. Present in 50% of women.
pain usually responds to NSAIDs or ovulation suppression.
What are some causes of secondary dysmenorrhoea?
Fibroids, adenomyosis, endometriosis, PID and ovarian tumours
Define precocious puberty
Menstruation occurs before age of 9 years or other secondary sexual characteristics are evident before 8 years.
What are the causes of precocious puberty?
80% = Physiological
Central causes: meningitis, encephalitis, CNS tumours, hydrocephaly, hypothyroidism may prevent normal pubertal inhibition of hypothalamic GnRH release.
Ovarian/adrenal causes: due to increased oestrogen production. E.g = hormone producing tumours of the ovary or adrean lands. McCune Albright syndrome- bone and ovarian cysts, cafe au lait spots and precocious puberty.
what is the treat of McCune albright syndrome?
Cyproterone acetate- antiandrogenic prostogen
What are the causes of ambigious development and intersex?
Congenital adrenal hyperplasia ( recessive inheritance): 21-hydroxylase defeciency.
Androgen insensitivty syndrome- male has cell receptor insensitivity to androgens. XY female phenotype.
How does congenital adrenal hyperplasia present?
Condition usually present at birth with ambigious genitalia, glucocorticoid deficiency may cause addisonian crisis.
Can present in adolescent with enlarged clitoris and amenorrhoea
What is the management of congenital adrenal hyperplasia?
Treatment = cortisol and mineralocorticoid replacement
How is androgen insensitibity syndrome managed?
Rudimentary testes are present. These are removes because of possible malignant changes.
Oestrogen replacement therapy is started.
Define Pre menstrual syndrome (PMS)? and how common is it?
PMS encompasses psychological, behavioural and physical symptoms that are experienced on a regular basis during luteal phase of the menstrual cycle and often resolve by the end of menstruation.
95% of women experience PMS, of which 5% are severly debilitated.
What are the clinical feautres of PMS?
Cyclical nature.
Behaviour changes include: tension, irritablity, aggression, depression and loss of control.
Physical symptoms: sesnsation of bloatedness, minor gastrointestinal upset and breast pain
What is the management of PMS?
After completion of menstrual diary and psychological evaluation to exclude depression and neurosis:
SSRIs- either continously or intermittently during the second half of the cycle.
Stopping regular cycles- COCP
2nd line- GnRH agonist trial and add back oestrogen therapy to induce a pseudomenopause.
Final resort- bilateral oopherectomy however combined HRT or COCP required for bone and endometrial protection.
May also consider CBT?
when should endometrial biopsy be considered?
IMB
thickened or irregular endometrium
Age >40
risk factors for endometrial cancer
Percentage of anteverted and retroverted uterus?
anterverted = 80% retro = 20%
Definition and epidemiology of fibroids.
Defintion: Leiomyomata are benign tumours of the myometrium
By age 50 70% of white women and >80% of black women have had at least one fibroid.
Risk factors:
asian and black ethniticty
early menarche
obese women
first degree relative also effected
Less common in parous women, COCP or used injectable progesterone
What are the different types of fibroids?
Subserous polyp Subserous intramural submucosal intracavity polyp cervical
What are the clinical features of fibroids?
50% asymptomatic, discovered by physical examination or US. Symptoms = site dependant
Menorrhagia
Dysmenorrhea
IMB if submucosal or polyp
Large fibroids can have pressure symptoms: urinary frequency, urinary retention- could lead to hydronephrosis.
Fertility impaired if tubal ostia are blocked.
What is the chance of malignancy from a fibroid?
0.1% of fibroids = leiomyosarcomata
Increased risk if fibroid growth in post menopausal women, rapidly enlarging or sudden onset of pain in women of any age
What complications arise in pregnancy due to fibroids?
premature labour, malpresentaion, transverse lie, obstructed labour and postpartum haemorrhage. Red degeneration is common in pregnancy and causes severe pain.
Fibroids should not be removed during caesarian as bleeding can be heavy.
What investigation are done if fibroids are suspected?
US- determine the number , size and postion of fibroids
MRI- if diagnosis is unclear or greater accuracy required to decide mode of treatment + differentiation from adenomyosis
If subfertility present- hysteroscopy, saline TVUS, hysterosalphingogram used to assess distortion of uterus
Bleeding present?- FBC + haemoglobin
also fibroids can secrete erythropoietin
what is the medical management of fibroids?
Tranexamic acid, NSAIDs, progestogens are ineffective but worth trying first line. IUS reduced efficacy + expulsion risk from submucosal fibroids. GnRhH analogues can cause temporary amenorrhoea and fibroid shrinkage - can only be used for 6 months withour addition of HRT. SPRMs- urlipristal acetate new class of drug used for HMB, shrink fibroids- volume reduce 50%. Can be used short term before surgery.
what is the surgical management of fibroids?
Transcervical resection of fibroid- 3cm polup or submucousal fibroid
Myomectomy- if medical management failed, can be preceded by 2-3 months gnRH analogues or urlipristal acetate to shrink and reduce vascularity of fibroid. Pre-op vasopressin injection reduces bleeding. Caesarean inidcated for large fibroid myomectomy- due to increased risk of uterine rupture.
Radical hysterectomy
Uterine artery embolization- not offered to women desiring pregnancy
What are the different types of benign cysts?
Simple cysts
Haemorrhagic cysts- feeding vessels haemorrhage
Endometrioma - endometriosis inside ovary respond to hormone produced therefore enlarge. Can rupture and cause infection.
Mature cystic teratoma- also called dermoid cyst
What factors are considered for management of ovarian cysts?
Age: pre-pubertal, reproductive, postmenopausal
Size of cysts- 3-5-7-< cm no symptom- some symptom- Pain present
Character of cyst- simple or complex
Symptoms of cyst- pain, bleeding
Co morbidity- endometriosis, sub fertility
What investigations are done for ovarian cysts?
Pain score, FBC, US, tumour markers, carbohydrate antigen 125, serum hCG, AFP
Ca-125 can be raised in reproductive age due to other causes: endometriosis
, PID, fibroids
What are the different US features of different cysts?
Simple cyst is clear
Haemorrhagic cyst slight shadow
Malignant cysts have papillary projections, solid components and also associated with Ascites.
What is Risk of malignancy index based on?
Postmenopausal status, CA-125, features on US
Management of cysts <5c simple cysts premenopausal?
Reassurance and no further action required
Management of 5-7cm simple asymptomatic cysts premenopausal ?
Repeat ultrasound 3-4 months, reassurance if no change, consider referral if there is an increase in size
Management of >7cm cysts with symptoms premenopausal ?
Referral to gynaecologist
Management of postmenopausal ovarian cysts seen on camera?
ca-125
When are postmenopausal woman referred to gynaecology for assessment ?
Some suspicious features
>7cm grossly abnormal features and abnormal ca-125 > 30- urgent referral
What are the complications of ovarian cysts?
Rupture
Torsion- gynaecology emergency 6 hour rule. Managed by laparoscopic detortion. Present with acute pain but as ovarian necrosis occurs pain resolves.
Malignant change.
Which ligaments attach to the ovary?
Ovarian ligament attaches to uterus, infundibular pelvic ligament. These ligaments are the ligaments that get tortes !
Define PID and what are its causes?
Inflammation of reproductive organs- cervix, uterus, tubes and ovaries
Causes: chlamydia
Gonorrhoea
Actinomycosis, gardnerella, anaerobes, mycoplasma
What are the risk factors of PID?
Multiple sexual partners
Foreign body/ IUD
Douching - squirting water into vagina to clean it
What are the clinical features of PID?
Abdominal pain, vaginal discharge(offensive/non offensive), dyspareunia, intermenstrual bleeding
What investigation are used for suspected PID diagnosed?
Clinical assessment- pyrexia, abdo tenderness, possible rigidity and guarding, cervical excitation
Investigation: WCC, CRP, high vaginal swab, chlamydia/ gonorrhoea NAAT
USS- rule out abscess
Laparoscopy
What is the management of PID? Come back to this
Analgesia
antibiotics dependent on OP (when systematically well) or IP.
Outpatient AB regime:
IM ceftriaxone stat, oral doxycycline BD, metronidazole BD for 14 days
Inpatient difference = iv ceftriaxone daily
What is Fitzh Hugh Curtis syndrome?
Chronic untreated PID descended upwards causing perihepatic adhesions to peritoneal wall
What are the complications of PID?
Infertility
Chronic pelvic pain
Turbo ovarian abscess
Ectopic pregnancy
What is the function of the Bartholin gland?
Provides lubrication during intercourse
What causes barthoin cyst formation ?
Blockage of gland could be congenital or due to infection
What is the management of bartholin cyst?
Asymptomatic and small cysts can be managed conservatively
Incision and drainage and word catheter
If recurrence- incision and drainage and marsupialisation
Define adenomyosis and its aetiology
Presence of endometrium and its stroma within the myometrium. Associated with endometriosis and fibroids.
What are the clinical features of adenomyosis ?
History: symptoms maybe absent but painful, heavy, regular, menstruation is common.
In examination uterus is mildly enlarged and tender.
What are the investigations for adenomyosis?
Adenomyosis can be suspected on ultrasound but clearly diagnosed on MRI
What is the management of adenomyosis?
IUS or COCP with or without NSAIDs may control the menorrhagia and dysmenorrhea but hysterectomy often required. Trial of GnRH to see if hysterectomy will relieve symptoms many be done.
Define endometritis
Often occurs secondary to infections as a complication of surgery, particularly caesarean and intrauterine procedure. Other causes = IUD and retained products of conception. Infection postmenopausal woman often due to malignancy.
What is the aetiology of intrauterine polyps?
Usually benign tumours that grow in intrauterine cavity often endometrial in origin but some are derived from submucousal fibroids. Common in woman aged 40-50. Can also be commonly found in postmenopausal woman taking tamoxifen for breast cancer.
How about interuterine polyps present ?
Often cause menorrhagia, IMB, may prolapse through the cervix. Diagnosed during USS or hysterescope
How are interuterine polyps managed?
Resection of polyp with cutting diathermy or avulsion.
what is congenital uterine maformation associated with?
Increased incidence of renal anomalies.
25% cause preganancy related problems- preterm labour, transverse lie, recurrent miscarraige
When is prevalence of endometrial cancer highest?
60 years. limetime risk = 1%
what are the two types of endometrial cancer?
type 1- low grade endometrioid cancers- oestrogen sensitive
type 2 - high grade endometrioid, clear cell, serous or carcinosarcoma cancers- not oestrogen sensitive and more aggressive.
what are the risk factors of endometrial cancer?
obesty, diabetes, early onset of menarche, nulliparity, late onset menopause, older age unopposed oestrogen, tamoxifen.
Lynch type 2- HNPCC
What is the management for endometrial hyperplasia with atypia?
consider hysterectomy. If fertility if a conern, progestogens (IUS or continous oral) and 3-6 monthly hysteroscopy and endomertial biopsy are used and referrral to fertility specialist
What are the clinical features of endometrial carcinoma?
PMB = 10% risk of carcinoma with risk increasing with age. Premenopausal women might have intermenstrual bleeding.
On examination pelvis often appears normal and atrophic vaginitis may coexist
Which lymph nodes does endometrial carcinoma spread to ?
Internal and external iliac lymph nodes then para aortic lymph nodes.
what are the different stages of endometrial carcinoma?
Stage 1A: confined to uterus <1/2 of myometrium 1B: >1/2 of myometrium Stage 2: cervical stromal invasion Stage 3: tumour invades through the uterus a- serosa/adnexa b- vagina/ parametrial involvement ci- pelvic node involvement cii- prara-aortic node involvement Stage 4:further spread a in bowel or bladder b distant metastases
Staging only done after hysterectomy
What investigations should be done after confirmation of endometrial carcinoma?
MRI to assess myometrial invasion chest X-ray to exclude pulmonary spread FBC ECG Glucose
what is the management of endometrial carcinoma?
75% present with stage 1: manged with total laparoscopic hysterectomy and bilateral salpingo-ooporectomy (BSO). Pelvic and para aortic lymphadenectomy dependant on staging.
Adjuvant therapy: external beam radiotherapy, vaginal vault radiotherapy
chemotherapy
What is the prognosis of endometrial carcinoma?
Five year survival rate stage 1 = 90% stage 2 = 75% stage 3 = 60% stage 4 = 25% overall = 75% survival rate
How can fibroids degenerate?
Red degeneration and hyaline degeneration.
what is protective againsts endometrial carcinoma?
COCP and pregnancy
what is endocervix and ectocervix lined by?
Endocervix lined by columnar epithelium, ectocervix lined by squamous epithelium.
Define cervical ectoprion and its risk factors
When columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix. Normal finding in younger women taking the pill.
What symptoms can a cervical ectropion cause?
Normally asymptomatic, may present with abnormal discharge and PCB
How is ectropion managed?
Cyrotherapy after exclusion of carcinoma with colposcopy.
Define chronic cervicitis.
chronic inflammation or infection of an ectropion.
How do cervical polyps present and how are they mananged?
IMB or PCB. Management - avulsion
what are nabothian follicles?
trapped secretion from columnar epitheiium where squamous epithelium has formed by metplasia over endocervical cells. Metaplasia is caused by the low vaginal pH
define cervical intraepithelial neoplase (CIN)
presence of atypical cells within the squamous epithelium. Dyskaryotic cells. CIN graded 1-3 starting with bottom 1/3 of epithelium.
Malignancy ensues if these abnormal cells invade the basement membrane.
What is the risk of CIN 2/3?
1/3 of women untreated with CIN 2/3 develop cervical cancer over the next 10 years.
When is the peak incidence of CIN 3?
99% of caes <45 with peak incidence at age 25-29 years.
What is the aetiology and risk factors of CIN?
HPV strain 16, 18, 31, 33. viral protein causes inactivity of tumour suppressor genes.
Risk factors - number of sexual contacts at an early age, smokingm oral contraceptive use, HIV and those on long term steroids
Which strain is in the quadstrain HPV vaccine?
6,11,16,18. 16,18 cause 75% of cervical cancers in UK
How often are cervical smears done normally?
25-49 every 3 years
50-64 every 5 years
from age 65 only those who haven’t been screened since 50 are tested
How is cervical smear done?
Using a cusco’s speculum a brush is gently scraped around the external os of the cervix to pick up loose cells over the transformation zone. Brush tip broken intro preservative fluid, which is centrifuged in a lab before being spread on a slide to be viewed under microscope. Process is called liquid based cytology. LBC also allows testing or HPV.
Smears identify dyskaryosis classified as borderline, low and high which is associated with different CIN levels.
what does the presence of abnormal columnar cells in smear test suggest?
cervical glandular intraepithelial neoplasia. Requires colposcopy, if no abnormality on colposcopy then hysteroscopy
what is the treatment for CIN 2/3?
if CIN 2/3 present large loop excision of transformation zone(LLETZ) done. RIsk = increased risk of preterm delivery in proportion to dept of LLETZ.
which cells do cervical cancers arise from?
Squamous cells = 90%
columnar cells = 10%(adenocarcinoma)
screening test better at identifying squamous cell carcinoma therefore these have a better prognosis
how does cervical carcinoma present?
Occult carcinoma - no symptoms
clinical carcinoma- PCB, offensive vaginal discharge
what are the different staging for cervical cancer?
Stage 1 is confined to the cervix
ai: invasion <3mm lateral spread <7mm
aii: invasion 3-5mm lateral spread <7mm
bi: clinically visible lesion larger than 1aii <4cm in greatest dimension
bii: clinically visible >4cm
stage 2 = invasion into vagina but not pelvic side wall
2ai= upper 2/3 of vagina without parametrial invasion <4cm in greatest dimension
2aii >4cm
b invasion of parametrium
stage 3 : invasion of lower vagina or pelvic wall or ureteric obstruction
stage 4 : invasion of bladder or rectal mucosa or beyond the true pelvis
What investigation are done for cervical cancer?
Tumour biospy to stage and confirm diagnosis
Vaginal and rectal examination to assess the size of the lesion and parametrial and rectal invasion
Cystoscopy: bladder involvement?
MRI: lymph node spread? tumour size?
Assess fitness for surgery: chest X-ray, FBC, UnE
Blood crossmatched before surgery
How is stage 1ai cervical cancer managed?
Cone biopsy as LN invovlement = 0.5%. Simple hysterectomy preferred in older women
How is stage 1aii- stage 2a cancer managed?
Surgical/ chemo-radiotherapy dependent on LN involvement- confirmed using MRI and LN sampling. No srugery if LN involved
Radical hysterectomy(Wertheim’s hysterectomy)- removal of uterus, parametrium, upper 1/3 of vaigna, pelvic node clearance. Ovaries left in young woman with squamous carcinoma.
Radical trachelectomy- preserve fertility removal 80% of cervix and upper vagina. LN invovlement = + chemo-radiotherapy. Approprate for stage 1aii-1bi
How is stage 2b+ or positive lymph node cervical cancer managed?
Treated with radiotheray and chemotherapy e.g. platinium agents.
what are the indication for chemo-radiotherapy in cervical cancer?
Lymph nodes positive on MRI or lymphadenectomy
Alternative to hysterectomy
Surgical resection margins not clear
Palliation for bone pain or haemorrhage
What is the prognosis for cervical cancer?
Five year surivaval rate 1a = 95% 1b = 80% 2 = 60% 3-4 = 10-30% LN involvement = 40% LN clear = 80% overall = 65%
how often are patients reviewed after treatment for cervical cancer?
Patients are reviewed at 3 months and six months and then every 6 months for 5 years.
Which cysts and tumours of the ovaries are beign?
Endometriotic cysts Follicular cysts Lutein cysts Brenner tumour arise from epithelium Germ cell tumour: Dermoid cysts Sex cord: Thecomas, Fibromas ( meig's syndrome- ascites and right pleural effusion)
which ovarian tumours can be either malignant or benign?
serous cystadenomas
mucinous cystadenomas
granulosa cell tumours`
which ovarian tumours are malignant?
Endometroid carcinoma clear cell carcinoma Solid teratoma dysgerminoma yolk sac tumours
Where do secondary malignancies of the ovaries arise from?
Breast or bowel (krukunberg tumours- present with signet ring cells)
Which tumours of the ovaries arise from epithelium?
serous cystadenoma, adenocarcinoma, endometroid carcinoma, clear cell carcinoma, mucinous cystadenoma or adenocarcinoma.
Which tumours of the ovaries arise from germ cells?
teratoma (dermoid cysts), yolk sac tumours, dysgerminoma
which tumours of the ovaries arise from the sex cord?
granulosa cell tumours
thecomas
fibromas
Number of cases/ death in UK from ovarian cancer and what is the life time risk?
4200 deaths, 7000 cases and 1/60 lifetime risk
What are the 4 most common type of ovarian cancer?
Serous adenocarcinoma- 75%
endometroid carcinoma- 10%
clear cell carcinoma- 10%
Mucinous adenocarcinoma- 3%
Which genes are associated with ovarian cancer?
BRCA1/2 HNPCC
What is the screening programme in UK for ovarian cancer?
Currently no screening program. Women with family history of ovarian cancer, tested for BRCA1/2 genetic mutation and offered prophylactic salpingo- oopherectomy
How does ovarian cancer present?
Symptoms are often vague
Abdominal bloating, early satiety, increased urinary frequency, pelvic/abdo pain. Also important to ask abut breast and gastro symptoms due to mets.
Examination may reveal cachexia
State the different staging of ovarian cancer
Stage 1: confined to ovaries a unilateral capsule is intact b bilateral capsule is intact c a/b ruptured capsule stage 2: disease extending to pelvis stage 3: abdo disease and lymph nodes involvement stage 4: diseae is beyong abdomen
Which investigation are done for suspected ovarian cancer in primary care?
CA125 level measured in women over 50 with abdo smptoms.
CA125 > 35iu/ml USS of abdo and pelvis arranged.
If USS scan reveals ascited and/or pelvic or abdominal mass urgent referral to secondary care.
Which investigation are done for suspected ovarian cancer in secondary care?
CA125: epithelial tumours HCG: choriocarcinoma S-AFP: for yolk cell tumours LDH: for dysgerminomas Serum inhibin: for germ cell tumour women under 40 AFP and bhCG measured to identify germ cell tumours. RMI calculated RMI > 250 referred to specialist MDT CT pelvis abdo, thorax if indicated to establish the extent of disease. Discuss in MDT for further management
How is risk of malignancy index (RMI) calculated?
ultrasound scan score x menopausal status x CA125 level
How is ovarian cancer managed?
Midline laparotomy for total hysterectomy , BSO and partial omentectomy.
Lymph node biopsy/removal
Debulk all advanced tumours
Possible laparoscopy and oopherctomy for women in early stage disease looking to preserve fertility
Then chemotherpay unless borderline or low risk stage 1a/b.
Which memebers of the MDT team are involved in ovarian cancer?
GP, macmillan nurses, gynae onco specialist
Which lymph nodes does the vulval lymph fluid drain into?
Inguinal lymph nodes, which drain into the femoral and thence to the external iliac nodes
what are the causes of pruritis vulvae?
Infectons: candidiasis, vulval warts, public lice, scabies
Dermatological disease: eczema, psoriasis, lichen simplex, lichen sclerosus, lichen planus
Neoplasia: carcinoma, premalignant disease
how is lichen simplex managed?
Irritants such as soap avoided. Emollients, moderately potent steroid creams and anti histamines are used to break itch-scratch cycle.
how does lichen planus present?
Effects paticularly mucosal surfaces such as mouth and genital. Presents with flat, papular, purpulish lesions. Presents with itching and pain.
How does lichen sclerosus present?
Probable cause = Auto immune disease. Thin epithelium due to loss of collagen, thyroid disease and vitiligo coexist in postmenopausal women. Severe pruritis, may cause bleeding + dyspareunia. Vulval carcinoma develops in 5% of cases.
Apperance = pink white papules
How is lichen sclerosus managed?
Biopsy important to exclude carcinoma and confirm diagnosis.
Treatment = ultrapotent steroids.
Which organism causes vulval donovanosis?
Klebsiella granulomatis
Which factors increase the risk of candidiasis?
Diabetes, obesity, pregnancy, antibiotics
Which organisms are commonly responsible for bartholin’s cyst and abscess?
Staphylococcus or escherichia coli
Define vaginal adnosis and its risk factor?
Columnar epithelium found in normal squamous epithelium of vagina. Commonly occurs in mothers who recieved diethylstillboestrol (prescribed in 1970s for miscarriage and preteerm labour.) Can turn into clear cell carcinoma.
What are the two types on vulval intraepithelial neoplasia and how do they present?
Usaual type VIN- more common (95%). Associated with HPV(16), smoking, CIN. Warty or basaloid squamous cell carcinoma.
Differentiated type VIN: lichen sclerosis older women, unifocal lesion with keratinizing squamous cell carcinomas of the vulva. Pruritis or pain is common.
What is the management for VIN?
Gold standard = local surgical excision
State the epidemiology of vulval cancer?
1200 cases 400 death common after age 60 50% present with stage 1 disease
How is vulval cancer staged?
stage 1: tumour confined to vulva/perineum
1a <2cm with stromal invasion depth <1mm; negative nodes
1b >2cm >1mm negative nodes
stage 2 : adjacent spread to urethra, vagina, anus; negative nodes
stage 3: tumour any size with inguinofemoral nodes positive
stage 4:
4a-tumour invades uper uretha, vagina, rectum, blader bone
4b- distant metastases
What investigation are done for vulval carcinoma?
Biospy taken for histology to establish diagnosis and stage disease
Assess fitness for surgery: chest X-ray, ECG, UnE, FBC, cross match blood
How is vulval carcinoma treated?
1a = wide local excision
for other stages:
State 3 maligancies of the vagina
secondary vaginal carcinoma due to mets from cervix, endometrium or vulva
primary carcinoma of the vagina
How are the three levels of the vagina supported?
level 1: cervix and the upper 1/3rd of the vagina are supported by cardinal and uterosacral ligaments.
level 2: mid portion of vagina is attached by endopelvic fascia laterally to the pelvic side walls
level 3: the lower third of the vagina are supported by the levator ani muscles and the perineal body. Levator ani + fascia = pelvic diaphragm
What are the different types of vaginal prolapse?
urethrocoele- prolapse of the lower anterior vaginal wall involving urethra only
cystocele- prolapse of the upper anterior vaginal wall involving the bladder. Often associated with urethral prolapse. Together called : cystourethrocoele
Apical prolapse: prolapse of uterus, cervix and upper vagina
Enterocoele: upper posterior wall involving bowel
Rectocele: lower posterior wall of vagina involving the anterior wall of the rectum
State the different grades in a baden- walker classification of a vaginal prolapse.
0: No descent during straining
1: leading surgace of prolapse >1cm above hymenal ring
2: 1cm above to 1cm below hymenal ring
3: prolapse extends >1cm below hymenal ring
4: complete vaginal eversion
How common are vaginal prolapse?
50% of parous women of which 10-20% seek medical help
What are the associated risk of a vaginal prolapse?
Pregnancy, large infants, prolonged second stage of labour and instrumental delivery
Congenital factors e.g ehlers danlos syndrome
Menopause
Chronic intraabdominal pressure + eg. = obesity, chronic cough, constipation, heavy lifting
Iatrogenic factors: pelvic surgery
How does vaginal prolapse present?
Dragging sensation or the sensation of a lump.
Cystourethrocoele: urinary frequency, incomplete bladder emptying + stress incontinence
Rectocoele: difficulty opening bowels
Which speculum is used to visualise a prolapse?
Sim’s speculum, patient lies laterally and told to bear down on the prolapse. Tell patient to strain/cough
How can vaginal prolapse be prevented?
Recognition of obstructed labour and avoidance of excessively long 2nd stage.
Pelvic floor muscle exercises after childbirth encouraged
How is vaginal prolapse managed if surgery isn’t appropriate?
Lifestyle advice: lose weight, treat chest problem, stop smoking, physiotherapy
Postmenopausal women: HRT or topical oestrogen prevent vaginal ulceration
Pessaries: ring commonly used, shelf for severe form of prolapse. Changed every 6-9 months.
What are the disadvantages of pessary use?
Cause pain, urinary retention, infection or may fall our
how is vaginal prolapse managed surgically?
Hysteropexy or vaginal hysterectomy for uterina prolapse
Anterior repair for cystocoele, posterior repair for rectocoele.
Sacrospinous fixation or sacrocolpopexy for vault prolapse.
colposuspension or tension free vaginal tape or transobturator tape or stress incontinence.
Describe the neural control of the bladder and urethra
Parasympathetic nerve aid voiding and symphathetic nerves prevent it
what is continence dependant on?
Pressure in urethra being greater than pressure in bladder.
Bladder pressure = detrusor + abdo
Urethral pressure = urethral muscle + pelvic floor + abdo pressure
Describe the two types of urinary incontinence
OAB- detrusor muscle overactivity
Urinary stress incontinence- due to intra abdo pressure not being transmitted to urethra because bladder neck has slipped below pelvic floor therefore increase in abdo pressure such as when coughing cause micturition.
What is the average number of times a woman voids bladder?
4-7 times
what is dysuria associated with?
UTI- also causes nitrite presence
What does haematuria suggest?
Calculi or carcinoma
How is chronic urinary retention investigated?
Post micturition catheterization or ultrasound
How is stress incontinence differentiated from OAB using urodynamic studies?
Cystometry measures pressure in bladder (vesical pressure) whilst bladder is filled and provoked with coughing. Pressure transducer placed in rectum or vagina to measure abdominal pressure.
Detrusor pressure = vesical pressure - abdo pressure
Detrusor pressure doesn’t normally alter with filling or provacation.
Leaking without incerase in detrusor pressure = stress incontinence
Leaking with increase = detrusor overactivity
what is methylene dye test used for?
Leakage from other places other than urethra e.g. fistulae can be visualised
what examinations are done when a patient persents with stress incontinence?
Sim’s speculum
leakage of urine with coughing
abdomen palpated to exclude distended bladder.
How is stress incontinence managed conservatively?
Obese patient encourage to lose weight
Causes of chronic cough e.g smoking addressed
reduce excessive fluid intake
Pelvic floor muscle training for 3 months taught by physiotherapist. 8 contractions 3x per day.
How is stress incontinence managed medically?
Duloxetine (SNRI) enhances urethral striated sphincter activity.
Sideffects: nausea, dyspepsia, drymouth, drowsiness, insomnia
How is stress incontinecne managed surgically?
First line= mid urethral sling e.g. = tension free vaginal tape and transobturator tape 90% cure rate
what is the initial investigation for suspected OAB?
urinary diary: may show frequent passage of small volumes of urine, particularly at night. High intake of caffeine containing drinks.
what is the conservative management for OAB?
Advice: reducing fluid intake and caffeine intake.
Bladder retraining: education; tied voiding with systematic delay; positive reinforcement. Done for 6 weeks.
how is OAB medically managed?
Anticholinergics(antimuscarinics) oxybutynin. Mirabegron for elderly. - however blood pressure monitoring required.
Oestrogen may help with symptoms
Botulinum toxin A 3-12 months cure for 60-90% patients
Referral to specialist clinic if oral relaxants fail to improve symptoms after 1-2months
How is OAB managed surgically?
Clam augmentation ileocystoplasty
What are the causes of bladder urgency and frequency?
Urinary infection Bladder pathology Pelvic mass compressing bladder OAB stress incontinence
what are the causes of acute urianry retention?
after childbirth (paticularly with epidural)
vulval or perineal pain
Surgery
what causes urethrovaginal fistulae?
Obstructed labour
Definition and aetiology of endometriosis?
Presence and growth of tissue similar to endometrium outside the uterus. 1-2% 30-45 years. More common in nulliparous women.
Where can endometriosis occur?
Commonly: uterosacra ligament, ovaries
also in : umbilicus, abdominal scars, vagina, bladder, rectum and lungs
what are the clinical features of endometriosis?
History: cyclical dysmenorrhoea, deep dyspareunia, subfertility, pain on passing stool(dyschezia) during menses.
Severe disease: cyclical haematuria, rectal bleeding or bleeding from umbilicus
Examination: Tenederness, thickening behind uterus/ adnexa. In advanced cases uterus retroverted and immobile
What is the gold standard on endometriosis diagnosis?
Laparoscopy: diagnosis only made with certainty after visualisation and biopsy.
Active lesions: red vesicles or punctuate mark
White scars or brown spots = less active
How is presence of adenomyosis confirmed?
Visualised in USS confirmed in MRI.
What grading system is used for endometriosis?
revised american fertility society(rev-AFS). At laporoscopy points are scored dependent on the presence and position of endometriosis deposits and adhesions. grade 1 minimal 2 mild 3 moderate 4 severe
How is endometriosis managed medically?
NSAIDS - management of pain COCP progesterone GnRH- 6months use can be extended to 2 years with add back HRT IUS
how is endometriosis managed surgically?
Scissors, laser or bipolar diathermy used to destroy endometriotic lesions- improves fertility
Radical surgery: dissection of adhesions, removal of endometriomas, hysterectomy and BSO
How does surgical and medical management of endometriosis effect fertility?
Medical management doesn’t improve fertility
Surgical management does.
IVF best option
what is the definition of chronic pelvic pain ?
6 months pain not occurring exclusively with menstruation or intercourse.
What is the pH of the vagina and which bacteria dominates the bacterial flora?
> 4.5 , lactobacilli
Which vaginal infections are associated with vaginal discharge?
bacterial vaginosis, trichomoniasis, candidiasis
Which bacteria does rise in pH facilitate and what histological feature does this lead to?
Gardnerella vaginalis, atopobium vaginae.
Grey white discharge
Positive whiff test- fishy odour when KOH added.
Clue cells: epithelial cells studded with coccobacilli.
How is BV treated?
clindamycin or metronidazole cream
What are the risk factors for candida infection?
Commonly caused by candida albicans, increased risk during pregnancy, diabetes and antibiotics use.
how does candidiasis present?
clinical features include: cottage cheese discharge with vulval irritation and itching.
superficial dyspareunia and dysuria may occur.
Diagnosis confirmed by culture
How is candidiasis treated?
Topical imidazole- clotrimazole pessary- or oral fluconazole
what principles are considered in the management of STIs?
screening for concurrent infection as more than one STI may be present
Contact tracing
Confidentiality. partners cannot be informed about diagnosis of STI without patient’s permission
Education
what is the most common STI and how does it present?
chlamydia trachomatis- 70% = symptom free
most common symptoms= altered vaginal discharge, IMB and PMB
Pelvic infection can lead to subfertility due to tubal damage
Which arthritis is chlamydia associated with?
sexually acquired reactive arthritis(SARA) characterized by triad of conjunctivitis, urethritis, and arthritis
how is chlamydia diagnosed and treated?
nucleic acid amplification test (NAATs) can be used on urine.
Treatment is with azithromycin or doxycycline
How does gonorrhoeae present and how is it diagnosed?
G- diplococcus, men develop urethritis, often asymptomatic in women.
NAAT of endocervical or vulvovaginal swabs. Positive NAAT should be followed by culture to check for AB sensitivities.
how is gonorrhoeae managed?
IM ceftriaxone
which HPV strain cause genital warts?
6 and 11
what is the treatment for HPV?
there is no treatment
How does primary HSV present?
HSV-1 often causes cold sores but can cause genital infection with oral sex. HSV-2 commonly affects genital and anal area.
1/3- experience primary infection within 4-14 days of becoming infected. Flu like symptoms- fever, tiredness and headaches. Followed by stinging or itching and vesicle appearance lasting 2-3 days which crust over.
Lymphadenopathy and dysuria are common.
how common is HSV recurrence?
HSV-2: 4-6 recurrence each year
HSV-1: less frequent -1 a year
recurrences are milder. tingling and mild flu like symptoms before an outbreak.
how is hsv managed?
aciclovir- for severe infection and reduce duration of symptoms if started early in reactivation
Which organism causes syphilis?
spirochaete treponema pallidum- spiral shape bacteria
what is the transmission history of syphilis?
syphilis is sexually transmissible up till 2 years of untreated infection.
Transmission to fetus may occur up to 10 years after the primary infection.
how does primary, secondary and tertiary syphilis present?
Primary: solitary painless genital ulcer (chancre)
Secondary: weeks after primary- rash, influenza like symptoms and warty genital or perioral growths (condylomata lata), systemic vasculitis + organ involvement
Tertiary: common complications include: aortic regurg, dementia, tabes dorsalis(degeneration of sensory nerve cells), gummata of skin and bone (small soft swelling)
which test are used to diagnose syphilis ?
enzyme immunoassay(syphilis EIA), venereal disease research laboratories (VDRL)
How is syphilis treated?
parenteral penicillin- usually intramuscular
describe the discharge produced by trichomonas vaginalis infection and the associated symptoms
Flagellate protozoan produces offensive grey green discharge.
Vulval irritation, dysuria and superficial dyspareunia.
Cherry red cervix
How is trichomonas diagnosed?
NAATs
How is trichomonas treated?
Systemic metronidazole
How common is cervical intraepithelial neoplasia amongst HIV + women and how frequently are they invited for smear test?
1/3, yearly
Can a HIV+ women give birth vaginally and is breast feeding recommended?
Yes vaginal delivery is safe if on antiretroviral therapy. Breast feeding not recommended.
What causes endometritis?
Result of instrumentation of uterus or retained product of conception. Causes - chlamydia and gonorrhoea
other causes = e.coli, staphylococci, clostridia
How does endometritis present?
heavy vaginal bleeding accompanied by pain. Uterus tender and cervical os open.
What investigations are done if endometritis is suspected?
USS
FBC
vaginal and cervical swab
How is endometritis managed?
Broad spectrum antibiotics
ERCP is indicated on USS
how does PID present?
subfertility, menstrual problems, bilateral lower abdominal pain, with deep dyspareunia = hallmark
severe cases examination reveals: tachycardia, fever, bilateral adnexal tenderness, cervical excitation
what investigations are done for suspected PID?
endocervical swabs for chlamydia and gonorrhoea
Blood culture if there is fever
WBC and c-reactive protein(CRP) may be raised
USS- exclude abscess or ovarian cyst
Gold standard for diagnosis = laparoscopy with fimbrial biopsy and culture - not commonly performed
how is PID treated?
Analgesia
IM ceftriaxone, doxycycline and metronidazole
alternate: ofloxacin with metronidazole
febrile patients admitted for intravenous therapy
no improvement = perform laparoscopy as abscess may not respond to antibiotics - requires drainage USS guidance or laparoscopic
what are the complication of PID?
Early complication = abscess formation or pyosalpinx ( fallopian tube filled with pus).
Ectopic pregnancy = 6x more likely after pelvic infection
tubal damage chance = 12% after one episode of acute PID.
when does vaginal discharge increase?
increases around ovulation, during pregnancy and in women taking COCP
what is the definition of subfertility?
conception hasn’t occurred after a year of regular unprotected intercourse. 15% of couples are` affected
what are the conditions for pregnancy?
ovulation - 30%
adequate sperm release- 25%
sperm must reach egg- fallopian damage will prevent this - 25%
fertilized egg must implant
which hormone is released by the trophoblast to maintain the corpus luteum up till 8-10 weeks gestation?
hCG - human chorionic gonadotrophin
what is pain during ovulation called?
MIttelschmerz pain
what body temperature changes occur pre and post ovulation?
body temperature drops 0.2C preovulation and rises 0.5C during luteal phase
When should progesterone be measured to get mid luteal phase level?
7 days before subsequent menstruation as luteal phase lasts 14 days
How can ovulation be detected?
mid luteal progesterone (21 in a 28 day cycle)- standard
USS follicular tracking
temperature charts
LH based urine predictor kit
what are the diagnostic criteria for PCOS?
Rotterdam criteria 2 or more out of:
Polycystic ovaries morphology on US (12+ cyst or >10ml volume)
Irregular periods 5 weeks or more apart
Hirsutism (clinical or biochemical)
what is the aetiology of PCOS?
Predisposed women demonstrate disordered LH production and peripheral insulin resistance. Raised LH and insulin acting on PCO causes increased androgen production + also from adrenals.
Raised insulin also reduce hepatic production of SHBG
-sex hormone binding globulin
leading to overall increase in androgen which causes anovulation and hirsutism
how does weight impact risk of PCOS?
increased weight = greater risk of insulin resistance and increased production of insulin. greater chance of PCOS. Woman effected with PCOS also show family history of type 2 diabetes
what are the clinical features of PCOS?
Subfertility oligomenorrhoea or amenorrhoea hirsutism and or acne obesity miscarriage
What investigation are done for is PCOS is suspected?
Anovulation investigated with: FSH, LH, AMH (high in PCOS low in ovarian failure), prolactin, TSH, Serum testosterone
TVUS to look for polycystic ovaries
Other: Fasting lipids and glucose.
Especially if woman is obese or has family history of diabetes, abnormal lipids or CVD
What are the complications of PCOS?
Up to 50% of women with PCOS develop type 2 diabetes.
30%- gestational diabetes
risk reduced with weight loss.
Endometrial cancer is more common
How is PCOS managed?
Advice regarding diet and exercise
COCP if fertility not required for regular periods- 3/4 bleeds per year spontaneous or induced required for endometrial protection. Oestrogen consider- cyproterone acetate as antiandrogenic
Spironolactone = antiandrogenic
Metformin
Eflornithine= topical anti androgen used for facial hirsutism
What are the hypothalamic causes of anovulation?
Anorexia nervosa
Excessive exercise
Kallmann’ syndrome- exogenous GnRH required
what are the pituitary causes of anovulation?
Hyperprolactinaemia- prolactinoma
enlarging ones may cause headaches and bitemporal hemianopia. CT imaging indicated if prolactin levels high
Sheehan’s syndrome following post partum haemorrhage
how is prolactinoma medically managed?
dopamine agonist- cabergoline or bromocriptine
What are the ovarian causes of anovulation?
premature ovarian insufficiency: lower oestradiol and inhibin levels causing FSH and LH rise. Bone protection with HRT or oral contraceptive required
Gonadal dysgenesis- present with primary amenorrhoea
what is Clomifene used for ?
first line ovulation induction drug for PCOS. Limited use of 6 months, results in 70% ovulation rate and 40% live birth rate.
How does clomifene work and what needs to be monitored when using it?
antioestrogenic effect on hypothalamus, therefore increases GnRH release consequently increasing FSH and LH level. Given on day 2-6.
Clomifene cycle monitored using TVUS to assess ovarian response and endometrial thickness.
If no follicles develop increase dose.
If 3 or more follicles develop cycle cancellation indicated to prevent multiple pregnancy.
how effective in metformin in treating anovulation?
More effective than clomifene in women with BMI >30 but less effective <30 BMI.
doesn’t cause multiple pregnancy but needs to be taken everyday multiple times and causes GI symptoms
Name an oral aromatase inhibitor which if off licence use for anovulation?
letrozole
