Passmed textbook - Gynaecology Flashcards
What is adenomyosis and which women does it mostly affect?
The presence of endometrial tissue within the myometrium
More common in multiparous women towards the end of their reproductive years
List the features of adenomyosis
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
Management of adenomyosis
GnRH agonists
hysterectomy
Define primary amenorrhoea
failure to establish menstruation
by 15 years of age in girls with normal secondary sexual characteristics (such as breast development)
or by 13 years of age in girls with no secondary sexual characteristics
Define secondary amenorrhoea
cessation of menstruation for 3-6 months in women with previously normal and regular menses,
or 6-12 months in women with previous oligomenorrhoea
(Oligomenorrhea = infrequent menstrual periods (<6-8 per year)
List the causes of primary amenorrhoea
• Gonadal dysgenesis Most common causes e.g. Turner's • Congenital malformations of the genital tract • Testicular feminisation
- Functional Hypothalamic amenorrhoea (e.g. 2o to anorexia)
- CAH
• Imperforate hymen
Testicular feminization is the syndrome when a male, genetically XY, because of various abnormalities of the X chromosome, is resistant to the actions of the androgen hormones, which in turn stops the forming of the male genitalia and gives a female phenotype.
List the causes of secondary amenorrhoea
- Exclude pregnancy
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise, weight loss, dieting, hypothalamic/pituitary tumour) - need to ask about these RF in the hx
- hyperprolactinaemia
- PCOS
- POI
- Early menopause
- Menopause
- thyrotoxicosis or hypothyroidism
- Sheehan’s syndrome
- Asherman’s syndrome
Patient presenting with amenorrhoea
List the initial investigations + possible findings
• exclude pregnancy with urinary or serum bHCG
• Serum levels - FSH, LH, estrogen, prolactin, TSH, testosterone, AMH
-Low AMH decreased egg reserve
• FSH, LH
High FSH + LH on 2 occasions taken 4-6 weeks apart - POI
N/Low FSH/LH - hypothalamic causes (weight loss, excessive exercise, stress, hypothalamic/pituitary tumour)
Normal FSH, raised LH - PCOS
• prolactin levels
if >1000 mIU/L - investigate further (MRI pituitary fossa)
Causes for high prolactin levels - pituitary adenaoma, empty sella syndrome, hypothyroidism, drugs (antipsychotics (risperidone), antidepressants (SSRI), antiemetics (metoclopramide, domperidone))
Other causes - pregnancy, breastfeeding, recent breast examination, needle phobia or traumatic venesection, PCOS (10-20%, rarely >1000 mIU/L), renal impairement (<2000), hypothyroidism (<1200)
• TSH
High in hypothyroidism
Prolactin secretion stimulated by TSH, therefore there is high prolactin if T4 is low
• Total testosterone
Cushing’s syndrome (high >5.0 nanomol/L)
Late onset CAH (high >5.0 nanomol/L)
Androgen-secreting tumour (moderately increased 2.5-5.0 nanomol/L)
PCOS
• Total testosterone – normal to slightly raised
o If total testosterone is >5 nmol/L, exclude androgen-secreting tumours and CAH
• Free testosterone – may be raised
• USS
PCOS (12 or more follicles measuring 2-9mm in diameter in one or both ovaries +/or increased ovarian volume (>10cm)
Structural issues - mullerian agenesis
No uterus/intraabdominal testes - androgen insensitivity syndrome
• Hysteroscopy
IUA
• Karyotype Turner Syndrome (45XO) Androgen Insensitivity syndrome (46XY but resistance to testosterone)
FSH, LH, prolactin, testosterone in
Hyperprolactinaemia
PCOS
POI
Hypothalamic (e.g. weight loss, excessive exercise, stress)
Hyperprolactinaemia FSH - N/L LH -N/L Prolactin - H Testosterone - N
PCOS FSH - N LH - H Prolactin - N Testosterone - H Free androgen index increased
POI FSH - H LH - H Prolactin - N Testosterone - N
Hypothalamic (e.g. weight loss, excessive exercise, stress) FSH - L LH - L Prolactin - N Testosterone - N
Primary + Secondary amenorrhoea management
Primary
• investigate + treat any underlying cause
• with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etc)
Secondary
• exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause
Early menopause management
• HRT unless contra-indicated until they reach 51 years
Premature ovarian insufficiency
• Sex steroid replacement + HRT or COCP (combined hormonal contraceptive)
o HRT/COCP should be continued until at least the age of natural menopause
What do you need to ask in a hx of a pt presenting with secondary amenorrhoea
Exclude physiological causes, including pregnancy, lactation, and menopause (in women 40 years of age or older)
Ask about: Contraceptive use (extended-cycle combined oral contraceptives, injectable progesterone, implantable etonogestrel [Nexplanon®], and levonorgestrel intrauterine system [Mirena®] may cause amenorrhea).
Symptoms of
POI/ menopause - Hot flushes and vaginal dryness
Pituitary tumour - Headaches, visual disturbances, or galactorrhoea
PCOS - Acne, hirsutism, and weight gain
Hypothalamic dysfunction - Stress, depression, weight loss, disturbance of perception of weight or shape, level of exercise, and chronic systemic illness
Thyroid and other endocrine disease
A history of
obstetric or surgical procedures (such as endometrial curettage) - IUA
chemotherapy and pelvic radiotherapy - POI
Cranial radiotherapy, head injury, or major obstetric haemorrhage - hypopituitarism
Drugs
Antipsychotics - increased prolactin levels - esp. risperidone
Antidepressants - increased prolactin levels - esp. SSRI
Antiemetics - - increased prolactin levels - esp. metoclopramide, domperidone
Illicit drug use - cocaine and opiates - can cause hypogonadism).
A family history of cessation of menses before 40 years of age (suggesting POI).
What is androgen insensitivity syndrome + features
- X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
- Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome
Features
• ‘primary amennorhoea’
• undescended testes causing groin swellings
• breast development may occur as a result of conversion of testosterone to oestradiol
Diagnosis of androgen insensitivity syndrome + management
Diagnosis
• buccal smear or chromosomal analysis to reveal 46XY genotype
Management
• counselling - raise child as female
• bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
• oestrogen therapy
Atrophic vaginitis
When does it occur
Symptoms
On examination
Treatment
Post-menopausal women
Vaginal dryness, dyspareunia and occasional spotting.
O/E dry and pale vagina
Treatment
vaginal lubricants and moisturisers
if these do not help -topical oestrogen cream
Main differentials for bleeding in the first trimester
Miscarriage
Ectopic pregnancy
Hydatidiform mole
Miscellaneous conditions Cervical ectropion Vaginitis Trauma Polyps Fibroids Implantation bleeding - Dx of exclusion
Worrying signs suggestive of an ectopic
- Positive pregnancy test
- Pain + abdominal tenderness
- Pelvic tenderness
- Cervical motion tenderness
If a woman has a +ve pregnancy test and any of those signs she should be referred immediately to the early pregnancy assessment service
Bleeding + >6/40 weeks/uncertain gestation
Refer to an early pregnancy assessment service
When do you manage bleeding in the first trimester conservatively and what advice would you give to the patient
Conservative management if
• Pregnancy <6/40
• Bleeding but NO pain + no RF for ectopic pregnancy
Advise • Return if bleeding continues • Return if pain develops • Repeat a urine pregnancy test after 7-10 days + return if positive • Negative test - miscarriage
Cervical cancer epidemiology
50% of cases of cervical cancer - <45
Incidence rates for cervical cancer in the UK - highest in people aged 25-29 years
Histology of cervical cancer
Squamous cell cancer (80%)
Adenocarcinoma (20%)
Symptoms of cervical cancer
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: PCB, IMB, postmenopausal bleeding
vaginal discharge
RF for cervical cancer
Human papillomavirus (HPV) - most important factor in the development of cervical cancer Particularly serotypes 16,18 & 33 is by far the
Other RF Smoking HIV lower socioeconomic status Early first intercourse, many sexual partners High parity COCP
Mechanism of HPV causing cervical cancer
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 - inhibits p53 tumour suppressor gene
E7 - inhibits RB suppressor gene
What is the aim of cervical cancer screening ?
To detect pre-malignant changes rather than to detect cancer
Note: cervical adenocarcinomas are frequently undetected by screening
Which population is offered the smear test?.
Women of ages 25-65
25-49 years - every 3 years
50-64 years - every 5 years
cervical screening cannot be offered to women over 64 unless
A recent cervical cytology sample is abnormal
They have not had a cervical screening test since 50 years of age and they request one
Patients cannot self-refer past screening age
Special situations
women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
Women may undergo colposcopy in late first, or early second trimester, unless there is a clinical contraindication
For low-grade changes, the assessment may be delayed until after delivery
Women seen in early pregnancy may require a further assessment in the late second trimester
When is the best time to take a cervical smear?
And when should the smear not be taken?
It is said that the best time to take a cervical smear is around mid-cycle
Whilst there is limited evidence to support this it is still the current advice given out by the NHS
A cervical sample should not be taken (unless you think the woman will not re-attend), if the woman:
Is menstruating.
Is less than 12 weeks postnatal.
Is less 12 weeks after a termination of pregnancy, or miscarriage
Has a vaginal discharge or pelvic infection — treat the infection and take the sample on another occasion
How is the cervical smear test performed?
Place the brush into the cervix + rotate 5 times
Take a sample from the whole of the transformation zone
The transformation zone can be identified by visual inspection as there is a change in colour and texture from the pale, pink, shiny, smooth surface of the ectocervix to a reddish, granular appearance of the columnar cells that line the endocervical canal
The position of the transformation zone may be affected by age and pregnancy
Then swirl the brush into the sample bottle containing the preservative fluid 10 times
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC)
Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC
reduced rate of inadequate smears
increased sensitivity and specificity
To take a cytology sample:
Visualize the cervix (using a speculum) — if the cervix appears abnormal, suggesting possible malignancy arrange urgent referral (within 2 weeks) to a gynaecologist
Note: there is no need for referral for colposcopy if there has been contact bleeding at the time a cervical sample is obtained (in the absence of other symptoms)
What does the cervical smear test look at?
What used to happen
Signs of dyskaryosis which may indicate cervical intraepithelial neoplasia
Patients with mild dyskaryosis were further risk-stratified, i.e. as HPV is such a strong risk factor patients who were HPV negative could be treated as having normal result
Now
The NHS has moved to an HPV first system
A sample is tested for high-risk strains of human papillomavirus (hrHPV) first
Cytological examination is only performed if this is positive
Management of cervical smear test results with a negative hrHPV
If Negative hrHPV (high-risk strains of papillomavirus) return to routine recall unless
Follow-up for borderline changes in endocervical cells
Follow-up for incomplete excised cervical glandular epithelial neoplasia (CGIN)/ stratified mucin producing epithelial lesion (SMILE) or cervical cancer
Test of Cure (TOC) pathway - individuals treated for CIN1, CIN2, CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
The untreated CIN1 pathway – Women with untreated CIN 1 must have a repeat Colposcopy and cytology test at 6 months
Should women who have had a hysterectomy be offered cervical screening?
Subtotal hysterectomy (that still have a cervix) should continue in the National Cervical Screening Programme (NHSCSP)
Women who have had a hysterectomy with CIN present are potentially at risk of developing vaginal intraepithelial neoplasia (VaIN) and invasive vaginal disease
Total hysterectomy (no longer have a cervix) are not required to take part in the NHSCSP.
How often should women who have been treated for CIN be offered cervical screening?
All women treated for CIN should be followed up for test of cure cervical cytology 6 months after treatment
• If the sample is negative, borderline or low-grade, a reflex high-risk human papillomavirus (HR–HPV) test should be taken
o HPV +ve - refer to colposcopy
o HPV -ve should be recalled for repeated cytology in 3 years, irrespective of their age.
• If the sample is high-grade dyskaryosis or invasive squamous carcinoma refer to colposcopy. An HR-HPV test is unecessary
Management of cervical smear test results with a positive hrHPV
Positive hrHPV
• Samples are examined cytologically
Abnormal cytology → colposcopy this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosi. high-grade dyskaryosis (moderate) high-grade dyskaryosis (severe) invasive squamous cell carcinom. glandular neoplasia
Normal cytology - Repeat test at 12 months
if repeat test is hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve + cytology still normal → further repeat test 12 months late:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
if inadequate sample at 24 months → colposcopy
How are cytology results reported?
Inadequate — this may be because the cervical sample:
Was taken but the cervix was not fully visualized.
Was taken in an inappropriate manner (for example, using an unapproved device).
Contains insufficient cells.
Contains an obscuring element (for example lubricant, inflammation, or blood).
(when taking a cervical sample try not to use too much lubricant)
Is incorrectly labelled.
Negative — no abnormality is detected.
Abnormal — the cervical samples may show:
Borderline changes in squamous or endocervical cells.
Low-grade dyskaryosis.
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Invasive squamous cell carcinoma.
Glandular neoplasia.
What should happen if results are unavailable or if there is an inadequate cervical cytology sample?
Sample is repeated in no less than 3 months
Exception: Individuals who have inadequate cytology at the 24 month repeat test* - refer to colposcopy.
*Positive hrHPV
Normal cytology - Repeat test at 12 months
if repeat test is hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve + cytology still normal → further repeat test 12 months late:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
if inadequate sample at 24 months → colposcopy
What is a cervical ectropion?
Symptoms
Treatment
On the ectocervix there is a transformation zone
Stratified squamous epithelium meets the columnar epithelium of the cervical canal
Elevated oestrogen levels (ovulatory phase, pregnancy, COCP use) result in larger area of columnar epithelium being present on the ectocervix
Symptoms
vaginal discharge
PCB
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
What is a complete hydatidiform mole?
List the symptoms + investigation findings
All the genetic material comes from the father
An empty oocyte lacking maternal genes is fertilised
Commonly this arises from a single sperm duplicating within an empty ovum
Less often an empty ovum is fertilised by 2 sperm
There is no fetal tissue
46 XY or 46XX
vaginal bleeding
hyperemesis
uterus size greater than expected for gestational age
abnormally high serum hCG
ultrasound: ‘snow storm’ appearance of mixed echogenicity
List causes of delayed puberty with
Short stature
Normal stature
Short stature
Turner’s syndrome 45XO
Prader Willi syndrome - Chr15 (loss of paternal gene, maternal gene is silenced by genomic imprinting)
Noonan’s syndrome
Normal stature PCOS Androgen insensitivity syndrome Kallman's syndrome Klinefelter's syndrome 47XXY
Kallmann syndrome is a condition characterized by delayed or absent puberty and an impaired sense of smell. This disorder is a form of hypogonadotropic hypogonadism, which is a condition resulting from a lack of production of certain hormones that direct sexual development
Klinefelter syndrome may adversely affect testicular growth, resulting in smaller than normal testicles, which can lead to lower production of testosterone
Define dysmenorrhoea
Excessive pain during the menstrual period
Features + Management of primary dysmenorrhoea
Features
• pain typically starts just before or within a few hours of the period starting
• suprapubic cramping pains which may radiate to the back or down the thigh
Management
• NSAIDs (mefenamc acid, ibuprofen) - inhibit PG production*
• COCP - 2nd line
- e. Excessive endometrial prostaglandin production is thought to be partially responsible for primary dysmenorrhoea
Causes of secondary dysmenorrhoea
How to differentiate with primary dysmenorrhoea
Endometriosis Adenomyosis PID IUD Copper coils Mirena may help with dysmenorrhoea Fibroids
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period
Symptoms of ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain
typically the first symptom
due to tubal spasm
pain is usually constant and may be unilateral
vaginal bleeding
usually less than a normal period
may be dark brown in colour
history of recent amenorrhoea
typically 6-8 weeks from the start of last period
if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
dizziness, fainting or syncope
symptoms of pregnancy e.g. breast tenderness
Examination findings for an ectopic pregnancy
Examination findings
abdominal tenderness
cervical excitation (cervical motion tenderness)
adnexal mass
NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy
A pelvic examination to check for cervical excitation is however recommended
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
RF for an ectopic pregnancy
Risk factors damage to tubes (pelvic inflammatory disease, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic)
Ectopic pregnancy investigations
Abdominal investigation Obs Urine pregnancy test Vaginal examination to test for cervical motion tenderness TVUS - investigation of choice
Bhcg After TVUSS if unable to locate the fetus (prefnancy of unknown origin)
NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy
A pelvic examination to check for cervical excitation is however recommended
Management of an ectopic pregnancy
Expectant
Medical
Surgical
Expectant mx - closely monitoring the patient over 48h • Size <35mm • Unruptured • Asymptomatic • No fetal heartbeat • Serum bhCG <1,000 IU/L
- If symptoms manifest or if bhCG levels rise again - intervention is performed
- Expectant management is suitable if there is another intrauterine pregnancy
Medical mx - methotrexate only if the patient is wiling to attend follow up • Size <35mm • Unruptured • No significant pain • No fetal heartbeat • Serum bhCG <1,500 IU/L
• Medical management is not suitable if there is another intrauterine pregnancy
Surgical mx - salpingectomy or salpingotomy • Size >35mm • Unruptured/Ruptured • Pain • Visible fetal heartbeat • Serum bhCG >1,500 IU/L
• Surgical management is suitable if there is another intrauterine pregnancy
Where are most ectopic pregnancies found + what is the pathophysiology?
97% are tubal, with most in the ampulla
Most dangerous in the isthmus
Trophoblast invades the tubal wall - bleeding which may dislodge the embryo
Natural history
tubal abortion
tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
tubal rupture
(commonest are abortion + absorption)
Epidemiology of endometrial cancer
classically seen in post-menopausal women
Around 25% of cases occur before the menopause
Usually carries a good prognosis due to early detection
Risk factors for endometrial cancer
Protective factors for endometrial cancer
Risk factors
Obesity
Nulliparity
Early menarche, late menopause
Unopposed oestrogen
Addition of a progestogen to oestrogen reduces this risk (e.g. In HRT)
Progestogen should be given continuously
Diabetes mellitus
Tamoxifen
PCOS
Hereditary non-polyposis colorectal carcinoma
Protective factors
Smoking
COCP
Features of endometrial cancer
Postmenopausal bleeding is the classic symptom
premenopausal women
Change intermenstrual bleeding
Pain and discharge are unusual features
Investigations for endometrial cancer
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
TVUS - first-line investigation
A normal endometrial thickness (< 4 mm) has a high negative predictive value
Hysteroscopy with endometrial biopsy if endometrial thickness >4mm
Management of endometrial cancer
Localised disease - total abdominal hysterectomy with bilateral salpingo-oophorectomy
Patients with high-risk disease
Post-operative radiotherapy
Not suitable for surgery (e.g. frail elderly women) - progestogen therapy
Endometrial hyperplasia
Definition
Features
Management
Definition
Abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle
A minority of patients with endometrial hyperplasia may develop endometrial cancer
Features
Abnormal vaginal bleeding e.g. intermenstrual
Management
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. LNG-IUD may be used
atypia: hysterectomy
Define endometriosis
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity
Around 10% of women of a reproductive age have a degree of endometriosis.
Clinical features of endometriosis
Symptoms
On examination
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
on pelvic examination
Reduced organ mobility
Tender nodularity in the posterior vaginal fornix
Visible vaginal endometriotic lesions
Endometriosis investigations
laparoscopy is the gold-standard investigation
there is poor correlation between laparoscopic findings and severity of symptoms
Endometriosis management
Management depends on clinical features
- NSAIDs and/or paracetamol - first-line treatments for symptomatic relief
- if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
Female genital mutilation definition
Refers to all procedures involving
partial or
total removal of the external female genitalia
or other injury to the female genital organs for non-medical reasons
WHO FGM Classification
Type 1
Type 2
Type 3
Type 4
Type 1
Clitoridectomy = Partial or total removal of the clitoris and/or the prepuce
Type 2
Excision = Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
Type 3
Infibulation = Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris
Type 4
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
Fibroid degeneration
Why does it happen
Symptoms
Management
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy
If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration
Low-grade fever
Pain
Vomiting
Conservative management Rest and analgesia
Should resolve within 4-7 days
Gynaecological causes of abdominal pain investigations
In addition to routine diagnostic work up of abdominal pain, all female patients should undergo
Urine pregnancy test
Bimanual vaginal examination
Consider abdominal + pelvic USS
If diagnostic doubt - laparoscopy to assess suspected tubulo-ovarian pathology
Differentials for abdominal pain in females (gynae) incl. features + investigations + treatments [5]
Mittelschmerz Features Mid-cycle pain Sharp onset Little systemic disturance Recurrent episodes Settles over 24-48 hours
Ix FBC - N USS - small quantity of free fluid --- Endometriosis Features Menstrual irregularity Infertility Pain Deep dyspareunia Complex disease - pelvic adhesion formation with episodes of intermittent small bowel obstruction Localised peritoneal inflammation from intra-abdominal bleeding Recurrent episodes are common
Ix
USS - free fluid
Laparoscopy - will show lesions
Management Usually managed medically Complex disease requires surgery Some pt may require formal colonic and rectal resections if these areas are involved ---
Ovarian torsion Features Sudden onset of deep seated colicky abdominal pain Vomiting + distress Adnexial tenderness
Ix
USS - free fluid
Laparoscopy - diagnostic + therapeutic
Management
Laparoscopy
—-
Ectopic gestation
Features
Symptoms of pregnancy without evidence of intrauterine gestation
Presents as an emergency - evidence of rupture or impending rupture
Open tubular ruptures - sudden onset abdominal pain + circulatory collapse
small amount of vaginal discharge
adnexal tenderness but should not perform adnexal palpation as there is a risk of rupture
Ix
elevated bhCG
USS - no intrauterine pregnancy, intraabdominal free fluid
Management
Laparoscopy or laparotomy if haem unstable
Salpingectomy or salpingotomy
—-
PID
Features
Fever >38
Bilateral lower abdominal pain associated with vaginal discharge
Dysuria
RUQ discomfort - Peri-hepatic inflammation 2o to chlamydia (Fitz Hugh Syndrome)
Ix FBC - leukocytosis Pregnancy test - negative Amylase - N or slightly raised High vaginal + urethral swabs
Management
Medical
Heavy menstrual bleeding ix
FBC - Hb
Routine TVUS if symptoms suggest a structural or histological abnormality IMB PCB pelvic pain Pressure symptoms) Abnormal pelvic exam findings.
Heavy menstrual bleeding mx
Does not require contraception
Mefenamic acid 500 mg tds (NSAID) (particularly if there is dysmenorrhoea as well) or
Tranexamic acid 1 g tds
Both are started on the first day of the period
Requires contraception,
LNG-IUS (Mirena) - 1st line
COCP - 2nd line
long-acting progestogens (depo-provera) - 3rd line
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
HRT SE
Nausea
Breast tenderness
Fluid retention
Weight gain
complications of HRT
o Oestrogen only – endometrial cancer, ovarian cancer
o Combined – breast cancer, ovarian cancer
Increased risk of breast cancer
increased by the addition of a progestogen
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
increased risk with all HRT
Risk of dying form breast cancer is not raised
increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of ovarian cancer
Risk increased with all HRT
increased risk of venous thromboembolism
increased by the addition of a progestogen
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
increased risk of stroke
slightly increased risk with oral oestrogen HRT
increased risk of coronary heart disease
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Hyperemesis gravidarum - when does it present and what associations are there
Most common between 8 + 12 weeks
May persist up to 20 weeks
Associations Nulliparity multiple pregnancies trophoblastic disease hyperthyroidism obesity
Smoking = decreased incidence of hyperemesis
When do you admit a woman presenting with hyperemesis gravidarum
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.
When do you diagnose hyperemesis gravidarum?
5% pre-pregnancy weight loss and
dehydration and
electrolyte imbalance
What can be used to classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis (PUQE)
Management of hyperemesis gravidarum
admission may be needed for IV hydration
antihistamines first-line
Promethazine
Cyclizine
ondansetron and metoclopramide second-line
metoclopramide may cause extrapyramidal side effects
ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
Complications of hyperemesis gravidarum
Wernicke’s encephalopathy
central pontine myelinolysis
Mallory-Weiss tear
acute tubular necrosis
fetal: small for gestational age, pre-term birth
Complications of hysterectomy
Acute
Urinary retention
Long-term
Enterocele
Vaginal vault prolapse
Initial investigations for infertility
Semen analysis
Serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
Interpretation of serum progestogen
>30 nmol/l indicates ovulation
16-30 nmol/l repeat
<16 nmol/l repeat, if consistently low refer to specialist
Epidemiology of infertility
Affects around 1 in 7 couples
Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes of infertility
male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15%
How to counsel someone trying for a baby
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Average age of menopause in the UK
51 years old
Symptoms typically last for 4 years on average
Until when should contraception be used for menopausal women?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Menopause management
Lifestyle modifications
Hot flushes
regular exercise, weight loss and reduce stress
Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene
Mood
sleep, regular exercise and relaxation
Cognitive symptoms
regular exercise and good sleep hygiene
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
HRT contraindications
- Any oestrogen-sensitive cancer
- Current or past Breast cancer
- Untreated endometrial hyperplasia
- Undiagnosed vaginal bleeding
- Hx of VTE
- Current thrombophilia (AT-III, FV Leiden)
- Severe liver disease
- Pregnancy
What do you say to a woman who wants to stop HRT treatment
For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment
Vaginal oestrogen may be required long term
Gradually reducing HRT is effective at limiting recurrence only in the short term
In the long term, there is no difference in symptom control
Menopausal symptoms
Vasomotor symptoms - affects around 80% of women. Usually occur daily and may continue for up to 5 years
hot flushes
night sweats
Urogenital changes - affects around 35% of women
vaginal dryness and atrophy
urinary frequency
Psychological
anxiety and depression may be seen - around 10% of women
short-term memory impairment
Longer term complications
osteoporosis
increased risk of ischaemic heart disease
Causes of menorrhagia
uterine fibroids
hypothyroidism
intrauterine devices*
Copper IUD
IUS (mirena) is used to treat menorrhagia
pelvic inflammatory disease
bleeding disorders, e.g. von Willebrand disease
dysfunctional uterine bleeding: menorrhagia in the absence of underlying pathology(accounts for approximately half of patients)
anovulatory cycles: these are more common at the extremes of a women’s reproductive life
Describe the different types of miscarriages
Threatened miscarriage • Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6-9 weeks • Mild symptoms of bleeding • Little/no pain • FH is present • Cervical os is closed
Inevitable miscarriage • Heavy bleeding with clots • Pain • Cervical os is open • Pregnancy will not continue – will proceed to incomplete/complete miscarriage
Missed (delayed) miscarriage
• Fetus is dead but retained
• Also described as early fetal demise/empty sac/blighted ovum
o a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
o blighted ovum/anembryonic pregnancy = when the gestational sac is >25mm and no embryonic/fetal part can be seen
• Mother may have light vaginal bleeding/discharge and the symptoms of pregnancy which disappear
• Pain is not usually a feature
• Uterus is small for dates
• Pregnancy test can remain positive for several days/weeks
• Hx of threatened miscarriage + persistent dark-brown discharge
• Early pregnancy symptoms may have decreased or stopped
Incomplete miscarriage – passage of products of conception but uterus not empty on USS
Pain and vaginal bleeding
Cervical os is open
Products of conception are partially expelled
Many incomplete miscarriages can be unrecognised missed miscarriages
Complete miscarriage • Hx of confirmed IU pregnancy • Heavy bleeding + clots • Passage of products of conception • Empty uterus on USS – no pregnancy tissue in the uterine cavity
Epidemiology of miscarriage
15-20% of diagnosed pregnancies will miscarry in early pregnancies
non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
recurrent spontaneous miscarriage affects 1% of women
85% of spontaneous miscarriages occur in the 1st trimester The risk falls rapidly with advancing gestation
Management of miscarriage
Expectant - 1st line
- Wait for 7-14 days unless
Increased risk of haemorrhage (late first trimester or coagulopathies or unable to have a blood transfusion)
Previous adverse +/or traumatic experience associated with pregnancy (stillbirth, miscarriage, APH)
Evidence of infection
Medical
- Vaginal misopostol
PG analogue - binds to endometrial cells - causes strong myometrial contractions leading to the expulsion of tissue
- Contact Dr if bleeding hasn’t started in 24h
- Should be given w anti-emetics + pain relief
Surgical - vacuum aspiration (suction curettage) LA as an OP - Surgical management in theatre (evacuation of retained products of conception) GA
Ovarian cancer epidemiology, RF, protective factors + prognosis
The 5th most common malignancy in females
Peak age of incidence - 60 years
Carries a poor prognosis due to late dx
RF
- FHx - BRCA1 or BRCA2
- Many ovulations - early menarches, late menopause, nulliparity
Protective factors
- COCP
- Having many pregnancies
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%
Pathophysiology of ovarian cancer
90% of ovarian cancers - epithelial in origin with 70-80% of cases being due to serous carcinomas
Distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
Clinical features of ovarian cancer
Abdominal distension and bloating
Abdominal and pelvic pain
Urinary symptoms e.g. Urgency
Early satiety
Diarrhoea
Ovarian cancer investigations
CA125
Done initially
If the CA125 is raised (35 IU/mL or greater) –> urgent ultrasound scan of the abdomen and pelvis should be ordered
Should not be used for screening for ovarian cancer in asymptomatic women
Other causes of increased CA125
Endometriosis
menstruation
benign ovarian cysts
Ultrasound
Diagnosis is difficult and usually involves diagnostic laparotomy
Ovarian cancer management
usually a combination of surgery and platinum-based chemotherapy
List the types of ovarian cysts
Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy
Describe the types of physiological (functional) ovarian cysts
Follicular cysts
- commonest type of ovarian cyst
- due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- commonly regress after several menstrual cycles
Corpus luteum cyst
- during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears
- If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
- more likely to present with intraperitoneal bleeding than follicular cysts
Describe the types of benign germ cell tumours
Dermoid cyst
- also called mature cystic teratomas
- Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
- Most common benign ovarian tumour in woman under the age of 30 years
- Median age of diagnosis is 30 years old
- Bilateral in 10-20%
- Usually asymptomatic
- Torsion is more likely than with other ovarian tumours
Describe the types of benign epithelial tumours
Arise from the ovarian surface epithelium
Serous cystadenoma
- the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
- bilateral in around 20%
Mucinous cystadenoma
- second most common benign epithelial tumour
- large and may become massive
- if ruptures may cause pseudomyxoma peritonei
Management of ovarian enlargement
USS - Initial imaging modality for suspected ovarian cysts/tumours
Cyst can be either
Simple - unilocular - more likely to be physiological or benign
Complex - multilocular - more likely to be malignant
Premenopausal women
- Conservative mx in younger women (esp. if < 35 years) as malignancy is less common
- Small cyst (e.g. < 5 cm) + ‘simple’
Highly likely to be benign
A repeat ultrasound should be arranged for 8-12 weeks
Referral considered if it persists
Postmenopausal women
Physiological cysts are unlikely
Any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
What is the ovarian hyperstimulation syndrome?
- Complication seen in some forms of infertility treatment
- up to 1/3 of women who are having IVF may experience a mild form of OHSS
- occurs in <1% of all women undergoing ovarian induction
- Multiple luteinized cysts within ovaries
- ovarian enlargement with multiple cystic spaces - high levels of oestrogen, progesterone, vasoactive substances (e.g. VEGF)
- Increased membrane permeability - loss of fluid from the intravascular compartment
- fluid shift from the intravascular to the extra-vascular space
- can be life-threatening if not identifies and managed promptly
Can result in multiple life-threatening complications
- Hypovolaemic shock
- Acute renal failure
- Venous or arterial thromboembolism
Seen after
- Gonadotrophin treatment
- hcg treatment
- clomifene therapy (rarely)
Classify OHSS (ovarian hyperstimulation syndrome) into mild, moderate, severe, critical
Mild
- Abdominal pain
- Abdominal bloating
Moderate
- Abdominal pain
- Abdominal bloating
- N+V
- USS evidence of ascites
Severe
- Abdominal pain
- Abdominal bloating
- N+V
- USS evidence of ascites
- Clinical evidence of ascites
- Oliguria
- Hct >45%
- Hypoproteinaemia
Critical
- Abdominal pain
- Abdominal bloating
- N+V
- USS evidence of ascites
- Clinical evidence of ascites
- Tense ascites
- Anuria
- Hct >45%
- Hypoproteinaemia
- Thromboembolism
- ARDS
Ovarian torsion definition
Adnexal torsion definition
Ovarian torsion
Partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply
Adnexal torsion
If the fallopian tube is also involved
RF for ovarian torsion
Ovarian mass: present in around 90% of cases of torsion
Being of a reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Features of ovarian torsion
Sudden onset of deep-seated colicky abdominal pain
Associated with vomiting and distress
Fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
Investigation + mx of ovarian torsion
USS
Free fluid
Whirlpool sign
Laparoscopy
Both diagnostic and therapeutic
List the 4 types of ovarian tumours
Surface derived tumours
Germ cell tumours
Sex cord-stromal tumours
Metastasis
Describe the types surface derived ovarian tumours
Account for around 65% of ovarian tumours, including the greatest number of malignant tumours.
Serous cystadenoma
- Benign
- Most common benign ovarian tumour, often bilateral
- Cyst lined by ciliated cells (similar to Fallopian tube)
Serous cystadenocarcinoma
- Malignant
- Often bilateral
- Psammoma bodies seen (collection of calcium)
Mucinous cystadenoma
- Benign
- Cyst lined by mucous-secreting epithelium (similar to endocervix)
Mucinous cystadenocarcinoma
- Malignant
- May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause of pseudomyxoma peritonei )
Brenner tumour
- Benign
- Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium - Typically have ‘coffee bean’ nuclei.
Describe the types of germ cell ovarian tumours
These are more common in adolescent girls
Account for 15-20% of tumours
Similar cancer types to those seen in the testicle
Dysgerminoma
- Malignant
- Most common malignant germ cell tumour
- Histological appearance similar to that of testicular seminoma
- Associated with Turner’s syndrome
- Typically secrete hCG and LDH
Teratoma
- Mature teratoma (dermoid cyst) - most common - benign
- Immature teratoma: malignant
- Account for 90% of germ cell tumours
- Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
Yolk sac tumour
- Malignant
- Typically secrete AFP
- Schiller-Duval bodies on histology are pathognomonic
Choriocarcinoma
- Malignant
- Rare tumour that is part of the spectrum gestational trophoblastic disease
- Typically have increased hCG levels
- Often characterised by early haematogenous spread to the lungs
Describe the types of sex cord-stromal ovarian tumours
Represent around 3-5% of ovarian tumours
Often produce hormones
Granulosa cell tumour - Malignant - Produces oestrogen leading to Precocious puberty in children Endometrial hyperplasia in adults - Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
Sertoli-Leydig cell tumour
- Benign
- Produces androgens → masculinizing effects
- Associated with Peutz-Jegher syndrome
Fibroma
- Benign
- Associated with Meigs’ syndrome (triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor)
- Solid tumour consisting of bundles of spindle-shaped fibroblasts
- Typically occur around the menopause, classically causing a pulling sensation in the pelvis
Describe the types of metastatic ovarian tumours
Account for around 5% of tumours
Krukenberg tumour
- Malignant
- Metastases from a GIT tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
For which couples is ovulation induction required?
For couples who have ovulation disorders
Ovulation disorders are the cause of infertility in approx 25% of couples who have difficulty conceiving naturally
Describe the process of normal ovulation and state what goes wrong in ovulatory dysfunction
Early follicular phase Increase in (GnRH) pulse frequency --> increases the release of FSH + LH --> stimulation + development of multiple ovarian follicles Usually only one of which will become the dominant ovulatory follicle in that menstrual cycle
Mid-follicular phase
FSH gradually stimulates estradiol production
Estradiol produces a negative feedback loop on the hypothalamus + pituitary gland –> suppression of FSH and LH concentrations
Luteal phase,
Switch from negative to positive feedback of estradiol –> surge of LH secretion –> follicular rupture + ovulation
If there is an alteration in this fine balance which may lead to irregular or complete anovulation
https://cdn.britannica.com/07/55707-050-5927EDFB/changes-woman-cycle.jpg
Which are the 3 main categories of ovulation disorders?
There are three main categories of anovulation:
Class 1
Hypogonadotropic hypogonadal anovulation
Notably hypothalamic amenorrhoea (5-10% of women)
Class 2
Normogonadotropic normoestrogenic anovulation
PCOS (80% of cases)
Class 3
hypergonadotropic hypoestrogenic anovulation
POI (5-10% of cases)
In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
Which is the goal of ovulation induction?
To induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable
What are the different forms of ovulation induction?
Exercise and weight loss
First-line treatment for patients with PCOS
ovulation can spontaneously return with even a modest 5% weight loss
—
Clomiphene citrate
While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women)
Mechanism of action: clomiphene is a selective estrogen receptor modulator (SERMs) –> acts primarily at the hypothalamus –> blocks the negative feedback effect of estrogens –> increase in GnRH pulse frequency –> FSH and LH production –> stimulating ovarian follicular development
Gonadotropin therapy
- Used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism
- For women with PCOS it is only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial
This is because the
Increased risk of multi-follicular development + subsequent multiple pregnancy
Increased risk of OHSS
Mechanism of action: pulsatile GnRH therapy involves - IV GnRH via IV infusion pump (or less frequently SC) –> endogenous FSH + LH production –> subsequent follicular development
OHSS (ovarian hyperstimulation syndrome) management
Depending on the severity, the management includes:
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination to prevent further hormonal imbalances
Serious complications of OHSS (ovarian hyperstimulation syndrome)
Can result in multiple life-threatening complications
- Hypovolaemic shock
- Acute renal failure
- Venous or arterial thromboembolism
Define PID pelvic inflammatory disease + wetiology
Infection and inflammation of the upper female genital tract including the uterus, fallopian tubes, ovaries and the surrounding peritoneum
It is usually the result of ascending infection from the endocervix
Causative organisms of PID pelvic inflammatory disease
Causative organisms
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
PID pelvic inflammatory disease symptoms and signs
Lower abdominal pain fever deep dyspareunia dysuria and menstrual irregularities may occur vaginal or cervical discharge cervical excitation
PID pelvic inflammatory disease investigations
Pregnancy test to exclude an ectopic pregnancy
High vaginal swab
These are often negative
Screen for Chlamydia and Gonorrhoea
PID pelvic inflammatory disease management
outpatient
inpatient
• Start Abx before swabs if you suspect PID
o Do not delay abx while waiting for the results
o Broad-spectrum abx treatment to cover C. trachomatis, N. gonorrhoea, anaerobic infection is recommended
outpatient • First line (all 3) o IM ceftriaxone 1g single dose and o Doxycycline 100mg PO BD 14 days and o Metronidazole 400mg BD 14 days
Inpatient – if pyrexial (>38) or septic
o IV ceftriaxone 2g OD + IV doxycycline 100mg BD
followed by
o PO Doxycycline 100mg BD + PO Metronidazole 400mg BD for a total of 14 days
PID pelvic inflammatory disease complications
Perihepatitis (Fitz-Hugh Curtis Syndrome)
10% of cases
RUQ pain, may be confused with cholecystitis
Infertility - the risk may be as high as 10-20% after a single episode
Chronic pelvic pain
Ectopic pregnancy
Commonest cause of pelvic pain
Primary dysmenorrhoea
List acute causes of pelvic pain [7 causes]
Primary dysmenorrhoea - commonest
Ectopic pregnancy o 6-8 weeks amenorrhoea with lower abdominal pain o Later develops vaginal bleeding o Shoulder tip pain o Cervical excitation
UTI
o Dysuria
o Frequency
o Suprapubic burning secondary to cystitis
Appendicitis
o Pain initially in the central abdomen before localising to the RIF
o Tenderness in RIF
o Rovsing’s sign - more pain in RIF than LIF when palpating LIF
o Anorexia
o Tachycardia
o Low-grade pyrexia
PID o Pelvic pain o Fever o Deep dyspareunia o Vaginal discharge o Dysuria o Menstrual irregularities may occur o Cervical excitation on examination
Ovarian torsion
o Sudden onset unilateral lower abdominal pain
o May coincide with exercise
o N+V are common
o Unilateral, tender adnexal mass on examination
Miscarriage
o Vaginal bleeding following a period of amenorrhoea
o Crampy lower abdominal pain
List chronic causes of pelvic pain
Endometriosis o Chronic pelvic pain o Secondary Dysmenorrhoea - pain often starts days before bleeding as opposed to primary dysmenorrhoea where pains starts pain typically just before or within a few hours of the period starting o Deep dyspareunia o Subfertility
IBS
o Extremely common
o Abdominal pain, bloating, change in bowel habit
o Lethargy, Nausea, Backache, bladder symptoms
Ovarian cyst
o Unilateral dull ache
o Intermittent or might only occur during intercourse
o Severe abdominal pain with torsion or rupture
o Abdominal swelling or pressure effects on the bladder (larger cysts)
Urogenital prolapse
o Older women
o Sensation of pressure/heaviness/bearing down
o Urinary symptoms - incontinence, frequency, urgency
PCOS polycystic ovarian syndrome features
Both hyperinsulinaemia and high levels of LH are seen and there appears to be some overlap with the metabolic syndrome
subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
PCOS polycystic ovarian syndrome investigations
o pelvic ultrasound: multiple cysts on the ovaries
o FSH, LH, prolactin, TSH, and testosterone are useful investigations (ix for infertility)
raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis
Prolactin may be normal or mildly elevated.
Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
o Check for impaired glucose tolerance
PCOS polycystic ovarian syndrome management
General
o Weight loss if appropriate
o COCP - regulate cycle + induce a monthly bleed
Hirsutism and acne
o COCP -
Third generation COC which has fewer androgenic effects
Co-cyprindiol which has an anti-androgen action
Increased risk of venous thromboembolism
No response to COCP –> topical eflornithine
Infertility
o Weight loss if appropriate (1st line)
o Clomiphene (2nd line or 1st line in women with normal BMI)
Should not be used for >6 months
o Metformin
May be used instead or together with clomiphene to improve pregnancy rates
Usually added after 3 failed cycles with clomiphene
Warn women about side-effects
Metformin is not recommended in pregnancy
o Gonadotrophins (3rd line)
There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene - women should have US monitoring during treatment
Metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
*work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
PCB - post coital bleeding causes
o no identifiable pathology is found in around 50% of cases
o cervical ectropion
Most common identifiable cause (33% of cases)
More common in women on the COCP
o Cervicitis e.g. secondary to Chlamydia
o cervical cancer
o polyps
o traumaPost-menopausal bleeding definition
Vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected
Can also occur in younger women who have experienced premature menopause or POI
Postmenopausal bleeding is usually benign, however, endometrial malignancy should be ruled out with urgency
Post-menopausal bleeding causes
o Vaginal atrophy - commonest cause
Thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause
o HRT
Also a common cause
Periods or spotting can continue in some women taking HRT for many months with no pathological cause
Endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
o Endometrial hyperplasia
An abnormal thickening of the endometrium
Precursor for endometrial carcinoma
RF - obesity, unopposed oestrogen use, tamoxifen use, PCOS and diabetes
o Endometrial cancer
10% of patients with postmenopausal bleeding have endometrial cancer
90% of patients with endometrial cancer present with postmenopausal bleeding
Must be ruled out urgently
o Cervical cancer
Obtain a full record of prior cervical screening programme attendance
o Ovarian cancer
Especially oestrogen-secreting (theca cell) tumours (granulosa cell tumour)
o Vaginal cancer
Uncommon but can present with postmenopausal bleeding
o Other uncommon causes include trauma, vulval cancer and bleeding disorders
Post-menopausal bleeding investigations
Women over the > 55 with postmenopausal bleeding
-> 2 week wait for USS for endometrial cancer
History taking
o Timing, consistency and quantity of the bleeding
o Full gynaecological and obstetric history
o RF for endometrial cancer
o Establish a menstrual timeline from menarche to menopause
o Full drug history including HRT use
o Red flag symptoms for gynaecological cancer should be enquired about
Examination
o A vaginal and a full abdominal examination
Look for any masses or abnormalities within the abdomen or felt from within the vagina,
o Speculum visualisation of the walls of the vagina and cervix
Blood or discharge may be seen
Immediate testing o Urine dipstick Haematuria Infection o FBC anaemia or a bleeding disorder o CA-125 levels
For those referred on a cancer pathway within two weeks:
o TVUS
The endometrial lining thickness is assessed
<3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy
Some centres use 4 mm or even 5 mm as a cut-off for endometrial biopsy.
However, it may miss some pathology and if clinical suspicion is high, further testing is required
o Endometrial biopsy
Definitive diagnosis of endometrial cancer
Taken during hysteroscopy or by an aspiration (pipelle) biopsy
Pipelle biopsy –> thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
Imaging in secondary care
o CT or MRI of the uterus, pelvis and abdomen
Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer
Post-menopausal bleeding treatment
Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
o Vaginal atrophy
Topical oestrogens
Lifestyle changes - Lubrication
HRT can also be used
o HRT
Different HRT preparations can be used to try to reduce this
o Endometrial hyperplasia
Dilatation + curettage
To remove the excess endometrial tissue
Minor symptoms of pregnancy
nausea/vomiting
tiredness
musculoskeletal pains
Premature ovarian insufficiency POI definition
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
It occurs in around 1 in 100 women.
Premature ovarian insufficiency POI causes
Idiopathic - the most common cause
Family history
bilateral oophorectomy
Hysterectomy with preservation of the ovaries - advances the age of menopause
radiotherapy
chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
genetic
endocrine
Premature ovarian insufficiency POI features
Similar to those of the normal climacteric but the actual presenting problem may differ
o Climacteric symptoms: hot flushes, night sweats infertility o secondary amenorrhoea o raised FSH, LH levels e.g. FSH > 40 iu/l o low oestradiol e.g. < 100 pmol/l
Premenstrual syndrome PMS definition
The emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
Only occurs in the presence of ovulatory menstrual cycles - it doesn’t occur prior to puberty, during pregnancy or after the menopause.
Premenstrual syndrome PMS symptoms
Emotional symptoms include: anxiety stress fatigue mood swings
Physical symptoms
bloating
breast pain
Premenstrual syndrome PMS management
Mild symptoms
o Lifestyle advice
o Advice on sleep, exercise, smoking and alcohol
o Specific advice - regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
Moderate symptoms
o New-generation COCP
Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
Severe symptoms
o SSRI
Taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
Define recurrent miscarriage and list some causes
3 or more consecutive spontaneous abortions
occurs in around 1% of women
Causes
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders
- PCOS
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
Semen analysis
When should it be performed?
should be performed after a minimum of 3 days and a maximum of 5 days abstinence
The sample needs to be delivered to the lab within 1 hour
Normal semen results (NICE 2013)
Semen volume pH sperm concentration total sperm number total motility (progressive motility + non-progressive motility) vitality sperm morphology (normal forms)
Semen volume – >1.5 ml
pH - >7.2
sperm concentration – >15 million spermatozoa per ml
total sperm number - >39 million spermatozoa per ejaculate or more
total motility (progressive motility + non-progressive motility) - >40% motile, >32% progressively motile
vitality - >58% live spermatozoa
sperm morphology (normal forms) >4%
Termination of pregnancy (TOP)
Key points of the abortion act
Current law based on he 1967 Abortion Act
In 1990 the upper limit changed from 28w to 24w
But these limits do not apply in cases where
- it is necessary to save the life of the woman
- there is evidence of extreme fetal abnormality
- there is risk of serious physical or mental injury to the woman
- Two registered medical practitioners must sign a legal document
- In an emergency only one is needed
- Only a registered medical practitioner must perform an abortion
- Abortion must be performed in an NHS hospital or a licensed premise
- that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
How is TOP/ termination of pregnancy carried out?
<9 weeks - mifepristone* + PG (48H later to stimulate uterine contractions)
<13 weeks - surgical dilation + suction of uterine contents
> 15 weeks - surgical dilation + evacuation of uterine contents or late medical abortion (induces mini-labour)
- mifepristone
- Anti-progestogen
- Often referred to as RU486
RF for urinary incontinence
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Define overactive bladder (OAB)/urge incontinence stress incontinence mixed incontinence overflow incontinence:
overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Urinary incontinence initial investigations
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
Urinary urge incontinence / overactive bladder OAB management
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line.
- Oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
- Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Urinary stress incontinence management
pelvic floor muscle training: 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- MOA: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
Define urogenital prolapse and list the RF
descent of one of the pelvic organs resulting in protrusion on the vaginal wall
affects around 40% postmenopausal women
RF increasing age multiparity, vaginal deliveries obesity spina bifida
Types of urogenital prolapse
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
Symptoms and management of urogenital prolapse
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency
Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery
Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy, vaginal sacrospinous hysteropexy, Manchester repair, colpocleisis
rectocele: posterior colporrhaphy
vaginal vault prolapse - sacrocolpopexy, vaginal sacrospnous fixation, colpoclesis
Uterine fibroids definition, epidemiology
Fibroids are benign smooth muscle tumours of the myometrium
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Uterine fibroids features
- may be asymptomatic
- menorrhagia
iron-deficiency anaemia - lower abdominal pain: cramping pains, often during menstruation
- bloating
- urinary symptoms, e.g. frequency, may occur with larger fibroids
- subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
Uterine fibroids dx
TVUS
Uterine fibroids management
Asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids
- NSAIDs e.g. mefenamic acid
- tranexamic acid
LNG-IUS
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
- COCP
- oral progestogen
- injectable progestogen
Treatment to shrink/remove fibroids Medical - GnRH agonists o May reduce the size of the fibroid o Typically useful for short-term treatment
- Ulipristal acetate
o SPRM (selective progesterone receptor modulator) with predominantly inhibitory action
o Shrinks fibroids, reduced bleeding – Inhibits cell proliferation inducing apoptosis
o Should only be used for intermittent treatment of moderate to severe uterine fibroid symptoms before menopause and when surgical procedures (including uterine fibroid embolisation) are not suitable or have failed
o Reports of serious liver injury
Perform LFTs at least once monthly
Stop treatment if transaminase levels are >2 x the upper limit of normal
Repeat LFTs 2 and 4 weeks after stopping treatment
surgical o myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically o hysteroscopic endometrial ablation o hysterectomy o uterine artery embolization
Uterine fibroids prognosis and complications
Fibroids generally regress after the menopause.
Subfertility
Iron-deficiency anaemia
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
Which is the most common species implicated in vaginal candidiasis
Candida albicans (80%)
the remaining 20% of cses are caused by other candida species
RF for vaginal candidiasis
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
Features of vaginal candidiasis
- ‘cottage cheese’, non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema
- fissuring
- satellite lesions
Investigations and management of vaginal candidiasis
Investigations
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Management
- Local or oral treatment
Local treatments:
- Clotrimazole pessary
Oral treatments:
- Itraconazole or fluconazole
If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent vaginal candidiasis
Define
Investigations
Management
Definition: 4 or more episodes per year
Investigations:
Check compliance with previous treatment
Confirm the diagnosis
High vaginal swab for microscopy and culture
Consider a blood glucose test to exclude diabetes
Exclude differential diagnoses such as lichen sclerosus
Management:
- Consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
List the common causes of vaginal discharge + key features of each
Physiological Candida - Cottage cheese discharge - Non-offensive - Vulvitis - Itch
Trichomonas vaginallis
- Yellow/green frothy discharge
- Offensive
- Vulvovaginitis
- Strawberry cervix
Bacterial vaginosis
- White/grey fishy discharge
- Offensive
- Thin
List less common causes of vaginal discharge
Gonorrhoea
Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
ectropion
foreign body
cervical cancer
Which is the most common type of vulval cancers?
Epidemiology
Around 80% are squamous cell carcinomas
Most cases occur in women over the age of 65 years
RF for vulval cancer
Age Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus
Features of vulval cancer
- lump or ulcer on the labia majora
- inguinal lymphadenopathy
- itching, irritation
62 y/o presenting with increased urinary frequency, urinary incontinence suprapubic tenderness
2ddx
first line investigation
In any patient presenting with urinary incontinence or increased urinary frequency, urinalysis should always be the first investigation to rule out a urinary tract infection (UTI) or diabetes mellitus
In patients over 65 years old, urinalysis is not performed to assess for UTIs as asymptomatic bacteriuria is common in this population and therefore urinalysis will not be reliable. As this patient is below 65 years old, urinalysis should be performed.
POP - advice to give to women regarding
Potential adverse effects
Starting the POP
Taking the POP
Missed pills
Other potential problems
Other information
discussion on STIs
**unless the antibiotic alters the P450 enzyme system, for example, rifampicin
otential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle –> immediate protection
Otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
if switching from a COCP gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at the same time every day, without a pill-free break (unlike the COC)
Missed pills
(Micronor, Noriday, Nogeston, Femulen) –> if < 3 hours* late: continue as normal
*for Cerazette (desogestrel) a 12 hour period is allowed
if > 3 hours*:
Take the missed pill as soon as possible - if >1 missed, only 1 should be taken
Continue with the rest of the pack
Extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
o If UPSI after missed pill + within 48h of restarting the POP – EC
Other potential problems
DV: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce the effectiveness
Other information
discussion on STIs - POP does not offer protection against STIs
**unless the antibiotic alters the P450 enzyme system, for example, rifampicin
Iota criteria for malignant ovarian cysts and management
Irregular, solid tumour. Ascites. At least 4 papillary structures. Irregular multilocular solid tumour with largest diameter ≥100 mm. Very strong blood flow.
Refer to gynae for biopsy of cyst
Simple Ovarian cyst
50-70mm in diameter
<50mm in diameter
My
50-70mm in diameter - yearly TVUS
<50mm in diameter - no follow up, likely to be physiological, almost always resolve within 3 menstrual cycles
Ectopic pregnancy in which of the locations is most associated with an increase risk of rupture?
Isthmus
Which area of the cervix needs to be visualised during colposcopy and what happens when this is difficult?
Transformation zone
Endocervical curettage is used when at colposcopy the transformation zone (the area most at risk of pre-cancerous changes) cannot be visualised. A curette is inserted into the cervical canal to remove cells which can be examined in the lab. Although this patient may undergo cervical curettage, colposcopy should be performed first.
When do you refer to fertility services a patient with endometriosis?
if the couple have not conceived after 6 months of regular unprotected vaginal sexual intercourse.
Surgical options such as laparoscopic adhesiolysis may improve fertility rates in patients with mild-moderate disease.
Adverse effects of injectable contraceptive (depo provera)
Weight gain
Irregular bleeding
Delayed return to fertility
Increased risk of osteoporosis
What is the Rokitansky protuberance?
Associated with dermoid cysts (teratomas)
The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance
Hydatidiform mole US findings
solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as ‘snow-storm’ appearance)
Hydatidiform mole has symptoms of which endocrinological condition and why?
Thyrotoxicosis
Hog has a structural resemblance to TSH
Endometrial hyperplasia rf
MOONTA Street
Menarchy extremes Obesity Oestrogen Nulliparity Tamoxifen Age35+ Smoking
MOA of the following contraceptives
Implantable rod
POP
IUD
IUS
All of them work by inhibiting ovulation except the POP and the intrauterine device + system.
Progesterone only methods all increase cervical mucus thickening
The implantable rod contains the hormone progesterone and the hormone will be slowly released into the systemic circulation. This typically lasts 3 years before replacement. Its primary function is to inhibit ovulation as progesterone inhibits the secretion of FSH and LH from the pituitary. While the rod also has an additional effect of increasing the thickness of mucous within the cervical lining, this is not the predominant mode of action of the rod.
Increasing cervical mucous thickening is also caused by the progesterone-only pill.
Decreasing sperm viability is the main mechanism of action of the intrauterine copper device.
The intrauterine system predominantly provides contraception by providing exerting local progesterone onto the uterine lining. This prevents the proliferation of the uterine lining and prevents implantation of the ovum.
HIV positive woman - how should she be followed up as part of the cervical screening programme?
Women with HIV should be offered cervical screening at dx Cervical screening (hrHPV) should then be offered annually for screening
Their management will follow the protocols for primary hrHPV testing in all other aspects other than the frequency of screening
Vesicovaginal fistulae suspicion and investigation
Suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
Missed POP - when is EC needed?
Other POPs - consider missed if more than 3 hours late
Desogestrel - considered missed if more than 12 hours late
POP needed if missed pill + UPSI within 48 h of restarting POP
Early menopause vs premature ovarian failure
Early menopause - cessation of ovarian function between the ages of 40-45
Premature ovarian failure - cessation of ovarian function <40
Medical conditions that are RF for endometrial cancer
T2DM
PCOS
Endometrial cancer - protective factors
Smoking
COCP
What can reduce the incidence of shoulder dystocia in women with gestational diabetes?
IOL
Mnemonics to remember which cancers COCP is associated with (either protective or increases the risk of)
COCP protects against Ovarian and endometrial cancer
COCP increases the risk of breast and cervical cancer
COCP = Causes Outside Cancers Predominantly Outside = breast + cervix Inside = endometrial and ovarian
COCP stops ovulation + endometrial thickening (therefore protects against ovarian and endometrial cancer)
COCO orevents babies + prevents ‘baby-maker’ cancers (endometrial, ovarian)
When would you advise a woman on the COCP to omit the pill free interval?
Omitting the pill-free interval is advised if 2 or more pills are missed in week 3 of a packet
If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval
Cervical cancer management
IAM IB II III IV recurrent disease
IA
Gold standard - hysterectomy +/- lymph node clearance
If wanting to maintain fertility - cone biopsy with negative margins
A2 - nodal evaluation, radical trachelectomy (also prserves fertility)
IB
B1 radiotherapy + concurrent chemo
B2 radical hysterectomy with pelvic node dissection
II, III
Radiation with concurrent chemo
IV
Radiation and or chemo
IVB palliative chemo
Recurrent disease
Chemoradiation or radiation
When is a COCP considered missed?
When it is 24 hours after it should have been taken
E.g. once 72 hours have passed since the last pill was taken, 2 pills have been missed
After how many missed pills wpuld you advise the woman to take emergency contraception and restart the pill as a new user?
If more than 7 consecutive pills are missed
When would you consider a woman on COCP to be protected during the pill free interval?
If she has taken 7 consecutive pills on the week prior to the interval
the COCP would theoretically be effective if given 7 days on 7 days off.
Featured of ruptured endometrioma
PMH of endometriosis
Acute abdomen
Pelvis filled with fluid
Management of
Cervical cancer (>IA2) Endometrial cancer Ovarian cancer
Cervical cancer (>IA2)= radical hysterectomy with lymphadenectomy Endometrial cancer = Hysterectomy with bilateral salpingo-oophorectomy with or without lymphadenectomy Ovarian cancer = Hysterectomy with bilateral salpingo-oophorectomy with lymphadenectomy, omentectomy
Just seems you remove the adjacent organ for each pelvic cancer!
Medical management if stess vs urge incintinence
Stress = duloxetine (SNRI - can causse nausea, dizziness, insomnia)
Urge = oxygutynin, tolterodine, solifenacin (antimuscatinics, 1st line), mirabegron (β3 agonist, 2nd line)
First line management od menorrhagian
Mirena (LGN-IUS)
FSH LH AMH (antimullerian hormone) in P OS
FSH LH normal or raised
AMH high due to anovilation
Contraception options right after delivery of baby
POP can be commenced immediately after delivery
an intrauterine device can be fitted during a caesarean section (ideally within 10 minutes of the passage of the placenta), once the wound is closed it is advised to wait 4-6 weeks post-partum before having it inserted vaginally
COCP CI -can suppress milk production and increase risk of DVT
Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy
is to be avoided.
How do youfigure out on which dsy you need to measure progesterone in order to confirm ovulatuion?
The serum progesterone level will peak 7 days after ovulation has occurred. The length of the follicular phase of the menstrual cycle can be variable, however, the luteal phase (after ovulation) remains constant at 14 days. Therefore, in a 35-day cycle, given that the luteal phase always lasts for 14 days, the follicular phase will be 21 days (ovulating on day 21). Therefore, the progesterone level will be expected to peak on day 28.
In simple terms, measure serum progesterone 7 days prior to expected next period (for 28-day cycle: 28 - 7 = 21. For 35-day cycle: 35 - 7= 28)
Dysmenorrhora mx
If primary
1st line NSAIDs e.g. mefanemic acid
2if NSAIDs contraindicated - paracetamol
If treatment with NSAIDs fails, combination of NSAIDs + paracetamol can be tried
If secondary
Refer all patients to gynae for investigation
If pt doesnt have plans to conceive + no contraindications to hormonal contraception - COCP
Menorrhagia mx
Mirena LNG IUS
Adenomyosis ix
Women with suspected adenomyosis
1.3.13 Offer transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) to women with HMB who have:
significant dysmenorrhoea (period pain) or
a bulky, tender uterus on examination that suggests adenomyosis. [2018]
- 3.14 If a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques. [2018]’
https: //www.nice.org.uk/guidance/ng88/chapter/recommendations
Classic sx of endometriosis
Cyclical abdominal pain, pelvic pain, dysmenorrhoea, dyspareunia and subfertility
When can you provide contraception to a person <18?
CHIMP:
Continuation (likely to continue sex with or without advice)
Health (physical or mental health compromised if not given treatment)
Interest (Advice is in their best interest)
Maturity (mature to understand nature of treatment)
Persuasion (can’t be persuaded to tell parents)
Where do we use the RMI score and what does it comprise of
Risk malignancy index
Used to aassess prognosis in ovarian cancer
RMI = US * menopause status * CA125 (U/ml)
US: no findings = 1 point, 1 finding = 2 points, 2-5 findings = 3 points
Pre-menopause = 1 point, post-menopause = 3 points
CA125 = actual level
US findings:
- multilocular cyst
- ascites
- mets
- bilateral cysts
- solid area
RMI =/<200 = low/moderate risk
RMI >200 = high risk, sensitivity 87%, specificity 97%
https://www.mdcalc.com/risk-malignancy-index-rmi-ovarian-cancer
Also, CA125 and US are not specific and should not be used as screening test i.e. in asymptomatic patients. Ovarian cancer also does not have an identified precursor lesion.
Woman missed taking a pill regularly for first 7 daysof cycle, 2 cocp pills on day 8 and 9 of cycle, continued on day 10
What kind of emergency contraception does she nned
If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken
This woman has missed 2 doses of the COCP. Provided the first 7 doses of the COCP are taken at the correct date and time, if 2 consecutive doses are missed between days 8-14 of the menstrual cycle, emergency contraception is not required. This woman has missed doses on days 8 and 9 of her menstrual cycle and has since restarted her medication on day 10. Therefore emergency contraception is not needed.
Important -> However, until 7 consecutive days of the COCP are taken, women are at risk of becoming pregnant, and therefore barrier contraception or abstaining from sex is advised.
After how many consecutive days of cocp are you considered protected?
until 7 consecutive days of the COCP are taken, women are at risk of becoming pregnant
How to remember the mx of stress + urge incontinence
Stresssss - Pelvisss (floor exercise)
Stressed -> Duloxetine (SNRI)
Urge - urge to breath oxygen - Oxybuynin
Urrrrrrge - RRRetraining of bladder
STRESS incontinence, tell them to relaxxx - sounds like Duloxxx(etine)
Duloxitine- Du ‘locks it in’- keeps your pee locked in, so treats stress incontinence.
Which of the ovarian tumours is associated with the development of endometrial hyperplasia?
Granulosa cell tumours secrete oestrogen
Endometriosis mx if cocp + nsaids fail
The correct answer is GnRH analogues injections. These drugs can be used to manage endometriosis when the combined oral contraceptive pill (COCP) and NSAIDs such as ibuprofen have failed. Their beneficial effects are thought to be due to a pseudo-menopause induced by the high circulating levels of GnRH.
Contraceptives - time until they are effective (if not taken on first day of period)
IUD
contraceptive depot
contraceptive implant
intrauterine system
POP
COCP
IUD - immediately
contraceptive depot - 7 days
contraceptive implant - 7 days
intrauterine system - 7 days
POP - 2 days
COCP - 5 days
How does clomiphene and metformin work in treating infertility in PCOS?
- Clomiphene – ovulation induction – stimulate FSH & LH release > development and maturation of ovarian follicle > corpeus luteum development >pregnancy
- Insulin resistance -> hyperinsulinaemia -> androgen excess -> arrest in antral follicular development -> anovulation.
Metformin treats insulin resistance and hyperinsulinaemia, therefore allowing follicular development and subsequent ovulation
Complications of imperforate hymen
Endometriosis
Peritonitis
absolute contraindication to IUD insertion
distorted uterine anatomy
including insertion of a copper IUD as emergency contraception.
Emergency contraception -when can the IUD be inserted
within 5 days after the first unprotected sexual intercourse in a cycle
or within 5 days of the earliest estimated date of ovulation
whichever is later
When should the dose of Levonorgestrel be doubled from 1.5mg to 3mg when used as an emergency contracepton
The dose should be doubled to 3mg levonorgestrel for those with a BMI >26 kg/m2 or weight over 70kg.
Emergency contraception in someone who is BF
Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions with levonorgestrel and so levonorgestrel is more appropriate for this patient.
Pt presenting with a cottage cheese discharge mx
Treat for candida albicans
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Important to rule out chlamydia and gonorrhoea in this age group, especially given their high prevalence, however, remember that 70% of chlamydia is asymptomatic in women, and the majority of gonorrhoea is also asymptomatic
Recurrent vaginal candidiasis definition
Mx
Recurrent vaginal candidiasis
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Most common ovarian cancer
Serous carcinoma
most common type of ovarian mass in woman of reproductive age
follicular cyst
what might a corpus luteum cyst present with?
Intra-peritoneal bleed
When can should you start the COCP to ensure immediate protection for pregnancy?
Day 1 of the menstrual cycle is typically the preferred day to start a COCP regimen, as it ensures immediate protection from pregnancy. However, it is not the earliest option in this scenario.
When can you start hormonal contraception after taking levonorgestrel as emergency contraception?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
Effect of Cu IUD on periods
Intrauterine copper coil should not be used as this can occasionally worsen dysmenorrhoea and can induce menorrhagia as well.
While this is a long-acting contraceptive, it often causes heavy menstrual bleeding. It should therefore be avoided in those with a history of heavy menstrual bleeding.
When can LGN-IUS or Cu IUD be inserted after a woman has given birth?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.
When do you measure the mid-luteal progesterone level?
Regardless of the length of the individual’s menstrual cycle - the progesterone levels should be carried out 7 days before the end of the cycle, so will, therefore, vary from individual to individual.
35 day cycle
When does ovulation occur?
When do you measure mid-luteal progesterone?
Ovulation = 35-14 = day 21
Midluteal progesterone = 35-7 or 21+7 = day 28
which type of contraception is licensed to be used as the progesterone component of HRT and for how long?
Mirena coil
4 years
How does clomifene work?
Clomifene is the traditional first-line drug used to induce ovulation in women with PCOS. It works by antagonising oestrogen receptors in the hypothalamus and pituitary, thus increasing the release of LH and FSH via negative feedback. This induces ovulation.
Gonadotrophins in the management of infertility
Gonadotropins are recognised second-line management options for inducing ovulation. A daily subcutaneous injection of FSH/LH is given to stimulate multiple follicles in the ovaries. Ovulation is then triggered by a single hCG injection of 5000–10,000 IU intramuscularly when the follicles are 15–18 mm in size.
Mx of
Trichomonas vaginalis
Neisseria gonorrhoea
Chlamydia trachomatis
Trichomonas vaginalis –> 5 or 7 day course of PO metronidazole
Neisseria gonorrhoea –> single dose of IM ceftriaxone (if sensitivity is not known) or a single dose of oral ciprofloxacin (if sensitivity is known and the organism is sensitive)
Chlamydia trachomatis - oral azithromycin (single dose) or oral doxycycline (for 7 days)
changes in puberty in girls chronological order
‘Boobs, Pubes, Grow, Flow’
most appropriate mx of miscarriage in a patient with past medical history of coagulopathy Von Willebrand disease
vaginal misoprostol
Coagulopathy is a contra-indication to expectant management, but not medical management.
When would you test the vaginal discharge for pH?
Test the pH of the discharge is, again, not required given the characteristic signs and symptoms of candidiasis. Testing pH may be done to differentiate candidiasis from bacterial vaginosis. In bacterial vaginosis, the pH is above 4.5
How does duloxetine work?
It is thought to work by increasing serotonin and norepinephrine levels in the pudendal motor nucleus of the sacral spinal segments, thereby increasing urethral muscular tone and closure pressure.
How does tranexamic acid work?
The most appropriate answer is therefore tranexamic acid, a plasminogen activator inhibitor that acts as an anti-fibrinolytic to prevent heavy menstrual bleeding.
Antibiotics and POP
• precautions should still be taken with enzyme inducing antibiotics such as rifampicin
The BNF states that: ‘effectiveness of oral progestogen-only preparations is not affected by antibacterials that do not induce liver enzymes’. Ciprofloxacin is a cytochrome P450 (CYP450) inhibitor, not an inducer. This means that the efficacy of this patient’s contraception is not affected and she does not need to use additional barrier contraception.
If she were taking rifampicin, an alternative choice for meningococcal contact prophylaxis, she should also use barrier contraception during and for four weeks after cessation of treatment as this drug is a potent enzyme inducer and therefore can decrease the plasma concentration and efficacy of contraceptive pills.
3 causes of ectropion
3Ps for Ectropions: Pregnancy; Pill (COCP); Puberty
indications for oral antibiotics in mastitis
an infected nipple fissure, symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive.
whiff test
clue cells
Whiff test - a sample of discharge is taken, and mixed with potassium hydroxide. If positive, the result smell fishy.
Clue cells - epithelial cells from the vagina that have a load of bacteria stuck to their surface, so the edges look fuzzy.
positive in BV
How does clomifene work
Clomifene is the traditional first-line ovulation induction drug used. As an antioestrogen, it works by blocking oestrogen receptors in the hypothalamus and pituitary and increasing the release of LH and follicle stimulating hormone (FSH), which are inhibited by oestrogen. It is only given on days 2 to 6 of each cycle to initiate follicular maturation. If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.
How does gonadotrophin induction work in infertility
Gonadotropin induction involves a daily subcutaneous injection of recombinant or purified urinary FSH and/or LH. This stimulates follicular growth and is monitored by ultrasound. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.
How does PCOS cause anovulation and how does metformin work
PCOS –> insulin resistance –> androgen excess –> arrest in antral follicular development –> anovulation.
Metformin increases peripheral insulin sensitivity
How does tamoxifen increase the risk of endometrial cancer?
Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.
