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
