Pelvic and Vulval Pain Flashcards
Define dysmenorrhoea
Pelvic pain that can occur a few days prior to menstruation but normally subsides with menstruation
- Primary: absence of any underlying uterine condition
- Secondary: pelvic pathology present
How can you assess the impact on QoL for someone with dysmenorrhoea?
- Do they miss school/work with their symptoms at least once per cycle?
What are some risk factors for dysmenorrhoea?
- Early menarche
- Nulliparity
- Family history
- Longer duration of menstruation, heavier flow
What is the pathophysiology of dysmenorrhoea in a normal menstrual cycle?
Multifactorial
- Progesterone withdrawal upregulates inflammatory cytokines, prostaglandins, vascular endothelial growth factor and matrix metallopreinases
- Degradation of these, loss of integrity of blood vessels, destruction of endometrial interstitial matrix = menstruation
- Prostaglandin also causes myometrium to contract
- ? stimulation of pain fibres secondary to ischaemia
Name some causes of secondary dysmenorrhoea
Common
- Endometriosis
- Chronic PID
- Adenomyosis
- Intrauterine polyps
- Submucosal fibroids
- IUCs
Less common
- Allen-Masters syndrome (scarring of broad ligaments during childbirth)
- Congenital uterine abnormalities
- Cervical stenosis
- Asherman’s syndrome
- Pelvic congestion syndrome
- Ovarian cysts
What medical therapies are there for primary dysmenorrhoea?
- NSAIDs
- COCP
- Progestogen-only methods
What surgical therapies are there for primary dysmenorrhoea?
- Uterosacral nerve ablation
- Presacral neurectomy
What complementary therapies are available for primary dysmenorrhoea?
- TENS machine
- Vitamin B1 and Mg
- Acupuncture
- Local application of heat
- Behavioural therapies
When does NICE recommend you should refer someone from primary care with suspected endometriosis?
- Severe, persistent, recurrent symptoms suggestive of endometriosis
- Pelvic signs of endometriosis
- Initial management not effective, tolerated, or contra-indicated
What are medical therapies for endometriosis?
- Analgesia (paracetamol, NSAIDs)
- Neuromodulators / neuropathic pain mx
- Hormonal treatment (LNG-IUS or CHC, can try progestogen-only based methods)
- GnRH analogues + add-back HRT
What are surgical therapies for endometriosis?
- Laparoscopic excision / ablation to endometriotic deposits / adhesiolysis
- Laparoscopic ovarian cystectomy
- Hysterectomy (trial of GnRH agonist + HRT prior to this)
What are some ultrasound features of adenomyosis?
- Subendometrial echogenic linear striations and/or nodules, extending from endometrium and into inner myometrium
- Hyperechoic islands
- Irregular endometrial/myometrial junction
- Tiny (1-5mm) anechoic myometrial and subendometrial cysts
Name some benign ovarian masses
- Functional cyst
- Endometrioma
- Haemorrhagic cyst
- Serous cystadenoma
- Mucinous cystadenoma
- Mature teratoma
What’s the difference between serous and mucinous cystadenoma?
- Serous are usually unilocular, mucinous are usually multilocular
- Serous are more common
- Mucinous require surgical removal due to malignant potential
Name some benign non-ovarian adnexal masses
- Paratubal cyst
- Hydrosalpinges
- Tubo-ovarian abscess
- Peritoneal pseudocyst
- Appendiceal abscess
- Diverticular abscess
- Pelvic kidney
Name malignant ovarian masses
- Germ cell tumour
- Epithelial carcinoma
- Sex-cord tumour
- Metastases (usually breast or GI)
What is the risk of malignancy index (RMI)?
RMI = U x M x Ca125
U = 1 point each for multilocular cyst, solid areas, metastases, ascites, bilateral lesions
U = 0 – none
U = 1 – one
U = 3 – two or more
M = menopausal status
M = 1 – pre-menopausal
M = 3 – post-menopausal
What are the IOTA rules for ovarian masses based on ultrasound?
B rules
- Unilocular
- Presence of solid components where largest component is <7mm
- Presence of acoustic shadowing
- Smooth multilocular tumour with largest diameter <100mm
- No blood flow
M rules
- Irregular, solid tumour
- Ascites
- At least four papillary structures
- Irregular, multilocular, solid tumour with largest diameter >100mm
- Very strong blood flow
What ultrasound features are there of a functional, follicular cyst?
- Most common (persistence of unruptured graffian follicle)
- Up to 10cm diameter
- Thin walled, unilocular
What ultrasound features are there of a functional, corpus luteal cyst?
- Less common (corpus luteum fails to regress following release of ovum)
- Right > left
- Diffuse, thick wall
- Peripheral vascularity
- 2-10cm
- ‘ring of fire’ on colour doppler
What are ultrasound features of theca lutein cysts?
- Associated with excessive amounts of hCG (i.e. multiple pregnancy, PCOS, DM, clomiphene, ovulation induction, GTD)
- Multiple, bilateral, thin-wall cysts with clear contents
What are ultrasound features of endometriomas?
- Size variable
- Usually unilocular
- Acoustic enhancement
- Diffuse, homogenous, ground-glass echoes
Name some sex cord stromal tumours
Granulosa Cell Tumours
- Malignant, slow-growing
- Secrete estrogen and inhibin B will be elevated
Theca Cell Tumours
- Commonly over 60s
- Secrete estrogen
Fibromas
- Commonly over 50s
- Rare
Sertoli-Leydig Tumours
- In 30s
- Rare, benign
- Secrete testosterone
Describe a granulosa cell tumour
- Often produce hormones and are called functioning tumours
- Secrete estrogen
- Can cause symptoms such as abnormal vaginal bleeding or breast tenderness
- Risk of endometrial hyperplasia from the excess estrogen
Describe ovarian fibroma
- Benign ovarian tumour
- Associated with Meig’s syndrome
- Rare
- Most commonly found in peri menopause
Describe sertoli-Leydig ovarian tumour
- Rare
- Benign
- Secrete testosterone so can show up with signs of virilisation
- Usually found in adolescence
How do you define chronic pelvic pain?
Intermittent or constant pain in lower abdomen/pelvis >6/12 duration and not occurring exclusively with menstruation, intercourse or pregnancy
What is the ROME III criteria for diagnosing IBS?
Recurrent abdominal pain / discomfort at least 3 days / month in the last 3/12, associated with >2 of:
- Improvement with defecation
- Onset associated with change in frequency of stool
- Onset associated with change in form / appearance of stool
What medical treatments are there for chronic pelvic pain?
Cyclical pain (give hormonal tx for 3-6/12 before considering diagnostic laparoscopy)
- Aim for ovarian suppression (COC, PO only, GnRH analogues)
- LNG-IUS
IBS
- Trial antispasmodic (mebeverine)
- Change diet
- TCA antidepressants
- Laxatives / anti diarrhoea agents
Other
- Analgesia
- NSAIDs
- Co-dydramol
- Neuropathic / gabapentin
- TENS / acupuncture
Describe the pathophysiology of Bartholin’s cyst / abscess
Bartholin’s cyst:
- Non-infectious occlusion of the distal Bartholin’s duct, with retention of secretions
Bartholin’s abscess:
- Polymicrobial non-gonorrhoeal infection of the cyst fluid, or primary infection of the gland or duct
What are the differentials of a bartholin’s?
- Mucous cyst
- Cyst of the canal of Nuck
- Epidermoid inclusion cyst
- Bartholin’s gland cancer (consider if >60mm firm, irregular mass)
What surgical managements are there for Bartholin’s?
- Marsupialisation
- Excision of the gland (may be required for recurrent cysts)
- Word catheter (creates a fistula / sinus tract to remain open)
What investigations can be done for pruritis vulvae?
Swabs
- Candida, BV, TV
Bloods
- FBC, Ferritin, TFTs, U&Es, HbA1c + blood glucose
Patch testing
Vulval biopsy
What are the signs of lichen sclerosus?
- Pale / atrophic / hypopigmented
- Purpura (echymosis) common
- Fissuring
- Erosions
- Kyperkeratosis
- Figure of eight distribution
- Loss of architecture - loss of labia minora +/- midline fusion, introital stenosis, clitoris buried
- Vagina unaffected
What histology findings would suggest lichen sclerosus?
- Epidermal atrophy
- Hyperkeratosis with sub-epidermal hyalinisation of collagen below dermo-epithelial junction
- Lichenoid infiltrate
What topical treatment is used for LS?
- Ultra-potent topical steroids (0.05% clobetasol proprionate [Dermovate])
- Daily for 4 weeks
- Alternate days for 4 weeks
- Twice weekly for 4 weeks
- Review at 3 months
- Emollients also
What alternatives are there for management of LS?
- Ultra-potent topical steroid with antibacterial and antifungal (clobetasol with neomycin and nystatin)
- Oral retinoids (dermatology only) for severe recalcitrant disease. Pregnancy should be avoided for 2 years after treatment with ascitretin
- Topical calcineuron inhibitors (tacrolimus 0.1%) - not licensed, contra-indicated in pregnancy and breastfeeding
- UVA1 phototherapy
What are the signs of lichen planus?
Classical
- Typical white pearly papules on keratinised anogenital skin +/- striae on inner aspect of vulva
- Hyperpigmentation on resolutation
Hypertrophic
- Thickened, warty plaques affecting perineum and perianal area (may be painful/ulcerated)
- Mimic malignancy, relatively rare
Erosive
- Mucosal surfaces eroded
- Wickham’s striae
What would be found on histology to diagnose lichen planus?
Irregular, saw-toothed acanthosis, increased granular layer and basal cell liquefaction
How is lichen planus managed?
Ultra-potent topical steroids (0.05% clobetasol proprionate [Dermovate])
- No evidence for optimum regime
- Maintenance with weaker steroid or less frequent use of potent steroid
- Safe in pregnancy and breastfeeding
Emollients
What are some alternative treatments for lichen planus?
- Ultra-potent topical steroid with antibacterial and antifungal (clobetasol with neomycin and nystatin)
- Systemic treatment (oral ciclosporin, retinoids, oral steroids, biologics)
Consider vulval MDT for erosive disease, recalcitrant cases, or if systemic therapy considered
What are the three types of vulval eczema?
- Atopic (seen in those with hay fever, asthma, and usually have eczema elsewhere)
- Allergic contact (delayed hypersensitivity)
- Irritant contact (i.e. irritating chemical, powder, cleaning agent)
What are the signs of vulval eczema?
- Erythema
- Lichenification and excoriation
- Fissuring
- Pallor or hyperpigmentation
How do you manage vulval eczema?
- Avoid precipitating factor
- Emollient
- Topical steroids: 1% hydrocortisone in milder cases, or betamethasone valerate 0.025% [ betnovate] or clobetasol proprionate 0.05% [dermovate] for limited periods if severe
What is lichen simplex?
- Localised plaque of chronic eczematous inflammation created by repeated rubbing / scratching of skin
- Can affect entire vulva and perianal area (localised, unilateral or bilateral, skin may appear leathery or lichenified)
- Pathology: hyperkeratosis and acanthosis
How do you manage lichen simplex?
- Avoid precipitating factor
- Emollient as soap substitute
- Topical corticosteroids - potent steroids for treating areas of lichenification
- Anxiolytic antihistamine (e.g. hydroxyzine at night)
- Education re. breaking the scratch-itch cycle
What are the signs of psoriasis?
- Poorly demarcated, highly erythematous, plaques
- Often asymmetrical
- Commonly affects natal cleft
- Usually lacks scaling
- Fissuring
- Involvement at other sites e.g. scalp, umbilicus, knees, elbows
- Can be worsened by urine, tight fitting clothes, or sex
How do you treat vulval psoriasis?
- Avoidance of precipitating factor
- Emollient as soap substitute
- Topical corticosteroids (weak to moderate) - 1% hydrocortisone to betamethasone valerate 0.025% +/- antifungal +/- antibiotic (trimovate)
- Weak coal tar preparations (alone or + steroids)
- Vitamin D analogues (talcalcitol)
Refer to vulval MDT if unresponsive or considering systemic treatment
Describe the types of FGM
- Type I: traditional circumcision with removal of prepuce with/without entire of clitoris
- Type II: clitoridectomy with removal of prepuce and clitoris together with partial or total excision of labia minora
- Type III: infibulation with removal of part or all of external genitalia and stitching/narrowing of vaginal opening, leaving a small aperture for passing urine and menstrual blood
- Type IV: unclassified
What does the Working Together to Safeguard Children 2015 say about FGM?
- Statutory obligation under national safeguarding protocols to protect girls and women at risk of FGM
- Mandatory reporting duty to report cases of FGM to the police where an under 18 either discloses or a professional observes physical signs of FGM
- When pregnant, NHS professionals should have identified that the woman has had FGM
- Consider the risks to other girls in the family and community
What actions should be taken if you observe an adult with capacity has had FGM?
- No requirement for automatic referral to social services or police
- Support the woman by offering to other services such as NHS FGM clinic
- Enquire about wider family context
- If other women/girls have not had FGM, ascertain if this was because of a change in attitude, a fear of prosecution, or a lack of opportunity
What laws are there around FGM?
- Female genital mutilation act 2003 (england, wales, NI)
- Prohibition of FGM act 2005 (Scotland)
- FGM is illegal
- Serious Crime Act 2015 strengthened the legislative framework around tackling FGM
- Regulated health and social care professionals and teachers in England and Wales must report known cases of FGM in under 18s to the police
- An offence to fail to protect a girl from the risk of FGM
- Extra-territorial jurisdiction over offences of FGM committed abroad by UK nationals and those resident in the UK
- Lifelong anonymity for victims of FGM
What information sharing processes are there for maternity services?
- All discharge information sent to GP and health visitors must include relevant FGM information or family history of FGM
- Reflect identified FGM in the red book
- Pre-natal assessment appt, every women should be asked if they have undergone FGM
How do GnRH analogues work for ovarian suppression?
- Hypothalamus produces GnRH
- GnRH stimulates the anterior pituitary gland
- Anterior pituitary produces LH/FSH
- LH/FSH stimulates follicles of the ovary, which release estrogen
- Estrogen then has a negative feedback effect on hypothalamus
Why might a patient get temporary worsening of symptoms when first commenced on GnRH analogues?
- Very potent causing a large initial release of LH and FSH
- Causes a flare of estrogen lasting a few days to a few weeks
What are the stages of endometriosis?
Stage 1: superficial lesions and filmy adhesions
Stage 2: deep lesions at cul-de-sac
Stage 3: as above + ovarian endometriomas
Stage 4: as above + extensive adhesions
What clinical features can be found on examination to diagnose/suspect endometriosis?
- Thickened pelvic ligaments, particularly the uterosacral ligaments (may be nodular)
- Blue nodules seen in posterior vaginal fornix
- Fixed, immobile, retroverted uterus
- Uterine or ovarian enlargement
- Tenderness in lateral and posterior fornices with applied pressure
- Cervical motion tenderness
Raised LDH is seen in which type of ovarian tumour?
Dysgerminomas
Raised bhCG is seen in which type of ovarian tumour?
Choriocarcinoma
Raised AFP is seen in which type of ovarian tumour?
Yolk sac (endodermal sinus) tumours
What is meigs syndrome?
Triad of symptoms
- Benign ovarian tumour (ovarian fibromas)
- Ascites
- Pleural effusion
Raised inhibin B is seen in which type of ovarian tumour?
Granulosa cell tumours
Raised estradiol is seen in which type of ovarian tumour?
Thecoma / theca cell / stromal cell tumours
Name some risk factors for ovarian cancer
- Nulliparity
- Early menarche
- Late menopause
- PCOS
- Endometriosis
- Smoking
How big an ovarian cyst in a post menopausal woman should you do a Ca 125 for?
Anything over >1cm
Women with endometriosis have an increased risk of what type of cancer?
Clear cell, low grade serous and endometrioid invasive ovarian cancer
What is the risk of malignant transformation in lichen sclerosis?
5%
What is the peak age for VIN?
Age 35 to 49
Which ligament does the ovarian artery/nerve/vein pass through?
Suspensory ligament
What is the corpus albicans?
- When the corpus luteum becomes fibrosed because of a lack of fertilisation
A woman over 50 has developed symptoms suggestive of IBS. What other investigations should you do?
- Ca 125
- US gynae pelvis
Is CT scan useful for initial investigation for postmenopausal ovarian mass?
- No - low specificity, limited assessment of ovarian internal morphology, and use of ionising radiation
- Order CT after TV USS + tumour markers suggesting malignant disease (referral to specialist) - usually if RMI >200
When would you use MRI scan for ovarian masses?
- Not routinely as primary imaging
- Second-line if ultrasound is non conclusive
A 60-year-old woman has an asymptomatic, simple, unilateral, unilocular ovarian cyst, less than 5 cm in diameter. Ca 125 normal. What is appropriate follow-up for her?
- Conservatively
- Repeat evaluation in 4–6 months
- Discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal CA125
What surgical options are there for a post menopausal cyst?
- If RMI <200, can have laparoscopy (bilateral BSO)
- If RMI >200, or histology showed malignancy at BSO, for full laparotomy and staging procedure
What is the incidence of the following cancers in England?
- Cervical cancer
- Ovarian cancer
- Endometrial cancer
- Vulval cancer
- Cervical 9/100,000 women
- Ovarian 22/100,000 women
- Endometrial 26/100,000 women
- Vulval 3.7/100,000 women
What inheritance pattern does BRCA 1 and BRCA 2 follow?
Autosomal dominant
Risk of female carrier developing breast cancer before age 70 is
- 60-80% in BRCA 1
- 45-85% in BRCA 2
