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MFSRH Part 2 (2023) > Pelvic and Vulval Pain > Flashcards

Pelvic and Vulval Pain Flashcards

1
Q

Define dysmenorrhoea

A

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
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2
Q

How can you assess the impact on QoL for someone with dysmenorrhoea?

A
  • Do they miss school/work with their symptoms at least once per cycle?
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3
Q

What are some risk factors for dysmenorrhoea?

A
  • Early menarche
  • Nulliparity
  • Family history
  • Longer duration of menstruation, heavier flow
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4
Q

What is the pathophysiology of dysmenorrhoea in a normal menstrual cycle?

A

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

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5
Q

Name some causes of secondary dysmenorrhoea

A

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

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6
Q

What medical therapies are there for primary dysmenorrhoea?

A
  • NSAIDs
  • COCP
  • Progestogen-only methods
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7
Q

What surgical therapies are there for primary dysmenorrhoea?

A
  • Uterosacral nerve ablation
  • Presacral neurectomy
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8
Q

What complementary therapies are available for primary dysmenorrhoea?

A
  • TENS machine
  • Vitamin B1 and Mg
  • Acupuncture
  • Local application of heat
  • Behavioural therapies
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9
Q

When does NICE recommend you should refer someone from primary care with suspected endometriosis?

A
  • Severe, persistent, recurrent symptoms suggestive of endometriosis
  • Pelvic signs of endometriosis
  • Initial management not effective, tolerated, or contra-indicated
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10
Q

What are medical therapies for endometriosis?

A
  • Analgesia (paracetamol, NSAIDs)
  • Neuromodulators / neuropathic pain mx
  • Hormonal treatment (LNG-IUS or CHC, can try progestogen-only based methods)
  • GnRH analogues + add-back HRT
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11
Q

What are surgical therapies for endometriosis?

A
  • Laparoscopic excision / ablation to endometriotic deposits / adhesiolysis
  • Laparoscopic ovarian cystectomy
  • Hysterectomy (trial of GnRH agonist + HRT prior to this)
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12
Q

What are some ultrasound features of adenomyosis?

A
  • 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
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13
Q

Name some benign ovarian masses

A
  • Functional cyst
  • Endometrioma
  • Haemorrhagic cyst
  • Serous cystadenoma
  • Mucinous cystadenoma
  • Mature teratoma
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14
Q

What’s the difference between serous and mucinous cystadenoma?

A
  • Serous are usually unilocular, mucinous are usually multilocular
  • Serous are more common
  • Mucinous require surgical removal due to malignant potential
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15
Q

Name some benign non-ovarian adnexal masses

A
  • Paratubal cyst
  • Hydrosalpinges
  • Tubo-ovarian abscess
  • Peritoneal pseudocyst
  • Appendiceal abscess
  • Diverticular abscess
  • Pelvic kidney
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16
Q

Name malignant ovarian masses

A
  • Germ cell tumour
  • Epithelial carcinoma
  • Sex-cord tumour
  • Metastases (usually breast or GI)
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17
Q

What is the risk of malignancy index (RMI)?

A

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

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18
Q

What are the IOTA rules for ovarian masses based on ultrasound?

A

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

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19
Q

What ultrasound features are there of a functional, follicular cyst?

A
  • Most common (persistence of unruptured graffian follicle)
  • Up to 10cm diameter
  • Thin walled, unilocular
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20
Q

What ultrasound features are there of a functional, corpus luteal cyst?

A
  • 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
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21
Q

What are ultrasound features of theca lutein cysts?

A
  • Associated with excessive amounts of hCG (i.e. multiple pregnancy, PCOS, DM, clomiphene, ovulation induction, GTD)
  • Multiple, bilateral, thin-wall cysts with clear contents
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22
Q

What are ultrasound features of endometriomas?

A
  • Size variable
  • Usually unilocular
  • Acoustic enhancement
  • Diffuse, homogenous, ground-glass echoes
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23
Q

Name some sex cord stromal tumours

A

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

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24
Q

Describe a granulosa cell tumour

A
  • 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
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25
Q

Describe ovarian fibroma

A
  • Benign ovarian tumour
  • Associated with Meig’s syndrome
  • Rare
  • Most commonly found in peri menopause
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26
Q

Describe sertoli-Leydig ovarian tumour

A
  • Rare
  • Benign
  • Secrete testosterone so can show up with signs of virilisation
  • Usually found in adolescence
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27
Q

How do you define chronic pelvic pain?

A

Intermittent or constant pain in lower abdomen/pelvis >6/12 duration and not occurring exclusively with menstruation, intercourse or pregnancy

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28
Q

What is the ROME III criteria for diagnosing IBS?

A

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

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29
Q

What medical treatments are there for chronic pelvic pain?

A

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

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30
Q

Describe the pathophysiology of Bartholin’s cyst / abscess

A

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

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31
Q

What are the differentials of a bartholin’s?

A
  • Mucous cyst
  • Cyst of the canal of Nuck
  • Epidermoid inclusion cyst
  • Bartholin’s gland cancer (consider if >60mm firm, irregular mass)
32
Q

What surgical managements are there for Bartholin’s?

A
  • Marsupialisation
  • Excision of the gland (may be required for recurrent cysts)
  • Word catheter (creates a fistula / sinus tract to remain open)
33
Q

What investigations can be done for pruritis vulvae?

A

Swabs
- Candida, BV, TV
Bloods
- FBC, Ferritin, TFTs, U&Es, HbA1c + blood glucose
Patch testing
Vulval biopsy

34
Q

What are the signs of lichen sclerosus?

A
  • 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
35
Q

What histology findings would suggest lichen sclerosus?

A
  • Epidermal atrophy
  • Hyperkeratosis with sub-epidermal hyalinisation of collagen below dermo-epithelial junction
  • Lichenoid infiltrate
36
Q

What topical treatment is used for LS?

A
  • 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
37
Q

What alternatives are there for management of LS?

A
  • 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
38
Q

What are the signs of lichen planus?

A

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

39
Q

What would be found on histology to diagnose lichen planus?

A

Irregular, saw-toothed acanthosis, increased granular layer and basal cell liquefaction

40
Q

How is lichen planus managed?

A

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

41
Q

What are some alternative treatments for lichen planus?

A
  • 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

42
Q

What are the three types of vulval eczema?

A
  • 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)
43
Q

What are the signs of vulval eczema?

A
  • Erythema
  • Lichenification and excoriation
  • Fissuring
  • Pallor or hyperpigmentation
44
Q

How do you manage vulval eczema?

A
  • 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
45
Q

What is lichen simplex?

A
  • 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
46
Q

How do you manage lichen simplex?

A
  • 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
47
Q

What are the signs of psoriasis?

A
  • 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
48
Q

How do you treat vulval psoriasis?

A
  • 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

49
Q

Describe the types of FGM

A
  • 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
50
Q

What does the Working Together to Safeguard Children 2015 say about FGM?

A
  • 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
51
Q

What actions should be taken if you observe an adult with capacity has had FGM?

A
  • 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
52
Q

What laws are there around FGM?

A
  • 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
53
Q

What information sharing processes are there for maternity services?

A
  • 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
54
Q

How do GnRH analogues work for ovarian suppression?

A
  • 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
55
Q

Why might a patient get temporary worsening of symptoms when first commenced on GnRH analogues?

A
  • Very potent causing a large initial release of LH and FSH
  • Causes a flare of estrogen lasting a few days to a few weeks
56
Q

What are the stages of endometriosis?

A

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

57
Q

What clinical features can be found on examination to diagnose/suspect endometriosis?

A
  • 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
58
Q

Raised LDH is seen in which type of ovarian tumour?

A

Dysgerminomas

59
Q

Raised bhCG is seen in which type of ovarian tumour?

A

Choriocarcinoma

60
Q

Raised AFP is seen in which type of ovarian tumour?

A

Yolk sac (endodermal sinus) tumours

61
Q

What is meigs syndrome?

A

Triad of symptoms
- Benign ovarian tumour (ovarian fibromas)
- Ascites
- Pleural effusion

62
Q

Raised inhibin B is seen in which type of ovarian tumour?

A

Granulosa cell tumours

63
Q

Raised estradiol is seen in which type of ovarian tumour?

A

Thecoma / theca cell / stromal cell tumours

64
Q

Name some risk factors for ovarian cancer

A
  • Nulliparity
  • Early menarche
  • Late menopause
  • PCOS
  • Endometriosis
  • Smoking
65
Q

How big an ovarian cyst in a post menopausal woman should you do a Ca 125 for?

A

Anything over >1cm

66
Q

Women with endometriosis have an increased risk of what type of cancer?

A

Clear cell, low grade serous and endometrioid invasive ovarian cancer

67
Q

What is the risk of malignant transformation in lichen sclerosis?

A

5%

68
Q

What is the peak age for VIN?

A

Age 35 to 49

69
Q

Which ligament does the ovarian artery/nerve/vein pass through?

A

Suspensory ligament

70
Q

What is the corpus albicans?

A
  • When the corpus luteum becomes fibrosed because of a lack of fertilisation
71
Q

A woman over 50 has developed symptoms suggestive of IBS. What other investigations should you do?

A
  • Ca 125
  • US gynae pelvis
72
Q

Is CT scan useful for initial investigation for postmenopausal ovarian mass?

A
  • 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
73
Q

When would you use MRI scan for ovarian masses?

A
  • Not routinely as primary imaging
  • Second-line if ultrasound is non conclusive
74
Q

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?

A
  • 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
75
Q

What surgical options are there for a post menopausal cyst?

A
  • If RMI <200, can have laparoscopy (bilateral BSO)
  • If RMI >200, or histology showed malignancy at BSO, for full laparotomy and staging procedure
76
Q

What is the incidence of the following cancers in England?
- Cervical cancer
- Ovarian cancer
- Endometrial cancer
- Vulval cancer

A
  • Cervical 9/100,000 women
  • Ovarian 22/100,000 women
  • Endometrial 26/100,000 women
  • Vulval 3.7/100,000 women
77
Q

What inheritance pattern does BRCA 1 and BRCA 2 follow?

A

Autosomal dominant
Risk of female carrier developing breast cancer before age 70 is
- 60-80% in BRCA 1
- 45-85% in BRCA 2

MFSRH Part 2 (2023) (22 decks)

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