Reproductive and Benign Gynaecology Flashcards
What are ovarian cysts?
Fluid filled sacs
Can be functional based on fluctuating hormones in premenopausal, concerning for malignancy if in postmenopausal
What is the presentation of ovarian cysts?
Usually asymptomatic, found incidentally on USS Pelvic pain Bloating Fullness in the abdomen Palpable pelvic mass if very large cysts
When might ovarian cysts present with acute pain?
Ovarian torsion, haemorrhage, rupture of cyst
What are functional ovarian cysts?
Follicular cysts due to the developing follicle
Most common type of cyst that are harmless and disappear after a few cycles
What are corpus luteum cysts?
Occurs when the corpus luteum fails to break down and instead fills with fluid, may cause pelvic discomfort, pain or delayed menstruation. Common in early pregnancy.
What is a serous cystadenoma?
Tumours of the epithelial cells in the ovary
What are mucinous cystadenomas?
Tumours of the epithelial cells, can become very large and take up lots of space in the abdomen.
What are endometriomas?
Lumps of endometrial tissue within the ovary, occurs in patients with endometriosis, can cause pain, disrupt ovulation.
What are dermoid cysts?
Teratomas, benign ovarian tumours
Come from germ cells, so may contain different tissue types like skin, teeth hair and bone.
Associated with ovarian torsion.
What are sex cord stromal tumours?
Rare, either benign or malignant
Come from stroma or sex cords
What is important in the assessment of an ovarian cyst?
Examine for bloating, reduced appetite, early satiety
Weight loss
Urinary symptoms, pain, ascites, lymphadenopathy
Assess for risk factors of ovarian malignancy
Age, postmenopause, increased number of ovulations
Obesity, HRT, smoking, breastfeeding (protective) FH
What factors will reduce the number of ovulations?
Later onset of menarche
Early menopause
Any pregnancies
Use of the combined oral contraceptive pill
What investigations are needed for ovarian cysts?
If premenoapusal with simple ovarian cyst less than 5cm on USS, do not need further investigations.
CA125 tumour marker for ovarian cancer.
Other tumour markers if complex ovarian mass -
lactate dehydrogenase, alpha fetoprotein, human chorionic gonadotropin
What are causes of a raised CA125?
Not very specific, tumour marker for epithelial cell ovarian cancer
endometriosis fibroids adenomyosis pelvic infection liver disease pregnancy
What is the risk of malignancy index?
Estimates risk of an ovarian mass being malignant
Menopausal status
Ultrasound findings
CA125 level
What is the management of ovarian cysts?
Possible ovarian cancer; complex cysts or raised CA125 requires 2WW referral.
Dermoid cyst - further investigation, consider surgery.
Simple cysts in premenopausal women
Less than 5cm should resolve within 3 cycles, follow up if not
5cm to 7cm routine referral and yearly ultrasounds
More than 7cm consider MRI or surgical evaluation
Simple cysts in postmenopausal women and normal CA125 monitored with USS every 4-6 months.
Persisting or enlarging cysts need surgery; laparoscopy, ovarian cystectomy, possible oophrectomy.
What are the complications of ovarian cysts?
Present with acute onset of pain
Torsion
Haemorrhage into the cyst
Rupture with bleeding into the peritoneum
What is Meig’s syndrome?
A triad of
ovarian fibroma - a benign ovarian tumour
pleural effusion
ascites
Typically occurs in older women
removal of the tumour results in complete resolution of effusion and ascites
What is ovarian torsion?
Where the ovary twits in relation to surrounding connective tissue, fallopian tube and blood supply (the adnexa)
What are the causes of ovarian torsion?
Usually due to ovarian mass larger than 5cm such as a cyst or tumour, more likely with benign tumours.
Can happen in normal ovaries in younger girls before menarche when they have longer infundibulopelvic ligaments.
Twisting leads to ischaemia, if persists can lead to necrosis and function of ovary lost, is an emergency.
What is the presentation of ovarian torsion?
Sudden onset severe unilateral pelvic pain
Pain is constant, gets progressively worse,
Nausea and vomiting
Pain not always severe, can be milder and last longer and can twist intermittently causing pain that comes and goes.
Localised tenderness on palpation, palpable mass in pelvis, but absence does not exclude diagnosis.
How can ovarian torsion be diagnosed?
Pelvic ultrasound, TV ideal, can do TA
Whirlpool sign - free fluid in the pelvic, oedema if the ovary
Doppler may shock lack of blood flow
Definitive diagnosis made with laparoscopic surgery
What is the management of ovarian torsion?
Emergency admission
Laparoscopic surgery to untwist and fix in place, or remove affected ovary by oophrectomy.
What are the complications of ovarian torsion?
Loss of function of that ovary
If the only ovary can lead to infertility and menopause
Necrotic ovary not removed - infection, abscess, sepsis
May rupture, causing peritonitis and adhesions
What is Asherman’s syndrome?
Where adhesions form within the uterus
Usually after pregnancy related dilatation and curettage after RPOC
Can also occur after uterine surgery or pelvic infection
What is the presentation of asherman’s syndrome?
Secondary amenorrhoea
Significantly lighter periods
Dysmenorrhoea
May also present with infertility
How can asherman’s be diagnosed?
Hysteroscopy - and allows for dissection and treatment of adhesions
Hysterosalpingography - contrast and x-rays
Sonohysterography - uterus filled with fluid and ultrasound performed
MRI
What is the management for asherman’s?
Dissecting the adhesions during hysteroscopy
Recurrence common
What is cervical ectropion?
Occurs when the columnar epithelium of the endocervix extends to the ectocervix, is visible on speculum
More fragile, prone to bleeding - PCB
What is cervical ectropion associated with?
Higher levels of oestrogen
More common in younger women, COCP, pregnancy
What is the transformation zone of the cervix?
Border between the columnar epithelium of the endocervix and the stratified squamous of the ectocervix
What is the presentation of cervical ectropion?
Asymptomatic found on speculum examination.
Increased vaginal discharge
Vaginal bleeding, dyspareunia
Intercourse causes minor trauma and PCB
What is the management of cervical ectropion?
Typically resolves as patient gets older, stops pill or no longer pregnant.
Problematic bleeding may need treatment - cauterisation using silver nitrate or cold coagulation during colposcopy.
What are nabothian cysts?
Fluid filled cysts often seen on the surface of the cervix
Columnar epithelium of the endocervix produces cervical mucus, if squamous epithelium slightly covers it the mucus is trapped.
What can cause nabothian cysts?
Childbirth, minor trauma, cervicitis.
What is the presentation of nebothian cysts?
Raised, discoloured appearance on cervix
Usually asymptomatic, may cause feeling of fullness
Usually near to the os, whitish or yellow
What is uterine prolapse?
The uterus itself descends into the vagina
What is vault prolapse?
After a hysterectomy, the top of the vagina descends
What is a rectocele?
Defect in posterior vaginal wall, allows rectum to prolapse into the vagina
Causes constipation and faecal loading
Urinary retention due to compression on urethra
Palpable lump in vagina
Pressing on lump corrects anatomical position of rectum and allows bowels to open
What is a cystocele?
Defect in anterior wall of vagina
Bladder can prolapse backwards into vagina
What is a urethrocele?
Prolapse of the urethra into the vagina
What is a cystourethrocele?
Prolapse of both the bladder and the urethra
What are risk factors for pelvic organ prolapse?
Weak and stretched muscles and ligaments
Multiple vaginal delivers
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
What is the presentation of pelvic organ prolapse?
Feeling of something coming down
Dragging or heavy sensation in the pelvis
Urinary symptoms e.g. incontinence, urgency, frequency, weak stream and retention
Bowel symptoms e.g. constipation, incontinence, urgency
Sexual dysfunction e.g. pain, altered sensation, less enjoyment
May have lump they can push back themselves
Worse on straining or bearing down
How is a patient examined for pelvic organ prolapse?
Empty bladder and bowels, dorsal and left lateral position for examination
Sim’s speculum, to support anterior and posterior walls
Cough and bear down to assess descent
What are the grades of uterine prolapse?
Pelvic organ prolapse quantification POP-Q
Grade 0 normal
Grade 1 lowest part more than 1cm above introitus (opening of vagina)
Grade 2 within 1cm of introitus
Grade 3 lowest part more than 1cm below
Grade 4 full descent, eversion of the vagina
Prolapse beyond the introitus is uterine procidentia
What management is available for prolapse?
Conservative
Vaginal pessary
Surgery
What conservative management is available for prolapse?
Physiotherapy and pelvic floor exercises
Weight loss
Lifestyle changes e.g. for associated stress incontinence - less caffeine, incontinence pads
Treatment of related symptoms e.g. anticholinergics for incontinence
Vaginal oestrogen cream
What pessaries are available for prolapse?
Inserted into the vagina for extra support, but can be easily removed
Ring pessaries sit around the cervix, hold uterus up
Cube, donut, hodge/rectangular
Can cause vaginal irritation and erosion, oestrogen cream helps protect against this
What surgery is available for prolapse?
For bladder or urethral prolapse:
Colporrhaphy - plication, folding of fibromuscular layer of anterior vaginal wall
Colposuspension - sutures used
For uterine prolapse:
Hysterectomy
Sacrohysteropexy - uterus attached to anterior longitudinal ligament, requires mesh
Sacrospinous fixation - fixed to sacrospinous ligament
Same surgeries for vault prolapse
Obliterative surgery - moves the pelvic viscera back into the pelvis and closes the vaginal canal
What are the complications of pelvic organ prolapse surgery?
Pain, bleeding, infection, dvt, risk of anaesthetic
damage to bladder or bowel
recurrence of prolapse
altered experience of sex
What is the complications with mesh repairs?
NICE recommends should be avoided entirely Chronic pain Altered sensation Dyspareunia Abnormal bleeding Urinary or bowel problems
What are the functions of the pelvic floor?
Support of abdominopelvic viscera
Resistance to increases in intra-pelvic pressure during activities e.g. heavy lifting, coughing
Urinary and faecal continence
What muscles make up the pelvic floor?
Levator ani muscles - puborectalis, pubococcygeus and ileococcygeus
Coccygeus muscle
Fascia coverings of the muscles
What investigations are needed in prolapse?
Diagnosis based on history and examination
If urinary symptoms, consider urinalysis, urodynamics, renal ultrasound
If bowel symptoms anal manometry, defecography
What are the indications for surgical referral of prolapse?
Failure of conservative treatment Presence of voiding problems or obstructed defecation Recurrence of prolapse after surgery Ulceration Irreducible prolapse Preference of treatment
What is urge incontinence?
Overactivity of the detrusor muscle of the bladder
Sudden urge to pass urine, rush to bathroom
What is stress incontinence?
Weakness of pelvic floor and sphincter muscles
Urine leaks with increased pressure on the bladder e.g. coughing or laughing.
What is mixed incontinence?
Combination of urge and stress
What is overflow incontinence?
When there is chronic urinary retention due to obstruction to the outflow
Due to anticholinergics
Fibroids
Pelvic tumours
Neurological conditions e.g. MS, diabetic neuropathy, spinal cord injuries
What are the risk factors for urinary incontinence?
Increased age Postmenopause Increased BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions e.g. MS Cognitive impairment and dementia
What are the side affects and risks of vaginal pessaries for prolapse?
Can cause discharge, odour, vaginal erosions, fistulas and sepsis
What is the first line non-surgical management option for urogenital prolapse?
16 weeks of pelvic floor muscle exercises
AND/OR
vaginal pressary
What should be assessed with incontinence?
Medical history for type of incontinence symptoms
Modifiable lifestyle factors e.g. caffeine, alcohol, medication, BMI
Severity - frequency of urination and incontinence, nighttime urination, use of pads and changing clothes
Examination to assess pelvic tone - look for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic masses
What are voiding symptoms?
Voiding symptoms occur usually due to bladder outlet obstruction making it more difficult to pass urine, therefore symptoms being hesitancy, intermittency, straining, terminal dribbling and incomplete emptying.
What are storage symptoms?
Storage symptoms occur when the bladder should otherwise be storing urine, symptoms being urgency, frequency, nocturia, and urgency incontinence.
What is functional incontinence?
Can’t get to toilet in time due to mobility issues
How is urinary incontinence investigated?
Bladder diary for 3 days
Urine dip - infection, glucose, protein?
Speculum - prolapse? visualise if able to contract pelvic flood muscles
Quality of life questionnaire
Post micturition bladder scan - residual volume
Urodynamic tests
Patients stop taking anticholinergic and bladder related medicines 5 days before tests
Thin catheter inserted into bladder, another into rectum
Measures pressure in bladder and rectum to compare
What readings are taken in urodynamic studies?
Cystometry - detrusor muscle contraction and pressure
Uroflowmetry - flow rate
Leak point pressure - point at which pressure in the bladder results in leaking of urine, pt coughs, jumps.
Post void residual volume - incomplete emptying
Video urodynamic test - fill with contract, x-ray
How can urinary incontinence be temporarily managed?
Pads - done until diagnosis and full management plan in place
What lifestyle changes are suggested in the management of urge incontinence?
Reduce caffeine
Lose weight - if BMI >30
Drink 2L per day
What is the stepwise management plan for urge incontinence?
1 - Bladder training
2 - Medication
3 - Botulinin toxin A injections
4 - percutaneous sacral nerve stimulation
What is bladder retraining?
6 week plan where patients have scheduled voiding times with increasing time intervals
What medication can be used for urge incontinence?
Antimuscarinics - effect may take 4 weeks to be seen
- Oxybutynin - immediate release
- Tolterodine - immediate release
- Darifenacin
Mirabegron for elderly as oxybutynin contraindicated
What is the MOA, ADR’s and CI’s for antimuscarinics in urge incontinence?
MoA - Relax urinary smooth muscle
ADR - Constipation, dizzy, dry mouth and eyes, flushing, temperature
CI - severe UC and urinary retention, oxybutynin not for frail elderly
How long does botulinin toxin A for incontinence last?
What are the risks?
Benefits seen after 4 days. Last 6-9 months
Risks - urinary retention requiring catheter, UTI
Describe the use of percutaneous sacral nerve stimulation in urge incontinence
Done in 2 stages - test phase and then implantation if test successful
Percutaneous sacral nerve stimulation
What medication can be used if nocturnal symptoms of urge incontinence are particularly severe?
Desmopressin
What is the conservative management for stress incontinence?
Pelvic floor exercises
8 Contractions 3x a day for 3 months
What is the surgical management for stress incontinence?
Colposuspension
Autologus rectal fascial sling
Retropubic mid-urethral mesh sling - NICE recommend offering the other 2 first as some concerns over mesh slings
What are the risks of surgical management of stress incontinence?
Damage to bladder and bowel
Damage to nerves
Urge incontinence
Pelvic pain
Dyspareunia
What are the specific risks of using a mesh sling for stress incontinence?
Vaginal mesh exposure can lead to pain
Discharge and bleeding
Mesh may come through bladder or urethra –> urinary symptoms
Women should be warned it is not reversible - the mesh may never be able to be completely removed
What management options are available for stress incontinence if the women doesn’t want surgery?
Intramural bulking agents
Duloxetine
What are the risks of intramural bulking agents?
Urinary retention
Urge incontinence
UTI
What are the ADR’s associated with duloxetine?
GI disturbance
Dry mouth
Headache
Decreased libido
Anorgasmia
What is the first line management for mixed incontinence?
Either bladder retraining therapy or pelvic floor muscle exercises
a bladder diary shows
a) reduced volume that is always the same
b) reduced volume that differs each time
What is the likely diagnosis?
a) bladder wall pathology eg carcinoma
b) overactive bladder i.e. detrusor overactivity
Describe the appearance of a flow rate graph (x axis is time and y axis is rate) for
a) stress
b) obstruction
a) very quick rise and then fall in flow rate as little resistance so get superflow
b) reduced flow rate and urinates over a longer period of time i.e. takes longer to empty bladder as reduced flow rate
What is atrophic vaginitis?
Dryness and atrophy of the vagina mucosa due to lack of oestrogen
Genitourinary syndrome of menopause
Oestrogen levels fall, mucosa becomes thinner, less elastic and more dry, prone to inflammation.
What is the presentation of atrophic vaginitis?
Itching
Dryness
Dyspareunia
Bleeding due to localised inflammation
Consider in those with recurrent UTIs, stress incontinence and pelvic organ prolapse.
What is seen on examination in atrophic vaginitis?
Examination of labia and vagina Pale mucosa, thin skin, reduced skin folds Erythema, inflammation Dryness Sparse pubic hair
What is the management of atrophic vaginitis?
Sylk, replens and yes vaginal lubricants.
Topical oestrogen e.g. cream, pessaries, tablets e.g. Vagifem, ring replaced every three months.
Contraindications include breast cancer, angina, VTE.
Where are the bartholin’s glands located?
Deep to posterior aspect of labia majora
Also called greater vestibular glands
What is the function of the bartholin’s glands?
Secrete mucus to lubricate vagina
What is the pathophysiology of a bartholin’s cyst?
Build up of mucus secretions can cause duct of gland to become blocked - cyst develop
Cyst can become infected and if untreated develop into abscess
What organisms can infect a bartholin’s cyst?
Usually aerobic
E.Coli, MRSA and STI’s most common
Who gets bartholin’s cysts?
Nulliparous women of reproductive age
How do bartholin’s cysts present?
Often asymptomatic
Vulval pain on sitting or walking
Superficial dyspareunia
Soft fluctuant and non tender mass
How do bartholin’s abscesses present?
Acute onset of pain
Difficulty passing urine
Hard mass and surrounding cellulitis
How are bartholin’s cysts diagnosed?
Clinical diagnosis
If >40yo a biopsy should be done - exclude vulval malignancy
If signs of STI - swab
How are bartholin’s cysts managed?
Warm bath - aid spontaneous rupture in small asymptomatic cysts
NO SIMPLE INCISION AND DRAINAGE - reaccumulate
Either word catheter or marsupialisation
Describe the use of word catheters for bartholin’s cysts
Small rubber tube with balloon at end
Local anaesthetic to numb area
Incision made, pus drained from abscess
Word catheter inserted into space, inflated to 3ml with saline
Fluid can drain round the catheter preventing cyst or abscess from recurring
Risks - recurrence, dyspareunia, scarring
Describe how marsupialisation is used for bartholin’s cysts
Incision into cyst allow drainage. Cyst wall everted and sutured to vaginal mucosa
General anaesthesia
Risks - hameatoma, dyspareunia
What is lichen sclerosus?
Chronic inflammatory skin disease which has the potential to progress to squamous cell carcinoma
Presents with patches of shiny white skin
Commonly affects the labia, perineum and perianal skin
Associated with type 1 diabetes, alopecia, hypothyroid and vitiligo.
What is the presentation of lichen sclerosus?
Typically 45-60 complaining of vulval itching and skin changes in the vulva, may be asymptomatic Itching Soreness and pain, worse at night Skin tightness Painful sex Erosions and fissures
Koebner phenomenon - worse with friction e.g. underwear.
What is the appearance of lichen sclerosus?
Porcelain white in colour Shiny, tight, thin Slightly raised May be papules or plaques Associated fissures, cracks, erosions, haemorrhages under the skin
What is the epidemiology of lichen sclerosis?
Bimodal incidence - prepubescent girls and post-menopausal women
What is the pathophysiology of lichen sclerosis?
Atrophy of the epidermis - thin stratified squamous epithelium
Band-like infiltrate of chronic inflammatory cells beneath epithelial layer
How would you investigate lichen sclerosis?
Biopsy
Only needed if suspicious of vulval cancer or not responding to treatment
What are the main differentials for lichen sclerosis?
Vitiligo
Vulval cancer
Candida
How would you manage lichen sclerosis?
Topical steroids and emollients- clobetasol propionate
Initially used once a day for four weeks, then reduced in frequency every four weeks to alternate days, then twice weekly.
Why is follow up important for lichen sclerosis?
Risk of developing squamous cell carcinoma (2-5% lifetime risk)
What are the complications of lichen sclerosus?
Risk of squamous cell carcinoma of the vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings
What acute conditions can lead to pelvic pain?
Dysmenorrhoea
Mittelschmerz
Ectopic pregnancy UTI Appendicitis PID Ovarian torsion Miscarriage
What chronic conditions can lead to pelvic pain?
Endometriosis
IBS
Ovarian cyst
Urogenital prolapse
Adhesions
Psychological issues
What investigations would you request for pelvic pain?
Pregnancy test
MSU
High vaginal swabs
USS
Laparoscopy
How is cyclical pain managed?
Trial of COCP or GnRH agonist for period of 3-6 months
Diagnostic laparoscopy
Pain management team
What are the causes of post-coital bleeding?
50% - no cause
33% - cervical ectropion (more common if COCP)
Cervicitis, cervical cancer, polyps, trauma
What are some causes of inter-menstrual bleeding?
Physiological - spotting can happen around ovulation
Pregnancy related - ectopic
Cervicitis due to infection Cervical ectropion Polyps - cervical or endometrial Uterine fibroids/cancer Missed OCP
How would you investigate abnormal vaginal bleeding?
Speculum examination
Cervical smear and HPV
Pregnancy test High vaginal swabs TV USS Cervical biopsy Colposcopy
How is post menopausal bleeding defined?
Vaginal bleeding after 12 months of amenorrhoea in women of menopausal age or in younger women with early menopause or primary ovarian failure
What must you do in primary care if a patient comes in with postmenopausal bleeding?
Confirm bleeding is vaginal
Risk factors - endometrial cancer
Full menstrual history
Gynae and abdo exam
FBC, urine dip (haematuria), CA-125
If worrying - 2 week wait referral
What are the common causes of postmenopausal bleeding?
Use of HRT
Vaginal atrophy
They don’t exclude cancer so need investigating
What happens in secondary care if a woman is referred via 2 week wait for postmenopausal bleeding?
Transvaginal USS - endometrial thickness >5mm = higher chance of cancer
Endometrial biopsy - during hysteroscopy or by pipelle biopsy
What are some other causes of postmenopausal bleeding?
Simple endometrial hyperplasia
Endometrial cancer
Bleeding disorders
Trauma
Polyps
Cervical, ovarian or vaginal cancer
What differentials may you consider if a woman presents with a labial or vulval mass?
Bartholin’s cyst/abscess
Vulval cancer - 90% = squamous cell carcinoma
Other cysts - sebaceous, scene’s duct, mucous
Bartholin gland carcinoma - rare
Bartholin’s benign tumour - adenoma and nodular hyperplasia (rare)
Other solid masses - fibroma, lipoma, leiomyoma
What is the initial imaging modality for ovarian masses?
Ultrasound
What can an ultrasound of an ovarian mass tell you about it?
Whether cyst is
Simple - unilocular, more likely to be physiological or benign
Complex - multilocular - more likely to be malignant
How are premenopausal women with an ovarian mass managed?
If cyst small (<5cm) and reported as simple, likely to be benign
- Repeat USS 8-12 weeks if problem persist
If cyst complex
- ca-125, alpha feta protein, b-HCG
- DO NOT ASPIRATE
How are postmenopausal women with an ovarian mass managed?
Physiological cysts unlikely
Refer to gynaecology for assessment regardless of nature or size
What is FGM?
Surgically changing the genitals of a female for non-medical reasons, a cultural practice before puberty
Safeguarding issue and form of child abuse
What is the Female Genital Mutilation Act 2003?
It is illegal, there is a legal requirement for healthcare professionals to report cases of FGM to the police.
What are the types of FGM?
1 - removal of all or part of the clitoris
2 - removal of part or all of the clitoris, and labia minora, the labia majora may also be removed
3 - narrowing or closing the vaginal orifice (infibulation)
4 - all other unnecessary procedures to the female genitalia
When must the risk of FGM be considered?
Coming from a community which practices FGM
Having relatives affected by FGM
Pregnant women with FGM with a possible female child
Siblings or daughters of women or girls affected
Extended trips with infants or children where FGM is done
Women that decline examination or cervical screening
New patients from communities which practise FGM
What are the immediate complications of FGM?
Pain, bleeding, infection
Swelling, urinary retention, urethral damage, incontinence
What are the long term complications of FGM?
Vaginal infections e.g. bacterial vaginosis
Pelvic infections
UTIs
Dysmenorrhoea
Sexual dysfunction, dyspareunia
Infertility, pregnancy related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening
What is the management of FGM?
Educate patients and relatives it is illegal
Mandatory to report all cases in patients under 18 to police
Over 18 - risk assessment to consider whether there are any other female relatives at risk, unborn child may be at risk then make a referral.
De-infibulation procedure can be performed for type 3, to correct narrowing or closure, improve symptoms, try to restore normal function. Illegal to perform re-infibulation procedure following childbirth.
What are common causes of pelvic pain?
PID UTI Miscarriage Ectopic pregnancy Torsion or rupture of ovarian cysts
What are pregnancy related causes of pelvic pain?
Miscarriage, ectopic, premature labour, placental abruption, uterine rupture
What are gynaecological causes of pelvic pain?
Ovulation, dysmenorrhoea, PID, rupture or torsion of ovarian cyst, degenerative changes in a fibroid, pelvic tumour, pelvin vein thrombosis
What is the definition of chronic pelvic pain?
Intermittent or constant pain in the lower abdomen or pelvis in women
Lasting for at least 6 months
Not occurring exclusively with menstruation or sexual intercourse
Not being associated with pregnancy
What are possible causes of chronic pelvic pain?
Endometriosis Adhesions IBS Interstitial cystitis MSK problems Pelvic organ prolapse Nerve entrapment
What are red flag symptoms or signs in chronic pelvic pain?
Bleeding PR New bowel symptoms New pain after menopause Pelvic mass Suicidal ideation Excessive weight loss Irregular vaginal bleeding PCB
What are the investigations for chronic pelvic pain?
Screen for STIs FBC, CRP CA125 if appropriate Urinalysis, send MSU TV USS, MRI ?adenomyosis Diagnostic laparoscopy gold standard if needed
What is the management of chronic pelvic pain?
If a non-gynae component - referral to relevant specialist
Cyclical pain - offered COCP or GnRH agonist for 3-6 months before having a diagnostic laparoscopy.
Women with IBS should be offered a trial with antispasmodics, and be encouraged to amend their diet to attempt to control their symptoms.
What structure do congenital structural abnormalities in the reproductive organs relate to in the fetus?
Mullerian ducts
What is a bicornuate uterus?
Two horns, diagnosed on pelvic ultrasound scan
Associated with adverse pregnancy outcomes
Complications include miscarriage, premature birth, malpresentation
What is an imperforate hymen?
Hymen at entrance of vagina is fully formed, without an opening.
Menses sealed in vagina, cyclical pain and cramps.
If not treated can lead to retrograde menstruation and endometriosis
What is a transverse vaginal septae?
Septum forms transversely across the vagina, either perforate or imperforate and completely sealed.
Diagnosis by examination, ultrasound, MRI. Treatment with surgical correction.
Complications are stenosis and recurrence.
What is vaginal hypoplasia and agenesis?
Abnormally small vagina.
Agenesis is an absent vagina.
Occur due to failure of the mullerian ducts and may be associated with an absent uterus and cervix.
What is androgen insensitivity syndrome?
Cells are unable to respond to androgen hormones due to lack of androgen receptors.
Extra androgens converted into oestrogen, resulting in female secondary characteristics.
Genetically male have XY, but absent response to testosterone so converted to oestrogen.
Do not have female reproductive organs, because anti-mullerian hormone has prevented their development.
Testes are in the abdomen.
What is the presentation of androgen insensitivity syndrome?
Inguinal hernias in infancy
Primary amenorrhoea
Raised LH, normal or raised FSH, normal or raised testosterone and oestrogen
What is the management of androgen insensitivity syndrome?
Bilateral orchidectomy - removal of testes to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery as usually raised as female
