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MSRA Content > Reproductive System - Level 2.2 > Flashcards

Reproductive System - Level 2.2 Flashcards

1
Q

Definition of breast fibroadenoma?

A
  • Benign overgrowth of collagenous mesenchyme of one breast lobule
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2
Q

Epidemiology of breast fibroadenoma?

A
  • Most common type of breast lesion in 20-30s

- Usually <30 but can occur up to menopause

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3
Q

Types of breast fibroadenoma?

A

o Common
o Giant - >5cm
o Juvenile – occurring in adolescent girls

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4
Q

Pathology of breast fibroadenoma?

A
  • Thought to be increased sensitivity to oestrogen and HRT increases incidence
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5
Q

Symptoms of breast fibroadenoma?

A 
-	Firm, smooth lump
o	Mobile
o	Painless
o	Well-defined, rubbery
-	May be multiple
-	1/3 regress, 1/3 stay same, 1/3 increase in size
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6
Q

Assessment of breast fibroadenoma?

A

Referral to specialist breast clinic – triple assessment
o Clinical examination
o US <40, mammography >40
o Needle biopsy (may or may not be required)

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7
Q

Management of breast fibroadenoma?

A

Observation and reassurance
o 25% get smaller or completely disappear

If large or woman over 40, surgical excision

If painful:
o Better-fitting bra during the day
o Soft support bra at night
o Oral PRN analgesia – paracetamol & ibuprofen

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8
Q

Types of breast cancer - malignant?

A

 Infiltrating/invasive ductal carcinoma (70/80%)
 Lobular Carcinoma (10%)
 Medullary
 Papillary

  • Spreads to liver, lung and bones
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9
Q

Types of breast cancer - benign?

A

 DCIS

 LCIS

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10
Q

Types of breast cancer - other?

A

Paget’s
• Paget cell tumour with eczema-like rash, straw/blood-coloured discharge and burning sensation

Phylloides tumour
• Fast-growing, leaf-like architecture from periductal stromal cells

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11
Q

Epidemiology of breast cancer?

A
  • Most common cancer in women
  • 15% of all new cancer cases in females
  • 1 in 8 women will develop breast cancer
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12
Q

Risk factors of breast cancer?

A 
o	Increased Age
o	Increased oestrogen exposure (late childbearing, nulliparity, early menarche, late menopause, obesity)
o	OCP and HRT
o	Obesity
o	Alcohol
o	Ionising Radiation
o	FHx
o	Genetics
	BRCA 1 &amp; 2
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13
Q

Symptoms of benign breast cancer?

A

o Peripheral (younger women), central (older)
o Small, soft lump
o Discharge – blood/fluid
o May be painful

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14
Q

Symptoms of malignant breast cancer?

A 
o	Painless, increasing mass, firm, fixed, irregular
o	Nipple Discharge
o	Skin Tethering
o	Ulceration
o	Oedema/Erythema
o	P’eau d’orange
o	Axilla/Supraclavicular lymphadenopathy
-	Metastatic Disease
o	Malaise, fatigue, weight loss
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15
Q

Screening programme of breast cancer?

A
  • Screening programme

o All women aged from 50 to 71st birthday invited every 3 years for mammogram

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16
Q

Assessment of breast cancer?

A 
-	Triple Assessment
o	Clinical assessment
o	Bilateral mammogram
o	Targeted USS and biopsy of area, axillae and sentinel nodes
	Core biopsy/FNA
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17
Q

Imaging of breast cancer?

A

o USS (if lump)
o CT Scan & Isotopic bone scan (if concerned about mets)
o PET CT (considering radical treatment)

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18
Q

Staging of breast cancer?

A

o TNM staging
o ER, PR, HER2 status on all invasive breast cancers
o BRCA 1 and 2 mutation testing if <50 with triple negative breast cancer

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19
Q

When to refer for 2 week appointment in suspected breast cancer?

A
  • 2-week referral
    o >30 with unexplained breast lump
    o >50 with discharge, retraction, other changes of concern
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20
Q

Management of breast cancer - early or locally advanced disease?

A 
	Neoadjuvant chemotherapy
	Neoadjuvant endocrine therapy
	Surgery ‘standard’
	Adjuvant Systemic Therapy
	Adjuvant Radiotherapy
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21
Q

Management of breast cancer - early or locally advanced disease - neoadjuvant chemotherapy?

A
  • If ER-negative invasive breast cancer
  • HER2-positive invasive breast cancer
  • Triple-negative invasive breast cancer
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22
Q

Management of breast cancer - early or locally advanced disease - neoadjuvant endocrine therapy?

A
  • Postmenopausal ER positive invasive breast cancer if no indication for chemotherapy
  • Pertuzumab + trastuzumab and chemotherapy if HER2-positive breast cancer
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23
Q

Management of breast cancer - early or locally advanced disease - surgery?

A

• For localised disease – mastectomy or wide local excision with post-op radiotherapy
o Selection depends on location, size, single or multifocal disease
• Assessment of axillary lymph nodes/clearance
• If no metastases, sentinel node biopsy
o Inject tracer and can be removed

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24
Q

Management of breast cancer - early or locally advanced disease - adjuvant systemic therapy?

A

Chemotherapy
o Reduces mortality when used adjuvant, best in women less than 55

Her 2 Targeted
o Trastuzamab in HER-2-positive and given for 12 months

Endocrine
o Tamoxifen given for 5 years when tumours ER/PR positive
 Increased risk of thrombosis and endometrial cancer, SE: mood changes, vaginal discharge and loss of libido
o Aromatase Inhibitors (Anastrazole)
 Offered in post-menopausal women ER-positive
 SE osteoporosis, mood changes, vaginal dryness, loss of libido

Bisphosphonates
o Postmenopausal women with node-positive invasive breast cancer

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25
Q

Management of breast cancer - early or locally advanced disease - adjuvant radiotherapy?

A
  • All patients to residual breast tissue, can have local chest wall radiotherapy
  • 40Gy Daily for 3 weeks (Mon-Fri)
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26
Q

Management of breast cancer - metastatic disease?

A

 If patients present with metastases or Stage 4 then surgery not an option and treatment palliative
 Neoadjuvant Endocrine
 Chemotherapy (docetaxel)
 Radiotherapy

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27
Q

Management of breast cancer - metastatic disease - neoadjuvant endocrine?

A

If ER/PR positive then can prolong duration for 1-2 years
o Tamoxifen and ovarian suppression given to premenopausal ER-positive
o Anastrazole – postmenopausal with ER-positive breast cancer

HER2 positive – give pertuzumab with trastuzumab and chemotherapy

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28
Q

Management of breast cancer - metastatic disease - chemotherapy?

A
  • Used in disease progression and triple-negative

* Used to palliate symptoms in metastatic disease

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29
Q

Management of breast cancer - metastatic disease - radiotherapy?

A

• Palliation of locally recurrent disease to control symptoms (bone pain from metastases)

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30
Q

Follow up in breast cancer?

A

o Annual mammography until eligible for screening programme (or if that age, annual mammography for 5 years)
o Primary care according to MDT review

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31
Q

Prognosis in breast cancer?

A 
-	Predict Index
o	Used to predict survival 
	Stage 1 95% 5-year survival
	Stage 4 25% 5-year survival
o	Takes into account age, tumour size, grade, ER/HER2 status, nodes
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32
Q

Definition of mastitis?

A
  • Mastitis is painful inflammation of mammary duct

- Usually occurs in lactating women but can occur in non-lactating women too

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33
Q

Classification of mastitis?

A

o Non-infectious – breast inflammation with no infectious cause
o Infectious – infection of breast tissue, occurs by retrograde spread through lactiferous duct or traumatised nipple

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34
Q

Definition of breast abscess?

A

Breast abscess = localised collection of pus within breast
o Lactational usually peripheral, most commonly in upper, outer quadrant
o Non-lactational tends to be localised in central or lower quadrants

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35
Q

Epidemiology of mastitis and abscess?

A
  • 10-30% of women develop lactational mastitis – within first 6 weeks post-partum usually
  • Breast abscesses develop in 3-11% of women with mastitis
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36
Q

Causes of mastitis - lactating women?

A

 Milk stasis – causes inflammatory response +/- infection – usually S.aureus

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37
Q

Causes of mastitis - non-lactating women?

A

 Central infection – secondary to periductal mastitis, age-related, duct ectasia
 Peripheral non-lactating infection – DM, RA, trauma, steroid treatment

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38
Q

Predisposing factors of mastitis?

A

o Poor infant attachment to breast – cleft lip, short frenulum (tongue-tie)
o Reduced number or duration of feeds – partial bottle feeding, painful, preferred breast, stress
o Nipple damage, smoking, trauma, immunosuppression

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39
Q

Symptoms of mastitis?

A

o Painful breast
o Fever
o Tender, swollen, red and hard area of breast, usually in wedge shaped distribution

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40
Q

Symptoms of breast abscesses?

A

o Hx of recent mastitis
o Fever and/or general malaise
o Painful, swollen lump in breast with redness, heat and swelling of overlying skin

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41
Q

Investigations in lactational mastitis?

A
  • Breast milk M, C & S in women with lactational mastitis if:
    o Severe or recurrent
    o Hospital-acquired infection
    o Severe, deep burning breast pain (ductal infection)
  • Collected by patient:
    o Clean nipple of affected breast, express small amount of milk by hand and discard – then express into sterile container, avoiding touching inside of container with nipple or hands
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42
Q

Management of mastitis in lactating women - admission?

A

 Signs of sepsis
 Infection progressing rapidly
 Haemodynamically unstable

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43
Q

Management of mastitis in lactating women - initial management?

A

• PRN paracetamol + ibuprofen
• Warm compress on breast, or bathe in warm water, to relieve pain and help with milk flow
• Continue breastfeeding if possible (if not then express milk until resume)
• Avoid wearing a bra, especially at night
• If symptoms not improved after 12-24 hours despite milk removal or breast culture positive, give antibiotics
o Oral flucloxacillin 500mg QDS for 10-14 days (erythromycin)
o Seek advice if Abx not settling symptoms

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44
Q

Management of mastitis in lactating women - advice to prevent recurrence?

A
  • Make sure infant attached correctly
  • Feed on demand, both for frequency and duration
  • Avoid missed feeds
  • Finish first breast before offering other
  • Hygiene measures – hand washing, rinse nipple before use
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45
Q

Management of mastitis in lactating women - if treatment failure or recurrent?

A

Treatment failure or recurrence (if not settled in 48 hours)
• Send sample of breast milk for M,C&S
• Co-amoxiclav 500/125mg TDS for 10-14 days

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46
Q

Management of mastitis in non-lactating women -initial management?

A
  • PRN paracetamol + ibuprofen
  • Warm compress on breast, or bathe in warm water, to relieve pain and help with pain
  • Co-amoxiclav 500/125mg TDS for 10-14 days (erythromycin plus metronidazole)
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47
Q

Management of mastitis in non-lactating women - preventing recurrence?

A
  • Stop smoking
  • Frequent hand washing
  • Removal of nipple rings
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48
Q

Management of breast abscesses?

A

o Refer urgently to general surgeon for:
 Dx by USS
 Drainage (by US guided needle aspiration or surgical drainage) with IV antibiotics
 Culture of fluid from abscess

o Encourage woman to continue to breast feed

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49
Q

Prognosis of mastitis?

A

o If treated properly – recovery prompt and complete

o Recurrence is common

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50
Q

Complications of mastitis?

A 
o	Breast abscess
o	Mammary duct fistula
o	Sepsis
o	Scarring
o	Necrotising Fasciitis
o	Emotional distress of stopping breast feeding
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51
Q

Epidemiology of ovarian cysts?

A
  • Ovarian cysts are extremely common and frequently physiological
  • 30% of women with regular menses
  • Mostly premenopausal
  • Due to follicular cyst (<3cm) and corpus luteal cyst (<5cm) formation during the menstrual cycle.
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52
Q

Classes of ovarian cysts - functional?

A

 Enlarged or persistent follicular or corpus luteum cysts

 Considered normal <5cm, usually resolve over 2-3 cycles

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53
Q

Classes of ovarian cysts - benign - epithelial neoplastic cysts?

A

 Epithelial neoplastic cysts (serous cystadenoma, mucinous cystadenoma)
• Serous Cystadenoma – papillary growths, common in women 40-50, 20% bilateral and 25% malignant
• Mucinous cystadenoma – large, filled with mucinous material, common in 20-40

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54
Q

Classes of ovarian cysts - benign - cystic tumours of germ cells?

A

Cystic tumours of germ cells

  • Benign cystic – rarely malignant
  • Benign mature teratoma – may contain well-differentiated tissue (hair/teeth)
  • 20% bilateral and most common in young women
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55
Q

Classes of ovarian cysts - benign - solid tumours?

A

Fibroma
o Associated with Meig’s syndrome
 Pleural effusion (right) + benign ovarian fibroma and ascites

Thecoma

Adenofibroma

Brenner’s tumour (display variant which may look malignant)

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56
Q

Risk factors of ovarian cysts?

A

o Obesity
o Infertility
o Early menarche
o Tamoxifen therapy.

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57
Q

Symptoms of ovarian cysts?

A 
o	Chronic pain
o	Dull ache
o	Pressure on other organs (urinary frequency or bowel disturbance)
o	Dyspareunia (endometrioma)
o	Cyclical pain (endometrioma)
o	Abnormal uterine bleeding
o	Hormonal effects – androgenic features
o	Mass in pelvis (adnexal)
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58
Q

Acute presentations of ovarian cysts?

A

o Rupture - contents into peritoneal cavity= intense pain. (esp with endometrioma or dermoid cyst)

o Haemorrhage - pain. Peritoneal cavity haemorrhage = severe hypovolemic shock.

o Torsion of pedicle - infarction and pain

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59
Q

Investigations of ovarian cysts?

A

Pregnancy Test

Bloods – FBC

Urinalysis

TV USS
o Pre-menopausal women - a cyst of <5cm: A re-scan at 6 weeks

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60
Q

Further investigations of ovarian cysts?

A

CT/MRI need if US not definitive

Diagnostic laparoscopy and FNA and cytology needed in some cases

Tumour Markers
o Ca125 – in women >40
o LDH, AFP and hCG – in women <40

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61
Q

Calculating risk of malignancy in ovarian cysts?

A
  • Identifying patients with a high risk of cancer who should be referred to a cancer centre for treatment.
  • RMI = USS x Menopausal status x CA125
  • RMI >200 – should have CT abdomen and pelvis
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62
Q

Management of ovarian cysts - admission?

A
  • Admit to hospital if acute, severe pain
  • If stable, urgent TVUS
  • If unstable, urgent laparoscopy
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63
Q

Management of ovarian cysts - premenopausal women?

A

Re-scan in 6 weeks.

If cyst <5cm and asymptomatic – no surgical intervention

If cyst >5 cm, symptomatic or features a dermoid/endometriosis – laparoscopic ovarian cystectomy
o Do not spill cyst contents (can cause peritonitis or can disseminate an early ovarian cancer)

Monitor with yearly USS

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64
Q

Management of ovarian cysts - postmenopausal women - low RMI, simple, <5cm cyst and normal Ca125?

A

o Follow up USS and CA125 every 4 months
o If no change after 1 year then discontinue monitoring
o If change and RMI still low or woman requests removal = laparoscopic oophorectomy.

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65
Q

Management of ovarian cysts - postmenopausal women - moderate RMI (25-250)?

A

o Oophorectomy (usually bilateral) is recommended

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66
Q

Management of ovarian cysts - postmenopausal women - high RMI (>250)?

A

o Refer to cancer centre for full staging laparotomy.

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67
Q

Definition of Asherman’s syndrome?

A

o Acquired uterine condition where adhesions form inside uterus

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68
Q

Risk factors of Asherman’s syndrome?

A

 D&C, myomectomy, C-section, infections, genital TB, obesity

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69
Q

Symptoms of Asherman’s syndrome?

A

 Menstrual problems – decreased in flow and duration (amenorrhoea or oligomenorrhoea)
 Infertility
 Pelvic pain – during menstrual and ovulation
 Placental problems

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70
Q

Investigations of Asherman’s syndrome?

A

 Hysteroscopy

 Hysterosalpingography

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71
Q

Management of Asherman’s syndrome?

A

 Hysteroscopy and adhesiolysis

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72
Q

Aetiology of vulvitis - infection?

A

o Candida, trichomoniasis, bacterial vaginosis
o Pubic lice, threadworm, scabies
o HSV, UTI, vulval vestibulitis
o In prepubertal girls – Group A B-haemolytic streptococcal

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73
Q

Aetiology of vulvitis - dermatological?

A

o Allergic dermatitis

o Psoriasis/Lichen planus/sclerosus

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74
Q

Aetiology of vulvitis - neoplasia?

A

o SCC

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75
Q

Aetiology of vulvitis - atrophic?

A

o Atrophic vaginitis

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76
Q

Symptoms of vulvitis?

A
  • Itch
  • Irritation
  • Soreness
  • Rawness
  • Burning
  • Dermatitis – intermittent itching when exposed to irritants
  • Discharge points to infection
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77
Q

Investigations in vulvitis?

A
  • Investigations
    o Bloods – FBC, serum ferritin, glucose
    o If infection considered – swabs or cultures
    o If STIs – swabs and/or blood tests
    o Skin biopsy if difficult to diagnosed (secondary care)
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78
Q

Management of vulvitis - general advice?

A

o Avoid contact to vulval skin with soap, bubble bath, shampoo, perfumes, wet wipes, detergents, dyes
o Wear loose cotton clothing
o Avoid spermicidal lubricants
o Abstain until symptoms resolve

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79
Q

Management of vulvitis - unknown cause?

A

o Emollients
o Oral antihistamines
o Low-potency topical corticosteroids (hydrocortisone 1% for 1-2 weeks)

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80
Q

Management of vulvitis - known cause?

A

o Topical steroids if inflammatory vulval disorders
o Infection – Abx, antifungal, antiviral
o Contact dermatitis – avoid irritants, topical corticosteroids
o Lichen simplex – topical betamethasone for 1-2 weeks
o Lichen sclerosus/planus – potent or superpotent topical corticosteroids
o Atrophic vaginitis – local vaginal oestrogens, non-hormonal lubricants

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81
Q

Management of vulvitis - referral?

A

o Unexplained lump, bleeding
o STI suspected and no screening capacity
o No response to treatment
o Contact allergy for patch testing

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82
Q

Epidemiology of endometriosis?

A

• Incidence of endometriosis:
- General population = 10-15%
- Dysmenorrhoea = 40 – 60%
• Most common gynaecological condition after fibroids.

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83
Q

Definition of endometriosis?

A
  • Endometriosis is the presence of endometrial like tissue outside the uterine cavity.
  • It is oestrogen dependent and therefore mostly affects women during their reproductive years.
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84
Q

Locations of endometriosis?

A 
-	Common = pelvis.
•	Pouch of douglas
•	Uterosacral ligaments
•	Ovarian fossae
•	Bladder
•	Peritoneum
-	Rare = lungs, brain, muscle, eye
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85
Q

Definition of adenomyosis?

A

Adenomyosis is invasion of myometrium by endometrial tissue, causes inflammation, pain and adhesions.

Cause of chronic pelvic pain, dyspareunia and infertility

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86
Q

Risk factors of endometriosis?

A

o Early menarche, late menopause, long menstrual flow
o Obstruction to vaginal outflow
o Genetics – risk when 1st degree relative is 6x more

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87
Q

Protective factors of endometriosis?

A

o Multiparity

o Use of OCP

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88
Q

Aetiology of endometriosis?

A

Retrograde menstruation with adhesion, invasion and growth of the tissue (most popular)
 During menstruation, endometrial tissue spills into the pelvic cavity through the fallopian tubes (retrograde menstruation) and then implants and becomes functional, responding to the hormones of the ovarian cycle.

Metaplasia of mesothelial cells

Systemic and lymphatic spread.
 Endometrial tissues transported through the body by lymph or venous channels.
 Explains the rare cases of distant sites for endometriosis

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89
Q

Sites of endometriosis?

A

o Peritoneum, pouch of Douglas (POD), ovary/tubes, ligaments, bladder and myometrium

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90
Q

Symptoms of endometriosis?

A

Severe dysmenorrhoea
 Cyclical - tends to occur prior to period and exacerbated by menstrual flow

Deep dyspareunia
 Affects QoL
 Involvement of uterosacral ligaments
 Heavier bleeding

Chronic Pelvic pain
 Cyclical (menstrual cycle) or continuous (adhesions/chronic inflammation)

Infertility
 Adhesions and tubal/ovarian damage can affect ovulation

Dysuria
 Involvement/invasion of bladder/bladder peritoneum

Dyschezia (pain on defecation) and cyclic pararectal bleeding
 Rectovaginal nodules with invasion of rectal mucosa

Chronic fatigue, bloating, low back pain

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91
Q

Signs of endometriosis?

A
  • Often normal
  • Speculum= visible lesions in vagina/cervix
  • Bimanual=fixed retroverted uterus (classic sign)
  • Adnexal masses (endometriomas – ‘chocolate cysts’ on ovaries) or tenderness.
  • Nodules/tenderness over uterosacral ligaments.
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92
Q

Investigations and diagnosis of endometriosis?

A

Transvaginal USS

  • Identifies endometriosis + deep into bowel//bladder & endometriomas
  • If not appropriate, can use transabdominal USS

Laparoscopy with biopsy (gold standard)
o Histological verification
 Positive is confirmative
 Endometriomas >3cm should be resected to rule out malignancy (rare)
o If normal – woman does not have endometriosis
o Avoid within 3 months of hormonal treatment (leads to underdiagnosis)
o Signs present – red dots, black ‘powder burn’ dots, large raised red/black vesicles, white area of scarring with surrounding abnormal blood vessels

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93
Q

Further investigations used in endometriosis?

A

• Pelvic MRI

- Used to assess extent of deep endometriosis involving bowel/urinary tract

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94
Q

Grading system of endometriosis?

A 
rASRM grading:
-	Location
-	Size
-	Depth
-	Adhesions
-	Stages
•	1 = Minimal endometriosis (1-5 points)
•	2 = Mild endometriosis (6-15 points)
•	3 = Moderate endometriosis (16-40 points)
•	4 = Severe endometriosis (>40 points)
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95
Q

Management of endometriosis - analgesia?

A

Analgesia
o Paracetamol/NSAIDs 1st line
 Naproxen
o If inadequate, consider other analgesia/referral

Neuropathic Pain
o Amitryptiline/gabapentin/pregabalin

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96
Q

Management of endometriosis -hormonal treatments?

A
  • COCP
    • Cyclically or continuous PO/IM/SC
    • Effect = ovarian suppression
    • SE = headaches, N&V, diarrhoea, stroke.
  • Medroxyprogesterone acetate or other progestagens
    • Effect = ovarian suppression
    • SE = weight gain, bloating, acne, irregular bleeding, depression
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97
Q

Management of endometriosis -specialist hormonal treatments?

A
  • GnRH analogues
  • Levonorgesterol releasing IUS
  • Danazol (anti-androgenic)
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98
Q

Management of endometriosis -surgical management?

A
  • Laparoscopic ablation/resection/cystectomy
    • Coagulation, excision or ablation
  • Hysterectomy
    • Last resort for severe endometriosis, not suitable if wanting to get pregnant
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99
Q

Management of endometriosis - fertility treatments?

A
  • Surgical ablation plus adhesiolysis

- In moderate to severe disease, IVF needed

100
Q

Monitoring of endometriosis?

A

o Follow-up for patients with deep endometriosis or 1 or more endometriomas

101
Q

Complications of endometriosis?

A 
o	Fibrosis/scarring
o	Infertility
o	Colonic/ureteric obstruction
o	Endometrial rupture
o	Malignant change
102
Q

Definition of uterine fibroids?

A

Benign tumours arising from the myometrium of the uterus (also called leiomyomata)

  • These tumours are composed primarily of smooth muscles and contain ECM with disordered collagen
  • Start as multiple, single-cell seedlings and increase slowly stimulated by oestrogen and progestogens
  • Centre may calcify as they grow due to inadequate blood supply
103
Q

Types of uterine fibroids?

A
  • Intramural = located within the myometrium.
  • Submucosal = >50% projection into the endometrial cavity.
  • Subserosal = >50% of the fibroid mass extends outside the uterine contours.
    o Can be uterine, cervical, intra-ligamentous, pedunculated
  • Endometrial polyps (adenoma)
    o These are focal overgrowth of the endometrium and are malignant in <1%.
104
Q

Risk factors of uterine fibroids?

A

o Obesity
o 3x more common in African-American women
o FHx of fibroids
o Early menarche

105
Q

Protective factors of uterine fibroids?

A

o Exercise
o Increased parity
o Smoking

106
Q

Symptoms of uterine fibroids?

A 
o	Asymptomatic
o	Dysmennorhoea
o	Menorrhagia
	Heavy and prolonged periods
	Anaemia
o	Pressure symptoms (esp. frequency)/Palpable mass
o	Pelvic pain
	Due to torsion of pedunculated fibroid, similar symptoms to torted ovarian cyst
o	Infertility
	Interfere with implantation
107
Q

Signs of uterine fibroids?

A

o Palpable abdominal mass arising from pelvis
o Enlarged, often irregular, firm, non-tender uterus on bimanual pelvic examination
o Signs of anaemia

108
Q

In pregnancy - symptoms of uterine fibroids?

A

o Red degeneration is when thrombosis of capsular vessels is followed by venous engorgement and inflammation causing abdominal pain, vomiting, fever
 Usually in last half of pregnancy or puerperium
 Treated expectantly (bed rest, analgesia) with resolution over 4-7 days
o If fibroid large enough, CS may be planned

109
Q

Investigations of uterine fibroids?

A

• Abdominal and bimanual pelvic examination
• Pregnancy Test
• Bloods – FBC, ferritin
• Pelvic USS
o Transvaginal or abdominal USS can differentiate the types and dimensions of the fibroids.
• MRI if USS not definitive and considering myomectomy
• Hysteroscopy with biopsies

110
Q

Management of uterine fibroids - if asymptomatic?

A

No treatment may be necessary if minimal symptoms – annual follow up

111
Q

Management of uterine fibroids - referral?

A
  • Compressive symptoms
  • Fertility or obstetric problems
  • Suspicion of malignancy
  • Fibroids palpable abdominally, or whose uterine length is >12cm
112
Q

Management of uterine fibroids - medical treatments?

A 
o	NSAIDs
o	Tranexamic acid to reduce menorrhagia
o	COCP if patient requires contraception
o	Mirena IUS
	Reduces menstrual loss and uterus size
113
Q

Management of uterine fibroids - prior to surgery?

A

3-6 months before surgery

o GnRH analogues (goserelin) OR Ullipristal Acetate

114
Q

Management of uterine fibroids - surgery indications?

A

 Excessively enlarged uterus
 Pressure symptoms
 Medical management not enough
 Fibroid is submucous and fertility reduced

115
Q

Management of uterine fibroids - surgical options?

A

 Myomectomy
• Used to maintain reproductive potential
• Can be done abdominal, laparoscopic or hysteroscopic

 Hysterectomy
• Women who have either completed their family or are over 45 years.
• Guaranteed cure of fibroids.

 Uterine artery embolization
• Uterine artery is catheterised generally using the unilateral approach
• Polyvinyl alcohol powder or gelatin sponge is used

116
Q

Definition of interstitial cystitis (bladder pain syndrome)?

A

 Persistent or recurrent pain in urinary bladder region, accompanied by at least one of:
• Pain worsening when bladder filling
• Daytime +/- urinary frequency
 No proven infection or pathology

117
Q

Aetiology of interstitial cystitis (bladder pain syndrome)?

A

 Epithelial dysfunction, subclinical infection, neurogenic inflammation, up-regulation of sensory nerves in bladder

118
Q

Symptoms of interstitial cystitis (bladder pain syndrome)?

A 
	Recurrent UTI symptoms (urgency, frequency, dysuria,
	Lower abdominal pain
•	Related to bladder increasing in size
•	Suprapubic, sometime radiating to groin/vagina/rectum/sacrum
•	Relieved by voiding
•	Aggrevated by food/drink
	Dyspareunia
	Pressure in bladder
119
Q

Investigations of interstitial cystitis (bladder pain syndrome)?

A

 Urinalysis
 MSU culture
 Bladder diary
 Cervical/urethral swabs
 Urodynamic studies – if overactive bladder suspected too
 Cystoscopy – if suspicion of malignancy
• Hunner’s ulcers (reddened mucosal areas associated with small vessels radiating towards central scar)

120
Q

Management of interstitial cystitis (bladder pain syndrome) - conservative?

A
  • Avoid caffeine, alcohol, acidic foods and drinks
  • Manage stress
  • Regular exercise
  • PRN analgesia
121
Q

Management of interstitial cystitis (bladder pain syndrome) - if fail to respond to conservative management?

A

• Drug Treatment – if conservative management failed
o 1st line – oral amitriptyline or cimetidine

• Intravesical treatments – if drug therapy fails
o Lidocaine, hyaluronic acid, botulinum toxin, dimethyl sulfoxide, herpain

• MDT - Further Options
o If Hunner lesions – cystoscopic fulguration and laser or transurethral resection

122
Q

Definition of Bartholin’s gland abscess?

A

 Ducts of Bartholin’s gland become blocked leading to an accumulation of fluid within the duct and cyst formation
 Abscess may develop
 E.coli most common

123
Q

Symptoms of Bartholin’s gland abscess?

A

 Bartholin’s cysts are painless swellings, recognised by their typical site at the lower third of the introitus
 An abscess is painful and red and may discharge puss

124
Q

Investigations of Bartholin’s gland abscess?

A

 Swab should be taken

 If >40, biopsy to rule out carcinoma

125
Q

Management of Bartholin’s gland abscess?

A

 Asymptomatic Bartholin’s cysts do not require treatment unless they interfere with intercourse
 Warm bath and symptomatic relief
 For abscess – incision and drainage needed
 For large cysts – Marsupialisation or catheter surgical treatment
 Small Bartholin’s abscess – culture and broad-spectrum antibiotics (co-amoxiclav)

126
Q

What is imperforate hymen? How is it treated?

A

o Primary amenorrhea with monthly lower abdominal pain and swelling
o Membrane bulging under pressure of dammed up menstrual blood (haematocolpos)
o Relieved by cruciate incision in membrane

127
Q

Definition of PID?

A
  • Infection of upper genital tract
  • Usually spread from cervix to the uterus (endometritis), Fallopian tubes (salpingitis), ovaries (oophoritis) or adjacent peritoneum (peritonitis)
  • Severity ranges from chronic low-grade infection to acute infection (severe symptoms and abscess formation)
128
Q

Epidemiology of PID?

A
  • Women between 15-20, who are sexually active most at risk
129
Q

Risk factors of PID?

A

o Age <25
o History of STIs
o New or multiple sexual partners

130
Q

Protective factors of PID?

A

o Barrier contraception
o Mirena IUS
o COCP

131
Q

Causes of PID?

A

o STIs (25% from chlamydia and gonorrhoea)
o Uterine instrumentation e.g. hysteroscopy, insertion of IUCD, TOP
o Post-partum – terminations or dilatation
o Descend from other infected organ (appendicitis)

132
Q

Organisms of PID?

A

o Chlamydia trachomatis commonest
o Neisseria gonorrhoea, Mycoplasma genitalium, Ureaplasma urealyticum
o BV
o Other organsims

133
Q

Symptoms of PID?

A

o Uni/Bilateral lower abdominal tenderness – constant or intermittent
o Vaginal discharge/bleeding – purulent/IMB/PCB/menorrhagia
o Deep dysparenuria
 Sudden onset, constant
o Fever >38 degrees
o Malaise, nausea
o Secondary dysmenorrhoea

134
Q

Signs of PID?

A

o Lower abdominal tenderness
o Cervical motion tenderness on bimanual
o Adnexal tenderness
o Fever >38

135
Q

Investigations of PID?

A
  • Pregnancy test
  • Vulvovaginal/endocervical/ HV swabs for chlamydia, gonorrhoea and trichomonas – M, C &S
  • Endocervical swabs for gonorrhoea culture
  • Urine dipstick + MSU
  • Bloods for HIV and syphilis
  • Bloods – FBC, ESR, CRP, cultures (if shocked)
  • Consider
    o TVS, laparoscopy
136
Q

Management of PID - initial management?

A

o IV fluids if shocked
o Urinalysis and send high vaginal swab and cervical swab (for chlamydia, gonorrhoea and M, C & S)
o Bloods – FBC, ESR, CRP, cultures (if sepsis/shocked)

137
Q

Management of PID - antibiotic therapy?

A

 IV Abx if symptoms severe (pyrexia >38, signs of tubo-ovarian abscess or pelvic periotinitis) – IV Ceftriazxone plus doxycycline
 Followed by – Oral doxycycline 100mg BDS plus oral metronidazole 400mg BDS for 14 days
 Follow-up 72h later

138
Q

Management of PID - when to admit urgently?

A

o Ectopic pregnancy cannot be ruled out
o Signs of pelvic peritonitis
o Tubo-ovarian abscess suspected
o Surgical abdomen cannot be ruled out

139
Q

Management of PID - outpatient management?

A

o Empirical Abx (Ceftriaxone 500mg IM stat + doxycycline 100mg PO BD and metronidazole 400mg PO BD for 14 days)
 OR PO oflaxacin 400mg BD + metronidazole 400mg BD for 14 days

140
Q

Management of PID - general advice?

A

o Analgesia – paracetamol/ibuprofen
o Removal of IUD if indicated
o No sex until they and partner have been treated
o Follow-up 72h later

141
Q

Management of PID - test of cure?

A

 Gonorrhoea – 2-4 weeks after
 Chlamydia – 3-5 weeks after if persisting symptoms or recurrent infection suspected
 Mycoplasma genitalium – 4 weeks after

142
Q

Management of PID - contact tracing?

A

o Contact anyone within 6 months
o Offer screening for chlamydia and gonorrhoea
o Give doxycycline 100mg BD for 7 days empirically
o Abstain from sex until both people completed course of treatment (use barrier protection)

143
Q

Complications of PID?

A
  • Fibrosis and adhesions
  • Ectopic Pregnancy – 5x risk
  • Tubal factor Infertility
  • Tubo-ovarian abscess
  • Fitz-Hugh-Curtis Syndrome (liver capsule inflammation with perihepatic adhesion)
144
Q

Definition of cervical ectropion?

A
  • Red ring around os because the endocervical epithelium has extended its territory
  • Extend temporarily under hormonal influence during puberty, with the COCP and during pregnancy
  • Prone to bleeding, excess mucous production and infection
145
Q

Treatment of cervical ectropion?

A

o None if asymptomatic, pregnant or pubertal
o If taking COCP, change to non-hormonal methods
o If woman wishes, cautery as outpatient

146
Q

Aetiology of trichomonas?

A
  • Trichomonas vaginalis – flagellate protozoan.

* Transmitted through sex and infects vagina, urethra and paraurethral glands

147
Q

Symptoms of trichomonas in women?

A

o Frothy green/yellow, offensive smelling discharge.
o Vulval itching and soreness.
o Dysuria
o Superficial dyspareunia.
o Cervix may have a ‘strawberry appearance’ from punctate haemorrhages

148
Q

Symptoms of trichomonas in men?

A

o Usually asymptomatic
o Non-gonococcal urethritis
o Dysuria, urethral discharge

149
Q

Complications in pregnancy of trichomonas?

A
  • Trichomonas is associated with pre-term delivery and low birth weight.
    It may be acquired perinatally, occurring in 5% of babies born to infected mothers
150
Q

Investigations of trichomonas?

A

• High vaginal swabs on wet mount microscopy
• Referral to GUM clinic
o Wet smear and culture (Diamond’s) – motile flagellates
o NAAT testing

151
Q

Management of trichomonas?

A

• Contact tracing
• Treat partners at same time
• Avoid sexual intercourse for >1 week following treatment & until partner treated
• Abx
o Metronidazole 2g orally in a single dose or Metronidazole 400mg twice daily for 5-7 days (latter in pregnancy)

152
Q

Causes of bacterial vaginosis?

A

o Overgrowth of mixed anaerobes, including Gardnerella and Mycolplasma hominis, which replace the usually dominant vaginal lactobacilli.
o pH <4.5 normally – in BV pH >4.5-6

153
Q

Risk factors of bacterial vaginosis?

A 
o	Sexual activity
o	New sexual partner
o	STIs
o	Ethnicity (women of Afro-Caribbean)
o	IUCD
o	Vaginal douching
o	Smoking
154
Q

Protective factors of bacterial vaginosis?

A

o COCP
o Condoms
o Circumcised partner

155
Q

Symptoms of bacterial vaginosis?

A
  • May be asymptomatic
  • Profuse, whitish grey, offensive smelling vaginal discharge.
  • Characteristic ‘fishy’ smell is due to the presence of amines released by bacterial proteolysis
156
Q

Pregnancy complications of bacterial vaginosis?

A

o Late miscarriage (mid-trimester).
o Preterm birth
o PPROM
o Post-partum endometritis

157
Q

When can an empirical diagnosis of bacterial vaginosis be made?

A 
o	Typical symptoms and signs
o	Not at increased risk of STI
o	Not pregnant, post-natal, TOP
o	No alternative signs
o	Raised pH
158
Q

Diagnosis in GP of bacterial vaginosis?

A

o Typical symptoms
o pH >4.5
o Low vaginal swab in transport medium

159
Q

Diagnosis in GUM clinic of bacterial vaginosis?

A

Amsel’s Criteria
 Homogenous discharge
 Microscopic detection of ‘clue cells’
• Squamous epithelial cells with bacteria adherent to their walls.
 Vaginal pH >4.5
 Characteristic fishy smell on adding 10% potassium hydroxide to the discharge.

Microscopy – Gram-stained smear using Ison/Hay criteria
 Grade 1-3

160
Q

Management of bacterial vaginosis - general advice?

A

o Avoid vaginal douching, shower gels, shampoo

o No treatment if asymptomatic, unless pregnant

161
Q

Management of bacterial vaginosis - treatments?

A

o Metronidazole 2g PO (single dose), gel PV OR
 Use metronidazole 400mg/12h PO for 5 days
 SE: Disulfiram-like reaction
o Clindamycin 2% cream vaginally at night for 7 days
o Can buy OTC medications

162
Q

Complications of BV?

A

o PID

o Risk of acquiring HIV and STIs

163
Q

Epidemiology of thrush?

A
  • About 70% of women will experience it at some point in their lives
  • Peak age 20-40 years
164
Q

Cause of thrush?

A
  • Caused by infection with a yeast-like fungus, the most common being Candida albicans.
  • It is not sexually transmitted
165
Q

Causative organism of thrush?

A

o Candida albicans (90%)

o Others: Candida glabrata, Candida tropicalis, Candida parapsilosis, Candida krusei

166
Q

Predisposing factors of thrush?

A
  • Antibiotics
  • Pregnancy
  • High dose COCP
  • Diabetes mellitus
  • Cushing’s disease
  • Anaemia
  • Immunocompromise
167
Q

Symptoms of thrush?

A

o Vulval itching and soreness.
o Thick, curd-like, white vaginal discharge.
 Non-offensive, foul smelling purulent discharge
o Dysuria
o Superficial dyspareunia

168
Q

Signs of thrush?

A
  • Vulval and vaginal erythema.
  • Vulval fissuring.
  • Satellite lesions
  • Typical white plaques adherent to the vaginal wal
169
Q

Investigations of thrush?

A

• MSU to exclude UTI
• Swabs not required
• In complicated/resistant/bacterial, swabs from anterior fornix/lateral vaginal wall for microscopy, culture and sensitivity in GUM clinic
o Spores and pseudohyphae on wet slides

170
Q

Management of thrush - general advice?

A
  • Soap substitute to clean vulval area
  • Emollient to moisturise
  • Wear loose-fitting underwear
  • Good hygiene
  • Wiping vulva from front to back
171
Q

Management of thrush - drug treatment?

A

• Chronic carriers, candidiasis should only be treated if symptomatic
• Topical/Oral azole therapy
o Clotrimazole 500mg pessary ± topical clotrimazole cream (if vulval symptoms) or
o Fluconazole 150mg PO (single dose) (contraindicated in pregnancy)
o Can be bought OTC so encourage self-treatment in uncomplicated patients
o 7-14 days if immunocompromised
• Return if symptoms not resolved in 7-14 days

172
Q

Management of thrush - severe infection?

A
  • Vaginal swabs for M, C &S
  • Two doses of fluconazole (150mg) three days apart
    o OR 500mg pessary clotrimazole two doses three days apart
173
Q

Management of thrush - Specialist advice?

A
  • <16 and treatment fails
174
Q

Management of thrush - recurrent candiasis?

A
  • 4 or more in one year with resolution in between episodes
  • Usually due to DM, immunosuppression, broad-spectrum Abx
  • May need induction or maintenance treatment
    o Prescribe as required/six-month regimen
175
Q

Definition of menopause?

A

o Permanent cessation of menstruation that results from loss of ovarian follicular activity (ovaries fail to develop follicles, so gonadotrophin hormones rise)
o Natural menopause is recognised to have occurred after 12 consecutive months of amenorrhoea for which no other obvious pathological or physiological cause is present.
o Time of waning fertility leading up to last period

176
Q

Definition of perimenopause?

A

o Period beginning with the first clinical, biological and endocrinological features of the approaching menopause, such as vasomotor symptoms and menstrual irregularity, and ends 12 months after the last menstrual period

177
Q

Definition of premenopause?

A

o Either the 1-2 years immediately before the menopause or the whole of the reproductive period before the menopause

178
Q

Definition of postmenopause?

A

o From the final menstrual period regardless of whether the menopause was induced or spontaneous

179
Q

Definition of early menopause?

Defintion of climaceric?

A

o Menopause <40, give COCP or HRT

o Phase encompassing the transition from the reproductive state to the non-reproductive state
o Menopause itself therefore is a specific event that occurs during the climacteric

180
Q

Cause of menopause?

A

o Natural process – oestrogen and progesterone levels fall and LH and FSH rise
o Can be induced by surgical removal of ovaries or ablation of ovarian function by chemotherapy, radiotherapy or GnRH analogues

181
Q

Symptoms of menopause - sexual dysfunction & menstrual cycle?

A
  • Changes in sexual behaviour and activity (female sexual dysfunction)
  • Vaginal dryness (due to  oestrogen) can cause dyspareunia.
  • Loss of sexual arousal/orgasm
  • UTIs
  • Stress incontinence

o Cycles become anovulatory, before stopping

182
Q

Symptoms of menopause - vasomotor symptoms?

A
  • Hot flushes (brief, nasty and may occur for >10 years)
  • Night sweats
  • Palpitations
  • Itchy
183
Q

Symptoms of menopause - psychological symptoms?

A
  • Poor sleep
  • Depressed mood/Psychosis
  • Anxiety
  • Irritability
  • Mood swings
  • Lethargy
  • Lack of energy
184
Q

Symptoms of menopause - other?

A
  • Skin/hair changes

- Muscle aches

185
Q

Long term complications of menopause?

A

• Osteoporosis

  • Increased risk of fracture (Colles’, hip, vertebrae)
  • Compromised bone strength

Cardiovascular disease

  • MI
  • Stroke

Urogenital atrophy

  • Frequency, urgency, nocturia, incontinence and recurrent infection.
  • Vaginal atrophy = dyspareunia, itching, burning, dryness.
186
Q

Diangosis of menopause?

A

o Tests not required in healthy women >45 with menopausal symptoms

187
Q

When is tests needed in menopause?

A

FSH in women using hormonal contraception
 2 levels 2 or 6 weeks apart
 Higher than usual due to loss of oestrogen and negative feedback

TFTs

Blood glucose, lipids

188
Q

Management of menopause - general measures?

A
  • Diet and exercise advice may help
  • Stop smoking
  • Limit alcohol
  • Use contraception until >1 year amenorrhoea if >50, 2 year amenorrhoea if <50
189
Q

Management of menopause - symptom control?

A
  • Menorrhagia responds to Mirena Coil
  • Vaginal Dryness responds to Oestrogen cream PV
  • Vasomotor symptoms – give fluoxetine/citalopram/clonidine
190
Q

Management of menopause - HRT in woman with uterus?

A
  • Women with uterus – combined HRT
  • Oestrogen and cyclical progestogen if still having periods, or within 12 months of period
  • Continuous combined HRT in post-menopausal women
191
Q

Management of menopause - HRT in women without uterus?

A

• Women without uterus – oestrogen-only HRT (unopposed oestrogens increases risk of endometrial cancer so only when hysterectomy)

192
Q

Definition of abnormal uterine bleeding?

A

 Any bleeding that is either:
• Abnormal in volume (excessive duration or heavy)
• Irregularity, timing (delayed or frequently)
• Non-menstrual bleeding – IMB, PCB, PMB

193
Q

Definition of amenorrhoea?

A

 Absence of menstruation

194
Q

Definition of primary amenorrhoea?

A

 Failure to start menstruating
 Suspect and assess when girls have not established menstruation by age of 13 (if no secondary sexual characteristics) or 15 (if normal secondary sexual characteristics)

195
Q

Causes of primary amenorrhoea?

A

Often due to late puberty (familial)

May be pregnant

Structural abnormalities of external/internal genitalia

HPO - Stress, emotions, exams, increased exercise, weight loss

Hyperprolactinaemia

Thyroid problems

Renal failure

Ovarian causes - PCOS, ovarian insufficiency/failure

Uterine - Pregnant, Asherman’s syndrome (uterine adhesions after D&C), post-pill amenorrhoea

Turner’s syndrome or androgen insensitivity syndrome

196
Q

Definition of secondary amenorrhoea?

A

 Previous normal menstruation but stops for 3-6 months or more, 6-12 months in women with irregular periods

197
Q

Causes of secondary amenorrhoea?

A

Physiological - Pregnancy, menopause, during lactation

HPO - Stress, emotions, exams, professional athletes, increased exercise, weight loss

Hyperprolactinaemia

Thyroid problems

Renal failure

Ovarian - PCOS, Ovarian insufficiency/failure (Secondary to chemotherapy, radiotherapy or surgery, Genetic disorders – Turner’s)

Uterine causes - Asherman’s syndrome (uterine adhesions after D&C), post-pill amenorrhoea

198
Q

Tests to perform in amenorrhoea?

A

BhCG to exclude pregnancy

Serum free androgen index (PCOS)

FSH/LH (low if HP axis cause)
• If FSH>20IU/L – premature menopause – karyotyping

Prolactin (Increased by stress, hypothyroidism, prolactinomas, metoclopramide)
• If >1000IU/L – MRI scan

TFTs

Testosterone levels
• >5nmol/L indicate androgen secreting tumour or late-onset CAH

199
Q

Management of amenorrhoea - refer?

A

 Refer to secondary care for specialist investigations

200
Q

Management of hypothalamic-pituitary-axis malformation - if mild?

A

o Medroxyprogesterone acetate (10mg/24h for 10 days) challenge will stimulate endometrium production and cause period
o Reassurance and diet advice, stress management
o Psychiatric help if depression indicated
o Still use contraception as ovulation may occur at any time
o Clomifene – restores period in mild cases

201
Q

Management of hypothalamic-pituitary-axis malformation - if axis shut down?

A

o Stimulation by gonadotrophin-releasing hormone

o Used in specialist fertility clinics only

202
Q

Definition of oligomenorrhoea?

A

o Menses occurring less frequently than every 35 days
o More common in extremes of reproductive life
o Common cause is PCOS

203
Q

Definition of menorrhagia?

A

o Excessive menstrual blood loss which interferes with QoL, social or emotional life
o Defined as >80ml/cycle but impossible to measure
o 30% of women report heavy periods

204
Q

Causes of menorrhagia?

A

Dysfunctional uterine bleeding (DUB) - no pathology, diagnosis of exclusion

Extreme reproductive life

IUCD

Local causes:
o	PID
o	Fibroids
o	Endometrial polyps
o	Endometriosis
o	Adenomyosis
o	Endometrial Cancer

Systemic Causes
o Hypothyroidism
o Liver or kidney disease
o Bleeding disorders

205
Q

Signs of menorrhagia?

A 
	Anaemia
	Abdomen exam
•	Masses
	Ensure smear up to date
	Inspect cervix and take swabs if needed
	If indicated bimanual examination
206
Q

Investigations in menorrhagia?

A

 Pregnancy test
 Bloods – FBC, TFTs, clotting (if indicated)
 Smear if due
 STI screen

207
Q

When to refer menorrhagia to secondary care?

A

o Persistent IMB
o Symptoms failed to improve on medical management
o Women >45 with heavy bleeding, endometrial pathology
o Abnormal examination
o Risk factors for endometrial cancer

208
Q

Management of menorrhagia - medical 1st line?

A

o Mirena IUS

209
Q

Management of menorrhagia - medical 2nd line?

A

o Tranexamic Acid

o NSAIDs (mefenamic acid) - Taken during days of bleeding

o COCP

210
Q

Management of menorrhagia - medical 3rd line?

A

Medroxyprogesterone acetate IM every 12 weeks

Norethiserone PO - Used short-term to stop heavy bleeding

GnRH rarely used, only in secondary care

211
Q

Management of menorrhagia - surgical management - when?

A

• Reserved for failed medical therapy

212
Q

Management of menorrhagia - surgical management - what?

A
  • Endometrial ablation
  • Uterine Artery Embolisation or Myomectomy
  • Hysterectomy
213
Q

Management of menorrhagia - surgical management - describe endometrial ablation?

A

o 1st line, if uterus is <10 weeks of gestation on palpation

o Removing the full thickness of endometrium with superficial myometrium and basal glands using diathermy/thermal balloon

o Performed with hysteroscopy

214
Q

Management of menorrhagia - surgical management - describe uterine artery embolisation?

A

o If uterus is >10 weeks in size or fibrois >3cm, retain ferility

215
Q

Management of menorrhagia - surgical management - describe hysterectomy?

A

o Women not wishing to retain fertility, who have fibroids >3cm
o Vaginal hysterectomy preferred, may need abdominal

216
Q

Definition of dysmenorrhoea?

A

o Low anterior pelvic pain, occurring with periods

o 50% women complain of moderate pain, 12% of severe

217
Q

Pathology of dysmenorrhoea?

A

 Imbalance of prostaglandins and leukotrienes in menstrual fluid which produces vasoconstriction and uterine contractions
 May be responsible for diarrhoea, nausea and headache

218
Q

Classes of dysmenorrhoea - primary?

A
  • Pain without organ pathology
  • Often starts with onset of ovulatory cycles
  • Pain begins with period and last 2-3 days
219
Q

Classes of dysmenorrhoea - secondary?

A 
o	Years after onset of menstruation
o	Precede start of period by several days and may last throughout period
o	Associated dysparenunia
o	Caused by:
	Endometriosis
	PID
	Fibroids
	Adhesions
	IUCD
220
Q

Symptoms of dysmenorrhoea?

A

 Crampy pain with ache in groin or back
 Worse in first few days (primary)
 Constant through period (secondary), deep dysparenunia

221
Q

Investigations of dysmenorrhoea?

A

 Abdominal/Vaginal exam
 Speculum and may need swabs/smear if due
 If mass – pelvic USS

222
Q

Management of dysmenorrhoea - general advice?

A
  • Stop smoking
  • TENS may help
  • Tea may help
  • Abdominal/back massage and lying down
223
Q

Management of dysmenorrhoea - drug therapy?

A 
•	NSAIDs (mefenamic acid) during menstruation
•	Paracetamol
•	If not wanting to conceive:
o	COCP
o	POP
o	Depot medroxyprogesterone acetate
o	Mirena IUS
224
Q

Management of dysmenorrhoea - surgery?

A

• If women completed family – hysterectomy in severe, refractory cases

225
Q

Definition of intermenstrual bleeding?

A

o Vaginal bleeding (other than postcoital) at any time during menstrual cycle other than normal menstruation

226
Q

Causes of intermenstrual bleeding?

A 
	Cervical polyps
	Ectropion
	Fibroids
	Carcinoma
	Cervicitis/Vaginitis
	IUCD
	Hormonal contraception
•	May get breakthrough bleeding when starting
	Chlamydia
	Pregnancy related
227
Q

Assessment of intermenstrual bleeding?

A

 Take menstrual, gynaecological, sexual history (obstetric if indicated)
 Abdominal and PV exam

228
Q

Investigations of intermenstrual bleeding?

A 
	Exclude pregnancy and STIs
•	Pregnancy test
•	Infection screen (chlamydia and gonorrhoea)
	Smear if overdue
	Bloods
•	FBC, clotting, TFT, FSH/LH
	TVUS if structural abnormality thought of
	Biopsy
229
Q

Referral of intermenstrual bleeding?

A

 Abnormal cervix (2 week wait)

 Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), >45 with IMB

230
Q

Management of intermenstrual bleeding - hormonal?

A

• Common in 1st 3 months after starting contraception
• May need speculum examination if >3 months
o Women >45 need biopsy
• COCP
o Stick with pill for 3 months, use pill with dose of ethinylestradiol to provide cycle control
o Different COCP may be tried
• POP
o Different POP tired
• PO implants/depot/IUS
o First line – COCP for up to 3 months continuously or in usual cycle regimen – repeat as often as needed

231
Q

Definition of postcoital bleeding?

A

o Non-menstrual bleeding through vagina immediately after sexual intercourse
o Around 5% women experience PCB

232
Q

Causes of postcoital bleeding?

A 
	Infection
	Cervical ectropion
	Cervical/Endometrial polyps
	Vaginal/Cervical cancer
	Sexual abuse
	Atrophic change
233
Q

Investigations of postcoital bleeding?

A 
	Exclude pregnancy and STIs
•	Pregnancy test
•	Infection screen (chlamydia and gonorrhoea)
	Smear if overdue
	Bloods
•	FBC, clotting, TFT, FSH/LH
	TVUS if structural abnormality thought of
	Biopsy
	Persistent PCB needs colposcopy
234
Q

Referral of postcoital bleeding?

A

 Abnormal cervix (2 week wait)

 Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), no cause of PCB

235
Q

Regimen of NHS cervical screening programmes?

A

o First invitation at age 25
o Routine recall three-yearly between 25-49, then 5-yearly until 65
 Women >65 only screened if not been screened since 50 or have had recent abnormal tests
o If HIV positive, annually

236
Q

Process of cervical smear test?

A

o Plastic speculum inserted vaginally to via squamocolumnar junction of cervix
 LBC – brush rotated against squamocolumnar junction
 Results available in 2 weeks

237
Q

Management of results of cervical smear - negative?

A

o Inform patient of result

o Recall as appropriate for screening rules

238
Q

Management of results of cervical smear -inadequate?

A

o Repeat sample immediately after treating infection (<3 months), as soon as convenient
o If three inadequate, advise assessment by colposcopy

239
Q

Management of results of cervical smear - borderline and mild dyskaryosis?

A

o High-risk HPV testing (HPV triage)
 Positive – referred for colposcopy within 6 weeks
 Negative – normal recall
 Inadequate – repeat smear/HPV in 6 months

240
Q

Management of results of cervical smear -moderate/severe dyskaryosis?

A

o Colposcopy within 2 weeks

241
Q

Management of CIN?

A
  • CIN1 – treatment or no treatment

* CIN2/3 – Excision to depth 8mm, LLETZ (large loop excision of transformation)

242
Q

Follow up for CIN1 untreated?

A

o Follow up 12 months with cytology and HPV testing
 If inadequate – Repeat 3 months
 If negative - normal recall
 If positive – colposcopy

243
Q

Follow up for treated CIN?

A

o Follow-up 6 months
 Test of cure with/without colposcopy
 Inadequate – repeat 3 months
 If HPV pos or both neg – repeat 12 months

o Repeated 12 months
 If inadequate – repeat 3 months
 If both neg – 3 year recall

244
Q

Test of cure for treated CIN?

A

o 6-month test of cure
 If inadequate – repeat 3 months
 If negative – follow up test then normal recall
 If positive – colposcopy

245
Q

HPV vaccine given when and what?

A 
o	Girls (and now boys for 2019-20 cohort) aged 12–13 years human papillomavirus (HPV) vaccine as part of the Childhood Immunization Programme.
o	Gardasil® quadrivalent vaccine (covering HPV types 16 and 18, and types 6 and 11 giving additional protection against genital warts) 
o	Two-dose schedule – given school Year 8 and then 6-24 months later

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