Reproductive System - Level 2.2 Flashcards
1
Q
Definition of breast fibroadenoma?
A
- Benign overgrowth of collagenous mesenchyme of one breast lobule
2
Q
Epidemiology of breast fibroadenoma?
A
- Most common type of breast lesion in 20-30s
- Usually <30 but can occur up to menopause
3
Q
Types of breast fibroadenoma?
A
o Common
o Giant - >5cm
o Juvenile – occurring in adolescent girls
4
Q
Pathology of breast fibroadenoma?
A
- Thought to be increased sensitivity to oestrogen and HRT increases incidence
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
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)
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
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
9
Q
Types of breast cancer - benign?
A
DCIS
LCIS
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
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
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 & 2
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
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
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
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
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)
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
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
20
Q
Management of breast cancer - early or locally advanced disease?
A
Neoadjuvant chemotherapy Neoadjuvant endocrine therapy Surgery ‘standard’ Adjuvant Systemic Therapy Adjuvant Radiotherapy
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
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
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
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
25
Management of breast cancer - early or locally advanced disease - adjuvant radiotherapy?
* All patients to residual breast tissue, can have local chest wall radiotherapy
* 40Gy Daily for 3 weeks (Mon-Fri)
26
Management of breast cancer - metastatic disease?
If patients present with metastases or Stage 4 then surgery not an option and treatment palliative
Neoadjuvant Endocrine
Chemotherapy (docetaxel)
Radiotherapy
27
Management of breast cancer - metastatic disease - neoadjuvant endocrine?
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
28
Management of breast cancer - metastatic disease - chemotherapy?
* Used in disease progression and triple-negative
| * Used to palliate symptoms in metastatic disease
29
Management of breast cancer - metastatic disease - radiotherapy?
• Palliation of locally recurrent disease to control symptoms (bone pain from metastases)
30
Follow up in breast cancer?
o Annual mammography until eligible for screening programme (or if that age, annual mammography for 5 years)
o Primary care according to MDT review
31
Prognosis in breast cancer?
```
- 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
```
32
Definition of mastitis?
- Mastitis is painful inflammation of mammary duct
| - Usually occurs in lactating women but can occur in non-lactating women too
33
Classification of mastitis?
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
34
Definition of breast abscess?
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
35
Epidemiology of mastitis and abscess?
- 10-30% of women develop lactational mastitis – within first 6 weeks post-partum usually
- Breast abscesses develop in 3-11% of women with mastitis
36
Causes of mastitis - lactating women?
Milk stasis – causes inflammatory response +/- infection – usually S.aureus
37
Causes of mastitis - non-lactating women?
Central infection – secondary to periductal mastitis, age-related, duct ectasia
Peripheral non-lactating infection – DM, RA, trauma, steroid treatment
38
Predisposing factors of mastitis?
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
39
Symptoms of mastitis?
o Painful breast
o Fever
o Tender, swollen, red and hard area of breast, usually in wedge shaped distribution
40
Symptoms of breast abscesses?
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
41
Investigations in lactational mastitis?
- 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
42
Management of mastitis in lactating women - admission?
Signs of sepsis
Infection progressing rapidly
Haemodynamically unstable
43
Management of mastitis in lactating women - initial management?
• 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
44
Management of mastitis in lactating women - advice to prevent recurrence?
* 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
45
Management of mastitis in lactating women - if treatment failure or recurrent?
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
46
Management of mastitis in non-lactating women -initial management?
* 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)
47
Management of mastitis in non-lactating women - preventing recurrence?
* Stop smoking
* Frequent hand washing
* Removal of nipple rings
48
Management of breast abscesses?
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
49
Prognosis of mastitis?
o If treated properly – recovery prompt and complete
| o Recurrence is common
50
Complications of mastitis?
```
o Breast abscess
o Mammary duct fistula
o Sepsis
o Scarring
o Necrotising Fasciitis
o Emotional distress of stopping breast feeding
```
51
Epidemiology of ovarian cysts?
* 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.
52
Classes of ovarian cysts - functional?
Enlarged or persistent follicular or corpus luteum cysts
| Considered normal <5cm, usually resolve over 2-3 cycles
53
Classes of ovarian cysts - benign - epithelial neoplastic cysts?
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
54
Classes of ovarian cysts - benign - cystic tumours of germ cells?
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
55
Classes of ovarian cysts - benign - solid tumours?
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)
56
Risk factors of ovarian cysts?
o Obesity
o Infertility
o Early menarche
o Tamoxifen therapy.
57
Symptoms of ovarian cysts?
```
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)
```
58
Acute presentations of ovarian cysts?
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
59
Investigations of ovarian cysts?
Pregnancy Test
Bloods – FBC
Urinalysis
TV USS
o Pre-menopausal women - a cyst of <5cm: A re-scan at 6 weeks
60
Further investigations of ovarian cysts?
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
61
Calculating risk of malignancy in ovarian cysts?
- 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
62
Management of ovarian cysts - admission?
* Admit to hospital if acute, severe pain
* If stable, urgent TVUS
* If unstable, urgent laparoscopy
63
Management of ovarian cysts - premenopausal women?
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
64
Management of ovarian cysts - postmenopausal women - low RMI, simple, <5cm cyst and normal Ca125?
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.
65
Management of ovarian cysts - postmenopausal women - moderate RMI (25-250)?
o Oophorectomy (usually bilateral) is recommended
66
Management of ovarian cysts - postmenopausal women - high RMI (>250)?
o Refer to cancer centre for full staging laparotomy.
67
Definition of Asherman's syndrome?
o Acquired uterine condition where adhesions form inside uterus
68
Risk factors of Asherman's syndrome?
D&C, myomectomy, C-section, infections, genital TB, obesity
69
Symptoms of Asherman's syndrome?
Menstrual problems – decreased in flow and duration (amenorrhoea or oligomenorrhoea)
Infertility
Pelvic pain – during menstrual and ovulation
Placental problems
70
Investigations of Asherman's syndrome?
Hysteroscopy
| Hysterosalpingography
71
Management of Asherman's syndrome?
Hysteroscopy and adhesiolysis
72
Aetiology of vulvitis - infection?
o Candida, trichomoniasis, bacterial vaginosis
o Pubic lice, threadworm, scabies
o HSV, UTI, vulval vestibulitis
o In prepubertal girls – Group A B-haemolytic streptococcal
73
Aetiology of vulvitis - dermatological?
o Allergic dermatitis
| o Psoriasis/Lichen planus/sclerosus
74
Aetiology of vulvitis - neoplasia?
o SCC
75
Aetiology of vulvitis - atrophic?
o Atrophic vaginitis
76
Symptoms of vulvitis?
- Itch
- Irritation
- Soreness
- Rawness
- Burning
- Dermatitis – intermittent itching when exposed to irritants
- Discharge points to infection
77
Investigations in vulvitis?
- 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)
78
Management of vulvitis - general advice?
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
79
Management of vulvitis - unknown cause?
o Emollients
o Oral antihistamines
o Low-potency topical corticosteroids (hydrocortisone 1% for 1-2 weeks)
80
Management of vulvitis - known cause?
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
81
Management of vulvitis - referral?
o Unexplained lump, bleeding
o STI suspected and no screening capacity
o No response to treatment
o Contact allergy for patch testing
82
Epidemiology of endometriosis?
• Incidence of endometriosis:
- General population = 10-15%
- Dysmenorrhoea = 40 – 60%
• Most common gynaecological condition after fibroids.
83
Definition of endometriosis?
* 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.
84
Locations of endometriosis?
```
- Common = pelvis.
• Pouch of douglas
• Uterosacral ligaments
• Ovarian fossae
• Bladder
• Peritoneum
- Rare = lungs, brain, muscle, eye
```
85
Definition of adenomyosis?
Adenomyosis is invasion of myometrium by endometrial tissue, causes inflammation, pain and adhesions.
Cause of chronic pelvic pain, dyspareunia and infertility
86
Risk factors of endometriosis?
o Early menarche, late menopause, long menstrual flow
o Obstruction to vaginal outflow
o Genetics – risk when 1st degree relative is 6x more
87
Protective factors of endometriosis?
o Multiparity
| o Use of OCP
88
Aetiology of endometriosis?
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
89
Sites of endometriosis?
o Peritoneum, pouch of Douglas (POD), ovary/tubes, ligaments, bladder and myometrium
90
Symptoms of endometriosis?
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
91
Signs of endometriosis?
- 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.
92
Investigations and diagnosis of endometriosis?
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
93
Further investigations used in endometriosis?
• Pelvic MRI
| - Used to assess extent of deep endometriosis involving bowel/urinary tract
94
Grading system of endometriosis?
```
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)
```
95
Management of endometriosis - analgesia?
Analgesia
o Paracetamol/NSAIDs 1st line
Naproxen
o If inadequate, consider other analgesia/referral
Neuropathic Pain
o Amitryptiline/gabapentin/pregabalin
96
Management of endometriosis -hormonal treatments?
- 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
97
Management of endometriosis -specialist hormonal treatments?
* GnRH analogues
* Levonorgesterol releasing IUS
* Danazol (anti-androgenic)
98
Management of endometriosis -surgical management?
- Laparoscopic ablation/resection/cystectomy
• Coagulation, excision or ablation
- Hysterectomy
• Last resort for severe endometriosis, not suitable if wanting to get pregnant
99
Management of endometriosis - fertility treatments?
- Surgical ablation plus adhesiolysis
| - In moderate to severe disease, IVF needed
100
Monitoring of endometriosis?
o Follow-up for patients with deep endometriosis or 1 or more endometriomas
101
Complications of endometriosis?
```
o Fibrosis/scarring
o Infertility
o Colonic/ureteric obstruction
o Endometrial rupture
o Malignant change
```
102
Definition of uterine fibroids?
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
Types of uterine fibroids?
- 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
Risk factors of uterine fibroids?
o Obesity
o 3x more common in African-American women
o FHx of fibroids
o Early menarche
105
Protective factors of uterine fibroids?
o Exercise
o Increased parity
o Smoking
106
Symptoms of uterine fibroids?
```
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
Signs of uterine fibroids?
o Palpable abdominal mass arising from pelvis
o Enlarged, often irregular, firm, non-tender uterus on bimanual pelvic examination
o Signs of anaemia
108
In pregnancy - symptoms of uterine fibroids?
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
Investigations of uterine fibroids?
• 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
Management of uterine fibroids - if asymptomatic?
No treatment may be necessary if minimal symptoms – annual follow up
111
Management of uterine fibroids - referral?
- Compressive symptoms
- Fertility or obstetric problems
- Suspicion of malignancy
- Fibroids palpable abdominally, or whose uterine length is >12cm
112
Management of uterine fibroids - medical treatments?
```
o NSAIDs
o Tranexamic acid to reduce menorrhagia
o COCP if patient requires contraception
o Mirena IUS
Reduces menstrual loss and uterus size
```
113
Management of uterine fibroids - prior to surgery?
3-6 months before surgery
o GnRH analogues (goserelin) OR Ullipristal Acetate
114
Management of uterine fibroids - surgery indications?
Excessively enlarged uterus
Pressure symptoms
Medical management not enough
Fibroid is submucous and fertility reduced
115
Management of uterine fibroids - surgical options?
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
Definition of interstitial cystitis (bladder pain syndrome)?
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
Aetiology of interstitial cystitis (bladder pain syndrome)?
Epithelial dysfunction, subclinical infection, neurogenic inflammation, up-regulation of sensory nerves in bladder
118
Symptoms of interstitial cystitis (bladder pain syndrome)?
```
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
Investigations of interstitial cystitis (bladder pain syndrome)?
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
Management of interstitial cystitis (bladder pain syndrome) - conservative?
* Avoid caffeine, alcohol, acidic foods and drinks
* Manage stress
* Regular exercise
* PRN analgesia
121
Management of interstitial cystitis (bladder pain syndrome) - if fail to respond to conservative management?
• 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
Definition of Bartholin's gland abscess?
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
Symptoms of Bartholin's gland abscess?
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
Investigations of Bartholin's gland abscess?
Swab should be taken
| If >40, biopsy to rule out carcinoma
125
Management of Bartholin's gland abscess?
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
What is imperforate hymen? How is it treated?
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
Definition of PID?
- 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
Epidemiology of PID?
- Women between 15-20, who are sexually active most at risk
129
Risk factors of PID?
o Age <25
o History of STIs
o New or multiple sexual partners
130
Protective factors of PID?
o Barrier contraception
o Mirena IUS
o COCP
131
Causes of PID?
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
Organisms of PID?
o Chlamydia trachomatis commonest
o Neisseria gonorrhoea, Mycoplasma genitalium, Ureaplasma urealyticum
o BV
o Other organsims
133
Symptoms of PID?
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
Signs of PID?
o Lower abdominal tenderness
o Cervical motion tenderness on bimanual
o Adnexal tenderness
o Fever >38
135
Investigations of PID?
- 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
Management of PID - initial management?
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
Management of PID - antibiotic therapy?
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
Management of PID - when to admit urgently?
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
Management of PID - outpatient management?
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
Management of PID - general advice?
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
Management of PID - test of cure?
Gonorrhoea – 2-4 weeks after
Chlamydia – 3-5 weeks after if persisting symptoms or recurrent infection suspected
Mycoplasma genitalium – 4 weeks after
142
Management of PID - contact tracing?
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
Complications of PID?
- Fibrosis and adhesions
- Ectopic Pregnancy – 5x risk
- Tubal factor Infertility
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis Syndrome (liver capsule inflammation with perihepatic adhesion)
144
Definition of cervical ectropion?
- 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
Treatment of cervical ectropion?
o None if asymptomatic, pregnant or pubertal
o If taking COCP, change to non-hormonal methods
o If woman wishes, cautery as outpatient
146
Aetiology of trichomonas?
* Trichomonas vaginalis – flagellate protozoan.
| * Transmitted through sex and infects vagina, urethra and paraurethral glands
147
Symptoms of trichomonas in women?
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
Symptoms of trichomonas in men?
o Usually asymptomatic
o Non-gonococcal urethritis
o Dysuria, urethral discharge
149
Complications in pregnancy of trichomonas?
- 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
Investigations of trichomonas?
• High vaginal swabs on wet mount microscopy
• Referral to GUM clinic
o Wet smear and culture (Diamond’s) – motile flagellates
o NAAT testing
151
Management of trichomonas?
• 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
Causes of bacterial vaginosis?
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
Risk factors of bacterial vaginosis?
```
o Sexual activity
o New sexual partner
o STIs
o Ethnicity (women of Afro-Caribbean)
o IUCD
o Vaginal douching
o Smoking
```
154
Protective factors of bacterial vaginosis?
o COCP
o Condoms
o Circumcised partner
155
Symptoms of bacterial vaginosis?
- 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
Pregnancy complications of bacterial vaginosis?
o Late miscarriage (mid-trimester).
o Preterm birth
o PPROM
o Post-partum endometritis
157
When can an empirical diagnosis of bacterial vaginosis be made?
```
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
Diagnosis in GP of bacterial vaginosis?
o Typical symptoms
o pH >4.5
o Low vaginal swab in transport medium
159
Diagnosis in GUM clinic of bacterial vaginosis?
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
Management of bacterial vaginosis - general advice?
o Avoid vaginal douching, shower gels, shampoo
| o No treatment if asymptomatic, unless pregnant
161
Management of bacterial vaginosis - treatments?
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
Complications of BV?
o PID
| o Risk of acquiring HIV and STIs
163
Epidemiology of thrush?
* About 70% of women will experience it at some point in their lives
* Peak age 20-40 years
164
Cause of thrush?
* Caused by infection with a yeast-like fungus, the most common being Candida albicans.
* It is not sexually transmitted
165
Causative organism of thrush?
o Candida albicans (90%)
| o Others: Candida glabrata, Candida tropicalis, Candida parapsilosis, Candida krusei
166
Predisposing factors of thrush?
- Antibiotics
- Pregnancy
- High dose COCP
- Diabetes mellitus
- Cushing’s disease
- Anaemia
- Immunocompromise
167
Symptoms of thrush?
o Vulval itching and soreness.
o Thick, curd-like, white vaginal discharge.
Non-offensive, foul smelling purulent discharge
o Dysuria
o Superficial dyspareunia
168
Signs of thrush?
- Vulval and vaginal erythema.
- Vulval fissuring.
- Satellite lesions
- Typical white plaques adherent to the vaginal wal
169
Investigations of thrush?
• 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
Management of thrush - general advice?
* Soap substitute to clean vulval area
* Emollient to moisturise
* Wear loose-fitting underwear
* Good hygiene
* Wiping vulva from front to back
171
Management of thrush - drug treatment?
• 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
Management of thrush - severe infection?
- 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
Management of thrush - Specialist advice?
- <16 and treatment fails
174
Management of thrush - recurrent candiasis?
- 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
Definition of menopause?
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
Definition of perimenopause?
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
Definition of premenopause?
o Either the 1-2 years immediately before the menopause or the whole of the reproductive period before the menopause
178
Definition of postmenopause?
o From the final menstrual period regardless of whether the menopause was induced or spontaneous
179
Definition of early menopause?
| Defintion of climaceric?
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
Cause of menopause?
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
Symptoms of menopause - sexual dysfunction & menstrual cycle?
- 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
Symptoms of menopause - vasomotor symptoms?
- Hot flushes (brief, nasty and may occur for >10 years)
- Night sweats
- Palpitations
- Itchy
183
Symptoms of menopause - psychological symptoms?
- Poor sleep
- Depressed mood/Psychosis
- Anxiety
- Irritability
- Mood swings
- Lethargy
- Lack of energy
184
Symptoms of menopause - other?
- Skin/hair changes
| - Muscle aches
185
Long term complications of menopause?
• 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
Diangosis of menopause?
o Tests not required in healthy women >45 with menopausal symptoms
187
When is tests needed in menopause?
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
Management of menopause - general measures?
- Diet and exercise advice may help
- Stop smoking
- Limit alcohol
- Use contraception until >1 year amenorrhoea if >50, 2 year amenorrhoea if <50
189
Management of menopause - symptom control?
- Menorrhagia responds to Mirena Coil
- Vaginal Dryness responds to Oestrogen cream PV
- Vasomotor symptoms – give fluoxetine/citalopram/clonidine
190
Management of menopause - HRT in woman with uterus?
* 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
Management of menopause - HRT in women without uterus?
• Women without uterus – oestrogen-only HRT (unopposed oestrogens increases risk of endometrial cancer so only when hysterectomy)
192
Definition of abnormal uterine bleeding?
Any bleeding that is either:
• Abnormal in volume (excessive duration or heavy)
• Irregularity, timing (delayed or frequently)
• Non-menstrual bleeding – IMB, PCB, PMB
193
Definition of amenorrhoea?
Absence of menstruation
194
Definition of primary amenorrhoea?
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
Causes of primary amenorrhoea?
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
Definition of secondary amenorrhoea?
Previous normal menstruation but stops for 3-6 months or more, 6-12 months in women with irregular periods
197
Causes of secondary amenorrhoea?
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
Tests to perform in amenorrhoea?
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
Management of amenorrhoea - refer?
Refer to secondary care for specialist investigations
200
Management of hypothalamic-pituitary-axis malformation - if mild?
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
Management of hypothalamic-pituitary-axis malformation - if axis shut down?
o Stimulation by gonadotrophin-releasing hormone
| o Used in specialist fertility clinics only
202
Definition of oligomenorrhoea?
o Menses occurring less frequently than every 35 days
o More common in extremes of reproductive life
o Common cause is PCOS
203
Definition of menorrhagia?
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
Causes of menorrhagia?
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
Signs of menorrhagia?
```
Anaemia
Abdomen exam
• Masses
Ensure smear up to date
Inspect cervix and take swabs if needed
If indicated bimanual examination
```
206
Investigations in menorrhagia?
Pregnancy test
Bloods – FBC, TFTs, clotting (if indicated)
Smear if due
STI screen
207
When to refer menorrhagia to secondary care?
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
Management of menorrhagia - medical 1st line?
o Mirena IUS
209
Management of menorrhagia - medical 2nd line?
o Tranexamic Acid
o NSAIDs (mefenamic acid) - Taken during days of bleeding
o COCP
210
Management of menorrhagia - medical 3rd line?
Medroxyprogesterone acetate IM every 12 weeks
Norethiserone PO - Used short-term to stop heavy bleeding
GnRH rarely used, only in secondary care
211
Management of menorrhagia - surgical management - when?
• Reserved for failed medical therapy
212
Management of menorrhagia - surgical management - what?
* Endometrial ablation
* Uterine Artery Embolisation or Myomectomy
* Hysterectomy
213
Management of menorrhagia - surgical management - describe endometrial ablation?
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
Management of menorrhagia - surgical management - describe uterine artery embolisation?
o If uterus is >10 weeks in size or fibrois >3cm, retain ferility
215
Management of menorrhagia - surgical management - describe hysterectomy?
o Women not wishing to retain fertility, who have fibroids >3cm
o Vaginal hysterectomy preferred, may need abdominal
216
Definition of dysmenorrhoea?
o Low anterior pelvic pain, occurring with periods
| o 50% women complain of moderate pain, 12% of severe
217
Pathology of dysmenorrhoea?
Imbalance of prostaglandins and leukotrienes in menstrual fluid which produces vasoconstriction and uterine contractions
May be responsible for diarrhoea, nausea and headache
218
Classes of dysmenorrhoea - primary?
* Pain without organ pathology
* Often starts with onset of ovulatory cycles
* Pain begins with period and last 2-3 days
219
Classes of dysmenorrhoea - secondary?
```
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
Symptoms of dysmenorrhoea?
Crampy pain with ache in groin or back
Worse in first few days (primary)
Constant through period (secondary), deep dysparenunia
221
Investigations of dysmenorrhoea?
Abdominal/Vaginal exam
Speculum and may need swabs/smear if due
If mass – pelvic USS
222
Management of dysmenorrhoea - general advice?
* Stop smoking
* TENS may help
* Tea may help
* Abdominal/back massage and lying down
223
Management of dysmenorrhoea - drug therapy?
```
• NSAIDs (mefenamic acid) during menstruation
• Paracetamol
• If not wanting to conceive:
o COCP
o POP
o Depot medroxyprogesterone acetate
o Mirena IUS
```
224
Management of dysmenorrhoea - surgery?
• If women completed family – hysterectomy in severe, refractory cases
225
Definition of intermenstrual bleeding?
o Vaginal bleeding (other than postcoital) at any time during menstrual cycle other than normal menstruation
226
Causes of intermenstrual bleeding?
```
Cervical polyps
Ectropion
Fibroids
Carcinoma
Cervicitis/Vaginitis
IUCD
Hormonal contraception
• May get breakthrough bleeding when starting
Chlamydia
Pregnancy related
```
227
Assessment of intermenstrual bleeding?
Take menstrual, gynaecological, sexual history (obstetric if indicated)
Abdominal and PV exam
228
Investigations of intermenstrual bleeding?
```
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
Referral of intermenstrual bleeding?
Abnormal cervix (2 week wait)
| Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), >45 with IMB
230
Management of intermenstrual bleeding - hormonal?
• 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
Definition of postcoital bleeding?
o Non-menstrual bleeding through vagina immediately after sexual intercourse
o Around 5% women experience PCB
232
Causes of postcoital bleeding?
```
Infection
Cervical ectropion
Cervical/Endometrial polyps
Vaginal/Cervical cancer
Sexual abuse
Atrophic change
```
233
Investigations of postcoital bleeding?
```
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
Referral of postcoital bleeding?
Abnormal cervix (2 week wait)
| Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), no cause of PCB
235
Regimen of NHS cervical screening programmes?
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
Process of cervical smear test?
o Plastic speculum inserted vaginally to via squamocolumnar junction of cervix
LBC – brush rotated against squamocolumnar junction
Results available in 2 weeks
237
Management of results of cervical smear - negative?
o Inform patient of result
| o Recall as appropriate for screening rules
238
Management of results of cervical smear -inadequate?
o Repeat sample immediately after treating infection (<3 months), as soon as convenient
o If three inadequate, advise assessment by colposcopy
239
Management of results of cervical smear - borderline and mild dyskaryosis?
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
Management of results of cervical smear -moderate/severe dyskaryosis?
o Colposcopy within 2 weeks
241
Management of CIN?
* CIN1 – treatment or no treatment
| * CIN2/3 – Excision to depth 8mm, LLETZ (large loop excision of transformation)
242
Follow up for CIN1 untreated?
o Follow up 12 months with cytology and HPV testing
If inadequate – Repeat 3 months
If negative - normal recall
If positive – colposcopy
243
Follow up for treated CIN?
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
Test of cure for treated CIN?
o 6-month test of cure
If inadequate – repeat 3 months
If negative – follow up test then normal recall
If positive – colposcopy
245
HPV vaccine given when and what?
```
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
```
