Revision 1 Flashcards
What are the 4 types of fibroids?
1) Intramural
2) Subserosal
3) Submucosal
4) Pedunculated
Where are submucosal fibroids located?
Just below the lining of the uterus (endometrium)
These can bulge into the uterine cavity
Where are subserosal fibroids located?
Just below the outer layer of the uterus
These can project to the outside of the uterus
Which type of fibroids can grow outwards and become large, sometimes filling the abdominal cavity?
Subserosal
What is the 1st line investigation for fibroids?
TV US
1st line mx for fibroids <3cm?
Mirena coil (same as for menorrhagia)
Other mx options for fibroids <3cm?
1) Symptomatic e.g. NSAIDs & TXA
2) COCP
3) Cyclical oral progestogens
Mx of fibroids >3cm?
Referral to gynae for investigation and management.
What may be given to reduce the size of fibroids prior to surgery?
GnRH agonists (induce a menopause like state)
What are the surgical options in fibroids?
1) Hysterectomy
2) Myomectomy –> only known fibroid treatment to improve fertility
3) Uterine artery embolisation
Clinical features of red degeneration of fibroids?
- severe abdo pain
- fever
- tachycardia
- vomiting
Mx of red degeneration of fibroids?
Rest & analgesia
Who deos red degeneration of fibroids usually occur in?
Pregnant women in 2nd/3rd trimester
Give some signs on examination during endometriosis
1) Endometrial tissue visible in vagina on speculum exam, especially in posterior fornix
2) Fixed cervix on bimanual
3) Tender nodularity in the posterior vaginal fornix
What is the gold standard for diagnosing abdominal and pelvic endometriosis?
Laparoscopic surgery –> biopsy of lesions
What is adenomyosis?
Endometrial tissue inside the myometrium (muscle layer)
Who is adenomyosis more common in? (2)
1) Older women in later reproductive years
2) Multiparous women
What can an examination in adenomyosis demonstrate?
An enlarged and TENDER uterus (note - fibroids is non-tender)
1st line investigation in adenomyosis?
TV US
Gold standard diagnosis of adenomyosis?
Histological examination of the uterus after a hysterectomy
Management of adenomyosis?
Depends on symptoms, age and plans for pregnancy.
NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding e.g. Mirena coil
When the woman does NOT want contraception, what treatment can be used during menstruation for symptomatic relief in adenomyosis when there is associated pain?
Mefenamic acid (NSAID - reduces bleeding and pain)
When the woman does NOT want contraception, what treatment can be used during menstruation for symptomatic relief in adenomyosis when there is NO associated pain?
TXA
What class of drug is TXA?
Antifibrinolytic
1st line management of endometriosis?
NSAIDs and/or paracetamol for symptomatic relief
2nd line management of endometriosis?
If analgesia doesn’t help then hormonal treatments such as the COCP or progestogens e.g. medroxyprogesterone acetate should be tried
How can uterine fibroids lead to polycythaemia?
This is rare.
Polycythaemia can occur 2ary to production of EPO by fibroids.
What marks the tranition from the ectocervix to the endocervical canal?
External os
What is the most common type of cervical cancer?
Squamous cell carcinoma of the epithelial lining of the cervix (80%) –> these are found in the ectocervix
What is the 2nd most common type of cervical cancer?
Adenocarcinoma –> endocervical canal
HPV produces 2 proteins that inhibit tumour suppressor genes.
What are these proteins?
What tumour suppressor genes do they inhibit?
E6 –> inhibits p53
E7 –> inhibits pRb
The greatest risk factor for developing cervical cancer is HPV infection.
What are some other factors?
- smoking
- inadequate screening
- high parity
- oral contraceptive use
What are some risk factors for catching HPV?
- early sexual activity
- increased number of sexual partners
- not using condoms
What is the cervical screening in place in the UK?
Women (and transgender men with a cervix) aged:
- 25 to 49 –> every 3 years
- 50 to 64 –> every 5 years
How often do women with HIV have cervical screening?
Every year
Who should fast track colposcopy be offered to?
(2ww)
1) Postmenopausal women with unexplained vaginal bleeding
2) Premenopausal women with persistent intermenstrual bleeding and negative pelvic exam
3) Women with clinical features suggesting cervical cancer if they have not been screened, or if the bleeding persists beyond 3 months
When is CIN diagnosed?
CIN is diagnosed at colposcopy (not with cervical screening)
What are the CIN grades?
Grade 1 - mild dysplasia, affecting 1/3 of thickness of epithelial layer, likely to return to normal without treatment
Grade 2 - moderate dysplasia, affecting 2/3 of thickness, likely to progress to cancer if not treated
Grade 3 - severe dysplasia (sometimes called cervical carcinoma in situ)
What 2 stains can be used during colposcopy?
1) Aceitic acid
2) Iodine
What is the effect of acetic acid on abnormal cells during colposcopy?
Turns them white
What is the effect of iodine on abnormal cells during colposcopy?
Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
What staging system is used to stage cervical cancer?
FIGO
FIGO staging for cervical cancer
Stage 1 - confined to cervix
Stage 2 - invades uterus or upper 2/3 of vagina
Stage 3 - invades pelvic wall or lower 1/3 of vagina
Stage 4 - invades bladder, rectum or beyond the pelvis
Is mx routinely offered for CIN 1?
No - observation
Mx for CIN II/III?
Consider LLETZ or cone biopsy
What is management of cervical cancer stage 1B-2A (early stage disease)?
Radical hysterectomy and removal of local lymph nodes (lymphadenectomy) with/without chemotherapy and radiotherapy –> NO aim to spare fertility
Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers –> the aim is to spare fertility
What is management of cervical cancer stage 2B-4A (locally advanced disease)?
Chemo & radiation
Which HPV strains are responsible for genital warts?
6 & 11
What is the most common type of endometrial cancer?
Adenocarcinoma
What is the 1ary source of oestrogen in postmenopausal women?
Adipose tissue
What enzyme does adipose tissue contain?
Aromatase
What is the role of aromatase?
Converts androgens to oestrogen
Why is oestrogen from adipose tissue or HRT post menopause unopposed?
This extra oestrogen is unopposed in women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.
What are 2 risk factors for endometrial cancer NOT related to unopposed oestrogen?
1) T2DM (due to increased production of insulin)
2) HNPCC (Lynch syndrome)
Which hormone causes the endometrium to become receptive to the implantation of a fertilised ovum?
Progesterone
If fertilisation does not take place, a fall in progesterone levels triggers menstruation and shedding of the thickened endometrial layer.
What is the purpose of a TV US in suspected endometrial cancer?
Measure endometrial thickness
What is the normal endometrial thickness post menopause?
<4mm
What ET on transvaginal US would be an indication for further investigatios such as endometrial biopsy?
≥4mm
Stage 1 - 4 of endometrial cancer?
Stage 1 - confined to uterus
Stage 2 - invades cervix
Stage 3 - invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4 - invades bladder, rectum or beyond the pelvis
What is the usual treatment for stage 1 and 2 endometrial cancer?
Total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO)
What is the most common type of ovarian cancer?
Epithelial cell tumours
What are 5 subtypes of ovarian epithelial cell tumours
1) Serous tumours –> most common
2) Endometrioid carcinomas
3) Clear cell adenomas
4) Mucinous adenocarcinoma
5) Undifferentiated tumours
Give 3 examples of other types of ovarian cancer
(i.e. not epithelial cell tumours)
1) Sex cord stromal tumours e.g. Sertoli-Leydig cell tumour, granulosa theca cell tumours
2) Germ cell tumours e.g. teratoma, choriocarcinoma
3) Mets from other sites e.g. gastric (Krukenberg tumour)
What does a Sertoli-Leydig cell tumour produce?
Testosterone
What complication are teratomas particularly associated with?
Ovarian torsion
Germ cell tumours may cause raised what?
hCG (can cause +ve pregnancy test) & AFP
what is a krukenberg tumour?
A met in the ovary, often from gastric cancer
what is the characteristic sign of a krukenberg tumour in histology?
Signet ring sign
What are the red flags in potential ovarian cancer that require a 2-week-wait referral?
1) pelvic mass (unless clearly due to fibroids)
2) ascites
3) abdo mass
What is the risk of malignancy index (RMI) in ovarian cancer?
1) Postmenopausal status
2) Ca-125
3) US results
The RMI estimates the risk of an ovarian mass being malignant.
What RMI score indicates a prompt referral to a specialist gynae-oncology centre?
> 200
Give some examples of non-malignant causes of a raised CA125.
Endometriosis
Fibroids
Adenomyosis
Liver disease
Pelvic infection
Pregnancy (don’t do a Ca125 in a pregnant woman!)
What is the most common type of vulval cancer?
Squmaous cell carcinoma
What premalignant conditions precipitates vulval cancer?
Vulval intraepithelial neoplasia (VIN)
What are the 2 types of VIN?
1) High grade squamous intraepithelial lesion
2) Undifferentiated VIN
What type of VIN is associated with HPV infection and typically occurs in YOUNGER women (35-50s)?
High grade
What type of VIN is associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years)?
Undifferentiated
What cream can be used in the mx of VIN?
Imiquimod cream
Where does ovarian cancer most commonly spread to first?
The para-aortic lymph nodes, which drain the ovaries and fallopian tubes.
What does the addition of progesterone to HRT increase the risk of?
Breast cancer
An 18 year old woman has a sudden sharp stabbing pain in her abdomen, lasting only a few minutes.
It is 14 days since her last period started.
She indicates that the pain is localised to the LIF.
A surge in which hormone is most likely to coincide with her pain?
LH
This is because the pain is localised to the LIF (where the ovary is located).
The surge in LH occurs just before ovulation and stimulates the release of an ovum from the ovary.
It is most likely that the pain was caused by the rupture of the follicle during ovulation.
