Selected Notes obgyn 2 Flashcards
What group is urinary incontinence most common in?
Elederly females
Name some risk factors for developing urinary incontinence
Advancing age<br></br>Previous pregnancy/childbirth<br></br>High BMI<br></br>Hysterectomy<br></br>Family history
Name the reversible causes of urinary incontinence
DIAPPERS<br></br>D-delirium<br></br>I-Infection<br></br>A-atrophic vaginitis or urethritis<br></br>P-Pharmaceuticals-meds)<br></br>P-Psychiatric disorders<br></br>E-Endocrine disorders-diabetes etc<br></br>R-Restricted mobility<br></br>S-Stool impaction
What causes urge incontinence?
Detrusor overactivity
What is functional incontinence?
Comorbid physical conditions impair the patient’s ability to get to a bathroom in time<br></br>Causes: dementia, medications, injury/illness causing impaired mobility
What is a cystometry?
Investigation to measure bladder pressure whilst voiding
What is a cystogram?
Contrast instilled into the bladder and a radiological image is obtained to see if the contrast travels anywhere else
In the surgical management of stress incontinence, {{c1::colposuspension and fascial slings}} involve <span>s</span>{{c2::uspending the anterior vaginal wall}} <span>to the </span>{{c3::iliopectineal ligament of Cooper}}
What are the surgical management options for treating urge incontinence?
Bladder instillation->botox injection to paralyse detrusor muscle<br></br>Sacral neuromodulation->only int mtertiary centres where all other treatments have failed
What causes overflow incontinence?
Either:<br></br>1. Underactivity of the detrusor muscle e.g. from neurological damage OR<br></br>2. Urinary outlet pressures are too high e.g. constipation or prostatism
What is a genital or pelvic organ prolapse?
Descent of one or more pelvic structures from their normal anatomical position moving towards or through the vaginal opening
Name some risk factors for developing a genital prolapse
-Vaginal childbirth, especially with traumatic or complicated deliveries<br></br>-Increasing age<br></br>-Menopause<br></br>-Hysterectomy<br></br>-Obesity<br></br>-Chronic cough<br></br>-Heavy lifting<br></br>-Connective tissue disorders<br></br>-Spina bifida
What are the types of anterior vaginal wall prolapse?
Cystocele-bladder<br></br>Urethrocele-urethra<br></br>Cystourethrocele-both bladder and urethra
What is a cystocele? What condition can it lead to?
<ul><li>Bladder prolapse</li></ul>
Sterss incontinence<br></br>
Name the posterior wall prolapses
Enterocele-small intestine<br></br>Rectocele-rectum
Name the atypical vaginal wall prolapses?
Uterine prolapse-uterus<br></br>Vaginal vault prolapse-roof of the vagina
What are some differential diagnoses for a uterogential prolapse?
<ul><li>Gynecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain</li><li>Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain</li><li>Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass</li></ul>
Name some investigations to diagnose a genital prolapse
-Pelvic exam<br></br>Imaging if compolx or required for surgical planning<br></br>Urodynamic studies if co-existing urinary symptoms
What is a vaginal fistula?
Unusual opening that connects your vagina to another organ<br></br>Can link vagina to bladder, ureters, urethra, rectum, intestines
Name some of the causes of a vaginal fistula?
Childbirth<br></br>Abdominal surgery<br></br>Pelvic, cervical or colon cancer<br></br>Radiation teatment<br></br>Bowel disease-Crohn’s or diverticulitis<br></br>Infection
Name some complications of a vaginal fistula
Vaginal/urinary tract infections that keep returning<br></br>Stool or gas that leaks through the vagina<br></br>Irritated/swollen skin around vagina/anus<br></br>Abscesses<br></br>
What are fibroids?
Benign smooth muscle tumours <span>originating from the myometrium of the uterus.</span>
Uterine fibroids develop in response to {{c1::oestrogen}}. The incidence increases with age until {{c1::menopause}}
In which group of people are uterine fibroids most common?
More common in Afro-Caribbean women
The growth of fiborids is promoted by {{c1::oestrogen and progesterone.}} Fibroids contain more oestrogen and progesterone than {{c1::normal uterine muscle cells}}
Name some symptoms of uterine fibroids
-Asymptomatic<br></br>-Menorrhagia and dysmenorrhoea-.can cause iron deficiency anaemia<br></br>-Bloating<br></br>-Lower abdominal pain, cramps<br></br>-Urinary symptoms<br></br>-Subfertility<br></br>Rare: polycythaemia
Name some differential diagnoses for uterine fibroids
<ul><li>Endometrial polyps: Present with irregular menstrual bleeding and spotting</li><li>Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility</li></ul>
Name some complications of uterine fibroids
-Subfertility<br></br>-Iron deficiency anaemia<br></br>-Red degeneration-> haemorrhage into tumour-> commonly occurs during pregnancy
What are the types of uterine fibroids?
- Intramural<br></br>2. Subserosal<br></br>3. Submucosal<br></br>4. Pedunculated
Intramural fibroids grow {{c1::within the myometrium}}. As they grow they {{c1::distort the uterus}}
Subserosal fibroids develop {{c1::just below the outer layer}} of the uterus. They grow outwards and can become very large filling the {{c1::abdominal cavity}}
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Red degeneration of fibroids refers to i{{c1::schaemia, infarction and necrosis}} of the fibroid due to disrupted blood supply. It is more likely to occur in larger fibroids during the {{c1::2nd and 3rd}} trimester of pergnancy. It may occur as the {{c1::fibroid rapidly enlarges during pregnancy,}} outrgrowing its blood supply and becoming ischamic or due to{{c1:: <span>kinking in the blood vessels</span>}}<span> as the uterus changes shape and expands during pregnancy.</span>
What is an ovarian cyst?
Fluid filled <span>sac that develops within or on the surface of an ovary.</span>
What are some differential diagnoses for ovarian cysts?
<ul><li>Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.</li><li>Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.</li><li>Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.</li></ul>
What investigations are done into a suspected ovarian cyst?
Pregnancy test to exclude ectopic<br></br>Diagnostgic laparoscopy-> especially if haemodynamically unstable<br></br>Ultrasound<br></br>Bloods: <br></br><ul><li>Ca125: tumour marker for ovarian cancer</li><li>LDH, aFP, HCG to assess for germ cfell tumour</li></ul>
What are the main possible complications of an ovarian cyst?
<ul><li>Torsion</li><li>Haemorrhage into the cyst</li><li>Rupture with bleeding into the peritoneum</li></ul>
What are the types of physiological/functional cysts?
<ol><li>Follicular cysts</li><li>Corpus luteum cysts</li></ol>
Serous cystadenoma are {{c1::benign}} tumours of the {{c1::epithelial cells}}
Mucinour cystadenomas mare also {{c1::benign tumours of the epithelial cells}} but these can {{c1::become huge,}} <span>taking up lots of space in the pelvis and abdomen.</span>
Sex cord stromal tumours are<span> rare tumours, that can be </span>{{c1::benign or malignant.}}<span> They arise from the </span>{{c1::stroma (connective tissue)}}<span> or </span>{{c2::sex cords (embryonic structures associated with the follicles).}}<span> There are several types, including </span>{{c2::Sertoli–Leydig cell tumours and granulosa cell tumours}}<span>.</span>
Name some risk factors for ovarian malignancy
<ul><li>Age</li><li>Postmenopause</li><li>Increased number of ovulations</li><li>Obesity</li><li>Hormone replacement therapy</li><li>Smoking</li><li>Breastfeeding (protective)</li><li>Family history and BRCA1 and BRCA2 genes</li></ul>
Name some protective factors for ovarian cancer
<ul><li>Anything that will reduce the number of ovulations:</li><li>Later onset of periods (menarche)</li><li>Early menopause</li><li>Any pregnancies</li><li>Use of the combined contraceptive pill</li></ul>
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Name some non-malignant causes of a raiserd CA125
<ul><li>Endometriosis</li><li>Fibroids</li><li>Adenomyosis</li><li>Pelvic infection</li><li>Liver disease</li><li>Pregnancy</li></ul>
In women under 40 with a complex ovarian mass what tests should be done?
Tumour markers for a possibole germ cell tumour:<br></br><ul><li><b><i>Lactate dehydrogenase</i></b> (<b><i>LDH</i></b>)</li><li><b><i>Alpha-fetoprotein</i></b> (<b><i>α-FP</i></b>)</li><li><b><i>Human chorionic gonadotropin</i></b> (<b><i>HCG</i></b>)</li></ul>
Ovarian torsion is usually due to an {{c1::ovarian mass}} larger than {{c1::5cm.}} It is more likely to occur with {{c1::benign t}}umours. Also more likely to occur during {{c1::pregnancy}}
Name some risk factors for developing ovarian torsion?
Ovarian mass<br></br>Being of reproductive age<br></br>Pregnancy<br></br>Ovarian hyperstimulation syndrome
Name some complications of an ovarian torsion
Fertility not typically affected as other ovary can compensate<br></br>If only functioning ovary removed-> infertility and menopause<br></br><br></br>If necrotic ovary not removed:<br></br><ul><li>Infection</li><li>Abscess</li><li>Sepsis</li></ul><div>If it ruptures-> peritonitis and adhesions</div>
What is lichen sclerosus?
Inflammatory dermatological condition
What is Koebner phenomenon?
When the signs and symptoms worsen with friction to the skin
Name a few things that cane make lichen sclerosus worse
Friction to the skin<br></br>Tight underwear<br></br>Sex<br></br>Urinary incontinence<br></br>Scratching the affected area
Name some differential diagnoses for lichen sclerosus
<ul><li><div>Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.</div></li><li><div>Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.</div></li><li><div>Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.</div></li></ul>
Name some complications of lichen sclerosus
<ul><li>5% risk of developing squamous cell carcinoma of the vulva</li><li>Pain and discomfort</li><li>Sexual dysfunction</li><li>Bleeding</li><li>Narrowing of vaginal/urethral openings</li></ul>
Name some risk factors for developing cervical cancer
<ul><li>HPV 16 and 18 infection or anything that increases the risk of this (early sexual activity, not suing condoms, increased number of sexual partners)</li><li>Smoking</li><li>Immunosuppression</li><li>Non engagementwith cervical screening</li><li>Using COCP for >5yrs</li></ul>
Name some differential diagnoses of cervical cancer
<ul><li>Vaginitis: itching, burning, pain, and abnormal discharge</li><li>Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding</li><li>Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss</li><li>Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse</li></ul>
What characteristics of a cervix would be worrying and prompt an urgen colposcopy?
Ulceration<br></br>Inflammation<br></br>Bleeding<br></br>Visible tumour
What does cervical screening involve?
<ul><li>Speculum exam</li><li>Collection of cells from the cervix</li><li>Cells examined for precancerous changes(dyskaryosis)</li><li>Transporting the cells: liquid based cytology</li></ul>
Name some exceptions to the usual cervical screening programme
<ul><li>Women with HIV are screened annually</li><li>Women over 65 may request a smear if they have not had one since aged 50</li><li>Women with previous CIN may require additional tests (e.g. test of cure after treatment)</li><li>Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)</li><li>Pregnant women due a routine smear should wait until 12 weeks post-partum</li></ul>
Name 3 infections that can be identified from smear testing for cervical cancer
<ul><li>Bacterial vaginosis</li><li>Candidiasis</li><li>Trichomoniasis</li></ul>
Management of smear results:<br></br><ul><li>Inadequate sample – {{c1::repeat the smear after at least three months}}</li><li>HPV negative – {{c2::continue routine screening}}</li><li>HPV positive with normal cytology – {{c3::repeat the HPV test after 12 months}}</li><li>HPV positive with abnormal cytology – {{c4::refer for colposcopy}}</li></ul>
What is a colposcopy?
Inserting a speculum and using a colposcope to magnify the cervix.<br></br>Allows epithelial lining of cervix to be examined
Tests used in a colposcopy:<br></br><div><ol><li><b><i>Acetic acid</i></b> causes abnormal cells to appear {{c1::white.}} This appearance is described as <b><i>acetowhite</i></b>. This occurs in cells with an increased {{c1::<b><i>nuclear to cytoplasmic ratio</i></b> (more <b><i>nuclear material</i></b>),}} such as {{c1::<b><i>cervical intraepithelial neoplasia</i></b> and <b><i>cervical cancer</i></b> }}cells.</li><li><b><i>Schiller’s iodine test</i></b> involves using an {{c1::<b><i>iodine solution</i></b> }}to stain the cells of the cervix. Iodine will stain {{c1::healthy cells a brown colour.}} Abnormal areas {{c1::will not stain.}}</li><li>A <b><i>punch biopsy</i></b> or <b><i>large loop excision of the transformational zone</i></b> can be performed during the colposcopy procedure to get a tissue sample.</li></ol></div>
<h3><b>Large Loop Excision of the Transformation Zone (LLETZ)</b></h3>
<div>A large loop excision of the transformation zone (<b><i>LLETZ</i></b>) procedure is also called a {{c1::<b><i>loop biopsy</i></b>.}} It can be performed with a {{c1::<b><i>local anaesthetic</i></b> d}}uring a {{c1::colposcopy procedure.}} It involves using a loop of wire with electrical current (<b><i>diathermy</i></b>) to {{c1::remove abnormal epithelial tissue on the cervix.}} The electrical current <b><i>cauterises</i></b> the tissue and stops bleeding.</div>
<div>{{c1::Bleeding and abnormal discharge}} can occur for several weeks following a LLETZ procedure. This varies between women. {{c1::Intercourse and tampon use should be avoided}} after the procedure to reduce the risk of infection. Depending on the depth of the tissue removed from the cervix, the procedure may increase the risk of {{c1::<b><i>preterm labour</i></b>.}}</div>
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What are the main risks associated with a cone biopsy?
<ul><li>Pain</li><li>Bleeding</li><li>Infection</li><li>Scar formation with stenosis of the cervix</li><li>Increased risk of miscarriage and premature labour</li></ul>
<h3><b>Staging of cervical cancer<br></br></b></h3>
<div>The{{c1:: <b><i>International Federation of Gynaecology and Obstetrics</i></b> (<b><i>FIGO</i></b>)}} staging system is used to stage cervical cancer:</div>
<ul><li>Stage 1: {{c2::Confined to the cervix}}</li><li>Stage 2: {{c3::Invades the uterus or upper 2/3 of the vagina}}</li><li>Stage 3: {{c4::Invades the pelvic wall or lower 1/3 of the vagina}}</li><li>Stage 4: {{c5::Invades the bladder, rectum or beyond the pelvis}}</li></ul>
<h3><b>Management of cervical cancer</b></h3>
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<ul><li><b><i>Cervical intraepithelial neoplasia</i></b> and <b><i>early-stage 1A</i></b>: {{c1::LLETZ or cone biopsy}}</li><li><b><i>Stage 1B – 2A</i></b>: {{c2::Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy}}</li><li><b><i>Stage 2B – 4A</i></b>: {{c3::Chemotherapy and radiotherapy}}</li><li><b><i>Stage 4B</i></b>: M{{c4::anagement may involve a combination of surgery, radiotherapy, chemotherapy and palliative care}}</li></ul>
What do HPV strains 6 and 11 cause?
Genital warts
Name some risk factors for developing endometrial cancer
<ul><li>Nulliparity</li><li>Obesity</li><li>Early menarche</li><li>Late menopause</li><li>Polycystic ovary syndrome</li><li>Oestrogen-only hormone replacement therapy</li><li>Tamoxifen</li></ul>
Name some protective factors against endometrial cancer
<ul><li>multiparity</li><li>combined oral contraceptive pill</li><li>smoking (the reasons for this are unclear)</li></ul>
Name some symptoms of endometrial cancer
<ul><li><strong>Postmenopausal bleeding(usually slight and intermittent then becomes heavier)</strong></li><li>Abnormal vaginal bleeding, such as intermenstrual bleeding</li><li>Dyspareunia</li><li>Pelvic pain-uncommon apart from in later stages</li><li>Abdominal discomfort or bloating</li><li>Weight loss</li><li>Anaemia</li></ul>
Name some differentials for endometrial cancer
<ul><li>Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.</li><li>Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.</li><li>Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.</li></ul>
What is endometrial hyperplasia?
Precancerous thickening of the endometrium
What are the 2 types of endometrial hyperplasia
<ul><li>Hyperplasia without atypia</li><li>Atypical hyperplasia</li></ul>
<b><i>Type 2 diabetes</i></b><span> may increase the risk of endometrial cancer due to the increased production of</span>{{c1::<span> </span><b><i>insulin</i></b><span>. </span>}} which<span> may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer. </span>
<b><i>Tamoxifen</i></b><span> has an </span>{{c1::anti-oestrogenic effec}}<span>t on breast tissue, but an </span>{{c1::oestrogenic}} <span>effect on the endometrium. This </span>{{c1::increase}}<span> the risk of endometrial cancer.</span>
What are the NICE suspected cancer referral guidelines concerning endometrial cancer?
Urgent 2 week wait: women with postmenopausal bleeding<br></br><br></br>Transvaginal US in women >55yrs with:<br></br><ul><li>Unexplained vaginal discharge</li><li>Visible haematuria+raised platelets, anaemia or elevated glucose levels</li></ul>
<div>The {{c1::<b><i>International Federation of Gynaecology and Obstetrics</i></b> (<b><i>FIGO</i></b>)}} staging system is used to stage endometrial cancer:</div>
<ul><li>Stage 1: {{c2::Confined to the uterus}}</li><li>Stage 2: {{c3::Invades the cervix}}</li><li>Stage 3: {{c4::Invades the ovaries, fallopian tubes, vagina or lymph nodes}}</li><li>Stage 4: {{c5::Invades bladder, rectum or beyond the pelvis}}</li></ul>
What are the different types of ovarian cancers?
<ol><li>Epithelial </li><li>Germ cell</li><li>Sex cord</li></ol>
What group of people do ovarian germ cell tumours typically arise from?
Young women-> atypical for most cases of ovarian cancer
What are the tumour markers for ovarian germ cell tumours?
Alpha fetoprotein and B-HCG
What is a Krukenbery tumour?
‘Signet ring’ sub-type of tumour typically GI in origin whcih has metastasised to the ovary
Name some risk factors for developing ovarian cancer
<ul><li>Advanced age</li><li>Smoking</li><li>Increased numbr of ovulations(early menarche, late menopause)</li><li>Obesity</li><li>HRT</li><li>Genetics: BRCA1&2</li></ul>
Name some protective factors against ovarian cancer
<ul><li>Childbearong</li><li>Breastfeeding</li><li>Early menopause</li><li>Use of COCP</li></ul>
Name some differentials for developing ovarian cancer
<div><div><div><div><div><div><ul><li>Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits</li><li>Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation</li><li>Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating</li><li>Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms</li></ul></div></div></div></div></div></div>
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What investigations are done to diagnose ovarian cancer?
<ol><li>CA125 blood test</li><li>Pelvic and abdominal US scan</li><li>CT scans for staging</li><li>AFP and B-HCG in younger women-germ cell tumours</li><li>Laparotomy for tissue biopsy</li></ol>
Name some conditions aside from ovarian cancer that can raise the CA125 level
<ul><li>Endometriosis</li><li>Menstruation</li><li>Benign ovarian cysts</li></ul>
<ul><li><div>Ovarian cancer staging:</div></li><li><div>Stage I ({{c1::limited to the ovaries):}}</div></li><li><div>Stage II {{c2::involving one or both ovaries with pelvic extension and/or implants:}}</div></li><li><div>Stage III {{c3::involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:}}</div></li><li><div>Stage IV ovarian cancer is {{c4::tumour involving one or both ovaries with distant metastasis.}}</div></li></ul>
What are the NICE suspected cancer guidelines relating to ovarian cancer?
2 week wait if:<br></br><ul><li>Ascites</li><li>Pelvic mass</li><li>Abdominal mass</li></ul><div>Further investigations includng CA125 if:</div><div><ul><li>New symptoms of IBS/change in bowel habit</li><li>Abdominal bloating</li><li>Early satiety</li><li>Pelvic pain</li><li>Urinary frequency/urgency</li><li>Weight loss</li></ul></div>
What does the risk of malignancy index relating to ovarian cancer take into account?
<div>Estimates the risk of an ovarian mass being malignant</div>
<ul><li>Menopausal status</li><li>Ultrasound findings</li><li>CA125 level</li></ul>
Name some risk factors for developing vulval cancer
<ul><li>Advancing age</li><li>HPV infeciton</li><li>Vulval intraepithelial neoplasia(VIN)</li><li>Immunosuppression</li><li>Lichen sclerosus</li></ul>
Name some differential diagnoses for vulval cancer
<div><div><div><div><div><div><ul><li>Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.</li><li>Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.</li><li>Bartholin's cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.</li></ul></div></div></div></div></div></div>
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What investigations might be done to diagnose vulval cancer?
<ul><li>Torough exam of vulva</li><li>Biopsy</li><li>Imaging/blood tests to a\ssess extent of disease and staging</li></ul>
What are the treatment options for VIN
<ul><li><b><i>Watch and wait</i></b> with close followup</li><li><b><i>Wide local excision</i></b> (surgery) to remove the lesion</li><li><b><i>Imiquimod</i></b> cream</li><li><b><i>Laser ablation</i></b></li></ul>
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What age group(s) are most at risk of developing a molar pregnancy?
Extreme ends of the fertility age range: <br></br><ul><li><16yrs</li><li>>45yrs</li></ul>
What is a complete molar pregnancy?
<ul><li>Formation from a single sperm and empty egg with no genetic material</li><li>Sperm replicates to provide a normal number of chromosomes-all paternal origin</li><li>No foetal tissue, only proligeration of swollen chorionic villi</li></ul>
What is a partial molar paregnancy?
<ul><li>Formed from 2 sperm and a normal egg</li><li>Both paternal and maternal genetic materials present</li><li>Variable evidence of foetal parts</li></ul>
Name some differential diagnoses for a molar pregnancy
<ul><li>Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.</li><li>Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.</li><li>Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.</li></ul>
Name 2 complications of molar pregnancies
Choriocarcinoma<br></br>Mole can metastasise-> patient may require systemic chemotherapy
What is endometriosis?
Growth of ectopic endometrial tissue outside of the uterine cavity
Name some theories thought to explain the cause of endometriosis
<ul><li>Retrograde menstruation</li><li>Coelomic metaplasia</li><li>Lymphatic/vascular dissemination of endometrial cells</li></ul>
Name some differential diagnoses for endometriosis
<ul><li>Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.</li><li>Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.</li><li>Adhesions: pelvic pain and possible bowel obstruction.</li><li>Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.</li></ul>
What investigations are used to diagnose endometriosis?
<ul><li>Transvaginal US-> Often normal but may ID an ovarian endometrioma</li><li>GS: Diagnositc laparoscopy</li></ul>
Name a complication of endometriosis
<ul><li>Infertility</li><li>Poor quality of life due to chronic pain</li></ul>
<div>The {{c1::<b><i>American Society of Reproductive Medicine</i></b> (<b><i>ASRM</i></b>)}} has a staging system for endometriosis.</div>
<ul><li>Stage 1: {{c2::Small superficial lesions}}</li><li>Stage 2: {{c3::Mild, but deeper lesions than stage 1}}</li><li>Stage 3: {{c4::Deeper lesions, with lesions on the ovaries and mild adhesions}}</li><li>Stage 4: {{c5::Deep and large lesions affecting the ovaries with extensive adhesions}}</li></ul>
What is adenomyosis?
Presence of endometrial tissue within the myometrium
In which group of people is adenomyosis most common in?
Multiparous women towards the end of their reproductive years
What conditions can adenomyosis occur with?
<ul><li>Endometriosis</li><li>Fibroids</li></ul>
What investigations are done to diagnose adenomyosis?
1st line: transvaginal US of pelvis<br></br>If unsuitable: MRI and transabdominal US<br></br>GS: Histological exam of the uterus after a hysterectomy(mostly unsuitable)
What complications relating to pregnancy can adenomyosis cause?
<ul><li>Infertility</li><li>Miscarriage</li><li>Preterm birth</li><li>Small for gestational age</li><li>Preterm rupture of membranes</li><li>Malpresentation</li><li>Need for C section</li><li>Postpartum haemorrhage</li></ul>
What is atrophic vaginitis?
Inflammation and thinning of the geniatl tissues due to a decrease in oestrogen levels
What causes atophic vaginitis?
Decline in oestrogen levels, typically post-menopause
On examination, what might you find in a patient with atrophic vaginitis?
Pale and dry vagina<br></br><ul><li>Loss of pubic hair</li><li>Thinning of vaginal mucosa</li><li>Narrowed introitus</li><li>Loss of vaginal rugae</li></ul>
Name some differentials for atrophic vaginitis
<ul><li>For postmenopausal bleeding: <strong>malignancy</strong>, endometrial hyperplasia</li><li>For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes</li><li>For narrowed introitus: female genital mutilation</li><li>For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis</li><li>For dyspareunia: malignancy, vaginismus</li></ul>
What investigations should be done in a patient presenting with likely atrophic vaginitis?
<ul><li>Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy</li><li>Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer</li><li>An infection screen if itching or discharge is present</li><li>A biopsy of any abnormal skin lesions, if needed</li></ul>
What is a miscarriage?
Loss of pregnancy <24 weeks gestation
Name some risk factors for having a miscarriage
<ul><li>Maternal age >30</li><li>Previous miscarriage</li><li>Obesity</li><li>Smoking</li><li>APS</li><li>Uterina abnormalities</li><li>Coagulopathies</li><li>Previous uterine surgeries</li><li>Chromosomal abnormalities</li></ul>
Name some symptoms of a miscarriage
<ul><li>Often found incidentally on US</li><li>Vaginal bleeding->clots/conception products</li><li>If lots of bleeding: signs of haemodynamic instability: pallor, dizziness, SOB</li><li>Suprapubic, cramping pain</li></ul>
<b>Signs a patient is having a miscarriage:</b><br></br><br></br><ul><li>Haemodynamic instability: {{c1::tachycardia, hypotension, tachypnoea}}<br></br></li><li>Abdominal exam: {{c2::distended, local areas of tenderness}}</li><li>Speculum exam: {{c3::diameter of cervical os, products of conception, bleeding}}</li><li>Bimanual exam: {{c4::uterine tenderness, adnexal masses/collections}}</li></ul>
Name some differentials for a miscarriage
<ul><li>Ectopic pregnancy</li><li>Hydatidiform mole</li><li>Cervical/uterine cancer</li></ul>
What blood might be done in a patient suspected of having a miscarriage?
b-HCG-important to also assess the possibility of an ectopic pregnancy
What are the different kinds of miscarriage?
<ul><li>Threatened</li><li>Inevitable</li><li>Missed/delayed</li><li>Incomplete</li><li>Complete</li><li>Septic</li></ul>
What is an ectopic pregnancy?
<ul><li>Embryo implants and beigns to grow outside fo the uterine cavity, usually in the fallopian tuubes</li></ul>
Name some of the causes/risk factors for having an ectopic pregnancy
<ul><li>Pelvic inflammatory disease</li><li>Endometriosis</li><li>Genital infections</li><li>Previous ectopic pregnancies</li><li>Having an IUD/coil in situ</li><li>Assissted reproduciton like IVF</li></ul>
Name some differentials for an ectopic pregnancy
<ul><li>Miscarriage</li><li>UTI</li><li>Appendicitis</li><li>Diverticulitis</li><li>PID</li><li>Ovarian accident</li></ul>
What investigations should be done in a patient with a suspected ectopic pregnancy?
<ol><li>B-HCG-POSITIVE</li><li>Pelvic US</li><li>Transvaginal US</li></ol>
<div>Can't find evidence of pregnancy on any scans</div>
<div><br></br></div>
<div><ul><li>Serum B-HCG</li></ul></div>
<b>Serum B-HCG in suspected ectopic pregnancy:<br></br></b><br></br><ul><li>Initial >1500iU: {{c1::ectopic-diagnostic laparoscopy}}</li><li>Initial <1500iU {{c2::and stable: repeat in 48 hours}}</li></ul><div><br></br></div><div><br></br></div>
Using B-HCG monitoring how can you tell if a patient is having a miscarriage or has a viable pregnancy?
<ul><li>Viable pregnancy: will double every 48 hours</li><li>Miscarriage: halves every 48 hours</li></ul>
What complications can arise from an ectopic pregnancy
<ul><li>Fallopian tube rupture-> hypovolaemic shock->organ failure-> death</li></ul>
Name some causes of oligohydramnios
<ul><li>Pre-term rupture of membranea</li><li>Non-functional kidneys</li><li>Renal agenesis(Potter's)</li><li>Obstructive uropathy</li><li>Placental insufficiency</li><li>Chromosomal abnormalities</li><li>Viral infections</li></ul>
What are the most common causes of oligohydramnios?
<ul><li>Pre-term rupture of membranes</li><li>Placental insufficiency </li></ul>
What causes symptoms in patients with oligohydramnios?
<ul><li>Decreased space around fetus</li><li>Lack of amniotic fluid for fetal growth and development</li></ul>
What investigations are typically done to diagnose oligohydramnios?
USS:<br></br><ul><li>Reduced amniotic fluid index</li><li>Reduced max pool depth(MPD) or single deepest pocket(SDP)</li></ul><div>To ID underlying cause:</div><div><ul><li>Meernal bloods</li><li>Karyotyping</li></ul><div>If membrane rup[ture suspecteD:</div></div><div><ul><li>IGFBP-1 or PAMG-1(usually in amniotic fluid)</li></ul></div>
What is important to remember if delivering a baby early via C-section due to oligohydramnios?
Give a course of steroids for fetal lung development and antibtiotics to lower risk of infection
What complications can arise from oligohydramnios and why?
<ul><li>Amniotic fluid allows fetus to move in utero</li><li>No fluid-> no exercise-> muscle contracures-> disability after birth</li></ul>
What investigations might be done in a patient with polyhydramnios?
USS-diagnostic<br></br>To look for cause:<br></br><ul><li>Maternal glucose tolerance test</li><li>Fetal anaemia</li><li>Karyotyping</li><li>Fetal anatomy for structural cause</li><li>Viral screen(TORCH)</li></ul>
<b>Viral screen: TORCH</b><br></br><ul><li>T{{c1::oxoplasmosis}}<br></br></li><li>P{{c2::arvovirus}}</li><li>R{{c3::ubella}}</li><li>C{{c4::MV}}</li><li>H{{c5::epatitis}}</li></ul>
What are the 2 stages of labour?
<ul><li>Latent phase: 0-3cm cervical dilation</li><li>Active phase: 3-10cm cervical dilation</li></ul>
Name some differentials for the first stage of labour
<ul><li>Braxton Hicks</li><li>Preterm labour</li></ul>
What investigations might be done if a woman is in the first stage of labour?
<ul><li>Regular assessment of maternal and foetal vital signs</li><li>Frequent exam to determine cervical dilation and effacement</li><li>Palpation to assess position and descent of foetus</li></ul>
Name some signs and symptoms of the second stage of labour
<ul><li>Foetal head flexion, descent and ngagement into the pelvis</li><li>Foetal internal rotation to face maternal back</li><li>Foetal head extension to deliver head</li><li>Foetal external rotation after delivery of head, positioning of shoulders in AP position</li><li>Delivery of anterior shoulder first then rest of foetus</li><li>Maternal desure to push</li></ul>
Name some signs indicative of the 3rd stage of labour
<ul><li>Gush of blood from vagina</li><li>Lengthening of umbilical cord</li><li>Ascension of uterus in abdomen</li></ul>
Name some indications for inducing labour
<ul><li>Post dates: >41 weeks gestation</li><li>Preterm prelabour rupture of membranes</li><li>Intrauterine foetal death</li><li>Abnormal CTG</li><li>Maternal conditions like pre-eclampsia, diabetes, cholestasis</li></ul>
Name some contrainidctaions for inducing labour
<ul><li>Previous classica/vertical incision during C-section</li><li>Multiple lower uterine segment C-sections</li><li>Transmissable infections </li><li>Placenta praevia</li><li>Malpresentations</li><li>Severe fetal compromise</li><li>Cord prolapse</li><li>Vasa previa</li></ul>
What investigations might be carried out prior to starting inductino of labour?
<ul><li>US: confirm gestational age, foetal position and placental location</li><li>Bloods: Check mother's health status-pre-eclampsia/diabetes</li></ul>
Name some differentials for pre-term labour
<ul><li>Braxton Hicks</li><li>UTI</li><li>Placental abruption</li><li>Uterine rupture</li></ul>
What investigations might be done in a patient presentign with pre term labour
<ul><li>Foetal fibroenctin tes(fFN)- assesss risk of pre term elivery after onset of pre-term labour</li></ul>
What age does menopause usually happen?
<ul><li>45-55</li><li>Average in UK: 52yrs</li></ul>
Name some symptoms of menopause
<ul><li>Vasomotor: hot flushes, night sweats</li><li>Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm</li><li>Psychological: depression, anxiety, brain fog</li></ul>
Name some differentials for menopause
<ul><li>Hyperthyroidism</li><li>Depression</li><li>premature ovarian insufficiency</li></ul>
What are the types of HRT
<ul><li>Oestrogens-can be oral, transdermal or topical</li><li>Progestogens-oral, transdermal, intrauterine</li></ul>
Name some benefits of HRT
<ul><li>Relief of vasomotor sx</li><li>Relief of urogential sc</li><li>Reduced risk of osteoporosis</li></ul>
Name some things HRT can increase the risk of?
<ul><li>Breast cancer</li><li>Endometrial cancer(especially if given alone)</li><li>VTE</li></ul>
Name some contraindications for prescribing HRT
<ul><li>Breast cancer</li><li>Oestrogen dependednt cancer</li><li>Vaginal bleeding of unknown cause</li><li>Pregnancy</li><li>Untreated endometrial hyperplasia</li><li>VTE</li><li>Liver disease with abnormal LFTs</li></ul>
Name some complications of menopause
<ul><li>Osteoporosis</li><li>Cardiovascular disease</li><li>Dyspareunia</li><li>Urinary incontinence</li></ul>
What does GnRH do for the menstrual cycle?
<ul><li>Released from the hypothalamus and stimulates LH and FSH release from anterior pituitary</li></ul>
What are the phases of the ovarian cycle?
<ul><li>Follicular </li><li>Ovulation</li><li>Luteal</li></ul>
What happens during the follicular phase of the ovarian cycle?
<ul><li>Follicles begin to mature and prepare to release an oocyte</li></ul>
<div>At the start: low ovarian hormoen profuction: little negative feedback at HPG axis so increase in FSH and LH</div>
<div>Only 1 follicle can reach maturity, other follicles form polar bodies</div>
<div>Oestrogen becomes high enough to initiate positive feedback, increases everything, especially LH but increased inhibin means FSH doesn't surge(inhibin selectively inhibits FSH)</div>
<div>Granulosa cells express LH receptors</div>
<div><img></img><br></br></div>
What happens during the ovulaton stage of the ovarian cycle
<ul><li>Response to LH surge: follicle ruptures and oocyte assissted to fallopiani tube by fimbria-> viable for fertilisaton for 24 hours</li><li>After ovulation, follicel remains luteinised, secreting oestrogen and progesterone</li></ul>
<div><img></img><br></br></div>
What happens in the luteal phase of the ovarian cycle?
<ul><li>In absence of fertilisation: corpus luteum regresses after 14 days, fall in hormones relieving negative feedback</li></ul>
<div><img></img><br></br></div>
What happens to the corpus luteum if fertilisation occurs?
<ul><li>HCG is produced exerting a leuteningin effect to maintain the corpus luteum</li></ul>
What are the stages of the uterine cycle?
<ul><li>Proliferative </li><li>Secretory</li><li>Menses</li></ul>
<div><br></br></div>
<div><img></img><br></br></div>
What happens in the proliferative phase of the uterine cycle?
<ul><li>Runs alongside follicular phase</li><li>Prepares reproductive tract for fertilisation and implantation</li><li>Oestrogen initiates fallopian tube formation-> endometrium thickening-> increased growth and motility o fmyometrium and productive of thin alkaline cervical mucus</li></ul>
<div><br></br></div>
<div><img></img><br></br></div>
What happens during the secretory phase of the uterine cycle?
<ul><li>Runs alongside luteal phase</li><li>Progesterone stimulates thickening of endometrium into glandular secretory form, thickening of myometrium, reduction of motility in myometrium, thick acidic cervical mucus production(prevent polyspermy)</li></ul>
<div><img></img><br></br></div>
What are the main hormones involved in:<br></br>a)proliferative phase<br></br>b)secretory phase?
a)oestrogen<br></br>b)progesterone
Name some differentials for PCOS
<ul><li>Menopause</li><li>Congenital adrenal hyperplasia</li><li>Hyperprolactinaemia</li><li>Androgen secreting tumour</li><li>Cushing's</li></ul>
What investigations might be done to diagnose PCOS?
<ul><li>Bedside: clinical exam to look for features of hyperandrogenism/insulin resistance</li><li>Bloods: LH:FSH ratio, total testosterone, fasting/oral glucose tolerance, TFT, prolactin, cortisol</li><li>Imaging: transabdominal/transvaginal USS</li></ul>
What diagnostic criteria is used for PCOS?
<ul><li>Rotterdam diagnostic criteria</li></ul>
Name some complications of PCOS
<ul><li>Infertility</li><li>Metabolic syndrome and dyslipidaemia</li><li>T2DM</li><li>CVD</li><li>Hypertension</li><li>Obstructive sleep apnoea</li></ul>
What is Asherman’s syndrome?
<ul><li>Adhesions(synechiae) form within uterus following damage to the uterus</li></ul>
Name some common causes of Asherman’s syndrome
<ul><li>Pregnancy related dilatation and curettage procedure</li><li>Post uterine surgery</li><li>Pelvic infections</li></ul>
Name some complications of Asherman’s syndrome
<ul><li>Menstruation abnormalities</li><li>Infertility</li><li>Recurrent miscarriages</li></ul>
What are congenital malformations of the female genital tract?
<ul><li>Deviations form normal anatomy resulting from embryonic maldevelopment of Mullerian or paramesonephric ducts</li></ul>
What are the most common types of congenital uterine abnormalities caused by?
<ul><li>Incomplete fusion of mullerian or paramesonephric ducts</li></ul>
Name some complications of congenital uteirne abnormalities
<ul><li>Dysmenorrhoea</li><li>Haematoemtra</li><li>Complicaitons during pregnancy and labour</li><li>Congenital renal abnormalities often co-exist</li></ul>
What are endometrial polyps?
<ul><li>Benign growths of endometrial lining of the uterus, consisting of glandular epithelium, stroma and blood vessels</li></ul>
What age groups are endometrial polyps found in?
<ul><li>Reproductive age women</li><li>Can occur post menopausal</li></ul>
Name some risk factors for polyps
<ul><li>Obesity</li><li>Htn</li><li>Tamoxifen</li><li>HRT</li></ul>
Name some differentials for a polyp
<ul><li>Fibroid</li><li>Adenomyoma</li><li>Endometrial carcinoma</li><li>Gestation trophoblastic disease</li></ul>
Name some complications fo endometrial polyps
<ul><li>Small percentage may have atypical hyperplasia/endometrial carcinoma</li><li>Anaemia due to chronic blood loss in those with heavy menstrual bleeding</li></ul>
Name the causative organisms of PID
<ul><li>Chlamydia trachomatis-most common cause</li><li>Gonnorhoea</li><li>Mycoplasma genitalium</li><li>Mycoplasma hominis</li><li>Sometiems no pathogen isolates</li></ul>
What is Fitz Hugh Curtis syndrome?
<ul><li>Adhesions form between anterior liver capsule and anterior wall/diaphragm in context of PIC</li></ul>
