Women's Health 1 (Gynae/Breast) Flashcards
What is pelvic organ prolapse?
When pelvic organs descend into the vagina as a result of weakness and lengthening of the ligaments and muscles which surround the uterus, rectum and bladder
What is vault prolapse?
occurs in women who have had a hysterectomy and is when the top of the vagina (the vault) descends into the vagina
What is a rectocele? What symptom is this commonly associated with?
caused by a defect in the posterior vaginal wall which allows the rectum to prolapse forwards into the vagina
they are particularly associated with constipation as women can develop faecal loading in the part of the rectum which has prolapsed into the vagina
women can use their fingers to press the lump backwards, correcting the anatomical position of the rectum and allowing them to open their bowels
What is a cystocele?
where a defect in the anterior vaginal wall allows the bladder to prolapse backwards into the vagina
the urethra can also undergo prolapse (urethrocele) and prolapse of both the bladder and urethra is called a cystourethrocele
What are some risk factors for pelvic organ prolapse?
multiple vaginal deliveries
instrumental, prolonged or traumatic delivery
advanced age and postmenopause status
obesity
chronic respiratory disease causing coughing
chronic constipation causing straining
What are the typical presenting symptoms of pelvic organ prolapse?
feeling of something coming down in the vagina
dragging or heavy sensation in the pelvis
urinary symptoms e.g. incontinence, urgency, frequency, weak stream and retention
bowel symptoms e.g. constipation, altered sensation, reduced enjoyment
lump or mass in the vagina
What are the gradings in the pelvic organ prolapse quantification (POP-Q) system?
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
What is the management for pelvic organ prolapse? 3 main options
Conservative management
- physio, weight loss, lifestyle changes, treatment of related symptoms, vaginal oestrogen cream
Vaginal pessary (ring, cube, donut, hodge, Shelf and Gellhorn)
Surgery (definitive treatment)
- many potential surgical methods including hysterectomy
- mesh repair used to be an option but NICE recommend avoiding them due to complications
What is an overactive bladder?
also known as urge incontinence
caused by overactivity of the detrusor muscle of the bladder
sudden feeling of needing to pass urine and inability to control bladder
What is stress incontinence?
when urine leaks at times of increased pressure on the bladder often when laughing, coughing or surprised
caused by weakness of the pelvic floor and sphincter muscles
What are some risk factors for urinary incontinence? x8
increased age
postmenopausal status
increased BMI
previous pregnancies and vaginal deliveries
pelvic organ prolapse
pelvic floor surgery
neurological conditions, such as MS
cognitive impairment and dementia
What are the investigations used to assess urinary incontinence?
bladder diary recording fluid intake and episodes of urination and incontinence
urine dipstick testing
post-void residual bladder volume
urodynamic testing (catheters inserted into bladder and rectum which assess pressures)
What is the management for urge incontinence?
bladder retraining
anticholinergic medication (oxybutynin, tolterodine and solifenacin)
mirabegron
invasive procedures e.g. botox injections, augmentation cystoplasty
What is the management for stress incontinence?/
avoiding caffeine, diuretics and overfilling of the bladder
avoid ecessive or restricted fluid intake
weight loss if needed
supervised pelvic floor exercises
surgery e.g. TVT, autologous sling procedures, colposuspension
duloxetine
What are the most common types of vaginal fistula?
vesicovaginal fistula = tract connecting the vagina and bladder
rectovaginal fistula = tract connecting the vagina and the rectum
colovaginal fistula = tract connecting the vagina and colon
enterovaginal fistula = tract connecting the vagina and small intestine
What are some potential causes of vaginal fistualae? x6
childbirth
abdo surgery (hysterectomy, c-section)
pelvic, cervical or colon cancer
bowel disease e.g. Crohn’s, diverticulitis
infection
traumatic injury
Briefly describe the embryological development of the female genital tract/
the paramesonephric ducts (mullerian ducts) are a pair of passageways along the outside of the urogenital region which fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina
in a male foetus anti-mullerian hormone is produced , which suppresses the growth of the mullerian ducts, causing them to disappear
What is a bicornate uterus? complications? management?
where there are two horns to the uterus, giving it a heart-shaped appearance
can be associated with adverse pregnancy outcomes like miscarriage, premature birth or malpresentation but usually pregnancies are successful
in most cases, no specific management is required
What is an imperforate hymen? treatment? complications?
where the hymen at the entrance of the vagina is fully formed without an opening
often discovered at menarche as the menses are sealed in the vagina causing cyclical pelvic pain and cramping without vaginal bleeding
treatment is with surgical incision to create an opening in the hymen
potential complication is retrograde menstruation leading to endometriosis
What is transverse vaginal septae? complications? treatment?
an error in development where a septum forms transversely across the vagina
can either be perforate or imperforate so some girls will still menstruate but have difficulty with intercourse or tampon use whereas those with imperforate septae will present similarly to an imperforate hymen
can lead to infertility and pregnancy-related complications
treatment is with surgical correction
What is vaginal hypoplasia and agenesis? management?
vaginal hypoplasia is an abnormally small vagina
vaginal agenesis is an absent vagina
these occur due to failure of the mullerian ducts to properly develop and can be associated with an absent uterus and cervix
management may involve the use of a vaginal dilator to create an adequate vaginal size
in some cases surgical intervention is required
What is adenomyosis?
endometrial tissue inside the myometrium (muscle layer of the uterus)
What is the typical presentation of adenomyosis
dysmenorrhoea
menorrhagia
dyspareunia
enlarged, boggy uterus
infertility or pregnancy-related complications
1/3 of patients are asymptomatic
How is adenomyosis diagnosed?
1st line - transvaginal USS
MRI and transabdominal USS can also be used
GS = histological examination of the uterus after a hysterectomy (not usually appropriate)
What is the management for adenomyosis?
same as the treatment for heavy menstrual bleeding
for women who do not want contraception:
- tranexamic acid (if no associated pain) = antifibrinolytic
- mefenamic acid (with associated pain) = NSAID
for women who want or are happy to have contraceptives:
- mirena coil (1st line)
- COCP
- cyclical oral progestogens
What are some potential pregnancy complications caused by adenomyosis? x8
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
What is Asherman’s syndrome?
where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus
these adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages
What causes Asherman’s syndrome?
it usually occurs after a pregnancy-related dilatation and curettage (scraping) procedure, e.g. in the treatment of retained products of conception (removing placental tissue left behind after birth)
can also occur after uterine surgery or several pelvic infections
the adhesions can bind the uterine walls together, or within the endocervix, sealing it shut
What are the presentations of Asherman’s syndrome? x4
secondary amenorrhoea
significantly lighter periods
dysmenorrhoea
infertility
How is a diagnosis of Asherman’s syndrome confirmed? what is the treatment?
hysteroscopy (GS) also the treatment as adhesions can be dissected during this procedure
hysterosalpingography (XR imaging of the uterus with contrast)
sonohysterography (uterus is filled with fluid before pelvic USS)
MRI scan
What is lichen sclerosis? what does lichen refer to?
a chronic inflammatory skin condition which presents with patches of shiny, ‘porcelain-white’ skin and commonly affects the labia, perineum and perianal skin in women
lichen refers to a flat eruption that spreads
What are the symptoms of lichen sclerosus?
itching
soreness and pain (possibly worse at night)
skin tightness
superficial dyspareunia
erosions
fissures
What is the Koebner phenomenon?
occurs in lichen sclerosus when the signs and symptoms are made worse by friction to the skin
What is the appearance of the skin in lichen sclerosus?
porcelain-white colour
shiny
tight
thin
slightly raised
may be papules or plaques
What is the management for lichen sclerosus?
cannot be cured but symptoms can be effectively managed
long term strong topical steroids like clobetasol propionate
emollients
What are the potential complications of lichen sclerosus?
5% risk of squamous cell carcinoma of the vulva
sexual dysfunction
narrowing of the vaginal or urethral openings
bleeding, pain, discomfort
What is endometriosis? what is an endometrioma?
a condition where there is ectopic endometrial tissue outside the uterus
endometrioma = a lump of endometrial tissue outside the uterus
What causes endometriosis? what are the theories for the growth of ectopic endometrial tissue?
no clear cause
seems to be a genetic element
- retrograde menstruation where the endometrial lining flows backwards through the fallopian tubes during menstruation, into the pelvis and peritoneum where it seeds itself
- embryonic cells destined to become endometrial tissue remain in areas outside the uterus during foetal development and then develop into ectopic endometrial tissue
- spread of endometrial cells through the lymphatic system (similar to cancer spread)
- metaplasia of cells outside the uterus into endometrial cells
What are the symptoms of endometriosis?
can be asymptomatic
cyclical abdominal or pelvic pain
deep dypareunia
dysmenorrhoea
infertility
cyclical bleeding from other site e.g. haematuria
What investigations are used to diagnose endometriosis?
pelvic USS - may reveal endometriomas and chocolate cysts but more commonly unremarkable
laparoscopic surgery (GS) with biopsy and potential to removed deposits for symptom relief
What are the management options for endometriosis?
important parts of initial management are education, analgesia and partnership with patient to establish their ICEs
hormonal management: COCP, progesterone pill, depo injection, nexplanon implant, mirena coil, GnRH agonists
Surgical management: laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions, hysterectomy
What are some differential diagnoses for endometriosis? x8
pelvic inflammatory disease
ectopic pregnancy
torsion of an ovarian cyst
appendicitis
primary dymenorrhoea
IBS
uterine fibroids
UTI
What is a vulval intraepithelial neoplasia? what are some types of VIN?
a premalignant condition affecting the squamous epithelium of the skin which can precede vulval cancer
High grade squamous intraepithelial lesions are a type of VIN associated with HPV infection which typically occur in younger women aged 35-50
Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (50-60 yrs)
What are some risk factors for vulval cancer
lichen sclerosus (5% get vulval cancer)
advanced age (75+)
immunosuppression
HPV infection
What are the treatment options for VIN? x4
watch and wait
wide local excision to remove the lesion
imiquimod cream
laser ablation
What are the symptoms of vulval cancer? x6
vulval lump
ulceration
bleeding
pain
itching
lymphadenopathy of the groin
What are some features of vulval tumours? what part of the vulva is usually affected?
irregular mass
fungating lesion
ulceration
bleeding
most commonly affect the labia majora
How is a diagnosis of vulval cancer established?
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)
What are the management options for vulval cancer?
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
What is HPV? What are the important strains and associations? How does it increase the likelihood of cancer?
a viral STI associated with anal, vulval, penis, mouth and throat cancers
important strains are type 16 and 18 which are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine
HPV produces two proteins (E6 and E7) which inhibit the tumour suppressor genes, P53 and pRb respectively, promoting cancer development as a result
What are some of the risk factors for cervical cancer?
HPV - early sexual activity, multiple sexual partners, not using condoms
not having cervical screening
smoking
HIV
COCP for 5+ years
family history
exposure to diethylstilbestrol during foetal development
What are some symptoms of cervical cancer?
abnormal vaginal bleeding
vaginal discharge
pelvic pain
dyspareunia
What is cervical intraepithelial neoplasia? what are the grades?
a grading system for the level of dysplasia in the cells of the cervix
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
How is cervical cancer staged?
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
What is the management for cervical cancer?
Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
What is colposcopy?
a procedure where the epithelial lining of the cervix is examined in detail and stains such as acetic acid and iodine solution are used to identify abnormal areas
What is large loop excision of the transformation zone (LLETZ)?
also known as a loop biopsy and can be performed with local anaesthetic during a colposcopy procedure
uses a loop of wire with electrical current to remove abnormal epithelial tissue on the cervix
What is a cone biopsy? what are the potential risks?
a treatment for CIN and very early-stage cervical cancer
an operation performed under general anaesthetic where the surgeon removes a cone-shaped piece of the cervix using a scalpel which is then sent for histology to assess for malignancy
risks:
- pain
- bleeding
- infection
- scar formation with stenosis of the cervix
- increased risk of miscarriage and premature labour
What is pelvic exenteration
an operation which can be used in advanced cervical cancer and involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum
What is bevacizumab ?
a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer
targets vascular endothelial growth factor A which is responsible for the development of new blood vessels
also used to treat wet age-related macular degeneration
What are the most common types of cervical cancer?
80% are squamous cell carcinomas
adenocarcinoma
rarely small cell cancer
What is the screening programme for cervical cancer in the UK?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
What are the potential cytology results of cervical screening?
inadequate
normal
borderline changes
low-grade dyskaryosis
high-grade dyskaryosis (moderate/severe)
possible invasive squamous cell carcinoma
possible glandular neoplasia
can also identify bacterial vaginosis, cadididasis and trichomoniasis
What are the management options for smear results?
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
What is endometrial hyperplasia? prognosis? types?
a precancerous condition involving thickening of the endometrium
most cases return to normal over time
less than 5% will progress to endometrial cancer
2 types:
hyperplasia without atypia and atypical hyperplasia
What is the treatment for endometrial hyperplasia?
intrauterine system e.g. mirena coil
continuous oral progestogens e.g. medroxyprogesterone
What are some risk factors for endometrial cancer? x8
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity (adipose tissue is a source of oestrogen)
Polycystic ovarian syndrome
Tamoxifen (oestrogenic effect on the endometrium)
Why is PCOS a risk factor for endometrial cancer?
it lead to increased exposure to unopposed oestrogen due to a lack of ovulation
when ovulation occurs a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg and its the corpus luteum which produces progesterone and provide endometrial protection during the luteal phase of the menstrual cycle
women with PCOS are less likely to ovulate and form a corpus luteum so progesterone is not produced and the endometrial lining has more exposure to unopposed oestrogen
What is used for endometrial protection in women with PCOS? x3
COCP
intrauterine system like mirena coil
cyclical progestogens to induce a withdrawal bleed
What are some protective factors against endometrial cancer?
COCP
mirena coil
increased pregnancies
cigarette smoking (due to anti-oestrogenic effect)
What are the symptoms of endometrial cancer? x7
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
What is the referral criteria for a 2 week-wait urgent cancer referral for endometrial cancer?
postmenopausal bleeding (12+ months after last menstrual period)
What potential symptoms of endometrial cancer trigger referral for a transvaginal USS in women over 55?
unexplained vaginal discharge
visible haematuria (with raised platelets, anaemia or raised blood glucose)
What are the 3 main investigations for diagnosing endometrial canceR?
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
What are the stages of endometrial cancer?
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
What is the management for endometrial cancer?
For stage 1 and 2 usually a total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAH and BSO) where the uterus, cervix and adnexa are removed
A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
What are the types of ovarian cancers
epithelial cell tumours (serous tumours (MC), endometrioid carcinomas, clear cell, mucinous tumours, undifferentiated tumours)
dermoid cysts/ germ cell tumours - teratomas (can contain other tissue types e.g. skin, teeth, hair and bone), particularly associated with ovarian torsion
sex cord-stromal tumours - rare and can be benign or malignant, arise from the stroma or sex cords, include sertoli-leydig cell tumours, granulosa cell tumours
metastasis - krukenberg tumour is a common type of metastasis in the ovary usually from the GI tract and these have characteristic signet ring cells on histology
What are some risk factors for ovarian cancer?
age (peak age 60)
BRCA1 and BRCA2 genes
increased number of ovulations
obesity
smoking
recurrent use of clomifene
What are 3 protective factors for ovarian cancer?
COCP
breastfeeding
pregnancy
What are the symptoms of ovarian cancer? x8
abdo bloating
early satiety
loss of appetite
pelvic pain
urinary symptoms
weight loss
abdo pain or pelvic mass
ascites
What examination findings trigger a 2 week-wait referral for ovarian cancer?
ascites
pelvic mass
abdo mass
What are the investigations for ovarian cancer?
CA1245 blood test
pelvic USS
CT scan
histology using a CT guided biopsy, laparoscopy or laparotomy
paracentesis
What are the factors considered in the risk of malignancy index (RMI) for an ovarian mass?
menopausal status
USS findings
CA125 level
Which tumour markers could indicate a possible germ cell tumour?
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
What are some non-malignant caused of a raised CA125? x6
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
What is the staging for ovarian cancer?
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
What is vaginal cancer? how does it usually present ?
a squamous cell carcinoma involving the posterior wall of the upper third of the vagina. It may directly invade the bladder or rectum. Lesions may be ulcerative or exophytic.
80% of vaginal cancers are metastatic spread i.e. from the urethra, bladder, rectum etc.
vaginal bleeding/bloody discharge
What are the investigations for vaginal cancer?
colposcopy
biopsy, cervical cytology, endometrial biopsy
CT scan
fluorodeoxyglucose-positron emission tomography
CXR
cytoscopy, sigmoidoscopy
What is the staging for vaginal cancer?
Stage 0 - squamous cell carcinoma in situ; this disease is usually multifocal and commonly occurs at the vaginal vault.
Stage I - the disease is limited to the vaginal wall mucosa.
Stage II - the disease involves the subvaginal tissue, but not the pelvic wall.
Stage III - the disease extends to pelvic wall.
Stage IV - the disease either extends beyond the true pelvis or involves the bladder or rectal mucosa:
Stage IVA - the disease has spread to adjacent organs.
Stage IVB - the disease has spread to distant organs.
What are the management options for vaginal cancer?
dependent on tumour stage
surgery and radiotherapy are very effective in early-stage disease
radiation therapy is the treatment of choice in most patient with vaginal cancer, particularly in later-stage disease
chemoradiation therapy (cisplatin, 5-fluorouracil)
What is a hydatidiform mole? complete vs partial?
also known as a molar pregnancy where a mass of tissue grows inside the womb which will not develop into a baby
a complete mole occurs when two sperm cells fertilise an ovum which contains no genetic material and so the genetic material of the sperm combine and divide
a partial mole is when 2 sperm cells fertilise a normal ovum at the same time so that it has 3 sets of chromosomes and then divides and multiplies into a tumour called a partial mole (some foetal material may develop)
What are some indicators for a molar pregnancy which differ from a normal pregnancy?
molar pregnancies generally behave like a normal pregnancy
- more severe morning sickness
- vaginal bleeding
- increased enlargement of the uterus
- abnormally high hCG
- thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3/T4)`
What is the characteristic sign of a molar pregnancy on USS?
snowstorm appearance (created by the presence of many hydropic villi which give the appearance of a central heterogenous mass filling the entire uterine cavity)
What is the management for molar pregnancies?
evacuation of the uterus to remove the mole
the products of conception need to be sent for histological examination to confirm a molar pregnancy
patients should be referred to the gestational trophoblastic disease centre for management and follow up
hCG levels should be monitored until they return to normal
occasionally the mole can metastasise and the patient may need systemic chemotherapy
What is gestational trophoblastic disease?
a group of pregnancy-related tumours which develop from the cells which surround the fertilised egg or embryo e.g. hydatidiform mole, choriocarcinoma, placental site trophoblastic tumour, epithelioid trophoblastic tumours
What are the potential causes of primary amenorrhoea? x3
primary amenorrhoea = when the patient has never developed periods
abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
abnormal functioning of the gonads (hypergonadotropic hypogonadism)
imperforate hymen or other structural pathology
What are some potential causes of secondary amenorrhoea? x9
pregnancy (MC)
menopause
physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
polycystic ovarian syndrome
medications, such as hormonal contraceptives
premature ovarian insufficiency (menopause before 40yrs)
thyroid hormone abnormalities (hypo or hyperthyroid)
excessive prolactin e.g. from a prolactinoma
Cushing’s disease
What is an endometrial polyp?
also known as uterine polyps
a fleshy tag of tissue which can appear on the neck or in the cavity of the uterus
usually benign but some can be cancerous or precancerous
What are some of the symptoms associated with endometrial polyps?
vaginal bleeding post-menopause
intermenstrual bleeding
frequent, unpredictable periods with varying length/heaviness
infertility
What are some risk factors for endometrial polyps? x4
being peri or post menopausal
obesity
tamoxifen (drug therapy for breast cancer)
HRT
What investigations would be used to diagnose endometrial polyps?
transvaginal USS
hysterosonography
hysteroscopy
endometrial biopsy
What is the treatment for endometrial polyps?
watch and wait
progestins or gonadotropin-releasing hormone agonists to relieve symptoms
polypectomy during hysteroscopy
What are uterine fibroids?
benign tumours of the smooth muscle of the uterus
also known as uterine leiomyomas
What are the types of uterine fibroids?
intramural (within the myometrium) - they change the shape of the uterus as they grow
subserosal (just below the outer layer of the uterus) - the grow outwards and can be very large
submucosal (just below the lining of the uterus)
pendunculated (on a stalk)
What are the symptoms of fibroids? x7
often asymptomatic
heavy menstrual bleeding (menorrhagia)
prolonged menstruation
abdo pain
bloating or feeling full in the abdomen
urinary or bowel symptoms (due to pelvic pressure or fullness)
deep dyspareunia
reduced fertility
What are the investigations for fibroids?
hysteroscopy
pelvic USS
MRI scanning
What are the management options for fibroids <3cm?
for fibroids less than 3cm (same as management for heavy menstrual bleeding):
mirena coil
symptomatic management
combined oral contraceptive
cyclical oral progestogens e.g. medroxyprogesterone acetate
endometrial ablation
resection of submucosal fibroids during hysterectomy
hysterectomy
What are the management options for fibroids >3cm?
for fibroids more than 3cm
referral to gynaecology needed
symptomatic management with NSAIDs and tranexamic acid
mirena coil
combined oral contraceptive
cyclical oral protestogens
uterine artery embolisation
myomectomy
hysterectomy
Briefly explain the following terms which are surgical treatments for fibroids:
myomectomy
endometrial ablation
hysterectomy
myomectomy = surgical removal of the fibroid via laparoscopic surgery or laparotomy
endometrial ablation = destruction of the endometrium by inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid which burn the endometrial lining of the uterus
hysterectomy = removal of the uterus and fibroids which can be laparoscopy (keyhole), laparotomy (open) or vaginal approach
What are some of the complications of uterine fibroids? x9
menorrhagia (+/- anaemia)
reduced fertility
pregnancy complications e.g. miscarriages, premature labour, and obstructive delivery
constipation
urinary outflow obstruction and UTIs
red degeneration of the fibroid
torsion of the fibroid
malignant change to a leiomyosarcoma (very rare)
What is red degeneration of the fibroid? why does it occur?
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
more likely to occur in larger fibroids (5cm+) in the 2nd or 3rd trimester of pregnancy
may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy
What symptoms indicate red degeneration of fibroids? what is the management?
severe abdo pain
low-grade fever
tachycardia
vomiting
management = supportive - rest, fluids and analgesia
What is an ovarian cyst?
a fluid-filled sac in the ovary
majority benign in premenopausal women but more concerning for malignancy in postmenopausal women
What is required for a diagnosis of PCOS?
anovulation
hyperandrogenism
polycystic ovaries on USS
What are some symptoms of ovarian cysts?
mostly asymptomatic
pelvic pain
bloating
fullness in the abdomen
palpable pelvic mass
What are the 2 types of functional ovarian cysts? what causes them?
follicular cysts - occur when the developing follicle fails to rupture and release the egg but a cyst persists
corpus luteum cysts - occur when the corpus luteum fails to break down and instead fills with fluid
What is the management for simple ovarian cysts in premenopausal women? size-dependent
less than 5cm - almost always resolve within 3 cycles and do not require a follow up scan
5-7cm - require routine referral to gynaecology and yearly USS monitoring
7+cm - consider an MRI scan or surgical evaluation
persistent or enlarging cysts may require laparoscopy or ovarian cystectomy or oophorectomy
What are some potential complications of ovarian cysts?
torsion
haemorrhage into the cyst
rupture with peritoneal bleeding
What is Meig’s syndrome
triad of:
ovarian fibroma
pleural effusion
ascites
typically occurs in older women and removal of the tumour results in complete resolution of the effusion and ascites
What is ovarian torsion?
where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
usually due to an ovarian mass >5cm e.g. cyst or tumour
twisting of the adnexa and blood supply to the ovary leads to ischaemia so if the torsion persists, necrosis occurs and the function of the ovary will be lost
therefore ovarian torsion is an emergency requiring prompt diagnosis and management
How does ovarian torsion present? what might be found on examination?
sudden onset severe unilateral pelvic pain
the pain is constant, gets progressively worse and is associated with nausea and vomiting
can take a milder and more prolonged course in some cases with less severe pain
occasionally the ovary can twist and untwist intermittently resulting in pain which comes and goes
localised tenderness and potentially a palpable mass in the pelvis on examination
How is ovarian torsion diagnosed? management?
pelvic USS which may show a whirlpool sign, free fluid in pelvis and oedema of the ovary
laparoscopic surgery is used to make a definitive diagnosis and treat it
detorsion or oophorectomy may be performed during laparoscopic surgery
What are the rotterdam criteria for PCIS?
oligoovulation or anovulation (irregular or absent menstrual periods)
hyperandrogenism (characterised by hirsutism and acne)
polycystic ovaries on USS
diagnosis requires 2 or 3 of these features
What are some key features of PCOS? x6
oligomenorrhoea or amenorrhoea
infertility
obesity (~70% patients)
hirsutism
acne
hair loss in a male pattern
What are some other conditions/symptoms linked with PCOS? x8
insulin resistance and diabetes
acanthosis nigricans (due to insulin resistance)
cardiovascular disease
hypercholesterolaemia
endometrial hyperplasia and cancer
obstructive sleep apnoea
depression and anxiety
sexual problems
What are some differential diagnoses for hirsutism? x5
PCOS
medications e.g. phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
ovarian or adrenal tumours secreting androgens
Cushing’s syndrome
congenital adrenal hyperplasia
What are the blood tests recommended in PCOS diagnosis? x6 which are usually raised?
testosterone
sex hormone-binding globulin
luteinizing hormone
follicle-stimulating hormone
prolactin
thyroid-stimulating hormone
LH, LH:FSH ratio, testosterone, insulin and sometimes oestrogen are all typically raised in PCOS
What is seen on USS in PCOS?
string of pearls appearance where the follicles are arranged around the periphery of the ovary
ovarian volume of >10cm3
What are the general management steps for PCOS?
weight reduction if appropriate
risk management for risks associated with diabetes, cardiovascular disease, endometrial cancer e.g. smoking cessation, antihypertensive medications, COCP, mirena coil (continuous endometrial protection)
What are some treatments for hirsutism and acne associated with PCOS?
COCP (1st line for acne)
topical adapalene (retinoid), antibiotics (clindamycin with benzoyl peroxide) or azelaic acid for acne
topical elflornithine (for facial hirsutism)
spironolactone (mineralocorticoid antagonist with anti-androgen effects), flutamide (non-steroidal anti-androgen) and finasteride (5a-reductase inhibitor which decreases testosterone production)
WHat are some treatments for infertility associated with PCOS?
weight reduction if applicable
metformin, clomifene or a combination to stimulate ovulation (ongoing efficacy debate)
gonadotrophins
ovarian drilling (puncturing holes into the ovaries to improve the woman’s hormonal profile and result in regular ovulation and fertility)
What is a prolactinoma? how can they be classified?
a type of pituitary adenoma
size classification: microprolactinoma = <1cm and macroprolactinoma = >1cm
hormonal status classification: secretory/functioning adenoma produces an excess of a particular hormone and a non-secretory/functioning adenoma does not produce excess hormone
What are some features of excess prolactin in women? x4
amenorrhoea
infertility
galactorrhoea
osteoporosis
What are some features of excess prolactin in men? x4
impotence
loss of libido
galactorrhoea
gynaecomastia
What are some symptoms of pituitary macroadenomas?
headache
visual disturbances e.g. bitemporal hemianopia or upper temporal quadrantanopia
symptoms and signs of hypopituitarism (lethargy, anorexia, decreased muscle strength and bone density, impotency)
How are prolactinomas diagnosed and managed>
diagnosis = MRI
management:
- dopamine agonists e.g. cabergoline, bromocriptine which inhibit the release of prolactin from the pituitary gland
- trans-sphenoidal surgery to remove the tumour (when medical therapy failed)
- radiation therapy
What are the minimum investigations for a palpable breast mass for women:
- under 25 years
- 25-40 years
- over 40 years
<25 yrs - histology or cytology only. No imaging if clinically feels benign. USS if clinically indeterminate or suspicious. Risk of malignancy negligible in this age group.
25-40 years: breast USS plus histology or cytology. Triple assessment
over 40 yrs: mammography and USS and either histology or cytology: Triple assessment
Why is USS favoured over mammography in women under 40?
In younger women the breast tissue is dense and predominately glandular. With age it becomes less dense and dominated by fatty tissue.
Mammograms struggle to differentiate between fluid-filled cysts and solid masses in dense breasts so are less useful diagnostically in younger women
What are breast cysts and what are they like on examination?
benign, individual, fluid-filled lumps
most common cause of breast lumps
on examination:
smooth
well-circumscribed
mobile
possibly fluctuant
What are the clinical assessment gradings of breast lumps?
P1 - Normal
P2 - Benign
P3 - Indeterminate
P4 - Suspicious
P5 - malignant
What is the most common cause of a breast lump?
breast cyst
What is fat necrosis in the breast? how does it present on examination? what are the common triggers? how is it diagnosed/managed?
localised degeneration and scarring of fat tissue in the breast which causes a benign lump
O/E:
painless
firm
irregular
fixed in local structures
may be skin dimpling or nipple inversion
may be associated with an oil cyst containing liquid fat
commonly triggered by localised trauma, radiotherapy or surgery –> an inflammatory reaction resulting in fibrosis and necrosis of the fat tissue
can appear similar to breast cancer on mammogram so biopsy may be required to rule this out
conservative management as can resolve spontaneously over time
surgical excision may be used if required for symptoms
What is a lipoma? how does it present on examination? management?
benign tumour of adipose tissue which commonly occurs in the breast
O/E:
soft
painless
mobile
do not cause skin changes
typically treated conservatively with reassurance, in some cases can be surgically removed
What is a galactocele? how do they present on examination? management?
breast milk filled cysts which occur when the lactiferous duct is blocked, preventing the gland from draining milk
O/E:
firm
mobile
painless
usually beneath the areola
usually resolve without treatment
is possible to drain them with a needle
small risk of infection
What is a phyllodes tumour? how are they managed?
rare tumour of the connective tissue of the breast which occur most often in 40-50yr old women
large and fast growing
can be benign (50%) or malignant (25%)
treatment involves surgical removal of the tumour and the surrounding tissue (wide excision)
can reoccur after removal
chemotherapy may be used in malignant or metastatic tumours
What are fibroadenomas? How do they present on examination? how are they managed?
common benign tumours of stromal/epithelial breast duct tissue
typically small and mobile within the breast tissue
more common in younger women between 20-40yrs
O/E:
painless
smooth
round
well circumscribed (well-defined borders)
firm
mobile
usually up to 3cm diameter
usually not treated, in some cases surgical removal is indicated
What are some risk factors for breast cancer? x7
female
increased oestrogen exposure (earlier onset of periods and later menopause)
more dense breast tissue (more glandular tissue)
obesity
smoking
family history (1st deg relative)
HRT (particularly combined)
*COCP –> small increase in breast cancer risk but it returns to normal ten years after stopping the pill
Which genes are assocaited with breast cancer? what chromosomes are they associated with?
BRCA1 on chromosome 17
BRCA2 on chromosome 13
What are some of the common types of breast cancer? x6
Invasive ductal carcinoma (MC) also known as ‘No Special Type’ while other rarer types are known as ‘Special type’
Invasive lobular carcinoma
Ductal carcinoma-in-situ
Lobular carcinoma-in-situ
Inflammatory Breast Cancer
Paget’s disease of the nipple
What are some rarer types of breast cancer?
medullary breast cancer
mucinous breast cancer
tubular breast cancer
multiple others
What is Paget’s disease of the nipple?
an eczematoid change of the nipple associated with an underlying breast malignancy and is present in 1-2% of patients with breast cancer
What is inflammatory breast cancer?
where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast
accounts for around 1 in 10,000 cases of breast cancer
What is the NHS screening program for breast cancer? how is this modified for high risk patients?
to offer a mammogram every 3 years to women aged 47-73yrs old
annual mammogram screening is offered to women with increased risk between specific age ranges, depending on their level of risk
What are some potential downsides to screening for breast cancer?
anxiety and stress
exposure to radiation, with a very small risk of causing breast cancer
missing cancer, leading to false reassurance
unnecessary further tests or treatment where findings would not have otherwise caused harm
What are the options for chemoprevention in patients at high risk of breast cancer?
tamoxifen if premenopausal
anastrozole if postmenopausal (except with severe osteoporosis)
What are some clinical features which may suggest breast cancer?
hard, irregular, painless or fixed lumps
lumps tethered to the skin or chest wall
nipple retraction
skin dimpling or oedema
lymphadenopathy (especially in the axilla)
What are the referral criteria according to NICE guidelines for suspected breast cancer?
an unexplained breast lump in patients aged 30 or above
unilateral nipple changes in patients aged 50 or above (discharge, retraction, other changes)
consider 2 week wait referral for:
an unexplained lump in the axilla in patients aged 30 or above
skin changes suggestive of breast cancer
What is included in the triple diagnostic assessment for suspected breast cancer? Why is it important?
clinical assessment
imaging (USS or mammography)
biopsy (fine needle aspiration or core biopsy)
Important to ensure concordance i.e. a clinically suspicious mass should
have suspicious imaging and cytology before a decision is made to remove a woman’s
breast. If there is discordance it may mean that the biopsy has missed the lesions and that further biopsies should be taken
What imaging is used in breast cancer assessment and why?
USS typically used to assess lumps in younger women (breasts are more dense and glandular), helpful in distinguishing solid lumps from cystic lumps
Mammograms are generally more effective in older women and can pick up calcifications not seen on USS
MRI scans can be used in women at higher risk of developing breast cancer, also to assess size and features of a tumour in more detail
What is a sentinel lymph node biopsy and when is it performed?
performed during breast surgery for cancer
an isotope contrast and a blue dye are injected into the tumour area and travel through the lymphatics to the first lymph node (the sentinel node)
this will show up blue on the isotope scanner and a biopsy can be performed to assess if cancer cells are present
What breast cancer receptors can be targeted with breast cancer treatments?
oestrogen receptors
progesterone receptors
human epidermal growth factor (HER2)
What is triple-negative breast cancer?
where the breast cancer cells do not express any of the breast cancer receptors resulting a worse prognosis due to limited treatment options
What are the main sites that breast cancer metastasises to?
Lungs
Liver
Bones
Brain
Can spread to anywhere though!
What are the management options for breast cancer? x5
surgery (mastectomy or wide local excision)
radiotherapy
hormone therapy
biological therapy
chemotherapy
What are some indications for mastectomy to treat a breast tumour? x4
multifocal tumour
central tumour
large lesion in small breast
DCIS >4cm
What are some indications for wide local excision of a breast tumour?
solitary lesion
peripheral tumour
small lesion in large breast
DCIS <4cm
When is radiotherapy recommended for breast cancer treatment?
whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around 2/3’s
radiotherapy is also offered to women who’ve had a mastectomy for T3-T4 tumours and for those with 4+ positive lymph nodes
when is hormonal therapy offered for breast cancer? what are the medications offered and how do they work?
if tumours are positive for hormone receptors
tamoxifen - a selective oestrogen receptor modulator whic either blocks or stimulates oestrogen receptors depending on the site of action (block in breast, stimulates in uterus and bone)
aromatase inhibitors (e.g. letrozole, anastrozole or exemestane) block the creation of oestrogen in fat tissue
What are some targeted treatments for HER2 positive breast cancer? x3
trastuzumab = monoclonal antibody which targets the HER2 receptor, may be used in patients with HER2 positive breast cancer
pertuzumab = monoclonal antibody which targets the HER2 receptor
neratinib = tyrosine kinase inhibitor, reducing the growth of breast cancers, may be used in HER2 positive breast cancer
What are the criteria for being classed as a high risk patient for breast cancer?
a first-degree relative with breast cancer under 40 yrs
a first-degree male relative with breast cancer
a first-degree relative with bilateral breast cancer, first diagnosed under 50 yrs
two first-degree relatives with breast cancer
When is radiotherapy indicated for breast cancer treatment?
- always given to the remaining breast after wide local excision
- after some mastectomies for poor prognosis, high-risk tumours
- as palliation for large or inoperable primary cancers
- to treat symptomatic bone mets
- to treat the axilla in women who cannot have axillary clearance surgery
- to reduce local recurrence rates (usually around 2/3rds)
Who is offered hormonal therapy for breast cancer?
all women with oestrogen sensitive breast cancer are offered 5 or more year of anti-oestrogen therapy
What are the 1st line hormonal therapies in pre and post menopausal women?
Pre-menopausal women:
- tamoxifen (30% increase in survival rate) (selective oestrogen receptor modulator which acts on oestrogen receptors throughout the body)
Post-menopausal women:
- aromatase inhibitors e.g. exemestane, letrozole, anastrozole (prevent the peripheral conversion of adrenal androgens to oestrogens by the aromatase enzyme in fatty tissues)
What is the follow up for a patient who has had breast cancer?
a mammogram every year for 5 years
What is the treatment for breast pain?
Reassurance that they do not have breast cancer is sufficient for 85% of women
Cyclical pain
1. simple explanation, reassurance and occasional simple analgesia
- Danazol - weak androgen and mild inhibitor of gonadal function by inhibition of LH and FSH (significant side effects to breast)
- Tamoxifen - can’t be given long term due to risk of endometrial cancer
- Goserelin - agonist of LH and FSH which causes stimulation of these receptors followed by a block
Non-cyclical pain - NSAIDs
What is mammary duct ectasia?
a benign condition where there is dilation of the large ducts in the breasts leading to intermittent discharge from the nipple which can be white, grey or green.
occurs most frequently in perimenopausal women
ectasia = dilation
What are the signs/symptoms of mammary duct ectasia?
nipple discharge
tenderness of pain
nipple retraction or inversion
a breast lump
What are the investigations used to diagnose duct ectasia?
Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (fine needle aspiration or core biopsy)
*Microcalcifications are a key finding on mammogram
Ductography
Nipple discharge cytology
Ductoscopy
What is the management for duct ectasia?
can resolve without any treatment
symptomatic management of mastalgia (breast pain)
antibiotics if infection is suspected or present
surgical excision of the affected duct in problematic cases
What is intraductal papilloma?
a warty lesion which grows within one of the ducts in the breast as a result of epithelial cell proliferation
What are the presenting signs/symptoms of intraductal papillomas?
can occur at any age
often asymptomatic
nipple discharge (clear or blood stained)
tenderness or pain
palpable lump
How does an intraductal papilloma present on ductography>
in ductography contrast is injected into the abnormal duct and a mammogram is then performed to visualise the duct
the papilloma will be seen as an area that does not fill with contrast
What is the management for intraductal papillomas?
they require complete surgical excision
What are the options for breast reconstruction following mastectomy?
Implants
Flap reconstruction
The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue.
Transverse Rectus Abdominis Flap (TRAM Flap)
Deep Inferior Epigastric Perforator Flap (DIEP Flap)
The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast.
what are the 3 features of physical examination which require 2ww referral for suspected ovarian cancer?
ascites
pelvic mass (unless clearly due to fibroids)
abdominal mass
What 3 factors are taken into account in the risk of malignancy index?
menopausal status
USS findings
CA125 level
What are some non-malignant causes of raised CA125?>
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy
