Women's Health

Question 1

Initial assessment of ovarian cyst in POST menopausal women

Answer 1

1st line Inv: TVUS + serum Ca125 to calculate RMI
Hx: ? symptoms of ovarian malignancy ? any fam Hx of ovarian, bowel or breast Ca
Inv of new onset (<12 months) of IBS symptoms in postmenopausal / >50 women
MRI should only be used as a 2nd line tool if US inconclusive. CT only be 2nd line to staging if US findings / Ca125 suspicious of malignancy
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg_34.pdf RCOG Greentop Guideline on Ovarian Cyst Mx

Question 2

Risk of Malignancy Index (RMI) for Ovarian Cancer: predicts risk of an adnexal mass being malignant

Answer 2

RMI = US score x Menopausal Status x CA125
US = 0 if no concerning features. US = 1 if 1 concerning feature. US = 3 if 2 or more concerning features.
Concerning US features: bilateral lesions, multi-loculated, solid areas, ascites, evidence of mets
M: 1 = if pre-menopausal. 3 = if post-menopausal (>12 months without periods or >50 with hysterectomy)

Question 3

RMI threshold suspicious of malignancy in post-menopausal women

Answer 3

Recommended threshold = RMI >200 = suspicious of malignancy = CT Abdo Pelvis + referral to gynae oncology MDT
(some centres use threshold >250 = less sensitive but more specific)

Question 4

Mx of low risk ovarian cysts in post menopausal women

Answer 4

If <5cm in diameter, no concerning US features, woman is asymptomatic, Ca 125 is normal and no high risk features in the history = conservative mx
Review / rescan in 4-6 months + consider discharge in 1 year if same size / smaller and Ca125 remains normal.

Question 5

Role of tumour markers for assessing risk of malignancy for ovarian cancer?

Answer 5

Evidence only in support of use of CA125 at present. NOT ENOUGH EVIDENCE to support the use of HE4, CEA, Ca19-9, alpha fetoprotein or any other markers for risk stratification at present.

Question 6

Which post menopausal ovarian cysts are suitable for laparoscopic management?

Answer 6

Only low risk post menopausal ovarian cysts (RMI <200) should be considered for laparoscopic management and if managed laparoscopically they should have bilateral salpingo-oophorectomy rather than cystectomy. They should be counselled on the risk of a full staging laparotomy should features of malignancy be revealed.
Women with RMI of 200 or above or CT findings suspicious of malignancy should have a full laparotomy and staging procedure.

Question 7

What are the features of Congenital VZV in the neonate?

Answer 7

Congenital varicella zoster presents with •skin scarring • limb hypoplasia •rudimentary digits •microcephaly

Risk is greatest if the mum is infected <20 weeks