Women's Health Flashcards
Name 3 hormones that are important in pregnancy.
Main hormones:
hCG.
Progestins.
Oestrogens.
Other hormones:
hPL.
Prolactin.
Oxytocin.
Where is hCG produced?
The trophoblast.
Give 2 functions of hCG.
- It signals the presence of the blastocyst.
- It prevents the corpus luteum from dying - luteal regression.
Where are progestins produced?
Initially from the corpus luteum and then from the placenta from week 7.
Give 3 functions of progestins.
- Prepares the endometrium for implantation.
- Promotes myometrial quiescence.
- Increases maternal ventilation.
How do progestins prepare the endometrium for implantation?
Progestins stimulate the proliferation of cells, vascularisation and the differentiation of endometrial stroma.
Where are oestrogens produced?
Initially in the ovary and then from a combination of fetal and maternal sources.
Give 2 functions of oestrogens in pregnancy.
- Promotes a change in the CV system.
- Alters carbohydrate metabolism.
What is the main oestrogen in pregnancy?
E3 - it indicates fetal well-being.
What is the role of E2 in pregnancy?
E2 is responsible for proliferation of the endometrial epithelium. It also facilitates progesterone action.
What is the role of human placental lactogen (hPL)?
- Mobilises glucose from fat.
- Acts as an insulin antagonist.
- Converts mammary glands into milk secreting tissues.
What is the role of prolactin?
Prolactin is responsible for milk production.
What is the role of oxytocin?
Oxytocin is responsible for milk secretion and uterine contractions.
Where is prolactin produced?
In the anterior pituitary gland.
Where is oxytocin produced?
In the posterior pituitary gland.
Where are FSH and LH produced?
In the anterior pituitary gland.
What hormone does the hypothalamus release that acts on the anterior pituitary gland and stimulates the production of FSH and LH?
GnRH.
What cells in the ovaries does FSH act on?
Granulosa cells -> oestrogen production.
What cells in the ovaries does LH act on?
Theca cells -> androgen production.
What hormone is released from the hypothalamus that acts on the anterior pituitary to inhibit prolactin release?
Dopamine.
What is the principle foetal nutrient?
Glucose.
Can the foetus produce any of its own glucose?
No, gluconeogenic enzymes are inactived in the foetus and so all its glucose has to come from its mother.
In early pregnancy, is plasma glucose high or low?
Plasma glucose is lower because glucose is being stored.
Why is plasma glucose lower in early pregnancy?
Because the mother is storing glucose.
In late pregnancy, is plasma glucose high or low?
Plasma glucose is higher. This is due to maternal insulin resistance and glucose sparing for the foetus.
Why is plasma glucose higher in late pregnancy?
- Because of increasing maternal insulin resistance.
- Glucose sparing for the foetus.
What are the consequences of maternal insulin resistance?
Maternal insulin resistance -> gestational diabetes -> increased risk of macrosomia and shoulder dystocia.
Why is the immune response suppressed in a pregnant lady?
It prevents foetal rejection.
Give 4 ways in which foetal rejection is prevented in a pregnant lady.
- A TH2 bias is observed.
- Syncytiotrophoblast has no self:non-self markers and so doesn’t stimulate an immune response.
- Extra-villous trophoblast cells have modified markers.
4.The overall immune response is suppressed.
In a normal pregnancy, a TH2 bias is observed, this helps prevent foetal rejection. Give 3 potential consequences if there is not a TH2 bias.
Pre-eclampsia.
IUGR.
Miscarriage.
How does the endometrial epithelium become adhesive to the blastocyst?
The blastocyst and endometrium communicate via the release of hormones -> ‘sticky endometrium’.
When in a woman’s cycle does the endometrium become sticky?
This usually happens between days 20-24. This is called the window of implantation and outside of this time implantation will not occur.
What reaction occurs when a blastocyst implants into the endometrium?
A primary decidual reaction occurs.
What part of the blastocyst facilitates placental formation?
The cytotrophoblast.
Placenta formation: What does the cytotrophoblast go on to form?
Anchoring villi -> extra villous trophoblast.
Floating villi are also involved
What can trigger the differentiation of anchoring villi into extra-villous trophoblast?
Hypoxia
What is the role of extra villous trophoblast (EVT) cells?
EVT invade and remodel spiral arteries. This leads to more hypoxia and so more EVT; a positive feedback effect is observed.
Why do EVT cells invade and remodel spiral arteries?
To allow for optimum nutrient delivery for the baby.
Give 3 potential consequences of poor endovascular remodelling.
Pre-eclampsia.
IUGR.
Pre-term birth.
Where should normal placenta invade into?
The decidua
What is placental accreta?
When the placenta invades into the superficial myometrium.
What is placental increta?
When the placenta invades into the deeper myometrium.
What is placental percreta?
Invasion of the placenta into nearby organs e.g. the bladder.
What are the potential consequences, if left untreated, of a rhesus negative mother having a rhesus positive foetus?
There is a risk of RBC lysis -> foetal anaemia and death.
Describe the pathophysiology of rhesus disease.
- Foetal Rh+ RBC’s leak through the placenta and interact with the mother’s blood -> IgM reaction -> sensitisation.
- IgM can’t cross the placenta and so there is no RBC lysis but memory B cells are created.
- On a subsequent pregnancy, IgG may cross the placenta and cause foetal RBC lysis.
What is the only antibody that can cross the placenta?
IgG
How can foetal RBC lysis be prevented in rhesus negative mothers?
Anti-D prophylaxis can be given. This destroys Rh+ IgG and so no RBC are attacked.
What is quiescence?
When the myometrium is inactive, there are no contractions.
Describe the physiology behind quiescence?
Increased cAMP -> K+ extrusion -> myocyte hyperpolarisation -> muscle fibres are unable to contract.
There is also phosphorylation of intracellular proteins -> actin-myosin ATPase is inactivated -> smooth muscle relaxation.
Give 2 theories behind the induction of labour
- Placental clock theory.
- Signals from the baby.
Induction of labour: describe the placental clock theory.
Increased release of CRH from the placenta -> foetal ACTH release -> release of oestrogens, formation of myometrial gap junctions -> regular and co-ordinated uterine contractions.
Induction of labour: describe the theory that suggests that there are signals from the baby.
Increased ACTH or increased foetal surfactant proteins activate amniotic fluid macrophages. These migrate to the uterine wall, there is up-regulation of inflammatory gene expression which stimulates labour.
Describe the 3 stages of parturition.
- Dilation - cervical remodelling and uterine contractions.
- Expulsion - full dilation to delivery of infant.
- Placental delivery.
Parturition: do progesterone levels fall when the cervix dilates and remodels?
Progesterone levels don’t fall but it becomes ineffective -> contractions.
Parturition: what happens in the expulsion phase that triggers myometrial contractions?
Oxytocin release -> increased intracellular Ca2+ -> myometrial contractions.
Why can nifedipine be used to inhibit premature contractions?
Nifedipine is a CCB and so can block the rise of intracellular calcium therefore inhibiting muscle contraction.
Name 2 drugs that can inhibit uterine contractions.
- Nifedipine - CCB.
- Atosiban - oxytocin antagonist.
Name an oxytocin analogue that can induce labour.
Syntocinon.
Define: pelvic organ prolapse
Descent of the pelvic organs into the vagina
uterine prolapse = uterus
Vault prolapse = women who have a hysterectomy so vagina descends
Rectocele = rectum due to defect in peoterior vaginal wall
cystocele = bladder due to defect in anterior vaginal wall
What are the risk factors for prolapse?
- multiple vaginal deliveries
- instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Presentation: prolapse
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
What are the grades of uterine prolapse?
Pelvic organ prolapse quantification (POP-Q)
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus (external opening of vagina)
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
Management: Prolapse
- conservative
- pelvic floor exercises
- weight loss
- treat stress incontinence symptoms
- vaginal oestrogen cream - Vaginal pessary
- inserted into vagina to give more support - Surgery
- repair anterior or posterior walls
- sacro spinous fixation = stick top of vagina to ligament
- sarocolpopexy = mesh in abdomen
- Hysterectomy
What are the types of urinary incontinence?
- Stress = weakness of the pelvic floor and sphincter muscles
- Urge = overactivity of the detrusor muscle of the bladder
- Mixed
- Overflow = due to chronic urinary retention due to an obstruction to the outflow of urine
What are the risk factors for urinary incontinence?
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
Presentation: stress incontinence
involuntary leakage
- cough
- laughing
- lifting
- exercise
- movement
- intercourse
- walking/running downhill
(sphincter weakness)
Presentation: urgency incontinence
Overactive bladder
Urgency incontinence
Frequency
Nocturia
Nocturnal enuresis
‘Key in the door’
‘Handwash’
Intercourse
Investigations: urinary incontinence
- bladder diary
- urine dipstick testing
- post-void residual bladder volume
- urodynamic testing
- measure detrusor muscle contraction
- measure flow rate
- measure pressure in bladder vs pressure in vagina/anus to calculate detrusor activity
What is the innervation of the detrusor muscle?
detrusor muscle
- smooth muscle, transitional epithelium
sacral parasympathetic (para pee) S2-4 = cause bladder wall to contract and sphincter to relax
neurotransmitter = acetylcholine
Receptors = muscarinic M2 + M3
Antagonists = atropine (oxybutynin, tolterodine)
Management: stress incontinence
Lifestyle
- Avoiding caffeine, diuretics and overfilling of the bladder
- smoking cessation
- Avoid excessive or restricted fluid intake
- Weight loss (if appropriate)
- Supervised pelvic floor exercises for at least three months before considering surgery
Containment
- bladder bypass (catheters)
- leakage barrier (pads + pants)
- vaginal support (pessaries)
- skin care (barrier creams
- Surgery
- Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
What are the mechanisms of mirabegnon?
Beta-3 adrenergic receptor agonist
Relaxes smooth muscle detrusor
Increases bladder capacity
What are the side effects of muscarine?
mimics effect of acetyl choline at muscarinic receptors
- increased salivation
- excessive sweating + lacrimation
followed by:
Abdominal pain, severe nausea, diarrhoea, blurred vision & laboured breathing.
Death may result from cardiac or respiratory failure
The specific antidote is atropine
Define: urinary tract calculi
Hard lumps of minerals that can from inside the bladder when its not completely empty of urine e.g. due to enlarged prostate gland
Presentation: urinary tract calculi
- lower abdominal pain
- pain or difficulty peeing
- peeing more frequently
- cloudy or dark coloured urine
- blood
MAnagement: urinary tract calculi
Surgery
- cystolitholapaxy = cystoscope camera tube inserted and stones crushed
What are the most common types of uterine abnormalities?
Incomplete fusion of mullein or paramesonephric ducts
- lead to double vagina, cervix, uterus
- uterus with midline septum
- double single-horned uteruses
Investigations: uterine abnormalities
- ultrasound
- hysterosalpingography
- MRI scan
Complications of uterine abnormalities?
- dysmenorrhoea
- haematometra
- pregnancy + labour complications
- fertility usually unaffected
- congenital renal abnormalities
Management: uterine abnormalities
- surgery = if affects viable pregnancy
- uterine reconstruction
What types of vaginal abnormalities occur?
- Vaginal agenesis: absent uterus but ovaries present.
- Vaginal atresia:
The lower portion of the vagina consists of fibrous tissue with a well-differentiated uterus. - Müllerian aplasia:
Nearly all of the vagina and most of the uterus are absent. - Transverse vaginal septa:
Can be present as single or multiple in the upper or lower segments and may be patent or perforated; can be the cause of haematometra or other fluid collections. - Longitudinal vaginal septa
anomalies:
The urethra can open into the vaginal wall or the vagina can open into a persistent urogenital sinus.
Define: androgen insensitivity syndrome
Condition where the cells are unable to respond to androgen hormones due to a lack of androgen receptors
- x- linked recessive
- mutation in androgen receptor gene
- extra androgens converted to oestrogen
Pathophysiology: androgen insensitivity syndrome
- genetically male with XY
- but female phenotype externally
- extra androgens converted to oestrogen
- patients have testes in abdomen or inguinal canal and absence of uterus, upper vagina, cervix, ovaries
- due to testes producing anti-mullerian hormone
Presentation: androgen insensitivity syndrome
- lack of pubic + facial hair
- inguinal hernias at infancy containing testes
- primary amenorrhoea
- raised LH
- normal or raised FSH
- normal or raised testosterone levels (for a male)
- raised oestrogen ( for a male)
Management: androgen insensitivity syndrome
- bilateral orchidectomy (removal of testes to avoid testicular tumour)
- oestrogen therapy
- vaginal dilators or vaginal surgery (to create an adequate vaginal length)
Define: menarche
First menstrual cycle
ages 11-15
What hormone changes occur in puberty?
- Hypothalamus releases Gonadotropin releasing hormone GnRH in a pulsatile manner
- stimulates release of LH and FSH from anterior pituitary gland
(rise in FSH stimulates an increase in oestrogen synthesis + oogenesis + sperm production) - FSH + LH act on gonads to stimulate synthesis of sex steroid hormones (oestrogen/progesterone and testosterone)
What are the physical changes in females in puberty?
- Thelarche = breast development aged 9-10
- Pubarche = growth of public hair
- Menarche = first period
What are the physical changes in males in puberty?
- genital changes = increased testicular size
- Increased LH stimulates testosterone synthesis by Leydig cells
- Increased FSH stimulates sperm production by Sertoli cells
- scrotal skin becomes thinner and darker
- ejaculation then occurs
- penis then grows in length then width - pubarche = growth of pubic hair
- Growth spurt
-rise in GH and IGF-1
- larynx and vocal cords enlarge
What are the stages of menopause?
Premature menopause = before age of 40 yrs
Perimenopause = time around the menopause and 12 months after last period
Menopause = point at which menstruation stops
Postmenopause = period from 12 months after the final menstrual period
What happens to hormones during menopause?
Lack of ovarian follicular function
- Oestrogen low
- progesterone low
- LH + FSH high (lack of feedback from oestrogen)
What is the process that starts menopause?
- reduced development of ovarian follicles
- reduced production of oestrogen
- Absence of negative feedback from oestrogen
- LH and FSH increase
What are some perimenopausal symptoms?
- Hot flushes
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier or lighter periods
- Vaginal dryness and atrophy
- Reduced libido
What does a lack of oestrogen increase the risk of?
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
What is contraception advice for menopausal women?
Still need to use contraception until:
- 2 yrs after last period in women <50 yrs
- 1 yrs after last period in women >50 yrs
Management: perimenopausal symptoms
- No treatment
- Hormone replacement therapy (HRT)
- Tibolone = synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine = agonists of alpha-adrenergic and imidazoline receptors
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants = fluoxetine or citalopram
- Testosterone can be used to treat reduced libido (usually as a gel or cream)
- Vaginal oestrogen cream or tablets = help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers = Sylk, Replens and YES
Define: adenomyosis
Endometrial tissue inside the myometrium (muscle layer of uterus)
- usually later in life after several pregnancies
Presentation: adenomyosis
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- infertility or pregnancy complications
Investigations: adenomyosis
- transvaginal USS
- transabdominal USS
- MRI
gold standard diagnosis = Hysterectomy with histology
Management: adenomyosis
Contraception wanted/acceptable
1. Mirena coil
2. combined oral contraceptive pill
3. cyclical oral progesterones
No contraception
1. tranexamic acid = when no associated pain, reduced bleeding
2. Mefenamic acid = reduced pain + bleeding
- GnHR analogues induce menopause like state
- endometrial ablation
- uterine artery embolisation
- hysterectomy
What is the effect of adenomyosis on pregnancy?
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
Define: Asherman’s syndrome
Adhesions form within the uterus following damage to the uterus
- Occurs after pregnancy related dilatation + curettage procedure (remove tissue left behind)
- uterine surgery
- pelvic infections
Presentation: Asherman’s syndrome
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
May present with infertility
Investigations: Asherman’s syndrome
- Gold standard = Hysteroscopy (can involved dissection + treatment)
- Hysterosalpingography = contrast injected into uterus + imaged with x-rays
- Sonohysterography = uterus filled with fluid + pelvic USS performed
- MRI scan
Management: Asherman’s syndrome
Hysteroscopy
- dissect adhesions
Define: Lichen Sclerosis
Chronic inflammatory skin condition
- commonly affects labia, perineum, and perianal skin in women
- men = foreskin and glans of penis
- autoimmune conditions
Presentation: lichen sclerosis
- patches of shiny, porcelain white skin
- itching
- soreness + pain
- skin tightness
- painful sex
- erosions
- fissures
- papules or plaques
- slightly raised
Koebner phenomenon = symptoms made worse by friction to skin
Management: lichen sclerosis
- potent topical steroids = clobetasol propionate (long term use)
- Emollients
What are the complications of lichen sclerosis?
Squamous cell carcinoma of the vulva
- pain + discomfort
- sexual dysfunction
- bleeding
- narrowing of the vagina or urethral openings
Define: Atrophic vaginitis
Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
- occurs in women entering menopause
- oestrogen causes epithelial to be thicker, more elastic and produce secretions
Presentation: Atrophic vaginitis
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
Signs
- pale mucosa
- thin skin
- reduced skin folds
- erythema + inflammation
- dryness
- sparse pubic hair
MAnagement: Atrophic vaginitis
- vaginal lubricants = Sylk, Replens, YES
- Topical oestrogen
- estriol cream, pessaries, tablets, ring
(SE = breast cancer, angina, venous thromboembolism)
Define: Vulval cancer
90 % = squamous cell carcinoma
less likely = malignant melanomas
What are the risk factors for vulval cancer?
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus
Define: vulval intraepithelial neoplasia
Premalignant condition affecting the squamous epithelium of the skin
- watch + wait
- wide local excision
- imiquimod cream
- laser ablation
Presentation: vulval cream
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
Labia majora = irregular mass, fungating lesion
Management: vulval cancer
- 2 week wait urgency cancer referral
- Biopsy of lesion
- Sentinel node biopsy = demonstrate lymph node spread FIGO
4.wide local excision to remove cancer - groin lymph node dissection
- chemo + radiotherapy
What is the cell type and cause of cervical cancer?
80% squamous cell carcinoma
Then adenocarcinoma
Cause = human papilloma virus (STI)
- p53 and pRb are tumour suppressor genes
- HPV produces E6 and E7 that inhibit these tumour suppressor genes
What are the risk factors for cervical cancer?
Increased risk of HPV
- early sexual activity
- multiple sexual partners
- not using condoms
Non-engagement with cervical screening
- smoking
- HIV
- COCO pill
- increased number of full term pregnancies
- family history
Presentation: cervical cancer
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
- ulceration
- bleeding
- visible tumour
Investigations: cervical cancer
Smear test:
- cervical smear test every 3 years aged 25-49 then every 5 yrs
- test involves collecting cells from the cervix using a small brush
Colposcopy
- inserting a speculum to magnify cervix
- stains (acetic acid + iodine solution) used to differentiate abnormal areas
Large loop excision of the transformation zone
- loop of wire with electrical current to remove abnormal epithelial tissue on the cervix
Cone biopsy
- cone shaped piece of cervix removed using a scalpel
- sent for histology
What is the staging for obs+gynae cancers?
The International Federation of Gynaecology and Obstetrics (FIGO)
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
Management: 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
Pelvic exenteration = advancesd, removes most of pelvic organs
What strains does the HPV vaccine protect against and what would these strains cause otherwise?
Given to girls and boys before becoming sexually active
Gardasil vaccine
strains 6 &11 =genital warts
strains 16 & 18 = cervical cancer
What is human papilloma virus?
DNA virus
- can infect all types of squamous epithelium
- high risk types = 16 + 18
- low risk types = 6 +11 > cause genital warts
Presentation: HPV
presence of new lumps/growths in the anogenital area
- cauliflower like growths
- flat, plaques
- pigmented
-
generally IP between 3-8 weeks
local irritation
bleeding
discomfort/itching
Management: HPV
Physical ablation
- excision
- cryotherapy
- electrosurgery
- laser treatment
Topical applications
- Podophyllotoxin (Warticon® and Condyline®)
- Imiquimod 5% cream
- Catephen® 10% ointment
- TCA 80-90% (specialist clinic setting only)
What is the most likely type of endometrial cancer?
Adenocarcinoma
oestrogen dependent cancer = oestrogen stimulates the growth of endometrial cancer cells
Define: endometrial hyperplasia
precancerous condition involving thickening of the endometrium
(less than 5% become endometrial cancer)
worrying types
- hyperplasia without atypia
- atypical hyperplasia
Treatment: endometrial hyperplasia
Using progesterones
- intrauterine system e.g. mirena coil
- continuous oral progesterones
What are the risk factors for endometrial cancer?
Unoppoed oestrogen = oestrogen without progesterone (as stimulates the endometrial cells)
- 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 = increased exposure to unopposed oestrogen due to lack of ovulation (less progesterone released)
- Tamoxifen = oestrogenic effect in endometrium
What are protective factors against endometrial cancer?
(most increase progesterone)
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking = anti-oestrogenic, oestrogen metabolised differently, smokers thinner
Presentation: endometrial cancer
- postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
What is the referral criteria for endometrial cancer?
2-week-wait urgent cancer referral:
- Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia or elevated glucose levels
Investigations: endometrial cancer
- transvaginal USS for endometrial thickness (normal <4mm post menopause)
- Pipelle biopsy = highly sensitive, sample from uterus
- Hysteroscopy with endometrial biopsy
Management: endometrial cancer
Stage 1 + 2:
Total abdominal hysterectomy with bilateral salpingo-oophorectomy (uterus, cervix, adnexa)
Other:
- radical hysterectomy
- radiotherapy
- chemotherapy
- progesterones hormone treatment
What are the types of ovarian cancer?
- epithelial cell tumours MC
- Dermoid cysts/ germ cell tumours
- benign ovarian tumours
- associated with ovarian torsion
- germ cells may cause raised a-FP and hCG - Sex cord stromal tumours
- benign or malignant - Metastasis
- Krukenberg tumour = metastasis form GI tract cancer
What are the risk factors for ovarian cancer?
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
( factors that increase number of ovulations, increase risk of ovarian cancer e.g. late menopause, early onset periods, no pregnancies)
Presentation: ovarian cancer
Can present with non-specific symptoms
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
What is the referral criteria for ovarian cancer?
2 week wait
- ascites
- pelvic mass
- abdominal mass
Investigations: ovarian cancer
- CA125 blood test (>35 is significant)
- pelvic USS
- CT scan
- histology using CT guided biopsy
- Paracentesis for ascitic fluid
women under 40 with complex ovarian masss check
- alpha fetoprotein (a-FP)
- human chorionic gonadotropin (HCG)
What are the causes of raised CA125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Management: ovarian cancer
specialist gynaecologist oncology MDT
- surgery
- chemotherapy
Define: dysfunctional uterine bleeding
Abnormal uterine bleeding in the absence of organic disease
- usually presents with menorrhagia (heavy) without any cause
What are the causes of menorrhagia?
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes and hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- Polycystic ovarian syndrome
What are the structural and non-structural differential diagnoses of menorrhagia?
Structural = PALM
- Polyp adenomyosis
- Leiomyoma (fibroids)
- Malignancy and hyperplasia
Non-structural = COEIN
- Coagulopathy Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
What are the key questions in menorrhagia history?
Age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening history
Migraines with or without aura (for the pill)
Past medical history and past drug history
Smoking and alcohol history
Family history
What are the red flags for bleeding?
- post menopausal bleeding
- bleeding during pregnancy
- pelvic mass
- haemodynamically unstable
- USS findings of thickness of endometrium (>12mm pre menopausal and >5mm peri-menopausal)
Investigations: Menorrhagia
- pelvic examination with a speculum and bimanual
- FBC = iron deficiency anaemia
- outpatient hysteroscopy = submucosal fibroids, endometrial pathology, persistent intermenstrual bleeding
- Pelvic + transvaginal USS = fibroids, adenomyosis
Swabs
coagulation screen
ferritin
thyroids function tests
Management: menorrhagia
Exclude pathology
No contraception
- tranexamic acid = reduce bleeding
- mefenamic acid = reduce bleeding + pain
Contraception
1. mirena coil
2. Combined oral contraceptive pill
3. Cyclical oral progesterones
Final: Endometrial ablation + hysterectomy
What are the terms used for variations in menstrual bleeding?
Irregular = metrorrhagia
absent = amenorrhea
frequent = polymenorrhea
infrequent = oligomenorrhoea
heavy = menorrhagia
Painful periods = dysmenorrhoea
Define: endometriosis
ectopic endometrial tissue outside the uterus
a lump of endometrial tissue outside uterus = endometrioma
What is the cause of endometriosis?
No clear cause just a few theories
1. Retrograde menstruation = during menstruation endometrial lining flows backwards through the Fallopian tubes and seeds itself around the pelvis
- embryonic cells meant to become endometrial tissue remain outside uterus
- spread of cells through lymphatic system
- metaplasia = cells outside uterus change
What is the pathophysiology of the symptoms of endometriosis?
Main symptom = pelvic pain
- endometrial tissue outside uterus still responds to hormones and bleeds in menstruation
- causing inflammation + irritation of tissue around the bleeding
- deposits in bladder or bowel can lead to blood in urine or stools
- can lead to adhesions = due to scar tissue from inflammation
Presentation: endometriosis
- Cyclical abdominal or pelvic pain (pain only during menstruating)
- Deep dyspareunia (pain on deep sexual intercourse)
- Dysmenorrhoea (painful periods)
- Infertility
- Cyclical bleeding from other sites, such as haematuria
- associated with IBS (follow ROME criteria to ensure endometriosis instead of IBS)
examination :
- Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
Investigations: endometriosis
- Examination
- pelvic USS
- Laparoscopic surgery (gold standard) = can remove deposits
Management: Endometriosis
- analgesia
- hormonal management = combined pill, POP pill, implant, coil, injections
- Zolendax (triggers menopause)
(can stop ovulation + reduce endometrial thickening)
(if pain goes away with these then can diagnose with endometriosis) - surgical
- laparoscopic surgery (50% see nothing)
- hysterectomy
Define: fibroids
Benign tumours of the smooth muscle of the uterus
also known as Uterine leiomyomas
Oestrogen sensitive
What are the types of fibroids?
- intramural = within the myometrium
- subserosal = just below the outer layer of the uterus, fill abdominal cavity
- submucosal = just below the lining of the uterus (endometrium)
- pedunculated = means on a stalk
Presentation: fibroids
Often asymptomatic
- Heavy menstrual bleeding (menorrhagia) MC
- Prolonged menstruation, >7 days
- Abdominal pain = worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
Investigations: fibroids
- Hysteroscopy = for submucosal fibroids with menorrhagia
- pelvic USS = larger fibroids
- MRI scan = before surgery
Management: Fibroids
Fibroids <3cm
1. Mirena coil
2. symptomatic management with NSAIDs + tranexamic acid
3. combined pill
4. Cyclical oral progesterones
5. Surgical = endometrial ablation, resection, hysterectomy
Fibroids >3cm
1. refer to gynaecologist
2. Symptomatic management = NSAIDs and tranexamic acid
3. Mirena coil – depending on the size and shape of the fibroids and uterus
4. Combined oral contraceptive
5. Cyclical oral progestogens
6. Surgical
- uterine artery embolisation
- Myomectomy
- Hysterectomy
Define: Ovarian cyst
A fluid filled sac
- premenopausal = usually benign, fluctuate with hormones
- post menopausal = concern for malignancy
What does a diagnosis of PCOS require?
Two of:
- Anovulation
- Hyperandrogenism
- Polycystic ovaries on USS
Presentation: ovarian cysts
Most are asymptomatic
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
What are the types of functional cysts?
- Follicular cysts = represent the follicle, persist after egg is released, usually disappear after a few menstrual cycles
- Corpus luteum cysts
- occur when corpus luteum fails to break down + instead fills with fluid
- often seen in early pregnancy
Investigations: ovarian cysts
premenopausal with cyst < 5cm on USS no further investigations needed
- USS
- Bloods = CA125, LDH, a-FP, HCG
Management: ovarian cysts
- rule out ovarian cancer
- dermoid cysts = refer to gynaecologist
- simple ovarian cysts in premenopausal women
<5cm = no follow up
5-7 cm = routine referral to gynaecologist + yearly USS
>7cm = MRI scan, surgical evaluation - Postmenopausal women
- CA125 bloods, refer to gynaecologist (ovaries not functioning so shouldn’t develop cysts)
- Then CT scan - surgery
- ovarian cystectomy
- oophorectomy
(never drain as will refill)
What is a cyst accident?
- includes rupture, haemorrhage and torsion
- cyst rupture + haemorrhage occurs with functional cysts and are generally self-limiting
- laparoscopy = required if diagnosis uncertain or patient haemodynamically unstable
Define: Meig’s syndrome
Triad of :
1. Ovarian fibroma (a type of benign ovarian tumour)
2. Pleural effusion
3. Ascites
Usually in older women
Removal of tumour = complete resolution
Define: ovarian torsion
Ovary twists in reaction to the surrounding connective tissue, Fallopian tube and blood supply
- usually due to an ovarian mass > 5cm
- more likely with benign tumours and in pregnancy
Presentation: ovarian torsion
Sudden onset severe unilateral pelvic pain
- constant
- gets progressively worse
- nausea and vomiting
- often non-specific (can assume its appendicitis)
examination
- localised tenderness
- palpable mass
Seen in women of reproductive age and can occur in pregnancy
Investigations: ovarian torsion
- pelvic USS = whirlpool sign, free fluid in pelvis, and oedema of the ovary
- Laparoscopic surgery = definitive diagnosis
Management: ovarian torsion
- emergency admission
- laparoscopic surgery
- un-twist ovary and fix it in place (detorsion)
- remove affected ovary (oophorectomy)
Define: Pelvic inflammatory disease
Inflammation and infection of the organs of the pelvis caused by infection spreading up through the cervix
Endometritis = inflammation of the endometrium
Salpingitis = fallopian tubes
Oophoritis = ovaries
Parametritis = parametrium, (connective tissue around the uterus)
Peritonitis = peritoneal membrane
What are the causes of pelvic inflammatory disease?
Usually STI
- Chlamydia trachomatis MC
- Neisseria gonorrhoeae (tends to produce more severe PID)
- Mycoplasma genitalium
other:
- gardnerella vaginalis
- haemophilus influenzae
- E.coli
What are the risk factors for inflammatory pelvic disease?
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
Presentation: pelvic inflammatory disease
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
(usually young person)
Examination findings may reveal:
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Investigations: pelvic inflammatory disease
- check for STIs
- NAAT swabs
- HIV test
- syphilis test - high vaginal swab = send to lab
- pregnancy test = exclude ectopic pregnancy
- inflammatory markers = ESR + CRP raised
Management: pelvic inflammatory disease
- antibiotics
- 14 days course
- single IM ceftriaxone
- plus PO doxycycline + metronidazole
avoid sexual intercourse until patient and partner completed treatment
Define: Fitz-Hugh-Curtis syndrome
Complication of pelvic inflammatory disease
- inflammation and infection of the liver capsule
- leads to adhesions between liver and peritoneum
- bacteria may spread from pelvis via cavity, lymphatic system or blood
Presentation
- RUQ pain referred to right shoulder tip
Laparoscopy
Adhesiolysis = to treat adhesions
Define: Polycystic ovarian syndrome
common condition causing metabolic and reproductive problems in women
- multiple ovarian cysts
- infertility
- oligomenorrhoea (irregular infrequent)
- hyperandrogegism
- insulin resistance
What is the Rotterdam criteria?
2 are required to diagnose PCOS:
- oligoovulation or an ovulation (irregular or absent periods)
- hyperandrogegism (hirsutism and acne)
- Polycystic ovaries on USS
Presentation: PCOS
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
What are some complications of PCOS?
- Insulin resistance and diabetes = high levels of insulin increase androgens released + halt development of follicles in ovaries
- Acanthosis nigricans = thickened, rough skin
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
Investigations: PCOS
- Blood tests:
- Raised Testosterone
- Sex hormone-binding globulin
- Raised LH
- FSH = high LH to FSH ratio
- Prolactin (may be mildly elevated in PCOS)
- Thyroid-stimulating hormone
- raised insulin
- normal/raised oestrogen
2.- Pelvic USS
- transvaginal USS - gold standard
- Oral glucose tolerance test
What diagnostic criteria is used for PCOS in USS?
String of pearls appearance
Either:
- 12 or more developing follicles in one ovary
- ovarian volume > 10cm3
Management: PCOS
- reduce risks associated with obesity, type 2 diabetes, hypercholersterolaemia and cardiovascular disease
- manage risk of endometrial cancer
- mirena coil
- induce a withdrawal bleed with COCP or cyclical progesterones - manage infertility
- manage hirsutism
- Co-cyprindiol (Dianette) COCP - Manage acne
- COCP
- topical adapalene (retinoid)
What is the perinatal mental health period?
- preconception
- during pregnancy
- mental health for the first 12 months after birth
What are the different stage of poor mental health in postpartum?
Baby blues = majority of women in 1st week (10 days)
Postnatal depression = 1in10, peak around 3 months after birth
Puerperal psychosis = 1in1000, few weeks after birth
What is the puerperium?
it is defined as the 6 week period immediately after the birth
- mother’s body physiological returns to pre-pregnancy state
What family history do you ask for in a postnatal mental health risk assessment?
- schizophrenia
- bipolar
What are the red flags signs for perinatal mental health?
Suicidal ideation
Feelings of incompetence as a parent
Estrangement from child
Hallucinations
Presentation: Baby blues
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
Baby blues may be the result of a combination of:
Significant hormonal changes
Recovery from birth
Fatigue and sleep deprivation
The responsibility of caring for the neonate
Establishing feeding
All the other changes and events around this time
Presentation: Postnatal depression
Triad:
1. low mood
2. anhedonia (lack of pleasure in activities)
3. low energy
What screening tool is used for postnatal depression?
Edinburgh scale
Patient health Questionnaire-9
Management: postnatal depression
Mild cases = additional support, self-help, GP
Moderate = antidepressants SSRI + CBT
Severe = specialist psychiatry services, mother + baby unit
What are the features of pathological anxiety in perinatal period?
chronic excessive worry (not situational)
Hyperarousal
Investigations: Perinatal anxiety
Screening:
Generalised Anxiety Disorder-2
Diagnosis:
GAD-7
What are common anxiety disorders during perinatal period?
Generalised anxiety
PTSD - flashbacks
Obsessive compulsive disorder - Intrusive thoughts, ideas or images which a woman finds distressing
Tocophobia - Morbid dread and fear of childbirth, Primary/secondary
Management: Anxiety
MDT
Behavioural
Medication - Anti-depressants
Benzodiazepines
- Associated with cleft palate, neonatal withdrawal syndrome & floppy baby syndrome
- Short term management of symptoms
- Lowest dose possible for shortest time possible
- Avoid in third trimester
Presentation: Puerperal psychosis
Insomnia, tearful and agitated at first
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
most present within in first 3 months
Management: Puerperal psychosis
emergency
- Admission to the mother and baby unit (need bonding to continue, baby is protective factor)
- Cognitive behavioural therapy
- Medications (antidepressants, antipsychotics (not teratogenic) or mood stabilisers)
- Electroconvulsive therapy (ECT)
What are the associated risks of antipsychotics in pregnancy?
Used: olanzapine = increased risk of weight gain, gestational diabetes
NOT USED
Lithium = cardiac abnormalities
Sodium valproate = neural tube defects
Define: ectopic pregnancy
A pregnancy that is implanted outside the uterus
- MC in the Fallopian tube
- Also in ovary, cervix, abdomen
What are the risk factors for an ectopic pregnancy?
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
Presentation: Ectopic Pregnancy
6- 8 weeks pregnant
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
- dizziness or syncope
- shoulder tip pain (peritonitis - phrenic nerve)
What are the USS findings in an ectopic pregnancy?
Transvaginal USS
- gestational sac containing a yolk sac or fetal pole may be seen in a Fallopian tube
- empty gestational sac
- tubal ectopic = moves separately to the ovary
- empty uterus
- fluid in the uterus = pseudogestational sac
with BHCG >1500
What is a pregnancy of unknown location and how to investigate?
Positive pregnancy test but no evidence of pregnancy on USS
Track HCG:
1. rise >63% = intrauterine pregnancy
2. rise of <63% after 48 hrs/ stays the same = ectopic pregnancy
3. a fall >50% = miscarriage
What is the MC location of an ectopic pregnancy?
- Tubal ectopic
in ampulla
- diagnosed by USS = adnexal mass that moves separately to the ovary
- 20% of cases a pseudo sac seen within the uterine cavity
- free fluid may be seen but no diagnostic
- serum b-hCG should be performed
Management: Ectopic pregnancy
Perform pregnancy test in all women with abdominal or pelvic pain caused by ectopic pregnancy
–> referred to early pregnancy assessment unit
ectopic pregnancy must be terminated, it is not viable.
Terminating options:
1. expectant management (awaiting natural termination = needs no heart beat, HCG<1500, no significant pain)
2. Medical management (methotrexate)
3. Surgical management (salpingectomy (remove affected Fallopian tube) or salpingotomy (cut made in tube and ectopic pregnancy removed))
When is conservative management allowed in ectopic pregnancy?
- patient must be clinically stable and pain free
- have a tubal ectopic pregnancy <35mm with no visible heartbeat
- serum hCG <1000
- patient is able to return for follow up
repeat hCG on day 2,4 and
When is medical management allowed for ectopic pregnancy termination?
Systemic methotrexate
- have no significant pain and be clinically well
- enraptured tubal ectopic with an adnexal mass <35mm with no visible FH
- Serum hCG <1500
- Do not have an intrauterine pregnancy
- Can return for follow up
How is methotrexate used in pregnancy termination?
Methotrexate is highly teratogenic
- IM injection into a buttock
- halts progress of pregnancy
- advise not to get pregnant for 3 months after
bhCG monitored on day 4 + 7 and then weekly until hCG is negative
What are the contraindications of methotrexate?
- thrombocytopenia
- hepatic or renal dysfunction
- immunocompromised
- breastfeeding
- peptic ulcer disease
When is surgical management advised for ectopic pregnancy?
First line in women who:
- have significant pain
- adnexal mass >35mm
- live ectopic
- HCG >5000
- signs of rupture
- haemodynamic instability
What are the options for surgical management in ectopic pregnancy?
- laparoscopically preferred
1. first line = salpingectomy
(remove affected Fallopian tube)
2. Salpingotomy - make incision in tube and remove ectopic pregnancy
Define: miscarriage types
Early miscarriage = 12 weeks gestation
late miscarriage = 12-24 weeks gestation
What is a missed, threatened, inevitable, and anembryonic miscarriage?
Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Anembryonic pregnancy – a gestational sac is present but contains no embryo
