WOMENS HEALTH 2 - Breast, Gynae, Sexual Health Flashcards
What are some risk factors for breast cancer
alcohol,
Obesity
Not breastfeeding
HRT, and the pill
Not having kids younger
Genetics
Exercise in protective
1 in 8 women will get breast cancer - (12%) most common !
Outline what types of HRT can lead to more of a risk of breast cancer
Combined hormone replacement therapy (HRT) appears to increase breast cancer risk, more so than oestorgen only HRT.
Interestingly, taking low dose progesterone in isolation of oestrogen does not seem to increase the likelihood of developing breast cancer.
Oestrogen-only HRT does not appear to increase the risk of breast cancer if used for less than 10 years. However oestrogen-only HRT increases endometrial cancer risk and should generally be avoided unless the patient has undergone hysterectomy.
Name some genes that increase your risk for breast cancer
BRAC - 1 - 80% chance of breast cancer, and 40% of ovarian cancer
BRAC - 2 - Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer
There are other rarer genetic abnormalities associated with breast cancer (e.g., TP53 and PTEN genes).
between what ages to we screen for breast cancer?
The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.
Screening aims to detect breast cancer early, which improves outcomes. Roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram.
What are some downsides to screening
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 some signs and symptoms of breast cancer
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla
Deformed/change in breast shape
ask if lumps change at all wiht menstraul cycle
Pain is only a symptom if pin point and very localised pain.
Pain that is MSK related can by shown by getting the pt to lie on the other side that is painful, and with breast dropping down ot the side w gravity - that’ll expose the muscles behind the breast which can show the source of the pain
What things are included in an assessment for breast cancer?
Triple assessment
1 is normal, 5 is clearly malignant
2 - benign
3 - indeterminate
4 suspicios of cancer
Clinical score ((from examination) 1-5
imaging score 1-5
Biopsy score 1-5
generalised breast pain in younger women - likely hormone related, general breast pain in older - likely MSK related
What imaging is used in breast cancer investigations?
Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps. - good for dense breast tissue in younger women -
+
Mammograms (xray) are generally more effective in older women. They can pick up calcifications missed by ultrasound. - used in over 40
as women get older, dense glandular tissue gets relapsed by fatty tissue - turns up as black/dark grey on mammogram (galndular tissue is light grey)
Cancer is white
Ultrasounds is more a focused assement, so cant be used for general screening as would take ages
MRI scans may be used:
For screening in women at higher risk of developing breast cancer (e.g., strong family history)
To further assess the size and features of a tumour
How and why is lymph node involvement investigated in breast cancer?
Women diagnosed with breast cancer require an assessment to see if the cancer has spread to the lymph nodes.
Offered an US of lymph nodes - if abnormal, do biopys of abnroaml lymph node, if normla, do SNB
A sentinel node biopsy (SLNB) is a surgical procedure used to determine whether breast cancer has spread to the lymph nodes. It specifically targets the sentinel lymph node, which is the first lymph node to receive drainage from a tumour.
A sentinel node biopsy is minimally invasive compared to other node surgeries, and helps determine the stage of breast cancer by assessing whether it has spread to the lymphatic system
What is a DCIS? Does it require treatment?
Ductal carcinoma in situ (DCIS), is a pre-cancerous or non-invasive cancerous lesion of the breast. (hasnt invaded the basement membrane of the duct - core biopsy useful for this seeing if this the case)
In DCIS, abnormal cells are found in the lining of one or more milk ducts in the breast.
the abnormal cells have not moved out of the mammary duct and into any of the surrounding tissues in the breast - its not yet become an invasive cancer
It does require treatment
What is the treatment options for a ductal carcinoma in situ?
. Treatment primarily involves wide excision and radiotherapy
or mastectomy if the disease is more extensive. Just to complicate matters, 1% of
high grade DCIS will have axillary node metastases from areas of micro-invasion
within the DCIS. It can be a difficult concept to explain to patients, especially those
with widespread disease who need mastectomy, that they need a mastectomy but
they don’t have invasive breast cancer. Below is a mammogram showing a large
area of typical DCIS associated microcalcification. This case would require a
mandatory mastectomy.
Surgery for breast cancer - what are the two options
Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy - reduces risk of recurrence, makes it the same as a mastectomy
Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction (also add radiotherapy if large tumour or spread to chest wall)
What are the options and what factors can influence Mastectomy vs breast conservation look at page 30 on breast cancer handbook
Needs masectomy if
Large tumour relative to breast size
more than ome cancer
can take up to 20% of breast, as a general rule
if they have inflammatory breast cancer -
breast cancer in different quadrants
Psychological [atinet choice
if they cba for teh radiotherapy needed with breast conserving therapy or cant have radiotherapy
can have breast conserving therapy if the tumour is small compared to the size of the breast
Radiotherapy can scar and shrink breasts
what are some reasons why people cant have radiotherapy, and so wil need a mastecotmy?
- (aka have had previous radiotherapy to the breast, or lymphoma, or unbale to lie flat and still)
a rare genetic TP53 gene - radiotherapy will lead to sarcoma
WHat is inflammatory breast cancer?
waht is the mangaement
red, oedematous, as cancer has invaded the dermal lymphatic system to cause inflammation/oedema
need mastectomy - as need to take over a 1/3 of the skin off the breast
When is axillary clearnace offered in breast cancer treatment?
Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm
Outline what is meant by grading in breast cancer
Grading - 1 to 3. How the tumour looks (not to be confused with Staging x)
Tumour grade varies from grade 1, where the cells are well differentiated with a
low mitotic rate (and look very similar to normal breast glands down the
microscope) to grade 3 where the reverse is true, and the cells look very abnormal
and have many more mutations in the genes. Tumour grade is an important
prognostic marker used to decide about whether a patient should be offered
chemotherapy or not.
Outline what is meant by staging in breast canc er
Stage 0: Also known as carcinoma in situ. Cancer cells are present but have not invaded surrounding tissues. There is no spread beyond the ducts or lobules.
Stage I: Invasive cancer is detected. Tumors are up to 2 cm and have not spread to lymph nodes or other parts of the body.
Stage II: Tumors range from 2 to 5 cm, or there may be lymph node involvement (cancer has spread to nearby nodes) but not to distant sites.
Stage III: Locally advanced cancer. Tumors may be larger than 5 cm and/or have spread extensively to nearby lymph nodes but not to distant organs.
Stage IV: Metastatic breast cancer. Cancer has spread to distant organs, such as the bones, liver, lungs, or brain.
Stage is anatomical!!
Outline what having the osterogen and progresterone recpetor means
The oestrogen receptor is expressed on about 70% of all breast cancers,
It denotes that the cancer is sensitive to oestrogen which stimulates tumour growth and also that anti-oestrogen therapy will help to control the disease.
==> marker of good prognosis because the women can be treated with anti-oestrogens and the cancers
tend to be less biologically aggressive.
The Progesterone receptor is also an indicator of sensitivity to anti-oestrogens (the ER and PgR are linked).
What are some immunophentupes that have a worse prognositc marker
The Her-2 receptor is over expressed in 15% of all breast cancers and is a poor prognostic marker. if this receptor is up regulated, (i.e. there are more copies on the cell surface,)
the growth pathway is up-regulated and the cells behave in a very aggressive manner.
Ki 67.
More recently, a proliferation marker called Ki 67 has entered clinical practice for cases of borderline aggression
Immunophenotypes with a poor prognostic marker (Her -2 and Ki67) - what is the common treatment of them both?
Her-2
Fortunately this can be combated by use of the new drug trastuzumab (Herceptin) which improves the prognosis substantially for this group
of women.
Ki 67
A high score is a poor prognostic marker - Likely that chemotherapy will be needed
What are the two main types of breast cancer?
Invasive Ductal Carcinoma – NST
NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Invasive Lobular Carcinomas (ILC)
Around 10% of invasive breast cancers
Originate in cells from the breast lobules (the milk-producing glands of the breast.)
ILC tends to grow in a distinctive, non-nodular pattern, often infiltrating surrounding tissues in a single-file formation, making it harder to detect on mammograms.
What are some horomonal therapies for treating breast cancer?
Pre-menopausal women:
1st line therapy is Tamoxifen which is associated with an approximate 30% increase in
survival rate. It is a selective oestrogen receptor modulator (SERM) (It binds to estrogen receptors on breast cells, blocking estrogen’s effects)
In the breast it has an inhibitory effect and causes tumours cells to stop proliferating and die.
Post menopausal Women:
Aromatase Inhibitors, (Exemestane, Letrozole and Anastrozole). These prevent the
peripheral conversion of adrenal androgens to oestrogens by the aromatase enzyme in
fatty tissues.
What are some side effects of Tamoxifen and aromatase inhibitors?
Side effects include : - - - - -
GI disturbance e.g. nausea, vomiting, usually mild
Hormonal disturbances e.g. hot flushes
Headache, rash (occasional)
Visual disturbances
Promotes thromboembolic disease-DVT, PE
can v rarely cause endometrial cacner
Side effects
include:
* Hot flushes
* Joint pain
* Bone density changes
* Vaginal dryness
What are some immunotherapies and other drugs that can be used in teh treatmet of cancer
2
TRASTUZUMAB (herceptin) AND OTHER HER2 TARGETING THERAPIES.
This drug binds to the Her-2 receptor which is over expressed in one third of all breast
cancers. Her-2 expressing cancers have the worst prognosis of any breast cancer subtype
and the use of trastuzumab helps to improve their survival substantially, to the extent that
use of this drug neutralises the adverse effect of Her-2 expression.
Bisphosphonates use
What three ways can chemotherapy be used in breast cancer treatment
Oncologists will guide chemotherapy. Chemotherapy is used in one of three scenarios:
Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer
Chemotherapy - can cause infertility
what are some reasons for offering women chemotherapy in breast cancer?
younger women more likely
whether its metastasised
High Grade tumour
receptor status
HER2 negative (so cant treat with Herceptin) , and ER negative (so cant given then anti oestrogens like tamoxifen) - so can only give chemo!!
What options for reconstructing breasts after mastcetomy are there
- Implants
- Flap reconstruction, eg
○ use portion of latissimus dorsi and associated skin and fat tissue
○ Transverse rectus abdominnus flap (TRAM FLAP)
○ Deep inferior epigastric perforator flap = use Skin and subcut fat from the abdomen as free flap, Taking deep inferior epigastric atery and veins transplanted to breastcant do flap surgery in active smokers!
- Flap reconstruction, eg
Name some plances that breast cancers can commonly metastise to.
You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs:
L – Lungs
L – Liver
B – Bones
B – Brain
TOM TIP: Breast cancer can spread to any region of the body. In patients with a metastatic tumour, regardless of where it is, the primary could be breast cancer. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario. If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).
name a key complication of breast cancer surgery.
Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area.
The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).
The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.
15% -20% in total axilllary clearnace,
2-5% in Wide Local excision
It is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.
What are some ways to manage lymphoedema?
There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include:
Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care
only high risk women are eligible for genetic testing for breast ca - how are these determined?
use online risk calculuotrs,
looks at age
periods
hormonal medication
which family members that have been diagnosed and at what age
CanRISK
or
IBIS 2
30% or higher lifetime risk is determined as high risk
Name some causes of benign breast lumps
Fibroadenoma
Fibrocystic Breast Changes
Breast Cysts
General variation in nodularity, often premenstrual
What are Fibroadenomas? In who are they more common in and why?
Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue.
They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.
What are fibroademonas like on examination?
They are sometimes called a “breast mouse”, as they move around within the breast tissue.
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
what is the management of fibroadenoma
1/3 will shrink. 1/3 will grow, 1/3 will stay the same
Women are usually reassured and only
advised to have surgical removal if they are large or prominent.
What are breast cysts? When do they most commonly occur?
Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period.
They are an abnormal response of part of the breast to hormonal stimulation.
What is the criteria that must be fulfilled, in order for a breast cyst to be classed as bengin?
A breast cyst can be considered
benign if it satisfies the following criteria:
- the fluid is not blood stained
- there is no residual lump
- the same cyst does not continually refill
- doesnt have an irregular/thickened wall
If any of the above is not fulfilled, an intracystic cancer should be considered and
appropriate investigation initiated.
How would a breast cyst fill on examination?
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant -Fluctuance refers to being able to move fluid around within the lump using pressure during palpation
What is a breast abscess? What are the two types
A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
a progression from mastitis
Lactational abscess (associated with breastfeeding, - usually peripheral in the breast)
Non-lactational abscess (unrelated to breastfeeding - usually associated with duct ectasia and therefore central.)
What is a key risk factor for a breast abscess/infection? What are some key signs and symptoms of it?
Smoking
The presentation of mastitis or breast abscesses is usually acute, meaning the onset is within a few days.
Mastitis with infection in the breast tissue presents with breast changes of:
Nipple changes
Purulent nipple discharge (pus from the nipple)
Localised pain
Tenderness
Warmth
Erythema (redness)
Hardening of the skin or breast tissue
Swelling
The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast.
What is the management for lactational mastitis?
Lactational mastitis caused by blockage of the ducts is managed conservatively, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.
Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.
What is the management for non-lactational mastitis?
Management of non-lactational mastitis involves:
Analgesia
Antibiotics
Treatment for the underlying cause (e.g., eczema or candidal infection)
Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either:
Co-amoxiclav
Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)
What should you do if inflammation and redness hasnt improved after one anbtx course for mastitis?
If redness/inflammation hasn’t improved after one antbx course - refer to a breast specialist on suspicion of cancer!
What is Duct Ectasia?
dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.
Itnwhat group does duct ectasia occur most frequently in? What are some presentations of it?
Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.
Presentation
Mammary duct ectasia may present with:
Nipple discharge
Tenderness or pain
Nipple retraction or inversion
A breast lump (pressure on the lump may produce nipple discharge)
What are some investigations of ductal ectasia?
The initial priority is to exclude breast cancer, as they can present in similar ways. This involves triple assessment with:
Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (fine needle aspiration or core biopsy)
Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
Nipple discharge cytology – examining the cells in a sample of the nipple discharge
What is the management of ductal ectasia?
Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.
Management depends on the individual patient:
Reassurance after excluding cancer may be all that is required
Symptomatic management of mastalgia (supportive bra and warm compresses)
Antibiotics if infection is suspected or present
Surgical excision of the affected duct (microdochectomy) may be required in problematic cases
What is Pagets disease of the nipple? When should it be suspected?
This is an eczematous change of the nipple due to an underlying malignancy
(invasive or in-situ) and should be suspected in apparent nipple eczema that does
not resolve with two weeks of steroid/anti fungal cream
How is Pagets disease caused? What is the management of it?
It is caused by the infiltration of tumours cells through the ducts onto the nipple surface where
they infiltrate the epidermis.
Treatment is by excision either as mastectomy or
central (nipple excising) wide local excision.
What is a breast papilloma?
intraductal papillomas are benign tumours, and are warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells.
What is the presentation and diagnosis of a breast papilloma?
Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.
They may present with:
Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump
Diagnosis
Patients require triple assessment with:
Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (usually by core biopsy or vacuum-assisted biopsy)
What is the management of a ductal papilloma?
Management
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.
Embyrology (fuck) - What does upper vagina, cervix, uterus and fallopian tubes develop from? Why does this not occur in males?
upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina.
In a male fetus, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear.
Congential malformations of the GU tract - what is a Bicronuate uterus? How do you manage it?
A bicornuate uterus is where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance
A bicornuate uterus may be associated with adverse pregnancy outcomes. However, successful pregnancies are generally expected. In most cases, no specific management is required.
Typical complications include:
Miscarriage
Premature birth
Malpresentation
Congential malformations of the GU tract - what is an imperforate hymen? How may it present, and what is the management?
Imperforate hymen is where the hymen at the entrance of the vagina is fully formed, without an opening.
Imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.
An imperforate hymen can be diagnosed during a clinical examination. Treatment is with surgical incision to create an opening in the hymen.
What is Androgen insensitivity syndrome? What does it lead to?
A condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.
It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome.
Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics.
Androgen insensitivity syndrome - what is the genotype of patients with it, and what sexual characteristics do they have?
are genetically male, with XY sex chromosomes. However, the absent response to testosterone and the conversion of additional androgens to estrogen result in a female phenotype externally.
Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue.
Patients will have testes in the inguinal canal, that produce antimullerian hormone, which prevents males form developing upper vagina, uterus, cervix and fallopian tubes.
What is the presenation of complete androgen insensitivity syndrome?
lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed.
Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.
What blood tests would you see in someone with androgen insensitivity syndrome?
- Raised LH
Increased LH results from the lack of negative feedback due to ineffective testosterone action, leading to higher stimulation of the testes. - Normal or Raised FSH
FSH may be normal or elevated due to the absence of feedback from testosterone and inhibin, as the Sertoli cells are not effectively stimulated. - Normal or Raised Testosterone Levels:
Testes produce normal or elevated testosterone, but body tissues cannot respond to it due to androgen receptor insensitivity. - Raised Estrogen Levels:
Elevated estrogen occurs from the conversion of excess testosterone to estradiol, contributing to the development of some secondary female characteristics
What is parital androgen insensitivity syndrome, and what are some signs of it?
where there the cells have a partial response to androgens.
This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.
What is the management for androgen insensitivity syndrome?
Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.
What is menopause?
- A retrospective diagnosis made after a woman has had no periods for 12 months
- It is defined as a permanent end to menstruation
- Menopause is the point at which menstruation stops
What is perimenopause, postmenopausal and premature menopause?
- Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
- Postmenopausal describes the period from 12 months after the final menstrual period onwards.
- Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
What causes menopause?
- It is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle
- Oestrogen and progesterone levels are low
- LH and FSH levels are high in response to an absence of negative feedback from oestrogen
Describe how oestrogen is released during the menstrual cycle ?
- In the ovaries the process of primordial follicles maturing is into primary and secondary follicles is always occurring
- At the start of the menstrual cycle FSH stimulates the further development of secondary follicles
- As the follicles grow the granulosa cells that surround them secrete increasing amounts of oestrogen
How does the menopause begin?
- The menopause begins with a decline in the development of ovarian follicles
- Without the growth and development of the follicles there is reduced production of oestrogen
- This results in increasing levels of LH and FSH as oestrogen has a negative feedback on these hormones in the pituitary gland
How is the menstrual cycle affected in the menopause?
- Falling follicular development means ovulation does not occur (anovulation)
- Without oestrogen the endometrium does not develop leading to a lack of menstruation (Amenorrhoea)
- The low levels of oestrogen lead to the perimenopausal symptoms
What are the 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 risks of?
- CVD
- Osteoporosis
- Pelvic organ collapse
- Urinary incontinence
How can menopause be diagnosed?
- Symptoms without blood test
- Use FSH blood test in women under 40 or aged 40-45 with menopausal symptoms
How long do women need to use contraception for after the menopause?
- Two years after the last menstrual period in women under 50
- One year after the last menstrual period in women over 50
What is the management of perimenopausal symptoms?
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers, such as Sylk, Replens and YES
What can be used to help with the vasomotor symptoms of the menopause? The hot flushses and night sweats
Clonidine which is a alpha-2 agonist
What are the indications of HRT?
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
What when is progesterone offered in HRT, as well as oestrogen? When is it not needed?
Women with a uterus require endometrial protection with progesterone (in addition to oestrogen)
The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
whereas women without a uterus can have oestrogen-only HRT.
What are the two regimes to take HRT?
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.
Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
What are the risks of HRT
- Breast and endometrial cancer
- Angina
- Increased risk of VTE with oral pill
- Women are not at increased risk under 50
What are some contraindications for HRT?
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
What is adenomyosis?
- When endometrial tissue (tissue that lines the uterus) grows in the Myometrium (the muscular layer of the uterus)
- It is more common in later reproductive years and those that have had several pregnancies
What is the presentation of Adenomyosis?
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
It may also present with infertility or pregnancy related complications. 1/3 of patients will be asymptomatic
What will an examination of Adenomyosis show?
- An enlarged tender uterus that will feel mores soft than a uterus containing fibroids
heavy periods, with an enlarged and boggy uterus. Adenomyosis is when endometrial tissue becomes embedded within the myometrium.
How would you diagnose Adenomyosis?
transvaginal ultrasound
- The gold standard is a histological examination of the uterus after a hysterectomy
What is the management of Adenomyosis when contraception is not wanted?
- Tranexamic acid when there is no associated pain (antifibrinolytic so reduces bleeding)
- Mefenamic acid where there is associated pain (NSAID reduces bleeding and pain)
What is the management of Adenomyosis when contraception is wanted or acceptable?
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
What complications can adenomyosis cause in pregnancy?
- 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?
- It is where adhesions (sometimes called synechiae) form within the uterus following damage to the uterus
Endometrial curettage (scraping) can damage the basal layer of the endometrium
Give some causes of Ashermans syndrome
Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth)
can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
What happens as a result of the adhesions Asherman’s syndrome?
- The damage endometrium forms scar tissue which connects areas of the uterus that are not usually connected
- These adhesions may bind the uterine walls together or the endocervix sealing it shut
- These adhesions form physical obstructions and distort the pelvic organs
What are the symptoms Asherman’s syndrome?
- Secondary amenorrhoea (as the adhesion tissue does not respond to oestrogen)
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.
How would you diagnose and manage Asherman’s syndrome? What is the management?
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with x-rays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan
Management is dissecting the adhesions during hysteroscopy
What is Lichen Sclerosis? Where does it occur
a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin.
It commonly affects the labia, perineum and perianal skin in women. Can affect foreskin and glans of the penis
What conditions is Lichen sclerosus assossciated with? describe the changes that occur
Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears:
“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques
Outline the presentation of Lichen sclerosus
The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus - worsened by tight underwear, and urinary incontinence
What is the treatment for lichen sclerosus?
- Topical potent steroids (dermovate) used long term and reduce the risk of malignancy
What is the main complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
What is atrophic vaginitis?
Is the dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections.
can also be referred to as genitourinary syndrome of menopause
What can a lack of oestrogen contribute to?
Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.
Weak or brittle bones
What is the presentation of atrophic vaginitis? What other conditiosn should make you consider it?
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
consider it in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse.
Specifcially ask symptoms of vaginal dryness and discomfort!!
What is the management of atrophic vaginitis?
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen
- Estriol Cream or pessaries
- Estradiol Tablets or a ring
Give some complicaitons of topical oestrogen and outline how its use should be used, in atrophic vaginitis.
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism.
Women should be monitored at least annually, with a view of stopping treatment whenever possible.
What is the main type of vulval cancer?
What are the risk factors for it
Around 90% are squamous cell carcinomas.
Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus .
What is Vulva Intraepithelial Neoplasia? What are two main types and what are they assossicated with?
It’s a type of premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.
Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).
What is the presentation of vulval cancer
Vulval cancer may present with symptoms of:
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
What are the investigations and management for vulval cancer?
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging
Management
Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy
What are the types of cervical cancer?
- 80% are squamous cell carcinomas
- Adenocarcinoma
- Rarely small cell cancer
What is the main risk factor for cervical cancer?
HPV
At what age are girls vaccinated against HPV?
12-13
What is HPV?
- It is a sexually transmitted infection that can cause anal, vulval, vaginal, penis, mouth and throat cancers
- HPV proteins e6 and e7 inhibit tumour suppressor genes p53(e6) and pRb(e7)
What types of HPV are the main causes of cervical cancer?
Type 16 and type 18. There is no treatment for HPV most resolve spontaneously
What puts you at increased risk of catching HPV?
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
What are some other risk factors for cervical cancer?
HPV infection
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
What are the symptoms of cervical cancer?
- Many paitents are asymptomatic and picked up on screening
- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
- Vaginal discharge
- Pelvic pain
- Dyspareunia (pain or discomfort with sex)
What appearance of the cervix is suggestive of cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
Patients should be referred for a colposcopy
What is Cervical Intraepithelial Neoplasia?
it is 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
CIN III is sometimes called cervical carcinoma in situ.
How cervical cancer screened for?
- A cervical smear test which is a collection of cells for the cervix
- Cells are examined under a microscope for precancerous changes (Dyskaryosis)
This method is called liquid-based cytology
How often should screening occur?
Every three years aged 25 – 49
Every five years aged 50 – 64
What are the exceptions to the normal cervical screening program?
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
What is the management of a cervical screen?
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, (if positive still after 24 months - refer for colp, if now hrHPV negative at 24 months then return to normal recall
HPV positive with abnormal cytology – refer for colposcopy
What are the different stages of cervical cancer?
FIGO staging
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 the different stages of cervical cancer
Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy - Moving a section of abnormal cells
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
5 year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4
What monoclonal antibody can be used to treat cervical cancer?
Bevacizumab (avastin)
r. It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels.
What is the vaccine for HPV?
Needs to be given to boys and girls before they become sexually active
Gardasil protects against strains 6, 11, 16 and 18:
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
What is the main type of endometrial cancer?
Endometrial Cancer
80% of cases are adenocarcinomas
It is an oestrogen dependant cancer meaning that oestrogen stimulates the growth of endometrial cancer cells
What is the key presentation of endometrial cancer?
- Post menopausal women with bleeding
What is endometrial hyperplasia?
- Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium
- Treated by a specialist using progestogens, with either:
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
What are the risk factors for endometrial cancer?
think - mostly oestrogen related!!
Unopposed oestrogen (oestrogen without progesterone)
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Why is obesity a risk factor for endometrial cancer?
- Fat tissue is a source of oestrogen as it produces aromatase which converts androgens
Why is T2DM a risk factor for endometrial cancer?
Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer.
PCOS is also associated with insulin resistance and increased insulin production. Insulin resistance further adds to the risk of endometrial cancer in women with PCOS.
What are some protective factors for endometrial cancer?
- Combined pill
- Mirena coil
- Increased pregnancies
- Cigarette smoking
Oestrogen may be metabolised differently in smokers
Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
Smoking destroys oocytes (eggs), resulting in an earlier menopause
What are the FIGO stages for 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 treatment for endometrial cancer?
- Stage 1 and 2 is a total abdominal hysterectomy with bilateral salpingo-oophorectomy
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
What is thought to cause endometrial polyps?
It is estimated that they are present in 25% of women with abnormal vaginal bleeding
No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen.
Risk factors include obesity, high blood pressure and a history of cervical polyps.[3] Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps
Define
a) Endometriosis
b) Lump of endometrail tissue outside uterus
c) Endometrial tissue in the myometrium
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus.
A lump of endometrial tissue outside the uterus is described as an endometrioma
Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
What is thought to cause endometriosis?
No genes have been found, but there does seem to be a genetic link
retrograde menstruation - endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum.
Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue.
endometrial cells may through the lymphatic system,
Cells outside the uterus under go metaplasic to become endometrial cells
Outline the pathophysiology of the symptoms seen in endometriosis
During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, - leads to irritation and inflammation of the tissues around the sites of endometriosis
This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis.
Deposits of endometriosis in the bladder or bowel can lead to blood in the urine or stools.
What would examination reveal in endometriosis, and what investigations would you do for it?
Examination may reveal:
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
US - can pick up chocolate cysts, but not always reliable
MRI - can pick up endometrioma
Patients with suspected endometriosis need referral to a gynecologist for laparoscopy.
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
If an endometrioma ruptures, it will cause sudden intense pain
Outline the staging endometriosis
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
What is the surgical management of endometriosis?
Laparoscopic surgery can be used to excise or ablate the ectopic endometrial tissue
urgery can be used to dissect the adhesions and attempt to return the anatomy to normal.
Hysterectomy and bilateral salpingo-opherectomy is the final surgical option. During the procedure, the surgeon will attempt to remove as much of the endometriosis as possible.
The surgery can lead help with infertility due to endometriosis
How are fibroids classified?
Fibroids are classified according tot heir position in the uterine wall, for example:
Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.
With regards to position in the uterine wall, what type of fibroids are most common?
Intramural - fibroids confined to the myometrium.
What are some complications of fibroids
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic.
Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
What is a hydatidiform mole?
- A type of tumour that grows like a pregnancy inside the uterus
- This is called a molar pregnancy
What are the two types of hydatidiform mole?
- Partial mole: when two sperm cells fertilise a normal ovum at the same time and it has 3 sets of chromones called a haploid cell
- Complete mole: when two sperm fertilise and ovum that contains no genetic material
Name some causes of galactorrhea.
Idiopathic (no cause can be found)
Prolactinomas (hormone-secreting pituitary tumours)
Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
Medications, particularly dopamine antagonists (i.e., antipsychotic medications) - as dopamine inhibits prolactin!
Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to suppress prolactin secretion.
What is a prolactinoma? What genetic condition are they often assossciated with?
This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.
Prolactinomas can be:
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
What are some symptoms of a prolactinoma?
Macroadenomas can have adverse effects relating to their size:
Headaches
Bitemporal hemianopia (loss of the outer visual fields in both eyes
Symptoms of increased prolactin:
Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
Menstrual irregularities, particularly amenorrhoea (absent periods)
Reduced libido (low sex drive)
Erectile dysfunction (in men)
Gynaecomastia (in men)
What are the symptoms of ovarian cancer?
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
Especially pain in older women
Ovarian cancer can present with urinary symptoms due to pressure effects from the tumour.
Can cause hip or groin pain due to compression on the obturator nerve
What is the criteria for the 2 week wait for ovarian cancer?
- Ascites
- Pelvic mass
- Abdominal mass
What is the FIGO 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)
(confined to…OPAM …. ovary, pelvis, Abdo, metastasised)
What is an ovarian cyst? What are the two types?
An ovarian cyst is a fluid-filled sac that develops on an ovary.
- Are very common in premenopausal women and are normally benign
- Postmenopausal cysts are more concerning for malignancy and need further investigations
Either functional or pathological
What is ovarian torsion?
Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue/ligaments , fallopian tube and blood supply (the adnexa).
What is used to diagnose an ovarian torsion?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal,
Will show a whirlpool sign, free fluid in pelvis and oedema of the ovary
Definitive diagnosis is made with laparoscopic surgery
What is the treatment of ovarian torsion?
Emergency laparoscopy to uncoil twisted ovary + fixation
What is Pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
PID - define
inflammation of the endometrium
inflammation of the fallopian tubes
inflammation of the ovaries
inflammation of the peritoneal membrane
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
Peritonitis is inflammation of the peritoneal membrane
What are the most common causes of pelic inflammatory disease
Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:
Neisseria gonorrhoeae tends to produce more severe PID - most common
Chlamydia trachomatis
Mycoplasma genitalium
Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:
Gardnerella vaginalis (associated with bacterial vaginosis)
Haemophilus influenzae
Escherichia coli
Outline some of the pathophysiolgy in PCOS, concerning LH and testosterone
Origin unclear, but basically inappropriate signaling to the hypothalamus and pituitary.
PCOS is characterized by a “steady state” of chronically elevated LH and chronically suppressed FSH levels, instead of their cyclic rise and fall in a normal menstrual cycle
- Increased LH stimulates ovaries to increase production of androgens. (testosterone), which perpetuateds chronic anovulation.
- As a result of suppressed FSH, new follicular growth is continuously stimulated but not to the point of full maturation and ovulation (corpus
lutea and corpus albicans are rarely detected).
Outline some of the pathophysiolgy in PCOS, concerning insulin and SHBG
Insulin resistance is a crucial part of PCOS.
Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone).
Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
What are some presenting features of PCOS?
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
Also:
Insulin resistance and diabetes
Acanthosis nigricans - thickened, rough skin, found in the axilla and elbow
Depression and anxiety
Sexual problems
What investigations would you do for PCOS
Pelvic US - would see string of pearls criteria
Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone
What blood test results would you see on the tests for PCOS? What is the diagnostic criteria for US
Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS.
What is a cystocele?
- Caused by a defect in the anterior vaginal wall allowing the bladder to prolapse backwards into the vagina
- Can also happen with the urethra (urethrocele) and a combined one is called a cystourethrocele
How would you examine a pelvic organ prolapse?
- Dorsal and left lateral position
- A Sim’s speculum would be used to support opposing vaginal wall to one being examined
What is the treatment of a more severe pelvic organ prolapse?
Vaginal pessaries –>inserted into the vagina to provide extra support to the pelvic organs.
Types
Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries are a cube shape
Donut pessaries consist of a thick ring, similar to a doughnut
Hodge pessaries are almost rectangular.
Can’t fit pessaries if there is an infection (aka thrush) or history of vaginal ulceration
Surgery
Surgery for big prolapse - What is a sacrocolpopexy ? When is it used?
A sacrocolpopexy is an operation to treat a prolapse of the vaginal vault (top of the vagina/front passage) in women who have had a hysterectomy (removal of womb) using a strip of synthetic mesh to lift the top of the vagina and hold it in place.
What is the grading system and what are the grades for pelvic organ prolapse?
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
Normal physiology - what happens when the bladder is half full with wee?
When bladder half full, stimulates stretch receptors in bladder wall
===> Send impulses to the sacral spinal chord, at levels S2 and S3 -
PELVIC SHPLANIC NERVE, these signals then go up to micturition centre in the pons
Normal physiology - activation of the pelvic sphlanic nerves when the bladder is half full leads to what?
Micturition reflex
Activation of pelvic splanchnic nerve S2-S4 cause the detrusor muscles to CONTRACT - at sacral micturition centre, Onuf’s Nucleus
- When the detrusor muscle contract, the change in bladder shape pulls open the internal urethral sphincter - is made of smooth muscle
Micturition reflex also decreases motor nerve stimulation to the external sphincter allowing it to relax as well.
At this point, urination should occur, but why don’t just wet ourselves every time the bladder is half full?
Normal physiology - what stops us from urinating every time our bladder is half full, aka what overrides the Micturition reflex
At this point we should just wee ourselves every time the bladder is half full, however at this point, the PONTINE STORAGE CENTRE OVERIDES MICURITION RELFEX
It does this by activating SYMPATHETIC, HYPOGASTIRC NERVES T10 - L2, that cause DETROUSER RELAXATION, and BLADDER NECK CONTRACTION
Outline the pathophysiology behind urge incontinence. What things can cause it? (known as Overactive bladder)
Sudden urge to urinate because of an “overactive bladder”, followed immediately by involuntary urination
typically due to an uninhibited detrusor muscle that contracts randomly.
Usually associated with urinary tract infections. Inflammation may trigger the detrusor muscle.
Outline the pathophysiology behind stress incontinence. What things can cause it?
Increased abdominal pressure overwhelms the sphincter muscles and allows urine to leak out. Causes include pregnancy and exertion, like sneezing, coughing, laughing.
Outline the pathophysiology behind overflow incontinence. What things can cause it?
Due to either - Obstruction due to blockage in urine flow
or
Ineffective detrusor muscle. ==> Detrusor cant contract properly so the bladder doesn’t empty properly
In both cases, leads to urine build up, to the point that the bladder is so full that urine dribbles/leaks out through sphincters
Obstruction - - eg benign prostatic hyperplasia,
Ineffective detrusor = Diabetes (neurogenic bladder) Multiple sclerosis, Spinal chord injury
What are some simple assessments you could do to assess incontinence
Urinalysis (MSU)
Frequency volume chart (FVC)
Residual urine measurement (RU)
Questionnaire (ePAQ)
Investigating incontinence: what is ePAQ?
A questionnaire regarding urinary, bowel, vaginal and sexual symptoms.
What are the most common types of kidney stones?
Calcium-based stones they account for 80%. Having a raised serum calcium and low urine output are key risk factors for calcium collecting into a stone
Other than calcium based kidney stones, what are the other 3 types of kidney stones?
- Uric Acid (red brown colour, not visible on xray (make up 5-10% of stones)
- Struvite, from bacteria (associated with infection) - forms dirty white stones, visible on xray (2-10%)
- Cystine - yellow/light pink coloured (1%)
What are some symptoms of kidney stones?
-
Acute, severe flank pain (renal colic)
- Classically ‘loin to groin’ pain
- Pain lasts minutes to hours and occurs in spasms (with intervals of no pain or dull ache)
- Fluctuating in severity as the stone moves and settles
-
Nausea and vomiting
Pain is not relieved - Urinary urgency or frequency
- Haematuria: microsopic or macroscopic
Flank/ renal angle tenderness
Left and right lumbar region pain
Fever (if sepsis)
What is the gold standard test for renal stones?
Non contrast CT scan of kidney, ureters and bladder (CT KUB) .
Should be performed within 14 hours of admission
^^For non pregnant adult
Renal ultrasound for pregnant adult or child
May use ultrasound if radiation needs to be avoided
What is the conservative management for Nephrolithiasis?
- Watchful waiting: stones <5mm should pass spontaneously and followed up in clinic
- Medical expulsive therapy (MET):Alpha-blocker, e.g.tamsulosin, for ureteric stones 5-10mm to help passage. Not indicated for renal stones. - *it helps relax muscles in the ureter, and can increase the flow of urine
What is the first line surgical treatment for both ureteric and kidney stones, size 5 - 10mm? Outline what happens in it
Extracorporeal shock wave lithotripsy (ESWL): utilises high energy ultrasound waves to break the stone into tiny fragments;
uncomfortable, requires analgesia and can cause organ injury. Contraindicated in pregnancy due to risk to the foetus (perform URS instead)
if stones are <5mm, then watchful waiting
What is the second line surgical treatment for both ureteric and kidney stones? Outline what happens in it
Ureteroscopy (URS): pass a ureteroscope through the urethra and bladder up to the ureter (retrograde) and retrieve the stone or fragment it with intracorporeal lithotripsy
What is the third line treatment for Nephrolithiasis, seen in large Kidney stones? (not used for ureteric stones)
Percutaneous nephrolithotomy (PCNL): accessing the renal collecting system percutaneously via a surgical incision in the back for intracorporeal lithotripsy or stone fragmentation
(not used for ureteric stones)
What are the different types of fistula?
Anovaginal or rectovaginal fistula is a hole joining the anus or rectum to the vagina.
A colovaginal fistula joins the space in the colon to that in the vagina.
A urinary tract fistula is an abnormal opening in the urinary tract or an abnormal connection between the urinary tract and another organ
What is bacterial vaginosis?
- It refers to an overgrowth of bacteria in the vagina specifically anaerobic bacteria
- It is not Sexually transmitted
MOST COMMON CAUSE OF VAGINITIS IN YOUNG WOMEN
Why does BV happen? What is the most common cause?
Loss of lactobacilli which produce lactic acid and keep the vaginal pH low
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
What are the investigations for BV?
- ## Test vaginal pH anything above 4.5 is badcharcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
What cells are shown with BV?
Clue cells
How does Thrush present?
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.
Symptoms:
Vulval itch
Vulval soreness
Vaginal discharge
Superficial dyspareunia
External dysuria
Erythema
Fissuring
Discharge, typically curdy but may be thin. Non-offensive.
What is the investigations for Candidias?
Microscopy and culture is standard for symptomatic women
Vaginal swab should be taken from the anterior fornix
(for the following:
Gram or wet film examination
Direct plating to solid fungal media. Speciation to albicans/non-albicans is essential if complicated disease suspected/present
What would someone with secondary syphilis present with?
ypically starts after the chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
What is Mycoplasma Genitalium? What can it cause?
a bacteria that causes non-gonococcal urethritis.
Most common cause of a NGU after Chlamydia, it’s an STI
name some situations (Sexual exposures) when PEP would be recommended for preventing HIV transmission
In known positive HIV patients, when HIV Viral load is unknown or detectable for:
Insertive and Receptive Anal Sex
Receptive Vaginal sex (consider in insertive vaginal sex)
If HIV status isn’t known, and from a country with high prevalence or high risk group :
Receptive anal sex
Consider PEP for insertive anal sex.
