Womens Health Flashcards
What are the types of ovarian cysts?
-95% benign
Benign neoplastic cysts
Serous or mucinoid epithelial cystadenomas.
- Common in women >40 years old
- 25% are bilateral and 25% are malignant.
Teratomas, including dermoid cysts, which are mature teratomas.
-Common in those <40 years old. 25% are bilateral. They can also be non-cystic.
Others: endometriotic cysts.
Non-neoplastic cysts:
Functional (hormone-releasing) follicular or corpus luteum cysts.
-The commonest type of growth in women of reproductive age.
-Follicular cysts are due to non-rupture of a follicle.
Non-cystic growths are usually fibromas.
What is the presentation of an ovarian cyst?
- Can be asymptomatic.
- Otherwise, they are similar to ovarian cancer
- Swollen abdomen ± palpable pelvic mass.
- Abdo pain, tender adnexa, dyspareunia.
- Bloating, nausea.
Local mass effects
- Bladder —>urinary frequency.
- Ureters —> hydronephrosis, recurrent UTI, haematuria.
- Bowel —> constipation, obstruction.
Severe manifestations
- Shock and peritonism due to rupture.
- Severe pain from torsion (which may be intermittent), infarction, or bleed.
- Meigs syndrome —> fibroma which results in ascites and right transudative pleural effusion.
- Functional tumours —> virilization, altered menstruation, postmenopausal bleeding.
What are the investigations for an ovarian cyst?
- Transvaginal US is 1st line.
- CA-125 —> in all postmenopausal women, and contributes to RMI score. -Not required if simple cyst has been diagnosed by USS in a premenopausal woman.
- Other basic investigations —> pregnancy test, FBC (↓Hb in bleed, ↑WBC in infection or torsion).
Further tests
-Cyst thought to be benign, FNA and cytology and/or diagnostic laparoscopy can confirm this. Contraindicated if you suspect cancer as it risks spreading the disease.
-If age <40 and complex ovarian mass on USS, screen for germ cell tumour with hCG, AFP, and LDH.
Laparotomy if acute abdomen.
What are the management for ovarian cyst?
Conservative
- Simple small cysts (<5 cm) in premenopausal women and in postmenopausal women with a normal CA-125. Usually resolve within 3 months.
- Can also be considered for larger cysts (5-7 cm), provided there is annual USS follow up.
Surgical
-Done to prevent malignant transformation and/or relieve symptoms.
-Indications: large cyst (>5 cm) and postmenopausal, persistent large cyst and premenopausal, expanding cyst, persistent symptomatic cyst.
-Procedures —> cystectomy if premenopausal and wanting to maintain fertility, otherwise bilateral oophorectomy.
Laparoscopic if possible. Laparotomy reserved for large cysts with solid components (e.g. dermoid) and/or high risk of malignancy
What is cervicitis and its common causes?
- Inflammation/infection or cervix.
- Commonly associated w STI —> chlamydia/gonorrhoea
- Can be chemical trauma (spermicides) or mechanical (tampon)
RF —> unprotected sexual intercourse, many sexual partners, young age
What is the presentation of cervicitis?
- Vaginal discharge —> yellow, green, mucopurlent
- Pelvic pain
- Pain during sex
- Temperature
Focused sexual history
- Duration of symptoms and any changes
- Number of sexual partners in 3 months
- Sexual encounter protected or not
- Nature of encounter
- Risky behaviours - IVDU
- Any previous STIs
- Any previous abnormal cervical cytology screen
- Ask about contraceptives
- Ask about periods - check whether pregnancy or tampons
What is the examination for cervicitis?
What else could it be?
- Get chaperone
- Bimanual and abdo exam —> check for any pelvic tenderness. Cervical excitation.
- Speculum —> redness, swelling, discharge
DD vaginitis, cervical ectropian
What are the investigations and management for cervicitis?
- Bloods —> HIV and hepatitis.
- Urine sample —> UTI or bHCG
A patient would like to start the OCP, what counselling do you need to give?
Potential harms and benefits
- COC is > 99% effective if taken correctly
- Small risk of blood clots
- Very small risk of heart attacks and strokes
- Increased risk of breast cancer and cervical cancer
How to tale
- If the COC is started within the first 5 days of the cycle –> no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
- Should be taken at the same time every day
- The COCP is conventionally taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation. However, there was a major change following the 2019 guidelines. ‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
- Advice that intercourse during the pill-free period is only safe if the next pack is started on time
Discussion on situations where efficacy may be reduced*
-If vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
-If taking liver enzyme-inducing drugs
Other information
-Discussion on STIs
*Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
Explain the classification of HTN in pregnancy
Remember, in normal pregnancy:
-BP usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
-Systolic > 140 mmHg or diastolic > 90 mmHg
or
-An increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Pre-existing hypertension
- A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
- No proteinuria, no oedema
- Occurs in 3-5% of pregnancies and is more common in older women
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
-No proteinuria, no oedema
-Occurs in around 5-7% of pregnancies
-Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
Pre-eclampsia
- Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
- Oedema may occur but is now less commonly used as a criteria
- Occurs in around 5% of pregnancies
