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Gynae 6 Flashcards

1
Q

What is an ovarian cyst?

A

Fluid-filled sac in ovarian tissue

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2
Q

What are the RFs for an ovarian cyst?

A
  • Hx of ovarian cysts
  • PCOS
  • Endometriosis
  • Pregnancy
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3
Q

What are the types of ovarian cyst?

A

Physiological/Functional:

  • Follicular
  • Corpus luteal
  • Haemorrhagic
  • Theca lutein

Benign Germ Cell:

  • Dermoid / Mature cystic teratoma

Benign Epithelial:

  • Serous cystadenoma
  • Mucinous cystadenoma
  • Brenner’s Tumour
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4
Q

Describe a follicular cyst

A

Dominant follicle fails to rupture

  • Commonest type of ovarian cyst
  • Lined by Granulosa cells
  • May occasionally continue to produce oestrogen and lead to EH
  • Commonly regress after several menstrual cycles
  • Cyst = >3cm (>5cm is at risk of torsion)
  • USS: thin walled, unilocular, anechoic
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5
Q

Describe a luteal cyst

A

Dominant follicle ruptures but then closes again and fills with fluid, or can fill with blood (haemorrhagic)

  • NORMAL in early pregnancy
  • Lined by Luteal cells
  • USS: diffusely thick wall, <3cm, lacey pattern
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6
Q

Describe a haemorrhagic cyst

A

Bleeding into a functional cyst

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7
Q

Describe a theca lutein cyst

A

Caused by overstimulation with HCG during pregnancy

  • More common when higher HCG e.g. multiple pregnancy, GTD
  • Often bilateral
  • USS: bilaterally enlarged, multicystic ovaries, thin-walled and anechoic
  • Resolve spontaneously
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8
Q

Describe a dermoid cyst

A
  • Most common benign tumour in those <30yo
  • Lined by epithelial cells
  • Benign, solid or cystic
  • Often asymptomatic but most likely to tort
  • Rokitansky protuberances = multiple or single white shiny masses that protrude out
  • Mature: USS: unilocular, diffusely or partially echogenic, may contain teeth, no internal vascularity
  • Immature: contains embryonic elements, malignant
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9
Q

Describe a serous cystadenoma

A

The most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)

  • Usually unilocular
  • Often bilateral
  • USS: unilocular, anechoic, no flow on colour Doppler
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10
Q

Describe a mucinous cystadenoma

A
  • Typically very large
  • If ruptures > pseudomyxoma peritonei (mucin in abdomen)
  • USS: multiloculated, many thin separations, low echogenicity due to mucin
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11
Q

Describe Brenner’s tumour

A
  • Small
  • Contain urothelial-like epithelium
  • USS: hypoechoic, occasionally calcifications may be seen
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12
Q

What are the S/S of an ovarian cyst?

A
  • Lower abdominal pain
  • Swelling with pressure symptoms (i.e. urinary symptoms)
  • Deep dyspareunia
  • Acute abdomen (torsion/haemorrhagic) – severe right or left iliac fossa pain (± vomiting in torsion)
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13
Q

What are the investigations for an ovarian cyst?

A
  • Exclude pregnancy
  • Abdominal and vaginal examination

1st line = TVUSS

+Bloods:
Pre-menopausal:

  • <40yo = LDH, aFP, b-hCG levels

Post-menopausal:

  • CA-125
  • RMI calculation
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14
Q

What is the management of an acutely presenting ovarian cyst?

A
  • ABC approach and resuscitate
  • Ovarian cystectomy with oophorectomy if there is any necrosis
  • Broad-spectrum antibiotics.
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15
Q

What is the pre-menopausal management of an ovarian cyst?

A

Simple/unilocular cyst:

  • <5cm = no follow-up required
  • 5-7cm = repeat USS yearly
  • > 7cm = MRI ± surgery

Recurrent or unresolved:

  • Medical (COCP > preventing ovulation will prevent recurrent cysts)

Recurrent, sustained >5cm, suspicious/multiloculated:

  • Surgical (laparoscopic cystectomy; usually curative)
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16
Q

What are the indications for watchful waiting management of an ovarian cyst?

A
  • Unilateral
  • Unilocular (no solid parts)
  • Pre-MP (3-10cm)
  • Post-MP (2-6cm)
  • Normal CA125
  • No free fluid
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17
Q

What is the post-menopausal management of an ovarian cyst?

A

If RMI >200 = CT-AP and MDT management with gynae-oncology

  • Total abdominal hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO) ± Omentectomy

If RMI <200:
All of… asymptomatic, simple cyst, <5cm, unilocular, unilateral
= Repeat USS and Ca-125 in 4-6m:

  • (1) Resolved = Discharge
  • (2) Unchanged = Repeat USS and Ca-125 in 4-6m
  • (3) Changed = Consider intervention (laparoscopic cystectomy)

Any of… symptomatic, non-simple features, >5cm, multilocular, bilateral
= BSO

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18
Q

What are the complications of an ovarian cyst?

A

Ovarian cyst rupture

  • Most common with functional cysts
  • Conservative (pain relief) + watchful waiting
  • Laparoscopy ± cautery (if evidence of active bleeding)

Also:

  • Ovarian torsion (if >5cm; most common in dermoid)
  • Subfertility
  • Malignant change
  • Oophorectomy
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19
Q

What is an ovarian tumour?

A

Tumours arising from the ovary. Can be classified into benign or malignant, or by type.

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20
Q

What are protective factors against ovarian tumours?

A
  • Pregnancy
  • COCP
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21
Q

What are RFs for ovarian tumours?

A
  • More ovulations; i.e. nulliparity, early menarche, late menopause
  • Increasing age
  • FHx (BRCA1/2, MLH1, MSH2)
  • Endometriosis
  • HRT
  • Obesity, smoking
  • Talcum powder
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22
Q

What is associated with ovarian tumours?

A
  • Lynch syndrome (Autosomal Dominant HNPCC; MLH-1, MSH-2)
  • Breast cancer (BRCA1/2)
  • Many genetic associations exist (p53 (serous), BRAF, K-ras)
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23
Q

What are the main types of ovarian tumour?

A
  • Epithelial (70%) - most common
  • Germ-Cell (15%)
  • Sex-Cord Stromal (5%)
  • Benign tumours
24
Q

Describe epithelial ovarian tumours

A
  • Originates from the epithelium covering the ovary
  • Post-menopausal (56yo)
  • Present LATE with a BAD prognosis
  • Endometriosis association with clear cell (>20%) > endometrioid (10-20%) ovarian cancer
  • Endometroid ovarian carcinoma often found alongside endometroid endometrial carcinoma

Type 1:

  • Low-grade serous (solid or cystic, most common)
  • Endometrioid (solid or cystic)
  • Mucinous (solid or cystic)
  • Clear cell tumour

Types 2:

  • High-grade serous (solid or cystic)
25
Q

Describe germ cell ovarian tumours

A
  • Undifferentiated primordial germ cells of the gonad.
  • Bimodal - Young premenopausal or postmenopausal women (15-20yo > 65-70yo)
  • Hilus cell tumours = Leydig cell tumours; secrete androgens

Types:

  • Teratoma (solid or cystic, majority) - most common benign growth <30yrs
  • Dysgerminoma
  • Endodermal sinus tumour
  • Choricocarcinoma
26
Q

Describe sex-cord stromal ovarian tumours

A
  • Originates from the stroma of the gonad
  • All Ages (post-menopausal)

Types:

  • Fibroma - no endocrine function
  • Thecoma - oestrogen
  • Granulosa cell tumour - oestrogen
  • Sertoli-Leydig cell tumour - androgens, variable
27
Q

What are the S/S of ovarian tumours?

A

Vague symptoms > late presentations…

Late presentation – 75% present in Stage 3

  • Lower abdominal pain
  • Deep dyspareunia
  • Pressure symptoms
  • Abdominal swelling
  • (note: may be asymptomatic).

Acute accident:

  • Severe right or left iliac fossa pain, accompanied by vomiting in torsion.

Vague/ absent symptoms:

  • Abdominal discomfort
  • Abdominal distension/mass
  • Fatigue, weight loss,
  • Pressure symptoms (urinary frequency/dyspepsia).
28
Q

What are the differences between ovarian and endometrial cancer?

A

Ovarian = adnexal mass and no PV bleeding

Endometrial = uterine mass and PMB

29
Q

What are the investigations for ovarian tumours?

A

1st = CA125

  • If ≥35 = 2ww referral to O&G and USS of abdomen and pelvis
  • CA125 also raised in pregnancy, endometriosis and alcoholic liver disease

2nd = USS abdo and pelvis
Characterise:

  • Size, Consistency, Presence of solid elements, Bilateral or not, Presence of ascites, Extraovarian disease (peritoneal thickening and omental deposits)

3rd = RMI

  • Score >250 is considered high-risk (<25 is low risk) = Refer to specialist MDT

4th = CT scan abdo and pelvis

  • Establish extent of disease / Staging

5th = Histopathology

  • Definitive diagnosis
30
Q

What is the management of an ovarian tumour?

A

Chemotherapy:

  • Offer women with high risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of 6 cycles of carboplatin

Surgery:

  • Midline Laparotomy: TAH + BSO + omentectomy
31
Q

What are the complications of ovarian tumours?

A
  • Prognosis – most important prognostic factor is no residual disease following laparotomy
  • Depends on stage, volume of disease following surgery and histological grade
  • 5-year survival = 46% (stage 1 = 90%; stage 3 = 30%)
32
Q

What is ovarian torsion?

A

The partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply.

  • If the fallopian tube is also involved then it is referred to as adnexal torsion.
33
Q

What are the RFs for ovarian torsion?

A
  • Ovarian cysts or tumours
  • Long ovarian ligaments
  • Pregnancy
  • Tubal ligation
  • ovarian hyperstimulation syndrome
  • being of a reproductive age
34
Q

What are the S/S of ovarian torsion?

A
  • Usually the sudden onset of deep-seated colicky abdominal pain.
  • Severe right or left iliac fossa pain
  • Unlikely to have shoulder-tip pain (differentiate from ectopic)
  • Associated with vomiting and distress
  • fever may be seen in a minority (possibly secondary to adnexal necrosis)
  • Vaginal examination may reveal adnexial tenderness
35
Q

What are the investigations for ovarian torsion?

A
  • Pregnancy test
  • FBC (may show high WCC)
  • Speculum (if PID is a differential)
  • Bimanual examination (adnexal mass) – this is ok in ovarian torsion
  • Urinalysis (rule out ureteric colic)

Urgent TVUSS with Dopplers

  • 25% of torsion occurs in children (do transabdominal rather than TVUSS)
  • Torsion of a normal ovary is VERY unlikely
  • Ovarian necrosis may cause lactic acidosis
  • May show free fluid or a whirlpool sign.

Laparoscopy usually diagnostic and therapeutic

36
Q

What is the management of ovarian torsion?

A
  • 1st line: laparoscopic detorsion ± cystectomy (if required)
  • 2nd line: salpingo-oophorectomy

If surgery is not prompt enough, removal of a necrotic ovary may be necessary

37
Q

Describe the different types of incontinence

A

Stress:

  • Increased pressure on bladder > incontinence
  • [SMALL LOSSES] - e.g. leaking small amounts when coughing or laughing

Urge:

  • Strong urge to urinate and often don’t get to toilet in time > incontinence
  • [LARGE LOSSES] - due to detrusor overactivity, the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying

Mixed:

  • ≥2 types (often stress and urge incontinence together)

Overflow:

  • Difficulty emptying bladder > filling > incontinence

Functional:

  • Cannot get to the toilet in time (issues in mobility) > incontinence
38
Q

What are the RFs for overactive bladder syndrome?

A
  • Advancing age
  • Previous pregnancy and childbirth
  • High BMI / obesity
  • Hysterectomy
  • FHx
39
Q

What are the investigations for overactive bladder syndrome?

A
  • Speculum: Exclude pelvic organ prolapse, check ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises), ask patient to cough (Valsalva) to check for fluid leakage
  • Urine dipstick, urine MC&S – rule out DM or UTI
  • Bladder diaries (minimum 3 days) > if inconclusive move to 2nd line…
  • 2nd: Urodynamic Testing (if mixed incontinence) – 3 pressures measured from inside rectum and urethra
40
Q

What is the management of stress incontinence?

A

CHECK NEED FOR REFERRAL TO SPECIALIST
(i.e. trigone tumour > needs to be checked)

1st line = Conservative:

  • WL (if BMI >30)
  • Pelvic floor exercises (8 contractions, TDS, 3 months)
  • Can refer to physiotherapist if difficulty with pelvic floor exercises

2nd line = Surgical treatment

  • Colposuspension: Stitching neck of bladder higher
  • Autologous rectus fascial sling: A sling placed around the neck of the bladder
  • Bulking agents: bulking agents injected into urethral sphincter to strengthen it

SNRI duloxetine:

  • if does not want surgical treatment
41
Q

What is the management of urge incontinence?

A

CHECK NEED FOR REFERRAL TO SPECIALIST
(i.e. trigone tumour > needs to be checked)

1st line = Conservative:

  • Bladder training (lasts for a minimum of 6 weeks, idea is to gradually increase the intervals between voiding (up to 25 minutes)
  • Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles)
  • Control any diabetes well (avoid diabetic nephropathy)

2nd line = Bladder stabilising drugs:

  • 1st = Antimuscarinics (oxybutynin, tolterodine)
  • Oxybutynin = increased risk of falls – do not give if frail and elderly
  • Mirabegron (beta-3-agonist) used if concerns about using anticholinergics in older, frail women

3rd line (surgical)

  • Botox injection - risk of urinary incontinence intermittently requiring self catheterisation
  • Neuromodulation - sacral nerve stimulation, percutaneous tibial nerve modulation
42
Q

What is the management of overflow incontinence?

A
  • Refer to specialist urogynaecologist
  • 1st line = timed voiding
43
Q

Post-partum dribbling incontinence?

A

Dribbling incontinence after having a child with a prolonged labour, suspect a vesicovaginal fistula > urinary dye studies

44
Q

What is PCOS?

A

A common condition that affects how your ovaries work (1 in 10)

The 3 main features of PCOS are:

  • Irregular periods – which means your ovaries do not regularly release eggs (ovulation) and you may find it hard to get pregnant
  • Excess androgen – high levels of “male” hormones in your body, which may cause physical signs such as excess facial or body hair
  • Polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs
45
Q

What are the RFs for PCOS?

A

FHx, obesity

46
Q

What are the S/S of PCOS?

A
  • Hirsutism (upper lips, lower abdomen)
  • Sub-fertility
  • menstrual disturbances: oligomenorrhoea and amenorrhoea
  • Weight gain, acne
  • Insulin resistance > acanthosis nigricans
47
Q

What are the investigations for PCOS?

A
  • Examination: Hirsutism, acne, obese
  • Obs + BMI
  • Bloods: high cholesterol, prolactin, testosterone, LH (raised LH: FSH index i.e. LH > FSH; 2: 1 or 3: 1), SHBG normal to low
  • OGTT
  • TVUSS = multiple fluid filled cysts (“Pearl Necklace” sign)

DM monitoring:
OGTT at diagnosis for…

  • BMI ≥25
  • Non-Caucasian ethnicity
  • Any BMI and >40yo, FHx DM, GDM hx

Annual OGTT for…

  • IFG (fasting 6.1-6.9mmol/L)
  • IGT (OGTT 7.8-11.1mmol/L)

CVD monitoring (assess risk with QRISK2):

  • Lipid profile
  • Blood pressure
  • Diet, exercise, smoking and weight loss
48
Q

What is the Rotterdam Criteria?

A

For PCOS (≥2 of the following):

  • Oligo/anovulation (>2 years)
  • Clinical or biochemical features of hyperandrogenism
  • Polycystic ovaries on USS (>12 in ≥1 ovary measuring 2-9mm OR increased ovarian volume ≥10cm3)
49
Q

What is the management of PCOS?

A

General:

  • Weight loss - diet and exercise

Irregular periods:
(Oligomenorrhoea (≥3m) = refer for TVUSS to assess endometrial thickness)

  • COCP to induce regular monthly bleed
  • LNG-IUS

Hirsutism and Acne:

  • 1st line: COCP or co-cyprindiol
  • If no response = Topical eflornithine cream

Infertility: Should be managed by a specialist

  • 1st line: weight loss if appropriate
  • 2nd line (up to 6 months): clomiphene +/- metformin (after 3 failed clomiphene cycles)
    -Induces ovulation
    -Increased risk of multiple pregnancy
  • 3rd line: gonadotrophins, IVF (risk: OHSS)
  • Surgery: laparoscopic ovarian drilling / LOD (destroy ovarian stroma and prompt cycles)
50
Q

What are the complications of PCOS?

A
  • Metabolic syndrome (DM and heart disease)
  • Sleep apnoea
  • Cardiovascular disease
  • Endometrial cancer (if >7mm, may be pathological)
  • Recommend withdrawal bleed every 3-4 months
  • Subfertility
51
Q

What is premature ovarian insufficiency (POI)?

A

The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.

(secondary amenorrhoea before the age of 40 years)

52
Q

What is the difference between the menopause and POI?

A

POI = ovulate sporadically
Menopause = stopped entirely

53
Q

What are the causes of POI?

A
  • Idiopathic (most common cause, may be FHx)
  • Radiotherapy, chemotherapy
  • Autoimmune disorders
  • Bilateral oophorectomy (having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause)
  • Infection: e.g. mumps
  • Resistant ovary syndrome: due to FSH receptor abnormalities
  • Unknown (Addison’s– steroid cell autoantibodies cross-react with granulosa cells and theca interna)
54
Q

What are the S/S of POI?

A
  • Menopause signs & symptoms
  • climacteric symptoms: hot flushes, night sweats
  • infertility
  • secondary amenorrhoea
55
Q

What are the investigations for POI?

A

Diagnosis = <40yo, 2 x FSH results >30 (these should be 4-6 weeks apart) + menopause symptoms

  • Oestrogen [LOW], FSH/LH [HIGH]
  • Antral follicle count, AMH levels [test ovarian reserve] – helpful, but don’t base diagnosis off of this
56
Q

What is the management of POI?

A

Lifestyle, HRT and non-HRT management
HRT or a COCP should be offered to women until the age of the average menopause (51 years)

Fertility management:

  • Donor oocyte IVF
  • Surrogacy and adoption are other options
  • Support groups
57
Q

What are the complications of POI?

A
  • Osteoporosis: regular DEXA scans, all of them should get HRT
  • Other: hypothyroid, sexual dysfunction, insomnia (vasomotor symptoms), stroke, heart disease
  • N.B. menopause (over 45 years) is a retrospective clinical diagnosis, whereas POI is a biochemical diagnosis

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