Zero To Finals - Gynae Flashcards
Primary amenorrhoea causes
Primary amenorrhoea is when the patient has never developed periods. This can be due to:
• Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
• Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
• Imperforate hymen or other structural pathology
Secondary amenorrhoea causes
Secondary amenorrhoea is when the patient previously had periods that subsequently stopped. This can be due to:
○ Pregnancy (the most common cause)
○ Menopause
○ Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
○ Polycystic ovarian syndrome
○ Medications, such as hormonal contraceptives
○ Premature ovarian insufficiency (menopause before 40 years)
○ Thyroid hormone abnormalities (hyper or hypothyroid)
○ Excessive prolactin, from a prolactinoma
○ Cushing’s syndrome
What can cause irregular menstrual bleeding?
§ Extremes of reproductive age (early periods or perimenopause)
§ Polycystic ovarian syndrome
§ Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
§ Medications, particularly progesterone only contraception, antidepressants and antipsychotics
§ Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
Causes of intermenstrual bleeding
□ Hormonal contraception
□ Cervical ectropion, polyps or cancer
□ Sexually transmitted infection
□ Endometrial polyps or cancer
□ Vaginal pathology, including cancers
□ Pregnancy
□ Ovulation can cause spotting in some women
□ Medications, such as SSRIs and anticoagulants
Causes of dysmenorrhea
® Primary dysmenorrhoea (no underlying pathology)
® Endometriosis or adenomyosis
® Fibroids
® Pelvic inflammatory disease
® Copper coil
® Cervical or ovarian cancer
Causes of menorrhagia
◊ Dysfunctional uterine bleeding (no identifiable cause)
◊ Extremes of reproductive age
◊ Fibroids
◊ Endometriosis and adenomyosis
◊ Pelvic inflammatory disease (infection)
◊ Contraceptives, particularly the copper coil
◊ Anticoagulant medications
◊ Bleeding disorders (e.g. Von Willebrand disease)
◊ Endocrine disorders (diabetes and hypothyroidism)
◊ Connective tissue disorders
◊ Endometrial hyperplasia or cance
◊ Polycystic ovarian syndrome
Post coital bleeding causes
} Cervical cancer, ectropion or infection
} Trauma
} Atrophic vaginitis
} Polyps
} Endometrial cancer
} Vaginal cancer
Pelvic pain causes
– Urinary tract infection
– Dysmenorrhoea (painful periods)
– Irritable bowel syndrome (IBS)
– Ovarian cysts
– Endometriosis
– Pelvic inflammatory disease (infection)
– Ectopic pregnancy
– Appendicitis
– Mittelschmerz (cyclical pain during ovulation)
– Pelvic adhesions
– Ovarian torsion
– Inflammatory bowel disease (IBD)
Vaginal discharge potential causes
Excessive, discoloured or foul-smelling discharge may indicate:
Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
Pruritus Vulvae = itching of the vulva and vagina
w Irritants such as soaps, detergents and barrier contraception
w Atrophic vaginitis
w Infections such as candidiasis (thrush) and pubic lice
w Skin conditions such as eczema
w Vulval malignancy
w Pregnancy-related vaginal discharge
w Urinary or faecal incontinence
w Stress
Hypogonadism and the two different types of
Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise before and during puberty.
A lack of these hormones causes a delay in puberty.
The lack of sex hormones is fundamentally due to one of two reasons:
○ Hypogonadotropic hypogonadism: a deficiency of LH and FSH
○ Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
Causes of Hypogonadotropic Hypogonadism
Hypogonadotropic Hypogonadism
○ Deficiency of LH and FSH, leading to deficiency of the sex hormones (oestrogen).
○ LH and FSH are gonadotrophins produced by the anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus.
○ Since no gonadotrophins are simulating the ovaries, they do not respond by producing sex hormones (oestrogen).
○ Therefore, “hypogonadotropism” causes “hypogonadism”.
○ A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland. This could be due to:
§ Hypopituitarism (under production of pituitary hormones)
§ Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
§ Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
§ Excessive exercise or dieting can delay the onset of menstruation in girls
§ Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
§ Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
§ Kallman syndrome
§ A genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia).
Causes of Hypergonadotropic Hypogonadism
Hypergonadotropic Hypogonadism
○ Where the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH).
○ Without negative feedback from the sex hormones (oestrogen), the anterior pituitary produces increasing amounts of LH and FSH.
○ Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”).
○ Hypergonadotropic hypogonadism is the result of abnormal functioning of the gonads. This could be due to:
§ Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
§ Congenital absence of the ovaries
§ Turner’s syndrome (XO)
Androgen sensitivity syndrome
Androgen Insensitivity Syndrome
® A condition where the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop.
® It results in a female phenotype, other than the internal pelvic organs.
® Patients have normal female external genitalia and breast tissue.
® Internally there are testes in the abdomen or inguinal canal, and an absent uterus, upper vagina, fallopian tubes and ovaries.
Initial investigations for primary amenorrhoea
Initial investigations assess for underlying medical conditions:
} Full blood count and ferritin for anaemia
} U&E for chronic kidney disease
} Anti-TTG or anti-EMA antibodies for coeliac disease
} Hormonal blood tests assess for hormonal abnormalities:
– FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
– Thyroid function tests
– Insulin-like growth factor I is used as a screening test for GH deficiency
– Prolactin is raised in hyperprolactinaemia
– Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia
} Genetic testing with a microarray test to assess for underlying genetic conditions:
– Turner’s syndrome (XO)
} Imaging can be useful:
– Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
– Pelvic ultrasound to assess the ovaries and other pelvic organs
– MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome
Treatment for primary amenorrhoea
Management
• Management of primary amenorrhoea involves establishing and treating the underlying cause.
• Where necessary, replacement hormones can induce menstruation and improve symptoms.
• Patients with constitutional delay in growth and development may only require reassurance and observation.
• Where the cause is due to stress or low body weight secondary to diet and exercise, treatment involves a reduction in stress, cognitive behavioural therapy and healthy weight gain. • Where the cause is due to an underlying chronic or endocrine condition, management involves optimising treatment for that condition.
Treatment for hypogonadotrophic hypogonadism
Hypogonadotrophic hypogonadism, such as hypopituitarism or Kallman syndrome,
• Treatment with pulsatile GnRH can be used to induce ovulation and menstruation.
• This has the potential to induce fertility.
• Alternatively, where pregnancy is not wanted, replacement sex hormones in the form of the combined contraceptive pill may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency.
Secondary amenorrhoea causes
Causes
• Pregnancy is the most common cause
• Menopause and premature ovarian failure
• Hormonal contraception (e.g. IUS or POP)
• Hypothalamic or pituitary pathology
• Ovarian causes such as polycystic ovarian syndrome
• Uterine pathology such as Asherman’s syndrome
• Thyroid pathology
• Hyperprolactinaemia
Hormone tests to identify secondary amenorrhoea
Hormone Tests
□ Beta human chorionic gonadotropin (HCG) urine or blood tests are required to diagnose or rule out pregnancy.
□ Luteinising hormone and follicle-stimulating hormone:
® High FSH suggests primary ovarian failure
® High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome
□ Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour.
□ Thyroid stimulating hormone (TSH) can screen for thyroid pathology. This is followed by T3 and T4 when the TSH is abnormal.
® Raise TSH and low T3 and T4 indicate hypothyroidism
® Low TSH and raised T3 and T4 indicate hyperthyroidism
□ Raise testosterone indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.
What are patients at risk of getting with amenorrhoea
Osteoporosis
Patients with amenorrhoea associated with low oestrogen levels are at risk increased risk of osteoporosis.
Where the amenorrhoea lasts more than 12 months, treatment is indicated to reduce the risk of osteoporosis:
} Ensure adequate vitamin D and calcium intake
Hormone replacement therapy or the combined oral contraceptive pill
What is premenstrual syndrome?
• Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.
Cause of PMS
Cause
• Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle.
• The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.
Management of PMS
Management
The following management options can be initiated in primary care:
○ General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
○ Combined contraceptive pill (COCP)
○ RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone has some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.
○ SSRI antidepressants
○ Cognitive behavioural therapy (CBT)
Severe cases should be managed by a multidisciplinary team, involving GPs, gynaecologists, psychologists and dieticians.
○ Continuous transdermal oestrogen (patches) can be used to improve symptoms.
○ Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen.
○ This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.
○ GnRH analogues can be used to induce a menopausal state.
○ They are very effective at controlling symptoms; however, they are reserved for severe cases due to the adverse effects (e.g. osteoporosis).
○ Hormone replacement therapy can be used to add back the hormones to mitigate these effects.
○ Hysterectomy and bilateral oophorectomy can be used to induce menopause where symptoms are severe and medical management has failed.
○ Hormone replacement therapy will be required, particularly in women under 45 years.
○ Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist. ○ Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.
Menorrhagia
Heavy menstrual bleeding is also called menorrhagia. On average, women lose 40 ml of blood during menstruation. Excessive menstrual blood loss involves more than an 80 ml loss. The volume of blood loss is rarely measured in practice. The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. Heavy menstrual periods can have a significant impact on quality of life.
Causes of heavy menstrual bleeding
Causes
• Dysfunctional uterine bleeding (no identifiable cause)
• Extremes of reproductive age
• Fibroids
• Endometriosis and adenomyosis
• Pelvic inflammatory disease (infection)
• Contraceptives, particularly the copper coil
• Anticoagulant medications
• Bleeding disorders (e.g. Von Willebrand disease)
• Endocrine disorders (diabetes and hypothyroidism)
• Connective tissue disorders
• Endometrial hyperplasia or cancer
• Polycystic ovarian syndrome
What investigations should be done on someone presenting with heavy periods?
Investigations
Pelvic examination with a speculum and bimanual should be performed, unless there is straightforward history heavy menstrual bleeding without other risk factors or symptoms, or they are young and not sexually active. This is mainly to assess for fibroids, ascites and cancers.
Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.
Outpatient hysteroscopy should be arranged if there is:
• Suspected submucosal fibroids
• Suspected endometrial pathology, such as endometrial hyperplasia or cancer
• Persistent intermenstrual bleeding
Pelvic and transvaginal ultrasound should be arranged if the is:
○ Possible large fibroids (palpable pelvic mass)
○ Possible adenomyosis (associated pelvic pain or tenderness on examination)
○ Examination is difficult to interpret (e.g. obesity)
○ Hysteroscopy is declined
Additional tests to consider in women with additional features:
§ Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
§ Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
§ Ferritin if they are clinically anaemic
§ Thyroid function tests if there are additional features of hypothyroidism
Types of fibroids
Types
• Intramural = within the myometrium (the muscle of the uterus).
○ As they grow, they change the shape and distort the uterus.
• Subserosal = just below the outer layer of the uterus.
○ These fibroids grow outwards and can become very large, filling the abdominal cavity.
• Submucosal = just below the lining of the uterus (the endometrium).
• Pedunculated = on a stalk.
Management for fibroids less than 3cm
Management
For fibroids less than 3 cm
The medical management is the same as with heavy menstrual bleeding:
§ Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
§ Symptomatic management with NSAIDs and tranexamic acid
§ Combined oral contraceptive
§ Cyclical oral progestogens
Surgical options for managing smaller fibroids with heavy menstrual bleeding are:
§ Endometrial ablation
§ Resection of submucosal fibroids during hysteroscopy
§ Hysterectomy
Presentation of fibroids
Presentation
Fibroids are often asymptomatic. They can present in several ways:
○ Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
○ Prolonged menstruation, lasting more than 7 days
○ Abdominal pain, worse during menstruation
○ Bloating or feeling full in the abdomen
○ Urinary or bowel symptoms due to pelvic pressure or fullness
○ Deep dyspareunia (pain during intercourse)
○ Reduced fertility
Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Management for fibroids more than 3cm
For fibroids more than 3 cm
Women need referral to gynaecology for investigation and management.
Medical management options are:
§ Symptomatic management with NSAIDs and tranexamic acid
§ Mirena coil – depending on the size and shape of the fibroids and uterus
§ Combined oral contraceptive
§ Cyclical oral progestogens
Surgical options for larger fibroids are:
§ Uterine artery embolisation
§ Myomectomy
§ Hysterectomy
GnRH agonists use in fibroids
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)
§ May be used to reduce the size of fibroids before surgery.
§ They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.
§ Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
Uterine artery embolisation
Uterine Artery Embolisation
§ Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists.
§ The radiologist inserts a catheter into an artery, usually the femoral artery.
§ This catheter is passed through to the uterine artery under X-ray guidance.
§ Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.
§ This starves the fibroid of oxygen and causes it to shrink.
Surgical options for fibroids
Surgical Options
§ Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery).
○ Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.
§ Endometrial ablation can be used to destroy the endometrium.
○ Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation.
○ This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.
§ Hysterectomy involves removing the uterus and fibroids.
○ Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach.
○ The ovaries may be removed or left depending on patient preference, risks and benefits.
Investigations for suspected fibroids
Investigations
• Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
• Pelvic ultrasound is the investigation of choice for larger fibroids.
• MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
Endometriosis
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. Endometriomas in the ovaries are often called “chocolate cysts”. Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
Suggested aetiology of endometriosis
One notable theory for the cause of ectopic endometrial tissue is that during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity.
Other possible methods for endometrial tissue exiting the uterus have been proposed:
• 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.
• There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer.
• Cells outside the uterus somehow change, in a process called metaplasia, from typical cells of that organ into endometrial cells.
What causes endometriosis to be painful?
The main symptom of endometriosis is pelvic pain. The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes 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.
What causes infertility problems with people with endometriosis?
Endometriosis can lead to reduced fertility. Often it is not clear why women with endometriosis struggle to get pregnant. It may be due to adhesions around the ovaries and fallopian tubes, blocking the release of eggs or kinking the fallopian tubes and obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.
Diagnosis of endometriosis
Diagnosis
Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist 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.
Hormonal and surgical management of endometriosis
Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:
○ Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
○ Progesterone only pill
○ Medroxyprogesterone acetate injection (e.g. Depo-Provera)
○ Nexplanon implant
○ Mirena coil
○ GnRH agonists
Surgical management options: § Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) § Hysterectomy Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
Explanation of treatment options for endometriosis
Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.
Adenomyosis
Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall. It may occur alone, or alongside endometriosis or fibroids. The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.
Presentation of adenomyosis
Presentation
Adenomyosis typically presents with:
• Painful periods (dysmenorrhoea)
• Heavy periods (menorrhagia)
• Pain during intercourse (dyspareunia)
It may also present with infertility or pregnancy-related complications. Around a third of patients are asymptomatic.
Examination can demonstrate an enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.
Diagnosis of adenomyosis
Diagnosis
Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.
Management of adenomyosis
Management
Management of adenomyosis will depend on symptoms, age and plans for pregnancy. NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding.
When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:
• Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
• Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Management when contraception is wanted or acceptable:
1. Mirena coil (first line)
2. Combined oral contraceptive pill
3. Cyclical oral progestogens
Progesterone only medications such as the pill, implant or depot injection may also be helpful.
Other options are that may be considered by a specialist include:
§ GnRH analogues to induce a menopause-like state
§ Endometrial ablation
§ Uterine artery embolisation
§ Hysterectomy
Physiology of menopause
Physiology
• Inside the ovaries, the process of primordial follicles maturing into primary and secondary follicles is always occurring, independent of the menstrual cycle.
• At the start of the menstrual cycle, FSH stimulates further development of the secondary follicles.
• As the follicles grow, the granulosa cells that surround them secrete increasing amounts of oestrogen.
• The process of the menopause begins with a decline in the development of the ovarian follicles. • Without the growth of follicles, there is reduced production of oestrogen. • Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. • As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH. • The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. • Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). • Lower levels of oestrogen also cause the perimenopausal symptoms.
Perimenopausal symptoms
Perimenopausal Symptoms
A lack of oestrogen in the perimenopausal period leads to symptoms of:
○ Hot flushes
○ Emotional lability or low mood
○ Premenstrual syndrome
○ Irregular periods
○ Joint pains
○ Heavier or lighter periods
○ Vaginal dryness and atrophy
○ Reduced libido
Risks of a lack of oestrogen during menopause
Risks
A lack of oestrogen increases the risk of certain conditions:
§ Cardiovascular disease and stroke
§ Osteoporosis
§ Pelvic organ prolapse
§ Urinary incontinence
Diagnosis of menopause
Diagnosis
A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.
NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in:
□ Women under 40 years with suspected premature menopause
□ Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
Contraception in peri menopausal women
Contraception
Fertility gradually declines after 40 years of age.
However, women should still consider themselves fertile.
Pregnancy after 40 is associated with increased risks and complications.
Women need to use effective contraception for:
® Two years after the last menstrual period in women under 50
® One year after the last menstrual period in women over 50
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms.
® This can make diagnosing menopause in women on hormonal contraception more difficult.
Good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause are:
® Barrier methods
® Mirena or copper coil
® Progesterone only pill
® Progesterone implant
® Progesterone depot injection (under 45 years) - may be unsuitable due to risk of osteoporosis
® Sterilisation
The combined oral contraceptive pill is UKMEC 2 (the advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications.
® Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.
Management of peri menopausal symptoms
Management of Perimenopausal Symptoms
} Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment.
} Management of symptoms depends on the severity, personal circumstances and response to treatment.
Options include:
} No treatment
} 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
} Cognitive behavioural therapy (CBT)
} SSRI antidepressants, such as fluoxetine or citalopram
} 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
PCOS
Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women.
There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.
Rotterdam criteria
Rotterdam Criteria
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome.
A diagnosis requires at least two of the three key features:
1. Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
2. Hyperandrogenism, characterised by hirsutism and acne
3. Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Presentation of PCOS
Presentation
Women with polycystic ovarian syndrome present with some key features:
§ Oligomenorrhoea or amenorrhoea
§ Infertility
§ Obesity (in about 70% of patients with PCOS)
§ Hirsutism
§ Acne
§ Hair loss in a male pattern
Other Features and Complications
§ Insulin resistance and diabetes
§ Acanthosis nigricans
○ Acanthosis nigricans describes thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.
§ Cardiovascular disease
§ Hypercholesterolaemia
§ Endometrial hyperplasia and cancer
§ Obstructive sleep apnoea
§ Depression and anxiety
§ Sexual problems
Insulin resistance and PCOS
Insulin Resistance
§ When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body.
§ 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.
§ The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
§ Diet, exercise and weight loss help reduce insulin resistance.
Differential diagnosis of hirsutism
Differential Diagnosis of Hirsutism
An important feature of polycystic ovarian syndrome is hirsutism. Hirsutism can also be caused by:
® Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
® Ovarian or adrenal tumours that secrete androgens
® Cushing’s syndrome
® Congenital adrenal hyperplasia
Diagnosis of PCOS
Investigations
The NICE clinical knowledge summaries recommend the following blood tests to diagnose PCOS and exclude other pathology that may have a similar presentation:
◊ Testosterone
◊ Sex hormone-binding globulin
◊ Luteinizing hormone
◊ Follicle-stimulating hormone
◊ Prolactin (may be mildly elevated in PCOS)
◊ Thyroid-stimulating hormone
Hormonal blood tests typically show:
◊ Raised luteinising hormone
◊ Raised LH to FSH ratio (high LH compared with FSH)
◊ Raised testosterone
◊ Raised insulin
◊ Normal or raised oestrogen levels
Managing hirsutism
Managing Hirsutism
Weight loss may improve the symptoms of hirsutism.
Women are likely to have already explored options for hair removal, such as waxing, shaving and plucking.
Co-cyprindiol (Dianette) is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne.
w It has an anti-androgenic effect, works as a contraceptive and will also regulate periods.
w The downside is a significantly increased risk of venous thromboembolism.
w For this reason, co-cyprindiol is usually stopped after three months of use.
Topical eflornithine can be used to treat facial hirsutism.
w It usually takes 6 – 8 weeks to see a significant improvement.
w The hirsutism will return within two months of stopping eflornithine.
Other options that may be considered by a specialist experienced in treating hirsutism include:
w Electrolysis
w Laser hair removal
w Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
w Finasteride (5α-reductase inhibitor that decreases testosterone production)
w Flutamide (non-steroidal anti-androgen)
w Cyproterone acetate (anti-androgen and progestin)
Managing the risk of endometrial cancer in patients with PCOS
Managing the Risk of Endometrial Cancer
Women with polycystic ovarian syndrome have several risk factors for endometrial cancer:
w Obesity
w Diabetes
w Insulin resistance
w Amenorrhoea
w Under normal circumstances, the corpus luteum releases progesterone after ovulation. w Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. w They continue to produce oestrogen and do not experience regular menstruation. w Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. w This is similar to giving unopposed oestrogen in women on hormone replacement therapy. w It results in endometrial hyperplasia and a significant risk of endometrial cancer. w Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. w Cyclical progestogens should be used to induce a period prior to the ultrasound scan. w If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer. w Options for reducing the risk of endometrial hyperplasia and endometrial cancer are: w Mirena coil for continuous endometrial protection w Inducing a withdrawal bleed at least every 3 – 4 months with either: w Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) w Combined oral contraceptive pill
Managing infertility in patients with PCOS
Managing Infertility
Weight loss is the initial step for improving fertility.
w Losing weight can restore regular ovulation.
A specialist may initiate other options where weight loss fails. These include:
w Clomifene
w Laparoscopic ovarian drilling
w In vitro fertilisation (IVF)
Metformin and letrozole may also help restore ovulation under the guidance of a specialist; however, the evidence to support their use is not clear.
Ovarian drilling involves laparoscopic surgery.
w The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy.
w This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
Women that become pregnant require screening for gestational diabetes.
w Screening involves an oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.
Ovarian cysts vs PCOS
A cyst is a fluid-filled sac. Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women. The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.
Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. A diagnosis of PCOS requires at least two of:
• Anovulation
• Hyperandrogenism
• Polycystic ovaries on ultrasound
Presentation of ovarian cysts
Presentation
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.
Occasionally, ovarian cysts can cause vague symptoms of:
• Pelvic pain
• Bloating
• Fullness in the abdomen
• A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Types of ovarian cysts
Functional Cysts
Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.
Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy.
Other Types of Ovarian Cysts
Serous Cystadenoma
These are benign tumours of the epithelial cells.
Mucinous Cystadenoma
These are also benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.
Endometrioma
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
Dermoid Cysts / Germ Cell Tumours
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.
Sex Cord-Stromal Tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
Ovulation and ovarian cancer risk
The number of times a woman has ovulated during her life correlates with her risk of ovarian cancer. More ovulations increases the risk of ovarian cancer. Factors that will reduce the number of ovulations are:
§ Later onset of periods (menarche)
§ Early menopause
§ Any pregnancies
§ Use of the combined contraceptive pill
Causes of raised CA125
Causes of Raised CA125
CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125:
• Endometriosis
• Fibroids
• Adenomyosis
• Pelvic infection
• Liver disease
• Pregnancy
Management of ovarian cysts
Management
The RCOG Green-top guidelines from 2011 on suspected ovarian masses provides recommendations on managing ovarian cysts. Always check local and national guidelines when deciding how to manage patients, and get advice from an experienced colleague.
Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist.
Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery.
Simple ovarian cysts in premenopausal women can be managed based on their size:
• Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
• 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
• More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
Meigs syndrome
Meig’s Syndrome
Meig’s syndrome involves a triad of:
• Ovarian fibroma (a type of benign ovarian tumour)
• Pleural effusion
• Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.
Cervical ectropion
Cervical ectropion can also be called cervical ectopy or cervical erosion. Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.
The cells of the endocervix (columnar epithelial cells) are more fragile and prone to trauma. They are more likely to bleed with sexual intercourse. This means cervical ectropion often presents with postcoital bleeding.
Cervical ectropion is associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.
Management of cervical ectropion
Management
Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
Nabothian cysts
Nabothian cysts are fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts. They are usually up to 1cm in size, but rarely can be more extensive. They are harmless and unrelated to cervical cancer.
The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.
Presentation of nabothian cysts
Presentation
Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis.
Nabothian cysts appear as smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.
Management of nabothian cysts
Management
Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously.
If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.
Types of pelvic prolapses
Pelvic organ prolapse =the descent of pelvic organs into the vagina.
• Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
Uterine Prolapse = the uterus itself descends into the vagina.
Vault Prolapse = occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
Rectocele = caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
• Rectoceles are particularly associated with constipation.
• Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina.
• Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.
• Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.
Cystocele = caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
• Prolapse of the urethra is also possible (urethrocele).
• Prolapse of both the bladder and the urethra is called a cystourethrocele.
