8 - Cervical and Ovarian Disorders Flashcards
(64 cards)
1
Q
What are cervical polyps and why do they occur?
A
Focal hyperplasia of columnar epithelium of endocervix
- Chronic inflammation
- Abnormal response to oestrogen (cervical polyps associated with endometrial hyperplasia)
- Localised congestion of cervical vasculature
2
Q
Who do cervical polyps tend to occur in?
A
- Multigravidae
- 50 to 60 year olds
Risk of malignancy
3
Q
What are the clinical features of cervical polyps?
A
Often asymptomatic and found incidentally on cervical screening
- Abnormal vaginal bleeding: IMB, PCB, PMB
- Increased vaginal discharge
- Infertility if large enough to block cervix
4
Q
What are some differential diagnoses for cervical polyps?
A
ALWAYS NEED TO EXCLUDE ENDOMETRIAL CANCER IF POST MENOPAUSAL
- Endometrial polyp projecting through cervix
- Cervical ectropion
- STI
- Fibroids
- Endometriosis
5
Q
What investigations are done for cervical polyps?
A
- Histology after removal
- Cervical smear to rule out CIN
- Triple swabs (endocervical and high vaginal)
6
Q
How are cervical polyps managed?
A
- Polypectomy Forceps: can be done in primary care if small, twist and pull. If any bleeding cauterise with silver nitrate
- Diathermy Loop excision: if large need to refer to colposcopy clinic
Need to send for histological exam. High recurrence rate. If still bleeding after removal do TVUS of endometrium as could be endometrial polyp
7
Q
What are some complications of polyp removal?
A
8
Q
What is cervical ectropion?
A
Eversion of endocervix (columnar epithelium) to the ectocervix (stratified squamous). Metaplasia of stratified squamous cells
It is benign and not linked to cervical cancer!!!
9
Q
What is the aetiology of cervical ectropion?
A
Induced by high levels of oestrogen so
- COCP
- Younger women
- Pregnancy
Cells of endocervix are more fragile so prone to trauma and bleeding so common to have post-coital bleeding
10
Q
What is the transformation zone?
A
Border between columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
When located on the ectocervix, it is visible during speculum examination as a border
11
Q
How may cervical ectropion present?
A
Often asymptomatic and found incidentally
Post coital bleeding
Excessive discharge as columnar cells have mucus secreting glands
Dysparaunia
12
Q
How does cervical ectropion appear on speculum examination?
A
Well-demarcated border between redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix
13
Q
What is the management for cervical ectropion?
A
No need to treat unless symptomatic
If symptomatic:
- Stop oestrogen drugs e.g COCP
- Cauterise with silver nitrate or cold coagulation
- Boric Acid pessary
14
Q
What investigations should you do for cervical ectropion ?
A
Exclude other causes:
- Pregnancy test
- Triple swabs for STIs
- Cervical smear for CIN
15
Q
What is a Nabothian cyst?
A
Fluid filled cyst on the surface of the cervix
Columnar epithelium of the endocervix produces cervical mucus. When squamous epithelium of ectocervix covers the mucus-secreting columnar epithelium, mucus becomes trapped and forms a cyst.
Causes: childbirth, minor trauma to the cervix or cervicitis secondary to infection.
16
Q
How may Nabothian cysts present?
A
Found incidentally on speculum exam
Usually white or yellow colour
Asymptomatic but if large enough can cause pelvic fullness
17
Q
How are Nabothian cysts managed?
A
If diagnosis is clear can be reassured and no treatment needed as often resolve spontaneously
If doubts then do colposcopy for excision and biopsy
18
Q
What is PCOS and the pathophysiology of this? (two main hormone
A
Endocrine condition characterised by menstrual irregularity (oligo/amenorrhoea), hyperandrogenism (e.g acne, hirsutism) and anovulatory infertility
- Genetics: strong
- Increased LH: Serum levels are elevated and its pulse frequency and amplitude can be increased. In addition increased expression of LH receptors may be seen in the thecal and granulosa cells of the ovary. These changes result in an increased LH to FSH ratio which leads to excess androgens production by theca cells (in the ovary). Although high LH
- Insulin resistance: Results in hyperinsulinaemia, due to increased pancreatic production of insulin to compensate for the resistance. This stimulates theca cells, causing secretion of more androgens and a reduction in sex hormone-binding globulin (SHBG), leading to increased biologically active free androgens.
19
Q
What are the characteristics of PCOS?
A
- multiple ovarian cysts
- Infertility
- Oligomenorrhea
- Hyperandrogenism
- Insulin resistance.
20
Q
What are some signs and symptoms of PCOS?
A
Symptoms
- Oligo/amenorrhoea
- Infertility/sub-fertility
- Acne
- Hirsutism
- Obesity
- Sleep apnea
Signs
- Hirsutism
- Obesity
- Male pattern baldness
- Acanthosis nigricans
- Anxiety/depression
21
Q
What are some pregnancy related complications with PCOS?
A
- High spontaneous abortion rate
- Pre-term labour
- Gestational diabetes
22
Q
What are some other conditions related to PCOS?
A
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
23
Q
What are some differential diagnoses for the presenting symptoms of PCOS and how can you test to rule these differentials out?
A
- Medications: phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours: that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
- Thyroid dysfunction
- Hyperprolactinaemia
- Premature ovarian insufficiency
24
Q
What investigations are done for suspected PCOS and what will they show in PCOS?
A
Bloods
- Total testosterone: normal or moderately elevated in PCOS
- Sex hormone-binding globulin (SHBG): tends to be normal or low in patients with PCOS. Low levels mean increase in free testosterone and more severe disease
- LH/FSH: LH is elevated, resulting in an increased LH/FSH ratio. FSH is elevated in those affected by premature ovarian failure
- Prolactin: hyperprolactinaemia can cause oligomenorrhoea, can be raised in PCOS
- Thyroid profile
- 17-hydroxyprogesterone: morning levels elevated in non-classic congenital adrenal hyperplasia
Transvaginal US (Gold standard)
- Usually transvaginal
- Over 12 or more follicles in one ovary (string of pearls)
- Increased ovarian volume >10cm3 without cysts
- Not valid in adolescents
25
Diabetes must be screened for in PCOS. How is this done?
2-hour 75g ***oral glucose tolerance test*** (***OGTT***).
In the morning before breakfast take baseline ***fasting plasma glucose***, give a **75g glucose drink** and then measuring plasma glucose **2 hours later**
* ***Impaired fasting glucose*** – fasting glucose of 6.1 – 6.9 mmol/l
* ***Impaired glucose tolerance*** – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
* ***Diabetes** –* plasma glucose at 2 hours above 11.1 mmol/l
26
How is the diagnosis of PCOS made?
**Rotterdam Criteria**
**Need 2 out of 3 of the following:**
1. **Polycystic ovaries** (12 or more follicles (2-9mm) on one ovary OR increased ovarian volume (\>10cm3))
2. **Oligo-anovulation or anovulation**
3. **Clinical and/or biochemical signs of hyperandrogenism**
***20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have PCOS***
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How is PCOS managed generally?
Crucial to reduce the risks associated with ***obesity***, ***type 2 diabetes***, ***hypercholesterolaemia*** and ***cardiovascular disease***
* **Weight loss**
* Low glycaemic index, calorie-controlled diet
* Exercise
* Smoking cessation
* Antihypertensive medications where required
* Statins where indicated (QRISK \>10%)
28
What is the most significant management of PCOS?
**Weight loss**
***Orlistat*** for weight loss in women with BMI\>30. It is a lipase inhibitor that stops absorption of fat
Reduces CVD risk, can improve chances of ovulation, can lower insulin resistance and hirsutism
29
Women with PCOS are at an increased risk of endometrial cancer. Why is this and how is this risk managed?
As women do not ovulate, they ***do not produce a corpus luteum*** so ***lack of progesterone*** so ***unopposed oestrogen*** so ***endometrial hyperplasia***
**_Mx_**
* If more than 3/12 between periods or abnormal bleeding ***need*** ***pelvic US*** to assess ***endometrial thickness***. Give c***yclical progestogens*** to induce a period ***prior to*** scan. If ***endometrial thickness \>10mm,*** ***refer for biopsy*** to exclude endometrial hyperplasia or cancer
* ***Mirena coil*** for continuous endometrial protection
* ***Inducing a withdrawal bleed*** at least every 3 – 4 months with:
* ***Cyclical progestogens*** (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) OR
* ***COCP***
30
How is infertility managed in PCOS?
* **Weight loss** (1st line)
* **Clomifene**: SERM
* **Letrozole**: aromatase inhibitor, stops androgen conversion to oestrogen
* **Metformin**
* **Laparoscopic ovarian drilling:** diathermy or laser therapy in ovaries, improves hormone profile
* **IVF**
31
When a women with PCOS becomes pregnant, what needs to be screened for?
Gestational Diabetes
Do OGTT before 24-28 weeks
32
Hyperandrogenism in PCOS can cause acne and Hirsutism. How can Hirsutism be managed?
* **Weight loss**
* **Cosmetic treatments** e.g shaving/waxing
* **Co-cyprindiol** (**Dianette**): anti-androgenic COCP, is a contraceptive and will also regulate periods. Increased risk of VTE so can only use for 3/12
* **Topical eflornithine:** for facial hirsutism, takes 6 – 8 weeks to see improvement and will return within two months of stopping
33
How can acne be managed in PCOS?
**1st Line:** COCP (usually Co-cyprindiol but high risk of VTE)
34
What is the difference in management for women with PCOS who are planning pregnancy and for those who are not planning pregnancy?
35
How are metabolic complications reduced in PCOS?
* Exercise and Diet Advice
* Smoking cessation advice
* Screen for T2DM, HTN and Dyslipidaemia on diagnosis
36
What is metformin used for in PCOS?
Induce ovulation and reduce circulating androgens by improving insulin sensitivity
Research has design flaws, small groups and lack of placebo group so not routinely used anymore
37
What are some psychological issues in PCOS and where can you signpost them to?
VERITY
* Anxiety and Depression
* Eating disorders
* Psychosexual issues
38
What is premature ovarian insufficiency and what are the symptoms of this?
**Menopause before the age of 40**
Typical menopause symptoms e.g irregular menstrual periods, amenorrhea, hot flushes, night sweats, vaginal dryness
Symptoms due to low oestrogen
39
What are some of the causes of premature ovarian insufficiency?
* ***Idiopathic***
* ***Iatrogenic: e.g*** chem, radio, oophorectomy
* ***Autoimmune:*** coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
* ***Genetic:*** family history, Turner’s syndrome
* ***Infections:*** mumps, TB, cytomegalovirus
40
How is premature menopause diagnosed?
***Younger than 40*** with ***typical menopausal symptoms*** plus ***elevated FSH***.
## Footnote
**FSH level**: needs to persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. Difficult to interpret if taking hormonal contraception
41
What are women with premature menopause at increased risk of?
Due to lack of oestrogen:
* Cardiovascular disease
* Stroke
* Osteoporosis
* Cognitive impairment
* Dementia
* Parkinsonism
42
How is premature menopause managed?
**HRT** until at least the age at which women typically go through menopause to reduce cardiovascular risk, osteoporosis.
Need **contraception** as still small chance of pregnancy
43
What HRT options are available for women with premature menopause and how do you choose which one to have?
**Traditional HRT or COCP**
* Traditional HRT lower blood pressure
* COCP has less stigma for younger women and acts as contraception
* HRT before the age of 50 does NOT increase risk of breast cancer. However increased risk of VTE, can lower this by using transdermal methods
44
What are some causes of ovarian cysts?
**Pre-menopausal:** Benign in response to hormone fluctuations
**Post-menopausal:** Malignancy
**PCOS:** string of pearls
45
How may ovarian cysts present?
Often asymptomatic and found incidentally on imaging
* Pelvic pain
* Bloating
* Fullness in the abdomen
* A palpable pelvic mass (large cysts such as mucinous cystadenomas)
Acute pelvic pain if ***ovarian torsion***, ***haemorrhage*** or ***rupture*** of the cyst
46
What are some different types of ovarian cysts?
* **Follicular cysts (Most common):** developing follicle that can fail to rupture and release the egg. Disappear after a few menstrual cycles. Thin walls and no internal structures on US
* **Corpus luteum cysts:** corpus luteum fails to break down and instead fills with fluid. Cause pelvic discomfort, pain or delayed menstruation. Often seen in early pregnancy
* **Serous Cystadenoma**
* **Mucinous Cystadenoma:** can become huge, taking up lots of space in the pelvis and abdomen.
* **Endometrioma:** occurring in patients with endometriosis, can cause pain and disrupt ovulation.
* **Dermoid Cysts / Germ Cell Tumours:** may contain various tissue types, such as skin, teeth, hair and bone. Associated with ovarian torsion.
* **Sex Cord-Stromal Tumours:** these are rare tumours, that can be benign or malignant
47
How can you assess via the history whether an ovarian cyst is benign or malignant?
Ask about the following symptoms:
* Abdominal bloating
* Reduce appetite
* Early satiety
* Weight loss
* Urinary symptoms
* Pain
* Ascites
* Lymphadenopathy
48
What are some investigations you can do for an ovarian cyst?
* **Pelvic US:** if premenopausal and \<5cm then no further investigation
* **CA125**
* **Germ cell tumour markers:** LDH, HCG, AFP
49
What are some causes of a raised CA125?
Non-specific:
* Epithelial cell ovarian malignancy
* Endometriosis
* Fibroids
* Adenomyosis
* Pelvic infection
* Liver disease
* Pregnancy
50
What is the risk of malignancy index?
Estimates risk of an ovarian mass being malignant:
* Menopausal status
* Ultrasound findings
* CA125 level
51
How are ovarian cysts managed?
* ***Possible ovarian cancer*** (***complex cysts*** or ***raised CA125***): two-week wait
* ***Possible*** ***dermoid cysts:*** refer to gynaecologist
* ***Simple ovarian cysts*** in ***premenopausal women***: \<5cm cysts will almost always resolve within three cycles, 5cm to 7cm: routine referral to gynaecology and yearly ultrasound monitoring, \>7cm: Consider MRI scan or surgical evaluation
* ***Cysts in postmenopausal women*** : raised CA125, ***two-week wait***. If \<5cm with normal CA125 monitor with US every 4 – 6 months.
* ***Persistent or enlarging:*** ***s***urgical intervention ovarian cystectomy possibly along with the affected ovary (oophorectomy).
52
What are some complications of ovarian cysts?
Will have acute onset pain
* ***Torsion***
* ***Haemorrhage*** into the cyst
* ***Rupture***, with bleeding into the peritoneum
53
What is Meig's syndrome?
**_Triad of:_**
* ***Ovarian fibroma*** (a type of benign ovarian tumour)
* ***Pleural effusion***
* ***Ascites***
Removal of the tumour results in complete resolution of the effusion and ascites.
54
How may an ovarian cyst rupture present and what are some differentials for this?
* Asymptomatic
* Acute unilateral pain
* Intraperitoneal haemorrhage with haemodynamic compromise
Differentials: ectopic pregnancy, ovarian torsion, appendicitis
55
What investigations should you do for an ovarian cyst rupture?
* Pregnancy to exclude ectopic
* Laparoscopic exploration for unstable patient
56
What are some causes of ovarian torsion?
* **Tumour larger than 5cm** (usually benign)
* **Pregnancy**
* **Before menarche** (when girls have longer infundibulopelvic ligaments so easily twists)
EMERGENCY PRESENTATION AS ISCHAEMIA AND NECROSIS
57
How does ovarian torsion present?
* Sudden onset severe unilateral pelvic pain
* Pain is constant and gets worse
* Nausea nad vomiting.
* Localised tenderness
* May be a palpable mass in the pelvis
58
How is ovarian torsion diagnosed?
**_First Line_**_:_
* **Pelvic US:** Preferably transvaginal. May show “***whirlpool sign***”, ***free fluid*** in pelvis and ***oedema*** of the ovary.
* **Doppler studies:** for lack of blood flow
**_Diagnostic_**:
* Laparoscopic surgery
59
How is ovarian torsion managed?
Laparoscopy and either:
* ***Un-twist*** the ovary and fix it in place (***detorsion***) OR
* ***Remove*** the affected ovary (***oophorectomy***)
60
What are some complications with ovarian torsion?
* If necrotic may develop an infection, form an abscess and become **septic**
* May rupture and chase **peritonitis** and **adhesions**
* **Lack of fertility**
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Fibroid embolisation
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