Gynae Flashcards
1
Q
What are fibroids?
A
Benign tumours of the smooth muscle of the uterus that are oestrogen sensitive (grow in response to oestrogen)
Also called uterine leiomyomas
2
Q
How common are fibroids?
A
- Very common - 40-60% of women in later reproductive years
- More common in black women
3
Q
What are the types of fibroids?
A
- Intramural: within myometrium
- Subserosal: just below outer layer of uterus (grow outwards)
- Submucosal: just below lining of uterus
- Pedunculated: on a stalk
4
Q
What is the presentation of fibroids?
A
Often asymptomatic
* Menorrhagia (heavy period)
* Prolonged period (> 7 days)
* Abdominal pain (worse during period)
* Bloating
* Urinary/bowel Sx: due to pelvic pressure/fullness
* Deep dyspareunia
* Reduced fertility
5
Q
What investigations should be done for fibroids?
A
- Hysteroscopy: submucosal fibroids presenting with heavy menstruation
- Pelvic USS
- MRI before surgery
6
Q
What is the medical management of fibroids?
A
- Mirena coil - depending on size & shape of fibroids/uterus
- NSAIDs and tranexamic acid - Sx management
- Combined oral contraceptive
- Cyclical oral progestogens
- Referral to gynaecology if > 3cm
7
Q
What is the surgical management of smaller and larger fibroids?
A
Smaller fibroids:
* Endometrial ablation
* Resection of submucosal fibroids
* Hysterectomy
Larger fibroids:
* Uterine artery embolisation
* Myomectomy- if still want to conceive
* Hysterectomy
8
Q
What is uterine artery embolisation?
A
- Catheter inserted into femoral artery, then passed through to uterine artery
- Once in correct place, particles injected that cause a blockage in the arterial supply to the fibroid: starves it of oxygen causing it to shrink
9
Q
What medications may be used before fibroid surgery?
A
GnRH agonists e.g. goserelin/leuprorelin
* Used to reduce size of fibroid before surgery by reducing the amount of oestrogen maintaining the fibroid
* Usually only used short-term
10
Q
What is myomectomy?
A
Surgically removing fibroid via laparoscopic surgery (keyhole) or laparotomy (open surgery)
* Only Tx known to potentially improve fertility in fibroid patients
11
Q
What is endometrial ablation?
A
- Used to destroy the endometrium
- Balloon thermal ablation: inserting specially designed balloon into endometrial cavity & filling it with high-temp fluid that burns the endometrial lining of uterus
12
Q
What is a hysterectomy?
A
Removing the uterus & fibroids
* May be laparoscopy, laparotomy or vaginal approach
* Ovaries may be removed or left (depends on patient preference, risks & benefits)
13
Q
What are some complications of fibroids? (7)
A
- Iron deficiency anaemia (from heavy period)
- Reduced fertility
- Pregnancy Cx e.g. miscarriages, premature labour, obstructive delivery
- Constipation
- Urinary outflow obstruction/ UTI
- Red degeneration of fibroid
- Torsion of fibroid (usually affects pedunculated fibroids)
- Malignant change to leiomyosarcoma (very rare)
14
Q
What is red degeneration of fibroids?
A
Ischaemia, infarction & necrosis of the fibroid due to disrupted blood supply
* More likely to occur in fibroids > 5cm during 2nd + 3rd trimester
15
Q
What are possible causes of ischaemia in red degeneration of fibroids?
A
- As fibroid rapidly enlarges during pregnancy it outgrows its blood supply
- Kinking in blood vessels as uterus changes shape & expands during pregnancy
16
Q
How does red degeneration of fibroids present?
A
- Severe abdo pain
- Low-grade fever
- Tachycardia
- Vomiting
17
Q
What is the management of red degeneration of fibroids?
A
Rest, fluid, analgesia
18
Q
What are ovarian cysts?
A
Cyst = Fluid-filled sac
* Functional ovarian cysts - related to fluctuating hormones of menstrual cycle
* Very common in pre-menopausal women (benign usually)
19
Q
What is the presentation of ovarian cysts?
A
- Most are asymptomatic
- Pelvic pain: if ovarian torsion, haemorrhage or rupture of cyst
- Bloating
- Fullness in abdomen
- Palpable pelvic mass
20
Q
What are the two types of functional cysts?
A
Follicular cysts (MC):
* Occur when follicle fails to rupture and release egg
* Harmless & tend to disappear after a few cycles
* Typically have thin walls & no internal structures = give reassuring appearance on USS
Corpus luteum cysts:
* Occur when corpus luteum fails to break down & instead fills with fluid
* May cause pelvic discomfort/pain/delayed period
* Often seen in early pregnancy
21
Q
What are some other types of ovarian cysts (not functional)?
A
- Serous cystadenoma: benign tumour of epithelial cells
- Mucinous cystadenoma: same as above but these can become huge & take up lots of space in pelvis/abdomen
- Endometrioma: lumps of endometrial tissue within ovary (occurs in endometriosis), can cause pain & disrupt ovulation
- Dermoid cysts/Germ cell tumours: benign ovarian tumours, teratomas (come from germ cells & may contain various tissue types e.g. skin, teeth, hair, bone), associated w/ ovarian torsion
- Sex Cord-stromal tumours: rare, can be benign or malignantm, arise from stroma or sex cords, several types - includes Sertoli-Leydig cell tumours & granulosa cell tumours
22
Q
What features of an ovarian cyst history/examination suggest malignancy?
A
- Abdo bloating
- Reduced appetite
- Wt loss
- Early satiety
- Urinary Sx
- Pain
- Ascites
- Lymphadenopathy
23
Q
What investigations are done for ovarian cysts?
A
- Premenopausal women w/ simple ovarian cyst < 5cm on USS don’t need further Ix
- Women < 40 years with complex ovarian mass require tumour markers for a possible germ cell tumour (LDH, alpha-FP, HCG)
-Laparoscopic ultrasound guided aspiration - CA125 = tumour marker for ovarian cancer
24
Q
What are some non-malignant causes of raised CA125?
A
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
25
What is the Risk of malignancy index (RMI)?
Estimates risk of an ovarian mass being malignant, takes into account:
* **Menopausal status**
* **USS findings**
* **CA125 level**
26
What is the management of ovarian cysts in pre-menopausal women?
* **< 5cm**: resolves within 3 cycles (no follow up needed)
* **5-7cm**: routine referral to gynae & **yearly US monitoring**
* **>7cm**: **MRI scan**/surgical evaluation
Persistent/enlarging cysts: **ovarian cystectomy** (removing cyst) possibly with **oophorectomy** (removing affected ovary)
27
What is the management of ovarian cysts in post-menopausal women?
* **Raised CA125**/**complex cysts**: 2-week wait suspected cancer referral
* **Simple cysts**/**normal CA125**: monitor with USS every 4-6 months
## Footnote
Requires correlation with CA125 result
28
What are the 3 main complications of ovarian cysts when patient presents with acute onset pain?
* **Torsion**
* **Haemorrhage** in cyst
* **Rupture** w/ bleeding into peritoneum
29
What is the triad of Meig's syndrome?
* **Ovarian fibroma**
* **Pleural effusion**
* **Ascites**
## Footnote
* Typically older women
* Removal of tumour = complete resolution of effusion & ascites
30
What is ovarian torsion?
**MEDICAL EMERGENCY**
Ovary **twists** in relation to the **adnexa**
(surrounding connective tissue, fallopian tube & blood supply)
31
What is the pathophysiology of ovarian torsion?
* Usually due to **ovarian mass** >5cm / normal ovaries in younger girls before menarche (longer **infundibulopelvic ligaments** that can twist more easily)
* Twisting of adnexa & blood supply to ovary = **ischaemia**
* If torsion persists = **necrosis** = function lost
32
What is the presentation of ovarian torsion?
**Sudden onset severe unilateral pelvic pain**
* constant
* gets progressively worse
* associated with N+V
* localised tenderness on exam & maybe palpable mass in pelvis
33
What investigation is done for ovarian torsion? And what does it show?
**Pelvic USS** shows:
* **whirlpool sign**
* **free fluid** in pelvis
* **oedema** of ovary
34
What is the management of ovarian torsion?
**Laparoscopic surgery** to either:
* **DETORSION** = untwist ovary & fix it in place
* **OOPHORECTOMY** = remove affected ovary
35
What are the complications of ovarian torsion?
* If left untreated = **loss of function of ovary** (fertility not typically affected because other ovary can usually compensate)
* When necrotic ovary isn't removed = **infected**/**develop abscess**/**sepsis**
* May also **rupture** - peritonitis & adhesions
36
What is Lichen Sclerosus?
**Chronic inflammatory** skin condition that presents with patches of shiny **porcelain-white** skin
* **Autoimmune condition**: associated with other AI diseases (**T1DM**, **hypothyroid**, vitiligo, alopecia)
37
Where does lichen sclerosus typically affect?
* Women: **labia**, **perineum**, **perianal** skin
* Men: **foreskin**, **glans** of penis
38
What is the presentation of lichen sclerosus?
* **45-60 y.o woman** complaining of **vulval itching** & **skin changes** in vulva
* Can be asymptomatic
* itching
* soreness/pain
* skin tightness
* superficial dyspareunia
* erosions
* fissures
39
What is the Koebner phenomenon?
When Sx are made worse by **friction** to the skin
* e.g. lichen sclerosus can be made worse by tight underwear, urinary incontinence & scratching
40
What is the appearance of lichen sclerosus?
* 'Porcelain-white'
* Shiny
* Tight
* Thin
* Slightly raised
* May be papules/plaques
41
What is the management of lichen sclerosus?
Control Sx with **potent topical steroids** and follow up every 3-6 months
* **Clobetasol propionate** (Dermovate)
* **Emollients** should be used regularly
42
What are the complications of lichen sclerosus?
* **5% risk of developing squamous cell carcinoma of the vulva**
* Pain/discomfort
* Sexual dysfunction
* Bleeding
* Vaginal/urethral openings narrowing
43
What are the most common types of cervical cancer?
* **Squamous cell carcinoma** - 80% (MC)
* Adenocarcinoma
44
Who does cervical cancer typically affect?
**Younger women**, peaking in reproductive years
45
What is the most common cause of cervical cancer?
**HPV** - types **16** and **18** (responsible for ~70% cervical cancers)
46
How does HPV cause cervical cancer?
* **P53** & **pRb** = **tumour suppressor genes**
* HPV produces two proteins: **E6** and **E7**
* **E6 inhibits p53**
* **E7 inhibits pRb**
* Therefore HPV promotes development of cancer by inhibiting tumour suppressor genes
47
What are the risk factors for cervical cancer?
* Increased risk of **catching HPV**: early sexual activity, more sex partners, not using condoms
* **Not engaging with screening** = later detection of precancerous/cancerous changes
* Smoking
* HIV
* Combined contraceptive pill
* FHx
48
What is the presentation of cervical cancer?
Non specific:
* Abnormal vaginal bleeding
* Vaginal discharge
* Pelvic pain
* Dyspareunia
Appearances that suggest cervical cancer:
* Ulceration
* Inflammation
* Bleeding
* Visible tumour
49
What are two prevention strategies for cervical cancer?
* **HPV vaccine**: HPV strongly associated w/ cervical cancer, so children 12-13 y.o. vaccinated to reduce risk
* **Cervical screening** with **smear tests**: screen for precancerous & cancerous changes to cells of cervix
50
What is the cervical intraepithelial neoplasia (CIN) grading system?
* Grading system for the levels of **dysplasia** in the cells of the cervix
* CIN is diagnosed at **colposcopy** (**NOT** with cervical screening)
Grades are:
* **CIN I** - mild dysplasia
* **CIN II** - moderate dysplasia
* **CIN III** - severe dysplasia / **cervical carcinoma in situ**
51
What is involved in cervical cancer screening?
Aims to pick up precancerous changes in epithelial cells of cervix
* **Smear test**: speculum exam & collection of cells from cervix
* Cells deposited into preservation fluid & transported to lab for microscopy to check for **dyskaryosis** (precancerous cervical cells)
* Samples initially tested for **high-risk HPV** before cells are examined: if HPV negative, the cells are not examined = smear considered negative
52
How often are smear tests in the cervical screening program?
* Every **3 years** for 25-49 y.o
* Every **5 years** for 50-64 y.o.
53
What is the management depending on the smear test results?
* HPV **negative** - continue routine screening
* HPV **positive with normal** cytology - repeat HPV test after **12 months**
* HPV **positive with abnormal** cytology - refer for **colposcopy**
54
What happens during colposcopy?
* Inserting speculum & using colposcope to magnify cervix (allows epithelial lining of cervix to be examined)
* **Acetic acid** / **iodine solution** stains used
* Acetic acid = abnormal cells appear **white** ("acetowhite"): occurs in cells with more **nucleic material** e.g. cervical cancer cells
* Schiller's iodine test = healthy cells appear **brown**, abnormal areas don't stain
* To get tissue sample = **punch biopsy**/large loop excision of the transformational zone (**loop biopsy**)
55
What is a loop biopsy?
Using a loop wire with electrical current (**diathermy**) to remove abnormal epithelial tissue on the cervix by **cauterising** it
* Bleeding/abnormal discharge can occur for weeks following LLETZ procedure
56
What is a cone biopsy?
Treatment for **cervical intraepithelial neoplasia** (CIN) & very early-stage cervical cancer
* Under general anaesthetic - cone-shaped piece of cervix removed using scalpel
* Sent to histology to assess for malignancy
Risks include:
* pain
* bleeding
* infection
* scar formation with **stenosis** of cervix
* increased risk of miscarriage & premature labour
57
What is the FIGO staging system for cervical cancer?
* Stage 1: confined to **cervix**
* Stage 2: invades **uterus** or **upper 2/3 vagina**
* Stage 3: invades **pelvic wall** or **lower 1/3 vagina**
* Stage 4: invades **bladder**, **rectum** or **beyond pelvis**
58
What is the management of each cervical cancer stage?
* **CIN** & **early-stage 1A**: LLETZ / cone biopsy
* **Stage 1B-2A**: radical hysterectomy & removal of local lymph nodes w/ chemo + radio
* **Stage 2B-4A**: chemotherapy + radiotherapy
* **Stage 4B**: combination of surgery, radio, chemo, palliative care
59
What is pelvic exenteration?
* Removing all/most of pelvic organs (vagina, cervix, uterus, fallopian tubes, ovaries, bladder, rectum)
* Used in advanced cervical cancer
60
What is Bevacizumab?
* **MAB** used in combo with other chemotherapies in treatment of metastatic/recurrent cervical cancer
* Targets **vascular endothelial growth factor A** (VEGF-A): responsible for growth of new blood vessels
61
What is endometrial cancer?
Cancer of the **uterus lining**
* **Oestrogen-dependent** cancer = oestrogen stimulates growth of endometrial cancer cells
62
What is the most common type of endometrial cancer?
**Adenocarcinoma** ~80%
63
What are the risk factors for endometrial cancer?
DO NOT HELP
Diabetes
Obesity
Nulliparity
Oestrogen
Tamoxifen
HNPCC
Early menarche
Late menopause
PCOS
## Footnote
Exposure to **unopposed oestrogen** (oestrogen without progesterone)
64
What is the primary source of oestrogen in postmenopausal women?
**Adipose tissue**
* Contains **aromatase** = enzyme that converts androgens (e.g. testosterone) into oestrogen
* More adipose tissue = more aromatase = more androgens converted
65
What are 4 protective factors against endometrial cancer?
* Combined contraceptive pill
* Mirena coil
* Increased pregnancies
* Cigarette smoking
66
What is the presentation of endometrial cancer?
**Postmenopausal bleeding**
* Postcoital bleeding
* Intermenstrual bleeding
* Menorrhagia
* Abnormal vaginal discharge
* Haematuria
* Anaemia
* Raised platelet count
67
What is the criteria for a transvaginal USS referral for women over 55 years?
* **post menopausal bleeding**
* **Unexplained vaginal discharge**
* **Visible haematuria** plus raised platelets/ anaemia/elevated glucose levels
68
What investigations should be done for endometrial cancer? (3)
* **Transvaginal USS** for endometrial thickness
* **Pipelle biopsy**: highly sensitive for endometrial cancer
* **Hysteroscopy** w/ endometrial biopsy
69
What is the FIGO staging for endometrial cancer?
* Stage 1: confined to **uterus**
* Stage 2: invades **cervix**
* Stage 3: invades **ovaries**/**fallopian tubes**/**vagina**/**lymph nodes**
* Stage 4: invades **bladder**/**rectum**/**beyond pelvis**
70
What is the management of stage 1 and 2 endometrial cancer?
**Total abdominal hysterectomy with bilateral salpingo-oophorectomy** (**TAH** and **BSO**): removal of uterus, cervix & adnexa
71
What are some other treatment options for endometrial cancer? (not TAH and BSO)
* **Radical hysterectomy** - also removes pelvic lymph nodes, surrounding tissues & top of vagina
* **Radiotherapy**
* **Chemotherapy**
* **Progesterone**: hormonal Tx to slow progression
72
What are the types of ovarian cancer?
* **Epithelial cell tumours** (MC): MC subtype = serous tumours
* **Dermoid cysts**/**Germ cell tumours**: teratomas, benign, may contain various tissue types e.g. teeth, hair, bone
* **Sex cord-stromal tumours**: rare
* **Metastasis**: from cancer elsewhere
73
What is a Krukenberg tumour?
Metastasis in ovary from **GI tract cancer**, particularly stomach
* Have '**signet-ring**' cells on histology
74
What are the risk factors for ovarian cancer?
* **Age** (60 y.o. peak)
* **BRCA1** & **BRCA2** genes
* Increased number of **ovulations** (early onset period, late menopause, no pregnancies)
* **Obesity**
* **Smoking**
* Recurrent use of **clomifene** - medication used for ovulation
75
What are protective factors for ovarian cancer?
Factors that **stop ovulation** or **reduce number of lifetime ovulations** reduce the risk:
* Combined contraceptive pill
* Breastfeeding
* Pregnancy
76
What is the presentation of ovarian cancer?
* **Non-specific Sx**
* Abdo bloating
* Early satiety
* Appetite loss
* Pelvic pain
* Urinary Sx (freq/urgency)
* Wt loss
* Abdo/pelvic mass
* Ascites
* Referred **hip**/**groin pain** (due to ovarian mass pressing on obturator nerve
77
What is the referral criteria for referring directly to a 2-week-wait for ovarian cancer? (Physical exam)
If physical exam reveals:
* **Ascites**
* **Pelvic mass**
* **Abdo mass**
78
What is the criteria for carrying out initial investigations in **primary** care before a referral for ovarian cancer?
Women over 50 years presenting with:
* New Sx of IBS/ **change in bowel habit**
* Abdo bloating
* Early satiety
* Pelvic pain
* Urinary freq/urgency
* Wt loss
79
What investigations should be done in primary care for ovarian cancer?
* **CA125 blood test** (>35 = significant)
* **Pelvic USS**
* **RMI**: Risk of Malignancy Index (estimates risk of ovarian mass being malignant)
80
What 3 things does the Risk of Malignancy Index for ovarian cancer take into account?
* Menopausal status
* USS findings
* CA125 level
81
What investigations should be done in **secondary** care for ovarian cancer?
* **CT scan**
* **Histology**
* **Paracentesis** (test ascitic fluid: cancer cells)
* Women < 40y.o with complex ovarian mass require tumour markers for possible germ cell tumour: **Alpha-fetoprotein** (a-FP) & **Human chorionic gonadotropin** (HCG)
82
What is the FIGO staging for ovarian cancer?
* Stage 1: confined to **ovary**
* Stage 2: spread past ovary but inside pelvis
* Stage 3: spread past pelvis but inside abdomen
* Stage 4: spread outside abdomen
83
What is the management of ovarian cancer?
Combination of **surgery** and **chemotherapy**
84
What is the prognosis of ovarian cancer?
* Often presents late due to **non-specific Sx**
* **> 70%** of patients present after it has spread beyond pelvis
85
What type of cancer is vulval cancer?
* Very rare
* ~90% = **squamous cell carcinomas**
* Less common = malignant melanomas
86
What are the risk factors for vulval cancer?
* Older (**>75**)
* **Immunosuppression**
* **HPV**
* **Lichen sclerosus** (~5% women with this get vulval cancer)
87
What is vulval intraepithelial neoplasia? (VIN)
Premalignant condition affecting **squamous epithelium** of skin that can precede vulval cancer
88
What are the 2 types of VIN?
* **High grade squamous intraepithelial lesion**: associated with HPV infection (typically younger - 35-50y.o.)
* **Differentiated VIN**: associated with lichen sclerosus (typically older - 50-60y.o.)
89
What is the management of Vulvar Intraepithelial Neoplasia?
**Biopsy** then:
* Watch & wait
* Surgery to remove lesion
* Iquimod cream
* Laser ablation
90
What is the presentation of vulval cancer?
* Vulval lump (irregular mass)
* Ulceration
* Bleeding
* Pain
* Itching
* Lymphadenopathy in groin
## Footnote
Usually affects labia majora
91
What investigations are done to diagnose vulval cancer?
* **Biopsy** of lesion
* **Sentinel node biopsy**: demonstrate lymph node spread
* Further imaging for staging e.g. **CT abdo & pelvis**
92
What is the management of vulval cancer?
* **2-week-wait** urgent cancer referral
* Wide local excision
* Groin lymph node dissection
* Chemotherapy
* Radiotherapy
93
What is the cause of vaginal cancer?
HPV
94
What are the symptoms of vaginal cancer?
* lump in vagina
* ulcers/skin changes around vagina
* abnormal bleeding from vagina
* Dyspareunia
* smelly/bloodstained discharge
* dysuria
95
What are the risk factors for vaginal cancer?
* Exposure to HPV infection
* > 75 y.o.
* Smoking
* If mother took **diethylstilbestrol** when pregnant (once used to prevent miscarriage)
96
What are the types of vaginal cancer?
* **Vaginal squamous cell carcinoma** (MC)
* **Vaginal adenocarcinoma**
* Vaginal melanoma (rare)
* Vaginal sarcoma (rare)
97
What investigations are done for vaginal cancer?
Colposcopy
98
What is the treatment of vaginal cancer?
* Radiotherapy
* Surgery - radical hysterectomy (early stage vaginal cancer)
* Chemotherapy
* HPV vaccine for prevention
99
What is a hydatidiform mole?
Type of tumour that grows like a pregnancy inside the uterus: **molar pregnancy**
100
What are the 2 types of molar pregnancy?
**Complete mole**:
* two sperm cells fertilise an '**empty ovum**' (contains no genetic material)
* These sperm combine genetic material - cells start to divide & grow into a tumour
* No fetal material will form
**Partial mole**:
* two sperm cells fertilise **normal ovum** (containing genetic material) at same time
* Cell now has 3 sets of chromosomes
* Cell divides & multiplies into a tumour
* Some fetal material may form
101
What signs indicate a molar pregnancy vs a regular pregnancy?
* More severe **morning sickness**
* **Vaginal bleeding**
* **Increased enlargement of uterus**
* **Abnormally high hCG**
* **Thyrotoxicosis** - hCG can mimic TSH & stimulate the thyroid to produce excess T3 and T4
## Footnote
In both types, period stops and hormonal changes of pregnancy occur
102
How is molar pregnancy diagnosed?
* Pelvic **USS**: shows **snowstorm appearance** of the pregnancy
* Dx confirmed with **histology**
103
What is the management of hyatidiform mole (molar pregnancy)?
* **Evacuation of the uterus/curettage**
* Referral to **gestational trophoblastic disease centre**
* Monitor **hCG levels** until normal
* If mole metastasises: systemic chemotherapy
104
What is endometriosis?
**Ectopic endometrial tissue** outside the uterus
105
What is an endometrioma? And give 2 examples of endometriomas in specific locations
A lump of **endometrial tissue** outside the uterus
* If in ovaries: "**chocolate cysts**"
* If in myometrium (muscle layer) of uterus: **adenomyosis**
106
What is the main theory for the cause of ectopic endometrial tissue?
**Retrograde menstruation**
* during menstruation endometrial lining flows backwards thru **fallopian tubes** out into pelvis/peritoneum
107
What is the presentation of endometriosis?
* **Cyclical pelvic/abdo pain**
* **Deep dyspareunia**
* **Dysmenorrhoea** (painful periods)
* **Infertility**
* Cyclical bleeding from other sites e.g. **haematuria**
* Cyclical urinary/bowel Sx if area affected
108
What investigations are done for endometriosis?
* **Pelvic USS**: large endometriomas & chocolate cysts, but usually unremarkable
* **Laparoscopic surgery** = **Gold Standard** (surgeon can remove deposits of endometriosis, potentially improving Sx)
* Definitive Dx made with **biopsy** of lesions
109
What is the staging system to be aware of for endometriosis?
**American Society of Reproductive Medicine** (ASRM)
110
What is the pathophysiology behind pelvic pain in endometriosis?
## Footnote
Pelvic pain = Main Sx
* Cells of endometrial tissue **outside uterus** respond to hormones in same way as tissue **inside** the uterus
* During menstruation endometrial tissue in uterus **sheds lining** & **bleeds** - same happens in endometrial tissue **elsewhere in body**
* This causes **irritation** & **inflammation** of tissues around sites of endometriosis
* Results in **cyclical**, **dull**, **heavy**/**burning pain** that occurs during menstruation
111
How does endometriosis cause adhesions?
* Localised **bleeding** & **inflammation** - causes damage and deveopment of **scar tissue** that binds organs together
* Adhesions lead to **chronic**, **non-cyclical pain** that can be sharp/stabbing/pulling & associated w/ nausea
112
What is the management of endometriosis?
* **Analgesia**: NSAIDs & paracetamol
* **Hormonal Mx**
* **Surgical Mx**
113
What hormonal managament options can be tried for endometriosis?
* COCP
* Progesterone only pill
* Nexplanon implant
* Mirena coil
* GnRH agonists (induce menopause-like state)
* Depot injection
## Footnote
**stop ovulation** and **reduce endometrial thickening**
114
What surgical managament options are available for endometriosis?
* **Laparoscopy**: excise/ablate endometrial tissue & remove adhesions (**adhesiolysis**)
* **Hysterectomy**
115
What is adenomyosis?
**Endometrial tissue** inside the **myometrium**
* **Hormone-dependent**, Sx tend to resolve after menopause (like endometriosis/fibroids)
* Can occur alone, or alongside endometriosis/fibroids
* More common in **later reproductive years** & those that have had **multiple pregnancies**
116
What is the presentation of adenomyosis?
* ~1/3 asymptomatic
* **Dysmenorrhoea**
* **Menorrhagia**
* **Dyspareunia**
* Infertility/pregnancy-related Cx
117
What investigations are done for adenomyosis?
* **Transvaginal USS** (1st line)
* **MRI**/**transabdo USS** (alternative Ix)
* **Histological exam** of uterus after hysterectomy (GS)
118
What is the management of adenomyosis for women **not** wanting contraception?
## Footnote
* Mx depends on Sx, age, plans for pregnancy
* NICE recommend same Tx as heavy menstrual bleeding
* When there's no associated pain: **Tranexamic acid** (antifibrinolytic - reduces bleeding)
* When there's associated pain: **Mefenamic acid** (NSAID - reduces bleeding & pain)
## Footnote
Other options:
* GnRH analogues (induce menopause-like state)
* Endometrial ablation
* Uterine artery embolisation
* Hysterectomy
119
What is the management of adenomyosis for women wanting/accepting contraception?
* **Mirena coil** (1st line)
* **COCP**
* **Cyclical oral progesterones**
## Footnote
Progesterone only meds e.g. pill, implant, depot may also help
120
What pregnancy complications are associated with adenomyosis?
* **Infertility**
* Miscarriage
* Preterm birth
* Small for gestational age
* Preterm PRoM
* Malpresentation
* Need for C section
* Postpartum haemorrhage
121
What is atrophic vaginitis
**dryness and atrophy** of the vaginal mucosa related to a lack of oestrogen.
122
Why does atrophic vaginitis usually occur in menopause
**LACK OF OESTROGEN during menopause**
- usually Epithelial lining in the vagina and urinary tract responds to oestrogen by getting thicker, producing secretions and being elastic
-less oestrogen means tissue is more prone to inflammation and infection
123
Presentation of atrophic vaginitis
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
**Post menopausal women:**
Recurrent UTI
Stress incontinence
Pelvic organ prolapse
124
Upon examination what will be the findings of atrophic vaginitis
-pale mucosa
-thin skin
-reduced skin folds
-dryness
-sparse pubic hair
-erythema and inflammation
125
Mx of atrophic vaginitis
-Vaginal lubricants e,g SYLK, replens
-topical oestrogen
Estriol cream
Estriol pessaries
Estradiol tablets - once daily
Estradiol ring
126
Topical oestrogen contraindications (4)
Breast cancer
Angina
VTE
Endometrial hyperplasia
127
What is menarche
Females first episode of menstruation
128
What is the Rotterdam criteria
A criteria used for making a diagnosis for polycystic ovarian syndrome of 2 out of three of:
1)Oligoovualtion/anovulation - irregular/ absent periods
2)Hyperandrogenism - characterised by hirsutism and acne
3)Polystic ovaries on Ultrasound
129
Presentation of PCOS (6)
-oligomenorrhoea/amenorrhoea (irregular/ absent periods)
-infertility
-obsesity
-hirsutism
-acne
-hair loss in a male pattern
130
Complications of Polycystic ovarian syndrome (7)
-insulin resistance + diabetes
-CVD
-obstructive sleep apnoea
-depression and anxiety
-sexual problems
-endometrial cancer
-hypercholesterolaemia
131
What is acanthosis nigrans and why is it seen in PCOS
-thickened rough dark skin typically on elbows and armpits
-due to INSULIN RESISTANCE
132
What are DDX for hirsutism
-PCOS
-ovarian/adrenal tumours
-cushings
-congential adrenal hyperplasia
-medications e.g phenytoin, ciclosporin, anabolic steroids, corticosteroids, artificial testosterone
133
How does insulin resistance occur in PCOS
**Insulin resistance is both a symptom and a driver for PCOS**
-Insulin resistance means pancreas has to produce more insulin to get the same response
-**insulin also promotes androgen release e.g testosterone** + suppresses **sex hormone binding globulin** which usually suppresses androgens
-this can lead to hyperandrogenism in women with PCOS and poor development of follicles in the ovaries
134
Ix for PCOS
Blood tests:
-**raised LH**
-**raised LH-FSH ratio (high LH compared to FSH)**
-raised testosterone
-raised insulin
-normal/raised oestrogen
-low sex hormone binding globulin
Exclude other pathology
-prolactin
-TSH
Pelvic ultrasound
GOLD STANDARD - Transvaginal ultrasound for observing ovaries - **string of peals appearance**
2hr oral glucose tolerance test- test for insulin resistance
135
Diagnostic criteria on transvaginal ultrasound for PCOS diagnosis
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
136
Risk factors for PCOS
Obesity
Lack of excercise
History of gestational diabetes
FHx
137
General management of PCOS
-Weight loss - can be aided with orlistat (lipase inhibitor)
-Low glycaemic index, calorie-controlled diet
-Exercise
-Smoking cessation
-Antihypertensive medications where required
-Statins where indicated (QRISK >10%)
138
How does PCOS increase the risk for endometrial cancer
-in PCOS patients dont experience regular menstruation
-so endometrial lining continues to proliferate under the influence of oestrogen and **does not shed**
-resulting in endometrial hyperplasia a pre cancerous stage of endometrial cancer
139
Management of the risk of endometrial cancer in PCOS
Mirena coil: thin the lining of the uterus
Inducing a period:
-cyclical progestrogens e.g medroxyporgesterone acetate once a day For 14 days
-COCP
140
How do you manage the infertility in PCOS
First step: Weight loss
If this fails:
Clomifene - increases FSH and LH levels
Laparscopic ovarian drilling
IVF
Metformin - increases insulin sensitivity
141
Management for hirsutism in PCOS
Weight loss
**Co-Cyprindiol**- COCP for the treatment of hirsutism and acne
Topical eflornithine - 6/8 weeks
Electrolysis
Laser hair removal
Spironolactone
Finasteride - decreases testosterone
Flutamide
Cypoterone acetate - anti androgen and progestin
142
Management of acne in PCOS
first line - COCP
Co-cyprindiol may be the best option as it has anti-androgen effects
Topical adapalene
Topical Abx
Topical azelaic acid
Oral tetracycline
143
Major side effect of using co cyprindiol
Significantly increased risk of VTE
144
What is ashermans syndrome
Where adhesions form within the uterus following damage
145
What can lead to ashermans syndrome (4)
-post pregnancy
-dilatation and curettage procedure e.g Tx of retained product of conception
-uterine surgery
-recurrent pelvic infection(Endometritis)
146
Presentation of ashermans syndrome
Secondary amenorrhoea (absent periods)
Lighter periods
Dysmenorrhoea (painful periods)
Infertility
147
Diagnosis for ashermans syndrome (4)
**GOLD STANDARD - Hysteroscopy**
Hysterosalpingography - contrast is injected into the uterus and imaged with X-ray
Sonohysterography - uterus filled with fluid and seen pelvic US
MRI scan
148
Mx of ashermanns syndrome
dissecting the adhesions during hysteroscopy
149
Where do the female reproductive tract develop from embryologically
Müllerian ducts
150
What is a bicornuate uterus
A congenital structural abnormality in the uterus causing it to be heart shaped
151
What complications are there for bicornuate uterus
Miscarriage
Premature birth
Malpresentation - poor position of baby in uterus
152
What is an imperforate hymen
where the hymen at the entrance of the vagina is fully formed, without an opening.
153
Tx of imperforate hymen
Surgical incision to create the opening
154
Complications for imperforate hymen
Retrograde menstruation leading to endometriosis - due to the debris remaining in the pelvic cavity
155
What is transverse vaginal septae
Where the septum wall form transversely across the vagina
Can be perforated or imperforated
156
Treatment of transverse vaginal septae
Complications of the treatment
Surgical correction
Complications:
Vaginal stenosis
Recurrence of the septae
157
What is vaginal hypoplasia
abnormally small vagina
158
What is vaginal agenesis
absent vagina
159
What is the reason for vaginal hypoplasia and vaginal agenesis
Failure of the Müllerian ducts to properly develop
160
Mx of vaginal hypoplasia and agenesis
Vaginal dilator for prolonged periods
Vaginal surgery
161
What is pelvic inflammatory disease
Inflammation and infection of the organs of the pelvis - caused by spreading of infection up through the cervix
162
What are the different types of pelvic inflammatory disease (5)
**Endometritis** - inflammation of the endometrium
**Salpingitis** - inflammation of the fallopian tubes
**Oophoritis** - inflammation of the ovaries
**parametritis** - inflammation of the parametrium, which is the connective tissue around the uterus
**Peritonitis** - inflammation of the peritoneal membrane
163
What are the most common causative organisms for pelvic inflammatory disease (3)
Sexually transmitted
-Neisseria gonorrhoeae
-chlamydia trachomatis
-mycoplasma genitalium
164
Risk factors for pelvic inflammatory disease (6)
-not using barrier contraception
-multiple sexual partners
-younger age
-previous PID
-having an IUD - e.g copper coil
-having existing STI
165
Presentation of Pelvic inflammatory disease
Pelvic/lower abdo pain + tenderness
Vaginal discharge - can be purulent
Abnormal bleeding - intermenstrual or after sex
Dyspareunia
Fever
dysuria
Cervical motion tenderness - movement of cervix causes unpleasant sensation
166
Investigations for Pelvic inflammatory disease
-NAAT swabs for gonnorhae/chlamydia/mycoplasma genitalium
-HIV test
-syphilis test
-vaginal swab -look for bacterial vaginosis/candiasis + look under microscope to look for pus cells
-CRP+ESR - raised
-pregnancy test - **rules out ectopic pregnancy**
167
Mx of Pelvic inflammatory disease
-Abx started empirically before swabs obtained
- IM ceftriaxone, and then 14 days of oral doxycycline and metronidazole
168
Complications for pelvic inflammatory disease
Sepsis
Abcess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz Hugh Curtis syndrome
169
What is fitz hugh Curtis syndrome
**complication of pelvic inflammatory disease**
Inflammation + infection of the **liver capsule ** leading to adhesion between peritoneum and liver
170
Treatment of fitz Hugh Curtis syndrome
Laparoscopy + adhesiolysis
171
Main symptoms of fitz hugh Curtis syndrome
RUQ pain
Shoulder tip pain if diaphragmatic involvement
172
What are prolactinomas
Tumours of the pituitary gland that secrete excesssive prolactin
173
What condition is associated with prolactinomas
Multiple endocrine neoplasia type 1
174
What is the difference between micro and macro prolactinomas
Micro - less than 10mm
Macro - more than 10mm
175
Give 5 Symptoms of prolactinomas
Bitemporal hemianopia
Headache
Osteoporosis
Galactorrhae
Amenorrhae
Gynocomastia
ED
Infertility
Decreased libido
176
Investigations for prolactinomas
MRI - to visualise the prolactinoma
Serum prolactin - raised
177
Tx for prolactinomas
Medication - dopamine agonist e.g cabergoline/ bromocriptine
Surgery transphenoidal removal of pituitary tumour - only really for macroprolactinomas or if medication doesnt work
178
What is menopause
When a woman has had no periods for 12 months retrospectively - over 50 years
24 months of no period for under 50 years
179
What is classed as premature menopause
Menopause before the age of 40
180
What are the changes to the sex hormones during menopause
Oestrogen - low
Progesterone - low
LH + FSH - high due to lack of negative feedback
181
What is the physiology of menopause
begins with a decline in the development of the ovarian follicles.
Without the growth of follicles, causes reduced production of oestrogen.
Oestrogen has 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.
Leads to irregular menstrual cycles
182
Give 5 perimenopausal symtoms (8)
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
183
What does menopause increase the risk of
Lack of oestrogen leading to:
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
184
Mx of perimenopausal symtoms
Help with vaginal dryness
Vaginal oestrogen - creams/ tablets
Vaginal moisturisers
Testosterone - help with libido
Help with mood
CBT
SSRI antidepressants - fluoxetine
HRT
Tibolone - acts as HRT
Clonidine
185
What are endometrial (uterine) polyps?
**Non-cancerous** growth attached to **endometrium**
186
What are the causes of endometrial polyps? (3)
* **Perimenopausal** or **postmenopausal**
* **Obese**
* Taking **tamoxifen**
187
What are possible symptoms of endometrial polyps?
* Irregular periods
* Heavy periods
* Postmenopausal bleeding
* Infertility
188
How are endometrial polyps diagnosed?
* **Transvaginal USS**
* **Hysteroscopy**
* **Endometrial biopsy**
189
What is the management of endometrial polyps?
* **Watch and wait**
* Hormonal meds (**progestins** & **GnRH agonists** to lessen Sx)
* **Surgery**
190
What is PCOS
Condition affecting women due to imbalance in hormones particularly an increase in androgens, which leads to disruption in egg release and menstruation aswell as other systemic sx
