Gynae 5 Flashcards
What is FGM?
All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
- Occurs in young girls (infancy – age 15, commonly before puberty)
- In the UK the most affected women come from: Somalia, Kenya, Eritrea, Ethiopia and the Yemen.
- It is common in Mali, Guinea and Egypt.
What are the types of FGM?
Type 1 – Clitoridectomy
- Removing part or all of the clitoris
Type 2 – Excision
- Removing part or all of the clitoris, labia minora ± labia majora
Type 3 – Infibulation
- Narrowing vaginal opening by creating a seal by cutting and repositioning the labia
Type 4
- Other harmful procedures to genitals including pricking, piercing, cutting, scraping, burning
What are the S/S of FGM?
- Constant pain
- Dyspareunia
- Bleeding, cysts, abscesses
- Incontinence
- Depression, flashbacks, self-harm
What is the management of FGM?
Deinfibulation:
- Offered to those unable to have sex, pass urine, or pregnant women at risk during delivery
- Analgesia to avoid flashbacks
Must record in notes:
- If <18yo = record in notes (name, DoB, address), report to police and social services
- If >18yo = record in notes, no obligatory duty to report though > may offer deinfibulation
What are the complications of FGM?
- Repeated infections → infertility
- Life-threatening complications during labour, childbirth
- Short term – haemorrhage, urinary retention, genital swelling, menstrual difficulties, infertility, HIV, HBV
What are fibroids?
AKA leiomyomas
Benign tumours arising from myometrium
What are the types of fibroid?
- Submucosal (bulge into uterine cavity)
- Intramural (within the muscular uterine wall)
- Subserosal (project to the outside of the uterus)
What are the risk / protective factors for fibroids?
RISK:
- Black women ± FHx
- Obesity
- Nulliparity
- Pregnancy
PROTECTIVE:
- Smoking
- Grand multiparity
- COCP
Describe the changes that fibroids can go through
- Hyaline degeneration
- Calcification (post menopausal)
- Red degeneration (pregnancy)
Do fibroids respond to hormones?
HORMONE-DEPENDANT (contain lots of oestrogen and progesterone receptors)
- Enlarge in pregnancy (due to oestrogen)
- Shrink in menopause
What are the S/S of fibroids?
- May be asymptomatic
- Menorrhagia, DUB (may result in iron-deficiency anaemia)
- Bulk-related symptoms - lower abdominal pain: cramping pains, often during menstruation - bloating, urinary symptoms, e.g. frequency, may occur with larger fibroids
- Subfertility, miscarriage
Signs:
- Abdominal swelling
- Pressure symptoms on bowel or bladder
- Palpable pelvic masses
- Uterine enlargement
What are the investigations for fibroids?
- Examination > speculum, bimanual
- 1st line: TVUSS (n.b. if >4mm when not expected, do a hysteroscopy)
- Endometrial biopsy - normal
- FBC - anaemia
What is the management of fibroids?
FOR FIBROIDS >3CM
(if no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis > DUB management)
1st line non-hormonal:
- Tranexamic acid (contraindications: renal impairment, thrombotic disease)
- Mefenamic acid / NSAIDs (contraindications: IBD)
1st line hormonal (contraceptive):
- COCP
- Cyclical oral progestogens
Medical:
Injectable GnRH Agonist:
- Short-term, usually used prior to surgery
- Shrinks fibroids
- Induces a menopausal state
- SEs (menopausal > hot flushes, sweating, vaginal dryness, osteoporosis)
Ulipristal Acetate:
- Short-term, selective progesterone receptor modulator
- Shrinks fibroids, reduce bleeding (use for 6/12)
- As effective as GnRH agonists BUT no menopausal state induced
- Not yet widely accepted into clinical practice
- Long-term use associated with liver injury
SURGICAL:
Myomectomy:
- Best for maintaining fertility
- Abdominally, laparoscopically, hysteroscopically
- Power morcellation is used to shrink the fibroids for removal
- Side effects: Uncontrolled life-threatening bleed (small risk), more likely to require a CS in the future as they have to make an incision into the uterus > risk of uterine rupture
Hysteroscopic resection / Transcervical Resection of Fibroids (TCRF):
- Small or submucosal fibroids
Hysterectomy:
- Large fibroids or severe bleeding and fertility not desired
Hysteroscopic Endometrial ablation:
- If heavy bleeding cannot be controlled with medication, endometrial ablation may be used
- May be performed in the presence of small fibroids
- Does not shrink the fibroid(s) but can help to decrease heavy menstrual bleeding caused by them
- Contraception still required
RADIOLOGICAL: Uterine artery embolisation (UAE):
- Minimally-invasive alternative to hysterectomy or myomectomy
- May preserve fertility (may also make ovaries fail…)
- Embolise both uterine arteries > infarct/degenerate fibroids
- Patients need admission to deal with pain associated (opiate analgesia)
- Complications: fever, infection, fibroid expulsion, potential ovarian failure (COUNCIL)
- 33% of women require further medical, radiological or surgical treatment <5 years
- As effective as myomectomy for alleviating fibroid DUB and pressure symptoms
What are the complications of fibroids?
Pregnancy:
- Red degeneration
- Miscarriage
- Malpresentation, transverse lie
- PTL
- PPH
Prognosis:
- 10-year recurrence rate after myomectomy is 20%
- Fibroids regress and calcify after menopause
Leiomyosarcoma (<1 per 100,000):
- Very rare cancer; smooth muscle cancer of the uterus
- Associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)
Describe the red degeneration of fibroids
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
- More likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy
- S/S = low fever, pain, vomiting
- Mx = conservative – resolve in 4-7 days
What is a gynaecological polyp?
An abnormal growth of tissue which projects from a mucous membrane.
What are the RFs for a gynaecological polyp?
- Obesity
- Hypertension
- HRT or Tamoxifen (increased oestrogen)
Protective factors include any method that increases progesterone levels – IUS which contain Levonorgestrel.
Describe a cervical ectropion
Ectocervical migration of columnar epithelium
(should be squamous)
Linked to increased oestrogen – pregnancy, COCP
- S/S = IMB, PCB, increased discharge
- Ix = speculum
- Mx = reassurance, ablative treatment e.g. cold coagulation used if troublesome sx
Describe a cervical polyp
Overgrowth of endocervical columnar epithelium
(benign + solitary)
Can also be linked to oestrogen
- S/S = asymptomatic or small bleeding and discharge, contact bleeding, PCB (if at cervix, PCB may be more apparent)
- Ix = speculum, TVUSS (will be able to see the polyp)
- Mx = reassurance, generally advised to remove (twist off if small or surgery) - send for histology
Describe an endometrial polyp
Benign abnormal growth of the endometrium
S/S
- Usually asymptomatic
- Irregular menstrual bleeding – spotting rather than flooding
- IMB
- Vaginal discharge – white or yellow mucus
- Infertility
Investigations:
- TVUSS - Will see endometrial thickness. Hypoechoic protrusion from the endometrium
- Outpatient hysteroscopy (OPH) and saline infusion sonography (SIS) are the most accurate
Management:
- May resolve spontaneously (if small)
- Polypectomy to alleviate AUB symptoms, optimise fertility and exclude hyperplasia/cancer
- Day-case under GA or under LA in OPD
Describe the types of HPV infection
Low-risk sub-types (6 and 11) = benign genital warts
High-risk (16 and 18) = CIN, VIN, VAIN > implicated in 70% of cervical cancers
