Gynae fifth yr Flashcards
What is adenomyosis?
refers to endometrial tissue inside the myometrium (muscle layer of the uterus)
more common in later reproductive years and with multiparity
can occur alone, or alongside endometriosis and fibroids
cause not fully understood - multiple factors involved - sex hormones, trauma, inflammation
Sx tend to resolve after menopause
Features of adenomyosis?
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
Enlarged, boggy uterus
Can also present with infertility or pregnancy-related complications. Also asymptomatic
O/E - enlarged, tender uterus - softer than uterus with fibroids
Dx of adenomyosis?
TVUS
MRI and TAUS are alternatives
Histological examination after hysterectomy is gold standard
Tx of adenomyosis?
Depends on Sx, age and plans for pregnancy
NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding.
No contraception - symptomatic relief during menstruation - tranexamic acid if no pain, or mefanamic acid if associated pain
If contraception wanted: IUS, COCP, cyclical oral progestogens
Other options - GnRH analogues, endometrial ablation, uterine artery embolisation, hysterectomy
Pregnancy and adenomyosis - associated w/ infertility, miscarriage, preterm birth, SGA, PPROM, malpresentation, need for C-section, PPH
What is pelvic organ prolapse?
refers to 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.
Types of prolapse?
Uterine prolapse is where 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.
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Associated w/ constipation, and can develop faecal loading, urinary retention and palpable lump in vagina.
Cystocele - caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
Risk factors for prolapse?
the result of weak and stretched muscles and ligaments
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
Features of uterine prolapse?
Sx:
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Lump or mass in vagina
O/E:
Ideally empty bladder and bowel before examination of a prolapse
Left lateral position w/ Sims speculum
What are grades of uterine prolapse?
pelvic organ prolapse quantification (POP-Q) system:
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
Management of uterine prolapse?
Conservative management - pelvic floor exercises, WL, lifestyle changes (for associated stress incontinence - reduce caffeine and incontinence pads), Tx of related Sx (anticholinergic meds), vaginal oestrogen cream
Vaginal pessary - provide extra support to pelvic organs - ring, shelf, donut, hodge - changed periodically - can cause vaginal irritation and erosion over time - can use oestrogen cream to protect vaginal walls
Surgery - definitive option - many methods including hysterectomy, complications include pain, bleeding, infection, DVT, risk of anaesthetic, damage to bladder or bowel, recurrence of prolapse, altered experience of sex
mesh repairs should be avoided due to chronic pain, altered sensation, dyspareunia, abnormal bleeding, urinary/bowel problems
What is ovarian torsion?
defined as the partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply. Hence necrosis can occur and function of ovary lost - therefore emergency
If the fallopian tube is also involved then it is referred to as adnexal torsion.
If necrotic - infected - abscess - sepsis, or rupture - peritonitis - adhesions
RFs for ovarian torsion?
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
younger girls before menarche and have longer infundibulopelvic ligaments that twist more easily
Features of ovarian torsion?
Usually the sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
Fever may be seen in a minority (possibly secondary to adnexal necrosis)
Can twist and untwist intermittently - pain that comes and goes
Vaginal examination may reveal adnexial tenderness and palpable mass
Ix and Tx for ovarian torsion?
Ultrasound may show free fluid or a whirlpool sign. Doppler show lack of blood flow
Laparoscopy is usually both diagnostic and therapeutic. Detorsion and potentially oophorectomy depending on visual inspection.
What is cervical ectropion?
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).
Cells of endocervix are more fragile and prone to trauma - post coital bleeding
Associated with higher oestrogen levels - common in young women, COCP, pregnancy
Features of cervical ectropion?
asymptomatic - found incidentally during speculum examination
increased vaginal discharge, vaginal bleeding or dyspareunia
postcoital bleeding
O/E
well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone.
Management of cervical ectropion?
Asymptomatic ectropion require no treatment - typically resolve as patient gets older
Not a contraindication to COCP
If problematic bleeding - Cauterisation using silver nitrate or cold coagulation during colposcopy
What is an ectopic pregnancy?
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
most in ampulla but more dangerous if in isthmus
Features of ectopic pregnancy?
history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdo pain - due to tubal spasm, constant, unilateral
vaginal bleeding - less than normal period, dark brown in colour
history of recent amenorrhoea - if longer than 10wks could suggest inevitable abortion
peritoneal bleeding - shoulder tip pain, pain on defeactation/urination
dizziness, fainting, syncope
Sx of pregnancy report
O/E - abdominal tenderness, CMT, adnexal mass (not recommended as can rupture)
serum bHCG >1500 points towards diagnosis
Epidemiology and RFs for ectopic pregnancy?
Incidence = 0.5% of all pregnancies
RF’s - anything slowing the ovum’s passage to the uterus:
damage to tubes (PID, surgery)
previous ectopic
endometriosis
IUCD
POP
IVF
Investigation and management of ectopic pregnancy?
Stable - EPAU, unstable - ED
Positive pregnancy test
Investigation of choice - TVUS - may see gestational sac containing yolk sac or fetal pole - empty gestational sac (blob, bagel, tubal ring sign), mass looks similar to corpus luteum but won’t move with the ovary
Beta hCG - A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. A fall of more than 50% indicates miscarriage
Expectant - size <35mm, unruptured, asymptomatic, no fetal heartbeat, hCG <1000, compatible if another intrauterine pregnancy - involves expectant management over 48 hours, if bHCG rises or symptoms manifest then intervention if performed
Medical - size <35mm, unruptured, no significant pain, no fetal heartbeat, hCG <1500, not suitable if intrauterine pregnancy - involves methotrexate, pt need to be willing to attend follow up, can’t get pregnant for 3 months following treatment
Surgical - size >35mm, can be ruptured, pain, visible fetal heartbeat, hCG >5000, compatible with another intrauterine pregnancy - involves salpingectomy or salpingostomy
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.
What is a hydatidiform mole?
type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.
Complete - two sperm cells fertilise ovum that contains no genetic material. sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
Partial - two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
Features of molar pregnancy?
Behaves like normal pregnancy
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
USS - snowstorm appearance
Confirmed Dx with histology of mole after evacuation
Tx of molar pregnancy?
evacuation of the uterus to remove the mole
Then send for histological examination
Patients should be referred to the gestational trophoblastic disease centre for management and follow up
hCG monitored until returns to normal
Can metastasise and pt may require systemic chemotherapy
Causes of delayed puberty?
With short stature:
Turners, Prader-Willi, Noonans
Normal stature:
PCOS, androgen insensitivity, Kallmans, Klinefelters
Summary of androgen insensitivity syndrome?
X-linked recessive condition. End-organ resistance to testosterone, causing genotypically male children (46XY) to have a female phenotype
Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and Fallopian tubes
Features of complete - primary amenorrhoea, little or no axillary and pubic hair, undescended testes causing groin swellings, breast development may occur as a result of the conversion of testosterone to estradiol
Partial - partial response to androgens. This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.
Dx - buccal smear or chromosomal analysis to reveal 46XY genotype, after puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys. High LH, normal/raised FSH, normal or raised testosterone (for male), raised oestrogen (for male)
Tx - counselling, raise child as female, bilateral orchidectomy (increased risk of testicular cancer due to undescended testes), oestrogen therapy, vaginal dilators
Grading system for colposcopy results?
grading system for the level ofdysplasia(premalignant change) in the cells of the cervix. CIN is diagnosed atcolposcopy(notwith cervical screening). The grades are:
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes calledcervical carcinoma in situ.
Summary of cervical cancer?
3rd most common tumour of lower female genital tract
Most arise in transformation zone
Commonly associated with HPV - high risk 16, 18, 33
2 types - squamous, adenocarcinoma
Cervical intraepithelial neoplasia - premalignant condition of cervix
Features of cervical cancer?
Asymptomatic – may be detected on smear
Blood-stained offensive discharge
Abnormal bleeding (intermenstrual, postmenopausal)
Post-coital bleeding
Pelvic pain/dyspareunia
Mucoid, or purulent vaginal discharge
Rarely, if advanced cancer, may present with pelvic discomfort/pain, renal failure, leakage of urine or faeces from a fistula, lymphoedema, or severe haemorrhage
O/E - cervix inflamed or friable, bleed on contact, visible ulceratingor fungating lesion, foul-smelling serosanguineous vaginal discharge.
Ix of cervical cancer?
Colposcopy
Large loop excision of the transformation zone
Needle excision of the transformation zone (NETZ)
Cone biopsy
Staging scans
Staging of gynaecological cancer?
FIGO Staging
E.g.,
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Management of cervical cancer?
Cervical intraepithelial neoplasiaandearly-stage 1A: LLETZ or cone biopsy (The surgeon removes a cone-shaped piece of the cervix using a scalpel)
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
The5-year survivaldrops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4.
Pelvic exenteration - removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum.
Bevacizumab - Monoclonal antibody that may be used in combination with other chemotherapies in the treatment ofmetastaticorrecurrentcervical cancer.
Summary of endometrial cancer?
Usually, good prognosis due to early detection
The 5-year survival is close to 80%.
Cancer of endometrium of the uterus
80% are adenocarcinoma
Oestrogen-dependent
Summary of endometrial hyperplasia?
Precancerouscondition involving thickening of the endometrium.
Risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer.
Most cases of endometrial hyperplasia will return to normal over time. Less than 5% go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of:
Hyperplasia without atypia
Atypical hyperplasia
Endometrial hyperplasia may be treated by a specialist usingprogestogens, with either:
Intrauterine system(e.g. Mirena coil)
Continuous oral progestogens(e.g. medroxyprogesterone or levonorgestrel)
Features of endometrial cancer?
Post menopausal bleeding (slight and intermittent initially, then heavier) - Also seen in cervical and ovarian cancer
Premenopausal women may have intermenstrual bleeding
Pain is an indicator of extensive disease
Vaginal discharge unusual
Haematuria
Anaemia
Raised platelet count
RF’s for endometrial cancer?
Unopposed Oestrogen:
^ age
Obesity - adipose tissue(fat) is a source ofoestrogen. containsaromatase. unopposedin women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.
Nulliparity
Early menarche
Late menopause
Tamoxifen - anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium
Polycystic ovarian syndrome - lack of ovulation, no corpus luteumthat producesprogesterone,and no providing endometrial protection during theluteal phaseof themenstrual cycle. Plus insulin resistance
The addition of a progestogen to oestrogen reduces EC risk (e.g. In HRT + PCOS Tx) > IUS, cyclical progestogens
Diabetes mellitus - increased production ofinsulin stimulate the endometrial cells
Hereditary non-polyposis colorectal carcinoma (Lynch syndrome)
Protective factors for endometrial cancer?
Smoking
Due to anti-oestrogenic effect
Oestrogen may be metabolised differently in smokers
Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
Smoking destroys oocytes (eggs), resulting in an earlier menopause
Increased pregnancies
Less time with unopposed oestrogen
Additional progestogens
COCP
Mirena coil
Ix for endometrial cancer?
The referral criteria for a2-week-waiturgent cancer referral for endometrial cancer is:
Postmenopausal bleeding(more than 12 months after the last menstrual period)
NICE also recommends referral for atransvaginal ultrasoundin women over 55 years with:
Unexplained vaginal discharge
Visible haematuriaplus raised platelets, anaemia or elevated glucose levels
First-line - TVUS (<4mm has high negative predictive value), pipette biopsy, hysteroscopy with endometrial biopsy
Management of endometrial cancer?
Localised disease (stage 1 and 2) is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. (TAH and BSO)
Other Tx options depend on individual presentation:
Patients with high-risk disease may have postoperative radiotherapy
Chemotherapy
Radical hysterectomy (also removing the pelvic lymph nodes, surrounding tissues and top of the vagina)
Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery, slows progression of cancer
Summary of ovarian cancer?
Peak at age 60 years
distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
Presents late due to non-specific Sx
Types of ovarian cancer?
Epithelial cell - serous, endometrioid, clear cell, mutinous, undifferentiated
Dermoid/germ cell - benign ovarian tumours - teratomas, associated with ovarian torsion, AFP, hCG
Sex cord/stromal - rare, benign/malignant, Sertoli-Leydig, Granulosa
Metastasis - Krukenberg tumour (typically from GI tumours), signet cells on histology
Features of ovarian cancer?
Abdominal distension and bloating
Abdominal and pelvic pain
Abnormal vaginal bleeding
Urinary symptoms e.g. Urgency
Early satiety
Diarrhoea
WL, fatigue, loss of appetite
Hip/groin pain (due to ovarian mass pressing on obturator nerve)
RF’s for ovarian cancer?
Age – peak 60
Family history: mutations of theBRCA1or theBRCA2 gene
Many ovulations*:early menarche,late menopause,nulliparity
Obesity
Smoking
Recurrent use of clomifene
Protective factors for ovarian cancer?
Factors that stop or reduce ovulations:
COCP
Breastfeeding
Pregnancy
Ix for ovarian cancer?
Refer directly on a2-week-waitreferral if a physical examination reveals:
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Carry out further investigations before referral in women presenting with symptoms of possible ovarian cancer, starting with a CA125 blood test. This is particularly important in women over 50 years presenting with:
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
CA125
TVUS
CT scan
Histology
Paracentesis
Germ cell tumour - AFP, hCG
What is Risk of Malignancy Index (RMI
Estimates ovarian mass being malignant
Considers:
Menopausal status
US findings
CA-125 level**
RMI score greater than 200: high risk, with referral to specialist gynaecological cancer service, and staging CT advised
Management of ovarian cancer?
Managed by specialist gynaecology oncology MDT
Usually, a combination of surgery and platinum-based chemotherapy
Exploratory laparotomy for tumour debulking – major procedure!! Generally comprisestotal abdominalhysterectomy (TAH)andbilateral salpingo-oophorectomy (BSO),infracolic omentectomy, pelvic and para-aorticlymph node sampling,peritoneal biopsies, multiplepelvic washings, sampling ofascites, inspection and sampling of theunderside of the diaphragm, and removal of pretty much anything else that looks suspicious
Can have second debulking after chemotherapy in some cases
Medical therapies adjunct to surgery
Adjuvant chemo – given to all patients > stage 1c, or stage 1a/b with high-grade malignancy. First line – carboplatin + paclitaxel
Radiotherapy – tumours tend to be radioresistant
Summary of vaginal cancer?
Mass or ulceration within the vagina
Need biopsy for diagnosis
Very rare
Most common subtype is squamous carcinoma - relation to HPV, adenocarcinoma related to diethylstilbestrol
Ix - colposcopy, biopsy, EUA, staging scans
Tx - radiotherapy main Tx
Summary of vulval cancers?
90% of vulval cancers are squamous cell carcinomas. Can also be malignant melanomas
Sx - lump/ulcer on labia majora, inguinal lymphadenopathy, itching, bleeding, irritation, redness
RFs for vulval cancer?
Advanced age (particularly over 75 years)
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
Summary of chlamydia infection?
Organism: Chlamydia trachomatis (intracellular organism)
Features = asymptomatic, cervicitis, dysuria, urethral discharge, pelvic/abdo tenderness, CMT
Screening - all men and women 15-24
Ix - NAATs
Tx - 1 - doxycycline, 2 - azithromycin, pregnancy - azithromycin, erythromycin or amoxicillin
Complications - Epididymitis, pelvic inflammatory disease, endometritis, increased incidence of ectopic pregnancies, infertility, reactive arthritis, perihepatitis (Fitz-Hugh-Curtis syndrome)
Management of vulval cancer?
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration, or bleeding.
Staging:
Biopsy of lesion (incisional)
Sentinel node biopsy (for LN spread)
Further imaging (CT abdo and pelvis)
Uses FIGO system
Management depends on stage:
Wide local excision to remove
Groin LN dissection
Chemotherapy
Radiotherapy
Summary of gonorrhoea?
Organism - Neisseria gonorrhoea - gram -ve diplococci
Features - odourless purulent discharge, dysuria, pelvic pain, prostatitis, conjunctivitis
Ix - NAAT, charcoal endocervical swab
Tx - IM ceftriazone 1g, oral ciprofloxacin
Complications - PID, infertility, gonococcal conjunctivitis, disseminated gonococcal infection
Summary of bacterial vaginosis?
Not STI
Gardnerella vaginalis
RFs - multiple sexual partners, excesive cleaning, recent ABx, smoking, copper coil
Sx - fishy, offensive, watery grey discharge - Amsels criteria
Ix - vaginal pH, charcoal swab, assess for co-infections - clue cells on microscopy
Tx - oral metronidazole 5-7 days, alternative = topical metronidazole or clindamycin
Summary of trichomoniasis vaginalis?
A protozoan
Sx - asymptomatic, vaginal discharge (frothy, yellow green, fishy), itchy, dysuria, dyspareunia, balantitis, strawberry cervix, raised pH
Ix - charcoal swab w/ microscopy - shows motile trophozoites
Tx - oral metronidazole
Complications - increased risk of contracting HIV, BV, cervical cancer, PID, pregnancy complications
Summary of herpes?
herpes simplex virus (HSV) (both HSV-1 and HSV-2). HSV-2 typically
Sx - painful genital ulceration (dysuria, pruritus), primary episode also has systemic Sx, tender inguinal lymphadenopathy
Ix - clinically, NAAT, HSV serology
Tx - Sx relief (saline bathing, analgesia, topical anaesthetic), oral Aciclovir
Pregnancy - risk of contracting to neonate during labour - elective C-section if primary infection. Primary infection before 28 wks treated with aciclovir, then prophylactic aciclovir from 36 wks. Asymptomatic then vaginal delivery.
Primary after 28wk, treated for initial infection then prophylactic immediately after. C-section after.
Recurrent genital herpes - low risk of neonatal infection, prophylactic aciclovir
Summary of syphilis?
Treponema pallidum
Primary - chancre - painless ulcer, local non-tender lymphadenopathy, often not seen in women
Secondary - 6-10wks, systemic symptoms - fevers, lymphadenopathy, rash on trunk, palms and soles, buccal ‘snail trail’, condylomata lata
Tertiary - gummas, ascending aortic aneurysms, general paralysis of the insane, tabes dorsals, Argyll-Robertson pupil
Ix - serology, antibody testing, dark field testing, PCR
Tx - IM benzathine penicillin, alternative - doxycycline, non-treponema and treponemal titres
Jarish-Herxheimer reaction after Tx - fever, rash, tachycardia NO wheeze or hypotension
Summary of candidiasis?
Candida albicans
RF - DM, drugs (ABx, steroids, pregnancy, immunosuppression), HIV
Features - cottage cheese, non-offensive discharge, vulvitis, itch, vulval erythema, fissuring
Ix - clinical features, can do high vaginal swab
Tx - oral fluconazole 150mg or clotrimazole pessary, pregnancy - only cream or pessary
Recurrent - 4 or more episodes, check BM, exclude DDx, consider induction-maintenance regime
Summary of genital warts?
HPV 6&11
Features - small (2-5mm) fleshy protuberances which are slightly pigmented, may bleed or itch
Tx - topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion
multiple, non-keratinised warts are generally best treated with topical agents
solitary, keratinised warts respond better to cryotherapy
genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
Pathophysiology of ovarian hyper stimulation syndrome?
Complication of ovarian stimulation during IVF infertility treatment.
It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.
There is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space. This results in oedema, ascites and hypovolaemia.
The use of gonadotrophins (LH and FSH) during ovarian stimulation results in the development of multiple follicles. OHSS is provoked by the “trigger injection” of hCG 36 hours before oocyte collection. HCG stimulates the release of VEGF from the follicles. The features of the condition begin to develop after the hCG injection.
There is also activation of the renin-angiotensin system. A notable finding in patients with OHSS is a raised renin level. The renin level correlates with the severity of the condition.
RFs for OHSS?
Younger age
Lower BMI
Raised anti-Müllerian hormone
Higher antral follicle count
Polycystic ovarian syndrome
Raised oestrogen levels during ovarian stimulation
Preventing OHSS?
Women individually assessed for risk
During stimulation with gonadotrgophins they are monitored - serum oestrogen levels and USS monitor of follicles
If at high risk, several strategies used to reduce risk:
Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol)
Lower doses of gonadotrophins
Lower dose of the hCG injection
Alternatives to the hCG injection (i.e. a GnRH agonist or LH)
Features of OHSS?
Early OHSS presents within 7 days of the hCG injection. Late OHSS presents from 10 days onwards.
Abdominal pain and bloating
N+V
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
Mild: Abdominal pain and bloating
Moderate: Nausea and vomiting with ascites seen on ultrasound
Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)
Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)
Management of OHSS?
Supportive:
oral fluids
monitoring fluid output
LMWH - to prevent VTE
paracentesis if required
IV colloids (e.g, HAS)
Patients with mild to moderate OHSS are often managed as an outpatient. Severe cases require admission, and critical cases may require admission to the intensive care unit (ICU).
Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.
Causes of post menopausal bleeding?
defined as vaginal bleeding occurring after 12 months of amenorrhoea
vaginal atrophy - most common cause of PMB - thinning, drying and inflammation of vaginal walls due to reduction in oestrogen following menopause
HRT - can occur with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur
Endometrial hyperplasia - abnormal thickening of endometrium and precursor for endometrial carcinoma, RF - obesity, unopposed oestrogen use, tamoxifen use, PCOS, DM
Endometrial cancer - 10% of pt’s with PMB
Cervical cancer - obtain full record of prior cervical screening
Ovarian cancer - can present with PMB if oestrogen secreting (theca cell) tumours
Vaginal cancer
Trauma
Vulval cancer
Bleeding disorders
Ix for post menopausal bleeding?
women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer
TVUS - acceptable depth is <5mm
Tx of vaginal atrophy?
Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
