Gynaecology Flashcards
(24 cards)
Ovarian cysts and cancer
Cyst type: Non-neoplastic and neoplastic
- Non-neoplastic: Functional or pathological (“chocolate cysts”, polycystic ovares, theca lutein cyst”
- Neoplastic cyst: Epithelial cysts (serous cystadenoma*, mucinous cysadenoma) or benign germ cell tumour (i.e. Dermoid cyst) or Sex cord tumours (e.g. Fibroma. Think Meig’s syndrome if ascites or pleural effusion present)
Tumour types: Serous cystadenocarcinoma, Mucinous cyadenocarcinoma)
Risk factors:
- Nulliparity
- HRT (oestrogen only)
- Early menarche
- Late menopause
- Obesity
- Smoking
- Genetics (BRCA1+2, HNPCC)
Protective:
- HRT (progesterone containing)
- Multiparous
- COCP
S/S
- Specific (Chronic pain, acute pain, PV bleeding, co-existing frequency or constipation)
- Non-specific (Bladder and bowel habit change, bloating, weight loss, IBS, PV bleeding)
Risk stratification: RMI (U x M x Ca125)
Management of cysts:
Premenopausal women: Bloods under40s (LDH, AFP and hCG. US rescan after 6 weeks. If persistent monitor 3-6 monthly with US and Ca125. If persistent of >5cm then laparoscopic cystectomy or oopherectomy
Post-menopausal women:
- Low RMI of <25 (Recheck US and Ca125 in 1 yr)
- Mod RMI 25-250 (BSO and histology. If malignancy confirmed, staging laparotomy and completion surgery)
- High RMI >250 (Referral for staging laparotomy)
Management of suspected cancer
- Abdominal exam for ascites or masses (if present 2 week referral pathway)
- Measure Ca125. If >35 then..
- Ultrasound abdomen and pelvis. If confirmed cancer…
- 2 weeks gynaeoncology referral for staging (CXR and CT abdomen/pelvis)
Follow-up Cancer
- 5 years for clinical exam and Ca125
Endometrial cancer
Type: Adenocarcinoma.
Cause: Unopposed oestrogen leads to endometrial hyperplasia. This predisposes to pre-cancerous stage of “atypia”
Risk factors
- Anovulation (low parity, HRT, PCOS, tamofixen use)
- Early menarche, late menopause
- Low parity
- Obesity
- Increased age
- Cancer history (Previous Breast Ca, HNPCC, ovarian cancer)
Protective:
- Smoking
- High parity
- Progesterone containing contraceptive (e.g. COCP, Mirena)
Presentation:
History= PMB. If advanced, abdo pain and weight loss. Uncommonly menstrual irregularities
Examination= Abdominal (masses), bimanual (assess size and axis of uterus before endometrial sampling)
DDx for PMB:
- Ovarian cancer
- Cervical ectropion
- Atrophic vaginitis
- Endometrial hyperplasia without malignancy
- Benign endometrial polyps
- Cervical cancer / polyps
Suspected cancer pathway indications:
Who? >45s with menstrual irregularities >55s with PMB
What? Specialist clinic appt for TVS. If the endometrial tissue is >4mm then pipelle biopsy taken for histology.
If high risk (multiple risk factors, heavy bleeding and endometrial thickening), sent for hysteroscopy with biopsy.
if MALIGNANCY CONFIRMED –> CT CAP and MRI pelvis
Staging: FIGO (I to IV)
Management: Endometrial hyperplasia (without atypia): Progestogens e.g. Mirena IUS. Surveillance biopsies taken Atypical endometrial hyperplasia: Total hysterectomy + BSO
Endometrial carcinoma:
Stage I: Total hysterectomy + BSO + peritoneal washing (either laparoscopy or open)
Stage II: Radical hysterectomy +/- pelvic lymph nodes +/- adjuvant radiotherapy
Stage III: Maximal debulking surgery. Chemo pre-op
Stage IV: Palliative approach (low dose radiotherapy or high dose progestogens).
Follow-up:
- 5 years required (3 monthly for 2 years, 6 monthly 1 year then 2 years of annual)
PCOS
What?
PCO + clinical/biochemical hyperandrogegism
Cause:
- No completely understood. Multi-factorial.
- Elevated LH production leads to high androgen release.
- Insulin resistance leads to elevated insulin levels which disturbs the production of SHBG from the liver, leading to increased free androgens.
- Elevated androgens lead to anovulation
Risk factors:
- Irregular menstruation
- Diabetes
- FH of PCOS
Presentation: At puberty.
History: Infertility (amennorhoea/oligomenorrhoea), hirsuitism, chronic pelvic pain, depression
Signs: Obesity, hirsuitism, acne, male patten hair loss, acanthosis nigricans, hypertension
Investigations Bloods: -LH:FSH ratio (on days 1-3. If 3:1 then can cause anovulation. -SHBG low -Free androgen index high -Progesterone low
- TSH to exclude hypothyroidism
- Prolactin to exclude hyperprolactinaemia
- OGTT to exclude DM
Imaging
- TVS for all adults (not adolescents) unless clinical and biochemical results obvious
Rotterdam criteria: Requires 2/3
1. Oligomenorrhoea or amennorhoea
2. Clinical or biochemical evidence of hyperandrogenism
3. PCO on TVS (12+ follicles between ovaries and/or ovarian volume >10ml)
Note: In adolescents BOTH hyperandrogenism and irregular menstrual cycle required for Dx. Review 8 years post-menarche for re-assessment if criteria not met.
Management:
Addressing oligomenorrhoea or amennorhoea: Prescribe cyclical progestogen (e.g. 2 weeks medroxyprogesterone OD) to induce a withdrawal bleed. Then refer for TVS. Endometrium not concerning, induce >3 bleeds a year using COCP.
Addressing infertility: Specialist referral. 1st line clomifene +/- metformin esp if overweight. Consider ovarian drilling if normal BMI.
Hirsuitism: 1st line cosmetic. 2nd line COCP . Anti-androgens e.g. spironolactone (*teratogenic)
Acne: 1st line COCP (e.g. co-cyprindiol). 2nd line Topical retinoids, Abx or oral abx.
Referral:
If pregnant or considering pregnancy:
- Medication review (metformin not recommended)
-Gestational diabetes screening with OGTT
Complications: T2DM Gestational diabetes Endometrial cancer OSA Depression
Adenomyosis
Define Presentation Risk factors Ddx Investigations Mx
Adenomyosis is a condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium). . It can cause the uterus to double/triple in size. Can be localised/involve whole uterus.
Adenomyosis: Endometrial tissue grows into the muscle of the uterus.
Endometriosis: Endometrial tissue grows outside the uterus and may involve the ovaries, fallopian tubes, pelvic side walls, or bowel.
Adeno more likely to cause heavy bleeding.
Presentation:
- Menorrhagia (progresses from HMB cyclically to daily IMB)
- Dysmenorrhoea
- Deep dyspareunia
Risk factors:
- High parity
- CS
- TOP
- Previous ablation
DDx
- Fibroids
- Endometriosis
- Endometrial hyperplasia or carcinoma
- Hypothyroidism
- Coagulation disorder
Investigations:
1st line TVS
2nd line MRI pelvis (shows “irregular thickening of endo-myometrial junction zone”
Definitive Dx: Histology following hysterectomy
Management
1st line symptom control: NSAID for pain. Hormone therapy for bleeding.
2nd line curative: Hysterectomy is definitive treatment. Uterine artery embolisation, ablation and laparoscopy with excision options
Endometriosis
Risk factors:
- Uterine abnormalities: CS, ablations, D+C
- Fallopian tube abnormalities
- Early menarche
- Short cycles
- Long duration of bleeding
- HMB
- FH
Clinical features:
- Cyclical pelvic pain (if constant, suggests adhesions)
- Dys- Menorrhoea, chezia, uria, pareunia
- Sub-fertility
- Asymptomatic?
Examination:
- Fixed, retrograde uterus
- General tenderness
DDx
- IBS
- Fibroids
- Ectopic
- PID
Ix:
1st - Abdo and pelvic exam
2nd TVS or transabdominal US
Gold standard: Laparoscopy: Biopsy possible. Treatment done if appropriate (no bladder/bowel/ureter involvement or uncomplicated ovarian endometrioma)
Management:
Asymptomatic –> No treatment
1st line: Symptomatic pain relief with NSAID. Hormonal treatment of low dose COCP or progestogen to suppress ovulation for 6-12 months.
2nd line: Surgery if serious impact on life. Done as laparoscopy excision, ablation and fulgaration. if bladder/bowe/ureter involvement give GnRH pre-op for 3 months
3rd line: Laparoscopic hysterectomy +- BSO with post-op hormone replacement
For women trying to conceive:
1. MDT involvement with fertility specialist
2. Surgical options
a. Not involved bladder/bowel/ureter –> Offer laparoscopic excision/ablation of endometriosis PLUS adhesiolysis
b. If ovarian endometriomas –> Offer laparoscopic ovarian cystectomy
c. Deep endometriosis –> Offer laparoscopic excision/ablation of endometriosis
Do not offer post-op hormonal treatment
Pelvic floor collapse
Risk factors
- Obesity
- Chronic raised intra-abdominal pressure (e.g. cough in COPD, constipation, heavy weight bearing)
- Child birth
- Older age + menopause
- Iatrogenic e.g. pelvic surgery
- Congenital factor e.g. Ehler’s Danlos syndrome, Marfan’s syndrome
Presentation
- Feels like “something coming down”
- If cysocoele: Urgency, frequency, incomplete emptying
- If rectocoele: Constipation, diarrhoea, digitation
- Commonly asymptomatic
Investigation Diagnosis: Clinical Rule out DDx: -UTI with dipstick and culture -Rule out stress incontinence by urodynamic testing -US for pelvic masses
Management:
If asymptomatic: Nothing
If symptomatic and affecting QoL:
- 1st line General (Weight reduction, pelvic floor physio exercises, topical oestrogen, smoking cessation)
-2nd line Pessary (Option of shelf or pessary. Change every 6-12 months. If post-menopausal required oestrogen)
3rd line surgery (For those with severe Sx. Procedure of anterior or posterior PFR, vaginal hysterectomy, SSF)
Recurrence:
In 1/3 of surgical patients.
Prevention:
- Avoid prolonged obstructed 2nd stage labour
- Weight management
- Encourage pelvic floor exercises after childbirth
Stress Incontinence
Cause: STRESS incontinence due to the pelvic floor weakness and ureteric instability
Causes:
- Childbirth
- Pelvic floor damage e.g. surgery
Presentation: Leakage of small volumes of fluid during increased abdominal pressure
Investigations:
1.Rule out UTI with urine dipstick and culture
Fluid chart: Normal result
Urodynamic testing: Checks for detrusor overactivity, shouldn’t contain.
Management: 1st line General - Pelvic floor physio for >3 months -Smoking cessation -Weight management - Address chronic cough 2nd line Surgery - TVT -Colposuspension -If unfit for surgery = Peri-urethral injection 3rd line Medication - Doluxetine
Prevention:
- Avoid prolonged 2nd stage labour
- Pelvic floor exercises after childbirth
Urge
What: URGE incontinence due to detrusor overactivity
Causes:
- Idiopathic
- Iatrogenic
- Neuropathic e.g. MS
Presentation:
- Leaking of large volumes
- Frequency
- Nocturia
- Urgency
Investigation:
1. Rule out a UTI
Volume/fluid charts: Increased
Diagnostic test: Urodynamic testing
Management
1st line Lifestyle
- Bladder retraining for min 6 weeks
-Advice on fluid intake, diuretics and caffiene
2nd line medication
1. Anti-muscarinics e.g. solifenacin, oxybutynin. CI: Acute angle closure glaucoma, GI obstruction, myasthenia gravis. SE: Dry mouth/eyes, constipation, confusion, blurred vision
2. Mirabegron (b3-agonist) for elderly
3rd line surgery
-Detrusor myomectomy and augmentation cytoplasty (for debilitating disease
PMB
What? Post menopausal bleeding 12+ months after last menstrual period
Classification
- Persistent (constant bleeding for 1+ month)
- Recurrent (2 PMB clinic appts with benign biopsies in last 2 years, 6 months apart)
DDx
- Endometrial carcinoma / hyperplasia with atypical
- Endometrial polyps
- Atrophic vaginitis
- Cervical carcinomma
- Cervicitis
- Ovarian carcinoma or polyps
Investigations
Initial: Abdo examination. Speculum and bimanual examination.
1st line: TVS (unless tamoxifen user, the hysteroscopy with biopsy)
Indications for pipelle biopsy at TVS:
- ET>4mm
- ET not seen e.g. due to fibroids
- Persistent PMB
- Suspicious polyp or mass seen on TVS
Indications for hysteroscopy:
- Unable to take adequate pipelle
- ET>11mm
- Patient taking tamoxifen
- Recurrent PMB
- Suspected polyp
Note: Use of CC HRT has limit of <4mm on ET. If sequential combined HRT used then higher limit
Menopause
Definiton: Permanent cessation of menstruation from loss of ovarian follicular activity. Diagnosed after 12+months of amennorhoea.
Average age: 51
Effects of oestrogen deficiency:
Early= Physiological symptoms, vasomotor symptoms
Intermediate: Vaginal atrophy, skin atrophy, urogenital atrophy, sexual dysfunction (lost libido, dyspareunia)
Later: Cerebrovascular accidents, cardiac disease, bone fractures (Colles F#, hip and spine)
Diagnosis:
- Clinically for women >45 with typical symptoms
- FSH blood test if indicated (women 45+ with atypical symptoms, or any women under 45 with symptoms)
Management:
COUNSELLING for menopause and treatment options
LIFESTYLE: Exercise, weight management, sleep hygiene, stress reduction,
HRT:
- If uterus present combined HRT. No uterus means oestrogen-only HRT
-Duration for 2-5 years. Consider dose reduction at annual reviews
-Contraindications: History of breast cancer, undiagnosed PMB, untreated endometrial hyperplasia, any oestrogen sensitive cancer.
-Risks: Oral HRT increased risk of VTE. Slight increase in stroke risk for oestrogen-only. Increase in breast cancer development, not death. Increase for ovarian cancer in all HRT. No increase in CHD or T2DM.
-Benefits: Decrease in fragility fractures. Maintained muscle mass and strength. Reduced CVD
NON-HRT:
-For vasomotor Sx= Venlafaxine, fluoxetine, citalopram
-For vaginal dryness: Moisturisers + lubricant. If need be consider topical vaginal oestrogen.
-For urogenital Sx= Vaginal oestrogen
-For psychological sx= CBT, antidepressants
Contraception:
- If >50 then use for 12 moths
- If <50 use for 24 months
Follow-up
-Review after 3 months then annually thereafter
Referral: Usually managed in primary care. Referred to gynaecology IF... - Symptoms on HRT -Side effect problem -PMB (urgent 2 week appt if >55)
Oligo or amennorhoea
Define
Cx of each
Ix
Mx
Oligomenorrhoea: Less than 9 cycles a year or period of 35+ days between periods
Amennorhoea:
- Primary the failed commencement of menses >16yrs old if secondary sexual characteristics are present, or > 14yrs old if secondary sexual characteristics haven’t started
Causes of amenorrhoea:
- Hypothalamic (Kallman’s syndrome X-linked recessive, functional, sever chronic disease)
- Pituitary (Prolactinoma, pituitary tumour, Sheehan’s syndrome, post-contraception)
- Ovarian (PCOS, premature ovarian failure, Turner’s syndrome 45 XO)
- Adrenal (e.g. congenital adrenal hyperplasia)
- Structural (ashermann’s syndrome or imperforate hymen r transvginal spetum)
Causes of oligomenorrhoea:
- PCOS
- Hormonal therapy
- Perimenopause
- Thyroid disease / DM
- Eating disorder or exercise excess
- Medication e.g. anti-psychotics or anti-epileptics
Investigations
1st line: Pregnancy tests, bloods (Hormone profile, TFTs, prolactin, 17 hydroxyprogesterone). Consider US, progesterone challenge test
Management:
Treat underlyingcause
Menorrhagia
define cause px ix referral tx
What: Excessive menstrual bleeding that occurs regularly and interfereswith womens QoL. Quantitively it’s 80ml+ of blood loss and/or duration of more than 7 days
Cause:
-If no cause found then termed “abnormal/dysfuntional uterine bleeding”
-PALM COEIN
Polyp – an abnormal but benign growth of tissue
Adenomyosis – a condition where the type of cells that normally line the uterus are found in the muscle layer of the uterus
Leiomyoma – a fibroid; a benign growth in the muscle of the uterus
Malignancy – a cancerous growth
Coagulopathy – a problem with blood clotting
Ovulatory dysfunction – problems with the regular cycle that leads to the release of an egg from the ovary
Endometrial – conditions that affect the inner lining of the uterus (the endometrium), such as endometriosis
Iatrogenic – caused by medical procedure or treatment
N - not otherwise classified
Presentation:
History = HMB, fatigue, SoB
O/E= Pallor, uterine tender (endometriosis or adenomyosis) or irregular (fibroids)
Investigations: 1st line history takes, urinary pregnancy test and FBC for Hb.
2nd line if clinically indicated: Coagulopathy, hormone profiling, US and TVS, pipelle biopsy (persistent IMB, >45 or failed pharmocology tx)
Referral:
- Mass or ascites O/E not attributable to fibroids –> Urgent referral
- Mass + cancer features –> 2 week cancer referral
- Failed Fe def treatment
- Complications e.g. fibroids compression
- Fibroids >3cm –> Specialist referral
Treatment
(If No identifiable pathology, fibroids <3cm and no adenomyosis)
1st line: LNG-IUS- levonorgestrel-releasing intrauterine system
2nd line: COCP and/or NSAID/tranexamic acid
3rd line (in secondary care): Remaining hormonal therapies (progesterone only e.g. depot, implant, oral norethisterone). Or surgical options (endometrial ablation or definitive hysterectomy. If fibroids myomectomy or uterine artery embolisation)
Conditions for IVF
<40
Should be offered 3 cycles of IVF if:
- Trying with regular unprotected sex for 2 years
- They have not been able to get pregnant after 12 cycles of artificial insemination
If you turn 40 during treatment, the currently cycle will be complete but further cycles won’t be offered
If tests show that IVF is the only treatment likely to help, you should be offered it straight away.
> 40
Should be offered 1 cycle of IVF on the NHS if ALL criteria are met:
- Trying with regular unprotected sex for 2 years
- They have not been able to get pregnant after 12 cycles of artificial insemination
- They’ve never had IVF treatment before
- No evidence of low ovarian reserve
- Informed of the additional implication of IVF and pregnancy at this age
Infertility
Subfertile definition: Couple having regular inprotected sex for 1 year without getting pregnancy (84% would get pregnant normally)
Causes:
Female: Anovulation and tubal defects
Male: Idiopathic, hypogonadotrophic hypogonadism, primary spermatogenic disorder, obstructive azoospermia, environmental, varicocele, cryptochidism
When to refer:
- Women with no periods
- Men with underdeveloped testes
- Women without fallopian tubes
- Couples with no success after 1 years (Early referral is women >35 and/or suspicion of underlying cause)
Initial investigations for all:
Men= Chlamydia screen, semen analysis
Women= Mid-luteal progesterone, chlamydia screen
Mangement
- Medical (1st line Clomifene. 2nd line gonadotrophins)
- Surgical if indicated
- Assisted conception (IUI, IVF, ICSI, donor insemination, oocyte donation)
Complications of assisted conception:
- OHSS
- Multiple pregnancy
- Pelvic infection
- Cancer
- Ectopic
Cervical cancer
What?
Most commonly squamous cell carcinoma (70%). Adenocarcinoma in 15%
Neoplasia arisen from CIN that develops over 1-20 years
Who?
2 peaks:25-29yrs and 80 yrs
Risk factors:
- HPV infection
- Prolonged STI
- Smoking
- Long term COCP
Presentation: - **Abnormal vaginal bleeding (IMB, PCB, PMB) - Abnormal vaginal discharge (blood stained and foul smelling) -Weight loss - Pelvic pain -Dyspareunia If advanced: - Bowel and bladder symptoms - Oedema -Radiculopathy
DDx:
- STI infection
- Endometrial carcinoma
- Cervical ectropion
- Atrophic vaginosis
- Fibroids
Investigations: 1st line - Premenopausal women get Chlamydia screening Postmenopausal women get URGENT Colposcopy and biopsy If cervical cancer confirmed: - CT CAP - MRI pelvic - PET - Bloods
Treatment:
CIN = Colposcopy with either biopsy+histology OR “see and treat”
Microscopic lesions confined to cervix= Radical trachelectomy to preserve fertility OR TLH
Gross lesions or invasion to upper vagina = <4cm get Radical hysterectomy. >4cm get chemoradiation
Lower vagina involvement ,hydronephrosis or pelvic sidewall involvement = Chemoradiation
Recurrence = 1. Chemoradiation 2. If confirmed to central pelvis, pelvic exenteration.
Prognosis
5 years of follow-up post-treatment (65% alive)
Mets spread once basement membrane breached –> LLBB (Lungs, liver, bowels and bones)
Prevention:
- HPV vaccine
- Cervical screening
CIN
What?
Dyskaryosis of the cervical epithelium
Classifications at cervical screening:
- Borderline changes in squamous cells
- Low-grade dyskaryosis
- High grade dyskaryosis (moderate and severe)
- Invasive squamous carcinoma
- Glandular neoplasia
Classification of CIN made at colposcopy : CIN I = 1/3 dysplasia CIN II = 2/3 dysplasia CIN III = 3/3 dysplasia SSC= In situ or invasive
Detection:
National cervical screening (2 yrly for 25-49yr old.5 yrly for 50-65 yr olds)
Causes:
HPV
Smoking
Management:
Upon referral from cervical screening service to colposcopy:
-Recall back to routine screening = Low grade or borderline dyskaryosis IF HPV negative
-Colposcopy within 6 weeks = Low grade or borderline dyskaryosis + HPV positive, 3 insufficient cervical smears
-Colposcopy within 2 weeks = High grade dyskaryosis, Invasive SCC, CGIN
At colposcopy appointment:
- Normal result –> No immediate treatment and discharged to usual screening
- CIN 1 –> No immediate treatment. Invited back for cervical screening in 12 months
- CIN 2 and 3 –> “See and treatment” with LLETZ. Cold-coagulation if if fertility a priority
- CGIN –> Removal treatment recommended
- SCC –> Referral to specialist team
Test of cure:
6 months follow-up with cervical screening and HPV. Result..
Negative/borderline + negative HPV= Discharged to routine screening
Neg /Borderline + ?HPV = 6 month repeat
Unsatisfactory + ?/neg HPV = 3 month repeat
Borderline + neg HPV = 6 month repeat
Abnormal grade = Colposcopy
Postive HPV = Colposcopy
Cervical polyps
Benign growths of hyperlasia of the columnar epilethelium
Risk factors:
- Multigravidae
- Age 50-60yrs
Presentation:
- Asymptomatic
- PV bleeding
- Increased discharge
DDx:
- Cervical ectropion
- Endometrial hyperplasia .. carcinoma
- Fibroids
- Atrophic vaginosis
- Cervical carcinoma
- STI
Investigation:
1st line STI swabs (HVS and endocervical) and cervical smear
Definitive: Histology after removal
Mangement:
1st line REMOVAL
- If small in primary care with polypectomy forceps. Silver nitrate to cauterise bleeding
-If large then at colposcopy with diathermy loop excision. If broad base use GA
Cervical ectropion
What?
Metaplasia of the ectocervical squamous epithelium into mucus secreting columnar epithelium, usually found in the endocervical canal.
Cause: Increase oestrogen levels?
Risk factors:
- COCP
- Pregnancy
- Adolescence (menstruating age)
Presentation:
History:Mainly asymptomatic. Can present with bleeding and excessive discharge
Speculum: Reddish appearance in ring around external os
Investigations: 1st line clinical Dx on speculum examination To exclude DDx: - Triple swab for STI -Cervical smear - Pregnancy test
Management:
Asymptomatic = No treartment
Symptomatic = Stop COCP.
Persistent symptoms = Ablation with cryotherapy or electrocautery
Vaginal cancer
Histology RF's Referral Ix Mx
What?
Very rare cancer.
Type = Squamous cell carcinoma
Risk factors:
- HPV infection
- Older age
- Immunocompromised
- VAIN~ Vaginal intra-epithelial neoplasia
Referral:
-2 weeks suspected cancer referral to specialist for colposcopy if unexplained mass in or at entrance to vagina.
Investigations:
At GP: Pelvic examination for vaginal masses
Upon specialist referral –> Colposcopy and biopsy
Management
VAIN 1 –> No treatment
VAIN 2/3 –> Laster treatment or surgery in wide local excision
Localised cancer: 1st line radiotherapy (internal and external) +/- chemo. 2nd line surgery
Distant mets: Palliative radiotherapy for Sx relief
Vulval cancer
Who?
Women over 65
Rare (1000 cases a year in the UK)
Risk factors:
- HPV
- VIN
- Immunosuppression
- Lichen sclerosus
- Older age
Presentation
- Vulval lump
- Ulceration
- Bleeding
Differential Diagnosis
-Vaginal thrush (Presents at itching, soreness, white discharge, dysuria)
Referral:
Two week cancer referral for Vulval if suspected.
If cancer confirmed: Request MRI pelvis and CT CAP
Classifications
- VIN
- Vulval cancer stage 1-4
Management
VIN: Surgery / laser/ topical imiquimod / monitor
If confined to volva = Wide local excision
If spread locally = Surgery +/- radiotherapy
If spread to pelvic lymph nodes = Radiotherapy + chemotherapy.
Follow-up:
If surgery: 6 week and 3 month follow-up appointment.
5 year total follow-up
65% 5 year survival.
Atrophic vaginitis
What?
Poorly oestrogenised walls of the vagina and vulva leads to predisposition for infection and injury
Risk factors:
- Menopausal women
- Oestrogen inhibitors e.g. tamoxifen and aromatase inhibitor
- Post-partum or breastfeeding
- Primary ovarian failure
- Oopherectomy
Presentation
- Vaginal dryness and soreness
- PV bleeding (PCB / spotting)
- Superficial dyspareunia
- Changes in discharge (profuse/ purulent/ blood-stained/ brown)
- Urinary symptoms
Differential Diagnosis
- Infection (BV, TV, candidiasis)
- Diabetes
- Endometrial hyperplasia/ carcinoma
Investigations Clinical diagnosis For exclusion: - BM - Infection screen - TVS (and biopsy if indicated)
Management
1st line Moisturised or lubricants
2nd line topical oestrogens (e.g. vagifem) or oral ospemifene (Class: SERM)
Uterine fibroids
What? Benign smooth muscle tumours within the walls of the myometrium. Classified as: Intramural, submucosal and subserosal
Risk factors:
- Tamoxifen/aromatase inhibitor
- Early menarche
- Nulliparous
- HRT
- Older age
- Obesity
- FH
- African american
Presentation: Asymptomatic mainly - HMB -Pressure symptoms +/- abdominal distension - Infertility -Abdominal mass -Compression problems e.g. bladder and bowel symptoms O/E: Non-tender, enlarged uterus.
DDx
- Endometrial polyp
- Ovarian tumours
- Leiomyosarcoma (myometrium malignancy)
- Adenomyosis
Investigation
1st line: US (TVS and transabdominal)
Check bloods for Fe deficient anaemia
Management:
Asymptomatic: Nothing. Annual monitoring
Symptomatic:
If <3cm….1st line: LNG IUS. 2nd line: NSAID or tranexamic acid
If >3cm….. Specialist referral. NSAID or tranexamic acid in interum. Options: UAU, surgery, hormonal meds
Indications for specialist referral
- > 3cm
- Fertility problems
- Compression symptoms
- Palpable abdominally
- Uterine length >12 cm
- Suspicion of malignancy
Contraception
1st line: IUS.
2nd line if uterus cavity distorted
HRT:
If already symptomatic, seek specialist advice
If asymptomatic, advice that HRT could increase size of fibroid.
Lichen Sclerosus
What?
Chronic inflammatory disorder of the women’s anogenital region
Who?
>13yrs + post-menopausal women
Risk factors:
FH
Autoimmune disease: T1DM, Thyroid disease, allopecia accreta
Presentation: Itching Superficial dyspareunia Fissuring+ erosions --> Pain Dysuria O/E= White atrophic patches. If severe, adhesions and scarring
DDx
- VIN
- Vulval cancer
- Vitiligo
- Candidiasis
Investigations:
1st line: Clinical diagnosis. Manage if confident
2nd line: Biopsy if indicated.
Mangement:
(If confident in clinical diagnosis) 1st line: Tropical steroids (Clobetasol Propionate) as induction regime for 3x4weeks. Start OD then tapers. Review in 3 months for improvement. If improved continue PRN steroids and moisurisers. If no improvement? Check compliance and reassess in 3-6 months. Consider biopsy
(If not clinical confident in Dx) 1st line 1% hydrocortisone and refer to dermatology/gynaecology
When to refer: To gynaecology / dermatology if: - Excessive steroid use - Psychosexual issues - Surgery consideration
URGENT referral to gynae oncology if:
SCC suspicion on 2 week-wait pathway
Bartholins Cyst
Define RF's Px O/E Ix Mx
Bartholins gland: Normal glands that lie under the labia majora of the vaginal to secrete mucus. If ducts get blocked becomes a cyst. If infected (MRSA, E.coli, STI) then forms an abscess
Risk factors for cyst development
- Younger age
- Nulliparous
- STI / sexually active
- History of Bartholins cyst
- History of vulval surgery
Presentation: - Cysts ○ Asymptomatic (if small) ○ Vulvar pain (If spontaneous rupture, relief of pain) ○ Superficial dyspareunia - Abscess ○ Acute onset of pain ○ Dysuria Examination - Unilateral labial bulge ○ Cyst = Soft, fluctuant and non-tender ○ Abscess = Tense + hard with surrounding cellulitis
Investigations:
Diagnosis clinical
Women >40: Biopsy for vulval cancer
Suggestion of STI? Infection screen
Management: Cyst
Small and asymptomatic=Conservative. Advice warm baths for spontaneous rupture
Large and symptomatic= 1st line Word Catheter or marsipuliation. 2nd line Silver nitrate cautery, CO2 laser and needle aspiration
Mangement: Abscess
1st line = Surgery
2nd line = ORAL co-amoxiclav 5-7 days
