Describe the physical, psychological, and behavioural changes observed in PMD (prev. PMS).
- physical: headache, mastalgia, weight gain, fluid retention, joint/skin pain
- psychological: irritability, emotional lability, low mood, tension
- behavioural: sleep disturbance, change in appetite, restlessness, poor conc., confusion, social withdrawal
What is the difference between PMD and PMDD?
- postmenopausal dysphoric disorder: occurs with accompanying mood swings, anxiety, and/or depression
- SSRIs can benefit
Describe the management options for PMD.
- 1st line: despiramine-containing COC (Yasmin, Eloine)
- 2nd line: GnRH agonists [can cause vasomotor symptoms, such as hot flushes, & osteoporosis]
- additional: vitamin B6, oil of evening primrose, oestrogen patches/implants
- SSRIs / psychotherapy for PMDD
Define heavy menstrual bleeding (HMB).
Blood loss that interferes with physical, social, emotional or material aspect of a woman’s life.
- accounts for 20% of gynae appts.
- most common cause of iron deficiency anaemia
What are the key causes of HMB?
- organic: fibroids, polyps, adenomyosis, age
- gynae: curettage (biopsy), surgical TOP, hormones (oestrogen/tamoxifen)
- haematological: bleeding disorders (coagulopathy)
- other: medication, malignancy
Describe the management options for HMB.
- 1st line: Mirena coil (LNG-IUS)
- 2nd line: tranexamic acid (anti-fibrinolytic) / COC
- 3rd line: DMPA
- 4th line: surgery
Name and describe the main types of miscarriage.
Miscarriage: pregnancy that ends spontaneously before the foetus reaches a viable age (<24wks)
- threatened: cervical os closed, foetus inferior uterus
- inevitable: cervical os opened, foetus at os
- incomplete: cervical os opened, products of conception in both uterus and cervix
- complete: cervical os closed, foetus in cervix
- anembryonic: empty gestational sac, no pole
Name the causes, investigation and management of miscarriage.
- causes: chromosomal abnormality, APLS, infection (CMV, rubella, toxoplasmosis, listeria), after CVS, smoking/alcohol etc.
- ABCDE, urgent evacuation if heavy bleed / haematological instability: misoprostol +/- mifeprisone to allow MVA/EPRC
- FBC, G&S, HCG, USS
- progesterone pessaries useful in unexplained cases
What is the most common cause of recurrent miscarriage, and how can it be reduced?
APLS: low dose aspirin + heparin allows live birth rate >75%
What are the symptoms of ectopic pregnancy?
- pain > bleeding
- dizziness, eclampsia, shoulder tip pain, dyspnoea
- pallor, haemodynamic instability, peritonism
- red flag: abdominal/pelvic pain requiring opiates
What is pregnancy of unknown location (PUL), and how is it managed?
- a halfway diagnosis of ectopic pregnancy (i.e., not found on any scans)
- M6 model: measurement of progesterone guides follow-up management
- theoretically reveal IU/ectopic pregnancy
- can be managed with methotrexate
Describe the management of ectopic pregnancy.
- acutely unwell: laparoscopic salpingectomy (98% of ectopic pregnancies are in Fallopian tubes)
- stable: manage with methotrexate
- GEM II: adds gefitinib to MTX; may reduce surgery
Describe the pathological and radiological appearances of molar pregnancy.
- pathological: grape-like clusters
- radiological: ‘snowstorm’ like appearance on USS
Name the two types of molar pregnancy, and how they arise.
- complete: sperm fertilises egg w/out female DNA; sperm duplicates within egg, leaving only paternal DNA -> 46
- partial: 2 sperm (or 1 that duplicates) fertilises an egg with 1 set of female DNA -> 69
Define hyperemesis gravidarum, and its main symptoms.
Excessive, protracted vomiting that alters QoL Diagnosis of exclusion (e.g., UTI, pancreatitis, hepatitis)
- dehydration, ketosis, electrolyte/nutritional disturbances
- in some: weight loss, altered liver function
- severe: malnutrition, emotional instability, anxiety
Describe the management options for hyperemesis gravidarum.
- rehydration, electrolyte replacement, antiemetic, nutritional support, thiamine & thromboprophylaxis
- 1st line: cyclizine, prochlorperazine
- 2nd line: metaclopromide (risk oculomotor crisis, which is treated with atropine)
- oral prednisolone can be considered
Name the differential for unilateral pelvic pain in the female.
- ectopic pregnancy
- appendicitis
- ovarian torsion, cyst accident, fibroid degeneration
- renal calculi
Name the differential for diffuse pelvic pain in the female.
- miscarriage
- PID, UTI, diverticulitis
- endometriosis
- constipation, IBS, urinary retention
What is the likely diagnosis for a female who experiences sudden unilateral pelvic pain after sexual intercourse or contact sport?
Cyst rupture/accident
What are the main causes of abnormal uterine bleeding (AUB, aka DUB)?
- uterine: anovulatory cycles, pregnancy, miscarriage, endometritis, polyp, leiomyoma, adenomyosis
- endocrine: PCOS, thyroid disorders, hyper PRL, hormone changes
- bleeding disorders
- hyperplasia, neoplasia
Describe the process by which one would take a uterine biopsy.
- TVUS prior to biopsy; >4mm postmenopausal or >16mm premenopausal indication for biopsy
- pipette: outpatient procedure, does not need anaesthesia or dilatation
- dilatation & curettage: most accurate method
Describe the histological findings of endometritis.
- mucous plug (cystic dilatation), w/ glandular nests
- periglandular fibrosis (chronic)
- presence of plasma cells
Describe the histological findings of molar pregnancy.
Hydropic villi (enlarged, dilated, oedematous, avascular)
- cavitation/cisterns present
- increase in synctio- and cytotrophoblast layers
Define adenomyosis and leiomyoma.
- adenomyosis: presence of endometrial tissue in the myometrium
- leiomyoma: benign, smooth muscle tumour
Define infertility and its initial investigation (e.g., at the GP).
Inability to conceive after 12m of regular unprotected intercourse. Female investigations:
- midluteal (e.g. day 21 in a 28 day cycle) progesterone
- follicular phase LH, FSH, E2; testosterone and SHBG (giving FAI); PRL
- TSH, TFTs
- Rubella, Chlamydia screen
Male investigations:
- sperm analysis. normal parameters 16million/ml, 30% progressive motility, 4% normal visible morphology
Define the following terms.
- azoospermia
- oligozoospermia
- asthenozoospermia
- teratozoospermia
- azoospermia: no sperm in ejaculate
- oligozoospermia: reduced conc. in ejaculate (e.g., under 16 million/ml)
- asthenospermia: reduced progressive motility (e.g., under 30%)
- teratozoospermia: reduced normal morphology (e.g., under 4%)
Name some infertility tests in secondary care.
- USS (anatomical/congenital abnormalities)
- hysterosalpingogram (HSG)
- laparascopic hydrotubation (HTB)
- hysteroscopy
Describe the Rotterdam criteria. Which condition are they used to diagnose?
PCOS. 2/3 is diagnostic
- oligo/amenorrhoea
- polycystic ovaries on scans (12+ follicles, volume >10ml)
- signs of hyperandrogenism (acne, hirsutism)
Describe the management options for PCOS.
- 1st line: clomifene citrate (30-40% conceive)
- 2nd line: tamoxifen (can be improved with weight loss and adjuvant metformin)
- 3rd line: [recombinant FSH] gonadotrophin injection (60-70% conceive)
- 4th line: laparascopic ovarian diathermy
Describe the management options for tubal infertility problems.
- generally no management options, requiring ART
- prior sterilisation may possibly be reversed; however, this is generally considered irreversible
- proximal blockage may be managed by cannulation with a guidewire/microcatheter
Describe the criteria for assisted reproductive technology, ART.
- female health: <40yr, BMI 18.5-30, non-smoker (3/12), no illegal or abusive substances (inc. methadone)
- relationship: stable >2yr, no biological children, neither sterilised, unexplained infertility >2yr
Describe the rough timeline for a woman undergoing ART.
- day 21: buserelin [GRH agonist, nasal spray] 4/day for 2/3 weeks
- baseline scan for downregulation
- FSH/HMG injection for 8-9 nights
- once ready, stop FSH/HMG, give one HCG injection late night to simulate LH surge
- 36hr after HCG injection -> harvest/fertilise eggs
How can the hormones oestrogen and progesterone be used to provide contraception?
- oestrogen: blocks FSH & follicle development
- progesterone: blocks LH surge, thickens mucous
- both: prevents implantation
Name the six categories of contraception.
- hormonal [pills, rod, DMPA/depo]
- barrier methods [condoms, cervical cap]
- intrauterine [copper coil, hormone coil]
- permanent [sterilisation]
- fertility awareness [calendar etc.]
- emergency [copper coil, oral]
What is the most successful method of contraception?
The rod (Nexplanon)
What are the non-contraceptive uses of the Mirena coil?
HMB, HRT, endometriosis, hyperplasia
How are the contraceptive pills initiated?
Start within 5 days of first period, or when sure not pregnant + 7 days of condom use
Taken daily for 21 days, then break for 7 days
What are the minor side effects of the COC?
- weight gain, nausea
- flushing, pigmentation
- mastaglia
What are the major side effects of the COC?
- VTE (smokers, >35yr, HTN, obesity)
- HTN (BP checked annually)
- ischaemic stroke (contraindicated in migraine with aura)
- risk of breast/cervical cancer [1.26 relative risk]
What are the three options for emergency contraception?
- copper coil
- ulipristal acetate
- levonogestrol
What are the risks associated with unplanned pregnancy?
- inc: preterm birth, postpartum depression/ substance misuse, neglect/child abuse
- dec: antenatal care, birthweight, breastfeeding/bonding, developmental outcomes
Describe the legislation surrounding abortion.
- Human Fertilisation & Embryology Act 1990 contains exemptions to Offences Against the Person Act 1861
- standard form: HSA1 via clause C (98%) or clause E (2% - mental or physical anomalies)
- emergency form: HSA2
- all abortions must be reported to CMO via HSA4
Describe the clinical pathway for those wishing an abortion.
- referral by self, GP, or RSH. aim for <5d between referral and initial consultation
- gestation is estimated by LMP +/- UPT
- USS is used for risk assessment, including ectopics, unsure about dates, or prior to STOP
MTOP (medical termination of pregnancy) is based on gestational dates. What are these and how does management differ?
- note: above timeframe extends to 21+6 during COVID
STOP (surgical termination of pregnancy) is based on gestational dates. What are these and how does management differ?
- cervical priming undertaken via miso or osmotic dilators to reduce risk of cervical injury
- <10wk: manual vacuum aspiration (LA)
- <14wk: electrical vacuum aspiration (GA)
- > 14wk: dilatation and evacuation
Abortion is generally very safe procedure; what are the rare complications that may arise?
- most common: haemorrhage (STOP > MTOP)
- infection (covered by doxycycline in COVID times)
- STOP-only: uterine perforation, cervical trauma
- may be a Rhesus sensitising event: ensure anti-D given
Describe the timeline associated with menopause and its different syndromes. Describe also their investigations.
- <40yr (1%): premature ovarian insufficiency (POI). autoimmune tests, FSH, E2, TFTs, glucose, FAI
- 40-45yr (57%): early menopause. FSH x2/wk
- 45-55yr (average 51). FSH x2/6wk if atypical
Name some of the symptoms associated with the menopause.
- hot flushes
- breast atrophy
- loss of libido
- aches and pains
- sleep disturbance
- irritability, depression
- loss of concentration
- weight gain
- vaginal dryness, dyspareunia
Name some of the non-hormonal management options for menopause.
- healthy diet (including phytooestrogens)
- healthy weight, exercise, smoking cessation
- good sleep hygiene, reduced alcohol/caffeine, stress
- cooler ambient temperature, ventilation, suitable clothing, neck cooling fans ec.
- ? herbal remedies, including St John Wort
- ? complementary therapies
Describe the benefits, risks, and contraindications for hormone replacement therapy (HRT).
- benefits: symptomatic, protects against osteoporosis, increases mental/sexual health
- risks: increased breast and endometrial cancer, VTE, stroke, and withdrawal bleed
- contraindications: history of breast cancer, coronary heart disease, TIA/stroke, unexplained vaginal bleeding, acute liver disease
Describe the oestrogenic and progestogenic side effects of HRT.
- oestrogen: bloating, breast enlargement, mastalgia, fluid retention, headache, leg cramp, mood swings, N&V
- progesterone: acne, anxiety, bloating, depression, headache, hirsutism, abdominal/ pelvic/ back pain, mood swings
Regarding a pelvic mass, the pelvis can be split into 4 main compartments. What are these, and what are the main pathologies that can affect each?
- anterior (bladder): bladder tumour, distension
- middle (uterus): fibroids, adenomyosis, carcinoma, sarcoma
- posterior (bowel): bowel tumours, appendiceal mass, hernia, diverticular abscess
- lateral (adnexae): ovarian, tubal mass, hydrosalpinx, ectopic pregnancy
Name the five main categories of ovarian malignancy.
- epithelial: serous, mucinous, endometrioid, clear cell, Brenner, undifferentiated
- germ cell: mature cystic teratoma (‘dermoid cyst’), immature teratoma (embryonal), dysgerminoma, yolk sac, choriocarcinoma
- stromal: fibroma, thecoma, granulosa, Sertoli, Sertoli-Leydig, steroid
- metastatic
- miscellaneous
Name the main pathologies affecting the Fallopian tubes.
- salpingitis, cysts, tumours, endometriosis, ectopic pregnancy
- ectopic pregnancy: implantation of conceptus outside endometrial cavity
- rupture may cause fatal haemorrhage
- consider the diagnosis in any female of reproductive age with amenorrhoea, pelvic pain, or acute abdomen
Name the tumour markers that are associated with ovarian cancers.
- CA-125 (produced by mesothelium, increased in mucinous cancers)
- CEA (most useful with CA-125/CEA ratio, suspicious when <25)
- AFP, HCG, LDH
Describe the risk of malignancy index (RMI) score used for ovarian cancer risk.
- premenopausal, postmenopausal [1, 3]
- USS findings (multiloculated, solid areas, bilateral, ascites, metastases) [none 0, 1 = 1, >1 = 3]
- serum CA-125 [absolute level]
- RMI = above 3 parameters multiplied
Describe ovarian cysts.
- follicular, luteal, endometriotic, epithelial, mesothelial
- follicular cysts are very common, occurring when menstruation doesn’t
- rarely >5cm, formed of thin-walled granulosa cells
- may cause menstrual disturbance, may bleed/rupture, may cause acute abdomen, may be incidental
Describe the pathology, clinical features, and complications of endometriosis
- glands/stroma present outside the uterine body
- may occur with regurgitation of endometrial tissue through the tubes, or with metaplasia of vascular dissemination
- ovarian chocolate cysts - dysmenorrhoea, deep dyspareunia, subfertility, retrouterine tenderness
- look out for peritoneal spots/nodules, fibrous adhesions etc.
- complications: pain, adhesions, infertility, ectopics, malignancy
Describe the pathology and clinical features of dermoid cysts.
- formed from pluripotent stem cells (germ cells), material can include teeth, sebaceous tissue, thyroid tissue etc.
- may be asymptomatic, pelvic pain, dyspareunia etc.
Describe the more unusual presentations of ovarian cancer, including those who we should test.
- persistent abdominal distention (bloating)
- early satiety
- pelvic/abdominal pain
- urinary frequency/urgency
- in women >50 with ‘IBS’
Describe the management options for ovarian cancer.
- staging laparotomy first used, where abdomen and pelvis are assessed for deposits and allow staging
- early: open hysterectomy, BSO, infracolic omentectomy
- late: radical debulking with aggressive cytoreduction
- neoadjuvant chemo
What is a Kruckenberg tumour?
Has a characteristic signet ring histology which metastasise from the GI tract (usually the stomach).
Describe the classification of endometrial hyperplasia.
- simple: general distribution, dilated glands, normal cytology
- complex: foetal, crowded glands, normal cytology
- atypical: atypical cytology, cancer precursor
Describe the classification of uterine adenocarcinoma.
- type 1: endometrioid, mucinous - unopposed oestrogen, atypical hyperplasia, PTEN, KRAS, PK3CA
- type 2: serous, clear cell - elderly postmenopausal women, more aggressive
How does obesity increase the risk of uterine adenocarcinoma?
- endocrine and inflammatory changes to adipocytes, which express aromatase
- dec. SHBG (inc. free biologically active hormone)
- altered insulin (IGF can then exert effects of the endometrium)
Describe the management options for uterine malignancy, including the complications.
- surgical removal of uterus and cervix, traditionally by open approach
- other options: BSO and/or PLND
- complications: haemorrhage, infection, bladder/bowel problems, DVT/PE, hernias etc.
Name and describe the main histological areas of the cervix.
- endocervix (inner): mainly glandular
- ectocervix (outer): squamous epithelium
- transitional zone (squamocolumnar junction): between ecto- and endo-, most likely to be infected by HPV
Describe the categories of pathology affecting the cervix.
- inflammation (cervicitis, follicular, chlamydia, HSV)
- CIN (HPV 16/18, many sexual partners, young at first intercourse etc.)
- condylomata acuminatum (HPV 6/11; thickened papillomatous squamous epithelium with cytoplasmic vacuolisation ‘koilocytosis’)
- cervical cancers (SCC 75-95%, adenocarcinoma 5-25%)
Describe the histological findings and classification of cervical intraepithelial neoplasia (CIN).
- delayed maturation and differentiation (immature basal cells)
- nucleolar hyperchromasia, increased N:C ratio, pleomorphism)
- excess mitotic activity
- CIN I, II, III (basal 1/3, extends to middle 1/3, then full thickness)
Cervical SCC is commonly asymptomatic and is highly preventable by screening. What are the possible presentations?
- AUB (PCB/PMB)
- brownish/blood staining
- contact bleeding due to friable epithelium
- pelvic pain
- haematuria, UTI
- ureteric obstruction, renal failure etc.
Describe the different types of vulvar pathology.
- VIN: usual-type (HPV-driven), dVIN (differentiated, independent of HPV)
- vulvar invasive SCC
- vulvar Paget’s (crusting rash with sharp demarcation, pruritis, and pain). may be primary (intraepithelial glandular) or secondary (colorectal, urothelial)
- candida
- Bartholin gland abscess
- dermatoses (lichen sclerosis, planus, psoriasis)
- vulvovaginal atrophy
Describe the surgical management of cervical cancer.
- stage 1a, 2: LLTEZ, coneloscopy (fertility desired); hysterectomy (family completed)
- stage Ib: trachelectomy (fertility), radical hysterectomy (family completed)
- > stage Ib: chemotherapy
Describe the surgical management of vulvar cancer.
- wide local incision of vulval lesions with 1cm free margin
- if depth >1mm, surgery should involve groin node removal (unilateral / bilateral depending on site)
Regarding public health and cervical pathology:
- who is eligible for screening?
- who is now vaccinated against HPV?
- why are both vaccination and screening required?
- all women or those with a cervix aged 25-64
- girls and boys of school age (12-13); two doses separated by 6 months
- the vaccination (HPV16/18) only offers protection against 70% of cancers, as 30% are not caused by these subtypes
Describe the screening pathway associated with cervical screening.
speculum exam, brush sample of transformation zone, testing for HPV 16/18
- negative: repeat 5y
- positive: perform cytology test
- positive: colposcopy
- negative: repeat screen 12m
Describe the risk factors for prolapse.
female sex, childbirth, forceps delivery, obesity
- stressors (smokers cough, COPD, heavy lifting, constipation)
- Marfan’s, Ehlers-Danlos
Describe the symptoms and classification of uterine prolapse.
- heaviness/pressure, bulging, tissue protrusion, urinary incontinence / retention, splinting, vaginal wall, trouble with bowel movements, dyspareunia
- 1st degree: within the vagina
- 2nd: at the introitus
- 3rd: outside the vagina
- 4th / proincidenta: entirely outside without the vagina
Describe the management options for gynaecological prolapse [3+3].
- lifestyle: weight loss, smoking cessation, avoiding heavy lifting, caffeine reduction etc.
- physiotherapy, pessaries etc.
- surgeries:
- cystocele: anterior colporrhaphy
- rectocele: posterior colporrhaphy
- uterine: sacrospinous fixation, mesh treatment etc.
Regarding ultrasound:
- describe the benefits and difficulties
- describe the two O&G approaches and their differences
[4]
- benefits: cheap and safe (no ionising radiation), very good definition of different pelvic organs and can be used as an adjunct to clinical examination
- difficulties: obesity, gaseous distension, operator dependant
- TA (transabdominal): requires full bladder, good initial view
- TV (transvaginal): requires empty bladder, higher frequency and spatial resolution, can be used to evaluate ovarian volume
Describe the key indications for CT [4], MRI [3], and HSG [1] in O&G disease.
- CT: acute abdomen (after USS), post-surgical complications, staging malignancy, assessing response to cancer treatment
- MRI: cervical cancer staging, evaluation of adnexal masses, subfertility (in conjunction with pituitary MRI)
- HSG (hysterosalpingogram): infertility by tubal patency
