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Gynaecology Flashcards

1
Q

What is androgen insensitivity syndrome

A

X-linked recessive
Cells are unable to respond to androgen hormones due to lack of androgen receptors
- Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics
- Genetically male (XY) but absent response to testosterone
- Female phenotype externally = normal female external genitalia and breast tissue
- Testes in abdomen or inguinal canal and absence of uterus, upper vagina, cervix, fallopian tubes and ovaries
- Testes produce anti-Mullerian hormone

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2
Q

Presentation of androgen insensitivity syndrome

A
  • Inguinal hernia in infancy containing testes
  • Primary amenorrhoea
  • Lack of pubic hair, facial hair and male type muscle development
  • Taller than female average
  • Infertility
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3
Q

Hormone tests for androgen insensitivity syndrome

A

o Raised LH
o Normal/raised FSH
o Normal/raised testosterone (for male)
o Raised oestrogen levels (for male)

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4
Q

Management of androgen insensitivity syndrome

A
  • MDT approach
  • Bilateral orchidectomy
  • Oestrogen therapy
  • Vaginal dilators/vaginal surgery
  • Counselling
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5
Q

Complications of androgen insensitivity syndrome

A

Testicular cancer

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6
Q

What is Ashermann’s syndrome

A
  • Adhesions form within uterus following damage to uterus
  • Endometrial curettage (scraping) can damage basal layer of endometrium
  • Adhesions form physical obstructions and distort pelvic organs
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7
Q

Risk factors for Ashermann’s syndrome

A
  • Pregnancy-related dilatation and curettage procedure
  • Uterine surgery
  • Several pelvic infections (endometritis)
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8
Q

Presentation of Ashermann’s syndrome

A
  • Secondary amenorrhoea
  • Significantly lighter periods
  • Dysmenorrhoea
  • Infertility
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9
Q

Investigations/management of Ashermann’s syndrome

A
  • Hysteroscopy (+ dissection)
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10
Q

Complications of Ashermann’s syndrome

A
  • Menstruation abnormalities
  • Infertility
  • Recurrent miscarriages
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11
Q

What is atrophic vaginitis

A
  • Epithelial lining of vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions.
  • As women enter the menopause, oestrogen levels fall, so mucosa becomes thinner, less elastic and more dry
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12
Q

Risk factors for atrophic vaginitis

A

Menopause = lack of oestrogen

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13
Q

Presentation of atrophic vaginitis

A
  • Itching
  • Dryness
  • Dyspareunia
  • Bleeding due to localised inflammation
  • Recurrent UTI
  • Stress incontinence
  • Pelvic organ prolapse
  • Pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Sparse pubic hair
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14
Q

Management of atrophic vaginitis

A
  • Vaginal lubricants
  • Topical oestrogen
    o Estriol cream
    o Estriol pessaries
    o Estradiol tablets (vagifem)
    o Estradiol ring (Estring)
  • Monitored annually
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15
Q

Risk factors for cervical cancer

A
  • Multiple sexual partners
  • Early first intercourse
  • High parity
  • Low SES
  • Smoking
  • COCP
  • HIV/ Immunosuppression
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16
Q

Causes of cervical cancer

A

HPV 16, 18, 33

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17
Q

Histology of cervical cancer

A
  • Squamous cell carcinoma (most common)
  • Adenocarcinoma
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18
Q

Presentation of cervical cancer

A
  • Asymptomatic
  • Abnormal vaginal discharge/bleeding = purulent, red/brown
  • Dyspareunia
  • Post-coital bleeding
  • Intermenstrual bleeding
  • Late Sx  Haematuria, PR bleeding, Urinary/bowel symptoms
  • Unusual appearance of cervix
  • Bulky masses on bimanual PB
  • Hepatosplenomegaly
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19
Q

Screening for cervical cancer

A
  • Cervical smear
    o 3 yearly from 25-50
    o 5 yearly from 50-64
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20
Q

Investigations for positive smear

A
  • Colposcopy and biopsy  Abnormal cells in cervix removed by large loop excision of transformation zone
    o Followed by cervical cancer screening test 6m later with HPV test
  • STI testing
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21
Q

Staging of cervical cancer

A
  • 1a = microscopic intraepithelial tumours
  • 1b = confined to cervix
  • 2 = spread into upper 2/3rd vagina or parametrium but not pelvic wall
  • 3 = spread throughout vagina or to pelvic sidewall
  • 4 = involvement of bladder, rectum or distant sites
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22
Q

Management of cervical cancer

A
  • CIN treatment
    o CIN1 = spontaneous regression within 2yrs
    o CIN2/3 = LLETZ
    o CGIN = LLETZ or cone biopsy
  • Hysterectomy and lymph node clearance (GS)
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23
Q

Risk factors for ovarian cancer

A
  • BRCA1/2 (FHx)
  • Early menarche, late menopause
  • Oestrogen HRT
  • Nulliparity
  • Smoking
  • Obesity
  • Clomifene
  • Hysterectomy
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24
Q

Protective factors for ovarian cancer

A

OCP, pregnancy, lactation

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25
Q

Presentation for ovarian cancer

A
  • Often late presentation as asymptomatic
  • Bloating
  • Eating difficulty (loss of appetite/early satiety)
  • Abdominal/pelvic pain/distention
  • Toilet changes  urinary/bowel Sx
  • Bleeding/discharge
  • Weight loss
  • Diarrhoea
  • Ascites +/- pleural effusion
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26
Q

Investigations for ovarian cancer

A
  • 2WW for any woman with ascites +/- pelvic mass that is not fibroids
  • Pregnancy test
  • CA125 >35IU/ml
  • Pelvic and abdominal USS
  • Biopsy
  • RMI score >250 = urgent referral to secondary care
  • Diagnostic laparoscopy
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27
Q

Other causes of raised Ca125

A
  • Adenomyosis
  • Ascites
  • Endometriosis
  • Menstruation
  • Breast cancer
  • Ovarian torsion
  • Endometrial cancer
  • Liver disease
  • Metastatic lung cancer
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28
Q

Management of ovarian cancer

A
  • Early stage = excision of all tumour during surgery, with adjuvant chemo
  • Late stage = debulking with amount of residual disease corresponding with prognosis
  • Chemo, radio
  • Hormonal/targeted therapy
  • Fertility preservation
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29
Q

Risk factors for endometrial cancer

A
  • Early menarche
  • Late menopause
  • Unopposed oestrogen (oestrogen only HRT)
  • Nulliparity
  • Endometrial hyperplasia
  • Obesity
  • DM
  • Tamoxifen
  • PCOS
  • HNPCC
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30
Q

Protective factors for endometrial cancer

A
  • Combined oral contraceptive pill
  • Pregnancy
  • Lactation
  • Smoking
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31
Q

Histology of endometrial cancer

A

Adenocarcinoma

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32
Q

Presentation of endometrial cancer

A
  • Postmenopausal bleeding
  • If premenopausal = change intermenstrual bleeding
  • Abnormal bleeding or discharge
  • Pelvic pain/pressure
  • Haematuria
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33
Q

Investigations for endometrial cancer

A
  • Women >55 referred to suspected cancer pathway
  • TV USS = endometrial thickness >4mm
  • Hysteroscopy with Endometrial biopsy
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34
Q

Staging of endometrial cancer

A
  1. confined to endometrium and myometrium
  2. invades cervical stroma but not extend outside uterus
  3. local or regional spread beyond uterus
  4. involvement of bladder, bowel or distant metastasis
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35
Q

Management of endometrial cancer

A
  • Total abdominal hysterectomy with bilateral salping-oophorectomy
    o +/- pelvic LN removal
  • Chemo, radio
  • Fertility preservation
  • Progesterone therapy
    o in frail elderly women not considered suitable for surgery
    o If they still have a uterus must be given progesterone
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36
Q

Risk factors for vaginal cancer

A
  • Age
  • HPV
  • Early age of 1st intercourse
  • HIV
  • Typically spreads from cervix or endometrial
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37
Q

Presentation of vaginal cancer

A
  • Abnormal bleeding/discharge
  • Change in toilet habits
  • Mass/lump
  • Itching
  • Soreness
  • Dysuria
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38
Q

Risk factors for vulval cancer

A
  • Age
  • HPV
  • Smoking
  • Skin disease = Lichen sclerosus
  • Immunosuppression
  • Vulval intraepithelial neoplasia
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39
Q

Presentation of vulval cancer

A
  • Delayed presentation
  • Vulval lump or ulcer on labia majora
  • Bleeding due to ulceration
  • Itching/burning of vulva
  • Pain
  • Skin changes
  • Inguinal lymphadenopathy
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40
Q

Staging of vulval cancer

A
  1. confined to vulva/perineum
  2. tumour extending to adjacent perineal structures
  3. inguino-femoral lymph node metastasis
  4. tumour invading other regional structures or with distant metastasis
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41
Q

Complications for vulval cancer

A
  • Psychological
  • Scarring and painful sex
  • Nerve damage
  • Groin and leg swelling
  • Bowel and bladder problems
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42
Q

2WW for vulval cancer

A

any woman presenting with unexplained vulval lumps, ulceration, bleeding

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43
Q

What is infertility

A
  • Failure to conceive after 1 year of trying
  • Primary = inability to conceive with no prior pregnancy
  • Secondary = inability to conceive but prior pregnancy occurred
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44
Q

Risk factors for infertility

A
  • Increasing age
  • Obesity
  • Smoking
  • Tight-fitting underwear
  • Excessive alcohol consumption
  • Anabolic steroid use
  • Illicit drug use
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45
Q

Female causes of infertility

A
  • Ovulatory (25%) = not ovulating or poor ovarian reserve
    o Hypogonadotropic hypogonadal anovulation = hypothalamic amenorrhoea, pituitary tumours, Sheehan’s syndrome, hyperprolactinaemia, Cushing’s syndrome
    o Normogonadotropic normoestrogenic anovulation = PCOS
    o Hypergonadotropic hypoestrogenic anovulation = premature ovarian failure, chromosomal abnormalities
  • Tubal (15%) = obstruction
    o Congenital anatomical abnormalities
    o Adhesions following PID
  • Uterine/peritoneal (10%) =
    o Fibroids/polyps
    o Bicornate uterus
    o Asherman’s syndrome
    o Endometriosis
  • Cervical abnormalities
    o Cervical damage after biopsy or LLETZ
  • Genetic causes = Turner’s syndrome
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46
Q

Male causes of infertility

A

o Cryptorchidism
o Varicocele
o Testicular cancer
o Congenital testicular defects
o Obstruction of ejaculatory system
o Disorders of ejaculation
o Kleinfelter’s syndrome

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47
Q

Referral criteria for infertility

A
  • Refer for testing after 1 yr of trying
  • Refer to treatment after 2 yrs of trying
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48
Q

Investigations for infertility

A
  • Ovulation/ovarian function
  • Semen quality
    o Count >15m/ml
    o Motility >32%
    o Morphology >4%
    o Total >39m
    o Repeat after 3 months if abnormal
  • Tubal patency (+uterus)
  • Ovarian reserve testing = need low FSH, high antral follicle count, high antimullerian hormone
  • Female hormone profile
    o Serum LH and FSH on day 2-5 = high FSH  poor ovarian reserve, high LH  PCOS
    o Serum progesterone on day 21 (7 days before end of cycle)
    o Anti-Mullerian hormone
    o TFTs
    o Prolactin = high  anovulation
  • BMI = low  anovulation, high  PCOS
  • Chlamydia screening
  • USS pelvis
  • Hysterosalpingogram
  • Laparoscopy and dye test
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49
Q

Early referral for infertility

A
  • Female age>35
  • Menstrual disorder
  • Previous abdominal/pelvic/urogenital surgery
  • Previous PID/STD
  • Abnormal pelvic/genital examination
  • Previous male genital pathology
  • Systemic illness
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50
Q

Preconception advice

A
  • Intercourse 2-3x week (don’t time with ovulation)
  • Folic acid daily – 0.4mg or 5mg (high risk)
  • Smear
  • Rubella
  • Smoking cessation and avoid alcohol
  • Pre-existing medical conditions
  • Drug history
  • Environmental/ occupational exposure
  • Reduce stress = affect libido and relationship
  • Weight (BMI 19-30)
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51
Q

Male infertility treatments

A

o Mild = intrauterine insemination
o Moderate = IVF
o Severe = intracytoplasmic sperm injection
o Azoospermia = surgical sperm recovery, donor insemination
o Surgery – correction of epidymal block, vasectomy reversal
o Hormonal – gonadotrophins

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52
Q

Male lifestyle advice

A

o Heat avoidance
o Underpants/boxers
o Smoking
o Alcohol
o Occupational exposure
o Diet/supplements = folic acid and zinc
o Weight

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53
Q

What is lichen sclerosis

A

Chronic autoimmune inflammatory skin condition often affecting labia, perineum and perianal skin

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54
Q

Risk factors for lichen sclerosis

A
  • T1DM
  • Alopecia
  • Hypothyroid
  • Vitiligo
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55
Q

Presentation of lichen sclerosis

A
  • Vulval itching
  • Soreness and pain possibly worse at night
  • Skin tightness
  • Painful sex (superficial dyspareunia)
  • Erosions
  • Fissures
  • Worse with tight underwear, urinary incontinence, scratching
  • Shiny “porcelain-white” patches of skin
  • Tight and thin skin
  • Slightly raised skin
  • Papules or plaques
  • Koebner phenomenon = sx worse by friction to skin
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56
Q

Management of lichen sclerosis

A
  • Follow up every 3-6 months
  • Potent topical steroids = clobetasol propionate 0.05% (dermovate)
  • Emollients regularly
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57
Q

Complications of lichen sclerosis

A
  • 5% risk of developing squamous cell carcinoma of vulva
  • Pain and discomfort
  • Sexual dysfunction
  • Bleeding
  • Narrowing of vaginal or urethral openings
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58
Q

What is premenstrual syndrome

A

Psychological, emotional and physical symptoms that occur during luteal phase of menstrual cycle

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59
Q

Presentation of premenstrual syndrome

A
  • Cyclical symptoms that occur just before and resolve after the onset of menstruation
  • Low mood
  • Anxiety
  • Mood swings
  • Irritability
  • Bloating
  • Fatigue
  • Headaches
  • Breast pain
  • Reduced confidence
  • Cognitive impairment
  • Clumsiness
  • Reduced libido
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60
Q

Management of premenstrual syndrome

A
  • Lifestyle  Diet, exercise, alcohol, smoking, stress, sleep
  • COCP  1st line containing drospirenone (Yasmin)
    o Continuous use as opposed to cyclical use
  • SSRI antidepressants ± CBT
  • Continuous transdermal oestrogen + Cyclical progestogens or Mirena coil a
  • GnRH analogues = induce menopausal state
    o Add HRT to reduce adverse effects (osteoporosis)
  • Hysterectomy and bilateral oophorectomy
    o Induce menopause
    o Use where severe symptoms and medical management failed
    o HRT required (mostly for women <45)
  • Danazole and tamoxifen
    o Options for cyclical breast pain
    o Initiated and monitored by breast specialist
  • Spironolactone = Reduce breast swelling, water retention, bloating
61
Q

What is menorrhagia

A
  • Excessive menstrual blood loss which affects a woman’s quality of life
  • Previously defined as >80ml blood loss
62
Q

Causes of menorrhagia

A
  • Structural
    o Polyp
    o Adenomyosis and endometriosis (PAINFUL)
    o Leiomyoma (Fibroid)
    o Malignancy and hyperplasia
  • Non-Structural
    o Coagulopathy (Von Willebrand’s, anticoagulant)
    o Ovulatory dysfunction (PCOS, hypothyroidism)
    o Endometrial
    o Iatrogenic (copper IUD)
    o Not yet classified (40-60%)
63
Q

Presentation of menorrhagia

A
  • Heavy menstrual bleeding
    o Changing pads every 1-2 hrs
    o Bleeding lasting >7days
    o Passing large clots
  • Affects QoL
  • Fatigue
  • Shortness of breath (anaemia)
  • Bruising (clotting)
  • Pallor
64
Q

History taking for menorrhagia

A
  • Age at menarche
  • Cycle length, days menstruating, variation
  • Intermenstrual bleeding and post coital bleeding
  • Contraceptive history
  • Sexual history
  • Possibility of pregnancy
  • Plans for future pregnancy
  • Cervical screening history
  • Migraines with or without aura
  • PMH and DHx
  • Smoking and alcohol history
  • FHx
65
Q

Investigations for menorrhagia

A
  • FBC, Ferritin, TFTs, Coagulation screen
  • Pelvic + transvaginal USS
    o Possible large fibroids
    o Possible adenomyosis
    o Obese
    o Hysteroscopy declined
  • Swabs (high vaginal and endocervical) = infection
  • Cervical smear if due
  • Pipelle endometrial biopsy
  • MRI (fibroid mapping)
  • Outpatient hysteroscopy
    o Intermenstrual or irregular bleeding (>40)
    o Infrequent heavy bleeding who are obese/PCOS
    o Tamoxifen
    o Unsuccessful medical Tx
66
Q

Management of menorrhagia

A
  • Aim to improve QoL rather than reduction in volume of menstrual loss
  • Not contraceptive symptom relief (1st line if want fertility)
    o Tranexamic acid 1g (reduce bleeding)
    o Mefenamic acid 500mg (reduce bleeding and pain)
  • Contraceptive symptom relief
    1. Mirena coil
    2. COCP
    3. Long-acting progestogens
  • Cyclical oral progestogens (norethisterone) = short-term option to stop heavy menstrual bleeding but not a contraceptive
  • Surgical options
    o Endometrial ablation (balloon thermal)
    o Hysterectomy
67
Q

Causes of dysmenorrhoea

A
  • Primary = excessive endometrial prostaglandin production
  • Secondary
    o Endometriosis
    o Adenomyosis
    o PID
    o Copper coil
    o Fibroids
68
Q

Management of dysmenorrhoea

A
  1. NSAIDs (mefenamic acid or ibuprofen)
  2. COCP
69
Q

Causes of primary amenorrhoea

A
  • Hypothalamic
    o Functional disorders = eating disorders, exercise
    o Severe chronic conditions = psychiatric, thyroid disease, sarcoidosis
    o Kallmann syndrome
  • Pituitary
    o Prolactinomas
    o Other pituitary tumours = Acromegaly, Cushing’s syndrome
    o Sheehan’s syndrome
    o Destruction of pituitary gland = radiation, autoimmune
    o Post-contraception amenorrhoea
  • Ovarian  PCOS, Turners syndrome
  • Adrenal gland  Late onset/mild congenital adrenal hyperplasia
  • Genital tract abnormalities
    o Ashermann’s syndrome
    o Imperforate hymen/transverse vaginal septum
    o Androgen insensitivity syndrome
70
Q

Investigations of primary amennorhoea

A
  • Do not perform internal examination
  • TFTs and prolactin
  • FSH, LH, oestradiol, progesterone, testosterone
  • 17 hydroxyprogesterone
  • Coeliac screen
  • Karyotyping (genetic abnormality)
  • Imaging  XR (constitutional delay), Pelvic US, MRI brain (pituitary)
  • Progesterone challenge  withdrawal bleed
    o Bleed = normal oestrogen levels but not ovulating (PCOS)
    o No bleed = low levels of oestrogen or outflow obstruction
71
Q

Management of primary amennorhoea

A
  • Lifestyle advice
    o Hypothalamic = Increase body fat to stimulate GnRH production
    o PCOS = balanced diet and regular exercise
  • Haematocolpos = incision and drainage of blood
72
Q

Referral to secondary care for primary amenorrhoea

A
  • Girls with no secondary sexual characteristics at 13 with primary amenorrhoea
  • Refer at 15y if secondary sexual characteristics present
  • Refer to gynaecologist earlier if concern regarding: growth retardation, genital tract problems, intracranial tumour, chromosomal problems, anorexia, puberty >5y with no menarche
  • Refer to endocrinologist if: signs of raised prolactin, thyroid disease or androgen excess
73
Q

What is secondary amenorrhoea

A

Cessation of periods for >6months after menarche

74
Q

Causes of secondary amenorrhoea

A
  • Physiological  Pregnancy, Lactation, Menopause
  • Hypothalamic hypogonadism = stress, excessive exercise
  • PCOS
  • Hyperprolactinaemia
  • Premature ovarian failure
  • Hyper/hypothyroidism
  • Sheehan’s and Asherman’s syndromes
75
Q

Investigations for secondary amenorrhoea

A
  • Urinary or serum beta-hCG = exclude pregnancy
  • Gonadotrophins (FSH/LH)
    o Low levels = indicate hypothalamic cause
    o Raised levels = ovarian problem
  • Androgen levels  Raised in PCOS
  • Prolactin
  • Oestradiol
  • TFTs
  • 17 hydroxyprogesterone
76
Q

Management of secondary amenorrhoea

A
  • Lifestyle advice = stress, exercise, diet
  • Treat underlying disorder (hyper/hypothyroidism)
  • Contraception (still become pregnant)
  • Regulate periods  COCP or progesterone-only pill, IUS
  • Hormone replacement
    o Cyclical hormone replacement therapy with oestrogen (and progesterone if have uterus)
    o Calcium and vit D supplements after bone density scan
  • Surgery  Remove pituitary tumours and genital tract abnormalities
77
Q

Symptom control in secondary amenorrhoea

A

o Excess hair = COCP (Yasmin), cyropterone acetate, spironolactone
o Acne = Abx, benzoyl peroxide, topical retinoids

78
Q

Fertility management in secondary amenorrhoea

A

o Clomifene = stimulate ovulation
o Metformin in PCOS
o IVF

79
Q

Referral to secondary care for secondary amennorhoea

A
  • Gynaecologist
    o Persistent high LH and FSH in women <40 (premature ovarian failure)
    o Suggestive of Asherman’s or cervical stenosis
    o Infertility
  • Endocrinologist
    o High prolactin (1 >1000 or 2 >500)
    o Low LH and FSH
    o Raised testosterone
    o Cushing’s/adrenal hyperplasia
80
Q

Causes of oligomenorrhoea

A
  • PCOS
  • Contraceptive/hormonal treatments
  • Perimenopause
  • Thyroid disease/diabetes
  • Eating disorders/excessive exercise
  • Medications = anti-psychotics, anti-epileptics
81
Q

Presentation of oligomenorrhoea

A
  • Interval between menstrual cycles of >35 days
  • or less than 9 periods per year
82
Q

Perimenopausal symptoms

A
  • Hot flushes
  • Emotional lability or low mood
  • Premenstrual syndrome
  • Irregular periods
  • Joint pains
  • Heavier/lighter periods
  • Vaginal dryness and atrophy
  • Reduced libido
83
Q

Management of menopause

A
  • Contraception need for 2 years after LMP <50 or 1 year if >50
  • HRT
    o Relieve perimenopausal symptoms
    o Decreased risk of osteoporosis and CVD
    o Oral, topical (patches and gels), IUS, vaginal ring
    o If uterus present, progesterone must be given as well as oestrogen
  • Tibolone = steroid hormone acts as continuous combined HRT
  • Clonidine = agonist of alpha-adrenergic and imidazoline receptors
  • CBT ± SSRI antidepressants (fluoxetine or citalopram)
  • Testosterone = reduced libido
  • Vaginal oestrogen = vaginal dryness
  • Vaginal moisturisers/lubricants
  • Bisphosphonates
84
Q

Complications of menopause

A
  • CVD and stroke
  • Osteoporosis
  • Pelvic organs prolapse
  • Urinary incontinence
85
Q

What is premature ovarian insufficiency

A

Onset of menopausal symptoms and elevated gonadotrophin levels before age of 40

86
Q

Causes of premature ovarian insufficiency

A
  • Idiopathic (most common)
  • Bilateral oophorectomy
  • Radiotherapy
  • Chemotherapy
  • Infection
  • Autoimmune disorders
  • Resistant ovary syndrome
87
Q

Presentation of premature ovarian insufficiency

A
  • Climacteric symptoms: hot flushes, night sweats
  • Infertility
  • Secondary amenorrhoea
88
Q

Investigations for premature ovarian insufficiency

A
  • Raised FSH, LH levels
    o FSH >40IU/l
    o Elevated FSH levels on 2 blood samples taken 4-6 wks apart
  • Low oestradiol = <100pmol/l
89
Q

Management of premature ovarian insufficiency

A
  • HRT or COCP until age of average menopause (51y)
    o HRT not provide contraception
90
Q

Presentation of ovarian cysts

A
  • Asymptomatic
  • Pelvic pain
  • Bloating
  • Fullness in abdomen
  • Palpable pelvic mass
91
Q

Red Flags for ovarian cysts

A
  • Abdominal bloating
  • Reduced appetite
  • Early satiety
  • Weight loss
  • Urinary symptoms
  • Pain
  • Ascites
  • Lymphadenopathy
92
Q

Investigations for ovarian cysts

A
  • TV/pelvic USS = no concern if <5cm
  • CA125 tumour marker (ovarian cancer)
  • Complex ovarian cysts  biopsy
  • Risk of malignancy index  Menopausal status, USS findings, CA125 level
93
Q

Management of ovarian cysts

A
  • Possible ovarian cancer = 2WW
  • Dermoid cysts = refer to gynae for Ix and surgery
  • Simple ovarian cysts in premenopausal women
    o <5cm = likely resolve in 3 cycles so no follow-up scan
    o 5-7cm = refer to gynae and yearly USS monitoring
    o >7cm = MRI scan or surgical evaluation
  • Cysts in postmenopausal women
    o Raised CA125 = 2WW
    o <5cm with normal CA125 = USS every 4-6 months
    o Moderate/high RMI = bilateral oophorectomy + staging
  • Persistent/enlarging cysts
    o Surgical intervention (laparoscopy)
    o Ovarian cystectomy
    o Oophorectomy
94
Q

Complications of ovarian cysts

A
  • Cysts in postmenopausal women = malignancy
  • Ovarian torsion
  • Haemorrhage into cyst
  • Rupture of cyst with bleeding into peritoneum
  • Infection
  • Pressure effects = DVT, urinary retention, intestinal obstruction
95
Q

What is Meig’s syndrome

A
  • Ovarian fibroma
  • Pleural effusion
  • Ascites
  • Older women
96
Q

Risk factors for ovarian torsion

A
  • Benign tumours
  • Pregnancy
  • Before menarche
97
Q

Presentation of ovarian torsion

A
  • Sudden onset severe unilateral pelvic pain
  • Pain is constant + gets progressively worse
  • N+V
  • Localised tenderness
  • Palpable mass in pelvis
98
Q

Investigations for ovarian torsion

A
  • TV USS  “whirlpool sign” = Free fluid in pelvis and oedema of ovary
  • Doppler = lack of blood flow
  • GS = laparoscopic surgery
99
Q

Management of ovarian torsion

A
  • Emergency laparoscopic surgery
    o Untwist (detorsion) and fix in place
    o Oophorectomy
  • Laparotomy if large ovarian mass/malignancy
100
Q

Complications of ovarian torsion

A
  • Ischaemia  necrosis
  • Loss of ovary
  • Infertility
  • Menopause
  • Infected necrotic ovary  abscess  sepsis
  • Rupture  peritonitis and adhesions
101
Q

Presentation of PCOS

A
  • Oligoovulation or anovulation
    o Oligomenorrhoea or amenorrhoea = irregular or absent menstrual periods
    o Menorrhagia ± clots
  • Hyperandrogenism
    o Hirsutism, acne, oily skin, alopecia, obesity
    o High LH, high testosterone, normal/low FSH
  • Polycystic ovaries on USS = >12 follicles in one/both ovaries or increased ovarian volume >10cm3
  • Prolactin normal
102
Q

Investigations for PCOS

A
  • FBC, TFT, HbA1c
  • Raised LH
  • Raised LH to FSH ratio
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
  • Abdo and TV US = 12+ developing follicles in one ovary/ ovarian volume >10cm3
  • Screening = OGTT
103
Q

Management of PCOS

A
  • Lifestyle/Reduce complications
    o Weight loss, exercise
    o Low glycaemic index, calorie-controlled diet
    o Smoking cessation
    o Antihypertensive medications, Statins
  • 2nd line = COCP or IUS (mirena)
  • Fertility
    o Clomifene +/- metformin
    o Ovarian drilling (if BMI normal)
    o IVF
  • Hirsutism = COCP, metformin, anti-androgens, eflomithine cream, hair removal
  • Acne = topical retinoids/Abx
104
Q

Complications of PCOS

A
  • Insulin resistance and diabetes
  • Acanthosis nigricans
  • CVD, Hypercholesterolaemia, HTN
  • Endometrial hyperplasia and cancer
  • Obstructive sleep apnoea
  • Depression and anxiety
  • Sexual problems = infertility, miscarriage, GDM
105
Q

Risk factors for PID

A
  • Sexually active, Hx of STIs
  • Recent partner change
  • Intercourse without barrier contraceptive protection
  • Personal Hx of PID
  • Gynae surgery
  • Termination of pregnancy
  • Insertion of IUD
106
Q

Causes of PID

A
  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Mycoplasma genitalium
  • Gardnerella vaginalis
107
Q

Presentation of PID

A
  • Lower abdominal pain
  • Deep dyspareunia
  • Menstrual abnormalities = menorrhagia, dysmenorrhoea or intermenstrual bleeding
  • Post-coital bleeding
  • Dysuria
  • Abnormal vaginal discharge (purulent, unpleasant odour)
  • Advanced = Fever, N+V
  • Cervical excitation tenderness
  • Palpable mass in lower abdomen
108
Q

Investigations for PID

A
  • Pregnancy test
  • Swabs = Endocervical and high vaginal
  • Urine dip +/- MSU
  • Transvaginal/pelvic USS
  • Full STI screen (HIV, syphilis etc)
  • Laparoscopy + biopsy (GS)
109
Q

Management of PID

A
  • 14 day Abx = IM ceftriaxone 1g single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily
  • Contact tracing of all sexual partners from last 6 months
  • Safe sex advice  Rest and avoid sexual intercourse
110
Q

Complications of PID

A
  • Ectopic pregnancy
  • Infertility (1 in 10)
  • Tubo-ovarian abscess
  • Chronic pelvic pain
  • Fitz-Hugh Curtis syndrome
111
Q

Causes of prolactinoma

A
  • Normal pregnancy and breastfeeding
  • Pituitary adenomas
  • Hypothalamus or pituitary stalk lesions
  • Empty sella syndrome
  • Hypothyroidism
  • Chronic renal failure
  • Drugs: phenothiazones, metoclopramide, methyldopa
112
Q

Presentation of prolactinoma

A
  • Amenorrhoea
  • Galactorrhoea
  • Headache
  • Visual field defects (bitemporal hemianopia)
  • Diabetes insipidus
  • Polydipsia and polyuria
113
Q

Investigations for prolactinoma

A
  • Serum prolactin levels (not that useful in pregnancy)
  • CT/MRI imaging of pituitary
114
Q

Management of prolactinoma

A
  • Bromocriptine
    o if concern of tumour expansion
    o continue through breastfeeding
  • Surgery for macroprolactinoma that fail to shrink despite drug therapy (usually delayed until after delivery)
115
Q

Risk factors for urinary incontinence

A
  • Increased age
  • Postmenopausal status
  • Increase BMI
  • Previous pregnancies and vaginal deliveries
  • Pelvic organ prolapse
  • Pelvic floor surgery
  • Neurological conditions (MS)
  • Cognitive impairment and dementia
  • Hysterectomy
  • FHx
116
Q

Types of urinary incontinence

A
  • Urge incontinence (overactive bladder)  Overactivity of detrusor muscle of bladder
  • Stress incontinence  Weakness of pelvic floor and sphincter muscles
  • Mixed incontinence (both urge and stress)
  • Overflow incontinence
    o Chronic urinary retention due to obstruction to outflow of urine
    o Causes = anticholinergic meds, fibroids, pelvic tumours, neurological conditions (MS, diabetic neuropathy, spinal cord injuries)
    o More common in men
  • Functional incontinence
    o Comorbid physical conditions impair patient’s ability to get to bathroom in time
    o Cause: dementia, sedating medication, injury
117
Q

Presentation of urge incontinence

A

o Suddenly feeling the urge to pass urine
o Having to rush to bathroom
o Not arriving before urination occurs
o Conscious about having access to toilet
o May avoid activities or places without easy access
o Significant impact on quality of life, stop work and leisure activities

118
Q

Presentation of stress incontinence

A

o Allows urine to leak at time of increased pressure on bladder
o E.g. when laughing, coughing or surprised

119
Q

Strength of pelvic muscles grading

A

Modified oxford grading system

120
Q

Investigations for urinary incontinence

A
  • Bladder diary
    o Track fluid intake
    o Episodes of urination and incontinence over at least 3 days
    o Mix of work and leisure days
  • Urine dipstick  Rule out infection, microscopic haematuria and other pathology
  • Post-void residual bladder volume  Measured using bladder scan to assess for incomplete emptying
  • Urodynamic testing
    o If 1st line medical treatment not working, difficulties urinating, urinary retention, previous surgery or unclear diagnosis
    o Cystometry
    o Uroflowmetry
    o Leak point pressure
    o Post-void residual bladder volume
    o Video urodynamic testing
121
Q

Management of urge incontinence

A

o Bladder retraining = 1st line
o Antimuscarinic = oxybutynin (avoid elderly women), tolterodine, darifenacin
o Anticholinergic medication
o Mirabegron
o Invasive procedures = botox, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion

122
Q

Management of stress incontinence

A

o Avoid caffeine, diuretics and overfilling of bladder
o Avoid excessive or restricted fluid intake
o Weight loss (if appropriate)
o Supervised pelvic floor exercises
o Surgery = tension-free vaginal tapes, autologous sling procedures, colposuspension, intramural urethral bulking
o Duloxetine (SNRI antidepressant) = 2nd line when surgery less preferred

123
Q

Risk factors for pelvic organ prolapse

A
  • Multiple vaginal deliveries
  • Instrumental, prolonged or traumatic delivery
  • Advanced age and postmenopausal status
  • Obesity
  • Chronic respiratory disease  coughing
  • Chronic constipation causing straining
  • Spina bifida
124
Q

Types of pelvic organ prolapse

A
  • Vault = had hysterectomy and top of vagina descends into vagina
  • Rectocele = defect in posterior vaginal wall, allowing rectum to prolapse forwards into vagina
  • Cystocele = defect on anterior vaginal wall, allowing bladder to prolapse backwards into vagina
125
Q

Presentation of pelvic organ prolapse

A
  • Feeling of ‘something coming down’ into vagina
  • Dragging or heavy sensation in pelvis
  • Urinary sx = incontinence, urgency, frequency, weak stream and retention
  • Bowl sx = constipation, incontinence, urgency
  • Sexual dysfunction = pain, altered sensation and reduced enjoyment
  • Worse on straining or bearing down
126
Q

Management of pelvic organ prolapse

A
  • If asymptomatic and mild prolapse = no treatment
  • Conservative management
    o Physiotherapy
    o Weight loss
    o Lifestyle changes = reduce caffeine
    o Treatment of related symptoms
    o Vaginal oestrogen cream
  • Vaginal pessaries + oestrogen cream
  • Surgery
    o Cystocele/cystourethrocele = anterior colporrhapy, colposuspension
    o Uterine: hysterectomy, sacrohysteropexy
    o Rectocele: posterior colporrhaphy
127
Q

What is adenomyosis

A

Endometrial tissue inside myometrium

128
Q

Risk factors for adenomyosis

A
  • Multiparous
  • Oestrogen
  • Trauma
  • Inflammation
  • Later reproductive years (40-50s) = Hormone-dependent so tends to resolve after menopause
129
Q

Presentation for adenomyosis

A
  • 1/3 asymptomatic
  • Dysmenorrhoea
  • Menorrhagia
  • Dyspareunia
  • Irregular bleeding
  • Enlarged tender uterus
  • Softer uterus than when contains fibroids
130
Q

Investigations for adenomyosis

A
  • Transvaginal USS = 1st line
  • Histological exam of uterus after hysterectomy = GS
  • MRI = thickening of endo-myometrial zone
131
Q

Management of adenomyosis

A
  • Non-contraceptive  Tranexamic acid, Mefenamic acid
  • Contraceptive
    1. Mirena coil
    2. COCP
    3. Cyclical oral progestogens
  • GnRH analogues
  • Endometrial ablation
  • Uterine artery embolization
  • Hysterectomy
132
Q

Complications for adenomyosis

A
  • Infertility
  • Miscarriage
  • Preterm birth
  • SGA
  • Preterm PROM
  • Malpresentation
  • Need for c-section
  • PPH
133
Q

What is endometriosis

A

Presence of endometrial tissue outside the endometrial cavity which induces chronic inflammatory reaction

134
Q

Risk factors for endometriosis

A
  • Early menarche
  • Late menopause
  • Delayed childbearing
  • Nulliparity
  • Vaginal outflow obstruction (imperforate hymen)
  • White ethnicity
  • Low BMI
  • Autoimmune disease
135
Q

Common sites of endometriosis

A

POD, uterosacral ligaments, ovaries, pelvis, bowel

136
Q

Presentation of endometriosis

A
  • Dysmenorrhoea = painful periods
  • Deep dyspareunia = pain during intercourse
  • Dyschezia = pain opening bowels
  • Dysuria
  • Other symptoms  Bloating, Lethargy, Low back pain, Rectal bleeding, Subfertility, Anxiety and depression
  • Endometrial tissue visible in vagina on speculum examination
  • Fixed cervix on bimanual examination
  • Tenderness in vagina, cervix and adnexa
  • Fixed retroverted uterus
  • Tender/nodular uterosacral ligaments
  • Palpable rectal nodules
  • Enlarged/tender ovaries
137
Q

Investigations for endometriosis

A
  • Pelvic USS = large endometriomas and chocolate ovarian cysts (ground-glass appearance)
  • Laparoscopic surgery + biopsy  Endometrioma, adhesions, peritoneal deposits
138
Q

Management of endometriosis

A
  • Analgesia = NSAIDs and paracetamol
  • Hormonal treatment
    o COCP or oral progesterone
    o GnRH agonists = Danazol
    o Depo-Provera (injection)
    o Nexplanon implant
    o Mirena coil (progesterone releasing)
  • Surgery  Ablation, Excision, Hysterectomy
139
Q

What are fibroids

A

Oestrogen sensitive benign tumours of smooth muscle of uterus

140
Q

Risk factors for fibroids

A
  • later productive years (>35)
  • More common in black women
  • Obesity
  • Early menarche
  • FHx
141
Q

Types of fibroids

A
  • Intramural = within myometrium
  • Subserosal = just below outer layer of uterus
  • Submucosal = just below lining of uterus
  • Pedunculated = on a stalk (mobile and prone to torsion)
  • Cervical
  • Parasitic = detached from uterus and attached to other structures
142
Q

Presentation of fibroids

A
  • Most = Asymptomatic
  • Heavy menstrual bleeding
  • Intermenstrual/post-coital bleeding
  • Prolonged menstruation (>7 days)
  • Abdo pain (worse on menstruation)
  • Bloating or feeling full in abdomen
  • Urinary/bowel symptoms (due to pelvic pressure or fullness)
  • Deep dyspareunia
  • Subfertility
  • Abdo = palpable pelvic mass
  • Bimanual exam = enlarged firm non-tender uterus
143
Q

Investigations for fibroids

A
  • Hysteroscopy = submucosal fibroids with HMB
  • Pelvic transvaginal USS = larger fibroids
  • MRI scanning = before surgical options
  • Pregnancy test
144
Q

Management of fibroids

A
  • No treatment necessary if mild symptoms
  • Lifestyle advice  Weight loss, Reduce red meat
  • GnRH analogues (triptorelin) = shrink fibroids before surgery
  • <3cm = IUS, COCP, NSAIDs, tranexamic acid
  • > 3cm = gynae referral
    o Sx control = tranexamic acid/mefenamic acid
    o Myomectomy
    o Hysterectomy (Women who completed family or >45)
  • Uterine artery embolization
145
Q

Referral criteria for fibroids

A
  • Compressive symptoms
  • Fertility/obstetric problems
  • Suspicion of malignancy
  • Palpable in abdominal exam or Us/hysteroscopy >12cm
146
Q

Complications of fibroids

A
  • HMB = iron deficiency anaemia
  • Reduced fertility
  • Pregnancy complications (miscarriage, premature labour, obstructive delivery
  • Constipation
  • Urinary outflow obstruction and UTIs
  • Red degeneration of fibroid
  • Torsion of fibroid
  • Malignant change
147
Q

Risk factors for endometrial polyps

A
  • Peri/post menopausal
  • Obesity
  • Tamoxifen
148
Q

Presentation of endometrial polyps

A
  • Intermenstrual bleeding
  • Menorrhagia
  • Post-coital bleeding
  • Subfertility
149
Q

Management of endometrial polyps

A
  • Watchful waiting if small
  • GnRH analogues before surgery
  • Resection during hysteroscopy
  • Send polyp for histological assessment

Finals (23 decks)

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