Gynaecology Flashcards
(96 cards)
1
Q
Average blood loss in a menstrual cycle
A
37-43ml
2
Q
Normal menstrual cycle
A
Days 1-4: menses
Days 5-13:
- Follicular phase ovarian cycle: follicles develop, one follicle becomes dominant
- Proliferative phase uterine cycle: endometrial proliferation
Day 14: ovulation
Days 15-28:
- Luteal phase ovarian cycle: formation of corpus luteum
- Secretory phase uterine cycle: endometrial changes to secretory lining under the influence of progesterone
3
Q
Hormones involved in the menstrual cycle and at which points
A
Days 5-13: rise in FSH -> development of follicles -> secretion of oestrogen
Day 14: when there is sufficient oestrogen, this causes a surge of LH to be released -> ovulation
Days 15-28: progesterone secreted by corpus luteum. if fertilisation does not occur then the corpus luteum will degenerate and progesterone levels fall. Oestrogen levels rise during this period.
4
Q
Differential diagnoses for IMB and PCB
A
Cervical bleeding: ectropion, polyps, malignancy, cervicitis
Intra-uterine: polyps, submucous fibroids, endometrial hyperplasia, endometrial malignancy, endometriosis
Hormonal: breakthrough bleeding
5
Q
Investigations for PCB and IMB
A
High vaginal swab and endocervical swabs (STIs) Cervical smear (CIN, cancer) Pelvic USS (polyps, fibroids) Hysteroscopy and endometrial biopsy Laparoscopy
6
Q
How much blood defines menorrhagia?
Signs/symptoms
Causes of menorrhagia
A
> 80ml/cycle
60-70% get anaemia
May have menstrual pain, lethargy, breathlessness, affects QoL
Causes:
- Systemic: thyroid disease, clotting disorders
- Iatrogenic: IUD, IUS, POP, implant, depo, anticoag
- Local pathology: dysfunctional uterine bleeding, fibroids, endometrial polyps, endometrial carcinoma, endometriosis, PID
7
Q
Dysfunctional uterine bleeding
- what is it
- diagnosis
- management
A
Most common cause of menorrhagia
Diagnosis of exclusion
Managed with OCPs or prostaglandin inhibitors (mefenamic acid)
8
Q
Investigations for menorrhagia
A
Subjective assessment/ pictorial blood loss chart to assess degree of menorrhagia
- Blood tests: FBC, TFT, clotting studies
- Pelvic USS
- Endometrial biopsy
- Cervical smears
- Diagnostic hysteroscopy
- Diagnostic laparaoscopy
9
Q
Management of menorrhagia
A
Correct iron deficiency anaemia
Treat systemic disease or focal pathology
First line if needing contraception: mirena IUS
Second line: COCP
Third line: long acting progesterone (eg. depo, implant)
First line if not needing contraception: tranexamic acid (or mefenamic acid, esp if dysmenorrhoea)
Surgical management:
- Hysteroscopy
- Open myomectomy
- Endometrial ablation
- Hysterectomy
10
Q
Tranexamic acid
- MoA
- Risk
- At which part of the menstrual cycle are these taken?
A
Antifibrinolytic. Prevents activation of plasminogen into plasmin -> reduces excessive fibrinolysis
Risk of thrombosis
Start taking at the beginning of menses for 4 days
11
Q
Mefenamic acid
- MoA
- At which part of the menstrual cycle are these taken?
A
NSAID.
Prostaglandin inhibitor.
Inhibits COX enzymes -> prevents conversion of arachidonic acid into prostaglandins (prostaglandins are vasodilators and they inhibit platelet aggregation)
Taken during menses
12
Q
Presentation of endometriosis
A
Growth of ectopic endometrial tissue outside of the uterine cavity
Chronic pelvic pain
Dysmenorrhoea (often starts before menses)
Deep dyspareunia
Subfertility
Urinary symptoms
Dyschezia (painful bowel movements)
13
Q
Differential diagnoses for endometriosis
A
PID Pelvic pain syndrome Submucous fibroids Ovarian accident Adhesions
14
Q
Examination, investigations and management for endometriosis
A
Examination:
Retroverted fixed uterus, tender vaginal fornices, uterine tenderness
Ix:
- Pelvic USS first as less invasive
- Diagnostic laparoscopy is gold standard (active endometriosis shows powder-burn spots and chocolate cysts)
Mx:
- First line analgesia: paracetamol and/or NSAIDs (mefenamic acid, naproxen, ibuprofen)
- COCP helps symptoms by stopping period
- POP, depot, implant, IUS
Secondary care:
- GnRH analogues can induce pseudo-menopause
- Surgical: laparoscopic diathermy, laser ablation, excision of deposits, total abdominal hysterectomy with bilateral salpingo-oophorectomy
15
Q
Uterine fibroids presentation
A
Asymptomatic Menorrhagia (due to increased surface area of endometrium, and production of prostaglandins) Abdominopelvic mass Abdominopelvic pain Subfertility Urinary frequency, urgency, nocturia Rectal pressure and abdo bloating
16
Q
Risk factors for uterine fibroids
Protective factors
A
African-caribbean
Later reproductive years
Nulligravidity
Obesity
Protective factors: smoking, COCP, full term pregnancy, post-menopause
17
Q
Investigations for uterine fibroids
A
Bimanual examination: fibroids are often palpated, the uterus may feel enlarged firm and irregular
Bloods: FBC, U+E, clotting screen
Pelvic USS is diagnostic to visualise the fibroids
18
Q
Management of uterine fibroids
A
Leave alone unless symptomatic, rapidly enlarging or concerned about subfertility
Medical:
Fibroids <3cm: IUS, tranexamic acid, mefenamic acid, COCP
Secondary care:
- GnRH analogues (zoladex) used as surgery adjuncts to reduce fibroid size by reducing oestrogen
- Mifepristone (antiprogesterone) shrinks fibroids over a 6m period
Surgery:
- Myomectomy (hysteroscopic approach for submucosal or pedunculated fibroids, abdominal approach for intramural or subserosal fibroids)
- Uterine artery embolisation (stops blood flow to fibroids)
- Myolysis (diathermy, laser ablation, high intensity focused US)
- Hysterectomy
19
Q
Primary vs secondary amenorrhoea
A
Primary: failure to commence menses (absence of menarche)
- 16+ in presence of secondary sexual characteristics
- 14+ in absence of secondary sexual characteristics
Secondary: cessation of periods for more than 6 months after menarche
20
Q
Causes of amenorrhoea
- hypothalamic
- pituitary
- ovarian
- adrenal glands
- genital tract
A
Hypothalamic causes (reduced GnRH):
- eating disorders, exercise
- severe chronic conditions (thyroid, sarcoid, psychiatric)
- Kallmann syndrome (x-linked recessive characterised by failure of migration of GnRH cells)
Pituitary causes:
- Prolactinoma (prolactin suppresses GnRH)
- Acromegaly/ cushings syndrome
- Sheehan’s syndrome (post-partum pituitary necrosis secondary to massive obstetric haemorrhage)
- Radiation or autoimmune disease destroying pituitary gland
- Post-contraception amenorrhoea
Ovarian causes:
- PCOS
- Turners (45XO)
- Premature ovarian failure
Adrenal gland causes:
-Late onset/mild congenital adrenal hyperplasia
Genital tract causes:
- Ashermann’s syndrome
- Imperforate hymen or transverse vaginal septum
21
Q
Androgen insensitivity syndrome
- what is it
- features
- diagnosis
- management
A
X-linked recessive
End-organ resistance to testosterone causing genotypically male children (46XY) with female phenotype
Features:
- primary amenorrhoea
- undescended testes causing groin swellings
- breast development may occur as a result of conversion of tesosterone to oestradiol
Diagnosis:
Buccal smear or chromosomal analysis to reveal 46XY genotype
Management:
Counselling (raise child as female)
Bilateral orchidectomy
Oestrogen therapy
22
Q
Causes of oligomenorrhoea
A
PCOS Contraception/hormonal treatment Perimenopause Thyroid disease DM Eating disorders Excessive exercise Medications (eg. antipsychotics) Antiepileptics
23
Q
Investigations for oligomenorrhoea and amenorrhoea
A
- Pregnancy test
- Gonadotrophins (LH and FSH) - reduced levels indicate hypothalamic cause, and increased levels indicate ovarian cause
- Prolactin
- Androgen levels (raised in PCOS)
- Oestradiol (converted from testosterone)
- Thyroid function tests
- 17 hydroxyprogesterone (CAH)
- Karyotype
- Pelvic USS
- Progesterone challenge test to elicit a withdrawal bleed
24
Q
PCOS presentation and differentials
A
Presentation:
Subfertility /infertility
Oligo-/Amenorrhoea
Hirsutism and acne (due to hyperandrogenism)
Obesity
Acanthosis nigricans due to insulin resistance
Differentials: Hypothyroidism Cushings syndrome Hyperprolactinaemia Congenital adrenal hyperplasia
25
PCOS investigations and management
Ix:
- Bloods: FSH, LH, prolactin, TSH, testosterone
- Pelvic USS (multiple cysts on ovaries)
Raised LH/FSH ratio
Raised free androgen index (ratio of testosterone/sex-hormone binding globulin)
Prolactin normal or raised
Management if normal weight and desiring fertility:
1. Clomifene (+/- metformin, +/- dexamethasone)
2. Gonadotrophins
Management if overweight and desiring fertility:
1. Weight loss +/- metformin
Management if not desiring fertility:
1. COCP +/- metformin
2. Anti-androgen (spironolactone, finasteride)
Weight loss
26
Premature overian failure
- what is it
- causes
- symptoms
Onset of menopause and increased gonadotrophins before the age of 40
Causes: idiopathic, chemo, autoimmune, radiation
Symptoms: perimenopause symptoms, infertility, secondary amenorrhoea, raised FSH and LH
27
Diagnosis of menopause
>45 with symptoms = clinical diagnosis
40-45 = FSH and LH blood tests, or clinical diagnosis
<40 = FSH and LH tests
Menopause = no period + FSH levels >40 on at least 2 occasions (4-6wks apart)
28
Symptoms of perimenopause
Change in period cycle length, dysfunctional uterine bleeding
Hot flushes, night sweats
Vaginal dryness, atrophy, urinary frequency
Anxiety, depression, short-term memory impairment
Osteoporosis, increased risk of IHD
29
Combined HRT
- Who to give it to
- Who to give cyclical combined HRT to
- Risks
Give combined HRT to women with a uterus (=oestrogen + progesterone)
Give cyclical combined HRT to perimenopausal women who have menopausal symptoms
```
Risks:
VTE (risk if given orally)
IHD (no risk if started <60y)
Breast cancer (risk reduces when stopped)
Ovarian cancer
```
30
Unopposed oestrogen HRT
- who to give it to
- risks
Give to women with no uterus
If given to women with a uterus it could cause endometrial proliferation and cancer (they need combined which includes progesterone to prevent overproliferation and cancer)
```
Risks:
VTE (risk if given orally)
Stroke (if oral)
Endometrial cancer (if they have a uterus)
Ovarian cancer
```
31
Contraindications to HRT
Benefits of HRT
CI: current/past breast cancer, oestrogen-sensitive cancer, undiagnosed vaginal bleeding, untreated endometrial hyperplasia
Benefits: prevents osteoporosis, reduces urinary symptoms, reduces risk of UTIs, most effective treatment for menopause
32
Non-hormonal management of menopause
Lifestyle (exercise, good sleep hygiene, weight loss, stress reduction, relaxation)
Vasomotor symptoms: fluoxetine, citalopram, venlafaxine
Vaginal dryness: lubricants
Psychological: self-help groups, CBT, antidepressants
Urogenital symptoms: vaginal oestrogen for atrophic vaginitis, lubricants, moisturisers
33
Causes of post-menopausal bleeding
- ovary
- uterus
- cervix
- vagina
- urethra
- vulva
Ovary: ovarian carcinoma, oestrogen-secreting tumour
Uterine body: submucous fibroid, atrophic changes, polyp, hyperplasia
Cervix: atrophy, squamous cell carcinoma, adenocarcinoma
Vagina: atrophy
Urethra; Urethral caruncle, haematuria
Vulva: vulvitis, dystrophies, malignancy
34
Investigations for PMB
```
Pelvic USS (endometrial thickness should be <5mm)
Hysteroscopy
Endometrial biopsy
```
35
Atrophic vaginitis features and management
Post-menopausal
Vaginal dryness, dyspareunia, occasional spotting
O/E: vagina is pale and dry
Mx: vaginal lubricants and moisturisers, or topical oestrogen cream
36
Risk factors for urinary incontinence
```
Advancing age
Previous pregnancy and child birth
High BMI
Hysterectomy/ previous pelvic surgery
Family history
Smoking -> chronic cough -> worsens incontinence
Neurological history
```
37
Different types of pelvic organ prolapses
Cystocele= bladder bulges into the anterior vaginal wall
Rectocele= rectum bulges into the posterior vaginal wall
Uterine prolapse- uterus hangs down into vagina, and may protrude outside of the body if severe
Enterocele= pouch of douglas bulges into posterior vaginal wall
38
Risk factor for prolapse
```
Increasing age
Multiparity
Obesity
Spina bifida
Constipation
Persistent chronic cough
Prolonged heavy lifting
Hysterectomy/ pelvic surgery
```
39
Management of prolapse
Conservative: weight loss, pelvic floor exercises, stop smoking, avoid constipation, avoid heavy lifting, avoid high-impact exercise
Vaginal oestrogen
Pessary: more beneficial for anterior and uterine prolapse
Surgery:
- Pelvic floor repair
- Sacrocolpopexy or supraspinous fixation
- Vaginal hysterectomy
- Colpocleisis (close the vagina)
40
Causes of chronic pelvic pain
Adenomyosis, endometriosis, adhesions (gynae operations, PID, appendicitis), gynae malignancy, GI pathology (diverticulosis, IBD)
41
Causes of acute pelvic pain
```
Ectopic pregnancy
Miscarriage
Ovarian torsion
PID
Ovarian cysts
UTI
Appendicitis
```
42
Presentation and investigations for ovarian cysts
Presentation: asymptomatic, or chronic pain, acute pain, PV bleed, bloating, change in bowel habit, change in urinary frequency, weight loss, IBS
Ix: transvaginal pelvic USS
43
Non-neoplastic ovarian cysts
Functional:
- Follicular cysts: most common, <3cm. Developing follicle.
- Corpus luteal cysts: <5mm. Luteal phase.
Pathological:
- Endometrioma (chocolate cyst)
- Polycystic ovaries (ring of pearls on US)
- Theca lutein cyst (raised hCG, eg. molar pregnancy)
44
Benign neoplastic cysts
Epithelial tumours:
- Serous cystadenoma: most common. 30% bilateral
- Mucinous cystadenoma: unilateral
- Brenner tumour: unilateral. grey/yellow
Benign germ cell tumours:
-Dermoid cyst: hair, skin, teeth, bone
Sex cord stromal tumours:
-Fibroma: most common
45
Management of ovarian cysts
Premenopause:
- Measure LDH, AFP, hCG
- Simple cyst <5cm -> rescan in 8-12wks. If persistent -> monitor with USS and CA-125 3-6monthly
- If >5cm -> laparoscopic cystectomy or oophorectomy
Postmenopause:
- Low malignant risk: monitor with USS and CA-125 for 1 yr
- Moderate risk: bilateral oophorectomy, if malignancy is found then stage it
- High risk: staging and laparotomy
46
Pelvic inflammatory disease risk factors and causes
```
History of STIs
Young age of onset of first sexual activity
Unprotected sex
Multiple sexual partners
IUD
History of PID
```
Causes: chlamydia trachomatis (most common), Neisseria gonorrhoea, Mycoplasma genitalium, Mycoplasma hominia
47
Presentation of PID
```
Lower abdo pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities
Vaginal or cervical discharge
Cervical excitation
```
Chandelier sign: patient reaches out to the ceiling during vaginal examination due to pain
Perihepatitis: Fitz-Hugh-Curtis syndrome. RUQ pain, often confused with cholecystitis
48
Investigations for PID
```
Pregnancy test
High vaginal swab
Endocervical swabs
Blood tests (FBC, CRP, ESR, blood cultures)
MSU
Transvaginal USS
```
49
Complications of PID
Low threshold for empirical treatment due to the risk of infertility and long-term morbidity
Complications if untreated: pelvic abscess, sepsis, infertility, ectopic, chronic pelvic pain, dyspareunia, menstrual disturbance, psychological effects
50
Management of PID
6months contact tracing and management
Empirical IM ceftriaxone 500mg stat + oral doxycycline 100mg BD + oral metronidazole 400mg BD for 14 days
Pain relief with paracetamol and ibuprofen
Consider removing IUS or IUD
Avoid sexual intercourse until treatment is complete
51
Ovarian torsion
- risk factors
- presentation
- investigations
- management
Risk factors: ovarian cysts, ovarian enlargement, pregnancy, fertility treatment, prior tubal ligation
Presentation: sudden onset deep seated colicky lower abdo pain, unilateral, vomiting, distress, fever
Vaginal examination may reveal adnexal tenderness
Exclude pregnancy
Investigations: pelvic USS may show free fluid, laparoscopy is diagnostic and therapeutic
Mx: pain relief, laparoscopy (untwist ovary)
52
Ectopic pregnancy risk factors
```
Damage to tubes (salpingitis, PID, previous surgery)
Previous ectopic
Endometriosis
IUD
POP
IVF
```
53
Ectopic pregnancy presentation and differential diagnoses
Presentation:
- Constant unilateral lower abdo pain (tubal spasm)
- Vaginal bleeding
- History of recent amenorrhoea (6-8wks)
- Shoulder tip pain and pain on defaecation/urination if peritoneal bleeding
DDx:
Ovarian cyst, ovarian torsion, PID, appendicitis, bowel obstruction, IBS, UTI, cervical ectropion/cervicitis, miscarriage, molar pregnancy
54
Examination, investigations and management of ectopic pregnancy
O/E: abdo tenderness, cervical excitation. Do not palpate for adnexal mass due to risk of rupture
Ix:
Pregnancy test positive
Pelvic USS is diagnostic
MRI is secondline
Repeat transvaginal scans and serial hCG levels to monitor
Management:
- Size <30mm, no pain, not ruptured, no heartbeat, bhCG <200 and reducing: monitor for 48 hours
- Size <35mm, not ruptured, no significant pain, no heartbeat, bhCG<1500: methotrexate injection (surgery if bhCG 1500-5000)
- Size >35mm, ruptured, severe pain, heartbeat, bhCG>1500: salpingectomy or salpingotomy
55
Causes of sporadic miscarriage
```
Foetal abnormality
Infection (ToRCH, TB, malaria, salmonella, listeria)
BV
Materan age
Abnormal uterine cavity
Maternal illness
Interventions
```
56
Causes of recurrent miscarriages
```
Antiphospholipid syndrome
Endocrine (poorly controlled DM, thyroid disorders, PCOS)
Uterine abnormalities
Cervical weakness
Parental chromocomal abnormalities
Smoking
```
57
Types of miscarriages and their presenting features
Threatened miscarriage: closed cervical os, painless PV bleeding <24wks gestation (typically 6-9wks), complication of pregnancy not an actual miscarriage
Missed miscarriage: closed cervical os, gestational sac contains dead foetus <20wks gestation without symptoms of expulsion, there may be light PV bleeding, usually painless, normal pregnancy symptoms may disappear
Inevitable miscarriage: open cervical os, heavy PV bleeding, clots, pain
Incomplete miscarriage: open cervical os, pain and PV bleeding, not all products of conception have been expelled
58
Investigations for miscarriage
Serial pelvic ultrasounds
Serum b-hCG measurements
Laparoscopy if ectopic likely
59
Management of miscarriage
Uterus usually expels the products on its own (may take weeks)
Expectant Mx: first line. Wait 7-14 days for miscarriage to complete spontaneously. Take pregnancy test at 3 weeks, return if positive.
Medical Mx: done if expectant hasnt worked or not appropriate.
Vaginal or oral misoprostol (synthetic prostglandin analogue) stimulates uterine expulsion
Take pregnancy test 3 weeks later and return if positive
Surgical Mx: done if products still remain despite medical management or if patient still has symptoms 14 days after expectant, or patient unstable.
Manual vacuum aspiration under LA, or surgical intervention under GA.
Rh-ve women need anti-D.
Syntocinon may be given to encourage uterine contraction and reduce blood loss
Send products of conception for histology.
60
Investigations for recurrent miscarriages
Karyotype both partners and the products of conception
Pelvic USS
High vaginal swab
Antiphospholipid antibodies assay on two occasions at least 6 weeks apart
61
Molar pregnancy
- what are they
- risk factors
- presentation
- Ix
- Mx
Hydatidiform moles are chromosomally abnormal pregnancies that have the potential to become malignant
Risk factors: extremes of maternal age, previous gestational trophoblastic disease
Presentation: usually presents in first trimester, PV bleeding, unusually large uterus for gestational age, hyperemesis gravidarum
Ix:
Serum bhCG >100,000
USS shows snow storm appearance in uterine cavity
Histological examination of products of conception
Mx:
Dilation and evacuation
Hysterectomy if no intention on becoming pregnant again
62
Adenomyosis
- what is it
- at risk group
- investigations
- management
Growth of endometrial tissue in the myometrium
Multiparous women towards the menopause
TVUS or MRI
```
Tranexamic acid or mefenamic acid
COCP, POP or IUS
GnRH analogues
Uterine artery embolisation
Hysterectomy
```
63
Criteria for PCOS
Rotterdam criteria: at least 2 of the 3 for diagnosis
1. Oligomenorrhoea/ anovulation
2. Clinical/ biochemical hyperandrogenism
3. Multiple cysts on USS (>= 12 follicles on 1 ovary)
64
What is infertility and what is primary vs secondary infertility
Infertility = failure to conceive after regular unprotected sexual intercourse for at least 1 year
Primary: never been able to conceive.
Secondary: has conceived before but now unable to
65
Causes of female infertility
Ovulatory dysfunction: chronic systemic illness, eating disorders, PCOS, hyperprolactinaemia, hypo/hyperthyroidism, cannabis, NSAIDs, congenital adrenal hyperplasia
Tubal damage: PID, previous tubal surgery, previous ectopic, endometriosis
Uterine dysfunction: fibroids, uterine septae, congenital anomaly, ashermann's syndrome (Adhesions following curettage or TOP)
Coital dysfunction: vaginismus, dyspareunia
66
Causes of male infertility
Semen: lack of semen, sperm that arent moving properly, abnormal sperm
Testicles: infection, testicular cancer, testicular surgery, congenital defect, undescended testes, trauma
Sterilisation
Ejaculation disorders
Hypogonadism
Drugs; Sulfasalazine, anabolic steroids, chemo, marijuana, cocaine
67
Investigations for female infertility
- Mid-luteal phase progesterone levels (7 days before the end of a cycle, eg. day 21 of a 28 day cycle)
- STI screen
- FSH and LH levels
- TFTs
- Prolactin levels
- Test for tubal patency: diagnostic laparoscopy and dye, or hysterosalpingography
- Consider: Pelvic USS, hysteroscopy, testosterone levels/ sex hormone binding globulin
68
Investigations for male infertility
```
Semen analysis
Chlamydia screen (/STI screen)
```
69
Semen analysis (what is normal?)
- sperm count
- motility
- vitality
- morphology
- volume
- fructose
- pH
```
Sperm count (conc): >15million/ml
Motility: 50%
Vitality (healthy living sperm): 60%
Morphology: >4% should have normal morphology
Vol: 1.5-5.0ml
Fructose: >13micromoles/sample
pH: 7.2-7.8
```
70
Management of infertility
Conservative: stress management, stop smoking, aim for BMI 19-25, occupational risks, reduce alcohol consumption, medication review
Medical treatment:
- Clomifene citrate (anti-oestrogen): raises FSH and LH levels
- Gonadotrophins: offerend to clomifene-resistant women
- Pulsatile GnRH and dopamine agonists can induce ovulation
Surgical treatment:
- Tubal microsurgery
- Surgical ablation or resection of endometriosis
Assisted conception:
- Intrauterine insemination (sperm is placed into the utuerus during ovulation)
- In-vitro fertilisation: fertilisation in a petri dish and then implant
- Intracytoplasmic sperm injection: inject sperms into the egg
- Donor insemination of sperm
- Oocyte donation
- Embry donation
71
Side effects of clomifene citrate
```
Multiple pregnancy
Reversible ovarian enlargement
Double vision
Headache
Hot flushes
Abnormal uterine bleeding
Breast tenderness
```
72
Cervical screening programme
Offered every 3 years for women aged 25-49, and every 5 years to women aged 50-64
Women >65 only need a smear if they have recently had abnormal tests
73
Cervical screening results interpretation
Inadequate: insufficient/ unsuitable sample. Repeat after 3 months. If 3 consecutive inadequate sample -> colposcopy within 6 weeks.
Negative (normal)
Borderline: abnormal nuclei but cant say for certain that it is dyskaryosis. Test HPV, if positive then colposcopy <6wks, if negative then return to normal screening programme
Mild dyskaryosis: usually cervical intraepithelial neoplasia grade 1 (CIN1) on biopsy. Test HPV, if positive colposcopy within 6 weeks, if negative return to normal screening programme.
Moderate dyskaryosis: CIN grade II. considered pre-cancerous with intermediate risk of developing into cancer. Colposcopy within 2 weeks.
Severe dyskaryosis: CIN grad III, high risk developing into cancer. Colposcopy within 2 weeks.
74
What happens during colposcopy?
Examines the cervix to look for any abnormalities suggesting precancerous/cancerous changes.
If acetic acid is applied to the cervix, abnormal areas (such as CIN) tend to turn white (sometimes referred to as acetowhite).
If an iodine solution is applied, normal tissue (on the outside of the cervix) stains dark brown. Pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix do not stain brown.
May take a biopsy to confirm the diagnosis.
Loop excision
Needle excision
Cone biopsy
75
Risk factors for cervical cancer
```
HPV 16 and 18
Early age of first intercourse
High number of sexual partners
Low socioeconomic group
Smoking
Partner with prostatic or penile cancer
Premenopausal age
```
76
Presentation and types of cervical cancer
90% are squamous cell carcinomas and 10% are adenocarcinomas
Presentation: may be asymptomatic.
PCB, discharge, IMB, ulcer/ mass
77
Investigations for cervical cancer
Borderline or mild dyskaryosis at smear: HPV test -> if positive then colposcopy clinic in 6 weeks, if negative then return to normal screening programme
Moderate or severe dyskaryosis: colposcopy within 2 weeks
Colposcopy investigations: staining with acetic acid or iodine, and a biopsy (loop, needle, cone biopsy)
Following diagnosis -> MRI/CT examination to check for mets and staging
Blood tests and CXR may also be done
78
Management and staging of cervical cancer
Staging:
0 - carcinoma in situ
1 - confined to cervix
2 - beyond the cervix
3 - spread to the pelvic side wall, or affecting ureter or lower third of vagina
4 - involves rectal or bladder mucosa, or beyond true pelvis
Management:
- If a large loop excision has been done and the lesion has been completely removed then no further Mx is necessary
- Surgery, chemo, radiotherapy are all options depending on patient circumstances
79
Endometrial cancer risk factors
| Endometrial cancer protective factors
```
Postmenopausal
Unopposed oestrogen (exogenous, obesity, PCOS, nulliparity, late menopause, tamoxifen)
```
Protective factors: COCP, combined HRT
80
Features and presentation of endometrial cancer
Most are adenocarcinomas
| Presentation: PMB, irregular bleeding, IMB, normal examination
81
Endometrial hyperplasia
Premalignant condition
Simple hyperplasia and complex hyperplasia - treated with progesterone to encourage regression
Atypical hyperplasia has a high chance of developing into cancer so hysterectomy is advised
82
Investigations for endometrial cancer
Gold standard: hysteroscopy and biopsy
Pelvic USS (measure endometrial thickness)
Endometrial sampling (pipelle biopsy)
MRI/CT for staging
Post menopausal women should have an endometrial thickness of <5mm due to their low oestrogen levels, endometrial cancer causes increased oestrogen which thickens the endometrium
83
Staging and prognosis of endometrial cancer
Stage 1: body of the uterus (85% 5yr)
Stage 2: extends to cervix (60% 5yr)
Stage 3: adnexae, or +ve peritoneal cytology (40% 5yr)
Stage 4: involves bladder or bowel mucosa (10% 5yr)
84
Management of endometrial cancer
Total abdominal hysterectomy and bilateral salpingo-oophorectomy = mainstay of treatment
Stage 3 requires surgical debulking before radiotherapy
Stage 4 requires a mixture of surgery, radiation and palliation
85
Risk factors for ovarian cancer
| Protective factors for ovarian cancer
```
Age (60-64 peak incidence)
FHx
BRCA 1/2
Lynch II syndrome
Nulliparity
Early menache and late menopause
Smoking
Obesity
```
Protective: pregnancy, breast feeding, exercise (due to less ovulation)
86
Features and presentation of ovarian cancer
Epithelial, germ cell, sex-cord stromal, secondary malignant
Presentation: often a silent killer. Abdo distension, bloating, abdo pain, abdo mass, urinary frequency, PMB, loss of appetite
87
Investigations for ovarian cancer
Pelvic USS
CA125 tumour marker
CT abdo pelvis (+/- chest)
Suspected patients under 40 should have AFP, b-hCG and CA125 levels
88
Staging and prognosis for ovarian cancer
Stage 1: localised to ovary/ovaries (80% 5yr)
Stage 2: peritoneal deposits in pelvis (60% 5yr)
Stage 3: peritoneal deposits outside of pelvis (25% 5yr)
Stage 4: distant mets (5-10% 5yr)
89
Management of ovarian cancer
Surgery: total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy (plus peritoneal washings)
Chemotherapy may be required post-op in stage 2 and 3
Surgery is usually for palliation in stage 4
90
Risk factors for vulval cancer
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Age >60
History of CIN, VIN or HPV
HIV/ SLE/ immunosuppression
Iatrogenic immunosuppression
Smoking
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91
Features and presentation of vulval cancer
Most are squamous cell
Presentation is often late.
Pruritis, bleeding, discharge, ulcer, mass, inguinal nodes
92
Staging for vulval cancer
1 - confined to vulva, <2cm diameter, no inguinal nodes
2 - confined to vulva, >2cm diameter, no inguinal nodes
3 - confined to vulva and suspicious nodes, or beyond vulva and no suspicious nodes
4 - obvious inguinal nodes, or involving rectum, bladder, urethra, or bone, or pelvic or distant mets
93
Investigations and management of vulval cancer
Biopsy, thorough examination, CT/MRI, staging
Management:
Wide local excision
Radical vulvectomy,
Bilateral groin lymphadenectomy +/- radiotherapy
94
Types of female genital mutilation
1: partial/total removal of clitoris and/or prepuce
2: partial/total removal of clitoris and labia minora +/- excision of labia majora
3: narrowing of vaginal orifice with creation of a covering seal (apositioning of labia)
4: all other harmful procedures for non-medical reasons
95
Cervical ectropion
- what is it
- presentation
- investigations
- management
High oestrogen causes the stratified squamous epithelium of the ectocervix to undergo metaplastic change into columnar epithelium with releases mucus
Presentation: asymptomatic, discharge, IMB, PCB
Ix: clinical diagnosis, pregnancy test, triple swabs, cervical smear
Mx: leave alone if asymptomatic, stop oestrogen medications, ablation (cryotherapy, or electrocautery)
96
Cervical polyps
- what are they
- presentaiton
- ix
- mx
Benign growths protruding form inner surface of cervix
Asymptomatic, abnormal vaginal bleeding (menorrhagia, IMB, PCB, PMB), vaginal discahrge
Histological exam after removal, triple swabs, cervical smear
Mx:
Small polyps -> grab and twist with forceps -> falls off
Large polyps -> remove with diathermy
Send polyps for histology
