Gynaecology Flashcards
(242 cards)
1
Q
Late menopause is a risk factor for what three cancers
A
- Endometrial Cancer
- Ovarian Cancer
- Breast Cancer
2
Q
Endometrial cancer is classically found in post-menopausal women. True or false
A
True. around 25% cases occur before menopause though
3
Q
Risk factors for endometrial cancer
A
- Obesity
- Nulliparity
- Early menarche
- Late menopause
- Unopposed oestrogen
- Addition of progesteron to oestrogen (eg in HRT) reduces the risk
- Diabetes mellitus
- Tamoxifen
- Polycystic Ovarian Syndrome
- Hereditary non-polyposis colorectal carcinoma
4
Q
What are some protective factors for endometrial cancer
A
- Combined oral contraceptive pill
- Smoking
5
Q
Features of endometrial cancer
A
- Postmenopausal bleeding
- Premenopausal women may have a change in intermenstrual bleeding
- Pain and discharge are unusual features
6
Q
Investigations for endometrial cancer
A
- >= 55 yrs presenting with postmenopauusal bleeding needs to be referred using suspected cancer pathway
- First-line investigation: Trans-vaginal ultrasound
- Hysteroscopy with endometrial biopsy
7
Q
Normal endometrial thickness that has high negative predictive value
A
- < 4mm
8
Q
Management of endometrial cancer
A
Localised disease
- Total abdominal hysterectomy with bilateral salpingo-oophorectomy
- High risk patients have post-op radiotherapy
- Progesteron therpay considered in frail elderly women not suitable for surgery
Salpingo = fallopian tube
hysterectomy = uterus
9
Q
Nulliparity is a risk factor for which three cancers
A
- Ovarian cancer
- Endometrial cancer
- Breast cancer
10
Q
Epidemiology and prognosis of ovarian cancer
A
- 5th most common malignancy in women
- Peak age of incidence = 60
- Poor prognosis due to late diagnosis
11
Q
What is the most common origin for ovarian cancers and what sub-type makes up for 70-80% of this sub-type
A
- 90% epithelial cell in origin
- Of the 90%, 70-80% are serous carcinomas (low or high grade)
12
Q
Risk factors for ovarian cancer
A
- Family History
- Mutations
- BRCA1 and BRCA2
- Increased ovulations
- Early menarche
- Late menopause
- Nulliparity
13
Q
What factor reduces the risk of ovarian cancer
A
Combined oral contraceptive pill
Reduces number of ovulations (as does having many pregnancies)
14
Q
Clinical features of ovarian cancer
A
Notoriously vague
- Abdominal distension
- Abdominal bloating
- Abdominal and pelvic pain
- Urinary syptoms (urgency etc)
- Early satiety
- Diarrhoea
15
Q
Investigations for ovarian cancer
A
- CA125
- If ≥ 35 IU/mL -> urgent ultrasound of abdomen and pelvis
- CA125 should NOT be used to screen for ovariuan cancer in asymptomatic women
- Ultrasound
- Abdomen and pelvis
16
Q
What other conditions usually show a raised CA125
A
- Ovarian Cancer
- Endometriosis
- Menstruation
- Benign ovarian cysts
17
Q
Diagnosis of ovarian cancer
A
- Diagnostic laparotomy
18
Q
How is ovarian cancer staged
A
- Stage 1: Confined to ovaries
- Stage 2: Local spread within the pelvis
- Stage 3: spread beyond the pelvis to the abdomen
Haematological and lymphatic routes are common but these occur after spread to local pelvis.
- Lymphatic spread: para-aortic lymph node
- Haem spread: liver
19
Q
Management of ovarian cancer
A
Combination:
- Surgery
- Platinum-based chemotherapy
20
Q
Prognosis of ovarian cancer
A
- 80% have advanced disease at presentation
- All stage 5-year survival is 46%
21
Q
Mode of action of COCP
A
Inhibits ovulation
22
Q
Mode of action of progesterone-only pill (excluding desogesterel)
A
Thickens cervical mucus
23
Q
Mode of action of desogesterel-only pill
A
- Primary: Inhibit ovulation
- Also: Thickens cervical mucus
24
Q
Mode of action for injectable contraceptive (medroxyprogesterone acetate)
A
- Primary: Inhibits ovulation
- Also: thickens cervical mucus
25
Modea of action of implantable contraceptive (etonogestrel)
* Primary: Inhibits ovulation
* Also: Thickens cercival mucus
26
Mode of action of intrauterine contraceptive device
* Decrease sperm motility and survival
27
Mode of action of intrauterine system (levonorgestrel)
* Primary: Prevents endometrial proliferation
* Also: thickens cervical mucus
28
Name three emergency contraceptions
* Levonorgestrel
* Inhibits ovulation
* Ulipristal
* Inhibits ovulation
* Itranuterine contraceptive device
* Primary: toxic to sperm and ovum
* Also: inhibits implantation
29
What are the NICE guidelines on routine care for the **healthy** pregnant woman
* 10 antenatal visits in the first pregnancy if uncomplicated
* 7 antenatal visits in subsequent pregnancies if uncomplicated
* Women do not need to be seen by consultant if pregnancy is uncomplicated
30
Describe how a bleed would present in cervical cancer
* Heavy vaginal bleeding usually unrelated to menstruation
* Post-coital bleeding is more typical presentation
* Bleeding is caused by ulceration of tumour and increased vascularity of the cancer
* Heavy bleeding tends to suggest fairly advanced cancer
31
Describe the bleed typically seen with fibroids
* Heavy menstrual bleeding or irregular bleeding#Causes bleeding by pressing on the endometrial lining causing erosion of the lining
* Can also compromise blood suppluy to the endometrial lining by pressure effect leading to endometrial shedding
32
Describe the bleed seen in a ruptured tubal ectopic pregnancy
* Usually associated with severe pain
* Bleeds catastrophically
33
Bleeding per vaginally is a typical presentation for ovarian cancer. True or false
False
* Typical presentation = late presentation, abdominal swelling, pain , ascites
* Rarely, secrete oestrogen and unopposed oestrogen can stimulate heavy pv bleeding (similar to anovulatory cycle bleeds)
* Can also predispose endometrial cancer which is likely to cause bleeding
34
In a patient presenting with dysfunctional uterine bleedinge, what are four factors in her history could be related to her bleeding
* Family history of cancer
* Recent pregnancy or miscarriage
* Results of retained placental tissue
* Contraceptive use
* IUCDs cause excessive bleeding
* Oral contraceptives can cause bleeds if dosage and hormone combination does not suit patient
* Hot flushes
* and other menopausal symptoms
* Declining ovarian function can cause anovulatory cycles
* When ovulation fails, the corpus luteum does not form and progesterone is not produced.
* Endometrium continues to proliferate in the second half of the cycle as well as in the first half leading to a bulky endometrium
* this eventually sheds and results in heavy and prolonged bleeding often occuring at a longer interval than the normal cycle
* SMOKING NOT RELEVANT
35
What are three causes of a bulky uterus
* Endometrial carcinoma
* Fibroids
* Pregnancy
Andometritis is NOT a cause as it is inflammation of endometrium and does not cause bulking.
36
What are some investigations for a patient with heavy bleed and bulky uterus
* Full blood count
* Anaemia
* Pregnancy Test
* Pelvic Ultrasound
* Initial imaging modailty for bulky uterus
* MR if suspected endometrial malignancy
* Hysteroscopy
* Examine endometrial lining and sample for histology
* Anovulatory cycle, endometrial hyperplasia, endometrial cancer
* All as result of unopposed oestrogenic stimulation
37
Define a fibroid
* Benign leiomyoma (tumour of smooth muscle)
* May contain fibrous tissue as a result of fibrosis when it has been present for some time but it is not primarily a tumour of fibrous tissue
38
Describe the growth pattern of fibroids
* Most commonly occur 30-50 years
* Growth is dependent on ovarian hormones and therefore tend to grow during reproductive years
* They then tend to shrink after menopause
* Grow rapidly during pregnancy and can cause complications by undergoing infarction by out growing their blood supply or by causing opbstruction during delivery
* Commoner in black women than white women
39
Clinical features of uterine fibroids
* May be asymptomatic
* Menorrhagia
* Lower abdominal pain
* cramps during menstruation
* Bloating
* Urinary symptoms
* Frequency with larger fibroids
* Subfertility
40
Diagnosis of uterine fibroids
`Transvaginal ultrasound
41
Management of uterine fibroids
* Symptomatic management:
* CKS 1st line: Levonorgesterel-releasing intrauterine ystem
* Tranexamic acid or COCP
* GnRH agonist
* May reduce size of fibroid but are typically useful for short-term treatment
* Surgery
* Myomectomy
* Hysteroscopic endometrial ablation
* Hysterectomy
* Uterine aretery embolisation
42
What can be used pre-myectomy for uterine fibroid to reduce size of fibroids
GnRH agonist
Useful for short-term treatment
43
Two types of cervical cancer
* Squamous cell cancer (80%)
* Adenocarcinoma (20%)
44
What are some complications of fibroids in pregnancy
* Grow rapidly during pregnancy and can cause complications by undergoing infarction by out growing their blood supply
* Causes obstruction during delivery
45
How does endometriosis impair fertility
* Causes pelvic adhesions and distortion
* This interfers with tubal function and egg capture
46
What two investigations are useful in aiding the diagnosis of endometriosis
* Transvaginal ultrasound
* **Diagnostic laparoscopy**
* GOLD Strnadard for diagnosis even if USS normal
47
What is a characteristic finding of endometriosis in diagnostic laparoscopy
* Powder burn spots affecting pelvic peritoneum
* Brown deposits under the peritoneum
48
What is an appropriate management for a patient with endometriosis
* Ablation of visible lesions during diagnostic laparoscopy
* Make sure patient is consentedand counselled before
49
What are some possible options after surgery to manage pain and prolong benefits of surgery in endometriosis
* Combined oral contraceptive pill
* Progesterone only pill
* GnRH analogue injections
Not ideal if fertility is a priority for patient
50
Define ovulatory/primary endometrial dysfunction
* Diagnosis for heavy bleeding that occurs in the absence of systemic or locally defineable genital tract
* Used to be called **dysfunctional uterine bleeding**
51
In a patient with ovarian/primary endometrial dysfunction, what treatmentoptions can you offer
* Anti-fibrinolytics
* Tranexamic Acid
* Mefenamic acid
* Non-hormonal therefore less side effects
* MA can help relieve pain
* Oral iron
* Correct anaemia until menstrual loss improved and normal Hb
* COCP
* Reduce menstrual loss
* hormonal therefore may have side effects
* Antibiotics if infection present
* Mirena Intrauterine system
* Only if patient is sexually active
52
What investigation is usually enought o make a diagnosis of iumperforate hymen
* Trans-abdominal ultrasound scan
53
Management of imperforate hymen
* Incision of the membrane under anaesthesia
* Drain accumulated blood to relieve urinary retention and abdominal distension
* Aspiration will be followed by re-accumulation of menstrual blood
54
What are some side effects of oestrogen (COCP)
* Fluid retention
* Headache
* Nausea and vomiting
* Venous thrombosis
* Increased cervical secretion/cervical erosion
55
What are some side effects of progesterone (COCP)
* Breast fullness
* Decreased libido
* Dry vagina
* Reduced menstrual flow
* Disturbaance in menstrual cycle
* Acne
* Premenstrual depression
56
What are some conditions that are contra indicated in COCP
* Pregnancy
* Migraine with aura
* Decompensated liver disease
* Positive anti-phospholibid antibodies
57
Benefits of hormone replacement therapy
* Control of menopausal symptoms
* Protection from osteoporosis
58
What are two proven risks of HRT
* Increased incidence of venous thromboembolism
* Increased incidence of endometrial cancer
59
What are **absolute** contraindications to starting HRT
* Undiagnosed vaginal bleeding
* Pregnancy
* History of venous thrombosis
* Severe liver disease
* Personal history of breast cancer
60
What are some risk factors for urinary incontinence
* Advancing age
* Previous pregnancy and childbirth
* High BMI
* Hysterectomy
* Family History
61
Classification of urinaruy incontinence
* Overactive bladder (OAB)/Urge incontinence
* Due to **detrusor overactivity**
* Stress incontinence
* Leaking small amounts when coughing or laughing
* Mixed incontinence
* Both urge and stress incontinence
* Overflow incontinence
* Bladder outlet obstruction (eg due to prostate enlargement)
62
Investigations for urinary incontinence
* Bladder diary for minimum 3 days
* Vaginal examination
* Exclude pelvic organ prolapse
* Ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercise)
* Urine dipstick and culture
* Urodynamic studies
63
Management of urge incontinence
* Bladder retraining
* minimum 6 weeks, increase the intervals between voiding
* Bladder stabilising drugs
* Anti-muscarinics 1st line
* Oxybutinin (immediate release)
* Tolterodine (immediate release)
* Darifenacin (once daily preparation)
* Mirabegron (Beta 3 agonist)
* Useful if there is concern about anticholinergic side-effects in frail elderly patients
64
What is the first line bladder stabilising drug class used in urinary incontinence and name some examples
* Anti-muscarinics 1st line
* Oxybutinin (immediate release)
* Avoid in frail older women
* Tolterodine (immediate release)
* Darifenacin (once daily preparation)
65
Management of stress incontinence
* Pelvic floor muscle training
* NICE: at least 8 contractions performed 3 times per day for a minimum of 3 months
* Surgical
* Retropubic mid-urethral tape procedures
66
RCOG diagnostic criteria for hyperemesis gravidarum
* 5% pre-pregnancy weight loss AND
* Dehydration AND
* Electrolye imbalance
## Footnote
*Occurs in 1% pregnancies and thought to be related to raised beta hCG levels*
67
When does hyperemesis gravidarum commonly occur and how long may it persist for
* Common between 8 and 12 weeks
* Persists up to 20 weeks
68
Hyperemesis gravidarum is associated with what 5 factors
* Multiple pregnancies
* Trophoblastic disease
* hyperthyroidism
* Nulliparity
* Obesity
69
What factor is associated with a decreased incidence of hyperemesis
* Smoking
70
When would you consider admitting a patient with nausea and vomiting in pregnancy
* Continued N+V and is unable to keep liquids or oral anti-emetics
* Continued N+V with **ketonuria** and/or weight loss (\>5% body weight) despite treatment with oral anti-emetics
* Confirmed or suspected co-morbidity (e.g. unable to tolerate oral antibiotics for a UTI)
* *Lower threshold to admit if patient has co-existing condition (e.g. diabetes) which may be adversely affected by the N+V*
71
What scoring system can be used to assess the severity of hyperemesis gravidarum
* Pregnancy-Unique Quantification of Emesis (PUQE)
72
Management of hyperemesis gravidarum
* Anti-histamines - 1st line
* NICE: Promethazine
* CKS: Cyclizine
* Ondansetron and metoclopramide 2nd line
* Meto can cause extrapyramidal SE
* Ginger and p6 (wrist) acupressuer
* little evidence
* Admission for IV hydration
73
Complications of hyperemesis gravidarum
* Wernicke's encephalopathy
* Mallory-Weiss Tear
* Central pontine myelinolysis
* Acute Tubular Necrosis
* Foetal:
* Small for gestational age
* Pre term birth
74
When are serial serum Beta-hCG levels for 48hrs done
Less acute presentations of suspected ectopic pregnancy
75
At 1000 IU of serum B-hCG, what can be seen on a transvaginal ultrasound
* Gestational sac should be seen in the uterus
* A higher level of B-hCG and an epty uterus raises the possibility of an ectopic pregnancy
* Lower leverls usually requier repeating over 48 hours and a rise of 60% or more indicates a healthy progressing pregnancy
76
How does methotrexate work to treat an ectopic pregnancy
* Only use in non-ruptured ectopic pregnancy based on B-hCG levels
* Acts by destroying rapidly dividing cells (foetal and trophoblastic tissue)
* Avoids surgery and takes some time to work
* Not suitable for acute cases
* Not used if a mass is seen on TVUS
77
In a patient with a ruptured ectopic pregnancy (right tube), a diagnostic laparoscopy and salpingectomy was done to treat her. What would you avice this patient now?
Contraception
* Avoid **copper intrauterine contraceptive device** and **progesterone only pill** as RF for ectopic and increase risk of ectopic, respectively
Future pregnancies
* Early pelvic ultrasound scans when she gets pregnant to ensure intrauterine implantation and exclude ectopic
* No risk of uterine rupture at the attachment with the removed right tube in a subsequent pregnancy
78
List and the six types of miscarriages
* **Threatened miscarriage**
* **Inevitable miscarriage**
* **Incomplete miscarriage**
* **Complete miscarriage**
* **Septic miscarriage**
* **Missed miscarriage**
79
Describe features of threatened miscarriage
* Painless pv bleeding before 24 weeks (typically occurs at 6-9 weeks) but foetus is still alive.
* Uterus size is expected from the dates. Cervical Os is closed (14.3a).
* 25% go to miscarry.
80
Describe features of Inevitable miscarriage
* heavier bleeding. Foetus may still be alive.
* Cervical os is open.
* Miscarriage is about to occur
81
Describe features of incomplete miscarriage
* Some foetal parts have been passed.
* Os is usually open (14.3b)
82
Describe features of complete miscarriage
* all foetal tissue has been passed. Bleeding has diminished.
* Uterus no longer enlarged.
* Cervical os is closed
83
Describe features of spetic miscarriage
* contents of uterus are infected causing endometriosis.
* Vaginal loss is usually offensive. uterus tender. fever can be absent.
* If pelvic infection occurs there is abdo pain and peritonism
84
Describe features of missed miscarriage
* foetus has not developed or died in utero. This is not recognised until bleeding occurs or ultrasound is performed.
* Gestational sac before 20 weeks without symptoms of expulsion.
* Uterus smaller than expected form the dates.
* Os is closed (14.3c)
* When gestational sac is \>25mm and no foetal part it is blighted ovumor anembryonic pregnancy
85
When can a clinical diagnosis of missed miscarriage be made
* Gestation sac is present but no evidence of foetal node.
* **Sac is \>20mm in diameter and/or foetal node is \>5mm in length**
86
What are the options for a patient with a (missed) miscarriage
* Surgical: Evacuation of retained products of conception (ERPC)
* Medical: combination of:
* Mifepristone
* Synthetic steroid, anti-progestin that blocks action of progesterone (P necessary to maintain pregnancy)
* Misoprostol
* Prostaglandin analogue (EP2, EP3, EP4 receptors)
* Binds to myometrial cells to cause strong myometrial contractions leading to expulsion of tissue
* Also causes cervical ripening with softening and dilation of the cervix
* Conservative: Discharge and review in early pregnancy clinic in 2 weeks
* Lowest chance of success (success = miscarriage completing itself)
* Least invasive intervention
87
What are some factors to counsel the patient about when going for Evacuation of retained products of conception (ERPC)
* Bleeding
* Infection
* Cervical Trauma
* Uterine Perforation
* Rateined Products of conception
* Repeat ERPC
88
Describe the stages of puberty in girls and at what ages do these happen
* 8 ys: Hypothalamic GnRH pulses increase in amplitude and frequency. LH and FSH release increases which then stimulate oestrogen release from ovary
* 9-11yrs: **thelarce** breast development as a result of oestrogen (hormone responsible for secondary sexual characteristics)
* 11-12yrs: **adrenarche** pubic hair growth (also dependent on adrenal activity)
* 13yrs: **menarche** menstruation starts. Irregular at first as oestrogen levels increase. Pregnancy is now possible
* 16yrs: growth has finished and epiphyses fuse.
89
At what age or how many days do the following occur:
* Menarche
* Menopause
* Menstruation length
* Cycle length
* Blood Loss
* Menarche **\<16yrs**
* Menopause **\>45yrs**
* Menstruation length **3-8d**
* Cycle length **24-38d**
* Blood Loss **\<80mL**
90
Describe the hormones and changes involved in the menstrual cycle
Days 1–4: menstruation
At the start of the menstrual cycle (designated as the
first day of menstruation), the endometrium is shed as
its hormonal support is withdrawn. Myometrial contraction, which can be painful, also occurs.
Days 5–13: proliferative phase
Pulses of GnRH from the hypothalamus stimulate LH
and FSH release which induce follicular growth. The
follicles produce oestradiol and inhibin which suppress
FSH secretion in a ‘negative feedback’, such that (normally) only one follicle and oocyte mature. As oestradiol levels continue to rise and reach their maximum, however, a ‘positive-feedback’ effect on the hypothalamus and pituitary causes LH levels to rise sharply: ovulation follows 36 hours after the LH surge. The oestradiol also causes the endometrium to re-form and become ‘proliferative’: it thickens as the stromal cells proliferate and the glands elongate.
Days 14–28: luteal/secretory phase
The follicle from which the egg was released becomes
the corpus luteum. This again produces oestradiol,
but relatively more progesterone, levels of which
peak around a week later (day 21 of a 28-day cycle).
This induces ‘secretory’ changes in the endometrium,
whereby the stromal cells enlarge, the glands swell and
the blood supply increases. Towards the end of the
luteal phase, the corpus luteum starts to fail if the egg is
not fertilized, causing progesterone and oestrogen levels to fall. As its hormonal support is withdrawn, the endometrium breaks down, menstruation follows and the cycle restarts (Fig. 2.3). Continuous administration of exogenous progestogens maintains a secretory endometrium. This can be used to delay menstruation.
91
Define Abnormal Uterine Bleeding (AUB)
* Any variation from normal menstrual cycle which includes changes in:
* Frquency (\>38d or \<24d apart)
* Regularity (cycle-to-cycle variation \>20d or no bleeding in 6-month interval)
* Duration of flow (\>8d or \<3d bleeds)
* Volume (bleeding that interferes with QoL)
92
Taking the definition of abnormal uterine bleeds, what kind of problems fall under this term
* **Volume**: Heavy menstrual bleeding (HMB)
* **Regularity** (cycle to cycle variation): Irreguler bleeding, amenorrhoea
* **Frequency**: Infrequent menstrual bleeding (prev known as oligomenorrhoea), frequent bleeding
* **Duration**: Prolonged, shortened bleeding
* **Irregular, non-menstrual bleeding**: Intermenstrual, Post-coital, Pre or post-menstrual spotting
* **Bleedig outside reproductive age**: Postmenopausal bleeding, precocious menstruation
93
What is the most common complaint under abnormal uterine bleeding (AUB)
Heavy menstrual bleeding (HMB)
94
What are the causes of Abnormal uterine bleeding (AUB)
**PALM COEIN**
_Structural_ - evaluated and diagnosed on imagingand/or biopsy
* **P**olyps
* **A**denomyosis
* **L**eimyomas (fibroids)
* Submucosal
* Other
* **M**alignancy and hyperplasia
Non-structural
* **C**oagulopathy
* **O**vulatroy dysfunction
* **E**ndometrial (primary disorder of mechanisms regulating local andometrial haemostasis
* **I**atrogenic
* **N**ot yet specified
95
Define Heavy Menstrual Bleeding (HMB)
Clinical
* Excessive blood loss that interferes with the woman's QoL which can occur alone or with other symptoms
Objective
* Blood loss of \>80 mL in an otherwise normal menstrual cycle
* Value corresponds with the max amount of blood loss without becoming iron deficient
1/3 women complain of HMB but most do not seek medical help
96
Two most common causes of HMB
* Uterine fibroids (30%)
* Polyps (10%)
97
Causes of irregular bleeding
* Chronic pelvic infection
* Ovarian tumours
* Endometrial malignancy
* Cervical malignancy
98
What features of the HPC are indicative of excessive loss
* Flooding
* Passage of large clots
99
Investigations for HMB
* Anaemia
* **FBC**
* Systemic cause
* **Coagulation screen**
* **TFT**
* Local Structural - if symptomatic (IMB, PCB, pelvic pain, pressure symptoms) or abnormal pelvic exam findigns
* **Transvaginal ultrasound of pelvis**
* **Endometrial Biopsy**
100
What does a transvaginal ultrasound of pelvis measure
* Endometrial thickness
* Detect fibroids or ovarian mass
* Detect intrauterine polyps
A saline ultrasound scan (5-15mL saline through cervix into uterine cavity) during this scan improves diagnosis of intrauterine pathology - polups and submucosal fibroids
101
What is the normal thickness of endometrium in premenopausal woman
Varies in thickness according to menstrual cycle stage
* 4mm in follicular phase
* Up to 16mm in Luteal phase
102
When should an endometrial biopsy be considered in a woman with HMB
* \> 4oyrs
* Bleeding not responsive to medical therapy
* Significant intermentrual bleeding
* younger women with risk factors for endometrial cancer (exclude endometral Ca and hyperplasia)
103
How is an endometrial biopsy taken
With a pipelle
104
Medical management of HMB
First line
* Progesterone Intrauterine System (decreases loss by \>90%)
* Not suitable for those wanting to conceive
Second line (not for contraception)
* Anti-fibrinolytic - tranexamic acid
* reduce loss by 50%
* NSAIDs - mefenamic acid
* Inhibit prostaglandin synthesis
* Reduce blood loss by 30%
* Useful for **dysmenorrhoea**
* Combined oral contraceptive
* Lighter menstruation but less effective if pelvic pathology present
* Limited use as complicartions are more common in older patients of whom have the most menstrual problems
Third line
* Progestogens (high dose oral or IM)
* Amenorrhoea but bleeding follows withdrawal
* GnRH analogues
* Amenorrhoea
* Limited to 6 months use unless HRT added (add-back hormone)
* Bleeding follows withdrawal
105
In a patient with HMB, what are the three options of medical managmeent if the patient requires contraception
* 1st line: Levonorgestrel-releaseing IUS
* 2nd line: Combined Contraceptive
* 3rd line: Long acting progestogens (Depo-Provera)
106
What can be used as a short term option to rapidly stop heavy menstrual bleeding
* 5mg tds Norethisterone
* Progestin/synthetic progestogen
* Agonist of progesterone receptor
* Increase mucus viscosity (contraceptice)
* Endometrium: atrophy, suppressed proliferation, irregular secretion. Therefore less bleeding at mens
* Hypothalamus: supress LH and FSH release
107
Surgical management of HMB
Hysteroscopic
* Polyp Removal
* Endometrial Ablation
* Amenorrhoea or lighter periods follow
* Most appropriate older women with pure menorrhagia and when uterus is \<10 weeks' size
* Reduces fertility but are non-sterilising
* 1st Generation techniques
* TCRE (Transcervical resection of endometrium)
* Transcervical rollerball ablation
* 2nd generation techniques
* Thermal balloons
* Microwave
* Cryotheraoy
* radiotherapy
* Transcervical Resection of fibroid (TCRF)
* If fertility not desired TCRE can be performed at same time as TCRF
Radical
* Myomectomy
* Removal of fibroids (if \<4 fibroids that are \<8cm diameter)
* GnRH used pre-op to reduce fibroid size
* Hysterectomy
* Last resort in AUB
* Uterine artery embolisation (UAE)
* Menorrhagia due to fibroids
* Suitable for women who want to retain uterus and avoid surgery
* No clear effects of UAE on fertility
108
In transcervical resection of fibroids (TCRF) how large must fibroid be to be resected
* Up to 3 cm diameter
109
Describe the difference between a complete and a partial hydatidiform mole
Complete hydatidiform mole
* Entirely paternal in origin, when one sperm fertilises an empty oocyte and undergoes mitosis
* Resultant tissue is diploid, usually 46 XX
* No foetal tissue, merely proliferation of swollen chorionic villi
* Snowstorm appearance on ulstrasound
Partial hydatidiform mole
* Derived from two sperms enetering one oocyte
* Triploid - two paternal sets and one maternal set
* Variable evidence of a foetus
110
Features of a complete hydatidiform mole
* Vaginal bleeding early pregnancy (first PC)
* Uterus size greater than expected for gestational age
* Abnormally high serum hCG
* Ultrasound: Snow storm appearance of mixed echogenicity
111
Define endometriosis
* presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature.
* Around 10% of women of reqporductive age have a degree of endometriosis
112
Clinical features of endometriosis
* Chronic pelvic pain
* Dysmenorrhoea - starts days before bleeding
* Deep dyspareunia
* Subfertility
* Non-gynaecological:
* Urinary symptoms (Dysuria, urganyc, haematuria
* Dyschezia (painful bowel movements)
* Examination
* Reduced organ mobility
* Tender nodularity in **posterior vaginal fornix**
* Visible vaginal endometriotic lesions may be seen
113
Investigation for endometriosis
* GOLD = laparoscopy
* If symptoms are significant the patient should be referred for a definitive diagnosis
114
Management of endometriosis
First line
* NSAIDs and/or paracetamol - symptomatic relief
* COCP or progestogens if analgesia helps
* Medroxyprogesterone acetate
Second line - if analgesia/hormonal treatment does not work
* GnRH analogues
* Induce pseudomenopause due to low osetrogen levels
* Surgery
* Laparoscopic excision and laser treatment
115
Define premature ovarian failure
* Onset of menopausal symptoms and elevated gonadotrophin levels before the age 40 yrs
* Occurs 1 in 100 women
116
Causes of premature ovarian failure
* Idiopathic - most common cause
* Chemotherapy
* Autoimmune
* Radiation
117
Features of premature ovarian failure
* Climacteric symptoms
* Hot flushes
* Night sweats
* Infertility
* Secondary amenorrhoea
* Raised FSH, LH levels
118
In cervical cancer screening, what is the management of the following results:
* Borderline or mild dyskaryosis
* Moderate dyskaryosis
* Severe dyskaryosis
* Suspected invasive cancer
* Inadequate
* Borderline or mild dyskaryosis
* Original smple tested for HPV
* Negative: patient goes back to routine recall
* Positive: patient referred for colposcopy
* Moderate dyskaryosis
* CIN II. Refer for urgent colposcopy (within 2 weeks)
* Severe dyskaryosis
* CIN III.Refer for urgent colposcopy (within 2 weeks)
* Suspected invasive cancer
* Urgent colposcopy (2 weeks)
* Inadequate
* Repeat smear - if persistent (3 inadequate samples) assess by colposcopy
CIN = Cervical intraepithelial neoplasia
119
After a woman is treated for CIN1 CIN2 or CIN3, when should they be offered their next cervical smear
CIN = cervical intraepithelial neoplasm
* 6 months test of cure
120
What is the management of miscarriage (2019 NICE)
**Expectant** Management - *Waiting for spontaneous miscarriage*
* _First-line_ - wait 7-14d for miscarriage to somplete spontaneously
* Offer medical or surgical management if expectant management is unsuccessful
**Medical** Management - *Using tablets to expedite the miscarriage*
* _Vaginal misoprostol_
* Prostaglandin analogue
* Binds to myometrial cells causing myometrial contractions leading to expulsion of tissue
* Addition of oral mifepristone not recomended in NICE
* Safety net: contact if bleeding has NOT started in 24hr
* Give anti-emetics and pain relief
* Preferred if high risk of haemorrhage (late first trimester or coagulopathies), infection or previous adverse experiences
**Surgical** Management - *surgical oprocedure under local or general anaesthetic*
* _Vacuum aspiration_ (suction curettage)
* Local anaesthetic in OPD
* Surgical managment in theatre
* _Evacuation of retained producrts of conception_
* Surgical or medical management if evidence of infection or increased risk of haemorrhage
121
What is MOA of syntocinon and what is it used for
* Oxytocin - binds oxytocin receptorto increase intracellular Calcium for contraction of uterine musculature
* Used in Post-Partum Haemorrhage
122
Features of cervical caner
* Abnormal vaginal bleeding
* Postcoital
* Intermenstrual
* Postmenopausal
* Vaginal discharge
May be detected during routine cervical cancer screen
123
Risk factors for cervical cancer
* **Human papillomavirus (HPV) 16, 18 & 33**
* Smoking
* HIV
* Early first intercourse
* Many sexual partners
* High parity
* Lower socioeconomic status
* COCP
124
Mechanism of HPV causing cervical cancer
* HPV 16 and 18 produce oncogenes E6 and E7 respectively
* **E6:** inhibits p53 tumour suppressor gene
* **E7:** inhibits RB suppressor gene
125
Define atrophic vaginitis
* Inflammation of the vagina as a result of tissue thining from los oestrogen levels
126
How does atrophic vaginitis present
* Vaginal dryness
* Dyspareunia
* Occasional spotting
* Examination: vagina is pale and dry
127
Treatment of atrophic vaginitis
* Vaginal lubricants and moisturisers
* Topical osetrogen cream
128
Define pelvic inflammatory disease (PID)
* Infection and inflammation of the female pelvic organs (uterus, fallopian tubes, ovaries, surrounding peritoneum).
* Result of ascending infection from the endocervix
129
Causative organisms of PID
* **Chlamydia trachomatis**
* Neisseria gonorrhoeae
* Mycoplasma genitalium
* Mycoplasma hominis
130
Featurtes of PID
* Lower abdominal pain
* Fever
* Deep dyspareunia
* Dysuria
* Menstrual irregularities
* Vaginal or cervical discharge
* Cervical excitation
131
Investigation for PID
* Pregnancy test to exclude ectopic
* **High** vaginal swab
* Often negative
* Screen for chlamydia and gonorrhoea
132
Management of PID
Difficult makiung accurate diagnosis and lots of potential complications of untreated PID, therefore **low threshold for treatment.** Take all of the below
* _IM ceftriaxone + Oral Doxycycline_
* 3rd gen cephalosporin + tetracycline
* Oral Ofloxacin (fluoroquinlone) -\> PID +Chlam + Gon
* Oral metronidazole
*Mild cases of PID: RCOG says intrauterine contraceptive devices may be left in. BASHH says limited evidence for this*
133
Complications of PID
* Perihepatitis (Fitz-Hugh Curtis Syndrome)#
* 10% of cases
* RUQ pain and may be confused with cholecystitis
* Infertility
* Risk 10-20% after single eppisode
* chronic pelvic pain
* Ectopic pregnancy
134
What is the lower back pain experienced in pregnancy caused by
* Relaxin - increased sacroiliac joint laxity
* Increased mechanical load fduring pregnancy
135
Define cervical ectropion (cervical erosion)
* When there is a larger area of columnar epithelium present on the ectocervix
* Transition zone = where stratified epithelium meets columnar epithelium of the cervical canal
136
Features of cervical ectropion
* Vaginal discharge
* Post-coital bleeding
137
Management of cervical ectropion
* No treatment
* Ablative treatment (cold coagulation) for troublesome symptoms
138
What markers would you look for in the following:
* Ovarian cancer
* Pancreatic cancer
* Bowel cancer
* Liver cancer and germ cell tumours (e.g. testicular)
* Breast cancer reeptor
* Ovarian cancer **CA 125**
* Pancreatic cancer **CA 19-9**
* Bowel cancer **CEA** (carcinoembryonic antigen)
* Liver cancer and germ cell tumours (e.g. testicular) **AFP (alpha-foeto-protein)**
* Breast cancer receptor **HER2**
139
Define menopause
* Permanent cessation of menstruation caused by the loss of follicular activity
* Clinical diagnosisusually in primary care when a woman has not had a period for 12 months
*Symptoms are very common and affect 75& of post-menopausal women. They last for 7 years but may resolve quicker and in some cases longer. Duration and severity are variable and may develop before start of menopause and in some cases may start years after the onset of menopaus*
140
How is menopause managed (three main approaches/categories)
* Lifestyle modifications
* Hormone Replacement Therapy (HRT)
* Non-HRT
141
What are some lifestyle modifications to manage menopause
* Hot flushes
* Regular exercise, weight loss, reduce stress
* Sleep disturbance
* Avoid late evening exercise, good sleep hygeine
* Mood
* Sleep, regular exercise and relaxation
* Cognitive symptoms
* Exercise and sleep hygeine
142
How would you counsel a patient with menopause about HRT
* If woman has uterus, then do not give unoppposed oestrogens as increases endometrial cancer risk
* Oral or transdermal combined HRT
* If woman has no uterus
* Oestrogen only, oral or transdermal
*10% women will have HRT to treat menopause. Current advice from NICE to increase this number as a lot of women are worried about cancer risk*
143
What is used as the progesterone component of HRT for 4 years
Mirena Intrauterine system
144
What are the risks you should advise a patient when treating their menopause with HRT
* VTE
* Increased with oral HRT. No increase in transdermal HRT
* Stroke
* Increased risk with oral oestrogen HRT
* Coronary heart disease
* Combined HRT associated with increased risk
* Breast cancer
* Increased risk with all combined HRT
* Risk from dying from breast cancer not raised
* Ovarian cancer
* Increased with all HRT
* *Endometrial cancer*
* *If you give unoipposed oestrogen*
145
Contraindications of HRT
* Current or past **breast cancer**
* Any **oestrogen-sensitive** cancer
* Undiagnosed **vaginal bleeding**
* Untreated **endometrial hyperplasia**
146
How can you manage menopause with non-HRT
* Vasomotor symptoms
* SSRI: fluoxetine, citalopram
* SSNRI: Venlaflaxine
* Vaginal dryness
* Vaginal lubricant or moisturiser
* + topical vaginal oestrogen if required
* Psychological symptoms
* Self-help groups, CBT or anti-depressants
* Urogenital symptoms
* If urogenital atrophy then vaginal oestrogen can be prescribed. Appropriate regardless whether they are on HRT or not
* For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.*
* *
147
When would you refer a patient to secondary care for menopause
* If treatment is ineffective
* If ongoing side effects
* Unexplained bleeding
148
In a female with postmenopausal bleeding, what diagnosis is given until proven otherwise
**Endometrial adenocarcinoma**
149
What are some factors that may make vaginal candidiasis more likely to develop
Majority women will have no predisposing factors
* Diabetes mellitus
* Drugs: antibiotics, steroids
* Pregnancy
* Immunosuppression: HIV, iatrogenic
150
Features of vaginal candidiasis (thrush)
* **Cottage cheese** non-offensive discharge
* Vulvitis
* Dyspareunia, dysuria
* Itch
* Vulval erythema, fissuring, satellite lesions
151
Investigations for vaginal candidiasis
* High vaginal swab NOT routinely indicated if clinical features are consistent with candidiasis
152
Management of vagianal candidiasis
* Local treatment
* Clotrimazole pessary (500mg PV stat)
* Oral treatment
* Itraconazole 200mg PO bd for 1d
* Fluconazole 150mg PO stat
* If pregnant then ONLY local treatments (cream or pessaries) may be used - Oral treatments are contraindicated
153
What is a contraindication for oral anti-fungal in vagial candidiasis
* Pregnancy
154
Define recurrent vaginal candidiasis
* 4 or more episodes per year
* Check compliance with previous treatments
* Confirm initial diagnosis (high vaginal swab, exclude DD lichen sclerosis)
* Exclude predisposing factors
* Consider use of induction-maintenance regime, with daily treatment for a week followed by maiuntenance treatment weeklyfor 6 months
155
What is the average age of a woman to go through menopause
51 years old in UK
156
Contraception is recommended in sexually active women until what time periods and at what age
* 12 months after last period in \>50 years OR
* 24 months after last period in women \<50 years
157
Define ectopic pregnancy
Implantation of a fertilized ovum outside the uterus
158
What are some features of ectopic pregnancy
* Lower abdominal pain
* Due to tubal spasm
* Typically first symptom
* Constant pain and may be unilateral
* PV bleeding
* Less volume than normal mens
* May be dark brown in colour
* Hx of recent amenorrhoea
* 6-8 weeks from start of last period
* If longer (10 weeks) this suggests another cause -\> inevitable abortion
* Peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
* Dizziness, fainting, syncope
* Symptoms of pregnancy (breast tenderness)
159
Examination findings of ectopic pregnancy
* Abdominal tenderness
* Cervical excitation (AKA cervical motion tenderness)
* Adnexal mass
* NICE advice NOT to examine for ednexal mass due to increased risk of rupturing the pregnancy
* Pelvic examination to check for cervical excitation is recommended
## Footnote
*Case of pregnancy of unknown location, serum BhCG levels \>1500 points towards ectopic pregnancy*
160
What are the investigations for an ectopic pregnancy
* Pregnancy test (urine B-HCG)
* Pelvic USS if positive
* If intrauterine pregnancy can not be detected, offer a transvaginal USS
161
If a pregnancy cannot be identified on ultrasound scan but B-HCG is positive, it is called
Pregnancy of unknown location
162
What are the three differentials for pregnancy of unknown location
* Very early intrauterine pregnancy
* Miscarriage
* Ectopic pregnancy
163
How would you differentiate between the differentials for pregnancy of unknown location (ie negative scans but positive urine B-HCG)
Serum B-HCG
* \>1500 IU
* Ectopic pregnancy until proven otherise
* Offer diagnostic laparoscopy
* \<1500 IU and patient is stable, further test done 48 hours later
* Variable pregnancy, HCG would double every 48 hrs
* Miscarriage, HCG would halve every 48 hours
Urinalysis for UTI
164
Management of tubal ectopic pregnancy
* Salpingectomy unless contraindicated
* CI: RF for infertility (cointra lateral tube damage)
* Salpingotomy is alternative
* COUNSEL: 1 in 5 women may need further treatment - methotrwexate and/or salpingectomy
165
Definitive treatment of Bartholin's abscess?
* Marsupialisation
* Bartholin’s glands are tiny organs on the labia near the vaginal opening. The glands help provide lubrication for sexual intercourse.
* The doctor will make a small cut in the abscess and gland to release the fluid, sewing the edges to the surrounding skin. This is done to keep the cut open so it can heal and for the contents of the abscess to drain out. This prevents another abscess from forming later. The small cut will completely heal by itself eventually.
166
In polycystic ovarian syndrome, what is the ratio of LH to FSH
greater than 3:1 (LH:FSH)
167
What are the broad causes of infertility
* Male factor 30%
* Unexplained 20%
* Ovulation failure 20%
* Tubal damage 15%
* Other causes 15%
Infertility affects 1 in 7 coupls. 84% who regularly have sex will conceive in 1 year and 92% withing 2 years
168
Investigations for infertility
* Semen analysis
* Serum progesterone 7d before next expected period (21st day of 28d cycle)
169
What results would you expext on the 21 day progesterone for infertility
170
What are some topics to counsel patients about with regartds to infertility/optimising fertilityy
* Folic acid supplementation
* BMI 20-25
* Advise regular sex every 2-3 days
* Smoking and dirnking advice (stop)
171
For people with unexplained infertility, _____ (milkd, moderate or severe) endometriosis or 'mild male factor infertility', who
are having regular unprotected sexual intercourse: do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a total of _____ (this can include up to 1 year before their fertility investigations) before IVF will be considered'. NICE CG156
For people with unexplained infertility, **mild** endometriosis or 'mild male factor infertility', who
are having regular unprotected sexual intercourse: do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a total of **2 years** (this can include up to 1 year before their fertility investigations) before IVF will be considered'. NICE CG156
172
What is the treatment for a vaginal vault prolapse
* Sacrocolpoplexy
* Suspends vaginal apex to the sacral promontory
* Support is usually afforded by the uterosacral ligaments
173
Describe when each of the following would be indicated:
* Anterior colporrhaphy
* Vaginoplasty
* Vaginal hysterectomy
* Bilateral oophorectomy
* Sacrocolpopexy
* Anterior colporrhaphy = Vaginal wall repair following a cystocele
* Vaginoplasty = reconstruction of vagina to make it tighter following childbirth
* Vaginal hysterectomy = removal of uterus via the vagina
* Bilateral oophorectomy = removal of ovaries
* Sacrocolpopexy = vaginal vault prolapse
174
List some types of urogenital prolapse
* Cystocele
* Cystourethrocele
* Rectocele
* Uterine prolapse
* Less common: urethrocele, enterocele (herniation of pouch of douglas, including small intestine into the vagina)
175
Risk factors for urogenital prolapse
* Increaseing age
* Multiparity
* Vaginal deliveries
* Obesity
* Spina bifida
176
How does urogenital prolapse present
* Sensation of pressure, heaveiness and bearing down
* Urinary symptoms
* Incontinence
* Frequency
* Urgency
177
Management of urogenital prolapse
* No treatment if asymptomatic or mild
* Conservative
* Weight loss, pelvic floor muscle exercises
* Ring pessary
* Surgery
178
What are the surgical options for urogenital prolapse
* Cystocele/cystourehtrocele -\> anterior colporrhaphy, colposuspension
* Uterine prolapse: Hysterectomy, sacrohysteropexy
* Rectocele: Posterior colporrhaphy
179
Define premature ovarian failure
* Onset of menopausal symptoms AND
* Elevated gonadotrophin levels \<40 years of age
1 in 100 women
180
Causes of premature ovarian failure
* Idiopathic - most common
* Chemotherapy
* Autoimmune
* Radiation
181
What are some features of premature ovarian failure
Similar to normal climacteric but actual presenting problem may differ:
* Climacteric symptoms
* Hot flushes, night sweats
* Infertility
* Secondary amenorrhoea
* Raised FSH, Raised LH
182
Define endometrial hyperplasia
* Abnormal proliferation of the endometrium in excess of normal proliferation that occurs during menstrual cycle
* Minority of patients may develop endometrial cancer
183
Types of endometrial hyperplasia
* Simple
* Complex
* Simple atypical
* Complex atypical
184
What tumour is associated with the development of endometrial hyperplasia
Granulosa Cell tumours
* Sub type of sex cord stromal tumours
* Thecomas, fibromas, sertoli cell and granulosa cell tumours
* Associated with increased hormone production
* Only GCT associated with development of endometrial hyperplasia
185
Features of endometrial hyperplasia
Abnormal vaginal bleeding
186
Management of endometrial hyperplasia
* Simple without atypia
* High dose progestogens
* Repeat sampling in 3-4 months
* Levonorgestral IUS may be used
* Atypia
* Hysterectomy
* Atypical hyperplasia of endometrium is classified as pre malignant condition
187
What are some risks or complications following a ToP? which is most common
* Infection 10% most common
* Need to give prophylactic antibiotics to reduce risk
* Retained tissue pregnancy 1%
* Haemorrhage \<1%
* More likely in pregnancies \>20 weeks gestation
* Failure \<1%
* Cervix injury \<1%
188
The COCP increases the risks of what cancers
* Breast cancer
* Cervical cancer
189
The COCP protects against which two cancers
* Ovarian cancer
* Endometrial cancer
190
What are the two types of amenorrhoea and define them
Primary amenorrhoea
* Failure to start menses by the age of 16
Secondary amenorrhoea
* Cessation of established, regular menstruation for 6 months or longer
191
Causes of primary amenorrhoea
* Turner's Syndrome
* Testicular feminisation
* Congenital adrenal hyperplasia
* Congenital malformations of the genital tract
192
Causes of secondary amenorrhoea
After excluding pregnancy:
* Hypothalamic amenorrhoea (stress, excessive exercise)
* PCOS
* Hyperprolactinaemia
* Premature ovarian failure
* Thyrotoxicosis
* Hypothyroidism
* Sheehan's Syndrome
* Aherman's Syndrome
193
What are some investigations for amenorrhoea
* Exclude pregnancy (urinary/serum bHCG)
* Gonadotrophins
* Low = hypothalamic cause
* raised = ovarian problem (premature ovarian failure)
* Prolactin
* Androgen levels
* Raised = PCOS
* Oestradiol
* Thyroid Function Tests
194
Diagnostic criteria for PCOS
* PCO on ultrasound (12 or more, 2-8mm, \>10mL ovary volume)
* Irregular periods (\>35d apart)
* Hisutism
* Clinical (Acne/excess body hair)
* Biochemical (raised tesosterone)
195
Other features of PCOS other than those in diagnostic criteria
* Subfertility and infertility
* Obesity
* Acanthosis nigricans (due to insulin resistance)
196
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both _____ and _____ levels of _____ are seen in PCOS and there appears to be some overlap with the _____ syndrome.
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both **_hyperinsulinaemia_** and **_high_** levels of **_luteinizing hormone_** are seen in PCOS and there appears to be some overlap with the **_metabolic_** syndrome.
197
Investigations for PCOS
* Pelvic ulstrasound - multiple cysts on ovaries
* FSH, LH, prolactin, TH, testosterone
* Raised LH:FSH = classical feature but no longer useful for diagnosis
* Prolactin = normal or raised
* Check gluocse tolerance
198
Descibre the ligaments involved in suypporting the pelvic floor
Level 1 - Cervix and upper third
* Cardinal (transverse cervical) ligament
* suspend uterus from pelvic side wall
* Uterosacral ligament
* Suspend uterus from sacrum
* Both attached to cervix
Level 2 - mid-portion of vagina
* Andofascial condensation (endopelvic fascia)
* Laterally to the pelvic side walls
Level 3 - lower third of vagina
* Levator ani muscles
* Form floow of pelvis from attachemtns of bony pelvic walls and incorporate the perinael body in the perineum
* Levator ani + associated fascia = **pelvic diaphragm**
* Perineal body
199
What are some types of uterovaginal prolapse
Classified anatomically according to the site of the defect and the pelvic viscera that are involved
* Urethrocoele
* Cystocoele
* Cystourethrocoele
* Apical prolapse
* Enterocoele
* Rectocoele
200
Describe urethrocoele
Prolapse of lower anterior vaginal wall, involves urethra only
201
Describe cystocoele
* Prolapse of upper anterior vaginal wall involving the bladder
* Additional involvement of urethra = cystourethrocoele
7.2 (c)
202
Define apical prolapse
* Prolapse uterus, cervix and upper vagina
* Ig uterus has been removed, the vault or top of vagina where uterus used to be can prolapse
203
Describe enterocoele
* Prolapse of upper posterior wall of vagina
* Resulting pouch containes loops of small bowel
204
Describe rectocoele
* Prolapse of lower posterior wall of vagina
* Involves anterior wall of rectum
205
What can be used to grade a prolapse
Baden-Walker Classification
* 0 = no descent of pelvic organs during straining
* 1 = leading surface of prolapse does not descend below 1cm above the hymenal ring
* 2 = leading edge extends from 1cm above to 1cm below hymenal ring
* 3 = prolapse extends 1cm or more below hymenal ring but without complete vaginal eversion
* 4= vagina completely everted (complete procidentia)
206
Causes of prolapse
* Vaginal delivery and pregnancy
* congenital collagen deficiency
* Ehlers-Danlos
* Menopause
* Deterioration of collagenous tissue from oestrogen withdrawal
* Chronic elevated abdominal pressures
* Obesity, cough, constipation, heavy lifting
* Iatrogenic factors
* Pelvic surgery
207
What are some symptoms of prolapse
General
* Dragging senstaion
* Vaginal lump
Cystourethrocoele
* Urinary frequency
* Incontinence
Rectocoele
* Occasional difficulty in defaecating
208
Diagnosis of prolapse
* Usually clinical diagnosis
* Consider pelvic ultrasound if pelvic mass suspected
* Urodynamic testing if incontinence is principal complaint
209
Pre3vention and management of prolapse
Preventiopn
* Recognition of obstructed labour and avoidance of long second stage of labour
* Pelvic floor exercises after childbirth
Management
* Asymptomatic - reassured (incidental finding)
* Weight reduction
* Pessaries
* Ring or shelf if frail
* Change every 6-9 months
* Surgery
210
Name some surgical options for management of prolapse (and indications)
Uterine prolapse
* Hysterectomy
* Hysteropexy
Vaginal vault prolapse
* Sacrocolpopexy
* Sacrospinous fixation.
Vaginal wall prolapse
* Anterior and posterior repairs
211
Describe what happens in a hysteropexy
* Corrects uterine prolapse without recourse to hysterectomy
* Open or laparoscopic
* Uterus and cervix attached to sacrum by a bifurcated non-absorbable mesh
* Restores length of vagina withotu compromising calibre
212
Describe what happens in a sacrocolpopexy and what prolapse it is indicated in
* Vaginal vault prolapse
* Open or laparoscopic
* Fixes vault to the sacrum using a mesh
* Complications: mesh erosion and haemorrhage
213
Describe indication for sacrospinous fixation and what happens
* Vaginal vault prolapse
* Performed vaginally
* Suspends vault to sacrospinous ligament
* Complications: nerve or vessel injury, infection, buttock pain
* Less effective than sacrocolpopexy but faster recovery
214
In a patient presents with prolapse + stress incontinence, what are some options for management
Concurrent surgical managmeent as prolapse
* Tension-free vaginal tape (TVT)
* Transobturator tape (TOT)
* Burch colposuspension
215
Define lichen sclerosus
* Chronic inflammatory skin disease of the anogenital region in women
216
Incidence of lichen sclerosis (age)
* Bimodal incidence
* Prepubescent girls
* Post-menopausal women
* Uncommon but debilitating disease
217
Lichen sclerosus has the potential to prgoress into what
Squamous cell carcinoma (5% of post menopausal group)
218
Aetiology of lichen sclerosus
* Unknown
* Patients have higher titre of extracellular matrix 1
* Suggests autoimmune aetiology
219
Risk factors for lichen sclerosus
* Genetic (FH)
* Other autoimmune disorders
* Thyroid, Diabetes, alopecia acreata
220
Histological features of lichen sclerosus
* Epidermal atrophy
* l;eads to thin stratified sqaumous epithelium
* Band-like infiltrate of chropnic inflammatory cells can be observed below epithelial layer
221
Clinical Symptoms of lichen sclerosus
* Itchy
* Fissures or erosions
* Painful
* Dyspareunia
* Some are asymptomatic
222
On examination, what might you see with a patient with lichen sclerosus
* White atrophic patches - well defined
* Usually within anogenital region, but can happen anywhere on body
* Adhesions/scarring
* Clitoral hood fusion
* Fusion of labia minora to the labia majhora
* Posterior fusion resulting in loss of vaginal opening
223
Differential diagnosis for lichen sclerosus
* Lichen simplex
* Vitiligo
* Vulvae cancer or intraepithelial neoplasia
* Candidiasis
* Post-inflammatory hypopigmentation
224
Diagnosis of lichen sclerosus
* Clinical diagnosis
* Biopsy to confirm uncertainty in diagnosis
* Particularly when malignancy needs to be excluded
225
Management of lichen sclerosus
* Immunosuppression
* 1st line = topical steroids
* Clobetasol proprionate once daily at night for 4 weeks
* Then on alternate nights for 4 weeks
* Then twice weekly for 4 weeks
* Follow up as risk of Squamous cell carcinoma in chronic cases (2-5% lifetime risk)
226
What are some causes of pruritis vulvae (ichty)
Infections
* Candidiasis
* Vulval warts
* Pubic lice, scabies
Dermatological
* Eczema, psoriasis
* lichen simplex, lichen sclerosus, lichen planus
* Contact dermatitis
Neoplasia
* Carcinoma
* Premalignant disease (vulval intraepithelial neoplasia)
227
Define vulval intraepithelial neoplasia (VIN)
* Presence of atypical cells in the vulval epithelium
228
What are the two categories of vulval intraepithelial neoplasia
* Usual type VIN
* More common
* Differentiated type VIN
* Rarer
229
Describe the gross appearance of usual type Vulval intraepithelial neoplasia and compare to the differentiated type
* Usual = may be multifocal, warty, basaloid or mixed
* Differentiated = unifocal, ulcer or plaque, keratinising
230
Compare the age group affected in usual vs differentiated VIN
* Usual = 35-55
* Differentiated = older women
231
What are some risk factors associated with usual type VIN
* HPV-16
* Cervical intraepithelial neoplasia (CIN)
* Cigarette smoking
* Chronic immunosuppression
232
What are some conditions associated with differentiated type VIN
* Lichen sclerosis
233
What are some symptoms seen in VIN
Pruritis or pain
234
What is the GOLD standard management of VIN and name the other managements
* GOLD = local surgical excision
* Relieve symptoms, confirm histology, exclude invasive disease
* Emollients
* Mild topical steroids
235
Name some types of carcinoma of the vulva
* **Squamous cell carcinoma** 95%
* Malenoma
* Basal cell carcinoma
* Adenocarcinoma
* Sarcoma
236
Risk factors for carcinoma of the vulva
* VIN
* NOTE: though VIN is premalignant, these carcinomas often arise *de novo*
* Lichen sclerosus
* Immunosuppression
* Smoking
* Paget's disease of the vulva
237
What are some clinical features of carcinomas of the vulva (symptoms/signs, O/E)
From history:
* Pruritis
* Bleeding or discharge
* Mass
* Malignancy often presents late as lesions go unnoticed or cause embarrassment
O/E:
* Ulcer or mass
* Commonly on labia majora or clitoris
* Enlarged inguinal nodes
* Hard and immobile
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How do carcinomas of the vulva spread
* Spreads locally via lymph drainage
* Superficial inguinal nodes
* Deep inguinal nodes
* Femoral nodes
* External iliac nodes
Contralateral spread may occur
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Staging is surgical and histological (ie after surgery). How are carcinomas of the vulva stages
* Stage 1
* Confined to vulva/perineum; negative nodes
* a = ≤ 2 cm in size, with ≤1 mm stromal invasion
* b = \>2 cm in size, with \> 1 mm stromal invasion
* Stage 2
* Tumour of any size + adjacent spread (lower urethra/vagina or anus); negative nodes
* Stage 3
* Tumour of any size + positive inguinofemoral nodes
* Stage 4
* Tumour invades upper urethra/vagina, rectum, bladder, bone (4a); or distant metastases (4b)
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Investigations for vulval carcinoma
Biopsy - establish diagnosis and histological type
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Management of vulval carcinoma
Stage 1a
* Wide local excision without inguinal lymphadenectomy
* Risk of spread is negligible
Other stages
* Sentinel lympho node biopsy
* Unifocal squamous cancers \<4cm no clinical or radiological suspicion of lymph node metastasis
* Radioactive dye injected aroudn tumour site and any sentinel nodes identified, biopsied for presence of mets
* If no setntinel lymph node identified, then complete inguinofemoral lymphadenectomy considered
* Wide local excision and groin lymphadenectomy
* Radiotherapy may be used pre-surgery to shrink tumours
* Reconstructive surgery
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