Gynaecology - Investigations Flashcards
(41 cards)
POP (pelvic organ prolapse) investigations
• Examination
o Abdominal examination
o Examine patient with them in both standing + left lateral position
o Ask the woman to strain + observe both whilst standing + supine
o Sim’s speculum – inserted along the posterior vaginal wall to assess the anterior wall + vaginal vault + vice versa – ask pt to strain
o Bivalve speculum – to identify the cervix or the vaginal vault
Ask pt to strain
Slowly remove speculum
Look for the degree of descent of the vaginal apex
o If prolapse protrudes beyond the hymen
Ulceration and hypertrophy of the cervix or vaginal mucosa with concomitant bleeding
o Rectal examination if there are bowel symptoms
For urinary symptoms • Urine dip • Speculum examination • Bladder diary (3 days) • Residual volume • Urodynamics • Cystoscopy • Renal USS
• Dx is usually clinical + based on hx + examination
o Speculum – grade and severity
• For urinary symptoms o Urine dip – Urinalysis +/- MSU o Post-void residual volume testing using a catheter or bladder USS o Urodynamic investigations o Urea and Creatinine o Renal USS
• For bowel symptoms
o Anal manometry
o Defecography
o Endo-anal USS – to look for an anal sphincter defect if faecal incontinence is present)
• USS or MRI
USI urinary stress incontinence investigations
• A full obstetric history should be taken in women
• Examination (speculum)
o Digital assessment of pelvic floor muscle contraction (Kegel exercises)
o Bimanual/vaginal examination to assess for the presence of prolapse
o Ask patient to cough (Valsalva) during exam to check for fluid leakage
o Look for signs of vaginal atrophy
o Perform an abdominal/pelvic/neurological examination
• Bladder diaries – 1st line
o Minimum of 3 days
• Urine dipstick testing (+/-MSU) – 1st line
o Look for blood, glucose, protein, leukocytes, nitrites
o Rule out UTI or DM
• Urodynamic studies – 2nd line
o Multi-channel cystometry, ambulatory urodynamics, video urodynamics
o After you start conservative treatment but before surgery for urinary incontinence
o Multi-channel filling + voiding cystometry should not be performed in women in whom pure stress or stress-predominant mixed urinary incontinence is identified by hx or examination
o Multichannel filling and voiding cystometry before surgery for stress urinary incontinence if
Urge-predominant mixed urinary incontinence or urinary incontinence in which type is unclear
Symptoms suggestive of voiding dysfunction
Anterior or apical prolapse / cystocele
Hx of previous surgery for stress urinary incontinence
o Consider ambulatory urodynamis/videourodynamics if dx remains unclear after conventional urodynamics
Other ix:
• Renal function tests
• Assessment of residual urine
o Post-void residual volume using a bladder scan
o Measure in women who have symptoms suggesting voiding dysfunction or recurrent UTI
o Can also be assessed using catheterisation
• Symptom scoring + QOL
o Use a validated urinary incontinence-specific symptom + WOL questionnaire when therapies are being evaluated
• Cystoscopy
OAB overactive bladder syndrome investigations
• Dx made from the symptoms
• Speculum examination
o Exclude pelvic organ prolapse
o Assess ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercises)
o Ask patient to cough (Valsalva) during exam to check for fluid leakage
• Urine dipstick + MSU – 1st line
o Rule out UTI or DM
• Bladder diaries – 1st line
o Minimum of 3 days
• Urodynamic studies – 2nd line
o To confirm the diagnosis
o Show involuntary contraction of the bladder during filling
o Multichannel cystometry
3 pressures measured from inside rectum + urethra
Bladder pressure = detrusor + IAP (intraabdominal pressure)
Detrusor = bladder – IAP
o Urinary flow rate
Men can hold 400ml and void at a rate of 10-15ml/s
Women can hold 500ml and void at a rate of 15-20ml/s
• Depending on presentation
o USS of the renal tract + cystoscopy
o Ix to consider differential dx – blood tests for renal function, electrolytes, calcium, fasting glucose
PID (pelvic inflammatory disease) investigations
- Start Abx before swabs if you suspect PID
- Pregnancy test – rule out ectopic pregnancy
• Triple swabs (2 x EC, 1x HVS)
o Cervical swabs for chlamydia + gonorrhoea
o A positive result supports dx of PID, a negative result does not exclude PID
• Speculum – look for signs of inflammation/discharge
• Bimanual – cervical excitation, adnexal masses (tubo-ovarian abscess)
o If tubo-ovarian abscess, confirm with TVUSS
- raised ESR, CRP
- If febrile – blood cultures, FBC, CRP
- Endometrial biopsy + USS
• Laparoscopy
o Direct visualisation of the fallopian tubes – the best single diagnostic test
o Invasive procedure + not appropriate in routine clinical practice
- Urinalysis to exclude UTI
- USS to exclude other conditions
Bartholin’s cysts ix
• Swab from the contents of the cyst (often organisms are skin commensals)
• If >40
o Biopsy to rule out carcinoma of the vulva
o A number of types of malignancy can present in this way
o Carcinoma of the Bartholin’s gland – 5% of vulval carcinoma
Endometriosis ix
• Acute setting bloods urinalysis + MC+S cervical swabs βHCG – helpful in excluding important differentials
• TVUSS can be used to:
o Investigate suspected endometriosis
o Make and to exclude the diagnosis of an ovarian endometrioma
o Identify deep endometriosis involving the bowel, bladder or ureter
o Association to clear cell + endometroid ovarian carcinoma
o If TVUSS not acceptable. consider a transabdominal USS
• Laparoscopy – the only reliable diagnostic test, gold standard
o Can be used to diagnose endometriosis if clinical suspicion remains or symptoms persist, even if USS was normal
o Active lesions = red vesicles or puncuae marks on peritoneum
o Less active endometriosis = white scars/brown spots
o Consider taking a biopsy to: a) confirm the dx, b) exclude malignancy (if an endometrioma is treated but not excised)
o Small risk of major complications – bowel perforation
o For women with suspected deep endometriosis involving bowel/bladder/ureter – consider a pelvic US or MRI before an operative laparoscopy
• Abdominal and pelvic examination for women with ?endometriosis – bimanual + speculum examination
o Identify abdominal masses + pelvic signs –
decreased organ mobility + enlargement
Tender nodularity in the posterior vaginal fornix
Visible vaginal endometriotic lesions
Fixed retroverted uterus (ectopic tissue on utero-sacral ligament)
o If pelvic examination not appropriate, offer abdominal examination to exclude abdominal masses
• Pelvic MRI
o Should not be used as the primary ix for dx
o Should be used to assess the extent of deep endometriosis involving the bowel, bladder, ureter before diagnostic/surgical laparoscopy
o Pelvic MRI before operative laparoscopy
• AFS (american fertility society) /ASRM (american society for reproductive medicine) – classification system that classifies endometriosis as minimal (stage I), mild (stage II), moderate (Stage III)
Fibroids investigations
- Abdominal examination
- Pregnancy test
- FBC (anaemia), iron studies
• Pelvic USS
o To exclude other causes of a pelvic mass
o To confirm presence + size of fibroids
o To exclude complications (e.g. urinary tract obstruction causing hydronephrosis)
o TVUSS is more accurate
- MRI – if USS is not definitive + myomectomy is being considered
- Submucous fibroids – saline infusion US
- Leiomyosarcoma – LDH, LDH isoenzyme 3, gadolinium enhanced MRI
- Abnormal uterine bleeding – Endometrial sampling (Pipelle)
- Hysteroscopy with biopsies
Cervical ectropion investigations
Speculum – red outer cervix due to shift of transformation zone Then colposcopy (1st line) to visualise suspicious area
Endometrial polyp investigations
o Pelvic US/TVUSS – 1st line ix – endometrial thickening
o OPH (outpatient hysteroscopy)
o SIS (saline infusion sonography)
OPH + SIS are the most accurate
Menopause ix
• Clinical dx, investigations not usually recommended
• Pregnancy test
• Laboratory tests not required in the following otherwise healthy women >45 with menopausal symptoms
o Perimenopause = vasomotor symptoms + irregular periods
o Menopause = women who have not had a period for at least 12 months and are not using hormonal contraception
o Menopause in women without uterus = based on symptoms
Investigations undertaken in some women with menopausal symptoms
• FSH levels
o Two levels are required 2 or 6 weeks apart
o Considered FSH testing to dx menopause only
In women aged 40-45 years with menopausal symptoms incl. a change in their menstrual cycle (? early menopause)
In women aged <40 years in whom POI is suspected (?POI)
Women >50 years who are amenorrhoeic and taking the POP/have an implant or a Mirena fitted who wish to consider stopping contraception
• >30 nmol/L, continue contraception for 1 year and then stop (there is no need to repeat this test)
• <30 nmol/L, continue with contraception and recheck FSH after 1 year.
o No need for the FSH level to be tested in most women
o Do not use FSH to dx menopause in women using COCP and progestogen contraception or high-dose progestogen
o A raised FSH it not diagnostic for the menopause – a high level will just indicate a lack of ovarian response at a point in time
• To rule out alternative dx – TFT, Blood glucose, prolactin, TVUSS (endometrial/ovarian cancer- bleeding = endometrial, no bleeding and mass = ovarian)
- Blood cholesterol and triglycerides – consider if the woman has any CV RF
- Cervical screening and mammograms – ensure the woman is up to date
- A pelvic scan – for women with atypical symptoms
- Tests that should not be used to dx perimenopause or menopause in women >45 years = anti-mullerian hormone, inhibin A or B, estradiol, antral follicle count, ovarian volume
Atrophic vaginitis ix
• May not be necessary if the dx is clear
• May be needed to exclude other problems
o Postmenopausal bleeding that requires investigation
o Infection – if there is discharge or bleeding
o Other causes of recurrent UTI
o Screen for diabetes may be considered
• Other ix
o Vaginal pH testing
Sample from mid-vagina, not the posterior fornix
Result: more alkaline in atrophic vaginitis
o Vaginal cytology
Lack of maturation of the vaginal epithelium (typical of atrophic vaginitis)
Asherman’s syndrome ix
• Hysteroscopy
o Gold standard
o Direct visualisation of the uterus
o Most reliable method for diagnosis
• Saline hysterosonography
• TVUS
o Subendothelial linear striations
o Boggy uterus
• Hysterosalpingogram
o Injection of a contrasting fluid into the uterus in order for an X-ray imaging to be generated
o Allows for the imaging of the uterine cavity shape which may be abnormal in the presence of intrauterine adhesions
Describe these findings in the 5 types of miscarriage + septic miscarriage
Threatened Inevitable Missed (delayed/late) miscarriage Incomplete miscarriage Complete miscarriage \+ Septic miscarriage
Bleeding Pain Os TVUSS state of pregnancy Fetal heartbeat=viability
Threatened Bleeding Yes Pain No Os Closed TVUSS state of pregnancy Present Fetal heartbeat=viability Present 25-50% progress to c complete miscarriage associated with a risk of subsequent preterm delivery
Inevitable Bleeding Yes (heavy, clots) Pain Yes Os Open TVUSS state of pregnancy Present, may be lower in the uterus Fetal heartbeat=viability No Progresses to (in)complete
Missed (delayed/late) Bleeding Normally asymptomatic Pain Normally asymptomatic Os Closed TVUSS state of pregnancy Present Fetal heartbeat=viability No other: CRL >7mm GS >25mm uterus is small for dates pregnancy test can remain positive for several days/weeks but early pregnancy symptoms may have decreased or stopped hx of threatened miscarriage + persistent dark-brown discharge
Incomplete miscarriage Bleeding Yes Pain Yes Os Open TVUSS state of pregnancy RPOC Fetal heartbeat=viability No
Complete miscarriage Bleeding resolved Pain resolved Os closed TVUSS state of pregnancy empty Fetal heartbeat=viability No
Septic miscarriage Bleeding light bleeding Pain yes Os slightly open TVUSS state of pregnancy RPCO Fetal heartbeat=viability No occurs with incomplete miscarriage signs of infection (temperature, foul smelling discharge, tachy, abdo pain)
Miscarriage ix
• Pregnancy test –> speculum (inspect Os) –> TVUS (FH (Foetal heartrate) –> CRL (Crown-rump length) /foetal pole or GS (Gestational sac) / YS (Yolk sac)
o Speculum – quantity + location of bleeding, os open/closed, can remove any products
o Abdo exam – exclude ectopic (=unilateral tenderness, cervical excitation, adnexal mass) (do not perform a PV exam if suspecting an ectopic - might rupture)
• TVUS
o Dating pregnancies using USS
<14 weeks –> CRL
A foetal pole may not be seen until 9 weeks
>14 weeks –> AC, HC, FL
o Need GS + YS to be a viable IUP – otherwise PUL
o Process of TVUS
If there is no visible heartbeat – second scan should be performed at minimum of 7 or 14 days
Look for FH –> foetal poles (either crown or rump) or CRL –> if not foetal pole, look for GS
Miscarriage [cannot be diagnosed as miscarriage on 1 USS alone – get 2nd opinion/re-scan] if
• No FH + CRL >7mm
• GS >25mm + no foetus
PUV (pregnancy of unknown viability) –> TVUS in 7 days if
• No FH + CRL <7mm
• GS <25mm + no foetus
• Serum hcg
o Can help exclude an ectopic pregnancy in women with a complete miscarriage or PUL
o Serial tests are required – they should complement clinical assessment and not replace it
o Two tests are taken 48 h apart
>63% increase – ongoing pregnancy
>50% decrease – pregnancy is unlikely to continue
Consider rare causes of raised hcg – gestational trophoblastic disease, cranial gem cell tumour
• RMC (recurrent miscarriage) o Cytogenic analysis of products of conception o Pelvic USS (structural abnormalities) o Anti-phospholipid antibodies o Anticardiolipin antibodies o Screen for BV (bacterial vaginosis)
gestational trophoblastic disease ix
• URINE AND BLOOD LEVELS OF β-hcg
o Molar pregnancy
Blood βhcg grossly elevated – will be very high for gestation
Βhcg similar to TSH - low TSH, high T4
o Malignancy
Persistently raised βhcg or rising after ERCP (evacuation of retained products of conception)
FBC, LFTs (mets)
o Urine pregnancy test should be performed in all cases of persistent or irregular vaginal bleeding >8 weeks after a pregnancy event
o Women with persistent abnormal vaginal bleeding after a non-molar pregnancy should undergo a pregnancy test to exclude persistent GTN
o Women who receive care for a miscarriage should be recommended to do a urine pregnancy test 3 weeks after miscarriage
o Women who undergo medical abortions should be recommended to do a urine pregnancy test 3 weeks after the procedure
o Used as a biomarker
o Bhcg May be of value in diagnosing molar pregnancies but are far more important in disease follow-up
• HISTOLOGY
o To make a definitive diagnosis
o The diagnosis of complete mole, partial mole, atypical PSN, PSTT, ETT require histological confirmation
o The diagnosis of GTN does not require histological confirmation
o All products of conception from a non-viable pregnancy/miscarriages obtained from medical or surgical treatment should undergo histological examination to exclude trophoblastic disease/neoplasia if no fetal parts are identified at any stage of the pregnancy
o No need to routinely send products of conception for histological assessment after TOP, provided foetal parts have been identified on prior US
o All forms of GTD have distinctive morphological features, depending on which tissues they are derived from
• PELVIC USS
o USS in the first trimester may not be reliable
o Second trimester
o Complete mole: Snowstorm appearance Cluster of grapes No foetal parts Heterogeneous mass with not fetal development Theca-lutein ovarian cysts
o Incomplete mole
No snowstorm/cluster of grapes
Foetal parts
o Malignancy
Snowstorm, vesicles or cysts
• STAGING ix where metastatic disease is suspected
o Doppler pelvic USS for local pelvic spread + vascularity
o CXR or lung CT – lung metastases
o Liver/Intra-abdominal masses CT – CT CAP
o MRI scan – brain mets
Staging - FIGO staging system
Disease risk - FIGO staging for GTD
https://www.obgproject.com/wp-content/uploads/2018/06/thumbnail.jpg
gestational trophoblastic disease staging
FIGO
o Stage I – disease confined to the uterus
o Stage II – extends outside the uterus but is limited to the genital structures (adnexa, vagina, broad ligament)
o Stage III – extends to the lungs +/- genital tract involvement
o Stage IV – all other metastatic sites
PCOS ix
• Raised LH
• FSH normal
• Raised LH:FSH ratio (>2)
o These 3 parameters are not part of the diagnostic criteria and may be normal
o Oral contraceptive pills affect levels
o Helps to exclude premature ovarian insufficiency (LH + FSH both raised) + hypogonadotropic hypogonadism (LH + FSH reduced)
• Total testosterone – normal to slightly raised
o If total testosterone is >5 nmol/L, exclude androgen-secreting tumours and CAH
• Free testosterone – may be raised
• SHBG – normal to low
o Can be used to calculate the free androgen index = (100 x total testosterone)/SHBG
• Free androgen index – normal or elevated
o Can be used as an alternative to measuring free testosterone if this is not locally available
• Transvaginal/pelvic USS
o Pearl necklace sign
o Characteristic ovaries (the average volume is 3x that of normal ovaries)
o Increased ovarian volume >10mL in either or both ovaries
o 12 or more follicles in each ovary (measuring 2-9 mm)
and/or
• Tests to exclude other causes –
TFT
17-hydroxyprogesterone levels (CAH, excludes 21-hydroxylase deficiency)
prolactin (hyperprolactinaemia)
DHEA-S + free androgen index (androgen-secreting tumours)
24-h urinary cortisol (Cushing’s syndrome)
• Fasting glucose, OGTT – to assess insulin resistance/diabetes
o Look for impaired glucose tolerance/type 2 DM – fasting glucose
(N - <6.1
impaired fasting glucose – 6.1-6.9
diabetes >7)
HbA1c (>6.5%, >48mm)
if either of these are abnormal, do an OGTT
• Assess CV risk, incl. lipid levels
o Fasting lipid profile – raised total cholesterol, LDL, triglycerides, low HDL – dyslipidaemia often observes in PCOS
Subfertility investigations - history
• Ask about general health – weight, smoking, drinking, recreational drugs
• Ask about sexual history
o Frequency of coitus (ideally 2-3x/7)
o Any prolonged/recurrent absences of one of the partners
o Potential physical problems – inadequate penetration or dyspareunia
• PMH
o Previous treatment for malignancy – chemo (sterility), radiotherapy and surgery (may be relevant if they involved the pelvic region)
o Systemic disease (may interfere with the HPA axis)
Autoimmune disease – rheumatoid disease, SLE, APL
CKD
Poorly controlled DM
Anorexia nervosa – can cause anovulation amenorrhoea
• Medication and drug history
o Phenothiazines + older typical antipsychotics + metoclopramide – can increase levels of prolactin
o NSAID use is associate with luteinised unruptured follicles
o Immunosuppressants
Subfertility investigations - examination
Examination
• Increased androgen levels
o Hirsutism
o Acne
o Male pattern alopecia with slight bitemporal recession
o Pubic hairline may extend up towards the umbilicus in a typical male pattern
• Abdominal examination must precede bimanual pelvic examination
o Very easy to miss a large mass e.g. big ovarian cyst
• Gynaecological examination
o May indicate undisclosed sexual difficulties e.g. vaginismus
• Bimanual examination
o Adnexal mass from an ovary of tubo-ovarian mass
o Tenderness suggesting PID or endometriosis
o Presence of uterine fibroids
Subfertility investigations - primary care
• Mid-luteal progesterone level – to assess + confirm ovulation
o If low, may need repeating as ovulation does not occur every month
o Blood test is taken 7 days before the anticipated period (i.e. on day 21 of a 28 day cycle)
o If POI you cannot do this – there are no periods to base the measurement off
<16 nmol/l - repeat, if consistently low refer to a specialist
16-30 nmol/l - repeat
>30 nmol/l - indicated ovulation
• FSH + LH – should be measured if there is menstrual irregularity
o High levels – may suggest poor ovarian function
o A comparatively high LH level relative to FSH – can occur in PCOS
• Test for rubella status
o If susceptible to rubella – vaccinate + advise not to become pregnant for at least one month following vaccination
Subfertility investigations - secondary care
• TUBAL PATENCY – tubal damage is estimated to account for 20% of infertility in women
o Hysterosalpingogram (HSG) or hysterosalpingo-contrast USS For women who are not known to have comorbidities (e.g. PID, ectopic pregnancy, endometriosis)
o Laparoscopy and dye test
For women who have comorbidities
o Prior to undergoing uterine instrumentation, offer women screening for Chlamydia trachomatis + treat appropriately
o Prophylactic antibiotics should be considered before uterine instrumentation if screening has not been undertaken
• OVARIAN RESERVE TESTING
o Woman’s age should be used as an initial predictor of her overall chance of success through natural conception or with IVF
o One of the following measures should be used (measured around Day 3 of the menstrual cycle) to predict the likely ovarian response to gonadotrophin stimulation in IVF
Total antral follicle count (TVUS)
• <4 – low response
• >16 – high response
Anti-Mullerian hormone – will be low in infertility
• <5.4 pmol/L – low response
• >25.0 pmol/L – high response
FSH – will be high in infertility – inaccurate during the luteal phase as it is being suppressed by progesterone
• >8.9 IU/L – low response
• <4 IU/L – high response
o People undergoing IVF should be offered screening for (if positive – offer specialist advice + counselling + appropriate clinical management)
HIV
Hep B
Hep C
Subfertility ix
• Semen analysis
• Blood hormone profile
o Look at early follicular phase FSH, LH and oestradiol levels (day 2-3)
o AMH – assesses ovarian reserve
Independent of the menstrual cycle
Produced by granulosa cells and does not change in response to gonadotrophins – it is the most successful biomarker of ovarian reserve
o Mid-luteal progesterone – used to confirm ovulation
o If irregular menstrual cycle – TFTs, prolactin, testosterone
• Ovarian reserve testing
• Regularity of menstrual cycles
o Ask about frequency + regularity of menstrual cycles
o Regular monthly menstrual cycles – women are likely ovulating
o Mid-luteal progesterone level
o If prolonged irregular menstrual cycles - blood test for serum progesterone (Conducted later in the cycle e.g. day 28 of a 35-day cycle, Repeated weekly thereafter until the next menstrual cycle starts) + blood test for serum gonadotrophins (FSH, LH)
• Prolactin measurement
o Should only be offered to women who have an ovulatory disorder, galactorrhoea or a pituitary tumour
• Investigation of suspected tubal + uterine abnormalities
o Not known to comorbidities – Hysterosalpingography (HSG) or hysterosalpingo-contrast-ultrasonography – screens for tubal occlusion
o Comorbidities – laparoscopy + dye (so that tubal + pelvic pathology can be assessed at the same time)
o Should not be offered hysteroscopy unless clinically indicated
• Testing for viral status
o People undergoing IVF should be offered testing for HIV, Hep B, Hep C
• Susceptibility to rubella
• Screening for Chlamydia trachomatis
o Before undergoing uterine instrumentation women should be offered screening for Chlamydia trachomatis
o Prophylactic antibiotics should be considered before uterine instrumentation if screening has not been undertaken
• TVUS o Assessment of pelvic anatomy o Identify pathology o Antral follicle count (important parameter of ovarian reserve) <4 = poor response 16+ = good response
When to refer the woman earlier for infertility ix in secondary care
• An earlier referral for specialist consultation should be offered when
o Woman is >36 y/o
o There is a known cause of infertility
o There is hx of predisposing factors for infertility
o Ix show there is apparently no chance of pregnancy with expectant management
