OB-GYN Revision 11

Question 2

Name some risk factors for vulval cancer [5]

Answer 2

• Older age
• Human papilloma virus (HPV) infection
• Vulval intraepithelial neoplasia (VIN)
• Immunosuppression
• Lichen sclerosus - big one (5% get vulval cancer)

Question 4

What causes high grade [1] and differentiated [1] VIN?

Answer 4

High grade:
HPV infection - younger women

Differentiated:
- Lichen sclerosis - older women

Question 5

Explain the key risk factors for endometrial cancer [+]

Answer 5

Unopposed oestrogen (oestrogen without progesterone)
- this stimulates the endometrial cells and increases hyperplasia and cancer
- risk factors are associated w/ factors that cause increased lifetime exposure to oestrogen, such as

Age
Early onset of menstruation
Late menopause
Oestrogen only HRT
Fewer / no pregnancies
Obesity
PCOS
Tamoxifen
DMT2

Question 6

Explain why obesity increases the risk of endometrial cancer [3]

Answer 6

adipose tissue (fat) is a source of oestrogen:
- primary source in post-menopausal woemn
- contains aromatase, which converts testosterone into oestrogen
- This extra oestrogen is unopposed as there is no corpus luteum making progesterone

Question 7

Explain why PCOS increases the risk of endometrial cancer [3]

Answer 7

Polycystic ovarian syndrome leads to lack of ovulation - which causes an increased exposure to oestrogen
- Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg.
- It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle
- Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum causing more unopposed oestrogen exposure

Question 8

For endometrial protection, women with PCOS should have one of: [3]

Answer 8

The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed.

Question 9

Why does tamoxifen have an increased risk of endometrial cancer? [1]

Answer 9

Tamoxifen has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer.

Question 10

Why is DMT2 linked with increased risk of endometrial cancer? [1]

Answer 10

Type 2 diabetes may increase the risk of endometrial cancer due to the increased production of insulin. Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer

Also related to PCOS

Question 11

How do you investigate for endometrial cancer? [4]

Answer 11

TVUS:
- An endometrial thickness of >5mm is associated with a 96% probability of endometrial cancer.

Endometrial bx:
- confirmatory diagnosis of endometrial cancer and provides a means of histological identification.
- pipelle biopsy - can be taken in the outpatient clinic. It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus

Hysteroscopy, dilatation and curettage:
- performed under general anaesthesia and is useful for histological confirmation if endometrial biopsy cannot be performed/will not be tolerated by the patient.

CT chest, abdomen and pelvis:
- useful for staging if significant, advanced disease is suspected.

NB: ZtF:

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
- Postmenopausal bleeding (more than 12 months after the last menstrual period)

NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Question 12

What are the 4 stage of endometrial cancer? [4]

Answer 12

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

Question 13

How do you treat stage 1 and 2 endometrial cancers?

Answer 13

Treatment for stage 1 and 2 endometrial canceri:
- a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
- if a younger patient wishes to retain fertility, can be counselled on alternative therapy like using progestin (not common use)

Radiotherapy may be used for stage 1B+
- Vaginal brachytherapy and pelvic external beam radiotherapy (EBRT)
- Also for palliative care

Chemotherapy

Question 14

Endometrial cancer may easily be confused with other causes of abnormal vaginal bleeding. Name three causes [3]

Answer 14

Atrophic vaginitis
Endometrial hyperplasia
Endometrial polyp

Question 15

Describe how you differentiate endometrial cancer from endoemetrial hyperplasia [1]

Answer 15

Endometrial hyperplasia: occurs when the endometrial lining becomes too thick and mainly affects post-menopausal women.
- Can only be differentiated from endometrial cancer by biopsy.

Question 16

Describe the two types of endometrial tumours [2]

Answer 16

Type 1 tumours (adenocarcinomas) account for the majority of endometrial cancers, and are directly linked to long term exposure to increased oestrogen levels.
- Endometrial adenocarcinoma results from the abnormal proliferation of the endometrial glands due to chronic oestrogen stimulation of the endometrium

Type 2 tumours are rarer and have non-endometrioid histology.
* They are made up of serous and clear cell carcinomas.
* 90% of type 2 tumours are associated with p53 mutations.

Question 17

Describe the clincial presentation of endometrial cancers [5]

Answer 17

Abnormal Uterine Bleeding
- most common
- menorrhagia or irregular, intermenstrual spotting in pre-menopausal women
- any form of vaginal bleeding in post-menopausal women

Pelvic pain
Discharge - non bloody
Systemic features
Dysuria
Bowel changes

Question 18

Name three pelvic examination findings that may indicate endometrial cancer [3]

Answer 18

An enlarged uterus:
- While this finding is not specific to endometrial cancer, a significantly enlarged uterus may suggest the presence of a neoplasm.

Cervical stenosis or an irregular cervical canal:
- These findings may suggest malignancy and warrant further investigation

A palpable pelvic mass:
- A mass could indicate advanced disease or a different gynaecological malignancy such as ovarian cancer.

Question 19

Describe the difference in referral for endometrial thickness and PV bleeding/not for ?endometrial cancer [2]

Answer 19

If PV bleeding and endometrial thickness >4mm - refer

If no PV bleeding and endometrial thickness >11mm - refer

Question 20

What does this image show? [1]

Answer 20

TVS of uterus – thickened endometrium

Question 21

Which are the most common type of endometrial cancer? [1]

Answer 21

Adenocarcinomas:
- more than 75% are endometrioid
- also clear cell, uterine serous carcinomas

Question 22

How do you treat stage 3-4 endometrial cancers? [4]

Answer 22

Stage 3-4 disease:
- Individualised treatment depending on symptoms
- Consideration of hysterectomy – can be minimal access
- Lymphadenectomy – removal of bulky lymph nodes versus full lymphadenectomy (less benefit)
- Removal of all visible disease – likely to improve survival but evidence not as strong as in ovarian cancer

Question 23

A patient wants fertility sparing treatment for their endometrial cancer

What is the treatment that can be given [1]
What stage of cancer would they need to have for this? [1]

Answer 23

Hormonal treatment: Grade 1A
- Mirena Coil +/- oral progesterones

NB: also if unfit for surgical management

Question 24

An endometrial cancer is dx as being a sarcoma.

What is the most common type? [1]

Answer 24

Leiomyosarcoma
Endometrial stromal sarcoma, low grade or high grade
Undifferentiated sarcoma

Question 25

What is important to note about carcinosarcoma endometrial cancers? [1]

Answer 25

**carcinosarcoma** are aggressive tumours with a poor prognosis - they are adenocarcinoma but behave like both types of cancer (adeno and sarcoma)

Question 26

Endometrial cancers are classified according to TCGA (The Cancer Genome Atlas) classification. Which mutations determine this? [2]

Answer 26

**TP53** and **POLE** (polymerase epsilon) **mutation**

Question 27

The following are all types of endometrial carcinoma based off molecular stratification. Which of the following is aggressive and will require adjuvant treatment? MMR abnormal POLE mutant P53 wild type P53 mutant

Answer 27

The following are all types of endometrial carcinoma based off molecular stratification. Which of the following is aggressive and will require adjuvant treatment? MMR abnormal POLE mutant P53 wild type **P53 mutant**

Question 28

The following are all types of endometrial carcinoma based off molecular stratification. Which of the following is associated with Lynch syndrome? MMR abnormal POLE mutant P53 wild type P53 mutant

Answer 28

The following are all types of endometrial carcinoma based off molecular stratification. Which of the following is associated with Lynch syndrome? **MMR abnormal** POLE mutant P53 wild type P53 mutant

Question 29

Radiotherapy is an adjuvant treatment for endometrial cancer. Which stages are indicated for it? [2] What are the modalities? [3]

Answer 29

**Radiotherapy**: - improves local control but not survival **Indications** * ?stage 1b grade 3 * Stage II-III **Modalities**: * Brachytherapy * External beam pelvic RT * Extended field

Question 30

Where is the most common place for endometrial cancer to reoccur? [1] How do you treat? [+]

Answer 30

Vault

Question 31

# Lecture: Describe the bimodal development of vulval cancers and how this is clinically significant [+] ## Footnote *Important to note - he said in lecture*

Answer 31

**Bimodal developmental pathway: HPV dependent and HPV independent** **HPV dependent**: - **younger** **age** group and **radiosensitive**, better prognosis - **HPV dependent associated with anal, vaginal and cervical tumours** - **Associated** with **VIN** **HPV Independent** - Older women; from lichen sclerosus - Worse prognosis

Question 32

Descrribe the aetiology of endometriosis [3]

Answer 32

**During** **menstruation**, the **endometrial** lining **flows backwards,** **through** the **fallopian tubes** and out **into** the **pelvis** and **peritoneum**. - This is called **retrograde menstruation.** The endometrial tissue then seeds itself around the pelvis and peritoneal cavity. Other possible causes: - **Embryonic** **cells** destined to become endometrial tissue may **remain in areas outside the uterus during the development of the fetus**, and later develop into ectopic endometrial tissue. OR - There **may be spread of endometrial cells** through the **lymphatic system**, in a similar way to the spread of cancer. OR - a process called **metaplasia** occurs, from typical cells of that organ into endometrial cells. ## Footnote NB: exact cause is unknown

Question 33

Describe the pathophysiology of the symptoms of endometriosis [3]

Answer 33

**The main symptom of endometriosis is pelvic pain** - During **menstruation** as the endometrial tissue in the **uterus** **sheds** its lining and bleeds, the **same thing happens** in the **endometrial** **tissue** **elsewhere** in the body. - This causes **irritation** and **inflammation** of the **tissues** around the **sites** of endometriosis - This results in the **cyclical, dull, heavy or burning pain** that occurs **during** **menstruation** in patients with endometriosis. **Deposits** of **endometriosis** in the **bladder** or **bowel** can lead to **blood in the urine or stools**. **Localised bleeding** and **inflammation** can lead to **adhesions**: - Adhesions lead to a **chronic, non-cyclical pain** that can be **sharp, stabbing** or pulling and associated with nausea.

Question 34

Why might endometriosis cause subfertility? [3]

Answer 34

The **pathophysiology** is **not** **fully** **understood** however current theories suggest that endometriotic lesions cause subfertility via: * The **release** of **cytokines** causing **acute and chronic inflammation in the fallopian tubes** and **ovaries**, as a result these **tissues** become **scarred and fibrosed**, rendering them **unable to function** * The **formation of adhesions and fibrosis** due to **lesions between the uterus, ovaries, fallopian tubes** and surrounding structures leading to a **distortion of the pelvic anatomy** * **Ovulatory dysfunction**. This is thought to occur due to the **formation of endometriomas**, **chronic** **inflammation** or the **surgical removal of deep-rooted endometriomas**, which has been **linked to the destruction of primordial follicles and scarring of the ovaries**

Question 35

Describe the clinical features of endometriosis [5]

Answer 35

**Chronic pelvic pain** lasting more than **6 months** - in **established disease pain can last everyday** for at least 6 months **Cyclical pelvic symptoms** i.e. symptoms that may only present or **worsen during menstruation**, including: - **Dysmenorrhoea** - **Cyclical GI symptoms** - **painful** **defecation**/ bowel movements: feels like **hot rod** when passing stool. Also **loose stools**. **Blood in stool** - **Cyclical urinary symptoms** - **pain** passing **urine** and **blood in urine** **Dyspareunia** (deep pain during or after sexual intercourse) **Subfertility** in up to 30-50% of women

Question 36

Describe how a clinical examination may present for a patient with endometriosis [4]

Answer 36

* **Endometrial tissue** **visible** in the **vagina** on **speculum examination, particularly in the posterior fornix** * A **fixed** **cervix** on **bimanual examination** * **Tenderness** in the **vagina, cervix and adnexa**

Question 37

Describe how you investigate for endometriosis [3]

Answer 37

**1st line: Transvaginal ultrasound** Identification of: - **Endometriomas** (endometrial cysts on the ovary) - **Superficial peritoneal lesions** - **Deep endometrial lesions** involving the bowel, bladder or ureters - However: picks up deep lesions, but not superficial. **Abdominal US** - If TVUS refued **Pelvic MRI** * Not used as primary investigation but may be considered to assess the extent of deep endometriosis involving the bowel, bladder or ureters **Laparoscopic surgery** - **gold standard way** to diagnose abdominal and pelvic endometriosis. - A **definitive diagnosis** can be established with a **biopsy** of the lesions during laparoscopy. - Laparoscopy has the added benefit of allowing the surgeon to **remove deposits of endometriosis and potentially improve symptoms.** ## Footnote **NB**: - Diagnostic laparoscopy traditionally gold standard but we are moving away from this - **Presumptive diagnosis** based on symptoms and signs

Question 38

What blood test might indicate endometriosis? [1]

Answer 38

This is not used to diagnose endometriosis. **A raised serum CA125** (**> 35 IU/ml or more**) may be consistent with having endometriosis however endometriosis can still occur despite a normal serum CA125

Question 39

If you find growths or adhesions in the pelvis, what other pathologies do you need to consider? [2] How would you differentiate? [1]

Answer 39

**ovarian cancer and colon cancer** are important to exclude after evidence is found of growths and adhesions in the pelvis. - **cancer and endometriosis is the age of presentation**, **ovarian** and **colon** **cancer** tend to present most commonly in **menopausal/post-menopausal women**, and thus endometriosis is significantly less likely in these patients. It is however important to remember that ovarian and colon cancer can still occur in younger

Question 40

What are the different stages of endometriosis? [4]

Answer 40

**Stage I:** - Minimal disease is characterized by isolated implants and no significant adhesions. **Stage II:** - Mild endometriosis consists of superficial implants that are less than 5 cm in aggregate and are scattered on the peritoneum and ovaries. No significant adhesions are present. **Stage III:** - Moderate disease exhibits multiple implants, both superficial and deeply invasive. Peritubal and periovarian adhesions may be evident. **Stage IV:** - Severe disease is characterized by multiple superficial and deep implants, including large ovarian endometriomas. Filmy and dense adhesions are usually present. ## Footnote **NB**: It is worth being aware of this staging system; however, it is not mentioned in the NICE guidelines, and does not necessarily predict the symptoms or the difficulty in managing the condition. NICE recommend documenting a detailed description of the endometriosis rather than using a specific staging system. The ASRM staging system grades from least to most severe:

Question 41

Describe the different management options for endometriosis [+]

Answer 41

**Analgesia**: - A short trial (3 months) of **paracetamol or an NSAID** alone or in combination should be considered for first-line management of endometriosis-related pain - Endometriosis specialists can prescribe **amitrypline or pregabalin** **Hormonal management** - works by suppressing ovarian function and oestrogen release - **COCP** - **POP** - **Mirena coil (IUS)** - **Medroxyprogesterone acetate injection** (e.g. Depo-Provera) - **GnRH agonists** - for more severe / if don't respond. **Hypogonadotropic hypogonadal state** **Surgical management options:** * **Laparoscopic surgery** to excise or ablate the endometrial tissue and remove adhesions - **GOLD STANDARD** - **Abdominal hysterectomy** **with or without bilateral salpingo-oophorectomy** is considered to be the most effective and last-line treatment available for treating the symptoms of endometriosis

Question 42

Describe the complications of endometriosis [4]

Answer 42

* **Infertility** * **Adhesions**, due to the 'sticky' nature of endometriotic lesions, leading to inflammation and obstruction of fallopian, GI, and ureteric tracts * **Endometrioma/ chocolate cyst rupture,** leading to acute pain and peritoneal signs * **Increased risk of early miscarriage or ectopic pregnancy** * **Surgical complications** (infection; perforation, bleeding, failure to remove all lesions)

Question 43

How would you treat fertility in endometriosis? [3]

Answer 43

Surgery: - clear adhesions surrounding ovaries - Remove cysts on ovaries - Normalise position of ovaries / uterus

Question 44

What are the features of adenomyosis? [3]

Answer 44

* dysmenorrhoea * menorrhagia * enlarged, boggy uterus * Pain during intercourse (dyspareunia)

Question 45

Describe how you would dx adenomyosis? [3]

Answer 45

**Transvaginal ultrasound** of the pelvis is the first-line investigation for suspected adenomyosis. **MRI** and **transabdominal ultrasound** are alternative investigations where transvaginal ultrasound is not suitable. The **gold standard is to perform a histological** **examination** of the **uterus** after a **hysterectomy**. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Question 46

How do you manage adenomyosis if: - the patient does not want contraception [2] - the patient accepts mx with contraception [3] - other (surgical) options [3]

Answer 46

**When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with**: * **Tranexamic acid** when there is **no associated pain** (antifibrinolytic – reduces bleeding) * **Mefenamic acid when there is associated pain** (NSAID – reduces bleeding and pain) **Management when contraception is wanted or acceptable:** * **Mirena coil** (first line) * **Combined oral contraceptive pill** * **Cyclical oral progestogens** **Other & Surgical** * **GnRH agonists** - to induce a menopause-like state * **uterine artery embolisation** * **hysterectomy** - considered the 'definitive' treatment

Question 47

Why would you do an abdominal exam if ?endometriosis? [1]

Answer 47

ID **abdominal wall endometriosis** and assess for **signs** of **peritonism**

Question 48

You suspect endometriosis in a patient. What examinations would you perform? [+]

Answer 48

**Abdominal exam:** - ID **abdominal wall endometriosis** and assess for **signs** of **peritonism** **Pelvic exam: speculum and bimanual** - ID areas of tissue present: in cervix or rectovaginal space - Bimanual exam will ellicit tenderness

Question 49

What does this image show? [1]

Answer 49

Umbilical endometrial lesion

Question 50

If deep endometriosis is suspected - what is often the first line Ix? [1]

Answer 50

**Pelvic MRI**

Question 51

What is important to note about laparoscopic investigations for endometriosis? [1]

Answer 51

50% don't reveal anything and can lead to dissapointment for women

Question 52

Describe what this image shows? [1]

Answer 52

**Endometriosis typica:** - **superficial endometriosis** - blue, black or red lesions often clustered together - fibrotic tissue which has formed small nodule on peritoneum. can be palpated with surgical instruments

Question 53

Describe what this image shows? [1]

Answer 53

**Superficial** **endometriosis** with **fibrosis of nodule at base** - caused **involution of tissue** and caused **peritoneal** **pocket** called **Alan masters pouch**

Question 54

Describe what this image shows? [1]

Answer 54

**Superficial endometriosis** - **Tannin** **deposit** caused by endometriosis ## Footnote **NB**: looks like a cigarette burn

Question 55

Answer 55

**Deep endometriosis** on the bowel

Question 56

How does the endometriosis lecturer describe how to take COCP? [1]

Answer 56

I tend to recommend ‘**flexible extended use**’, where the woman takes the **pill continuously** until she **experiences bleeding.** She can then **stop the pill for 4 days** to have a short period and then restart continuously again. **This limits the length of period and the number of periods per year and gives greater control**.

Question 57

Describe what is meant by Dienogest? [+] - Main side effect [1] - Other advise [1]

Answer 57

Recently licenced **POP** in the UK after a long delay – only for women with **endometriosis** AKA Zalkya®/Visanne® **Less androgenic** than other progestogens - so less side effects **Main side effect is vaginal spotting** **Manufacturer advises** **additional** **contraception**

Question 58

What are the main benefits of Dienogest? [3]

Answer 58

**Less androgenic** than other progestogens - **so less side effects** Particularly useful for: - **Volume reduction of endometriomas** - **Reduction of size of deep endometriotic nodule**

Question 59

**GnRH agonists** can be used for endometriosis. What might you give alongside this [2] What management would you also need to do

Answer 59

Give **HRT** as induces menopausal like state **Encourage excersise and good diet** Give **bisphosphinates** as GnRH analogues can cause osteoporosis - Start **DEXA** scan at **time of treatment and repeat after two years**

Question 60

Where should patients with deep endometriosis be treated? [1]

Answer 60

**Tertiary endometriosis centres**

Question 61

What advise would you give about endometriosis and subfertility to a patient? [4]

Answer 61

Most women with endometriosis will conceive spontaneously, however, endometriosis is a leading cause of subfertility Laparoscopic treatment of SPE improves spontaneous fertility rates Laparoscopic treatment of DPE is more controversial and MDT input is advisable Ovarian endometriomas result in reduced monthly fecundity rates