OB-GYN Revision 13

Question 2

A diagnosis of PCOS requires at least two of: [3]

Answer 2

Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound

Question 3

Describe the presentation of ovarian cysts [5]

Answer 3

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.

Occasionally, ovarian cysts can cause vague symptoms of:
* Pelvic pain
* Bloating
* Fullness in the abdomen
* Pain during sex
* A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
* Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst

Question 4

Describe the difference between follicular and corpus luteums cysts [2]

Answer 4

Follicular cysts
- represent the developing follicle.
- When these fail to rupture and release the egg, the cyst can persist.
- Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles.
- Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.

Corpus luteum cysts
- occur when the corpus luteum fails to break down and instead fills with fluid.
- They may cause pelvic discomfort, pain or delayed menstruation.
- They are often seen in early pregnancy.

Question 5

Give a basic overview of the follicular and luteal phase of an average cycle with regards to structures created in the ovaries [2]

Answer 5

First two weeks of average 28 day cycle, the ovaries go through the follicular phase:
- couple of follicles become the dominant follicle that releases an ovum in ovulation
- the rest degress and die off
- the follicles secrete oestrogen - which inhibits FSH

At ovulation the oocyte is released into the fallopian tube and luteal phase begins (remaining 2 weeks of 28 day cycle):
- corpus luteum (remnant of ovarian follicle) makes progesterone, which inhibits LH
- if fertilisation occurs the corpus luteum continues to make progesterone until the placenta forms.
- If no fertilisation, then becomes fibrotic and becomes the corpus albicans

Question 6

Describe what theca lutein cysts are [1] and when they occur [2]

Answer 6

Caused by overstimulation of hCG during pregnancy
- stimulates growth in follicular theca cells
- occur in high hCG: multiple pregnancy; trophoblastic disease

NB: Theca cells are essential for female reproduction being the source of androgens that are precursors for follicular oestrogen synthesis

Question 7

Describe what is meant by a Dermoid Cysts / Germ Cell Tumours [1]

What pathology are they particularly associated with? [1]

Answer 7

These are benign ovarian tumours.

They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone.

They are particularly associated with ovarian torsion.

Question 8

Which type of tumours are the most common type in young women? [1]

Answer 8

Mature cystic teratomas

Question 9

What are the two types of serous and mucinous cysts? [2]

Answer 9

Serous or Mucinous cystadenomas

Serous or Mucinous cystadenocarcinomas

Question 10

Which investigations would you conduct for ?ovarian cysts [2]

Answer 10

Blood tests:
- If premenopausal w simple cyst < 5cm on US - none
- CA125 helps determine if cyst is related to cancer
- If under 40 and complex cysts - need tumour markers (AFP; LDH; HCG)

Abdominal Ultrasounds:
* simple: unilocular, more likely to be physiological or benign
* complex: multilocular, more likely to be malignant

Question 11

As per RCOG how do you monitor cysts if:

o If pre-menopausal + asymptomatic simple cyst < 5 cm [1]
o If 5-7 cm –> [1]
o If > 7 cm –> [1]
o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> [1]
o If post-menopausal –> [2]

Answer 11

o If pre-menopausal + asymptomatic simple cyst < 5 cm –> no follow-up

o If 5-7 cm: - repeat USS in 1 year, and if growing –> refer

o If > 7 cm –> refer

o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> refer

o If post-menopausal –> CA-125, and if normal + asymptomatic simple cyst < 5 cm –> repeat USS in 4-6 months

Question 12

What would be the referral protocol if:
- postmenopausal, raised CA125

Answer 12

• Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral.
• Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Question 13

Describe what is meant by Meig’s syndrome [3]

Answer 13

• Meig’s syndrome involves a triad of:
• Ovarian fibroma (a type of benign ovarian tumour)
• Pleural effusion
• Ascites

Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.

Question 14

Describe the examination results of ovarian torsion [2]

Answer 14

On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.

Question 15

Describe why you should still suspect ovarian torsion in younger girls [1]

Answer 15

Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.

Question 16

Describe the diagnosis and management of ovarian torsion [3]

Answer 16

Diagnosis:
Pelvic US:
- Transvaginal is 1st choice, but transabdominal can also be used
- “whirlpool sign”: free fluid in pelvis and oedema of the ovary.
- Doppler studies may show a lack of blood flow
- The definitive diagnosis is made with laparoscopic surgery.

Management:
Laparoscopic surgery to either:
* Un-twist the ovary and fix it in place (detorsion)
* Remove the affected ovary (oophorectomy)

Question 17

It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.

What are these other conditions? [2]

Answer 17

Lichen simplex
- chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

Lichen planus
- an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Question 18

Lichen sclerosus carries a small risk of malignant transformation to [] due to chronic inflammation and cellular atypia.

Answer 18

Lichen sclerosus carries a small risk of malignant transformation to squamous cell carcinoma due to chronic inflammation and cellular atypia.

Question 19

Describe the presentation of anogenital lichen sclerosus [5]

Answer 19

Pruritus:
- This is typically the earliest and most common symptom. It may be severe and unresponsive to topical treatments.

Dyspareunia:
- Pain during sexual intercourse is a common complaint due to atrophic changes leading to skin fragility and fissures.

Pain and discomfort:
- These are frequently reported symptoms which may be exacerbated by secondary infection or trauma.

Physical changes: The skin may appear pale or white with a shiny surface. There may be visible thinning (atrophy) or thickening (hyperkeratosis).
Wrinkling of the skin may disappear (effacement), especially noticeable on the labia minora in women or foreskin in men.

Question 20

Describe the anatomical alterations that can ocur in anogenital lichen sclerosus [3

Answer 20

Anatomic alterations: Chronic disease can lead to significant architectural distortion including phimosis in males, narrowing of the vaginal introitus, adhesions, fusion of labia minora, clitoral hood obliteration and burying of the clitoris in females.

Question 21

Describe the extragenital lichen sclerosus manifestations [3]

Answer 21

This form typically presents as asymptomatic white patches with follicular delling (plugging). The plaques might have a smooth surface but hyperkeratotic papules could also be present.
* Most common sites of involvement are the trunk, proximal extremities and scalp. However, any part of the body can be affected excluding the palms and soles.

Question 22

Which associated autoimmune pathologies are linked to lichen sclerosus? [4]

Answer 22

thyroid disease, vitiligo, alopecia areata and pernicious anaemia.

Question 23

Describe the diagnosis of lichen sclerosus [2]

Answer 23

The RCOG advises the following:
- Skin biopsy is not necessary when a diagnosis can be made on clinical examination.
- Biopsy is required if the woman fails to respond to treatment or there is clinical suspicion of VIN or cancer

Question 24

What are the 4 types of FGM? [4]

Answer 24

Type 1: Removal of part or all of the clitoris

Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.

Type 3: Narrowing or closing the vaginal orifice (infibulation).

Type 4: All other unnecessary procedures to the female genitalia.

Question 25

You identify a case of FGM. How do you handle this situation?

Answer 25

It is **mandatory** to **report** all cases of **FGM** in patients **under 18 to the police**. Also get the following involved: * **Social services and safeguarding** * **Paediatrics** * **Specialist gynaecology or FGM services** * **Counselling** **In patients over 18**: - careful consideration about whether to report cases to the police or social services. - The RCOG recommends using a risk assessment tool to tackle this issue (available on the gov.uk website). The risk assessment includes considering whether the patient has female relatives that may be at risk.

Question 26

Describe what is meant by a transverse vaginal space [1]

Answer 26

**Transverse vaginal septae** is caused by an error in development, where a **septum (wall) forms** **transversely** **across** the **vagina**. This **septum** can either be **perforate** (with a **hole**) or **imperforate** (**completely** **sealed**). - Where it is **perforate**, girls will still **menstruate**, but can have difficulty with **intercourse or tampon use.** - Where it is **imperforate**, it will **present** **similarly** to an **imperforate** **hymen** with **cyclical pelvic symptoms without menstruation**

Question 27

How do you manage transverse vaginal septae? [1] What are the main complications? [2]

Answer 27

Treatment is with **surgical** **correction**. The main complications of surgery are **vaginal stenosis and recurrence of the septae.**

Question 28

Describe what is meant by Vaginal Hypoplasia and Agenesis [2] Why do they occur? [1]

Answer 28

**Vaginal** **hypoplasia** refers to an **abnormally small vagin** **Vaginal agenesis** refers to an **absent vagina** These occur due to **failure of the Mullerian ducts to properly develop**, and may be **associated with an absent uterus and cervix**. The ovaries are usually unaffected, leading to **normal female sex hormones.** The exception to this is with** androgen insensitivity syndrome,** where there are testes rather than ovaries.

Question 29

Define Asherman's syndrome [1]

Answer 29

**Asherman**’s **syndrome** is where **adhesions** (sometimes called synechiae) **form within the uterus**, following **damage** to the **uterus**.

Question 30

Explain when Asherman's syndrome occurs and the pathophysiology? [3]

Answer 30

After a **pregnancy-related dilatation and curettage procedure**, for example in the treatment of **retained products of conception** (removing placental tissue left behind after birth). It can also occur after **uterine** **surgery** (e.g. myomectomy) or **several pelvic infection** (e.g. endometritis). **Endometrial** **curettage** (scraping) can **damage the basal layer of the endometrium**. This damaged tissue may heal abnormally, **creating scar tissue** (adhesions) **connecting** **areas** of the **uterus** that are generally **not** **connected** - There **may be adhesions binding** the **uterine** **walls** **together**, or **within the endocervix**, sealing it **shut**.

Question 31

Describe the typical presentation of Asherman's syndrome [4]

Answer 31

**Asherman’s syndrome** typically presents following **recent dilatation and curettage**, **uterine** **surgery** or **endometritis** with: * **Secondary** **amenorrhoea** (absent periods) * **Significantly** **lighter** **periods** * **Dysmenorrhoea** (painful periods)

Question 32

What are the options for dx Asherman's? [4] Which is the gold standard? [1]

Answer 32

* **Hysteroscopy** is the gold standard investigation, and can involve dissection and treatment of the adhesions * **Hysterosalpingography**, where contrast is injected into the uterus and imaged with xrays * **Sonohysterography**, where the uterus is filled with fluid and a pelvic ultrasound is performed * **MRI scan**

Question 33

Describe how Nabothian Cysts occur [2]

Answer 33

The **columnar epithelium of the endocervix** (the **canal**) produces **cervical** **mucus**. When the **squamous** **epithelium** of the **ectocervix** slightly **covers** the **mucus-secreting columnar epithelium**, the **mucus** becomes **trapped** and forms a **cyst** . This can happen after **childbirth**, **minor trauma to the cervix or cervicitis secondary to infection.**

Question 34

Describe the presentation of nabothian cysts [2]

Answer 34

**Nabothian cysts appear** as **smooth rounded bumps** on the **cervix**, usually **near to os** (opening). They can range in size from **2mm to 30mm**, and have a **whitish or yellow appearance.** ## Footnote **TOM TIP:** It is worth becoming familiar with photographs of nabothian cysts. They are relatively common. They can have a raised and discoloured appearance, creating concern when you first see them. With practice, you will be able to identify them correctly, and the woman can be reassured. Getting a senior opinion if there is any doubt creates a feedback loop that helps you confirm your impression and build your confidence in making the correct diagnosis.

Question 35

Describe what a cervical ectropian is [2]

Answer 35

On the **ectocervix** there is a **transformation** **zone** where the **stratified squamous epithelium** meets the **columnar** **epithelium** of the cervical canal - **Elevated oestrogen levels** (ovulatory phase, pregnancy, combined oral contraceptive pill use) **result in larger area of columnar epithelium being present on the ectocervix**

Question 36

How do you treat cervical ectropian? [1]

Answer 36

Treatment involves **cauterisation** of the ectropion using **silver nitrate or cold coagulation** during **colposcopy**. ## Footnote **NB**: asymptomatic ectropion do not require treatment

Question 37

Describe what is meant by a vault prolapse [1] When does it occur? [1]

Answer 37

**Vault prolapse** occurs in women that have had a **hysterectomy**, and **no longer have a uterus.** **The top of the vagina (the vault) descends into the vagina**.

Question 38

Define rectocele [1]

Answer 38

**Rectoceles** are caused by a **defect** in the **posterior vaginal wall**, allowing the **rectum** to **prolapse forwards into the vagina.**

Question 39

Describe the presentation of rectocele [3]

Answer 39

Rectoceles are particularly associated with **constipation**. Women can develop **faecal loading** in the part of the rectum that has **prolapsed** into the **vagina**. Loading of faeces results in **significant constipation, urinary retention** (due to compression on the urethra) **and a palpable lump in the vagina.**

Question 40

Describe what is meant by a cystocele [1] What is a urethrocele and a cystourethrocele? [2]

Answer 40

**Cystoceles** are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (**urethrocele**). Prolapse of both the **bladder** and the **urethra** is called a **cystourethrocele**.

Question 41

What are the 4 grades of uterine prolapse? [4]

Answer 41

**Grade 0**: Normal **Grade 1:** The lowest part is more than 1cm above the introitus **Grade 2:** The lowest part is within 1cm of the introitus (above or below) **Grade 3:** The lowest part is more than 1cm below the introitus, but not fully descended **Grade 4**: Full descent with eversion of the vagina

Question 42

How do you manage uterine prolapse? [3]

Answer 42

**Pelvic floor physiotherapy** for stage 1-2 prolapse **Pessary use** - inserted into vagina to provide extra support to the pelvic organs - oestrogen cream helps prevent vaginal walls from irritation **Surgery**: - **Anterior or posterior colporrhaphy**: reinforce the pubocervical fascia or the rectovaginal fascia to support structures - **Sacrocolpopexy**: Considered for apical prolapse. Attach the vaginal vault or cervix to the sacral promontory using synthetic mesh.

Question 43

For management of associated urinary incontinence, NICE guidelines recommend offering a trial of **[]** least 3 months before considering surgical options such as midurethral sling procedures

Answer 43

NICE guidelines recommend offering a trial of **supervised pelvic floor muscle training** for at **least 3 months** before considering surgical options such as midurethral sling procedures

Question 44

Pelvic organ prolapse can be classified according to the affected compartments. What are they? [3]

Answer 44

**Anterior** **compartment**: - cystocele (bladder herniation) and urethrocele (urethral herniation) **Middle compartment**: - uterine prolapse (uterus descent) and vaginal vault prolapse (post-hysterectomy) **Posterior compartment**: - rectocele (rectal herniation) and enterocele (small bowel herniation)