Reproductive system - Level 2.3 Flashcards
1
Q
Epidemiology of cervical cancer?
A
- 3rd most common gynaecological cancer after uterus and ovary
- Most common cancer in women under 35
- Age peaks 25-34
2
Q
Definition of CIN?
A
• Cervical intraepithelial neoplasia (CIN) precursor lesion for carcinoma of the cervix
o CIN 1 – disease confined to lower third of epithelium
o CIN 2 – disease confined to lower and middle thirds of epithelium
o CIN 3 – affecting full thickness
3
Q
Classes of cervical cancer?
A
o Breeches epithelial basement membrane
o If deepest part is <5mm from surface of epithelium – micro-invasive
o If it extends beyond 5mm or wider than 7mm – invasive carcinoma
4
Q
Types of cervical cancer?
A
- Squamous cell = 70%
- Adenocarcinoma = 15%
- Mixed = 15%
- Neuroendocrine tumour, clear cell carcinoma, glassy cell carcinoma, sarcoma botryoides, lympohoma = <1%
5
Q
Spread of cervical cancer?
A
- Direct = Parametrium, vagina, bowel and bladder and then to the pelvic side wall.
- Lymphatic = parametrial nodes, internal, external and common illiac nodes, obturator nodes, pre-sacral and para-aortic nodes
- Ovarian spread is rare
- Haematological = liver and lungs
6
Q
Risk factors of cervical cancer?
A
- Exposure to HPV (early first sexual experience, multiple partners, non-barrier contraception)
- COCP
- High parity
- Smoking
- Immunosuppression (esp. HIV and transplant patients)
7
Q
Symptoms of cervical cancer?
A
Common symptoms
o Post-coital bleeding (PCB)
o Post-menopausal bleeding
o Vaginal discharge - blood stained, offensive, serous
Late Symptoms • Painless haematuria • Urinary frequency • Weight loss • Bowel disturbance • Fistula • Pain
8
Q
Signs of cervical cancer?
A
o White or red patches on cervix
o Roughened hard cervix or ulcer +/- loss of fornices
o Fixed cervix if there is extension of the disease
9
Q
When to refer of cervical cancer - postmenopausal?
A
o Refer all women urgently to gynaecology if suspicious, persistent vaginal discharge not explained
2-week gynaecology clinic if not on HRT and vaginal bleeding or persistent or unexplained vaginal bleeding after stopping HRT for 6 weeks
10
Q
When to refer of cervical cancer - premenopausal?
A
Gynaecology clinic if persistent intermenstrual bleeding, post-coital bleeding, blood-stained discharge
2-week if negative pelvic exam, not had smear, >3 months, new symptoms
11
Q
Investigations of cervical cancer?
A
o Colposcopy
Cervix visualised, transformation zone is identified and painted with acetic acid, taken up by neoplastic cells
Aceto-white areas identify abnormal areas and enable punch biopsy to be taken to diagnose histologically
Punch biopsies for histology (not LLETZ in cancer)
Irregular cervical surface, abnormal vessels dense aceto-white changes.
o Bloods - FBC, U&Es, LFTs
o Fitness for surgery- CXR, U&E, FBC, IV pyelogram
12
Q
Staging investigations of cervical cancer?
A
o CT abdomen and pelvis o MRI pelvis o EUA (bimanual vaginal examination, cystoscopy, hysteroscopy, PV/PR examination)
13
Q
Staging of cervical cancer?
A
• FIGO Staging
o 0 – no primary tumour
o Tisb – carcinoma in-situ (pre-invasive)
o 1 – confined to uterus
o 2 – Extended locally to upper 2/3 of vagina
o 3 – Spread to lower 1/3 of vagina +/- hydronephrosis
4 – spread to blader or rectum
14
Q
Vaccinations of cervical cancer?
A
- Part of the NHS childhood vaccination programme – will include boys next academic year 2019/20
- Gardasil (Merck) – HPV 16, 18 + 6, 11 (used)
- Cervarix (GSK) – HPV 16, 18
15
Q
Management of CIN1?
A
o If HPV +ve offer 6-month colposcopy and LLETZ if persistent
LLETZ – large loop excision of transformation zone, dine under LA with loop diathermy
16
Q
Management of CIN2/3?
A
o Excised with LLETZ, smear at 6 months with high-risk HPV testing
o If negative, return to 3-year smears
o If abnormal, repeat assessment with colposcopy
17
Q
Management of cervical cancer - Stage 1A1?
A
Stage 1A1 (<3mm depth)
o Local excision (radical trachelectomy, cervicectomy) or hysterectomy
18
Q
Management of cervical cancer - Stage 1A2 & 1B1?
A
Stage 1A2 (<5mm depth) and 1B1 (<4cm diameter)
o Lymphadenectomy and if node negative, proceed to Wertheim’s hysterectomy
Excision of primary tumour with 1cm margin and en bloc resection of main pelvic lymph node areas
May involve – removing upper 1/3 of vagina and ligaments
19
Q
Management of cervical cancer - Stage 1B2?
A
o Chemoradiotherapy (cisplatin) Involves external beam and brachytherapy o If negative lymph nodes, consider Wertheim’s hysterectomy
20
Q
Management of cervical cancer - >Stage 2B?
A
o Combination chemoradiotherapy (cisplatin)
Involves external beam and brachytherapy
21
Q
Management of cervical cancer - Stage 4B?
A
o Chemoradiotherapy (cisplatin) Involves external beam and brachytherapy o Palliative radiotherapy to control bleeding
22
Q
Complications of Weirthem’s hysterectomy?
A
- Bleeding
- Infection
- DVT/PE
- Ureteric fistula
- Bladder dysfunction
- Lymphoedema
- Lymphocysts
23
Q
Compications of radiotherapy for cervical cancer?
A
- Acute bowel and bladder dysfunction (tenesmus, mucositis, bleeding)
- 5% late bowel and bladder dysfunction (ulceration, strictures, bleeding, fistula formation)
- Vaginal stenosis, shortening and dryness
24
Q
Follow up of cervical cancer?
A
- Patients are reviewed at 6 weeks post treatment, every 3-4 months for 1-2 years, annually for a total of 5 years
25
Survival of cervical cancer
- 90% survival in women under 40 years of age
- 1-year survival >80%
- 5-year survival >65%
26
Epidemiology of endometrial cancer?
* 4th most commonly diagnosed cancer in women in the UK
* More than 9 in 10 cases are diagnosed in women aged 50 and over
* North America 7:1 China
27
Pathology of endometrial cancer?
* Endometrial hyperplasia with atypia (but not without) is a premalignant condition
* Unopposed oestrogen leads to hyperplasia - predisposing to cytological atypia - precancerous
28
Types of endometrial cancer?
- Adenocarcinomas (80%)
o Main types: oestrogen-dependent endometrioid (Type 1) and oestrogen-independent non-endometrioid (Type 2)
- Adenosquamous carcinoma
- Clear cell or papillary serous carcinoma
- Mixed mesodermal Mullerian tumours (MMMT)
29
Spread of endometrial cancer?
- Direct = through myometrium to the cervix and upper vagina. The ovaries may be involved and the fallopian tubes. Surface of bowel and liver.
- Lymphatic = to pelvic then para-aortic lymph nodes.
- Haematological = occurs late liver, lungs.
- Recurrence is most common at the vaginal vault, normally in the first three years
30
Risk factors of endometrial cancer?
```
o Early/Late menopause
o Nulliparity
o PCOS
o Breast cancer +/- Tamoxifen
o Oestrogen-only HRT
o Oestrogen-secreting ovarian tumours
o Obesity
o DM2
o Hypothyroidism
o HTN
o HNPCC (Lynch 2 syndrome)
```
31
Aetiology of endometrial cancer?
UNOPPOSED OESTROGEN
Endogenous:
Peripheral conversion in adipose tissue of androstenedione to oestrone.
Oestrogen-producing tumour (granulosa cell tumour)
PCOS or anovulatory cycles at menarche or during climacteric period (lack of progesterone as no luteal phase)
Exogenous:
Oestrogen only HRT
Tamoxifen (oestrogen agonist in the endometrial tissue)
32
Protective factors of endometrial cancer?
o Parity
| o COCP
33
Symptoms of endometrial cancer?
• Post-Menopausal Bleeding (PMB)
- 1 in 10 women with PMB will have endometrial cancer or atypical hyperplasia.
- Atypical hyperplasia = abnormalities of the cellular or glandular architecture (premalignant).
- Most common cause of PMB is vaginal atrophy.
o Reassure, lubricants, E2 creams
• Irregular menstrual cycle
• Heavy or irregular periods (premenopausal women)
• PV discharge and pyometra (pus in the uterine cavity)
34
Investigations of endometrial cancer?
o Vulval, vagina and speculum examination
| o Bloods – FBC, U&Es, LFTs
35
Referral within 2 weeks of endometrial cancer?
o >55 with PMB, consider if <55
o Direct access USS in >55 with:
Unexplained vaginal discharge – new, thrombocytosis, haematuria
Visible haematuria – low Hb, thrombocytosis, high glucose
36
Investigations of endometrial cancer?
Speculum and Bimanual to exclude other causes
TVUS
<4mm endometrial thickness (ET) = very low risk - no need for endometrial sampling unless recurrent
>4mm - biopsy
Biopsies
o Blind outpatient sampling (e.g. pipelle, vabra)
o Hysteroscopy (under LA as outpatient, or GA as in patient)
37
Staging investigations of endometrial cancer?
CT/MRI pelvis
| CXR to exclude lung spread
38
Staging of endometrial cancer?
o Stage I – confined to body of uterus (corpus uteri)
o Stage II - involving the cervix
o Stage III - spread outside the uterus, but not beyond pelvis
o Stage IV - with bowel, bladder or distant organ involvement
39
Management of endometrial cancer - Stage 1?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy with peritoneal washings
40
Management of endometrial cancer - Stage 2?
Radical hysterectomy with systematic pelvic node clearance
| Para-aortic lymphadenectomy
41
Management of endometrial cancer - Stage 3/4?
Maximal de-bulking surgery
| Palliation – high-dose progesterone and external beam radiotherapy
42
Management of endometrial cancer - other treatments?
o Adjuvant radiotherapy used in low-grade disease with deep myometrial invasion and high-grade disease with superficial invasion
o Radiotherapy used in pelvic recurrence
43
Follow up of endometrial cancer?
- 6 weeks post-surgery
- Every 3-4 months for 2 years
- Annually to 5 years
44
Epidemiology of ovarian cancer?
* 2nd most common gynaecological cancer after uterus.
* Most common cause of gynaecological cancer death.
* Peak incidence = 75-84 years.
* Lifetime risk 2% in UK
45
Types of ovarian cancer?
90% are epithelial ovarian cancers (EOC).
o Epithelial – derived from Mullerian epithelium (>50)
Serous, endometrioid, clear cell, mucinous, Brenner
o Sex cord or stromal – derived from ovarian stroma, sex cord derivatives or both
Fibroma, fibrosarcoma, Sertoli-Leydig tumour, Granulosa tumours
o Germ cell – derived from ovarian germ cells (<30)
Dysgerminoma, endodermal sinus tumours, teratoma, choriocarcinoma, sarcoma
46
Spread of ovarian cancer?
- Transcolemic spread = pelvis and abdomen
- Lymphatic
- Haematological
47
Risk factors of ovarian cancer?
- Nulliparity
- Early menarche and/or late menopause
- Endometriosis
- HRT
- Difficulty conceiving
- BRCA 1 and BRCA 2 mutations
- HNPCC (Lynch II syndrome – bowel, ovarian and endometrial ca)
- Age, smoking, obesity
48
Protective factors of ovarian cancer?
- COCP
- Pregnancy
- Female sterilisation
49
Symptoms of ovarian cancer?
- Vague which may look like IBS or diverticular disease
- Most present at Stage 3
o Abdominal distension (often described as persistent bloating).
o Abdominal pain.
o Weight loss, loss of appetite, early satiety
o Fatigue
o Urinary symptoms
o Change in bowel habit
o Vaginal bleeding
50
Signs of ovarian cancer?
```
o Fixed pelvic mass
o Ascites
o Omental mass
o Pleural effusion
o Supraclavicular lymph node enlargement
```
51
When to refer for clinical genetics in ovarian cancer?
Two primary cancers in one 1st or 2nd degree relative
Three 1st or 2nd degree relatives with breast/ovarian/stomach/endometrial cancers
Two 1st or 2nd degree relatives, one having ovarian cancer at any age and the other with breast cancer <50
Two 1st or 2nd degree relatives with ovarian cancer at any age
If gene mutation - yearly TVUS and Ca125
Offer BSO if BRCA positive
52
When to refer in ovarian cancer?
- Refer urgently in any woman with ascites and/or pelvic or abdominal mass which is not fibroids
53
Tests performed in primary care in ovarian cancer?
Bloods – FBC, U&Es, LFTs (esp. albumin)
54
Tumour markers of ovarian cancer?
CA125
• Raised in 80% of epithelial cancers (serous, endometrioid).
• Also raised in endometriosis, PID, pregnancy, torsion, rupture, other cancers, HF
CEA (carcinoembryonic antigen)
• Raised in colorectal cancers, normal in ovarian cancer.
CA19.9
• Raised in mucinous tumours
AFP, hCG, LDH
• If woman <40
55
Tests to perform in secondary care of ovarian cancer?
```
o Ca125, TVUS and abdominal US
o CT/MRI staging
o Work out RMI, >250 needs MDT review
o CXR
o Ascites or pleural effusion sampled and sent for cytology
```
56
Staging of ovarian cancer?
o Stage I – ovaries only
o Stage II – beyond ovaries and confined to pelvis
o Stage III – disease beyond pelvis, confined to abdomen (SI, omentum, peritoneum)
o Stage IV - distant metastases
57
Management of ovarian cancer - of ascites and pleural effusion?
- Drainage of massive tense ascites (Bonanno suprapubic catheter) or a pleural effusion pre-operatively.
- Albumin may drop following ascitic draining
58
Management of ovarian cancer - early stages?
Exploratory laparotomy - histological confirmation, staging and tumour debulking
o Total abdominal hysterectomy and bilateral salpingo-oophorectomy
o Omentectomy
o Para-aortic and pelvic lymph node sampling
o Peritoneal washings and biopsies
Adjuvant chemotherapy - Carboplatin with paclitaxel
o Everyone but low-grade stage 1A and 1B
59
Management of ovarian cancer - stages 3/4?
Same as Stage 1/2 with:
- Stage 3/4 – Neoadjuvant chemotherapy
60
Management of ovarian cancer - follow up?
* 6 weeks post-surgery.
* Every 3-4 months for 1-2 years.
* Annually to 5 years
* Ca125 often used to monitor
61
Epidemiology of vulval cancer?
- Vulval carcinomas are uncommon.
- Mostly occur in older women (~74 years)
- Labia majorum most common site
62
Types of vulval cancer?
o ~90% are squamous cell carcinomas.
o ~5% are primary vulval melanomas with basal cell, Bartholin’s gland carcinoma and rarely sarcomas accounting for the rest
63
Spread of vulval cancer?
o Usually locally, slow metastases to groin nodes and then pelvic nodes
o Local to vagina, urethra and anus
64
Risk factors of vulval cancer?
```
o Lichen sclerosis
o VIN.(vulval intraepithelial neoplasia)
o HPV
o Psoriasis
o Smoking
o Pagets Disease of vulva (adenocarcinoma in situ)
```
65
Management of VIN?
Dysplastic lesion of squamous epithelium associated with persistent infection with HPV (esp. 16)
Histological diagnosis so biopsies taken
Types:
• Usual type – HPV related
• Differentiated type – chronic dermatological conditions
Rx – Laser therapy, wide local excision, imiquimod
66
Symptoms and signs of vulval cancer?
- Lump
- Pain
- Irritation
- Bleeding
- Ulceration
- Pruritus
- Palpable groin lymph nodes – enlarged, hard, immobile
67
Diagnosis of vulval cancer?
o Examination and biopsy (wedge)
68
Other investigations of vulval cancer?
o Cystoscopy
o Proctoscopy
o MRI (staging)
o CXR (staging and preoperative)
69
Staging of vulval cancer?
o 1 – confined to vulva
o 2 – extension to adjacent perineal structures (lower 1/3 urethra, lower 1/3 lower vagina, anus) with negative nodes
o 3 – with or without extension to adjacent perineal structures (lower 1/3 urethra, lower 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes
o 4 – Invades regional (Upper 2/3 vagina, upper 2/3 urethra) or distant
70
Referral of vulval cancer?
o Women with unexplained vaginal lump, vulval bleeding or ulceration
o Women with pruritus or pain which has been treated and still persists
71
Management of vulval cancer - local disease?
- All patients with >1mm deep, triple incision surgery
o Wide local excision + ipsilateral groin node biopsy (lymphadectomy) + sample contralateral side
o If tumour <2cm width and <1mm deep, LN excision is not needed
72
Management of vulval cancer - advanced disease?
o Radical vulvectomy (wide excision of vulva + removal of inguinal glands)
o Radiotherapy used pre-op to shrink tumours
- Chemoradiation used if unsuitable for surgery, to shrink tumours pre-operatively or for relapses
73
Definition of recurrent miscarriages?
• Three or more miscarriages occurring in succession before 24 weeks gestation (1% of couples)
74
Aetiology of recurrent miscarriages?
Antiphospholipid antibodies can cause recurrent miscarriage
```
Chromosomal defects (4% of couples)
Usually balanced reciprocal or Robertsonian translocation
```
Uterine abnormalities are common with late miscarriage.
Cervical incompetence, polycystic ovary syndrome, adhesions etc.
Thrombophilia
Factor V leiden, prothrombin gene and protein C and S deficiency
Bacterial vaginosis – associated with 2nd trimester loss
75
Definition of antiphospholipid syndrome?
Defined as presence of antibodies on 2 occasions plus 3 or more consecutive miscarriages <10 weeks, 1 foetal loss 10 weeks or older or 1 or more births of normal foetus >34/40 with severe pre-eclampsia or growth restriction
76
Investigations of recurrent miscarriages?
Antiphospholipid antibodies (positive if 2 tests +ve, 12 weeks apart)
Thrombophilia screening
Pelvic US to assess uterus
Karyotype foetal products
• If abnormal chromosome – karyotype parental blood
High cervical swab for bacterial vaginosis
77
Management of recurrent miscarriages?
Referral to specialist recurrent miscarriage clinic
o Antiphospholipid syndrome
Aspirin 75mg PO from day of positive pregnancy test
Enoxaparin 40mg SC as soon as foetal heart seen
o Thrombophilia
LMWH (Enoxaparin)
o Bacterial vaginosis
Treat infection
78
Definition of miscarriage, early and late?
- Loss of a pregnancy before 24 weeks gestation
- Early miscarriage, if it occurs before 13 weeks of gestation.
- Late miscarriage, if it occurs between 13 and 24 weeks of gestation
79
Epidemiology of miscarriage?
- 15-20% of pregnancies miscarry, mostly in 1st trimester
| - Rate increases with maternal age
80
Definition of threatened miscarriage?
o There is bleeding but the foetus still alive, the uterus is the size expected from the dates and the OS is closed.
o Only 25% will go on to miscarry
81
Definition of inevitable miscarriage?
o Bleeding is usually heavier.
o Although the fetus may still be alive, the cervical OS is open.
o Miscarriage is about to occur
82
Definition of incomplete miscarriage?
o Some fetal parts have been passed, but the os is usually open
83
Definition of complete miscarriage?
o All fetal tissue has been passed.
| o Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed
84
Definition of septic miscarriage?
o The contents of the uterus are infected causing endometritis.
o Vaginal loss is offensive and the uterus is tender.
o A fever can be absent.
o If pelvic infection occurs there is abdominal pain and peritonism
85
Definition of missed miscarriage?
o The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or USS is performed
o The uterus is smaller than expected for dates and the OS is closed
86
Aetiology of miscarriage?
- Isolated non-recurring chromosomal abnormalities – 60% of one off miscarriages
- Exercise, intercourse and emotional trauma DO NOT cause miscarriage
87
Symptoms of miscarriage??
- Bleeding PV in first 24 weeks
- Pain
- Enquire about: nausea, vomiting, dizziness, fainting, shoulder tip pain, urinary symptoms, passage of tissue
- Need to assess state of os and uterine size
88
Investigations of miscarriage?
- Urine pregnancy test
- TVUS
- Bloods: FBC, Rh group
- Blood culture (if indicated)
89
Management of early pregnancy bleeding - initial management?
o If >6 weeks and no pain, tenderness, cerical motion tenderness – refer for EPAU services
o If <6 weeks and no pain
Return if bleeding continue or pain develops
Repeat urine PT in 7 days and return if positive
Negative pregnancy test means pregnancy has miscarried
90
Management of early pregnancy bleeding - findings on TVUS?
Foetal heartbeat
• If bleeding gets worse or persists >14 days, return
• If bleeding stops, start or continue antenatal care
Crown-rump length
• If <7mm and no visible heartbeat –2nd scan after 7 days
• If >7mm and no visible heartbeat -2nd scan after 7 days or 2nd opinion
Gestational sac diameter
• If <25mm and no visible fetal pole – 2nd scan after 7 days
• If >25mm and no visible fetal pole - 2nd scan after 7 days or 2nd opinion
91
Management of early pregnancy bleeding - diagnosing miscarriage?
Diagnosis cannot be 100% accurate from 1 US scan, particularly at early stages
92
Management of early pregnancy bleeding - if confirmed miscarriage?
o If unacceptable pain or bleeding – surgical management of miscarriage
Evacuation of retained products of conception (ERPC)
o Immediate admission if haemodynamically unstable
IV fluids
If bleeding profuse – ergometrine 0.5mg IM
If there is a fever, swabs for bacterial culture are taken and IV abx are given
93
Management of early pregnancy bleeding - uncertain viability?
o Arrange rescan in 10-14 days
94
Management of early pregnancy bleeding - miscarriage couselling?
o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o There is a likelihood of bleeding, but foetal tissue usually absorbed
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages
95
Management of early pregnancy bleeding - non-viable miscarriage - expectant management?
If scan confirms 1st trimester miscarriage (incomplete or missed)
Offer for 7-14 days when confirmed miscarriage
Offer rescan in 2 weeks to ensure complete if no significant bleeding or persistent/increasing bleeding/pain
Repeat pregnancy test at 3 weeks and return if positive
96
Management of early pregnancy bleeding - non-viable miscarriage - when to explore other managements?
Risk of haemorrhage (last 1st trimester), previous traumatic pregnancy, infection
97
Management of early pregnancy bleeding - non-viable miscarriage - medical management?
Offered when failed expectant treatment
Give analgesia and anti-emetic
Misoprostol either orally/vaginally for missed (800mcg) or incomplete miscarriage (600mcg)
Bleeding should start within 24 hours and may continue for 3 weeks
Pregnancy test after 3 weeks and return if positive
98
Management of early pregnancy bleeding - non-viable miscarriage - surgical management?
If heavy or persistent bleeding > 2 weeks, infected retained tissue or patient choice
Manual vacuum aspiration under LA OR Suction evacuation under GA and <13 weeks
99
Management of early pregnancy bleeding - non-viable miscarriage - anti-D prophylaxis?
o Anti-D immunoglobulin 250IU given to all surgical patients who are Rhesus negative
Do not offer to medical management, threatened miscarriage, complete miscarriage, unknown location
100
Aetiology of mid-trimester miscarriage?
o May be due to mechanical causes (cervical weakness), uterine abnormalities, chronic maternal disease (DM, SLE), infection or no cause identified
101
Management of mid-trimester miscarriage?
o Cervical cerclage at 14 weeks of pregnancy – removed prior to labour
o Investigate to ensure any treatable cause is treated next time
102
Management of pregnancy of unknown location - investigation?
• Measure hCG – 2 samples 48 hours apart
103
Management of pregnancy of unknown location - if decreased hCG >50%?
o Pregnancy unlikely to continue but not confirmed
o Take urine pregnancy test 14 days after 2nd serum hCG and if negative, no action needed, if positive then return to EPAU
104
Management of pregnancy of unknown location - if decrease in hCG <50% or increase <63%?
o Refer for review in EPAU withint 24 hours
105
Management of pregnancy of unknown location - if increased hCG >63%?
o Likely a developing intrauterine pregnancy (although may be ectopic)
o Offer TVUS to determine location between 7-14 days later
If viable intrauterine pregnancy confirmed – offer routine antenatal care
If viable intrauterine pregnancy not confirmed – refer for review by gynaecologist
106
Definition of premenstrual syndrome?
o Distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease
o Recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation
107
Pathology of premenstrual syndrome?
- Suggestion abnormal response to normal progesterone excursions
- Affects GABA receptors
- Neurons in PMS preferentially metabolise progesterone into pregnenolone (heightens anxiety) rather than allopregnanolone (anxiolytic)
108
Risk factors of premenstrual syndrome?
o FHx of PMS
o High BMI
o Stress
o Traumatic events
109
Symptoms of premenstrual syndrome?
- Mood swings
- Irritability
- Depression
- Stress/Tension
- Bloating and breast tenderness
- Headache
- GI upset
110
Diagnosis of moderate premenstrual syndrome?
o Severe PMS involves disruption of interpersonal/work relationships or interference with normal activities
111
Diagnosis of severe premenstrual syndrome?
o >5 symptoms present for most of the luteal phase and absence of symptoms post menses (at least one symptom must be from the first 4):
Markedly depressed mood, feelings of hopelessness or self-deprecation.
Marked anxiety, tension (being ‘on edge’)
Marked affective lability (e.g. feeling suddenly sad or tearful)
Persistent and marked anger/irritability/increased conflicts.
Decreased interest in usual activities.
Subjective sense of difficulty in concentrating.
Lethargy, easy fatigability/lack of energy.
Marked change in appetite, overeating or specific food cravings.
Hypersomnia or insomnia
Subjective sense of being overwhelmed or out of control.
Other physical symptoms (breast tenderness or swelling, headaches, joint or muscle pain, a sense of ;bloating;, weight gain).
112
Investigations of premenstrual syndrome?
• Exclude underlying organic/psychiatric causes
o BP, pulse, thyroid and breast examination
• Symptoms diary filled in over 2 cycles (2-3 months)
113
Management of premenstrual syndrome - general measures?
• Improve Healthy Diet
o Less fat, sugar, salt, caffeine and alcohol.
o Regular, frequent small balanced meals rich in complex carbohydrates
• Increase exercise
• Stop smoking
• Schedule stressful tasks to better half of month if needed
• Stress reduction
o Relaxation techniques
o Yoga
o Meditation
o Breathing techniques
114
Management of premenstrual syndrome - 1st line moderate?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
115
Management of premenstrual syndrome - 1st line severe?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
• SSRI (fluoxetine/sertraline/citalopram)
o Continuous or just for luteal phase of menstruation
o Give 3 months, if benefit then continue for 6-12 months
116
Management of premenstrual syndrome - secondary care options?
- Progesterone or progestogens used alone.
- Antidepressants other than SSRIs
- Alprazolam.
- Diuretics
- Danazol
- Transdermal oestrogen
- GnRH analogues +/- addback HRT
117
Management of premenstrual syndrome - surgery?
- Hysterectomy including oophorectomy with oestrogen-only HRT, last resort for severe PMS
