Vulval/Vaginal/Urogenital

Question 1

Around 80% of vulval cancers are

Answer 1

squamous cell carcinomas

Question 2

Vulval carcinoma cases occur in women over the age

Answer 2

65 years

Question 3

Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.

Answer 3

true

Question 4

Vulval carcinoma - Other than age, risk factors include:

Answer 4

Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus

Question 5

Vulval carcinoma Features

Answer 5

lump or ulcer on the labia majora

may be associated with itching, irritation

Question 6

Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of ?, with the remaining 20% being caused by other candida species.

Answer 6

Candida albicans

Question 7

The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:

Answer 7

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV

Question 8

Vaginal candidiasis Features

Answer 8

‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

Question 9

Vaginal candidiasis ix

Answer 9

a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis

Question 10

Vaginal candidiasis mx

Answer 10

options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Question 11

BASHH define recurrent vaginal candidiasis

Answer 11

4 or more episodes per year

Question 12

recurrent vaginal candidiasis ix

Answer 12

compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus

Question 13

recurrent vaginal candidiasis mx

Answer 13

consider the use of an induction-maintenance regime

induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months

Question 14

Trichomonas vaginalis

Answer 14

Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix

Question 15

Urogenital prolapse Types

Answer 15

cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

Question 16

Urogenital prolapse Risk factors

Answer 16

increasing age
multiparity, vaginal deliveries
obesity
spina bifida

Question 17

Urogenital prolapse Presentation + Management

Answer 17

Presentation
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency

Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery

Question 18

Urogenital prolapse Surgical options

Answer 18

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy

Question 19

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.

Risk factors

Answer 19

advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history

Question 20

Urinary incontinence Classification

Answer 20

overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Question 21

Urinary incontinence ix

Answer 21

bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies

Question 22

Urinary incontinence

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:

Answer 22

bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Question 23

Urinary incontinence If stress incontinence is predominant: mx

Answer 23

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures

Question 24

What is duloxetine

Answer 24

a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction

Question 25

WHO FGM Classification:

Answer 25

Type 1 Partial or total removal of the clitoris and/or the prepuce (clitoridectomy). Type 2 Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). Type 3 Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). Type 4 All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Question 26

Ovulation disorders are the cause of infertility in approximately

Answer 26

one-quarter of couples who have difficulty conceiving naturally, and whilst ovulation may occur sometimes, natural spontaneous conception is usually unlikely

Question 27

Normal ovulation The early follicular phase

Answer 27

requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.

Question 28

Normal ovulation In the mid-follicular phase,

Answer 28

FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.

Question 29

Normal ovulation In the luteal phase,

Answer 29

there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.

Question 30

Categories of ovulatory disorders

Answer 30

``` Class 1 (hypogonadotropic hypogonadal anovulation) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome Class 3 (hypergonadotropic hypoestrogenic anovulation) ```

Question 31

Categories of ovulatory disorders epidiomology

Answer 31

Class 1 5-10% of women Class 2 80% of cases Class 3 5-10% of cases

Question 32

Class 3 (hypergonadotropic hypoestrogenic anovulation) how successful is ovulation induction

Answer 32

In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

Question 33

Goals of ovulation induction

Answer 33

It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable

Question 34

Forms of ovulation induction

Answer 34

Exercise and weight loss Letrozole Clomiphene citrate Gonadotropin therapy

Question 35

polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest ?% weight loss

Answer 35

polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered

Question 36

Letrozole mechanism

Answer 36

letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction

Question 37

Letrozole side effects

Answer 37

fatigue (20%), dizziness (10%)

Question 38

first-line medical therapy Ovulation induction | why is this first line?

Answer 38

Letrozole first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate

Question 39

clomiphene treatment highest rate live births

Answer 39

most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead

Question 40

clomiphene Mechanism of action:

Answer 40

clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development

Question 41

clomiphene Side effects

Answer 41

hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)

Question 42

Gonadotropin therapy | This tends to be the treatment used mostly for women with

Answer 42

class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome

Question 43

Mechanism of action: pulsatile GnRH

Answer 43

therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development

Question 44

Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly

Answer 44

true

Question 45

In OHSS what happens

Answer 45

ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including: Hypovolaemic shock Acute renal failure Venous or arterial thromboembolism

Question 46

OHSS mx

Answer 46

Depending on the severity, the management includes: Fluid and electrolyte replacement Anti-coagulation therapy Abdominal ascitic paracentesis Pregnancy termination to prevent further hormonal imbalances

Question 47

Ovarian hyperstimulation syndrome pathophysiology

Answer 47

It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment

Question 48

Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 48

true

Question 49

The RCOG uses the following classification of OHSS

Answer 49

``` Mild: Abdominal pain, Abdominal bloating Moderate: As for mild Nausea and vomiting, Ultrasound evidence of ascites Severe: As for moderate • Clinical evidence of ascites • Oliguria • Haematocrit > 45% • Hypoproteinaemia Critical: • As for severe • Thromboembolism • Acute respiratory distress syndrome • Anuria • Tense ascites ```