WOMENS HEALTH - GYNAE Flashcards
(315 cards)
1
Q
CONGENITAL STRUCTURES
What are congenital structural abnormalities and what are the causes?
What can it lead to?
A
- Abnormal development of pelvic organs prior to birth, may be result of faulty genes or occur randomly in otherwise healthy people
- Menstrual, sexual + reproductive problems
2
Q
CONGENITAL STRUCTURES
What is the basic embryology of the female genital tract?
A
- Upper third of vagina, cervix, uterus + fallopian tubes develop from paramesonpehric (Mullerian) ducts
- Errors in their development can lead to congenital structural abnormalities
3
Q
CONGENITAL STRUCTURES
Give 3 examples of congenital structural abnormalities
A
- Bicornuate uterus
- Transverse vaginal septae
- Vaginal hypoplasia + agenesis
4
Q
CONGENITAL STRUCTURES
What is bicornuate uterus?
Associations?
A
- 2 horns to uterus giving heart-shape on pelvic USS
- May be associated with adverse pregnancy outcomes (miscarriage, premature birth, malpresentation)
5
Q
CONGENITAL STRUCTURES
What is a transverse vaginal septum?
A
- Septum (wall) forms transversely across the vagina, can be perforate (with a hole) or imperforate (completely sealed)
6
Q
CONGENITAL STRUCTURES
How does transverse vaginal septae present?
A
- Perforate = still menstruate but difficulty with intercourse + tampon use
- Imperforate = cyclical pelvic Sx but no menses as sealed, can lead to endometriosis by retrograde menstruation
- May have infertility + pregnancy related issues
7
Q
CONGENITAL STRUCTURES
What is the management of transverse vaginal septae?
A
- Dx by examination, USS or MRI with surgical correction
- Main complications of surgery are vaginal stenosis or recurrence
8
Q
CONGENITAL STRUCTURES
What is vaginal hypoplasia and agenesis
What causes it?
A
- Hypoplasia = abnormally small vagina
- Agenesis = absent
- Failure of Mullerian ducts to develop properly + may be associated with absent uterus + cervix
9
Q
CONGENITAL STRUCTURES
In vaginal hypoplasia and agenesis what structure is not affected?
What is the management?
A
- Ovaries – leading to normal female sex hormones
- Prolonged period with vaginal dilatation for adequate size or surgery
10
Q
MENORRHAGIA
What is menorrhagia?
A
- Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle + interferes with QOL (no measurable quantity)
11
Q
MENORRHAGIA
What are some causes of menorrhagia?
A
- Unknown = dysfunctional uterine bleeding
- Fibroids (most common cause in gynae)
- Bleeding disorder (vWD)
- Hypothyroidism
- Polyps, endometriosis, adenomyosis, PID, contraceptives (IUD)
- Endometrial hyperplasia or cancer
12
Q
MENORRHAGIA
What are some investigations for menorrhagia?
A
- Bimanual exam (?fibroids if bulky non-tender, ?adenomyosis if bulky tender ‘boggy’)
- FBC for ALL women, ferritin (anaemic), TFTs, clotting screen
- STI screen
- Pelvic (TV>TA) USS
- Hysteroscopy ± endometrial biopsy if ?endometrial pathology
13
Q
FIBROIDS
What are fibroids?
A
- Benign tumours of the smooth muscle of the uterus (uterine leiomyomas)
14
Q
FIBROIDS
What are the different types of fibroids?
A
- Intramural (most common) = within the myometrium
- Subserosal = >50% fibroid mass extends outside uterine contours
- Submucosal = >50% projection into the endometrial cavity
- Subserosal + submucosal can be pedunculated (on stalk = risk of torsion)
15
Q
FIBROIDS
What are the issues with intramural fibroids?
A
As they grow, they change the shape + distort the uterus
16
Q
FIBROIDS
What can cause fibroids?
A
- Oestrogen dependent so grow in response to it (rare before puberty or after menopause)
- Associated with mutation in gene for fumarate hydratase
17
Q
FIBROIDS
What are some risk factors for fibroids?
A
- Afro-Caribbean
- Obesity
- Early menarche
- FHx
- Increasing age (until menopause)
18
Q
FIBROIDS
What is the clinical presentation of fibroids?
A
- Menorrhagia (#1)
- Prolonged menstruation, deep dyspareunia
- Lower abdo cramping pain (worse during menstruation)
- Bloating
- Urinary or bowel Sx due to pelvic pressure or fullness
19
Q
FIBROIDS
What are some investigations for fibroids?
A
- Abdo + bimanual exam = palpable pelvic mass or bulky non-tender uterus
- FBC for ALL women (?Fe anaemia)
- Pelvic (TV>TA) USS for larger fibroids
20
Q
FIBROIDS
What are some complications of fibroids?
A
- Red degeneration
- Benign calcification if centre of larger fibroids not receiving adequate blood supply
- Reduced fertility (submucosal interfere with implantation)
- Obstetric issues (miscarriage, premature labour)
21
Q
FIBROIDS
What is red degeneration of fibroids?
A
- Ischaemia, infarction + necrosis of fibroid due to disrupted blood supply
- Fibroids sensitive to oestrogen so can grow rapidly in presence (like pregnancy) + outgrow their blood supply > ischaemia
22
Q
FIBROIDS
How does red degeneration of fibroids present and what is the management?
A
- Low-grade fever, pain + vomiting (classically in pregnant woman)
- Supportive management like analgesia, fluids
23
Q
FIBROIDS
How is the management of fibroids split?
A
- Fibroids <3cm
- Fibroids >3cm (with referral to gynae for investigation + management)
- Also split into non-hormonal + hormonal depending on if woman wants to get pregnant
24
Q
FIBROIDS
What is the first line non-hormonal management of fibroids <3cm?
A
- Tranexamic acid (antifibrinolytic) taken during bleeding to reduce it
- Mefenamic acid (NSAID) to reduce bleeding + pain
25
FIBROIDS
What is the first line hormonal management of fibroids <3cm?
- Mirena coil is 1st line (fibroids <3cm with no uterus distortion)
- 2nd = COCP triphasing (back-to-back for 3m then break)
- Cyclical oral progestogens
- Norethisterone 5mg TDS can be used short-term to rapidly stop menorrhagia from 3d before period until bleeding acceptable
26
FIBROIDS
What is the management of fibroids <3cm that fail medical treatment or are severe?
- Surgery
27
FIBROIDS
What is the management of fibroids >3cm?
- Same medical Mx but surgery offered too
- GnRH agonists (goserelin) can be given to shrink fibroids by inducing menopausal state (reduced oestrogen) in short-term (can demineralise bone) for surgery
- Selective progesterone receptor modulators (SPRMS) like ulipristal acetate can be used instead to avoid SEs
28
FIBROIDS
What are the 5 main surgical options of managing fibroids?
- Trans-cervical resection of fibroid via hysteroscopy
- 2nd gen endometrial ablation
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
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FIBROIDS
What is...
i) trans-cervical resection of fibroid?
ii) endometrial ablation?
iii) uterine artery embolisation?
iv) myomectomy?
v) hysterectomy?
i) Removal of submucosal fibroid, offered to women planning on having more children
ii) Destroys endometrium via radiofrequency ablation, non-hysteroscopic, day case
iii) Blocked arterial supply to fibroid starves of oxygen + shrinks
iv) Removal of fibroid via laparoscopy/laparotomy
v) Removal of uterus + fibroids ± oophorectomy depending on situation (last resort)
30
FIBROIDS
What management of fibroids is the only one considered to improve subfertility?
What is a risk of this management?
- Myomectomy
- Avoid during pregnancy or c-section as massive haemorrhage risk
31
ADENOMYOSIS
What is adenomyosis?
- Endometrial tissue inside the myometrium – oestrogen dependent
- Can occur alone or alongside endometriosis or fibroids
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ADENOMYOSIS
What is the epidemiology of adenomyosis?
- More common in later reproductive years + those who are multiparous (contrast to fibroids)
33
ADENOMYOSIS
How does adenomyosis present?
- Dysmenorrhoea, menorrhagia + dyspareunia are classic Sx
- Cyclical pain worse as period starts but can last 2w after it stops (much longer than endometriosis)
- May cause infertility or pregnancy-related issues
34
ADENOMYOSIS
What are the investigations for adenomyosis?
- Bimanual exam = bulky + tender uterus, 'BOGGY'
- TVS is 1st line investigation
- Gold standard - histological examination of uterus after hysterectomy (not always suitable though)
35
ADENOMYOSIS
What are some complications of adenomyosis?
- Infertility
- Miscarriage
- Preterm birth
- SGA
- PPROM
- Malpresentation
- PPH
36
ADENOMYOSIS
What is the initial management of adenomyosis?
if pt does NOT want contraception
- anti-fibrinolytic = TRANEXAMIC ACID (when there is no associated pain)
- NSAID = MEFANAMIC ACID (when there is associated pain)
if pt does want contraception
- 1st line = mirena coil
- COCP
- cyclical oral progestogens
other options (considered by specialist)
- GnRH analogues
- endometrial ablation
- uterine artery embolism
- hysterectomy
37
ENDOMETRIOSIS
What is endometriosis?
- Presence of ectopic endometrial tissue outside the uterus
38
ENDOMETRIOSIS
Where might endometriosis occur?
- Pouch of Douglas > PR bleeding
- Uterosacral ligaments
- Bladder + distal ureter > haematuria
- Pelvic cavity incl. ovaries > endometrioma in ovaries
- Less common - lungs, nose, umbilicus, previous scars (lump gets big + painful)
39
ENDOMETRIOSIS
What is the pathophysiology of endometriosis?
- Cells of endometrial tissue outside uterus respond to hormones in same way > oestrogen dependent condition
- During menstruation, endometrial tissue sheds lining + bleeds leading to irritation + inflammation of nearby tissues
- Chronic + constant inflammation > cyclical pain
40
ENDOMETRIOSIS
What is the epidemiology of endometriosis?
- Higher prevalence in infertile women
- Exclusive to women of reproductive age
41
ENDOMETRIOSIS
What are 3 theories about the cause of endometriosis?
- Sampson's = retrograde menstruation (endometrial lining flows backwards through fallopian tubes + into pelvis/peritoneum where endometrial tissue seeds itself
- Meyer's = metaplasia of mesothelial cells
- Halban's = via blood or lymphatics
42
ENDOMETRIOSIS
What are some risk factors for endometriosis?
- Early menarche,
- late menopause,
- obstruction to vaginal outflow (imperforate hymen)
43
ENDOMETRIOSIS
What is the clinical presentation of endometriosis?
- Dysmenorrhoea, deep dyspareunia + cyclical chronic pelvic pain
- Pain worse 2–3d before periods + better after
- Cyclical bowel + bladder Sx = pain on defecation (dyschezia), dysuria, urgency
- Sub-fertility + cyclical bleeding from various sites
44
ENDOMETRIOSIS
What are the investigation of endometriosis?
- Bimanual = ?adnexal masses or tenderness, nodules in uterosacral ligaments or fixed + retroverted uterus due to adhesions
- TVS for ovarian endometrioma (chocolate cyst) = brown fluid as old blood + tissue
- Gold standard = laparoscopy with biopsy
45
ENDOMETRIOSIS
What might laparoscopy and biopsy show?
What is the benefit of this investigation?
- White scars or brown spots = 'powder burn'
- Added benefit of being able to remove deposits during procedure
46
ENDOMETRIOSIS
What are some complications of endometriosis?
- Subfertility
- Adhesions
47
ENDOMETRIOSIS
How does endometriosis cause subfertility?
- Areas of endometriosis release cytokines + harmful chemicals which can damage reproductive tract
- Can cause reduced fallopian tube motility, scarring, bleeding, toxicity to oocyte
48
ENDOMETRIOSIS
How does endometriosis cause adhesions?
- Localised bleeding + inflammation causes damage + development of scar tissue that binds the organs together (adhesions)
49
ENDOMETRIOSIS
What is the initial management of endometriosis?
- NSAIDs ± paracetamol first line for Sx relief
- COCP triphasing (can't take for longer as if not irregular bleeding
- POP like medroxyprogesterone acetate
- GnRH analogues to "induce" menopause, reversible, quicker than triphasing but need HRT + only short-term as risk of osteoporosis
50
ENDOMETRIOSIS
What fertility-sparing treatments are there for endometriosis?
- Laparoscopic removal of adhesions either by ablation (burning) or excision (cutting) away endometriotic tissue
51
ENDOMETRIOSIS
What is the last resort treatment of endometriosis?
- Hysterectomy ± bilateral salpingo-oopherectomy as no ovaries = no cycle
52
PCOS
What is polycystic ovarian syndrome (PCOS)?
- Syndrome of excess androgen production by theca cells of ovaries due to hyperinsulinaemia + increased LH levels (due to pituitary production increase, genetics like Turner's or Klinefelter's)
53
PCOS
How does insulin resistance contribute to PCOS?
- Insulin resistance = pancreas produces more insulin
- Insulin mimics action of insulin-like growth factor 1 which augments androgen production by theca cells in response to LH
- Higher insulin = higher androgens (testosterone)
54
PCOS
How does high insulin levels contribute to PCOS?
- Insulin suppresses sex hormone-binding globulin (SHBG) produced by liver which normally binds to androgens + suppresses their function further promoting hyperandrogenism
- Also contribute to halting development of follicles in ovaries > anovulation + multiple partially developed follicles (polycystic ovaries)
55
PCOS
What are the 3 main presenting features of PCOS?
- Hyperandrogenism
- Insulin resistance
- Oligo or amenorrhoea + sub/infertility
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PCOS
How does hyperandrogenism present in PCOS?
- Acne, hirsutism, deep voice, male-pattern hair loss
- Hirsutism is growth of thick, dark hair often in male pattern (facial hair)
57
PCOS
What are some differentials of hirustism?
- Ovarian or adrenal tumours that secrete androgens
- Cushing's syndrome
- CAH
- Iatrogenic (steroids, phenytoin)
58
PCOS
How does insulin resistance present?
- Obesity, acanthosis nigricans (thickened, rough skin often axilla + elbows with velvety texture), psychological Sx
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PCOS
What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) –
- Oligo- or anovulation (may present as oligo- or amenorrhoea)
- Hyperandrogenism (biochemical or clinical)
- Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
60
PCOS
What hormone tests may be used in PCOS?
- Testosterone (raised)
- SHBG (low)
- LH (raised) + raised LH:FSH ratio (LH>FSH)
- Prolactin (normal), TFTs (exclude causes)
61
PCOS
What other investigation may be useful at indicating PCOS?
2h 75g OTT for DM –
- IFG = 6.1–6.9mmol/L
- IGT (at 2h) = 7.8–11.1
- Diabetes (at 2h) = >11.1
62
PCOS
What is the gold standard for visualising the ovaries?
What might it show?
- TVS
- "String of pearls" appearance where follicles arranged around periphery of ovary (≥12 cysts or >10cm^3 ovarian volume)
- Can also visualise endometrial thickness
63
PCOS
What are some associations and complications of PCOS?
- DM, CVD + hypercholesterolaemia
- Obstructive sleep apnoea, MH issues, sexual problems
- Endometrial hyperplasia or cancer
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PCOS
Why does PCOS increase risk of endometrial hyperplasia + cancer?
- Oligo/anovulation means endometrial lining continues proliferating with unopposed oestrogen as no corpus luteum releasing progesterone
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PCOS
What is the most crucial part of PCOS management?
- Weight loss as can improve overall condition
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PCOS
How is the risks of obesity, T2DM, CVD etc. managed in PCOS?
- Lifestyle > diet + exercise, weight loss to reduce insulin resistance, smoking cessation
- Orlistat (lipase inhibitor that stops fat absorption in intestines) may be given to assist weight loss if BMI >30kg/^m2
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PCOS
What are the PCOS risk factors for endometrial cancer?
How is the risk of endometrial cancer managed in PCOS?
- Obesity, DM, insulin resistance, amenorrhoea
- Mirena coil for continuous endometrial protection
- Induce withdrawal bleed AT LEAST every 3m with COCP or cyclical progesterones medroxyprogesterone 10mg 14d)
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PCOS
How is infertility managed in PCOS?
- Weight loss initial step to restore regular ovulation
- Clomiphene to induce ovulation
- Metformin may help (+ helps insulin resistance)
- Laparoscopic ovarian drilling or IVF last resort
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PCOS
How is hirsutism + acne managed?
- Hair removal cream, topical eflornithine to treat facial hirsutism
- Co-cyprindiol is COCP licensed for hirsutism + acne as anti-androgen effect but only used for 3m as increased VTE risk
- Spironolactone by specialist (mineralocorticoid antagonist with anti-androgen effects)
70
CERVICAL CANCER
What is cervical cancer?
- Most common cancer in women <35
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CERVICAL CANCER
What has a strong association with development of cervical cancer?
- Human papillomavirus (HPV) types 16 + 18 primarily a STI
- Also associated with anal, vulval, vaginal, penis, mouth + throat cancers
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CERVICAL CANCER
What genes may be implicated in cervical cancer?
- P53 + pRb are tumour suppressor genes
- HPV produces two oncoproteins (E6 + E7)
- E6 inhibits P53, E7 inhibits pRB
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CERVICAL CANCER
What are some risk factors for cervical cancer?
- Increased risk of catching HPV = early (unsafe) sex, lots of sexual partners
- Smoking (limits availability to clear HPV)
- HIV
- COCP
- High parity
- Previous CIN/abnormal smear or FHx
74
CERVICAL CANCER
How does cervical cancer present?
- Asymptomatic + smear detected
- Abnormal PV bleeding (POSTCOITAL, intermenstrual or postmenopausal)
- PV discharge, pelvic pain, dyspareunia
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CERVICAL CANCER
How would advanced cervical cancer present?
- Menorrhagia
- Ureteric obstruction
- Weight loss
- Bowel disturbance
- Vesico-vaginal fistula
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CERVICAL CANCER
What are some initial investigations for cervical cancer?
- Speculum + swabs to exclude infection
- Abnormal cervix (ulcerated, inflamed, bleeding, visible tumour) = urgent referral for colposcopy
- Bimanual = rough + hard cervix
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CERVICAL CANCER
How would you confirm a diagnosis of cervical cancer?
Colposcopy –
- Acetic acid causes abnormal cells to appear white "acetowhite"
- Schiller's iodine test = healthy cells stain brown, abnormal do not stain
- Punch biopsy or large loop excision of transformation zone (LLETZ) for histology
78
CERVICAL CANCER
How is cervical cancer staged?
FIGO staging –
- 1 = confined to cervix
- 2 = invades uterus or upper 2/3 vagina
- 3 = invades pelvic wall (e.g. ureter) or lower 1/3 vagina
- 4 = invades beyond pelvis
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CERVICAL CANCER
What is the cervical cancer screening?
- Sexually active women 25–64 (triennially 25–50, 5y 50–64) smear test
- Exceptions = HIV pts screened annually, women with previous CIN may require additional tests
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CERVICAL CANCER
What is the process of cervical smears?
- Smear test where cells collected from cervix + placed in preservation fluid for microscopy
- Aims to identify precancerous changes (dyskaryosis) in epithelial cells of cervix for early treatment
- Samples initially tested for high-risk HPV before examined
81
CERVICAL CANCER
What is dyskaryosis?
What results would warrant investigating?
- Abnormal nucleus in cell
- Borderline/mild = test sample for HPV (-ve = routine recall, +ve = normal 6w colposcopy referral)
- Moderate = consistent with CIN II (urgent 2w colposcopy)
- Severe = consistent with CIN III (urgent 2w colposcopy)
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CERVICAL CANCER
How do you manage smear results?
- Repeat inadequate smears within 3m or after 2 consecutive refer for colposcopy
- HPV +ve but normal cytology = 12m, if +ve, 12m, if +ve at 24m > colposcopy (if HPV -ve then normal recall)
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CERVICAL CANCER
What is used to grade the level of dysplasia, or premalignant change, in the cells of the cervix after colposcopy?
- Cervical intra-epithelial neoplasia (CIN)
- CIN I = mild, affects 1/3 thickness of epithelial layer, likely to return to normal without Tx
- CIN II = mod, affects 2/3 thickness of epithelial layer, likely to progress to cancer without Tx
- CIN III or cervical carcinoma in situ = severe, v likely to progress to cancer without Tx
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CERVICAL CANCER
After treatment for CIN, when do patients have screening?
- Screening at 6m for test of cure
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CERVICAL CANCER
What is the prophylaxis for cervical cancer?
- Children 12–13 HPV vaccine (6+11 genital warts, 16+18 cervical cancer)
- Cervical screening
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CERVICAL CANCER
What is the management of...
i) CIN or early stage 1A cervical cancer?
ii) Stage 1B-2A
iii) Stage 2B-4A
iv) Stage 4B
i) LLETZ or cone biopsy with -ve margins (maintain fertility)
ii) Radical hysterectomy + removal of pelvic LN with chemo (cisplatin) + radiotherapy
iii) Chemo + radiotherapy
iv) Combination of surgery, chemo/radio + palliative care
87
CERVICAL CANCER
What is the difference between LLETZ and cone biopsy?
- LLETZ = LA during colposcopy, loop of wire with electrical current to cauterise tissue
- Cone = GA where cone-shaped piece of cervix removed with scalpel
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CERVICAL CANCER
What are the side effects of LLETZ and cone biopsy?
- Bleeding + abnormal discharge weeks after, intercourse + tampon avoided as infection risk, may increase preterm labour
- Pain, bleeding, infection, increased risk of premature labour + miscarriage
89
OVARIAN CANCER
What is ovarian cancer?
When do patients present?
- Cancer of ovaries, usually presents late as non-specific Sx > worse prognosis
- ≥70% present after spread beyond pelvis (most commonly para-aortic LN + liver)
90
OVARIAN CANCER
What are the 4 types of ovarian cancer?
- Epithelial cell tumours (85–90%)
- Germ cell tumours (common in women <35)
- Sex cord-stromal tumours (rare)
- Metastatic tumours
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OVARIAN CANCER
What are some types of epithelial cell tumours?
- Serous carcinoma (#1)
- Endometrioid, clear cell, mucinous + undifferentiated tumours too
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OVARIAN CANCER
What are germ cell tumours?
- Often benign teratomas containing various tissue types like skin, teeth, hair
- Rokitansky's protuberance
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OVARIAN CANCER
What are sex-cord stromal tumours?
- Arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)
- Sertoli-Leydig + granulosa cell tumours
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OVARIAN CANCER
What are metastatic tumours?
- Secondary tumours
- Krukenberg = metastasis in ovary, usually from GI (stomach) > CLASSIC "SIGNET-RING" CELLS ON HISTOLOGY
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OVARIAN CANCER
What are some risk factors of ovarian cancer?
Unopposed oestrogen + increased # of ovulations –
- Early menarche
- Late menopause
- Increased age
- Endometriosis
- Obesity + smoking
Genetics (BRCA1/2, HNPCC/lynch syndrome)
96
OVARIAN CANCER
Hence, what are some protective factors of ovarian cancer?
- COCP
- Early menopause
- Breast feeding
- Childbearing
97
OVARIAN CANCER
How does ovarian cancer present?
- Abdo pain, discomfort + bloating (IBS like)
- Early satiety or loss of appetite
- Urinary Sx as pressure on bladder (freq, urgency)
- Change in bowel habit (obstruction later)
- Abdo or pelvic mass, ascites
- Germ cell = rapidly enlarging abdo mass (often causes rupture or torsion)
98
OVARIAN CANCER
What warrants a 2ww gynae oncology referral?
- Ascites
- Abdo or pelvic mass (unless clearly fibroids)
- ≥250 risk of malignancy index score
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OVARIAN CANCER
How is the risk of malignancy index calculated?
- Menopausal status = 1 (pre) or 3 (post)
- Pelvic USS findings = 1 (1 feature) or 3 (>1 feature)
- CA-125 levels IU/mL as marker for epithelial cell ovarian cancer
100
OVARIAN CANCER
What are concerning pelvic USS findings?
- Ascites
- Metastases
- Bilateral lesions
- Solid areas
- Multi-locular cysts
101
OVARIAN CANCER
What can cause falsely elevated CA-125 levels?
- Endometriosis
- Fibroids + adenomyosis
- Pelvic infection
- Pregnancy
- Benign cysts
102
OVARIAN CANCER
What other investigations should be performed in ovarian cancer?
- CT CAP for Dx + staging
- Biopsy for histology
- Paracentesis if ascites to test ascitic fluid for cancer cells
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OVARIAN CANCER
What staging is used in ovarian cancer?
FIGO staging –
- 1 = confined to ovary
- 2 = past ovary but contained to pelvis
- 3 = past pelvis but inside abdomen (can be microscopically in lining of abdomen)
- 4 = spread to other organs
104
OVARIAN CANCER
What is the management of ovarian cancer?
- Abdominal hysterectomy + bilateral salpingo-oopherectomy
- May need bowel resections + chemo
105
OVARIAN CYST
What is a cyst?
- Fluid-filled sac
106
OVARIAN CYST
What are the 4 types of ovarian cysts?
- Functional (physiological)
- Benign epithelial neoplasms
- Benign germ cell neoplasms
- Benign sex-cord stromal neoplasms
107
OVARIAN CYST
What are functional cysts?
Who are they seen in?
How do they present
- Cysts relating to fluctuating hormones in the menstrual cycle
- Pre-menopause, COCP is protective (inhibits ovulation)
- Simple cysts = 2-3cm (can be up to 10cm), clear serous liquid, smooth internal lining, thin walls
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OVARIAN CYST
What are the three types of functional cysts?
- Follicular (most common)
- Corpus luteum
- Theca lutein
109
OVARIAN CYST
What are follicular cysts?
How is it managed?
- Non-rupture of dominant follicle or failure of atresia > growth
- Commonly regress after several cycles
110
OVARIAN CYST
What are corpus luteum cysts?
When are they seen?
- Corpus luteum fails to breakdown, may fill with fluid or blood
- May burst causing intraperitoneal bleeding
- Early pregnancy
111
OVARIAN CYST
What are theca lutein cysts?
Association?
- Stimulates growth of follicular theca cells so usually bilateral as resting follicles on both sides
- Overstimulation of hCG (multiple + molar pregnancy as hCG v high)
112
OVARIAN CYST
What are some features of neoplastic cysts?
- Often complex
- >10cm
- Irregular borders
- Internal septations appearing multi-locular
- Heterogenous fluid
113
OVARIAN CYST
What are the 2 benign epithelial neoplasms?
- Serous cystadenoma (most common epithelial tumour)
- Mucinous cystadenoma
114
OVARIAN CYST
How does serous cystadenoma present?
- May be bilateral, filled with watery fluid, 30–50y
115
OVARIAN CYST
How does mucinous cystadenoma present?
- Often very large + contain mucus-like fluid
- Pseudomyxoma peritonei where abdo cavity fills with gelatinous mucin secretions if rupture
- 30–40y
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OVARIAN CYST
What are benign germ cell neoplasms?
- Dermoid cysts or teratomas
- Common in women <35
- May contain various tissue types (skin, teeth, hair + bone)
- Can be bilateral, associated with ovarian torsion as heavy
117
OVARIAN CYST
What is an example of sex cord-stromal neoplasms?
- Fibromas (small, solid benign fibrous tissue tumour)
- Associated with Meig's syndrome
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OVARIAN CYST
What are some risk factors of ovarian cysts?
- Obesity, tamoxifen, early menarche, infertility
- Dermoid cysts = most common in young women, can run in families
- Epithelial cysts = most common in post-menopausal (?malignant)
119
OVARIAN CYST
What is the clinical presentation of ovarian cyst?
- Unilateral dull pelvic ache + may have dyspareunia
- Pressure effects (frequent urination or bowel movements)
- Abdo swelling or mass (ascites suggests malignancy, ruptured mucinous cystadenoma or Meig's syndrome)
120
OVARIAN CYST
What is Meig's syndrome?
Who is it commonly seen in?
What is the management?
- Triad of fibroma, pleural effusion + ascites
- Older women
- Removal of fibroma = complete solution
121
OVARIAN CYST
What clinical presentation would suggest ovarian cyst rupture?
- Acute, sharp abdo/pelvic pain
- PV bleed, N+V (esp. torsion)
- Shoulder tip pain if referred diaphragmatic pain
- If peritonitis + shock occurs (fever, syncope, low BP, high HR)
122
OVARIAN CYST
What investigations should be done for ovarian cysts?
- Beta-hCG to exclude uterine or ectopic
- FBC for infection or haemorrhage
- CA-125 if >40
- Germ cell tumour markers if <40 with complex ovarian mass
- Imaging (TVS or MRI abdo if larger mass)
- Diagnostic laparoscopy (gold standard in ruptured cyst)
- May need USS guided aspiration + cytology to confirm benign
123
OVARIAN CYST
What are the germ cell tumour markers?
- Lactate dehydrogenase
- Alpha-fetoprotein
- Human chorionic gonadotropin
124
OVARIAN CYST
What are some complications of ovarian cysts?
- Torsion leading to ovarian ischaemia = pain may be intermittent if untwists or stop if necrotic
- Haemorrhage into cyst = sudden increase in size + pain (follicular + corpus luteal cysts)
- Rupture of contents into peritoneum = peritonitis (associated with sex)
125
OVARIAN CYST
What is the management of a ruptured ovarian cyst?
- ABCDE approach + admission
- Stable = analgesia, fluids
- Unstable or bleeding = surgery (?laparotomy)
126
OVARIAN CYST
What is the management of simple cysts in pre-menopausal women?
- Small <5cm = likely to resolve within 3 cycles, no follow up
- Mod 5–7cm = routine gynae referral + yearly USS
- Large >7cm = ?MRI + surgical evaluation
127
OVARIAN CYST
What is the management of post-menopausal women presenting with an ovarian cyst?
- Risk of malignancy index calculation
- Simple cysts <5cm + normal CA-125 = monitor with 4–6m USS
- Complex cyst or raised CA-125 = 2ww gynae oncology referral
128
OVARIAN CYST
What is the surgical management of ovarian cysts?
What are the indications?
What are the cautions?
- Laparoscopic ovarian cystectomy ± oophorectomy
- Persistent or enlarging cysts, Sx, ovarian torsion or Sx of rupture
- Caution of chemical peritonitis with dermoid cysts if contents spill
129
OVARIAN TORSION
What is ovarian torsion?
- Ovary twists in relation to surrounding connective tissue, fallopian tube + blood supply (adnexa) leading to ischaemia ± necrosis if persists
130
OVARIAN TORSION
What are some risk factors of ovarian torsion?
- Pregnancy
- Ovarian tumours/cysts
- Previous surgery
- Reproductive age
131
OVARIAN TORSION
What is the clinical presentation of ovarian torsion?
- Sudden onset, severe unilateral iliac fossa pain
- Colicky if twists/untwists
- May occur during exercise
- N+V
- Fever + pain stopping may indicate necrotic ovary
132
OVARIAN TORSION
What are the investigations for ovarian torsion?
- Localised tenderness ± palpable mass in pelvis
- Beta-hCG to exclude ectopic
- USS with colour doppler
133
OVARIAN TORSION
What might USS show in ovarian torsion?
- Free fluid in pelvis + oedema of ovary
- "Whirlpool sign" = wrapping of vessels around central axis
- Doppler studies may show lack of blood flow
134
OVARIAN TORSION
What are some complications of ovarian torsion?
- Delay in treatment may lead to loss of function > infertility or menopause if other ovary non-functional
- Necrotic ovary may become infected > abscess > sepsis (or rupture causing peritonitis + adhesions)
135
OVARIAN TORSION
What is the management of ovarian torsion?
- Laparoscopy for definitive diagnosis + treatment
- Untwist ovary + fix into place (detorsion)
- Oophorectomy based on visual appearance (necrotic)
- Analgesia + fluid resus
136
ENDOMETRIAL CANCER
What is endometrial cancer?
What is the prognosis?
- Cancer of endometrium (lining of uterus) = oestrogen dependent
- 90% women are >50, good prognosis, 5-year survival in stage 1 = 80%
137
ENDOMETRIAL CANCER
What is the most common histological type of endometrial cancer?
What are some others?
- Adenocarcinoma (80%)
- Adenosquamous, squamous, papillary serous, clear cell + uterine sarcoma
138
ENDOMETRIAL CANCER
What are some risk factors for endometrial cancer?
Unopposed oestrogen –
- Obesity (adipose tissue contains aromatase)
- Nulliparous
- Early menarche
- Late menopause
- Oestrogen-only HRT
- Tamoxifen
- PCOS
- Increased age
- T2DM
- HNPCC (Lynch syndrome)
139
ENDOMETRIAL CANCER
What are some protective factors for endometrial cancer?
- COCP
- Mirena coil
- Multiparity
- Cigarette smoking (Seem to have anti-oestrogenic effect)
140
ENDOMETRIAL CANCER
What is the clinical presentation of endometrial cancer?
- PMB is endometrial cancer until proven otherwise
- May have abnormal bleeding (PCB, IMB, menorrhagia)
- Abnormal PV discharge + pain less commonly
141
ENDOMETRIAL CANCER
What are the investigations for endometrial cancer?
- TVS (first line) = endometrial thickness should be <4mm
- Recommended for >55 w/ unexplained PV discharge + visible haematuria
- Pipelle biopsy via speculum (highly sensitive so useful for exclusion in low risk)
- Hysteroscopy with endometrial biopsy
142
ENDOMETRIAL CANCER
What is the staging for endometrial cancer?
FIGO staging –
- 1 = confined to endometrium + uterus
- 2 = tumour invaded cervix
- 3 = cancer spread to ovary, vagina, fallopian tubes or LN
- 4 = cancer invades bladder, rectum or beyond pelvis
143
ENDOMETRIAL CANCER
What is the management of stage 1 + 2 endometrial cancer?
- Total abdominal hysterectomy with bilateral salpingo-oopherectomy + pelvic LN
144
ENDOMETRIAL CANCER
What other treatments are there for endometrial cancer?
- Surgery = radical hysterectomy ± pelvic LN
- Radiotherapy = adjuvant (brachytherapy/external beam)
- Chemo, progesterone therapy to slow progression of cancer
146
ENDOMETRIAL POLYP
What is an endometrial polyp?
What is the main differential?
- Benign growths of endometrium, some may be (pre)cancerous
- Fibroids
147
ENDOMETRIAL POLYP
What are some risk factors of endometrial polyps?
- Being peri or post-menopausal
- HTN
- Obesity
- Tamoxifen
148
ENDOMETRIAL POLYP
What is the clinical presentation of endometrial polyps?
- Irregular menstrual bleeding (IMB, PMB), menorrhagia
- Infertility in younger as competing with foetus for space
149
ENDOMETRIAL POLYP
What are the investigations for endometrial polyps?
- TVS/TAS
- Hysteroscopy ± endometrial biopsy
150
ENDOMETRIAL POLYP
What is the management of endometrial polyps?
- Conservative but monitor or biopsy if concerns
- GnRH analogues as oestrogen sensitive
- If post-menopause or pre but symptomatic = hysteroscopic resection or morcellation of polyps
- Hysterectomy if severe
151
VULVAL CANCER
What is vulval cancer?
What is the most common histological type?
- Rare compared to other cancers
- Squamous cell carcinomas (90%), malignant melanoma less common
152
VULVAL CANCER
What are some risk factors for vulval cancer?
- Vulval intraepithelial neoplasia (VIN) due to HPV in younger women
- Lichen sclerosus in older women
153
VULVAL CANCER
What is the clinical presentation of vulval cancer?
- Vulval itching, soreness + persistent lump on labia majora
- Ulceration, bleeding, pain (sometimes on urination)
- May be lymphadenopathy in groin
154
VULVAL CANCER
What are the investigations for vulval cancer?
- Suspected = 2ww urgent gynae oncology referral
- Biopsy lesion with sentinel node biopsy to see if LN spread
155
VULVAL CANCER
How is vulval cancer staged?
FIGO staging –
- 1 = <2cm
- 2 = >2cm
- 3 = adjuvant organs or unilateral nodes
- 4 = distant mets or bilateral nodes
156
VULVAL CANCER
What is vulval intraepithelial neoplasia (VIN)?
- Premalignant condition affecting squamous epithelium that can precede vulval cancer
157
VULVAL CANCER
What are 2 types of VIN?
- High grade squamous intraepithelial lesion = type of VIN associated with HPV typically in younger women 35–50
- Differentiated VIN associated with lichen sclerosus
158
VULVAL CANCER
What is the management of VIN?
- Biopsy to Dx
- Watch + wait with close follow up
- Wide local excision to surgically remove lesion
- Imiquimod cream or laser ablation
159
VULVAL CANCER
What is the management of vulval cancer?
- Radical or conservative surgery (WLE ± groin LN dissection)
- Radio ± chemotherapy
159
VAGINAL CANCER
What is the most common histological type of vaginal cancer?
- 90% squamous
160
MENOPAUSE
What is menopause?
- Permanent cessation of menstruation where ovarian activity ceases to function, can occur after TAH-BSO
161
MENOPAUSE
What is perimenopause?
- Time around menopause where woman may have vasomotor Sx + irregular periods
- Includes time leading up to LMP + 12m after
162
MENOPAUSE
What is the physiology of menopause?
- Starts with decline in development of ovarian follicles
- Less oestrogen + progesterone production
- Absence of -ve feedback loop so FSH + LH rises
- Falling follicular development = anovulation so irregular menstrual cycles
- Low oestrogen = endometrium does not develop so amenorrhoea + perimenopausal Sx
163
MENOPAUSE
What are the peri-menopausal symptoms?
- Vasomotor = hot flushes, night sweats, impact on QOL
- General = mood swings, decreased libido, vaginal dryness, headache, dry skin, loss of energy, joint aches, muscles pains, irregular periods
164
MENOPAUSE
What are some medium-term presentations of menopause?
- Urogenital atrophy leading to dyspareunia, recurrent UTIs + PMB
165
MENOPAUSE
Why does urogenital atrophy occur?
- Urogenital tract has oestrogen receptors + continual stimulation keep it strong + supple
166
MENOPAUSE
What are the investigations for menopause?
- Retrospective diagnosis after 12m of amenorrhoea in women >45y
- NICE recommends FSH (high) blood test in women <40 with suspected premature menopause or women 40–45 with menopausal Sx or change in menstrual cycle
167
MENOPAUSE
What are the long-term complications of menopause?
- Osteoporosis as oestrogen inhibits osteoclasts + can become hyperactive
- CVD, stroke (esp. in early menopause) + dementia
168
MENOPAUSE
When is contraception recommended in relation menopause?
Why?
- 2y after LMP in <50, 1y after LMP in >50
- Pregnancy >40 has increased risks + complications
169
MENOPAUSE
What contraception is suitable in older women?
How do hormonal contraceptives affect the menopause?
- UKMEC1 = barrier, IUS/IUD, POP, long-acting progesterone (<45), sterilisation
- UKMEC2 = COCP after 40 used until 50, try ones with levonorgestrel or norethisterone as lower VTE risk
- They don't but may mask Sx
170
MENOPAUSE
What is the initial management of menopause?
Lifestyle –
- Vasomotor symptoms last 2-5y without intervention so ?no treatment
- Regular exercise can improve hot flushes, mood + cognitive Sx
- Good sleep hygiene can improve sleep disturbance
171
MENOPAUSE
What is the management of menopause in more severe cases?
- HRT first-line for vaso-motor Sx as most effective
- Clonidine (alpha adrenergic receptor agonist) second line with low-dose antidepressants like venlafaxine (not C/I in breast cancer Tx) or fluoxetine
- CBT
- Vaginal oestrogen cream/tablets + moisturisers for dryness
172
MENOPAUSE
What is the mechanism of action of clonidine?
- Alpha-adrenergic receptor agonist
173
HRT
What is Hormone Replacement Therapy (HRT)?
How does this compare to the COCP?
- Treatment to alleviate Sx associated with menopause by giving physiological dose of oestrogen as replacement for what body is used to
- COCP gives a supraphysiological dose of oestrogen
174
HRT
What are some indications for HRT?
- Replacing hormones in POI even without Sx
- Reducing vasomotor + other Sx in menopause
- Reduce osteoporosis risk in women <60
175
HRT
What are some benefits of HRT?
- Improved Sx control
- Improved QOL
- Reduced risk of osteoporosis
176
HRT
What are some risks with HRT?
- Increased risk of breast cancer by adding progesterone
- Increased risk of endometrial cancer by oestrogen alone
- Increased risk of VTE
- Increased risk of stroke + IHD
177
HRT
How can the HRT risks be managed for...
i) breast cancer?
ii) endometrial cancer?
iii) VTE?
iv) IHD?
i) Local (Mirena) instead of systemic progesterones, risk declines after 5y stopping
ii) Add progesterone (esp Mirena) to prevent endometrial hyperplasia
iii) Transdermal patch
iv) Do not take for >10y after menopause
178
HRT
What are some contraindications to HRT?
- Undiagnosed PV bleeding
- Current or past breast cancer
- Any oestrogen sensitive cancer (endometrial)
179
HRT
What HRT would you give to...
i) woman without uterus?
ii) woman with uterus?
iii) woman with period within past 12m?
iv) woman with period >12m ago?
i) Continuous oestrogen-only HRT
ii) Add progesterone (combined HRT)
iii) Cyclical combined HRT
iv) Continuous combined HRT
180
HRT
What preparations of HRT are there?
- Pessary + cream (local Sx like bleeding, pain, UTI), transdermal patch, tablets
- Tibolone is a synthetic steroid hormone that acts as continuous combined (only used >12m from LMP)
181
HRT
When would patches be used for HRT?
What is the most common side effect?
- Pt choice
- GI upset (Crohn's)
- VTE risk
- Co-morbidities like HTN
- Skin irritation #1
182
HRT
How can oestrogen be given?
- Tablets or transdermal (patches or gels)
183
HRT
When would you use cyclical progesterone compared to continuous?
- Perimenopausal women to allow monthly breakthrough bleed during oestrogen-only part of cycle (10–14d/month)
- Continuous after amenorrhoeic for 2y <50 or 1y >50 as before this can cause irregular breakthrough bleeding
- After 12m of treatment can switch to continuous
184
HRT
How can progesterone be given?
- Tablets, transdermal (patches) or IUS (Mirena)
185
HRT
What would you give for...
i) cyclical combined HRT?
ii) continuous HRT?
i) Sequential tablets or patches
ii) Mirena licensed for 4 years for endometrial protection – also treats menorrhagia
186
HRT
What are the side effects associated with oestrogen?
- Nausea,
- bloating,
- headaches,
- breast swelling or tenderness,
- leg cramps
187
ATROPHIC VAGINITIS
What is atrophic vaginitis?
- Dryness + atrophy of vaginal mucosa related to lack of oestrogen
188
ATROPHIC VAGINITIS
What is the pathophysiology of atrophic vaginitis?
- Epithelial lining of vagina + urinary tract responds to oestrogen by becoming thicker, more elastic + producing secretions so reduced oestrogen has opposite effect
- Tissue more prone to inflammation + changes in vaginal pH + microbial flora that contribute to localised infections
189
ATROPHIC VAGINITIS
What are some risk factors for atrophic vaginitis?
- Menopause
- Oophorectomy
- Anti-oestrogen (tamoxifen, anastrozole)
190
ATROPHIC VAGINITIS
What is the clinical presentation of atrophic vaginitis?
- Postmenopausal with PV dryness, dyspareunia + occasional spotting
- Consider with recurrent UTIs, stress incontinence or pelvic organ prolapse
191
ATROPHIC VAGINITIS
What might the PV examination show in atrophic vaginitis?
- Sparse pubic hair
- Pale mucosa
- Dryness
- Thin skin
- Reduced vaginal folds
- May be painful
192
ATROPHIC VAGINITIS
What is the management of atrophic vaginitis?
HORMONAL
- local oestrogen replacement (estradiol vaginal ring, vaginal oestrogen pessaries)
- systemic HRT
NON-HORMONAL
- vaginal lubricants
- vaginal moisturisers
- laser therapy
- ospemifene
193
URINARY INCONTINENCE
What is urinary incontinence?
- Involuntary leakage of urine at socially unacceptable times
- Affects 20% of adult women
194
URINARY INCONTINENCE
What is the physiology of micturition?
- Detrusor = smooth muscle, transitional epithelium normally only contracts during micturition = sacral parasympathetic innervation from S2-4
- M2+3 muscarinic receptors with ACh
- Sympathetic nerve fibres from T11-L2 maintain relaxation of bladder for storage
195
URINARY INCONTINENCE
What are the 6 main types of incontinence?
- Overactive bladder/urge incontinence
- Stress incontinence
- Mixed incontinence (of the 2 above)
- Overflow incontinence
- Fistula
- Neurological
196
URINARY INCONTINENCE
What causes urge incontinence/OAB?
- Overactivity + involuntary contractions of the detrusor muscle
197
URINARY INCONTINENCE
What is the pathophysiology of stress incontinence?
- Weakness of pelvic floor + sphincter muscles
- Detrusor pressure > closing pressure of urethra
198
URINARY INCONTINENCE
What is overflow incontinence?
- Chronic urinary retention due to outflow obstruction leads to overflow of urine + incontinence without the urge to pass, M>F
199
URINARY INCONTINENCE
What are some causes of overflow incontinence?
- Anticholinergics
- Fibroids
- Pelvic tumours
- BPH (men)
- Neuro (damage, MS, diabetic neuropathy, spinal cord injuries)
200
URINARY INCONTINENCE
How does neurology cause incontinence?
Nerve damage, MS or functional
201
URINARY INCONTINENCE
What are some risk factors for urinary incontinence?
- Increasing age
- Multiparity
- High BMI
- FHx
- Previous pelvic surgery (hysterectomy)
202
URINARY INCONTINENCE
What is the clinical presentation of urge incontinence/OAB?
- Urgency, frequency, nocturia
- 'Key in door' + 'handwash' trigger bladder contractions
- Intercourse
- May affect activities + QOL as worried about toilet access
203
URINARY INCONTINENCE
What is the clinical presentation of stress incontinence?
- Involuntary leakage when increased pressure (cough, laugh, lifting, exercise)
204
URINARY INCONTINENCE
What are some investigations in urinary incontinence?
- Hx most important
- Bladder diary (frequency volume chart) first line
- Urine dipstick + MSU
- Residual urine measurement
- Electronic Personal Assessment Questionnaire
- Urodynamics
- Cystogram with contrast
205
URINARY INCONTINENCE
What does a bladder diary look at?
- Frequency + quantity of both urination and leakage
- Fluid intake + diurnal variation
206
URINARY INCONTINENCE
What are you looking for in urine dipstick + MSU?
- Nitrites + leukocytes = infection
- Microscopic haematuria = glomerulonephritis
- Proteinuria = renal disease
- Glycosuria = DM, nephropathy
207
URINARY INCONTINENCE
How do you measure residual urine?
- In/out catheter or USS
208
URINARY INCONTINENCE
What is the Electronic Personal Assessment Questionnaire (ePAQ)?
Determines impact on QOL + assesses –
- Urinary (pain, voiding, stress, OAB, QOL)
- Vaginal (pain, capacity, prolapse, QOL)
- Bowel (IBS, constipation, continence, QOL)
- Sexual (dyspareunia, overall sex life)
209
URINARY INCONTINENCE
What is the purpose of urodynamics?
Measures pressure in abdomen + bladder to deduce detrusor pressure
210
URINARY INCONTINENCE
What is some lifestyle advice for urinary incontinence?
- Weight loss
- Stop smoking
- Reduce caffeine + alcohol
- Avoid straining + constipation
211
URINARY INCONTINENCE
What are some conservative treatments for urinary incontinence?
- Leakage barriers (pads), skin care + odour control
- Bladder bypass with urethral, suprapubic or intermittent self-catheters
- PV oestrogen to reduce urinary Sx
212
URINARY INCONTINENCE
What is the stepwise management of urge incontinence/OAB?
- 1st line = bladder retraining (6w gradually increasing time between voiding)
- 1st line drugs = anti-muscarinics (oxybutynin, tolterodine, darifenacin)
- Mirabegron (beta-3-adrenergic agonist) if anti-muscarinics not tolerated
- specialist referral for botox injections + surgery
213
URINARY INCONTINENCE
What is the mechanism of action of anti-muscarinics?
- Parasympathetic so Pissing = decreases need to urinate + spasms
214
URINARY INCONTINENCE
What is the mechanism of action of beta-3-adrenergic agonists?
- Sympathetic so Storage = relaxes detrusor + increases bladder capacity
215
URINARY INCONTINENCE
What are last resort options for urge incontinence?
- Augmentation cystoplasty with bowel tissue
- Bypass (urostomy)
- Botox can paralyse detrusor + block ACh release
216
URINARY INCONTINENCE
What is the first line management of stress incontinence?
- Pelvic floor exercises with physio for 3m
- Pelvic floor muscle contraction > clamping of urethra > increased urethral pressure so reduced leakage
217
URINARY INCONTINENCE
What medical management can be used in urinary incontinence?
- Duloxetine (SNRI)
218
URINARY INCONTINENCE
What are the surgical interventions for stress incontinence?
- Colposuspension
- Tension free vaginal tape (TVT)
- Autologous sling procedures (TVT but strip of fascia from abdo wall)
219
URINARY INCONTINENCE
What are the aims of surgical interventions of stress incontinence?
- Restore pressure transmission to urethra
- Support or elevate urethra (anterior wall + pubic symphysis stitches in colposuspension, mesh sling looping urethra in TVT)
- Increase urethral resistance
220
PELVIC ORGAN PROLAPSE
What is pelvic organ prolapse?
- Descent of ≥1 pelvic organs resulting in protrusion on the vaginal walls
- Due to weakness + stretching of ligaments + muscles surround uterus, rectum + bladder (levator ani + endopelvic fascia support pelvic organs)
221
PELVIC ORGAN PROLAPSE
What are the 5 types of prolapse?
- Cystocele
- Rectocele
- Enterocele
- Uterine prolapse
- Vault prolapse
222
CYSTOCELE
What is a cystocele?
- Defect in ant. vaginal wall = bladder prolapses backwards into vagina (can get urethrocele or cystourethrocele)
223
RECTOCELE
What is a rectocele?
- Defect in post. vaginal wall = rectum prolapses forwards into vagina
224
PELVIC ORGAN PROLAPSE
What is an enterocele?
Defect in upper posterior wall of vagina > intestine protrusion
225
PELVIC ORGAN PROLAPSE
What are some risk factors of pelvic organ prolapse?
- Age
- BMI
- Multiparity (vaginal)
- Spina bifida
- Pelvic surgery
- Menopause
226
CYSTOCELE
What is the clinical presentation of a cystocele?
- "Something coming down" = dragging/heavy sensation in pelvis
- Pain, lump, discomfort
- incontinence, urgency, frequency, poor stream + retention
- Sexual dysfunction = pain, altered sensation + reduced enjoyment
227
PELVIC ORGAN PROLAPSE
What are the investigations for pelvic organ prolapse?
- Sim's speculum (U-shaped) to show if something is there
- May have urodynamics, USS or MRI
228
PELVIC ORGAN PROLAPSE
What is the management for pelvic organ prolapse?
- Conservative = pelvic floor exercises, weight loss + diet changes
- Vaginal pessary = ring (preferred as can have sex), shelf or Gellhorn
- Surgery (symptomatic or severe like outside vagina, ulcerated, failed Mx)
229
PELVIC ORGAN PROLAPSE
What surgical intervention is provided for cystocele/cystourethrocele?
Anterior colporrhaphy or colposuspension
230
PREMENSTRUAL SYNDROME
What is premenstrual syndrome (PMS)?
- Psychological, emotional + physical Sx that occur prior to menstruation
231
PREMENSTRUAL SYNDROME
What is thought to cause PMS?
- Fluctuation in oestrogen + progesterone during the cycle
232
PREMENSTRUAL SYNDROME
How may PMS present?
- Mood = anxiety, swings, stress, fatigue, low confidence
- Physical = bloating, headaches, breast pain
- Resolves on menstruation
- Absent before menarche, during pregnancy or after menopause
233
PREMENSTRUAL SYNDROME
How is PMS diagnosed?
- Sx diary spanning 2 menstrual cycles
- Definitive Dx with GnRH to temporarily induce menopause = Sx resolve
234
PREMENSTRUAL SYNDROME
What is the management of PMS?
MILD SYMPTOMS
- lifestyle advice = regular, frequent (2-3hrly) small balanced meals rich in complex carbohydrates
MODERATE SYMPTOMS
- COCP = yasminu (drospirenone 3mg and ethinylestradiol 0.03mg)
SEVERE SYMTPOMS
- SSRI (either taken continuously or just during luteal phase)
235
DYSMENORRHOEA
What is dysmenorrhoea?
- Painful menstruation ± N+V
236
DYSMENORRHOEA
What is primary dysmenorrhoea?
No underlying pathology, may be due to excessive endometrial prostaglandins – presents as suprapubic cramps just before or within few hours of period starting
237
DYSMENORRHOEA
What is the management of primary dysmenorrhoea?
- NSAIDs like mefenamic acid during menstruation
- COCP second line
238
AIS
What is androgen insensitivity syndrome (AIS)?
- X-linked recessive condition (androgen receptor gene mutation) with end-organ resistance to testosterone causing male genotype 46XY but female phenotype
239
AIS
What is the pathophysiology of AIS?
- Absent response to testosterone + conversion of additional androgens to oestrogen result in female secondary sexual characteristics
- Typical male sexual characteristics (Wollfian structures) do not develop
240
AIS
What is the clinical presentation of AIS?
- Infancy = inguinal hernias with undescended testes
- Puberty = primary amenorrhoea + infertile
- Tend to be taller than average, lack of pubic + facial hair as well as male muscle development
- Female external genitalia (but not internal) + breasts
241
AIS
Why is their female external genitalia but not internal in AIS?
- Undescended testes in abdo or inguinal canal produce AMH which prevents uterus, upper vagina, tubes + ovaries developing (Mullerian duct structures)
242
AIS
What is the clinical presentation of partial AIS?
- More ambiguous
- Micropenis
- Clitoromegaly
- Bifid scrotum
- Hypospadias
- Reduced male features
243
AIS
What are the investigations for AIS?
Hormone tests show raised –
- LH
- FSH (or normal)
- Testosterone (or normal for male)
- Oestrogen (for male)
Pelvic USS = absent female internal organs
Karyotyping = 46XY
244
AIS
What is the management of AIS?
- Specialist MDT (paeds, gynae, urology, endo, psychology)
- Bilateral orchidectomy to avoid testicular cancer
- Oestrogen therapy
- Vaginal dilators or surgery to create adequate length
- In general, raised as female but counselling for support
245
ASHERMAN'S SYNDROME
What is Asherman's syndrome?
- Adhesion formation within uterus following damage
246
ASHERMAN'S SYNDROME
What is the pathophysiology of Asherman's?
- Damage to basal layer of endometrium, damaged tissue may heal abnormally, creating scar tissue (adhesions)
- Adhesions can bind uterine walls together or endocervix, sealing it shut causing obstruction > infertility, 2* amenorrhoea
247
ASHERMAN'S SYNDROME
What causes Asherman's syndrome?
- Pregnancy-related dilatation + curettage procedures
- After uterine surgery
- Pelvic infection like endometritis
248
ASHERMAN'S SYNDROME
What is the clinical presentation of Asherman's syndrome?
- Secondary amenorrhoea
- Infertility
- Significantly lighter periods
- Dysmenorrhoea
249
ASHERMAN'S SYNDROME
What is the management of Asherman's syndrome?
- Hysterosalpingography = contrast injected into uterus + XR
- Sonohysterography = uterus filled with fluid + pelvic USS
- Hysteroscopy gold standard + can dissect adhesions (recurrence after common)
250
FIBROIDS
What are the issues with subserosal fibroids?
Grow outwards + can become very large, filling the abdominal cavity
251
ENDOMETRIOSIS
What are some protective factors?
Multiparity + COCP
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CERVICAL CANCER
What is cervical cancer?
What is the histological type of cervical cancer?
- Most common cancer in women <35
- Squamous cell carcinoma 80%, then adenocarcinoma (small cell rare)
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VAGINAL CANCER
What is the management?
Intravaginal radiotherapy or sometimes radical surgery
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VAGINAL CANCER
What causes it?
HPV or metastatic spread from cervix or vulva
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VAGINAL CANCER
What is the prognosis like?
Poor prognosis, average survival at 5 years 50%
256
VAGINAL CANCER
How does it present?
Bleeding or discharge, evident mass or ulcer
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MENOPAUSE
What is the average age of onset? When is it premature?
Average age = 51,
premature <40
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MENOPAUSE
What can urogenital atrophy lead to?
Urinary incontinence + pelvic organ prolapse
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HRT
What are the side effects associated with progesterone?
Mood swings,
fluid retention,
weight gain,
acne
greasy skin
260
RECTOCELE
How may this present?
- Faecal loading in that part of rectum may lead to lump in vagina + have to use finger to press lump to aid defecation
- "Something coming down" = dragging/heavy sensation in pelvis
- Pain, lump, discomfort
- constipation, incontinence + urgency
- Sexual dysfunction = pain, altered sensation + reduced enjoyment
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PELVIC ORGAN PROLAPSE
What is a vault prolapse?
If had total hysterectomy, top of vagina (vault) descends into the vagina
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PELVIC ORGAN PROLAPSE
What is a uterine prolapse?
Uterus descends into vagina
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PELVIC ORGAN PROLAPSE
What is the clinical presentation of pelvic organ prolapse?
- "Something coming down" = dragging/heavy sensation in pelvis
- Pain, lump, discomfort
- Urinary Sx (cystocele) = incontinence, urgency, frequency, poor stream + retention
- Bowel Sx (rectocele) = constipation, incontinence + urgency
- Sexual dysfunction = pain, altered sensation + reduced enjoyment
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PELVIC ORGAN PROLAPSE
What surgical intervention is provided for uterine prolapse?
Hysterectomy or sacrohysteropexy
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PELVIC ORGAN PROLAPSE
What surgical intervention is provided for rectocele?
Posterior colporrhaphy
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DYSMENORRHOEA
What are the two types?
Primary + secondary
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HYDATIDIFORM MOLE
What is a hydatidiform mole?
- Part of group of rare tumours known as gestational trophoblastic disease
- Growing mass of tissue that implants into uterus that will not come to term (non-viable fertilised egg, result of abnormal conception)
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HYDATIDIFORM MOLE
What are the 3 types of hydatidiform mole?
- Complete
- Partial
- Invasive
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HYDATIDIFORM MOLE
What is a complete mole?
- Diploid trophoblast cells
- Empty egg + sperm that duplicates DNA (all genetic material comes from father)
- 46 chromosomes
- No foetal tissue
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HYDATIDIFORM MOLE
What is a partial mole?
- Triploid (69XXX, 69XXY) trophoblast cells
- 2 sperm fertilise 1 egg
- Some recognisable foetal tissue
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HYDATIDIFORM MOLE
What is an invasive mole?
What is the significance of this?
- When a complete mole invades the myometrium
- Metaplastic potential to evolve into a choriocarcinoma
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HYDATIDIFORM MOLE
What are some risk factors for hydatidiform mole?
- Extremes of reproductive age
- Previous molar pregnancy
- Multiple pregnancies
- Asian women
- OCP
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HYDATIDIFORM MOLE
What is the clinical presentation of hydatidiform mole?
SYMPTOMS
- hyperemesis gravidarum (abnormally high b-hCG)
- vaginal bleeding
- vaginal passage of grape-like masses
SIGNS
- uterus large for dates
- thyrotoxic features (tachycardia, tremor, sweating, hypertension)
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HYDATIDIFORM MOLE
What are some investigations for hydatidiform mole?
- Serum beta-hCG = abnormally high (trophoblastic tissue producing excessive amounts > hyperemesis + thyrotoxicosis)
- TFTs (b-hCG can mimic TSH) = high T4 with normal TSH
- pelvic USS = snowstorm appearance
- Dx confirmed with histology after evacuation
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HYDATIDIFORM MOLE
What is the main complication of hydatidiform mole?
- 2-3% complete moles transition to highly malignant choriocarcinoma which can metastasise to the lungs
- These are placental site trophoblastic tumours
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HYDATIDIFORM MOLE
What is the management for hydatidiform mole?
- Urgent referral to specialist centre
- Complete moles = suction dilation + curettage
- Partial moles = suction or medical evacuation
- Invasive = suction D+C but not all removed, some resolve
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HYDATIDIFORM MOLE
What is the management of hydatidiform mole after evacuation?
- Check urinary pregnancy test in 3w – if high or mets may need chemo (cisplatin)
- Effective contraception as advised to avoid pregnancy for 12m
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PELVIC INFLAMMATORY DISEASE
What is pelvic inflammatory disease?
- Inflammation + infection of the pelvic organs (upper genital tract), caused by ascending infection through the cervix.
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PELVIC INFLAMMATORY DISEASE
What are the STI causes of PID?
- N. gonorrhoea (tends to be more severe),
- chlamydia trachomatis (most common),
- Mycoplasma genitalium
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PELVIC INFLAMMATORY DISEASE
What are some risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Intrauterine device
- Younger age
- Existing STIs
- Previous PID
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PELVIC INFLAMMATORY DISEASE
What is the clinical presentation of PID?
- Pelvic/lower abdo pain (chronic)
- Abnormal PV discharge (purulent), urinary Sx (dysuria, frequency).
- Abnormal bleeding (IMB, PCB, dysmenorrhoea).
- Deep dyspareunia
- Fever (± other signs of sepsis)
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PELVIC INFLAMMATORY DISEASE
What are some differentials of PID?
- Appendicitis
- Ectopic
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PELVIC INFLAMMATORY DISEASE
What might you find on a clinical examination in PID?
- Pelvic/adnexal tenderness.
- Cervical excitation (motion tenderness)
- Cervicitis
- Purulent discharge
284
PELVIC INFLAMMATORY DISEASE
What investigations would you do in PID?
- Pregnancy test to exclude ectopic
- NAAT swabs for gonorrhoea + chlamydia
- HVS for BV, candidiasis + trichomoniasis
- HIV + syphilis bloods
- FBC, blood cultures + CRP/ESR if acutely unwell/septic
- TV USS if abscess suspected
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PID
What might you look for on microscopy in PID?
What is the relevance?
- Pus cells on swabs from vagina or endocervix
- Absence is useful to exclude PID
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PELVIC INFLAMMATORY DISEASE
What are the complications of PID?
- Sepsis
- Abscess
- Subfertility from tubal blockage
- Chronic pelvic pain
- Ectopics
- Fitz-Hugh-Curtis syndrome
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PELVIC INFLAMMATORY DISEASE
What is Fitz-Hugh-Curtis syndrome?
What does it cause?
- Inflammation + infection of liver (Glisson's) capsule.
- Leads to adhesions between liver + peritoneum, bacteria may spread from pelvis via peritoneal cavity, lymphatics or blood
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PELVIC INFLAMMATORY DISEASE
What is the management of PID?
- 1g stat IM ceftriaxone (gonorrhoea)
- 100mg BD doxycycline for 14d (chlamydia + MG)
- Metronidazole 400mg BD for 14d (Gardnerella)
- GUM referral for specialist Mx + contact tracing
- Hospital admission for IV Abx if signs of sepsis or pregnant
- Pelvic abscess > drainage
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PELVIC INFLAMMATORY DISEASE
What organs can be infected?
Uterus - Endometritis
Fallopian tubes - salpingitis,
Ovaries - oophoritis,
Peritoneum - peritonitis,
Parametrium - parametritis (parametrium which is connective tissue around the uterus).
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PELVIC INFLAMMATORY DISEASE
What are the non-infective causes of PID?
- Post-partum (retained tissue),
- uterine instrumentation (hysteroscopy, IUCD),
- descended from other organs (appendicitis)
291
PELVIC INFLAMMATORY DISEASE
What are the non-STI infective causes of PID?
Gardnerella vaginalis,
H. influenzae,
E. coli.
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PELVIC INFLAMMATORY DISEASE
What is the clinical presentation of Fitz-Hugh-Curtis syndrome?
RUQ pain ± referred R shoulder pain if diaphragmatic irritation
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PELVIC INFLAMMATORY DISEASE
How is Fitz-Hugh-Curtis syndrome managed?
- Inflammation + infection of liver (Glisson's) capsule.
- Leads to adhesions between liver + peritoneum, bacteria may spread from pelvis via peritoneal cavity, lymphatics or blood
- RUQ pain ± referred R shoulder pain if diaphragmatic irritation
- Laparoscopy to visualise + adhesiolysis
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GENITAL TRACT FISTULA
what is a genital tract fistula?
Abnormal connection between vagina and other organs, such as the bladder, colon, rectum
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GENITAL TRACT FISTULA
what are the causes of genital tract fistulas?
injury (primarily in childbirth),
surgery,
infection
radiation.
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GENITAL TRACT FISTULA
what are the different types?
➢ Vesicovaginal fistula
➢ Ureterovaginal fistula
➢ Urethrovaginal fistula
➢ Rectovaginal fistula
➢ Enterovaginal fistula
➢ Colovaginal fistula
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GENITAL TRACT FISTULA
what are the risk factors for genital tract fistulas?
➢ Childbirth
➢ Surgery
➢ Infection
➢ IBD
➢ Radiation
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GENITAL TRACT FISTULA
what are the symptoms of genital tract fistulas?
➢ Passage of gas, pus and fluid from the vagina
➢ Recurrent UTI’s
➢ Dyspareunia
➢ Irritation of vulva/vagina/anus/perineum
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GENITAL TRACT FISTULAS
what are the investigations for genital tract fistulas?
➢ Vaginal/anal examination (could use proctoscope or
speculum)
➢ Contrast tests (barium enema)
➢ Blue dye test ➔ put a tampon in the vagina then blue
dye in rectum. If tampon is stained = test positive
➢ CT, MRI, Ultrasound, Manometry
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GENITAL TRACT FISTULAS
what is the management for genital tract fistulas?
➢ Antibiotics, infliximab
➢ Surgery – must be done when there is no inflammation/infection
* Sewing of fistula
* Tissue graft
* Repairing anal sphincter
* Colostomy?
➢ Lifestyle changes → wash, avoid irritants, keep dry, loose clothes...
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OVERACTIVE BLADDER
what is an overactive bladder?
Involuntary leakage of urine accompanied by, or immediately preceded by, a strong desire
to pass urine (void).
Urgency, with or without urge urinary incontinence, usually with frequency and
nocturia is also defined as overactive bladder (OAB) syndrome →Detrusor overactivity.
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OVERACTIVE BLADDER
what are the causes of overactive bladder?
➢ Idiopathic
➢ Neurogenic DO in MS, Spina bifida, upper motor neuron lesions...
➢ Pelvic or incontinence surgery
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OVERACTIVE BLADDER
what are the risk factors for overactive bladder?
➢ Old age
➢ Pregnancy/childbirth
➢ Hysterectomy
➢ Obesity
➢ Family history
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OVERACTIVE BLADDER
what are the signs/symptoms of an overactive bladder?
➢ Symptoms of OAB include urinary frequency, urgency, urge incontinence, and nocturia.
➢ Provocative factors often trigger it, such as cold weather, opening the front door, or hearing
running water.
➢ Bladder contractions may also be provoked by increased intra-abdominal pressure (coughing
or sneezing), leading to complaint of stress incontinence, which may be misleading.
➢ Quality of life can be significantly impaired by the unpredictability and large volume of
leakage.
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OVERACTIVE BLADDER
what are the investigations for overactive bladder?
➢ Urine culture (Exclude UTI)
➢ Frequency/volume chart
➢ Urodynamics (looks for involuntary detrusor contractions during the filling phase in the
micturition cycle – spontaneous or provoked)
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OVERACTIVE BLADDER
how is it diagnosed?
➢ Urodynamic studies
➢ Exclusion of other factors → Metabolic diseases (hypercalcemia/diabetes), physical causes
(prolapse or fecal impactions), urinary pathology (UTI, cystitis) ...
307
OVERACTIVE BLADDER
what is the management for overactive bladder?
1. Behavioral therapy (less liquids, avoid caffeine, avoid diuretics/antipsychotics)
2. Bladder retraining
3. Pharmacological interventions
➢ Anticholinergics (Oxybutynin): side effects include dry mouth, constipation, nausea,
dyspepsia, palpitations, blurred vision...)
➢ Estrogens
➢ Botulinum toxin A
4. Neuromodulation and nerve stimulation
5. Surgical management – detrusor muscle myomectomy and augmentation cystoplasty...
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CERVICAL CANCER SCREENING
when is screening offered?
25-49yrs = every 3 years
50-64yrs = every 5 years
not offered to people over 64yrs
309
CERVICAL CANCER SCREENING
when is cervical screening done in pregnancy?
it is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
310
URINARY INCONTINENCE
what can cause stress incontinence?
- low oestrogen in menopause
- weakened pelvic floor
- parity
- pelvic surgery
311
URINE INCONTINENCE
how does fistulas cause incontinence?
- another outflow between urinary tract and vagina or bowel meaning urine can flow involuntarily
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URINARY INCONTINENCE
What is the purpose of cystogram with contrast?
visualise the bladder
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URINARY INCONTINENCE
What are some side effects of anti-muscarinics?
- "Can't see, spit, pee or shit" > caution in elderly as falls esp oxybutynin immediate release in frail
314
URINARY INCONTINENCE
What is a caution of beta-3-adrenergic agonists?
- C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
315
DYSMENORRHOEA
What is secondary dysmenorrhoea?
Secondary to endometriosis, adenomyosis, fibroids, PID, IUDs, cancer
