Womens Health (Joe) Flashcards
Define Pelvic Organ Prolapse?
Descent of the pelvic organs into the vagina.
What is the pathology of a Prolapse?
The result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
What types of prolapse can result from a weakness in the Apical Vaginal Wall?
- Uterine prolapse
- Vaginal Vault Prolapse
what is a Uterine Prolapse?
Where the uterus itself descends into the vagina
What is a Vault Prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus.
The top of the vagina (the vault) descends into the vagina
What types of Prolapse can result from a weakness in the Posterior Vaginal Wall?
- Enterocele
- Rectocele
What is an Enterocele?
Defect in the posterior vaginal wall allowing the small intestine to prolapse forwards into the vagina
What is a Rectocele?
Defect in the posterior vaginal wall allowing the rectum to prolapse forwards into the vagina
What type of prolapse can result from a weakness in the Anterior Vaginal Wall?
- Cystocele
- Urethrocele
- Cystourethrocele
What is a Cysteocele?
Prolapse of the bladder backwards into the vagina due to a defect in the anterior vaginal wall
What is a Urethrocele?
Prolapse of the Urethra backwards into the vagina due to a defect in the anterior vaginal wall
What is a Cystourethrocele?
Prolapse of both the bladder and the urethra into the vagina through the anterior vaginal wall.
What is the Epidemiology of Pelvic Organ Prolapse?
- Common condition
- More common in Postmenopausal women
- More common in those who have undergone childbirth
- Prevalence increases with age
What are some risk factors for developing pelvic organ prolapse?
- Multiple vaginal deliveries
- Increasing age
- Instrumental, prolonged or traumatic delivery
- Hysterectomy
- Advanced age and postmenopausal status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
- Heavy lifting
- Connective tissue disorders
What are the clinical features of a pelvic organ prolapse?
Depend on the type and severity
- Pelvic discomfort or Sensation of Heaviness or Sensation of something coming down
- Visible protrusion of tissue from the vagina
- Urinary Symptoms such as Incontinence, recurrent UTIs or voiding difficulties
- Defecatory symptoms such as Constipation or incomplete bowel emptying
- Sexual Dysfunction
- Women may notice a lump or mass that they will often push back up themselves.
What clinical features are Rectoceles particularly associated with?
Constipation
- Women can develop Faecal loading in the part of the rectum that ha prolapsed.
- This may lead to significant constipation and urinary retention
What are some differential diagnoses for pelvic organ prolapse?
- Gynaecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain
- Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain
- Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass
What are the investigations for a Pelvic Wall Prolapse?
- Detailed Pelvic Examination
- Imaging studies: MRI or Ultrasound may be used in complex cases
- Urodynamic studies if co-existing urinary symptoms.
What is used to examine the pelvis when investigating for Pelvic organ prolapse?
Sim’s Speculum
- U shaped speculum that is used to support the anterior or posterior vaginal wall whilst the other walls are examined.
- Women are asked to cough or bear down to assess the full decent of the prolapse.
- Dorsal and Left Lateral position are used.
How is a uterine prolapse graded?
Pelvic organ prolapse quantification system (POP-Q):
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
What is the management for Pelvic Organ Prolapse?
- Conservative management: appropriate for women able to cope with mild symptoms, who do not tolerate pessaries or are not suitable for surgery
- Pelvic floor Exercise
- Avoidance of triggers: Straining, heavy lifting, weight loss (if overweight)
- Topical Oestrogen
- Vaginal Pessaries: Inserted into the vagina to provide extra support to the pelvic organs.
- Surgery: Definitive option for treating Pelvic organ prolapse but must consider the risk and benefits of each individual.
What conservative management options are there for Pelvic Organ Prolapse?
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
What are some options for Vaginal Pessaries?
- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
- Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
- Cube pessaries are a cube shape
- Donut pessaries consist of a thick ring, similar to a doughnut
- Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
What is some key information about Vaginal Pessaries?
- Should be removed and cleaned or changed periodically (every 4 months)
- Can cause vaginal irritation and erosion over time
- Oestrogen cream helps protect the vaginal walls from irritation
What are some possible complications of Pelvic Organ Prolapse Surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
Define Urinary Incontinence?
Involuntary passage of urine
Define Overactive Bladder Syndrome?
A chronic condition that results rom hyperactivity of the detrusor muscle. This is primarily characterised by urinary urgency and urge incontinence
What are the clinical features of Overactive Bladder Syndrome?
- Urinary Urgency
- Urge Incontinence
- Frequency
- Nocturia
What is a typical presentation of Overactive Bladder syndrome and Urge incontinence?
- Typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
- Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
- This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
What are some differential diagnoses for Overactive Bladder Syndrome?
- Urinary tract infections: Characterised by dysuria, urgency, frequency, suprapubic pain and haematuria.
- Bladder stones: Symptoms include lower abdominal pain, dysuria, intermittent stream, and blood in the urine.
- Interstitial cystitis: Presents with symptoms such as chronic pelvic pain, a persistent, urgent need to urinate, and frequent urination.
- Diabetic neuropathy: Can cause bladder dysfunction, resulting in symptoms like frequent urination and incontinence.
What are the investigations for Overactive Bladder Syndrome?
- Urinalysis and culture: To rule out infection
- Frequency/volume chart: To assess the severity of the condition
- Urodynamics: To evaluate bladder muscle function
What is the management for Overactive Bladder Syndrome?
First Line: For at least 6 weeks:
- Bladder retraining: Which aims to increase the interval between voids, and suppress the urinary urge
- Behavioural modifications: Such as reducing oral fluid intake, and avoiding caffeine and alcohol
Second Line:
- Anticholinergic drugs: Like oxybutynin, Tolterodine and solifenacin
- Mirabegron: An alternative to anticholinergics
- Vaginal oestrogens: Used if urogenital atrophy is a likely contributory factor
Invasive options when medical treatments fail
- Botulism toxin: Used specifically for refractory cases
Give some anticholinergic drugs used to treat an Overactive Bladder?
- Oxybutynin
- Tolterodine
- Solifenacin
What are sine side effects of Anticholinergic Mediations?
- Dry mouth and eyes
- Urinary Retention
- Constipation
- Postural Hypotension
- Cognitive decline and memory problems
- Worsening of Dementia
What is Mirabegron?
A beta 3 agonist that stimulates the sympathetic nervous system causing relaxation of the bladder.
What is a contraindication of Mirabegron?
Uncontrolled Hypertension.
- Since it stimulates the sympathetic nervous system it can lead to a raised blood pressure and can result in a hypertensive crisis!
- Can also increase the risk of stroke and TIA
What are some examples of Invasive options to treat Overactive Bladder Syndrome when the bladder has failed to respond to medication?
- Botulinum toxin type A injection into the bladder wall
- Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
- Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
- Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
Define Urinary Incontinence
The loss of control of urination leading to involuntary passage of urine
What is the Physiology of the Storage phase of Continence?
- Impulses from the cerebral cortex are transmitted to the pontine continence centre.
- The pontine continence centre sends signals to sympathetic nuclei within T10-L2 sympathetic ganglia, which then sends further signals to the detrusor and internal urethral sphincter muscles via the sympathetic hypogastric nerve, stimulating:
- Relaxation of the detrusor muscle.
- Contraction of the internal urethral sphincter.
- Somatic innervation of the external urethral sphincter also contributes to continence during bladder filling
What is the Physiology of the Voiding phase of Continence?
- Afferent signals from the distended bladder ascend via the spinal cord to the pontine micturition centre and the cerebral cortex (conscious urge to pass urine).
- Efferent parasympathetic signals to the detrusor cause it to contract, transmitted via S2-4 pelvic splanchnic nerve.
- Inhibition of Onuf’s nucleus (due to pontine micturition centre activity) reduces sympathetic storage-promoting activity.
- Conscious relaxation of external urethral sphincter via somatic pudendal nerve fibres allows passage of urine.
Give a summary of the neurology involved in continence?
Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing
- Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening
- Somatic afferent - S2-4 pudendal - sensation of bladder fullness
- Somatic efferent - S2-3 pudendal - closes / opens EUS.
What are the continence mechanisms in response to a raised intra-abdominal pressure?
- Reflexive contraction of the pelvic floor muscles elevates the IUS.
- Augmentation of pelvic floor muscle closure by suspensory ligaments.
- Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure
What are the different types of Urinary Incontinence?
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
- Mixed incontinence
What is Urge incontinence?
Caused by Overactivity of the detrusor muscle.
This is also known as overactive bladder syndrome
What is Stress incontinence?
Leaking of urine when intra-abdominal pressure is raised that puts pressure on the bladder. The pressure overcomes the mechanisms to maintain continence.
This occurs due to weakness of the pelvic floor and sphincter muscles
What are some risk factors for Stress incontinence?
- Childbirth (Especially vaginal)
- Hysterectomy
What are some triggers for Stress incontinence?
Anything that can increase abdominal pressure sufficiently
- Coughing
- Laughing
- Sneezing
- Exercising
What is the management for Stress incontinence?
Lifestyle Advice:
- Avoid caffeine, fizzy and sugary drinks
- Avoid excessive fluid intake
- Pelvic floor exercises (8x contractions x3 per day)
Medical Management:
- Duloxetine (only recommended if conservative management fails and the patient is not a surgical candidate)
Surgical Management:
- Pessaries
- Bulking agents placed at the bladder neck
- Colposuspension and fascial slings
- **Mid urethral slings
What is the gold standard treatment for Stress incontinence?
Mid-urethral slings is the gold standard surgical treatment of stress incontinence.
It compresses the urethra against a supportive layer and assists in closing the urethra.
What is Functional incontinence?
Individual has the urge to pass urine but for whatever reason they are unable to access the necessary facilities and are aw a result incontinent.
What are some potential causes of Functional Incontinence?
- Sedating Medications
- Alcohol
- Dementias
What is Overflow incontinence?
Occurs when small amounts of urine leak without warning.
This may happen when the pressure within the bladder overcomes the pressures of the outlet structure and thus urine leaks
What are some causes of Overflow incontinence?
- Underactivity of the detrusor muscle such as from neurological damage
- Urinary outlet pressures are too high Such as in constipation or prostatism
- Chronic urinary retention due to an obstruction.
- Anti-cholinergic medications.
What is Mixed incontinence?
A combination of urge incontinence and stress incontinence.
It is crucial to identify which of the 2 is having the more significant impact and address this first.
What are the investigations of Incontinence?
First Line:
- Medical history and Assessment
- Physical Examination
- Bladder Diary: tracking fluid intake, episodes of urination and incontinence over at least 3 days
- Urinalysis and Urine-Dip stick: To look for infection or other pathology
Second Line:
- Urinary Stress Tests: Cough stress test, empty supine stress test
- Cystometry and Cystogram: Bladder scan to assess for bladder pressures when voiding or fistulas
- Urodynamics
What information should be obtained from a Medical history assessment for Incontinence?
Differentiate between Stress or Urge:
- Urinary leakage with coughing, laughing or sneezing (Stress)
- Urinary leakage due to sudden urge to pass with loss of control (Urge)
Assess for Modifiable lifestyle factors:
- Caffeine consumption
- Alcohol consumption
- Medications (anticholinergics)
- BMI
Assess the Severity:
- Frequency of urination
- Frequency of incontinence
- night-time urination
- Use of pads and changes of clothing.
What should be done during a Physical examination to look for incontinence?
Assessment of Pelvic Tone:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
Also examine for
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- urinary incontinence (asking the patient to cough)
What are the indications for Urodynamic testing?
- Patients with Urge incontinence not responding to first line medical treatments
- Difficulties urinating
- Urinary retention
- Previous surgery in and around the pelvis
- Unclear diagnosis
What is done in Urodynamic testing for incontinence?
- Patients should stop taking anticholinergic and bladder related medications for 5 days before testing.
- A catheter is inserted into the bladder and the rectum and they measure the pressures for comparison. The bladder is filled with liquid and different measurements are taken.
What are each of these measurements for?
- Cystometry
- Uroflowmetry
- Leak Point Pressure
- Poist-void residual bladder volume
- Video urodynamic testing
- Cystometry measures the detrusor muscle contraction and pressure
- Uroflowmetry measures the flow rate
- Leak Point Pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
- Poist-void residual bladder volume tests for incomplete emptying of the bladder
- Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Define Urolithiasis?
Urinary tract stones or Urolithiasis refer to solid concretions or crystal aggregations formed in the urinary system from substances present in the urine
Define Renal Colic?
A condition characterised by severe pain caused by the presence of a stone in the urinary tract
What is the epidemiology of Urinary tract stones?
- Common condition affecting 2-3% of western population
- More common in males
- More common in people younger than 65
What is the aetiology of renal stones?
Calcium oxalate stones:
- Represent 85% of stones. They are radiopaque, formed in variable urine pH, and majorly linked to hypercalciuria.
Calcium phosphate stones:
- Account for 10% of stones. They are radiopaque and linked to renal tubular acidosis type 1 & 3, leading to increased urine pH and supersaturation of calcium and phosphate in the urine.
Cystine stones:
- Make up 1% of stones. Characterised by a semi-opaque “ground glass” appearance, they result from inherited recessive inborn errors of metabolism causing disruption in cystine transport and decreased absorption from the renal tubule.
Uric acid stones:
- Comprise 5-10 of stones. They are radiolucent, formed due to acid produced from purine metabolism and precipitate when urinary pH is low. They can be linked to diseases causing extensive tissue breakdown.
Struvite stones:
- Account for 2-20% of stones. They are radiopaque and formed from magnesium, ammonium, and phosphate, often associated with chronic UTIs from urease producing bacteria like ureaplasma, proteus.
Indinavir stones:
- Associated with the antiretroviral protease inhibitor Indinavir** used in HIV treatment. It can crystallize in renal tubules and result in renal stones. These stones are radiolucent on CTKUB.
What is the most common cause of Renal stones?
Hypercalcaemia/Hypercalciuria
Patients may present with symptoms of hypercalcaemia (renal stones, painful bones, abdominal groans and psychiatric moans)
3 Main causes of Hypercalcaemia:
- Calcium supplementation
- Hyperparathyroidism
- Cancer (Myeloma, Breast, Lung)
What are the risk factors for Nephrolithiasis?
Modifiable risk factors include:
- Obesity
- Dehydration
- Diet rich in oxalate-rich foods like fruits, nuts, and cocoa
Non-modifiable risk factors include:
- Previous stone disease
- Anatomical abnormalities of the collecting system
- Family history
Underlying medical conditions, such as:
- Hyperparathyroidism
- Renal tubular acidosis
- Myeloproliferative disorders
- All chronic diarrhoeal conditions
What is Staghorn Calculus?
Where the stone forms in the shape of the renal pelvis giving it a similar appearance to the antlers of a deer stag.
Often associated with Struvite stones
What are the clinical features of Renal Colic?
- Unilateral ** Colicky loin to groin pain** that can be excruciating (“worse than childbirth”)
- Haematuria
- Nausea or vomiting
- Reduced urine output
- Symptoms of sepsis (Fever), if infection is present
What are some differential diagnoses for Renal Colic?
- Pyelonephritis: Presents with fever, flank pain, and urinary symptoms such as frequency, urgency, and dysuria.
- Appendicitis: Presents with right lower quadrant pain, nausea, vomiting, and possibly fever.
- Diverticulitis: Presents with left lower quadrant pain, fever, nausea, vomiting, and changes in bowel habits.
- Ovarian torsion: Presents with acute lower abdominal pain, nausea, vomiting, and sometimes fever.
- Ectopic pregnancy: Presents with lower abdominal pain, vaginal bleeding, and a positive pregnancy test.
- Abdominal aortic aneurysm: Presents with central abdominal pain, pulsatile/expansile abdominal aorta and if ruptured, haemodynamic instability.
What are the investigations for Renal Colic?
Bedside investigations:
- Urinalysis to detect haematuria
- Urine MC+S as there may be a co-existing infection/precipitant.
- Observations to look for any signs of sepsis
Blood tests:
- Full Blood Count to detect any inflammatory response
- Urea and Electrolytes to assess any impairment in renal function.
- Calcium & Uric acid to identify underlying metabolic conditions predisposing to stone formation.
Radiological investigations:
- A non-contrast helical CT KUB, the gold standard for identifying renal calculi.
- An x-ray for managing renal colic if there’s a confirmed stone on CT KUB, necessary for the use of extracorporeal shockwave lithotripsy.
What is the initial and gold standard investigation for Renal Colic?
Non-contrast CT Kidney, Ureter and Bladder (CTKUB) is both the initial and Gold standard investigation
- NICE recommend a CT within 24 hours of presentation
What is the management for Renal Colic?
- Analgesia: NSAIDs such as IM Diclofenac
- Anti-emetics: Metoclopramide, Cyclizine
- Antibiotics: If infection is present
- Medical Expulsive Therapy: Uses Tamsulosin to help passage of distal ureter stones < 5mm
- Watchful Waiting: If stones are less than 5mm
- Surgical Intervention: required in larger stones 10mm or more or ones that do not pass spontaneously. Also required if there is complete obstruction or infection.
What are some surgical options for Renal Colic?
Stones < 2cm
- Extracorporeal shockwave lithotripsy (ESWL): shock waves fragment the stone to then be passed
- Ureteroscopy: Treatment of choice for middle or distal ureteric stones and for Pregnant women
Stones > 2cm
- Percutaneous nephrolithotomy: for large stones or complex calculi like staghorn or cysteine.
- Open Stone surgery: when other options have failed.
What is a complication of renal stones?
- Significant risk of recurrent episodes
- Obstructive infection
- Sepsis
- Renal Failure
What advice can be given to reduce the risk of recurrent stones?
- Increase oral fluid intake (2.5 – 3 litres per day)
- Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
- Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
- Reduce dietary salt intake (less than 6g per day)
- Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)
Define Oligomenorrhea?
Infrequent/irregular menstrual periods (fewer than 6-8 per year)
Define Amenorrhoea?
Absence of a menstrual period
Primary: absence of a period at age 15 in the presence of normal secondary sexual characteristics or at age 13 with no secondary sexual characteristics
Secondary: Absence of a period for 3 consecutive cycles in a women with a previously established menstrual cycle
What are some causes of Primary Amenorrhoea?
- Constitutional delay (Familial)
- Imperforate hymen
- Endocrinological: Hypo-hyperthyroidism, Hyperprolactinaemia, Cushing’s Syndrome
- Androgen Insensitivity Syndrome
- Turners syndrome
What are some causes of Secondary Amenorrhoea?
- Pregnancy (most common cause)
- Breastfeeding
- Menopause
- Intrauterine adhesions leading to outflow tract obstruction (Asherman’s syndrome)
- Polycystic ovary syndrome (PCOS)
- Drug-induced amenorrhoea (e.g. contraceptive use)
- Functional Hypothalamic Amenorrhoea: Physical stress, excess exercise, and weight loss
- Pituitary gland pathology: such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
Define Androgen Insensitivity Syndrome?
An X-linked Recessive genetic condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors This results in Genetic Males with a Female Phenotype
What is the pathophysiology of Androgen Insensitivity Syndrome?
- Mutation in Androgen receptor gene on the *X chromosome** results in cells becoming unable to respond to androgens.
- Excess androgens are converted to Oestrogen resulting in female secondary sexual characteristics
(Previously known as Testicular feminisation syndrome) - Males are genetically XY with a female phenotype
What is the anatomy of a patient with Androgen Insensitivity Syndrome?
- Female External Genitalia and Breast Development
- Testes located within the abdomen or inguinal canal.
- Absence of Female internal organs (Uterus, upper vagina, cervix, fallopian tubes and ovaries) due to the testes producing anti-Mullerian hormone.
- Patients are taller than female average, with a lack of pubic hair, facial hair and male type muscle bulk.
What is a risk of patients with Androgen Insensitivity Syndrome?
High risk of Testicular cancer unless the testes are removed
What is the Presentation of Androgen Insensitivity Syndrome?
- Often presents in infancy with Inguinal hernias containing testes
- May present at puberty with Primary Amenorrhoea
What are the investigations for Primary Amenorrhoea?
Hormonal Tests: To assess levels of FSH, LH and Oestradiol
Genetic Testing: Identify chromosomal or genetic abnormalities
Imaging: To identify structural abnormalities
What are the results of hormonal tests in Androgen Insensitivity Syndrome?
- Raised LH
- Normal or raised FSH
- Normal or Raised Testosterone levels (For a male)
- Raised Oestrogen levels (For a male)
What is the management of Primary Amenorrhoea?
Depends on the underlying cause
- Hormone replacement therapy: For hormonal imbalances
- Surgery: For structural abnormalities
- Psychological support: For conditions related to stress or eating disorders
- Lifestyle modifications: For issues related to excessive exercise or low body weight
- Monitoring and regular follow-ups: To assess effectiveness of treatment and adjust as necessary
What is the management of Androgen Insensitivity Syndrome?
MDT Specialist Coordination: Paediatrics, Gynaecology, Urology, Endocrinology, Clinical Psychology
- Bilateral Orchiectomy: To avoid testicular tumours
- Oestrogen Therapy
- Vaginal Dilators or Vaginal Surgery: To create and adequate length vagina
Generally patients are raised as female but this is tailored to the individual
What is responsible for the embryological development of the upper vagina, cervix, uterus and fallopian tubes?
They develop from the paramesonephric ducts (Mullerian ducts)
Why do males not develop female gentalia?
The testes in a male foetus produce Anti-Mullerian hormone which suppresses the growth of the paramesonephric ducts and so they do not form.
What ae some Congenital structural Abnormalities for the Female Reproductive Tract?
- Bicornuate Uterus
- Uterus Agenesis
- Imperforate Hymen
- Transverse vaginal Septae
- Vaginal Hypoplasia and Agenesis
What is a Bicornuate Uterus?
- Uterus has 2 horns giving it a heart shaped appearance.
- This can be associated with adverse pregnancy outcomes however successful pregnancies are generally expected.
What are some complications of a Bicornuate Uterus?
- Miscarriage
- Premature Birth
- Malpresentation
What is an Imperforate Hymen?
Where the hymen at the entrance of the vagina is fully formed without an opening.
How does an Imperforate Hymen Present?
- May be discovered when the girl starts to menstruate, and the menses are sealed in the vagina.
- This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.
What is the management of an Imperforate Hymen?
- Diagnosed during a clinical examination
- Treatment is a Surgical incision to create an opening in the hymen.
What is a complication of an Imperforate Hymen?
- If not treated then retrograde menstruation could occur leading to endometriosis
- Amenorrhoea
What is a Transverse Vaginal Septae?
Caused by an error in development, where a septum (wall) forms transversely across the vagina.
This septum can either be perforate (with a hole) or imperforate (completely sealed).
What is the Presentation of a Transverse Vaginal Septae?
- Perforate Septae: Girls will menstruate but can have difficulty with intercourse or tampon use
- Imperforate Septae: Presents similarly to an Imperforate Hymen
What are some complications of a Transverse Vaginal Septae?
- Infertility
- Pregnancy related complications
- Vaginal Stenosis
- Recurrence of the Septae
What is the management of a Transverse Vaginal Septae?
- Diagnosis is by Examination, Ultrasound or MRI
- Treatment with with Surgical Correction
What is Vaginal Hypoplasia and Agenesis?
Hypoplasia: An Abnormally small vagina
Agenesis: An absent vagina
These occur due to failure of the Mullerian ducts to properly develop and are often associated with an absent uterus and cervix
What is the difference between Vaginal Hypoplasia and Agenesis and Androgen Insensitivity Syndrome?
The Mullerian Ducts fail to develop but not due to Anti-Mullerian Hormone.
Therefore patients do not have Testes (like in AIS) but do have Ovaries
What is the management of Vaginal Hypoplasia and Agenesis?
- Vaginal Dilator over a prolonged period of time to create and adequate vaginal size
- Vaginal Surgery may be necessary
Define Menarche?
The first occurrence of Menstruation
At what age does Menarche normally occur?
Mean age 13
11-15 usually.
Define Menopause?
This term describes the permanent cessation of menstruation, characterised by at least 12 months of amenorrhoea in otherwise healthy women over the age of 45 who are not using hormonal contraception.
When does Menopause typically occur?
Between the ages of 45-55 with the average age being around 51-52 years old.
Define Perimenopause?
- The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
- Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards.
- This is typically in women older than 45 years.
Define Postmenopause?
The period from 12 months after the final menstrual period
Define Early Menopause?
Menopause before the age of 40 years old.
It is the result of premature ovarian insufficiency
What is the Aetiology of Menopause?
Caused by ovarian failure which leads to oestrogen deficiency
What is the physiology of Menopause?
- Decline in the development of Ovarian follicles
- Without the follicles there is reduced production of oestrogen
- Oestrogen has a negative feedback effect on the pituitary
- As oestrogen levels fall in the perimenopause period, this negative feedback is lost
- Increasing levels of LH and FSH
- Failing follicular development means ovulation does not occur
- This results in irregular menstrual cycles.
- Without Oestrogen the endometrium does not develop eventually leading to a lack of menstruation (amenorrhoea)
What is the cause of the perimenopausal symptoms?
Lower levels of Oestrogen
What are some perimenopausal symtpoms?
Vasomotor Symptoms:
- Hot flushes
- Night sweats
- Irregular periods, Heavy or lighter periods
- Joint Pains
Sexual Dysfunction:
- Vaginal dryness and atrophy
- Reduced libido
- Problems with Orgasm
- Dyspareunia
Psychological Symptoms:
- Depression
- Anxiety
- Mood Swings, Low mood and emotional lability
- Lethargy
- Reduced Concentration
What are some risks of menoupause?
Reduced oestrogen increases the risk of certain conditions:
- Cardiovascular disease and stroke
- Osteoporosis due to increased bone turn over since normal oestrogen levels inhibit osteoclast activity
- Pelvic Organ Prolapse
- Urinary Incontinence
What are some differential diagnoses for Menopause?
- Thyroid disease: symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle
- Depression: exhibits mood swings, lethargy, reduced concentration
- Premature ovarian insufficiency: can cause hot flushes, night sweats, vaginal dryness, and reduced libido
What are the investigations for Menopause?
Diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms without performing any investigations
NICE Guidelines (2015) recommend FSH Blood test to help with Diagnosis:
- Women under 40 years with suspected premature menopause
- Women aged 40-45 with menopausal symptoms or a change in menstrual cycle
- Elevated FSH level (>30 IU/L) may predict impending menopause after several months of amenorrhoea
How long after the last menstrual period should women continue to use contraception?
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
What is the relationship between hormonal contraceptives and menopause?
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms.
This can make diagnosing menopause in women on hormonal contraception more difficult.
What are some good contraceptive options for women approaching menopause?
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation
What are 2 main side effects of the progesterone depot injection?
Weight Gain and Reduce bone mineral density (osteoporosis)
This is why this form of contraception is unsuitable for women Over 45 years old
What is the management of Perimenopausal Symptoms?
Vasomotor symptoms likely resolve after 2-5 years without treatment
Management of Symptoms depends on severity, personal circumstances and response to treatment
First Line: Lifestyle Measures
- Regular Exercise
- Weight Loss (as necessary)
- Avoidance of triggers (Smoking, alcohol, spicy food)
Second line: Hormone replacement therapy (HRT)
- Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants, such as fluoxetine or citalopram
- Testosterone can be used to treat reduced libido (usually as a gel or cream)
- Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers, such as Sylk, Replens and YES
What is the purpose of HRT?
Oestrogens: Overcome oestrogen deficiency
Progesterone’s: Required for endometrial protection from unopposed systemic oestrogens
- HRT can be given cyclically (for perimenopause) or continuously (for post menopause)
What are some benefits and risks of HRT?
Benefits
- Relief of Vasomotor symptoms
- Relief of urogenital symptoms
- Reduced risk of Osteoporosis
Risks
- Increased risk of Breast Cancer
- Increased risk of Endometrial Cancer (if given oestrogen alone)
- Increased risk of VTE
What are some Absolute Contraindications to HRT?
- History of breast cancer, any oestrogen-dependent cancer, current undiagnosed PV
bleeding, current endometrial hyperplasia. - History of idiopathic VTE (if not anticoagulated).
- Thromboembolic disease e.g. MI, angina
- Liver disease.
- Inherited thrombophilia.
- Pregnancy.
Define Adenomyosis?
Refers to a condition where endometrial tissue is inside the myometrium (muscle layer of the uterus)
What is the Epidemiology of Adenomyosis?
- More common in later reproductive years
- More common in those who have had several pregnancies (Multiparous)
- Occurs in around 10% of women
- May occur alone or alongside endometriosis or fibroids
What is the Aetiology of Adenomyosis?
Not fully Understood
- Multiple factors involved including Sex hormones, trauma and inflammation
- Condition is hormone dependent
What are the clinical features of Adenomyosis?
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- Infertility or pregnancy related complications
- 1/3 of patients are asymptomatic
What are the investigations for Adenyomyosis?
First Line:
- Transvaginal Ultrasound of the pelvis
- MRI and Transabdominal ultrasound are alternatives if transvaginal is unsuitable
Gold Standard:
- Histological examination of the uterus after a hysterectomy
- Not usually a suitable way of establishing the diagnosis for obvious reasons
What is the management of Adenomyosis?
Depends on symptoms, age and plans for pregnancy
Women does NOT want contraception
- Tranexamic Acid when there is no pain associated (antifibrinolytic)
- Mefenamic Acid when there is pain associated (NSAID)
Women DOES want Contraception:
- Mirena coil - First Line
- Combined Oral Contraceptive Pill (COCP)
- Cyclical oral progestogens
Other options considered by specialist
- GnRH analogues to induce menopause like state
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
What are some pregnancy complications associated with Adenomyosis?
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
Define Asherman’s Syndrome?
Where adhesions form within the uterus (intrauterine adhesions) following damage to the uterus that lead to outflow tract obstruction.
What is the Aetiology of Asherman’s syndrome?
Anything that creates scar tissue within the uterus causing adhesions that are normally not connected
- Pregnancy related dilateion and Curettage procedure
- Treatment of retained productions of conception (removing placental tissue left behind after birth)
- Uterine surgery (myomectomy)
- Pelvic infection (endometritis)
What is the pathophysiology of Asherman’s Syndrome?
- Damage to the uterus causing scar tissue formation and subsequent adhesions.
- Adhesions form Physical Obstructions and distort the pelvic organs
- Leads to menstruation abnormalities, infertility, recurrent miscarriages
What are the clinical features of Asherman’s Syndrome?
Presents following recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
Incidentally found adhesions that are asymptomatic are not classed as Asherman’s Syndrome
What are the investigations for Asherman’s Syndrome?
History of uterine surgery
Hysteroscopy is Gold Standard investigation and can involve dissection and treatment of adhesions.
Others:
- Hysterosalpingography when contrast is injected into the uterus and imaged with X-rays
- Sonohysterography uterus is filled with fluid and pelvic USS is performed
- MRI Scan
What is the management of Asherman’s Syndrome?
- Dissecting the adhesions during hysteroscopy.
- Reoccurrence of the adhesions after treatment is common
What are the clinical features of Secondary Amenorrhea?
The primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer.
Additional symptoms, depending on the underlying cause, may include:
- Pregnancy symptoms: nausea, breast tenderness, increased urination, food cravings or aversions
- Menopause symptoms: hot flashes, night sweats, sleep problems, mood changes
- Symptoms of PCOS: acne, weight gain, hirsutism (excessive body hair), thinning hair
- Symptoms of pituitary gland issues: headaches, vision problems, unexplained weight gain or loss
What are the investigations for Secondary Amenorrhoea?
- Pregnancy test
- Hormone level checks: including FSH, LH, TSH, prolactin, and testosterone
- Ultrasound or other imaging studies, to identify potential structural abnormalities
- Hysteroscopy, in cases where intrauterine adhesions are suspected
What is the management of Secondary Amenorrhoea?
Management of secondary amenorrhoea is determined by the underlying cause:
- Pregnancy: regular prenatal care
- Menopause: hormone replacement therapy (HRT) if symptoms are troublesome
- PCOS: lifestyle changes, hormonal contraceptives, and potentially metformin
- Asherman’s syndrome: surgical removal of adhesions and hormone therapy
- Drug-induced amenorrhoea: discontinuing the offending drug if possible and safe to do so
- Conditions related to physical stress, weight loss, or excessive exercise: lifestyle modifications and nutritional counselling.
Define Lichen Sclerosus?
A chronic inflammatory skin condition that presents with patches of Porcelain-white skin.
It typically affects the genital and anal regions of the body: labia, perineum, perianal skin, foreskin and glans penis
What is the epidemiology of Lichen Sclerosus?
- Typically affects women
- Can affect men
- Considered to be an autoimmune condition and therefore is associated with T1DM, Alopecia, hypothyroid and vitiligo
What is the Aetiology of Lichen Sclerosus?
The cause of lichen sclerosus is currently unknown, but it is likely multifactorial.
Potential contributing factors could include autoimmune condition, genetic predisposition, and hormonal factors.
Some studies suggest a possible link with previous skin damage or trauma.
What is Lichen in medicine?
Lichen refers to a flat eruption that spreads.
*It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.
Define Lichen simplex
Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
Define Lichen planus
An autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
What is a typical presentation of Lichen Sclerosus?
**Woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. **
The condition may be asymptomatic, or present with several symptoms:
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
What is the Koebner phenomenon?
When signs and symptoms are made worse by friction to the skin.
This occurs with Lichen Sclerosus
What is the appearance of Lichen Sclerosus?
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin.
The affected skin appears:
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
What are some differential diagnoses for Lichen Sclerosus?
- Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
- Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
- Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.
What are the investigations for Lichen Sclerosus?
Primarily Clinical Diagnosis based on characteristic appearance of skin lesions
- Skin biopsy may be performed to confirm diagnosis
- Blood tests may rule out other potential autoimmune conditions
What is the Management of Lichen Sclerosus?
Lichen Sclerosus cannot be cured but symptoms are controlled and should be followed up every 3-6 months
First Line
-
Potent Topical Steroids: Clobetasol propionate 0.05% (dermovate)
- Steroids used long term to control symptoms
- Once daily for 4 weeks. Then gradually reduce frequency every 4 weeks to alternate days then twice weekly.
- Daily steroids when condition flares
- Emollients should be used regularly both with steroids and as part of maintenance
- Avoidance of soaps in affected areas to prevent further irritation.
What are some complications of Lichen Sclerosus?
- 5% risk of developing squamous cell carcinoma of the vulva
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
Define Atrophic Vaginitis?
vulvovaginal atrophy is inflammation and thinning of the genital tissues, dryness and atrophy of the vaginal mucosa due to reduced oestrogen levels
What is the Aetiology of Atrophic Vaginitis?
Decrease in oestrogen levels most commonly due to menopause
What are the clinical features of Atrophic Vaginitis?
Presents in post-menopausal women with:
- Itching and dryness
- Loss of pubic hair
- Dyspareunia (discomfort or pain during sex)
- Post coital Bleeding due to localised inflammation
- recurrent UTIs or Stress incontinence
- Pelvic organ prolapse may also occur.
What are some differential diagnoses for Atrophic Vaginitis?
- Postmenopausal bleeding:** malignancy, endometrial hyperplasia
- For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes
- For narrowed introitus: female genital mutilation
- For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis
- For dyspareunia: malignancy, vaginismus
What are the investigations for Atrophic Vaginitis?
- Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy
- Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer
- An infection screen if itching or discharge is present
- A biopsy of any abnormal skin lesions, if needed
What would be seen on examination in Atrophic Vaginitis?
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
What is the management of Atrophic Vaginitis?
Hormonal treatment:
-
Topical oestrogen preparations:
- Estriol cream
- Estriol pessaries
- Estradiol Tablets
- Estradiol ring
Non-hormonal treatments:
- Lubricants such as Sylk, Replens, YES:, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
- Moisturisers, which should be used regularly
What are some contraindications to Topical Oestrogens?
- Breast Cancer
- Angina
- Venous Thromboembolism
Define Vulval Cancer?
Malignant growth that primarily affects the skin of the vulva (the external part of the female genitalia).
It can be host to various types of Skin cancers however Squamous Cell Carcinoma is the most prevalent.
What is the Epidemiology of Vulval cancer?
- Rare gynaecological cancer accounting for 4%
- Most commonly found in older women >60 (but can occur at any age)
- 90% are Squamous Cell Carcinomas
What are some risk factors for Vulval Cancer?
- Advanced age (particularly over 75 years)
- Immunosuppression
- Human papillomavirus (HPV) infection
- Lichen sclerosus
Around 5% of women with lichen sclerosus get vulval cancer.
What are the different types of Vulval Cancer?
- Squamous Cell Carcinoma (90%)
- Malignant Melanomas
- Basal Cell Carcinoma
What are the clinical features of Vulval Cancer?
- A lump, which may be associated with lymphadenopathy of the groin
- Itching or discomfort in the vulval area
- A non-healing ulcer
- Vulval pain
- Changes in the skin of the vulva, such as thickening or changes in color
- Bleeding or discharge not related to the menstrual cycle
What region of the Vulva is most common affected in Vulval Cancer?
Labia Majora
What are some differential diagnoses for Vulval Cancer?
- Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
- Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
- Bartholin’s cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
What are the investigations for Vulval Cancer?
Physical Examination
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Establishing the diagnosis and staging involves:
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
What is system is used to stage Vulval Cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
Management of Vulval Cancer depends on the stage
What is the Management of Vulval Cancer?
Depends on the Stage
- Wide local excision to remove the cancer
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
What is Vulval Intraepithelial Neoplasia?
- VIN is a premalignant condition affecting the squamous epithelium of the skin.
- VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia)
What are the different types of Vulval Intraepithelial Neoplasia?
- High grade squamous intraepithelial lesion: A type of VIN associated with HPV infection that occurs in younger women aged 35-50 years.
- Differentiated VIN: Type of VIN associated with lichen Sclerosus and typically occurs in older women aged 50-60 years.
How is Vulval intraepithelial neoplasia diagnosed?
A biopsy
What are the management options for Vulval Intraepithelial Neoplasia?
- Watch and wait with close follow-up
- Wide local excision (surgery) to remove the lesion
- Imiquimod cream
- Laser ablation
Define Cervical Cancer?
Malignant proliferation of the cells of the Cervix (the lower part of the uterus that connects to the vagina)
What is the Epidemiology of Cervical Cancer?
- 3rd most common cancer worldwide and 4th biggest cause of cancer death
- Strongly associated with Human papilloma virus (HPV)
What are the different types of Cervical Cancer?
- Squamous Cell Carcinoma (80%)
- Adenocarcinoma (10-20%)
- Very rarely, Small cell Cancer
What are some risk factors for Cervical Cancer?
HPV 16 and 18 infection (accounts for 70% of cases)
Non Engagement with Cervical Screening
Activities that increase risk of catching HPV
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
Other risk factors:
- Smoking
- Immunosuppression (e.g. HIV or organ transplants)
- Combined Contraceptive pill use for >5 years
- Family History
- Increased number of full term pregnancies
- Exposure to Diethylstilboestrol previously used to prevent miscarriages
What is the Human Papilloma Virus?
- HPV is a Sexually Transmitted Infection of the virus that is associated with anal, vulval, vaginal, penile, mouth and throat cancers
- There are over 100 strains but theHPV 16 and 18 are responsible for 70% of cervical cancers
- HPV Infection spontaneously resolves within 2 years in 90% of women. At this point the risk returns to baseline.
Which strains of HPV are targeted in the HPV vaccine and when is the vaccine given?
Current NHS vaccine is Gardasil protecting against HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
- HPV 6 and 11 cause Genital Warts
- HPV 16 and 18 cause Cervical Cancer (plus others)
- Girls and boys are given the HPV vaccine around age 12-13 years old
How does HPV promote cancer development?
- HPV produces two proteins (E6 and E6) that inhibit tumour suppressor genes.
- E6 inhibits p53
- E7 inhibits pRb
- These cause dysregulated cell cycle regulation leading to the formation of a pre-malignant monoclonal cell population
- This cell population is cervical intraepithelial neoplasia (CIN) which subsequently mutates further to become an invasive carcinoma
What is Cervical Intraepithelial Neoplasia?
What is Cervical Intraepithelial Neoplasia (CIN) is a grading system for the level of dysplasia and premalignant change in the cells of the cervix
CIN is diagnosed at Colposcopy (not with cervical screening)
What are the grades of Cervical Intraepithelial Neoplasia?
- CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
- CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
- CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
What is the typical presentation of Cervical cancer?
Most cases are picked up asymptomatically during cervical screening or smears.
- When symptoms are present these are often non-specific and so an examination of the cervix is required to exclude cancer
What are some clinical features of Cervical Cancer?
- Vaginal discharge
- Abnormal Vaginal Bleeding (e.g. postcoital or with micturition or defaecation)
- Dyspareunia
- Vaginal discomfort
- Urinary or bowel habit change
- Suprapubic pain
- Abnormal white/red patches on the cervix.
- Pelvic bulkiness on PV examination
- Mass felt on PR examination
What are some differential diagnoses for Cervical Cancer?
- Vaginitis: itching, burning, pain, and abnormal discharge
- Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding
- Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
- Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse
What are the investigations for Cervical Cancer?
- Clinical History prompting Cervix examination with Speculum +/- Swabs to exclude infection
If there is an abnormal appearance of the cervix suggestive of cancer:
- First line investigation is an Urgent cancer referral for Colposcopy for visualisation and biopsy of the cervix.
- HPV testing
- CT Chest, Abdomen and Pelvis is used for Cancer Staging
What is Colposcopy?
- Involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail.
- Stains such as Acetic acid and Iodine solution are used to identify abnormal areas
- A Punch biopsy or LLETZ Biopsy can be performed to get a tissue sample
What is seen on staining during Colposcopy?
Acetic Acid Stain:
- Abnormal cells appear white (Acetowhite)
Schiller’s Iodine Test:
- Stains healthy cells of the cervix a brown colour.
- Abnormal areas/cells will not stain
What may be seen on examination of the cervix that may suggest cervical cancer?
- Ulceration
- Bleeding
- Inflammation
- Visible tumour
What may be seen on Colposcopy that is suspicious of Cervical Cancer?
- Abnormal vascularity
- White change with Acetic Acid
- Exophytic Lesions
What are the Stages of Cervical Cancer?
FIGO system
Stage 1: Confined to cervix
Stage 2: Extending into the uterus or upper 2/3 of the vagina
Stage 3: Extending into lower third of the vagina or pelvic wall
Stage 4: Spread beyond true pelvis or bladder / rectum involvement
What is the management of Cervical Cancer?
Depends on the Stage
CIN and Early Stage 1A:
- Cone Biopsy
- Large Loop Excision of the Transformation Zone (LLETZ)
Stage 1B - 2A
- Fertility Preserved: Radical Trachelectomy which is removal of the cervix, upper vagina and pelvic lymph nodes
- Fertility not Preserved: Hysterectomy and Lymphadenectomy +/- Chemo/radiotherapy
Stage 2B-4A:
- Chemotherapy and Radiotherapy + Bevacizumab (Avastin)
- Werthelm’s Hysterectomy (radical): Is removal of the uterus, primary tumour, pelvic lymph nodes and upper 1/3 of the vagina used in invasive, infiltrating early metastatic cancer
Stage 4b:
- Management is a combination of Surgery, Radiotherapy, Chemotherapy and Palliative Care
What is the Prognosis for Cervical Cancer?
5 year survival drops significantly with an advanced stage.
- Stage 1a: 98% 5 year survival
- Stage 4: 15% 5 year survival
What is Bevacizumab (Avastin)?
- Monoclonal antibody used in combination with other chemotherapies in the treatment of Metastatic or Recurrent Cancers.
- It is a Vascular Endothelial Growth Factor A Inhibitor (VEGF-A) to reduce the development of new blood vessels from the cancer.
What is a Cone Biopsy?
- A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
- It involves a general anaesthetic.
- The surgeon removes a cone-shaped piece of the cervix using a scalpel.
- This sample is sent for histology to assess for malignancy
What are the main risks of a Cone Biopsy?
- Pain
- Bleeding
- Infection
- Scar formation with stenosis of the cervix
- Increased risk of miscarriage and premature labour
What is a Large Loop Excision of the Transformation Zone (LLETZ)?
Also called a Loop Biopsy
- Involves a Local Anaesthetic
- Often performed during a Colposcopy procedure
- Involves a wire loop with electrical current (diathermy) to remove the abnormal epithelial tissue on the cervix.
- Electrical current cauterises the tissue and stops bleeding
What are the main risks of Large Loop Excision of the Transformation Zone (LLETZ)?
- Bleeding and Abnormal discharge can occur for several weeks following a LLETZ procedure
- Intercourse and tampon use after the procedure should be avoided to reduce infection
- May increase the risk of Preterm labour
Who is Eligible for the Cervical Screening Program?
- For all Women and People (Transmen) with a cervix between the age of 25-64 years
- Cervical sample is taken and tested for High -risk HPV viruses (hrHPV)
What are the normal intervals for Cervical Screening?
- 3 yearly for women aged 25-49
- 5 yearly for women aged 50-64
What is involved in the Cervical Screening tests?
Aims to pick up precancerous changes in epithelial cells of the cervix.
- Involves a smear test performed by a qualified practice nurse
- Test consists of a Speculum examination and collection of cells from the cervix using a small brush.
- The samples are initially tested for high-risk HPV before examination.
- The cells are then examined under a microscopy using liquid based cytology (LCB) for precancerous changes (dyskaryosis)
If the HPV is negative then the cells are not examined
What do the results of the Cervical Smear Test indicate?
Smear Test for hrHPV:
- Positive: further testing is indicated with LBC
- Negative: Return to normal recall (age based intervals)
1st Positive hrHPV:
- Use LBC to detect cellular atypia
- Cytology Positive: Colposcopy is indicated
-
Cytology Inadequate: Cytology is repeated in 3 months
- Repeat cytology inadequate - refer for colposcopy
- If Colposcopy is normal - test hrHPV in 12 months
- Cytology Negative: Perform 2nd hrHPV test in 12 months
2nd hrHPV:
- Negative: return to normal recall
- Positive: Offer 3rd hrHPV test in a further 12 months (24 months after first positive test)
3rd hr HPV:
- Negative: Return to normal Recall
- Positive: Refer to Colposcopy
What are some different Cytology results that may be seen following a smear test and liquid based cytology for cervical screening?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Possible invasive squamous cell carcinoma
- Possible glandular neoplasia
- Infections such as bacterial vaginosis, candidiasis, trichomoniasis
Which groups of people may have exceptions to the normal Cervical Screening Program?
- Women with HIV are screened annually
- Women over 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
Define Menorrhagia?
Clinical condition defined as Heavy menstrual bleeding (excessive blood loss) during a menstrual period to the extent that it is affecting a woman’s quality of life
What volume of blood is considered menorrhagia?
- Average menstruation women lose 40ml of blood
- Excessive menstrual blood loss involves more than 80ml loss
Volume of blood loss is rarely measured in practice
What is the epidemiology of Menorrhagia?
- Common gynaecological complaint
- 50% of cases no underlying pathology is found and the condition is called Dysfunctional Uterine/endometrial bleeding
Define Dysfunctional Endometrial Bleeding?
Menorrhagia (heavy menstrual periods) where there is no underlying pathology identified
What is the Aetiology of Menorrhagia?
Local:
- Dysfunctional Uterine Bleeding
- Fibroids
- Adenomyosis
- Endometrial polyps
- Endometriosis
- Pelvic inflammatory disease
- PCOS
- Contraceptives such as copper coil
- Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding)
Systemic:
- Bleeding disorders
- Hypothyroidism
- Liver and kidney disease
- Obesity
What is the Clinical Presentation of Menorrhagia?
Heavy or prolonged menstrual bleeding
Other features: (Due to Iron deficiency Anaemia)
- Fatigue
- Weakness
- Shortness of Breath
What are some differential diagnoses for Menorrhagia?
Differentials that include abnormal uterine bleeding:
- Fibroids: Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination.
- Adenomyosis: Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse.
- Endometrial polyps: Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding.
- Endometrial cancer: Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.
What are the key things to ask in any presentation with a gynaecological problem?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
What investigations should be performed in Menorrhagia?
- FBC + Iron studies: to look for iron deficiency anaemia
- Pelvic examination with a speculum: Should be performed unless there is a straightforward history without other risk factors or symptoms or they are young and not sexually active
Imaging Studies if Indicated:
- Hysteroscopy (outpatient)
- Pelvic and Transvaginal Ultrasound
Additional Tests based on features:
- Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
- Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
- Ferritin if they are clinically anaemic
- Thyroid function tests if there are additional features of hypothyroidism
What may indicate the need for an Outpatient Hysteroscopy in Menorrhagia?
- Suspected submucosal fibroids
- Suspected endometrial pathology, such as endometrial hyperplasia or cancer
- Persistent intermenstrual bleeding
What may indicate the need for Pelvic and Transvaginal Ultrasound in Menorrhagia?
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
What is the Management of Menorrhagia?
Exclude underlying pathology/Treat pathology first
Women does NOT want Contraception:
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Women DOES want Contraception:
- Mirena coil (first line)
- Combined oral contraceptive pill
- Progesterone only contraception can be tried
Medical management Failed:
- Hysterectomy
- Endometrial Ablation
Referral to Secondary Care:
- If treatment is unsuccessful
- Symptoms are Severe
- Large fibroids (>3cm)
Define Endometrial Cancer?
Malignant proliferation that originals from the endometrium (the inner lining of the uterus)
It is an Oestrogen Depending cancer meaning that oestrogen stimulates the growth of Endometrial cancer cells
What is the epidemiology of Endometrial Cancer?
- 6th Most commonly diagnosed cancer in women
- 15th most common cancer
- 80% of cases are adenocarcinoma
What is Endometrial Hyperplasia?
a precancerous condition that involves thickening of the endometrium
- The risk factors, presentation, investigations are similar to Endometrial cancer
- Most cases of Endometrial Hyperplasia will return to normal over time and <5% become endometrial cancer.
What are the types of Endometrial Hyperplasia?
- Hyperplasia without atypia
- Atypical Hyperplasia
How can Endometrial Hyperplasia be treated?
Without Atypical Cells:
- Reversal of risk factors: Weight loss, stopping HRT
- Intrauterine System (IUS/Mirena coil)
- Continuous Oral Progestogens (Medroxyprogesterone)
With Atypical Cells:
- Total Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO)
What are the risk factors for Endometrial Cancer?
Anything that causes increased Exposure to Unopposed Oestrogen (Oestrogen without progesterone):
- Increased Age
- Nulliparity (never given birth or carried child)
- Obesity
- Diabetes
- Early menarche
- Late menopause
- Polycystic ovary syndrome
- Oestrogen-only hormone replacement therapy
- Tamoxifen
How does PCOS increase your risk of Endometrial Cancer?
Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation.
Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg.
It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle).
Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum.
Without developing a corpus luteum during the menstrual cycle, progesterone is not produced, and the endometrial lining has more exposure to unopposed oestrogen
What should be given to women with PCOS for Endometrial Protection?
One of:
- Combined Contraceptive Pill
- Intrauterine System (Mirena coil)
- Cyclical Progestogens
How does Obesity increase the risk of Endometrial Cancer?
Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen.
Adipose tissue is the primary source of oestrogen in postmenopausal women.
Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen
This extra Oestrogen is unopposed in women that are not ovulating (PCOS/post-menopause)
How does Tamoxifen increase the risk of Endometrial Cancer?
Tamoxifen has an anti-oestrogenic effect on breast tissue however it has an oestrogenic effect on the endometrium increasing the risk of endometrial cancer.
What are some protective factors for Endometrial Cancer?
- Combined Contraceptive Pill
- Mirena Coil
- Increased Pregnancies
- Cigarette Smoking
What are the clinical features of Endometrial Cancer?
Features vary but commonly include:
- Postmenopausal Bleeding
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Dyspareunia
- Abdominal discomfort or bloating
- Weight Loss
- Haematuria
- Anaemia
- Raised platelet count
What must you think about in women with postmenopausal bleeding?
This is endometrial cancer until proven otherwise
Other key risk factors include obesity and diabetes
What are some differential diagnoses for Endometrial Cancer?
- Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.
- Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.
- Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.
What is the Referral Criteria for Endometrial Cancer?
Guidelines for a 2 week wait urgent Endometrial cancer referral:
- Postmenopausal Bleeding more than 12 months after the last menstrual period.
NICE also recommends referral for Transvaginal Ultrasound in women Over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria Plus raised platelets, anaemia, or elevated glucose levels
What are the different types of Fibroid?
- Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk.
