Zero To Finals - Gynae Flashcards

Question

Causes of heavy menstrual bleeding

Answer 1

Causes • Dysfunctional uterine bleeding (no identifiable cause) • Extremes of reproductive age • Fibroids • Endometriosis and adenomyosis • Pelvic inflammatory disease (infection) • Contraceptives, particularly the copper coil • Anticoagulant medications • Bleeding disorders (e.g. Von Willebrand disease) • Endocrine disorders (diabetes and hypothyroidism) • Connective tissue disorders • Endometrial hyperplasia or cancer • Polycystic ovarian syndrome

Answer 2

Investigations Pelvic examination with a speculum and bimanual should be performed, unless there is straightforward history heavy menstrual bleeding without other risk factors or symptoms, or they are young and not sexually active. This is mainly to assess for fibroids, ascites and cancers. Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia. Outpatient hysteroscopy should be arranged if there is: • Suspected submucosal fibroids • Suspected endometrial pathology, such as endometrial hyperplasia or cancer • Persistent intermenstrual bleeding Pelvic and transvaginal ultrasound should be arranged if the is: ○ 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 Additional tests to consider in women with additional 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

Answer 3

Types • Intramural = within the myometrium (the muscle of the uterus). ○ As they grow, they change the shape and distort the uterus. • Subserosal = just below the outer layer of the uterus. ○ These fibroids grow outwards and can become very large, filling the abdominal cavity. • Submucosal = just below the lining of the uterus (the endometrium). • Pedunculated = on a stalk.

Answer 4

Management For fibroids less than 3 cm The medical management is the same as with heavy menstrual bleeding: § Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus § Symptomatic management with NSAIDs and tranexamic acid § Combined oral contraceptive § Cyclical oral progestogens Surgical options for managing smaller fibroids with heavy menstrual bleeding are: § Endometrial ablation § Resection of submucosal fibroids during hysteroscopy § Hysterectomy

Answer 5

Presentation Fibroids are often asymptomatic. They can present in several ways: ○ Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom ○ Prolonged menstruation, lasting more than 7 days ○ Abdominal pain, worse during menstruation ○ Bloating or feeling full in the abdomen ○ Urinary or bowel symptoms due to pelvic pressure or fullness ○ Deep dyspareunia (pain during intercourse) ○ Reduced fertility Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

Answer 6

For fibroids more than 3 cm Women need referral to gynaecology for investigation and management. Medical management options are: § Symptomatic management with NSAIDs and tranexamic acid § Mirena coil – depending on the size and shape of the fibroids and uterus § Combined oral contraceptive § Cyclical oral progestogens Surgical options for larger fibroids are: § Uterine artery embolisation § Myomectomy § Hysterectomy

Answer 7

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap) § May be used to reduce the size of fibroids before surgery. § They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. § Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Answer 8

Uterine Artery Embolisation § Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists. § The radiologist inserts a catheter into an artery, usually the femoral artery. § This catheter is passed through to the uterine artery under X-ray guidance. § Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid. § This starves the fibroid of oxygen and causes it to shrink.

Answer 9

Surgical Options § Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). ○ Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids. § Endometrial ablation can be used to destroy the endometrium. ○ Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation. ○ This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus. § Hysterectomy involves removing the uterus and fibroids. ○ Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach. ○ The ovaries may be removed or left depending on patient preference, risks and benefits.

Answer 10

Investigations • Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. • Pelvic ultrasound is the investigation of choice for larger fibroids. • MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 11

Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma. Endometriomas in the ovaries are often called “chocolate cysts”. Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.

Answer 12

One notable theory for the cause of ectopic endometrial tissue is that during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity. Other possible methods for endometrial tissue exiting the uterus have been proposed: • Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue. • There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer. • Cells outside the uterus somehow change, in a process called metaplasia, from typical cells of that organ into endometrial cells.

Answer 13

The main symptom of endometriosis is pelvic pain. The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis. This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis.

Answer 14

Endometriosis can lead to reduced fertility. Often it is not clear why women with endometriosis struggle to get pregnant. It may be due to adhesions around the ovaries and fallopian tubes, blocking the release of eggs or kinking the fallopian tubes and obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.

Answer 15

Diagnosis Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy. Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

Answer 16

Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy: ○ Combined oral contractive pill, which can be used back to back without a pill-free period if helpful ○ Progesterone only pill ○ Medroxyprogesterone acetate injection (e.g. Depo-Provera) ○ Nexplanon implant ○ Mirena coil ○ GnRH agonists Surgical management options: § Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) § Hysterectomy Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.

Answer 17

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.

Answer 18

Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall. It may occur alone, or alongside endometriosis or fibroids. The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.

Answer 19

Presentation Adenomyosis typically presents with: • Painful periods (dysmenorrhoea) • Heavy periods (menorrhagia) • Pain during intercourse (dyspareunia) It may also present with infertility or pregnancy-related complications. Around a third of patients are asymptomatic. Examination can demonstrate an enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.

Answer 20

Diagnosis Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis. MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable. The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Answer 21

Management Management of adenomyosis will depend on symptoms, age and plans for pregnancy. NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding. When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: • Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding) • Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain) Management when contraception is wanted or acceptable: 1. Mirena coil (first line) 2. Combined oral contraceptive pill 3. Cyclical oral progestogens Progesterone only medications such as the pill, implant or depot injection may also be helpful. Other options are that may be considered by a specialist include: § GnRH analogues to induce a menopause-like state § Endometrial ablation § Uterine artery embolisation § Hysterectomy

Answer 22

Physiology • Inside the ovaries, the process of primordial follicles maturing into primary and secondary follicles is always occurring, independent of the menstrual cycle. • At the start of the menstrual cycle, FSH stimulates further development of the secondary follicles. • As the follicles grow, the granulosa cells that surround them secrete increasing amounts of oestrogen. • The process of the menopause begins with a decline in the development of the ovarian follicles. • Without the growth of follicles, there is reduced production of oestrogen. • Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. • As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH. • The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. • Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). • Lower levels of oestrogen also cause the perimenopausal symptoms.

Answer 23

Perimenopausal Symptoms A lack of oestrogen in the perimenopausal period leads to symptoms of: ○ Hot flushes ○ Emotional lability or low mood ○ Premenstrual syndrome ○ Irregular periods ○ Joint pains ○ Heavier or lighter periods ○ Vaginal dryness and atrophy ○ Reduced libido

Answer 24

Risks A lack of oestrogen increases the risk of certain conditions: § Cardiovascular disease and stroke § Osteoporosis § Pelvic organ prolapse § Urinary incontinence

Answer 25

Diagnosis A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations. NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in: □ Women under 40 years with suspected premature menopause □ Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 26

Contraception Fertility gradually declines after 40 years of age. However, women should still consider themselves fertile. Pregnancy after 40 is associated with increased risks and complications. Women need to use effective contraception for: ® Two years after the last menstrual period in women under 50 ® One year after the last menstrual period in women over 50 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. Good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause are: ® Barrier methods ® Mirena or copper coil ® Progesterone only pill ® Progesterone implant ® Progesterone depot injection (under 45 years) - may be unsuitable due to risk of osteoporosis ® Sterilisation The combined oral contraceptive pill is UKMEC 2 (the advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications. ® Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.

Answer 27

Management of Perimenopausal Symptoms } Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. } Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include: } No treatment } 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

Answer 28

Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women. There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.

Answer 29

Rotterdam Criteria The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: 1. Oligoovulation or anovulation, presenting with irregular or absent menstrual periods 2. Hyperandrogenism, characterised by hirsutism and acne 3. Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Answer 30

Presentation Women with polycystic ovarian syndrome present with some key features: § Oligomenorrhoea or amenorrhoea § Infertility § Obesity (in about 70% of patients with PCOS) § Hirsutism § Acne § Hair loss in a male pattern Other Features and Complications § Insulin resistance and diabetes § Acanthosis nigricans ○ Acanthosis nigricans describes thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance. § Cardiovascular disease § Hypercholesterolaemia § Endometrial hyperplasia and cancer § Obstructive sleep apnoea § Depression and anxiety § Sexual problems

Answer 31

Insulin Resistance § When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. § Insulin promotes the release of androgens from the ovaries and adrenal glands. § Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). § Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. ○ SHBG normally binds to androgens and suppresses their function. ○ Reduced SHBG further promotes hyperandrogenism in women with PCOS. § The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan). § Diet, exercise and weight loss help reduce insulin resistance.

Answer 32

Differential Diagnosis of Hirsutism An important feature of polycystic ovarian syndrome is hirsutism. Hirsutism can also be caused by: ® Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids ® Ovarian or adrenal tumours that secrete androgens ® Cushing’s syndrome ® Congenital adrenal hyperplasia

Answer 33

Investigations The NICE clinical knowledge summaries recommend the following blood tests to diagnose PCOS and exclude other pathology that may have a similar presentation: ◊ Testosterone ◊ Sex hormone-binding globulin ◊ Luteinizing hormone ◊ Follicle-stimulating hormone ◊ Prolactin (may be mildly elevated in PCOS) ◊ Thyroid-stimulating hormone Hormonal blood tests typically show: ◊ Raised luteinising hormone ◊ Raised LH to FSH ratio (high LH compared with FSH) ◊ Raised testosterone ◊ Raised insulin ◊ Normal or raised oestrogen levels

Answer 34

Managing Hirsutism Weight loss may improve the symptoms of hirsutism. Women are likely to have already explored options for hair removal, such as waxing, shaving and plucking. Co-cyprindiol (Dianette) is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne. w It has an anti-androgenic effect, works as a contraceptive and will also regulate periods. w The downside is a significantly increased risk of venous thromboembolism. w For this reason, co-cyprindiol is usually stopped after three months of use. Topical eflornithine can be used to treat facial hirsutism. w It usually takes 6 – 8 weeks to see a significant improvement. w The hirsutism will return within two months of stopping eflornithine. Other options that may be considered by a specialist experienced in treating hirsutism include: w Electrolysis w Laser hair removal w Spironolactone (mineralocorticoid antagonist with anti-androgen effects) w Finasteride (5α-reductase inhibitor that decreases testosterone production) w Flutamide (non-steroidal anti-androgen) w Cyproterone acetate (anti-androgen and progestin)

Answer 35

Managing the Risk of Endometrial Cancer Women with polycystic ovarian syndrome have several risk factors for endometrial cancer: w Obesity w Diabetes w Insulin resistance w Amenorrhoea w Under normal circumstances, the corpus luteum releases progesterone after ovulation. w Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. w They continue to produce oestrogen and do not experience regular menstruation. w Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. w This is similar to giving unopposed oestrogen in women on hormone replacement therapy. w It results in endometrial hyperplasia and a significant risk of endometrial cancer. w Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. w Cyclical progestogens should be used to induce a period prior to the ultrasound scan. w If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer. w Options for reducing the risk of endometrial hyperplasia and endometrial cancer are: w Mirena coil for continuous endometrial protection w Inducing a withdrawal bleed at least every 3 – 4 months with either: w Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) w Combined oral contraceptive pill

Answer 36

Managing Infertility Weight loss is the initial step for improving fertility. w Losing weight can restore regular ovulation. A specialist may initiate other options where weight loss fails. These include: w Clomifene w Laparoscopic ovarian drilling w In vitro fertilisation (IVF) Metformin and letrozole may also help restore ovulation under the guidance of a specialist; however, the evidence to support their use is not clear. Ovarian drilling involves laparoscopic surgery. w The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. w This can improve the woman’s hormonal profile and result in regular ovulation and fertility. Women that become pregnant require screening for gestational diabetes. w Screening involves an oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.

Answer 37

A cyst is a fluid-filled sac. Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women. The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation. Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. A diagnosis of PCOS requires at least two of: • Anovulation • Hyperandrogenism • Polycystic ovaries on ultrasound

Answer 38

Presentation Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, ovarian cysts can cause vague symptoms of: • Pelvic pain • Bloating • Fullness in the abdomen • A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

Answer 39

Functional Cysts Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound. Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy. Other Types of Ovarian Cysts Serous Cystadenoma These are benign tumours of the epithelial cells. Mucinous Cystadenoma These are also benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen. Endometrioma These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation. Dermoid Cysts / Germ Cell Tumours These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Sex Cord-Stromal Tumours These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

Answer 40

The number of times a woman has ovulated during her life correlates with her risk of ovarian cancer. More ovulations increases the risk of ovarian cancer. Factors that will reduce the number of ovulations are: § Later onset of periods (menarche) § Early menopause § Any pregnancies § Use of the combined contraceptive pill

Answer 41

Causes of Raised CA125 CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: • Endometriosis • Fibroids • Adenomyosis • Pelvic infection • Liver disease • Pregnancy

Answer 42

Management The RCOG Green-top guidelines from 2011 on suspected ovarian masses provides recommendations on managing ovarian cysts. Always check local and national guidelines when deciding how to manage patients, and get advice from an experienced colleague. Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist. Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery. Simple ovarian cysts in premenopausal women can be managed based on their size: • Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. • 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. • More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months. Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Answer 43

Meig’s Syndrome Meig’s syndrome involves a triad of: • Ovarian fibroma (a type of benign ovarian tumour) • Pleural effusion • Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites. TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.

Answer 44

Cervical ectropion can also be called cervical ectopy or cervical erosion. Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix. The cells of the endocervix (columnar epithelial cells) are more fragile and prone to trauma. They are more likely to bleed with sexual intercourse. This means cervical ectropion often presents with postcoital bleeding. Cervical ectropion is associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.

Answer 45

Management Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill. Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.

Answer 46

Nabothian cysts are fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts. They are usually up to 1cm in size, but rarely can be more extensive. They are harmless and unrelated to cervical cancer. The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

Answer 47

Presentation Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis. Nabothian cysts appear as smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.

Answer 48

Management Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously. If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.

Answer 49

Pelvic organ prolapse =the descent of pelvic organs into the vagina. • Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder. Uterine Prolapse = the uterus itself descends into the vagina. 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. Rectocele = caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. • Rectoceles are particularly associated with constipation. • Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. • Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. • Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels. Cystocele = caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. • Prolapse of the urethra is also possible (urethrocele). • Prolapse of both the bladder and the urethra is called a cystourethrocele.

Answer 50

Stage 1: The uterus is in the upper half of the vagina Stage 2: The uterus has descended nearly into the opening of the vagina Stage 3: The uterus has protruded just out of the vagina Stage 4: The uterus is completely out of the vagina

Answer 51

Risk Factors Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include: • Multiple vaginal deliveries • Instrumental, prolonged or traumatic delivery • Advanced age and postmenopause status • Obesity • Chronic respiratory disease causing coughing • Chronic constipation causing straining

Answer 52

Presentation Typical presenting symptoms are: ○ A feeling of “something coming down” in the vagina ○ A dragging or heavy sensation in the pelvis ○ Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention ○ Bowel symptoms, such as constipation, incontinence and urgency ○ Sexual dysfunction, such as pain, altered sensation and reduced enjoyment ○ Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. ○ They may notice the prolapse will become worse on straining or bearing down.

Answer 53

Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management involves: • 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

Answer 54

Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems. There are many types of pessary: • 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. Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Answer 55

Surgery is the definitive option for treating a pelvic organ prolapse. • It is essential to consider the risks and benefits of any operation for each individual, taking into account any co-morbidities. • There are many methods for surgical correction of a prolapse, including hysterectomy. • Surgery can be very successful in correcting the problem. • Possible complications of pelvic organ prolapse surgery include: ○ Pain, bleeding, infection, DVT and risk of anaesthetic ○ Damage to the bladder or bowel ○ Recurrence of the prolapse ○ Altered experience of sex

Answer 56

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause. The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections. Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.

Answer 57

Management Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES. Topical oestrogen can make a big difference in symptoms. Options include: • Estriol cream, applied using an applicator (syringe) at bedtime • Estriol pessaries, inserted at bedtime • Estradiol tablets (Vagifem), once daily • Estradiol ring (Estring), replaced every three months Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.

Answer 58

• The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). • They are usually pea-sized and not palpable. • They produce mucus to help with vaginal lubrication. • When the ducts become blocked, the Bartholin’s glands can swell and become tender, causing a Bartholin’s cyst. • The swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm. • Cysts can become infected, forming a Bartholin’s abscess. ○ A Bartholin’s abscess will be hot, tender, red and potentially draining pus. • A diagnosis of a Bartholin’s cyst or abscess is made clinically with a history and examination.

Answer 59

Management • Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. • Incision is generally avoided, as the cyst will often reoccur. • A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years). • A Bartholin’s abscess will require antibiotics. ○ A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. ○ E. coli is the most common cause. ○ Send specific swabs for chlamydia and gonorrhoea. ○ Surgical interventions may be required to treat a Bartholin’s abscess. ○ There are two options for surgical management: i. Word catheter (Bartholin’s gland balloon) – requires local anaesthetic ii. Marsupialisation – requires general anaesthetic

Answer 60

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis. Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo. The diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis.

Answer 61

Presentation The typical presentation in your exams is a 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 The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Answer 62

Management The management here is based on the 2018 guidelines from the British Association of Dermatologists. Lichen sclerosis cannot be cured, but the symptoms can be effectively controlled. Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist. Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy. Steroids are initially used once a day for four weeks, then gradually reduced in frequency every four weeks to alternate days, then twice weekly. When the condition flares patients can go back to using topical steroids daily until they achieve good control. A 30g tube should last at least three months. Emollients should be used regularly, both with steroids initially and then as part of maintenance.

Answer 63

Premature ovarian insufficiency is defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause. Premature ovarian insufficiency is characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show: • Raised LH and FSH levels (gonadotropins) • Low oestradiol levels

Answer 64

Causes • Idiopathic (the cause is unknown in more than 50% of cases) • Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) • Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease • Genetic, with a positive family history or conditions such as Turner’s syndrome • Infections such as mumps, tuberculosis or cytomegalovirus

Answer 65

Presentation Premature ovarian insufficiency presents with irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness.

Answer 66

Diagnosis NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in women younger than 40 years with typical menopausal symptoms plus elevated FSH. The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.

Answer 67

Associations Women with premature ovarian failure are at higher risk of multiple conditions relating to the lack of oestrogen, including: • Cardiovascular disease • Stroke • Osteoporosis • Cognitive impairment • Dementia • Parkinsonism

Answer 68

Management Management involves hormone replacement therapy (HRT) until at least the age at which women typically go through menopause. HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required. There are two options for HRT in women with premature ovarian insufficiency: • Traditional hormone replacement therapy • Combined oral contraceptive pill Traditional hormone replacement therapy is associated with a lower blood pressure compared with the combined oral contraceptive pill. The combined pill may be more socially acceptable (less stigma for younger women) and additionally acts as contraception. Hormone replacement therapy before the age of 50 is not considered to increase the risk of breast cancer compared with the general population, as women would ordinarily produce the same hormones at this age. There may be an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches).

Answer 69

Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa). Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy. Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily. Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.

Answer 70

Presentation The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes. On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.

Answer 71

Management Patients need emergency admission under gynaecology for urgent investigation and management. Depending on the duration and severity of the illness they require laparoscopic surgery to either: • Un-twist the ovary and fix it in place (detorsion) • Remove the affected ovary (oophorectomy) The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.

Answer 72

Diagnosis Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow. The definitive diagnosis is made with laparoscopic surgery.

Answer 73

Complications A delay in treating ovarian torsion can result in loss of function of that ovary. The other ovary can usually compensate, so fertility is not typically affected. Where this is the only functioning ovary, loss of function leads to infertility and menopause. Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.

Answer 74

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus. Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery(e.g. myomectomy) or several pelvic infection (e.g. endometritis). Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages. Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.

Answer 75

Presentation Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with: • Secondary amenorrhoea (absent periods) • Significantly lighter periods • Dysmenorrhoea (painful periods) It may also present with infertility.

Answer 76

Diagnosis There are several options for establishing a diagnosis of intrauterine adhesions: • Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions • Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays • Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed • MRI scan

Answer 77

Management Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common.

Answer 78

Urinary incontinence refers to the loss of control of urination. There are two types of urinary incontinence, urge incontinence and stress incontinence. Establishing the type of incontinence is essential, as this will determine the management.

Answer 79

Urge Incontinence Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The 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.

Answer 80

Stress Incontinence The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis. Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.

Answer 81

Overflow Incontinence Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management. In women it is usually due to detrusor hypotonia. In men it is usually due to obstruction (BPH).

Answer 82

Risk Factors for Urinary Incontinence • Increased age • Postmenopausal status • Increase BMI • Previous pregnancies and vaginal deliveries • Pelvic organ prolapse • Pelvic floor surgery • Neurological conditions, such as multiple sclerosis • Cognitive impairment and dementia

Answer 83

Investigation A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology. Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying. Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 84

Urodynamic Tests Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests. A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken.

Answer 85

Assessment A medical history should distinguish between the types of incontinence. Try to differentiate between urinary leakage with coughing or sneezing (stress incontinence), and incontinence due to a sudden urge to pass urine with loss of control on the way to the toilet (urge incontinence). Assess for modifiable lifestyle factors that can contribute to symptoms: • Caffeine consumption • Alcohol consumption • Medications • Body mass index (BMI) Assess the severity by asking about: • Frequency of urination • Frequency of incontinence • Nighttime urination • Use of pads and changes of clothing Examination should assess the pelvic tone and examine for: • Pelvic organ prolapse • Atrophic vaginitis • Urethral diverticulum • Pelvic masses During the examination, ask the patient to cough and watch for leakage from the urethra. The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system: • 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

Answer 86

Management of stress incontinence involves: • Avoiding caffeine, diuretics and overfilling of the bladder • Avoid excessive or restricted fluid intake • Weight loss (if appropriate) • Supervised pelvic floor exercises for at least three months before considering surgery • Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 87

Surgical options to treat stress incontinence include: ○ Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence. ○ Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape ○ Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra ○ Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, specialist centres may offer an operation to create an artificial urinary sphincter. This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.

Answer 88

Management of urge incontinence and overactive bladder involves: • Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line • Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin (act on the parasympathetic nervous system) ○ Anticholinergic medications need to be used carefully, as they have anticholinergic side effects. These include dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia, which can be very problematic in older, more frail patients. • Mirabegron is an alternative to anticholinergic medications ○ Mirabegron is used as an alternative medical treatment for urge incontinence with less of an anticholinergic burden. However, it is worth noting that mirabegron is contraindicated in uncontrolled hypertension. Blood pressure needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke.

Answer 89

• Invasive procedures where medical treatment fails Invasive options for overactive bladder that has failed to respond to retraining and medical management include: ○ 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

Answer 90

Female genital mutilation (FGM) involves surgically changing the genitals of a female for non-medical reasons. FGM is a cultural practice that usually occurs in girls before puberty. It is a form of child abuse and a safeguarding issue. Female genital mutilation is illegal as stated in the Female Genital Mutilation Act 2003, and there is a legal requirement for healthcare professionals to report cases of FGM to the police.

Answer 91

Bicornuate Uterus A bicornuate uterus is where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance. It can be diagnosed on a pelvic ultrasound scan. A bicornuate uterus may be associated with adverse pregnancy outcomes. However, successful pregnancies are generally expected. In most cases, no specific management is required. Typical complications include: • Miscarriage • Premature birth • Malpresentation

Answer 92

Imperforate Hymen Imperforate hymen is where the hymen at the entrance of the vagina is fully formed, without an opening. Imperforate hymen 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. An imperforate hymen can be diagnosed during a clinical examination. Treatment is with surgical incision to create an opening in the hymen. Theoretically, if an imperforate hymen is not treated retrograde menstruation could occur leading to endometriosis.

Answer 93

Transverse Vaginal Septae Transverse vaginal septae is caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed). Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use. Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation. Vaginal septae can lead to infertility and pregnancy-related complications. Diagnosis is by examination, ultrasound or MRI. Treatment is with surgical correction. The main complications of surgery are vaginal stenosis and recurrence of the septae.

Answer 94

Vaginal Hypoplasia and Agenesis Vaginal hypoplasia refers to an abnormally small vagina. Vaginal agenesis refers to an absent vagina. These occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix. The ovaries are usually unaffected, leading to normal female sex hormones. The exception to this is with androgen insensitivity syndrome, where there are testes rather than ovaries. Management may involve the use of a vaginal dilator over a prolonged period to create an adequate vaginal size. Alternatively, vaginal surgery may be necessary.

Answer 95

The upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina. Errors in their development lead to congenital structural abnormalities in the female pelvic organs. In a male fetus, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear. This is why men do not have a uterus.

Answer 96

Androgen insensitivity syndrome is a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. It was previously known as testicular feminisation syndrome. Patients with androgen insensitivity syndrome are genetically male, with XY sex chromosome. However, the absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue. Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes. The insensitivity to androgens also results in a lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed.

Answer 97

Presentation Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea. The results of hormone tests are: • Raised LH • Normal or raised FSH • Normal or raised testosterone levels (for a male) • Raised oestrogen levels (for a male)

Answer 98

Management Management is coordinated by a specialist MDT, involving paediatrics, gynaecology, urology, endocrinology and clinical psychology. Medical input involves: • Bilateral orchidectomy (removal of the testes) to avoid testicular tumours • Oestrogen therapy • Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.

Answer 99

Cancer of the cervix tends to affect younger women, peaking in the reproductive years. 80% of cervical cancers are squamous cell carcinoma. Adenocarcinoma is the next most common type. Very rarely there are other types, such as small cell cancer. Cervical cancer is strongly associated with human papillomavirus. Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer. Cervical screening with smear tests is used to screen for precancerous and cancerous changes to the cells of the cervix. Early detection of precancerous changes enables prompt treatment to prevent the development of cervical cancer.

Answer 100

Human Papilloma Virus The most common cause of cervical cancer is infection with human papillomavirus (HPV). HPV is also associated with anal, vulval, vaginal, penis, mouth and throat cancers. HPV is primarily a sexually transmitted infection. There are over 100 strains of HPV. The important ones to remember are type 16 and 18, as they are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine. There is no treatment for infection with HPV. Most cases resolve spontaneously within two years, while some will persist. P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.

Answer 101

Presentation Cervical cancer may be detected during cervical smears in otherwise asymptomatic women. The presenting symptoms that should make you consider cervical cancer as a differential are: • Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) • Vaginal discharge • Pelvic pain • Dyspareunia (pain or discomfort with sex) These symptoms are non-specific, and in most cases, not caused by cervical cancer. The next step is to examine the cervix with a speculum. During examination, swabs can be taken to exclude infection. Where there is an abnormal appearance of the cervix suggestive of cancer, an urgent cancer referral for colposcopy should be made to assess further. Appearances that may suggest cervical cancer are: ○ Ulceration ○ Inflammation ○ Bleeding ○ Visible tumour The NICE Clinical Knowledge Summaries (2017) recommend against unscheduled cervical screening with a smear test. They also advise against using the result of cervical screening to exclude cervical cancer where it is suspected for another reason, even if the smear result was normal.

Answer 102

Cytology results: § Inadequate § Normal § Borderline changes § Low-grade dyskaryosis § High-grade dyskaryosis (moderate) § High-grade dyskaryosis (severe) § Possible invasive squamous cell carcinoma § Possible glandular neoplasia

Answer 103

□ Inadequate sample – repeat the smear after at least three months □ HPV negative – continue routine screening □ HPV positive with normal cytology – repeat the HPV test after 12 months □ HPV positive with abnormal cytology – refer for colposcopy

Answer 104

Staging The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer: • Stage 1: Confined to the cervix • Stage 2: Invades the uterus or upper 2/3 of the vagina • Stage 3: Invades the pelvic wall or lower 1/3 of the vagina • Stage 4: Invades the bladder, rectum or beyond the pelvis

Answer 105

Colposcopy A specialist performs colposcopy. It 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. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas. Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells. Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain. A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.

Answer 106

Large Loop Excision of the Transformation Zone (LLETZ) A large loop excision of the transformation zone (LLETZ) procedure is also called a loop biopsy. It can be performed with a local anaesthetic during a colposcopy procedure. It involves using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix. The electrical current cauterises the tissue and stops bleeding. Bleeding and abnormal discharge can occur for several weeks following a LLETZ procedure. This varies between women. Intercourse and tampon use should be avoided after the procedure to reduce the risk of infection. Depending on the depth of the tissue removed from the cervix, the procedure may increase the risk of preterm labour.

Answer 107

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. The main risks of a cone biopsy are: • Pain • Bleeding • Infection • Scar formation with stenosis of the cervix • Increased risk of miscarriage and premature labour

Answer 108

Management Management of cervical cancer depends on the stage and the individual situation. The usual treatments are: • Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy • Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy • Stage 2B – 4A: Chemotherapy and radiotherapy • Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care The 5-year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4. Early detection makes a significant difference, which is one reason the screening program is so valuable and important. Pelvic exenteration is an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life. Bevacizumab (Avastin) is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer. It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels. Therefore, it reduces the development of new blood vessels. You may also come across this medication as a treatment for wet age-related macular degeneration, where it is injected directly into the patient eye to stop new blood vessels forming on the retina.

Answer 109

The HPV vaccine is ideally given to girls and boys before they become sexually active. The intention is to prevent them contracting and spreading HPV once they become sexually active. The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18: • Strains 6 and 11 cause genital warts • Strains 16 and 18 cause cervical cancer

Answer 110

Epithelial Cell Tumours Epithelial cell tumours (tumours arising from the epithelial cells of the ovary) are the most common type. Subtypes of epithelial cell tumours include: • Serous tumours (the most common) • Endometrioid carcinomas • Clear cell tumours • Mucinous tumours • Undifferentiated tumours

Answer 111

Dermoid Cysts / Germ Cell Tumours • These are benign ovarian tumours. • They are teratomas, meaning they come from the germ cells. • They may contain various tissue types, such as skin, teeth, hair and bone. • They are particularly associated with ovarian torsion. • Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).

Answer 112

Sex Cord-Stromal Tumours • These are rare tumours, that can be benign or malignant. • They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). • There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

Answer 113

Metastasis • Ovarian tumours may be due to metastasis from a cancer elsewhere. • A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. • Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.

Answer 114

Risk factors ○ Age (peaks age 60) ○ BRCA1 and BRCA2 genes (consider the family history) ○ Increased number of ovulations ○ Obesity ○ Smoking ○ Recurrent use of clomifene Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include: ○ Early-onset of periods ○ Late menopause ○ No pregnancies

Answer 115

Protective Factors Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk: □ Combined contraceptive pill □ Breastfeeding □ Pregnancy

Answer 116

Presentation Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include: ® Abdominal bloating ® Early satiety (feeling full after eating) ® Loss of appetite ® Pelvic pain ® Urinary symptoms (frequency / urgency) ® Weight loss ® Abdominal or pelvic mass ® Ascites An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.

Answer 117

Investigations The initial investigations in primary or secondary care are: – CA125 blood test (>35 IU/mL is significant) – Pelvic ultrasound The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: – Menopausal status – Ultrasound findings – CA125 level Further investigations in secondary care include: – CT scan to establish the diagnosis and stage the cancer – Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy – Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour: – Alpha-fetoprotein (α-FP) – Human chorionic gonadotropin (HCG)

Answer 118

Causes of Raised CA125 CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: w Endometriosis w Fibroids w Adenomyosis w Pelvic infection w Liver disease w Pregnancy

Answer 119

Staging The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is: w Stage 1: Confined to the ovary w Stage 2: Spread past the ovary but inside the pelvis w Stage 3: Spread past the pelvis but inside the abdomen w Stage 4: Spread outside the abdomen (distant metastasis)

Answer 120

• Vulval cancer is rare compared with other gynaecological cancers. • Around 90% are squamous cell carcinomas. • Less commonly, they can be malignant melanomas.

Answer 121

Risk Factors • Advanced age (particularly over 75 years) • Immunosuppression • Human papillomavirus (HPV) infection • Lichen sclerosus ○ Around 5% of women with lichen sclerosus get vulval cancer.

Answer 122

Presentation Vulval cancer may be an incidental finding in older women, for example, during catheterisation in a patient with dementia. Vulval cancer may present with symptoms of: § Vulval lump § Ulceration § Bleeding § Pain § Itching § Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: § Irregular mass § Fungating lesion § Ulceration § Bleeding

Answer 123

Vulval Intraepithelial Neoplasia ○ Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. ○ VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia). ○ High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years. ○ Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years). ○ A biopsy is required to diagnose VIN. ○ A specialist will coordinate management. Treatment options include: ○ Watch and wait with close followup ○ Wide local excision (surgery) to remove the lesion ○ Imiquimod cream ○ Laser ablation

Answer 124

Management 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) The International Federation of Gynaecology and Obstetrics (FIGO) system is used to stage vulval cancer. Management depends on the stage, and may involve: ® Wide local excision to remove the cancer ® Groin lymph node dissection ® Chemotherapy ® Radiotherapy

Answer 125

• Endometrial cancer is cancer of the endometrium, the lining of the uterus. • Around 80% of cases are adenocarcinoma. • It is an oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells.

Answer 126

Presentation The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding. Endometrial cancer may also present with: – Postcoital bleeding – Intermenstrual bleeding – Unusually heavy menstrual bleeding – Abnormal vaginal discharge – Haematuria – Anaemia – Raised platelet count

Answer 127

Investigations There are three investigations to remember for diagnosing and excluding endometrial cancer: w Transvaginal ultrasound for endometrial thickness (normal is < 4mm post-menopause) w Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer ○ A pipelle biopsy can be taken in the outpatient clinic. ○ It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. ○ This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer. ○ Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women. w Hysteroscopy with endometrial biopsy Depending on local guidelines, a normal transvaginal ultrasound (endometrial thickness < 4mm) and normal pipelle biopsy are sufficient to demonstrate a very low risk of endometrial cancer and discharge the patient.

Answer 128

Stages The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer: w Stage 1: Confined to the uterus w Stage 2: Invades the cervix w Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes w Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 129

Management The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa). Other treatment options depending on the individual presentation include: A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina Radiotherapy Chemotherapy Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Answer 130

Risk Factors § Exposure to unopposed oestrogen. □ Unopposed oestrogen refers to oestrogen without progesterone. □ Unopposed oestrogen stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer. □ The risk endometrial cancer is associated with the amount of unopposed oestrogen the endometrium is exposed to during the patient’s life. Situations where there is increased exposure of unopposed oestrogen are: Increased Age Earlier onset of menstruation Late menopause Oestrogen only HRT No or fewer pregnancies Obesity PCOS Tamoxifen

Answer 131

Protective factors against endometrial cancer include: ◊ Combined contraceptive pill ◊ Mirena coil ◊ Increased pregnancies ◊ Cigarette smoking

Answer 132

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than 12 months after the last menstrual period) NICE also recommends referral for a transvaginal ultrasound in women over 55 years with: Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Answer 133

Endometrial Hyperplasia • Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium. • The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. • Most cases of endometrial hyperplasia will return to normal over time. • Less than 5% go on to become endometrial cancer. • There are two types of endometrial hyperplasia to be aware of: a. Hyperplasia without atypia b. Atypical hyperplasia • Endometrial hyperplasia may be treated by a specialist using progestogens, with either: ○ Intrauterine system (e.g. Mirena coil) ○ Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

Answer 134

• Hormone replacement therapy (HRT) is used in perimenopausal and postmenopausal women to alleviate symptoms associated with menopause. • These symptoms are associated with a declined in the level of oestrogen. • Exogenous oestrogen is given to alleviate the symptoms. • Progesterone needs to be given (in addition to oestrogen) to women that have a uterus. ○ The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.

Answer 135

• Women with a uterus require endometrial protection with progesterone • Whereas women without a uterus can have oestrogen-only HRT. • Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. • Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.

Answer 136

Clonidine • Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. • It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. • It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT. • Common side effects of clonidine are: ○ Dry mouth ○ Headaches ○ Dizziness ○ Fatigue. • Sudden withdrawal can result in rapid increases in blood pressure and agitation.

Answer 137

Indications for HRT The indication for HRT are: § Replacing hormones in premature ovarian insufficiency, even without symptoms § Reducing vasomotor symptoms such as hot flushes and night sweats § Improving symptoms such as low mood, decreased libido, poor sleep and joint pain § Reducing risk of osteoporosis in women under 60 years

Answer 138

Benefits of HRT In women under 60 years, the benefits of HRT generally outweigh the risks. The key benefits to inform women of include: □ Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms) □ Improved quality of life □ Reduced the risk of osteoporosis and fractures

Answer 139

Risks of HRT Women may be concerned about the risks of HRT. It is crucial to put these into perspective. In women under 60 years, the benefits generally outweigh the risks. Specific treatment regimes significantly reduce the risks associated with HRT. The risks of HRT are more significant in older women and increase with a longer duration of treatment. The principal risks of HRT are: ® Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk) ◊ If used for 5 years then not used for 5 years risk will go back to normal ® Increased risk of endometrial cancer ® Increased risk of venous thromboembolism (2 – 3 times the background risk) ® Increased risk of stroke and coronary artery disease with long term use in older women (>60) ® The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal These risks do not apply to all women: ® The risks are not increased in women under 50 years compared with other women their age ® There is no risk of endometrial cancer in women without a uterus ® There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT) Ways to reduce the risks: ® The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus ® The risk of VTE is reduced by using patches rather than pills

Answer 140

Contraindications to HRT There are some essential contraindications to consider in patients wanting to start HRT: – Undiagnosed abnormal bleeding – Endometrial hyperplasia or cancer – Breast cancer – Uncontrolled hypertension – Venous thromboembolism – Liver disease – Active angina or myocardial infarction – Pregnancy

Answer 141

Take a full history to ensure there are no contraindications Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE Check the body mass index (BMI) and blood pressure Ensure cervical and breast screening is up to date Encourage lifestyle changes that are likely to improve symptoms and reduce risks

Answer 142

Choosing the HRT Formulation There are three steps to consider when choosing the HRT formulation: Step 1: Do they have local or systemic symptoms? w Local symptoms: use topical treatments such as topical oestrogen cream or tablets w Systemic symptoms: use systemic treatment – go to step 2 Step 2: Does the woman have a uterus? w No uterus: use continuous oestrogen-only HRT w Has uterus: add progesterone (combined HRT) – go to step 3 Step 3: Have they had a period in the past 12 months? w Perimenopausal: give cyclical combined HRT w Postmenopausal (more than 12 months since last period): give continuous combined HRT

Answer 143

Options for Oestrogen Delivery Oestrogen is the critical component of HRT for reducing the symptoms of menopause. There are two options for delivering systemic oestrogen: Oral (tablets) Transdermal (patches or gels) ○ Patches are more suitable for women with: § Poor control on oral treatment § Higher risk of venous thromboembolism § Cardiovascular disease § Headaches.

Answer 144

Cyclical progesterone, given for 10 – 14 days per month, is used for women that have had a period within the past 12 months. Cycling the progesterone allows patients to have a monthly breakthrough bleed during the oestrogen-only part of the cycle, similar to a period.

Answer 145

Continuous progesterone is used when the woman has not had a period in the past: w 24 months if under 50 years w 12 months if over 50 years Using continuous combined HRT before postmenopause can lead to irregular breakthrough bleeding and investigation for other underlying causes of bleeding. You can switch from cyclical to continuous HRT after w At least 12 months of treatment in women over 50 w 24 months in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.

Answer 146

In a women with no uterus: • Oestrogen-only pills, for example, Elleste Solo or Premarin • Oestrogen-only patches, for example, Evorel or Estradot

Answer 147

In a perimenopausal woman with periods: • Cyclical combined tablets, for example, Elleste-Duet, Clinorette or Femoston • Cyclical combined patches, for example, Evorel Sequi or FemSeven Sequi • Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin • Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot Or POP with oestrogen pills or patches

Answer 148

In a postmenopausal woman with a uterus: • Continuous combined tablets, for example, Elleste-Duet Conti, Kliofem or Femoston Conti • Continuous combined patches, for example, Evorel-Conti or FemSeven Conti • Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin • Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot

Answer 149

• Tibolone is a synthetic steroid that stimulates oestrogen and progesterone receptors. • It also weakly stimulates androgen receptors. • The effects on androgen receptors mean tibolone can be helpful for patients with reduced libido. • Tibolone is used as a form of continuous combined HRT. • Women need to be more than 12 months without a period (24 months if under 50 years). They would be expected not to have breakthrough bleeding. • Tibolone can cause irregular bleeding, resulting in further investigations to exclude other causes.

Answer 150

Testosterone • Testosterone is a male sex hormone (androgen). • It is naturally present in low levels in women. • Menopause can be associated with reduced testosterone, resulting in low energy and reduced libido (sex drive). • Treatment with testosterone is usually initiated and monitored by a specialist. • It is given by transdermal application, applied as a gel or a cream to the skin.

Answer 151

Oestrogenic side effects: § Nausea and bloating § Breast swelling § Breast tenderness § Headaches § Leg cramps

Answer 152

Progestogenic side effects: § Mood swings § Bloating § Fluid retention § Weight gain Acne and greasy skin

Answer 153

Where patients experience side effects, it is worth changing the type of HRT or the route of administration (switch between patches and pills). Patients with progestogenic side effects may do better switching to an HRT with a different form of progesterone. § For example, patients with acne and mood swings may do better with a dydrogesterone progesterone (e.g. Femoston). § In contrast, patients with reduced libido may do better with a norethisterone progesterone (e.g. Elleste-Duet). § Progestogenic side effects can be avoided altogether by using a Mirena coil for endometrial protection. Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.

Answer 154

Stopping HRT There is no specific regime for stopping HRT. It can be reduced gradually or stopped abruptly, depending on the preference of the woman. This choice does not affect long term symptoms. Gradually reducing the HRT may be preferable to reduce the risk of symptoms recurring suddenly.

Answer 155

High LH & FSH Absence of negative feedback from oestrogen

Answer 156

• Lack of oestrogen • CVD & stroke • Osteoporosis • Pelvic organ prolapse • Urinary incontinence

Answer 157

• Women should use effective contraception for: • Two years after the last menstrual period (under 50) • One year after last menstrual period (over 50) Hormonal contraceptives do not affect the menopause • Good options : Barrier , Mirena coil, progesterone – implant, tablets, depot • HRT IS NOT A CONTRACEPTIVE

Answer 158

• Vaginal oestrogen Indication • Urogenital atrophy symptoms predominate • May be required in addition for some patients taking systemic HRT Options • Estradiol – vaginal tablets or ring • Estriol – Ovestin & Gynest cream , pessaries , gel • Use nightly for two/three weeks then twice weekly • Can continue long term • Systemic absorption minimal • Progestogen not required

Answer 159

• Breast cancer • Oestrogen dependent malignant carcinomas • Untreated oestrogen-dependent carcinomas • Active liver disease with abnormal LFTs • Current idiopathic thromboembolic disease or previous idiopathic unless on treatment • Active or recent arterial thromboembolism (angina or MI) • Pregnancy • Undiagnosed vaginal bleeding

Answer 160

• Persistent side effects • Poor symptom control • Complex medical history • Past history of hormone dependent cancer • Bleeding problems • Sequential : if increase in heaviness or duration of bleeding or it’s irregular • Continuous combined : if bleeding beyond 6 months of therapy or if occurs after a spell of amenorrhoea

Zero To Finals - Gynae Flashcards

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