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GYNAE Flashcards

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1
Q

MENSTRUAL CYCLE
When is the last menstrual period?
What are the stages of the menstrual cycle?

A
  • 1st day of last period (cycle runs from 1st day of last to 1st day of next
  • Menstruation (D1-5) > proliferation (D6-14) > ovulation (D14) > secretion (D16-28)
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2
Q

MENSTRUAL CYCLE

What 2 cycles exist within the menstrual cycle?

A
  • Ovarian cycle (development of follicle + ovulation)

- Uterine cycle (functional endometrium thickens + shreds)

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3
Q

MENSTRUAL CYCLE

What happens in the menstrual and proliferative phases?

A
  • Old endometrial lining from previous cycle shed marking day 1 (lasts 5d)
  • High oestrogen > thickening of endometrium, growth of endometrial glands + emergence of spiral arteries from stratum basalis to feed the functional endometrium
  • Consistency of cervical mucus changes to make more hospitable for sperm
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4
Q

MENSTRUAL CYCLE

What happens in the follicular phase?

A
  • Independently primordial follicles mature into primary + secondary follicles with FSH receptors
  • Low oestrogen + progesterone = pulses of GnRH > LH + FSH release
  • FSH leads to follicular development + recruitment
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5
Q

MENSTRUAL CYCLE

What happens as secondary follicles grow during follicular phase?

A
  • Theca cells develop LH receptors + secrete androgens
  • Granulosa cells develop FSH receptors + secrete aromatase
  • Leads to increased oestrogen > -ve feedback on pituitary to reduce LH + FSH leading to some follicles to regress
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6
Q

MENSTRUAL CYCLE

What occurs during ovulation?

A
  • Follicle (dominant) with most FSH receptors continues developing
  • Secretes further oestrogen which at a threshold causes spike in LH (+ slight rise in FSH) causing release of ovum on day 14
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7
Q

MENSTRUAL CYCLE

What occurs during the luteal phase?

A
  • Dominant follicle > corpus luteum + luteinised granulosa cells converts cholesterol into progesterone for 10d to facilitate implantation + reduce FSH/LH + oestrogen
  • Also secretes inhibin to reduce FSH
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8
Q

MENSTRUAL CYCLE

What happens if the egg is fertilised?

A
  • Syncytiotrophoblast of embryo secretes human chorionic gonadotropin (hCG) which maintains corpus luteum
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9
Q

MENSTRUAL CYCLE

What happens if the egg is not fertilised?

A
  • hCG absence > corpus luteum degenerates into corpus albicans
  • Fall in progesterone + oestrogen causes endometrium to breakdown + menstruation occurs
  • FSH + LH levels rise
  • Stromal cells of endometrium release prostaglandins to encourage endometrium breakdown + uterine contraction
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10
Q

MENSTRUAL CYCLE

What happens in the early secretory phase of the menstrual cycle?

A
  • Progesterone mediated + signals ovulation occurred to make endometrium receptive, cause spiral arteries to grow longer + uterine glands to secrete more mucus
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11
Q

MENSTRUAL CYCLE

What happens in the late secretory phase of the menstrual cycle?

A
  • Cervical mucus thickens + less hospitable for sperm

- Decrease in oestrogen + progesterone > spiral arteries collapse + constrict + functional layer prepares to shred

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12
Q

1* AMENORRHOEA

What is primary amenorrhoea?

A

Absence of menstruation by –

  • 14y if no secondary sexual characteristics (more indicative of a chromosomal abnormality)
  • 16y with secondary sexual characteristics (breast buds)
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13
Q

1* AMENORRHOEA

What is the difference between hypogonadotrophic hypogonadism and hypergonadotrophic hypogonadism?

A
  • Deficiency in gonadotrophins (LH + FSH) stimulating ovaries due to abnormal hypothalamus or pituitary means they do not respond by producing sex hormones (oestrogen)
  • Gonads fails to respond to stimulation of gonadotrophins meaning no negative feedback + increasing amounts of FSH/LH
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14
Q

1* AMENORRHOEA

What are some causes of hypogonadotrophic hypogonadism?

A
  • Constitutional delay (temporary delay, no pathology, ?FHx)
  • Hypopituitarism
  • Kallmann’s (failure to start puberty + anosmia)
  • Excessive exercise, dieting or stress causes hypothalamic failure
  • Endo = Cushing’s, prolactinoma, thyroid
  • Damage (cancer, surgery)
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15
Q

1* AMENORRHOEA

What are some causes of hypergonadotrophic hypogonadism?

A
  • Turner’s syndrome XO
  • Congenital absence of ovaries
  • Previous damage to gonads (torsion, cancer, infections like mumps)
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16
Q

1* AMENORRHOEA

What are some other causes of primary amenorrhoea and how may they present?

A
  • Congenital adrenal hyperplasia (tall, deep voice, facial hair)
  • Androgen insensitivity syndrome (46XY but female phenotype)
  • Congenital malformations of genital tract (if ovaries unaffected = secondary sexual characteristics but no menses)
  • Gonadal dysgenesis (no ovaries or uterus form)
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17
Q

1* AMENORRHOEA

What are some first line investigations for primary amenorrhoea?

A
  • Examination = signs of puberty, PV exam, BMI, visual fields
  • FBC + ferritin (anaemia), U+E for CKD, anti-TTG for coeliac, urinary beta-hCG crucial
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18
Q

1* AMENORRHOEA

What hormonal blood tests would you do for primary amenorrhoea?

A
  • FSH + LH (low or high)
  • TFTs, prolactin (if indicated)
  • Free androgens raised in PCOS, AIS + CAH
  • Insulin-like growth factor I used for screening for GH deficiency
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19
Q

1* AMENORRHOEA

What other investigations may be useful for primary amenorrhoea?

A
  • XR of wrist to assess bone age + Dx constitutional delay
  • Pelvic USS for structural causes
  • ?MRI head if pituitary
  • Karyotyping for Turner’s syndrome, AIS
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20
Q

1* AMENORRHOEA
What is the management of…

i) constitutional delay?
ii) ovarian causes (PCOS, damage/absence of ovaries)
iii) genital tract abnormalities?
iv) pituitary tumour?
v) stress?

A

i) May only require reassurance + observation
ii) COCP can induce regular menstruation + prevent Sx of oestrogen deficiency
iii) Surgery
iv) Surgery, chemo, radio or bromocriptine if prolactinoma
v) CBT, healthy weight gain, stress reduction

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21
Q

1* AMENORRHOEA

What is the management of hypogonadotrophic hypogonadism?

A
  • Pulsatile GnRH can induce ovulation, menstruation + potentially fertility
  • COCP if pregnancy not wanted to replace sex hormones, induce regular menstruation + prevent Sx of oestrogen deficiency
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22
Q

2* AMENORRHOEA
What is secondary amenorrhoea?
What is oligomenorrhoea?

A
  • Previously normal menstruation ceases for >3m in a non-pregnancy woman
  • Where menses are >35d apart (up to 6m), can be ovarian normality but exclude PCOS
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23
Q

2* AMENORRHOEA

What are the causes of secondary amenorrhoea?

A
  • Pregnancy (most common), breastfeeding, menopause (physiological)
  • Iatrogenic (contraception)
  • Hypothalamic/pituitary
  • Ovarian causes (PCOS, POI)
  • Thyroid, uterine pathology (Asherman’s)
  • Excessive exercise, stress or eating disorders
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24
Q

2* AMENORRHOEA

What are the hypothalamic or pituitary causes of secondary amenorrhoea?

A
  • Sheehan’s syndrome = pituitary necrosis following PPH
  • Pituitary tumour like prolactinoma leading to hyperprolactinaemia which prevents GnRH
  • Trauma, radiotherapy or surgery
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25
2* AMENORRHOEA | How does excessive stress or eating disorders cause secondary amenorrhoea?
- Hypothalamus reduces GnRH in times of stress > hypogonadotrophic hypogonadism to prevent pregnancy in adverse situations
26
2* AMENORRHOEA | What hormonal tests would you do in secondary amenorrhoea?
- Urine/blood beta-hCG - High FSH (POI) - Low FSH/LH (hypgonadotrophic hypogonadism) - High LH or LH:FSH ratio suggests PCOS - Free androgen raised in PCOS - Mid-luteal (day 21) progesterone to check ovulation happened - Prolactin + TFTs if indicated
27
2* AMENORRHOEA | What other investigations may you do in secondary amenorrhoea?
- Pelvic USS to Dx PCOS | - MRI head if ?pituitary tumour
28
2* AMENORRHOEA What is the management of... i) hyperprolactinaemia? ii) hypothalamic failure?
i) Bromocriptine or cabergoline (dopamine agonists) | ii) GnRH replacement
29
CONGENITAL STRUCTURES What are congenital structural abnormalities and what are the causes? What can it lead to?
- Abnormal development of pelvic organs prior to birth, may be result of faulty genes or occur randomly in otherwise healthy people - Menstrual, sexual + reproductive problems
30
CONGENITAL STRUCTURES | What is the basic embryology of the female genital tract?
- Upper third of vagina, cervix, uterus + fallopian tubes develop from paramesonpehric (Mullerian) ducts - Errors in their development can lead to congenital structural abnormalities
31
CONGENITAL STRUCTURES | Give 3 examples of congenital structural abnormalities
- Bicornuate uterus - Transverse vaginal septae - Vaginal hypoplasia + agenesis
32
CONGENITAL STRUCTURES What is bicornuate uterus? Associations?
- 2 horns to uterus giving heart-shape on pelvic USS | - May be associated with adverse pregnancy outcomes (miscarriage, premature birth, malpresentation)
33
CONGENITAL STRUCTURES | What is a transverse vaginal septum?
- Septum (wall) forms transversely across the vagina, can be perforate (with a hole) or imperforate (completely sealed)
34
CONGENITAL STRUCTURES | How does transverse vaginal septae present?
- Perforate = still menstruate but difficulty with intercourse + tampon use - Imperforate = cyclical pelvic Sx but no menses as sealed, can lead to endometriosis by retrograde menstruation - May have infertility + pregnancy related issues
35
CONGENITAL STRUCTURES | What is the management of transverse vaginal septae?
- Dx by examination, USS or MRI with surgical correction | - Main complications of surgery are vaginal stenosis or recurrence
36
CONGENITAL STRUCTURES What is vaginal hypoplasia and agenesis What causes it?
- Hypoplasia = abnormally small vagina - Agenesis = absent - Failure of Mullerian ducts to develop properly + may be associated with absent uterus + cervix
37
CONGENITAL STRUCTURES In vaginal hypoplasia and agenesis what structure is not affected? What is the management?
- Ovaries – leading to normal female sex hormones | - Prolonged period with vaginal dilatation for adequate size or surgery
38
MENORRHAGIA | What is menorrhagia?
- Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle + interferes with QOL (no measurable quantity)
39
MENORRHAGIA | What are some causes of menorrhagia?
- Unknown = dysfunctional uterine bleeding - Fibroids (most common cause in gynae) - Bleeding disorder (vWD) - Hypothyroidism - Polyps, endometriosis, adenomyosis, PID, contraceptives (IUD) - Endometrial hyperplasia or cancer
40
MENORRHAGIA | What are some investigations for menorrhagia?
- Bimanual exam (?fibroids if bulky non-tender, ?adenomyosis if bulky tender 'boggy') - FBC for ALL women, ferritin (anaemic), TFTs, clotting screen - STI screen - Pelvic (TV>TA) USS - Hysteroscopy ± endometrial biopsy if ?endometrial pathology
41
FIBROIDS | What are fibroids?
- Benign tumours of the smooth muscle of the uterus (uterine leiomyomas)
42
FIBROIDS | What are the different types of fibroids?
- Intramural (most common) = within the myometrium - Subserosal = >50% fibroid mass extends outside uterine contours - Submucosal = >50% projection into the endometrial cavity - Subserosal + submucosal can be pedunculated (on stalk = risk of torsion)
43
FIBROIDS What are the issues with... i) intramural fibroids? ii) subserosal fibroids?
i) As they grow, they change the shape + distort the uterus | ii) Grow outwards + can become very large, filling the abdominal cavity
44
FIBROIDS | What can cause fibroids?
- Oestrogen dependent so grow in response to it (rare before puberty or after menopause) - Associated with mutation in gene for fumarate hydratase
45
FIBROIDS | What are some risk factors for fibroids?
- Afro-Caribbean - Obesity - Early menarche - FHx - Increasing age (until menopause)
46
FIBROIDS | What is the clinical presentation of fibroids?
- Menorrhagia (#1) - Prolonged menstruation, deep dyspareunia - Lower abdo cramping pain (worse during menstruation) - Bloating - Urinary or bowel Sx due to pelvic pressure or fullness
47
FIBROIDS | What are some investigations for fibroids?
- Abdo + bimanual exam = palpable pelvic mass or bulky non-tender uterus - FBC for ALL women (?Fe anaemia) - Pelvic (TV>TA) USS for larger fibroids
48
FIBROIDS | What are some complications of fibroids?
- Red degeneration - Benign calcification if centre of larger fibroids not receiving adequate blood supply - Reduced fertility (submucosal interfere with implantation) - Obstetric issues (miscarriage, premature labour)
49
FIBROIDS | What is red degeneration of fibroids?
- Ischaemia, infarction + necrosis of fibroid due to disrupted blood supply - Fibroids sensitive to oestrogen so can grow rapidly in presence (like pregnancy) + outgrow their blood supply > ischaemia
50
FIBROIDS | How does red degeneration of fibroids present and what is the management?
- Low-grade fever, pain + vomiting (classically in pregnant woman) - Supportive management like analgesia, fluids
51
FIBROIDS | How is the management of fibroids split?
- Fibroids <3cm - Fibroids >3cm (with referral to gynae for investigation + management) - Also split into non-hormonal + hormonal depending on if woman wants to get pregnant
52
FIBROIDS | What is the first line non-hormonal management of fibroids <3cm?
- Tranexamic acid (antifibrinolytic) taken during bleeding to reduce it - Mefenamic acid (NSAID) to reduce bleeding + pain
53
FIBROIDS | What is the first line hormonal management of fibroids <3cm?
- Mirena coil is 1st line (fibroids <3cm with no uterus distortion) - 2nd = COCP triphasing (back-to-back for 3m then break) - Cyclical oral progestogens - Norethisterone 5mg TDS can be used short-term to rapidly stop menorrhagia from 3d before period until bleeding acceptable
54
FIBROIDS | What is the management of fibroids <3cm that fail medical treatment or are severe?
- Surgery
55
FIBROIDS | What is the management of fibroids >3cm?
- Same medical Mx but surgery offered too - GnRH agonists (goserelin) can be given to shrink fibroids by inducing menopausal state (reduced oestrogen) in short-term (can demineralise bone) for surgery - Selective progesterone receptor modulators (SPRMS) like ulipristal acetate can be used instead to avoid SEs
56
FIBROIDS | What are the 5 main surgical options of managing fibroids?
- Trans-cervical resection of fibroid via hysteroscopy - 2nd gen endometrial ablation - Uterine artery embolisation - Myomectomy - Hysterectomy
57
FIBROIDS What is... i) trans-cervical resection of fibroid? ii) endometrial ablation? iii) uterine artery embolisation? iv) myomectomy? v) hysterectomy?
i) Removal of submucosal fibroid, offered to women planning on having more children ii) Destroys endometrium via radiofrequency ablation, non-hysteroscopic, day case iii) Blocked arterial supply to fibroid starves of oxygen + shrinks iv) Removal of fibroid via laparoscopy/laparotomy v) Removal of uterus + fibroids ± oophorectomy depending on situation (last resort)
58
FIBROIDS What management of fibroids is the only one considered to improve subfertility? What is a risk of this management?
- Myomectomy | - Avoid during pregnancy or c-section as massive haemorrhage risk
59
ADENOMYOSIS | What is adenomyosis?
- Endometrial tissue inside the myometrium – oestrogen dependent - Can occur alone or alongside endometriosis or fibroids
60
ADENOMYOSIS | What is the epidemiology of adenomyosis?
- More common in later reproductive years + those who are multiparous (contrast to fibroids)
61
ADENOMYOSIS | How does adenomyosis present?
- Dysmenorrhoea, menorrhagia + dyspareunia are classic Sx - Cyclical pain worse as period starts but can last 2w after it stops (much longer than endometriosis) - May cause infertility or pregnancy-related issues
62
ADENOMYOSIS | What are the investigations for adenomyosis?
- Bimanual exam = bulky + tender uterus, 'BOGGY' - TVS is 1st line investigation - Gold standard - histological examination of uterus after hysterectomy (not always suitable though)
63
ADENOMYOSIS | What are some complications of adenomyosis?
- Infertility - Miscarriage - Preterm birth - SGA - PPROM - Malpresentation - PPH
64
ADENOMYOSIS | What is the initial management of adenomyosis?
- Same as fibroids or menorrhagia in general - TXA or mefenamic acid - Mirena coil 1st line if no uterus distortion - COCP triphasing - Cyclical progesterone - Norethisterone 5mg TDS short-term
65
ADENOMYOSIS | What is the other management of adenomyosis?
- GnRH analogues like goserelin to induce menopause-like state - Endometrial ablation, UAE or hysterectomy (if family completed)
66
ENDOMETRIOSIS | What is endometriosis?
- Presence of ectopic endometrial tissue outside the uterus
67
ENDOMETRIOSIS | Where might endometriosis occur?
- Pouch of Douglas > PR bleeding - Uterosacral ligaments - Bladder + distal ureter > haematuria - Pelvic cavity incl. ovaries > endometrioma in ovaries - Less common - lungs, nose, umbilicus, previous scars (lump gets big + painful)
68
ENDOMETRIOSIS | What is the pathophysiology of endometriosis?
- Cells of endometrial tissue outside uterus respond to hormones in same way > oestrogen dependent condition - During menstruation, endometrial tissue sheds lining + bleeds leading to irritation + inflammation of nearby tissues - Chronic + constant inflammation > cyclical pain
69
ENDOMETRIOSIS | What is the epidemiology of endometriosis?
- Higher prevalence in infertile women | - Exclusive to women of reproductive age
70
ENDOMETRIOSIS | What are 3 theories about the cause of endometriosis?
- Sampson's = retrograde menstruation (endometrial lining flows backwards through fallopian tubes + into pelvis/peritoneum where endometrial tissue seeds itself - Meyer's = metaplasia of mesothelial cells - Halban's = via blood or lymphatics
71
ENDOMETRIOSIS What are some risk factors for endometriosis? What are some protective factors?
- Early menarche, late menopause, obstruction to vaginal outflow (imperforate hymen) - Multiparity + COCP
72
ENDOMETRIOSIS | What is the clinical presentation of endometriosis?
- Dysmenorrhoea, deep dyspareunia + cyclical chronic pelvic pain - Pain worse 2–3d before periods + better after - Cyclical bowel + bladder Sx = pain on defecation (dyschezia), dysuria, urgency - Sub-fertility + cyclical bleeding from various sites
73
ENDOMETRIOSIS | What are the investigation of endometriosis?
- Bimanual = ?adnexal masses or tenderness, nodules in uterosacral ligaments or fixed + retroverted uterus due to adhesions - TVS for ovarian endometrioma (chocolate cyst) = brown fluid as old blood + tissue - Gold standard = laparoscopy with biopsy
74
ENDOMETRIOSIS What might laparoscopy and biopsy show? What is the benefit of this investigation?
- White scars or brown spots = 'powder burn' | - Added benefit of being able to remove deposits during procedure
75
ENDOMETRIOSIS | What are some complications of endometriosis?
- Subfertility | - Adhesions
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ENDOMETRIOSIS | How does endometriosis cause subfertility?
- Areas of endometriosis release cytokines + harmful chemicals which can damage reproductive tract - Can cause reduced fallopian tube motility, scarring, bleeding, toxicity to oocyte
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ENDOMETRIOSIS | How does endometriosis cause adhesions?
- Localised bleeding + inflammation causes damage + development of scar tissue that binds the organs together (adhesions)
78
ENDOMETRIOSIS | What is the initial management of endometriosis?
- NSAIDs ± paracetamol first line for Sx relief - COCP triphasing (can't take for longer as if not irregular bleeding - POP like medroxyprogesterone acetate - GnRH analogues to "induce" menopause, reversible, quicker than triphasing but need HRT + only short-term as risk of osteoporosis
79
ENDOMETRIOSIS | What fertility-sparing treatments are there for endometriosis?
- Laparoscopic removal of adhesions either by ablation (burning) or excision (cutting) away endometriotic tissue
80
ENDOMETRIOSIS | What is the last resort treatment of endometriosis?
- Hysterectomy ± bilateral salpingo-oopherectomy as no ovaries = no cycle
81
PCOS | What is polycystic ovarian syndrome (PCOS)?
- Syndrome of excess androgen production by theca cells of ovaries due to hyperinsulinaemia + increased LH levels (due to pituitary production increase, genetics like Turner's or Klinefelter's)
82
PCOS | How does insulin resistance contribute to PCOS?
- Insulin resistance = pancreas produces more insulin - Insulin mimics action of insulin-like growth factor 1 which augments androgen production by theca cells in response to LH - Higher insulin = higher androgens (testosterone)
83
PCOS | How does high insulin levels contribute to PCOS?
- Insulin suppresses sex hormone-binding globulin (SHBG) produced by liver which normally binds to androgens + suppresses their function further promoting hyperandrogenism - Also contribute to halting development of follicles in ovaries > anovulation + multiple partially developed follicles (polycystic ovaries)
84
PCOS | What are the 3 main presenting features of PCOS?
- Hyperandrogenism - Insulin resistance - Oligo or amenorrhoea + sub/infertility
85
PCOS | How does hyperandrogenism present in PCOS?
- Acne, hirsutism, deep voice, male-pattern hair loss | - Hirsutism is growth of thick, dark hair often in male pattern (facial hair)
86
PCOS | What are some differentials of hirustism?
- Ovarian or adrenal tumours that secrete androgens - Cushing's syndrome - CAH - Iatrogenic (steroids, phenytoin)
87
PCOS | How does insulin resistance present?
- Obesity, acanthosis nigricans (thickened, rough skin often axilla + elbows with velvety texture), psychological Sx
88
PCOS | What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) – - Oligo- or anovulation (may present as oligo- or amenorrhoea) - Hyperandrogenism (biochemical or clinical) - Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
89
PCOS | What hormone tests may be used in PCOS?
- Testosterone (raised) - SHBG (low) - LH (raised) + raised LH:FSH ratio (LH>FSH) - Prolactin (normal), TFTs (exclude causes)
90
PCOS | What other investigation may be useful at indicating PCOS?
2h 75g OTT for DM – - IFG = 6.1–6.9mmol/L - IGT (at 2h) = 7.8–11.1 - Diabetes (at 2h) = >11.1
91
PCOS What is the gold standard for visualising the ovaries? What might it show?
- TVS - "String of pearls" appearance where follicles arranged around periphery of ovary (≥12 cysts or >10cm^3 ovarian volume) - Can also visualise endometrial thickness
92
PCOS | What are some associations and complications of PCOS?
- DM, CVD + hypercholesterolaemia - Obstructive sleep apnoea, MH issues, sexual problems - Endometrial hyperplasia or cancer
93
PCOS | Why does PCOS increase risk of endometrial hyperplasia + cancer?
- Oligo/anovulation means endometrial lining continues proliferating with unopposed oestrogen as no corpus luteum releasing progesterone
94
PCOS | What is the most crucial part of PCOS management?
- Weight loss as can improve overall condition
95
PCOS | How is the risks of obesity, T2DM, CVD etc. managed in PCOS?
- Lifestyle > diet + exercise, weight loss to reduce insulin resistance, smoking cessation - Orlistat (lipase inhibitor that stops fat absorption in intestines) may be given to assist weight loss if BMI >30kg/^m2
96
PCOS What are the PCOS risk factors for endometrial cancer? How is the risk of endometrial cancer managed in PCOS?
- Obesity, DM, insulin resistance, amenorrhoea - Mirena coil for continuous endometrial protection - Induce withdrawal bleed AT LEAST every 3m with COCP or cyclical progesterones medroxyprogesterone 10mg 14d)
97
PCOS | How is infertility managed in PCOS?
- Weight loss initial step to restore regular ovulation - Clomiphene to induce ovulation - Metformin may help (+ helps insulin resistance) - Laparoscopic ovarian drilling or IVF last resort
98
PCOS | How is hirsutism + acne managed?
- Hair removal cream, topical eflornithine to treat facial hirsutism - Co-cyprindiol is COCP licensed for hirsutism + acne as anti-androgen effect but only used for 3m as increased VTE risk - Spironolactone by specialist (mineralocorticoid antagonist with anti-androgen effects)
99
BREAST CANCER What is the pre-malignant form of breast cancer? How is it detected? What is the pathology?
- Non-invasive ductal carcinoma in situ (DCIS) - Asymptomatic on screening - Epithelial lining of breast ducts thickens as cells proliferate, often with central necrosis - Microcalcification on mammography, unifocal lesion in one area of breast
100
BREAST CANCER | What are the 2 most common histological types of invasive breast cancer?
- Invasive ductal carcinoma (70%) = invaded basement membrane, grows as little hard nots in breast - Lobular carcinoma (10%) = harder to feel, less likely to be visible on mammography, more diffuse so difficult to excise
101
BREAST CANCER | What are some other types of breast cancer?
- Inflammatory breast cancer (presents like mastitis, no Abx response) - Medullary cancers (younger) - Colloid/mucoid cancers (elderly) - Breast sarcomas, phyllodes tumour + lymphoma rare
102
BREAST CANCER | What is Paget's disease of the nipple?
- Eczematous change of nipple due to underlying malignancy (invasive or in-situ) - Suspect if nipple eczema unresolved with 2w of steroid or anti-fungal cream
103
BREAST CANCER What causes Paget's disease of the nipple? What is the management?
- Infiltration of tumours cells through the ducts onto nipple surface where they infiltrate the epidermis - Needs biopsy, excision via mastectomy or central (nipple excising) wide local excision
104
BREAST CANCER | What is the epidemiology of breast cancer?
- 1 in 8 women will develop breast cancer in their lifetime | - Most common cancer in women + second most common cause of death
105
BREAST CANCER | What are some modifiable risk factors of breast cancer?
- Weight - Exercise - Smoking - Alcohol
106
BREAST CANCER | What are some non-modifiable risk factors of breast cancer?
- Female (99%) - Breast density - Age of menarche + menopause - BRCA1/2 status + FHx - Increasing age - Nulliparous - Not breastfeeding - HRT use >5y
107
BREAST CANCER | What are some protective factors of breast cancer?
- Breastfeeding - Multiparity - Late menarche + early menopause
108
BREAST CANCER | What are the 2 main genes involved in breast cancer and how do they act?
- BRCA1 = mutation of C17, 60-80% lifetime risk, stronger incidence - BRCA2 = mutation of C13, 45% lifetime risk - Tumour suppression genes that act as inhibitors of cellular growth
109
BREAST CANCER | What are some other genetic mutations associated with breast cancer?
- TP53 (Li Fraumeni) | - Peutz-Jeghers
110
BREAST CANCER | What is the classic clinical presentation of breast cancer?
- Normal appearing breast with palpable painless lump - Pain + tenderness uncommon - Visually = nipple inversion, bloody nipple discharge
111
BREAST CANCER | What are some clinical signs of breast cancer?
- Hard, irregular, painless, fixed lesions tethered to skin or chest wall - Indrawn nipple, peau d'orange (skin tethering), oedema or erythema - Palpable axillary nodes (axillary > supraclavicular > infraclavicular > neck)
112
BREAST CANCER What warrants an urgent 2ww cancer referral? What happens under the 2ww referal?
- ≥30 with unexplained breast lump ± pain - ≥50 with discharge, retraction or other change of concern - Triple assessment
113
BREAST CANCER What is the triple assessment? What happens at end?
- Clinical assessment (Hx + Examination) - Imaging (<35 USS as dense tissue, >35 USS + mammography) - Biopsy (histology + cytology) with core needle biopsy (or fine needle aspiration) - Each scored /5 (1=ok, 5=malignant), aim for score concordance (repeat test if one really high) - Pt discussed + reviewed in breast MDT
114
BREAST CANCER | What imaging choices are there for investigating breast cancer and what would influence your choice?
- Mammography, high resolution USS (good at Dx + targeting biopsy) - MRI (good assessment of implants, dense breasts or high-risk screening)
115
BREAST CANCER | If someone has breast cancer, what would you like to check now?
- Oestrogen receptor (ER) - Human epidermal growth factor 2 (HER2) - Progesterone - Ki67 status - Nottingham Prognostic index = grade, size + nodal status to predict survival
116
BREAST CANCER | What staging is used in breast cancer?
- CT CAP for TNM staging - T1 = confined to breast, mobile - T2 = confined to breast + LN in ipsilateral axilla - T3 = fixed to muscle, locally advanced disease - T4 = fixed to chest wall, metastatic
117
BREAST CANCER | What tumour marker can be used to monitor response to breast cancer treatment and disease recurrence?
- CA 15-3
118
BREAST CANCER What is the NHS breast screening programme? What is the process?
- Women 50–70 invited triennially for dual-view mammography - Breast pressed between 2 plates to flatten + improve resolution - Cranio-caudal (CC) + medio-lateral oblique (MLO) views - Graded 1 (normal) to 5 (likely malignant)
119
BREAST CANCER | What are the pros and cons of breast cancer screening?
- Earlier detection, reduces morbidity + mortality, detects asymptomatic cancers before present, not overly invasive - ?Overdiagnosis (frail women Dx with small low-grade cancers), anxiety if recalled, low dose XR > small amount of malignancies
120
BREAST CANCER | What are some reasons that a woman may be recalled for further views, USS or biopsy?
- Mass (well or poorly defined, rough edges, spiculated = carcinoma) - Microcalcification (associated with DCIS) - Parenchymal deformity - Asymmetrical density - Clinical or technical recall
121
BREAST CANCER | What is the high risk screening for breast cancer?
BRCA1/2 screening – - 30–40 annual MRI - 40–50 annual MRI + mammograms - 50–60 annual mammogram (+ MRI if dense breasts) - 60–70 triennial mammograms (+ MRI if dense breasts)
122
BREAST CANCER | What is the management of BRCA1/2 women?
- Genetic pedigree to identify at risk - Additional screening, lifestyle advice - ?Prophylactic tamoxifen or aromatase inhibitors - ?Risk reducing salpingo-oopherectomy or mastectomy
123
BREAST CANCER | What are some complications of breast cancer?
- Locally advanced (rare), try shrink with radio, chemo, or hormone therapy to try operate, salvage surgery + stage for mets - Metastatic breast cancer (2Ls 2Bs) = Lungs, Liver, Bones, Brain
124
BREAST CANCER How may metastatic breast cancer present? What is the management?
- Bony pain or # | - Bisphosphonates + denosumab, radio/chemo + Sx control
125
BREAST CANCER What is breast conservation treatment? What are the indications? What factors affect the outcome?
- Lumpectomy or wide local excision where remaining breast tissue gets localised radiotherapy - Small tumour relative to breast (<25%), DCIS, no previous radiotherapy, not underneath nipple, pt choice - Tumour size relative to breast, position of tumour in breast (lateral more favourable), radiotherapy fibrosis
126
BREAST CANCER What is mastectomy? What are the indications?
- Uni or bilateral removal of breast - Large tumour relative to breast size, >1 cancer in same breast, tumour under nipple, immediate or delayed reconstruction, pt choice
127
BREAST CANCER What is full axillary clearance? What are the indications + benefits? What are the risks?
- Removal of all glands - Glands clinically involved, good control, no need for further surgery or axillary radiotherapy - 10% lymphoedema, high complication rate (seromas, arm stiffness, drains, axillary numbness), extends surgical time
128
BREAST CANCER What is limited axillary surgery? What are the benefits?
- Clinically normal glands but removal of targeted 'hot' node by sentinel LN biopsy or blindly removes 4–6 nodes - Day surgery, no significant complications, no drains, no effect on mortality but may need full clearance if +ve
129
BREAST CANCER | What adjuvant endocrine therapy may be given to women?
- All ER+ve women need endocrine therapy as increases survival - Bisphosphonates to reduce rate of bone mets in ER+ve - Trastuzumab (Herceptin) used in HER2+ve + chemo
130
BREAST CANCER What endocrine therapy is given if... i) pre-menopausal? ii) post-menopausal?
i) Tamoxifen – inhibits oestrogen receptor on breast cancer cells ii) Anastrozole (aromatase inhibitors) – inhibits aromatase which converts androgens > oestrogen
131
BREAST CANCER What are the important side effects of... i) tamoxifen? ii) anastrozole?
i) Menopausal Sx, rarely VTE + endometrial cancer as acts on oestrogen receptors there ii) Hot flushes, reduced bone density, joint pains but no rare SEs like tamoxifen
132
BREAST CANCER | What other adjuvant treatment may be offered?
- Radiotherapy = always after WLE, sometimes after mastectomy if high risk (cons = skin viability risk, fibrosis, fat necrosis, loss of elasticity) - Chemotherapy = high/risk or aggressive disease (HER2+ve, ER-ve, node+ve)
133
BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of primary reconstruction?
- Increased skin preservation options, reduced psychological trauma - May delay chemo/radiotherapy if complications, radiotherapy may ruin results (fibrosis)
134
BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of delayed reconstruction?
- Minimal risks of delay in adjuvant therapies, healthy tissue used to recreate breast - Limited skin preservation options, psychological impact (no breast)
135
BREAST CANCER | What are some options for breast mound recreation?
- Implant based (implant alone or implant augmented latissimus dorsi) - Autologous (own tissues) such as TRAM flap, lat dorsi - Lat dorsi uses muscle ± skin ± fat but C/I if chronic back pain or physical hobby
136
BREAST CANCER | What are some risks with breast mound recreation?
- Capsule formation - Shape changes with age, gravity - Rupture - Infection
137
BENIGN BREAST DISEASE | What are 3 main causes of benign breast lumps?
- Nodularity - Fibroadenoma - Breast cyst
138
BENIGN BREAST DISEASE What is nodularity? What is the management?
- Normal variation, some ladies have lumpy breasts, often cyclical (more prominent pre-menstrual) - Re-examine after period as nodularity should lessen or disappear
139
``` BENIGN BREAST DISEASE What is a fibroadenoma? What are some features? Rule with fibroadenomas? How does it present? Management? ```
- Benign tumours of stromal/epithelial breast duct tissue - Most common benign lump in <35, most <3cm diameter - 1/3 shrink, 1/3 same, 1/3 enlarge - Very mobile on exam, reassurance + only remove if large
140
BENIGN BREAST DISEASE What are breast cysts? What are features of a benign cyst? How is it managed?
- Abnormal response of part of the breast to hormonal stimulation, commonly seen in 40–60y - Fluid not blood stained, no residual lump, same cyst does not continually refill - Dx confirmed on aspiration
141
BENIGN BREAST DISEASE | What are some causes of nipple discharge?
- Duct ectasia - Duct papilloma - Galactorrhoea - Infection
142
BENIGN BREAST DISEASE | What are some features of surgically significant nipple discharge?
- Persistent - Unilateral + unifocal - Spontaneous - Bloody or clear
143
BENIGN BREAST DISEASE | What are some differentials of bloody nipple discharge?
- Duct papilloma - Duct ectasia - Occasionally invasive/in-situ Ca
144
BENIGN BREAST DISEASE What is duct ectasia? How does it present? What is the management?
- Ducts become dilated + fill with debris, prone to secondary infections - Yellow, green, thick + occasionally bloody nipple discharge - Expectant management
145
BENIGN BREAST DISEASE What is duct papilloma? How does it present?
- Benign warty growth behind nipple | - Bloody or clear discharge
146
BENIGN BREAST DISEASE What is galactorrhoea? How does breast infection nipple discharge present?
- Milky (physiological or iatrogenic) | - Purulent
147
BENIGN BREAST DISEASE | What are the 2 types of breast infection (mastitis)?
- Lactational (usually peripheral in breast) | - Non-lactational (associated with duct ectasia + so central)
148
BENIGN BREAST DISEASE | What is the management of lactational mastitis?
- Continue breastfeeding - Rx if systemically unwell with flucloxacillin or erythromycin if allergic - May develop abscess (lump + erythema) so need drainage
149
BENIGN BREAST DISEASE | What is the management of non-lactational mastitis?
- Same as lactational mastitis (flucloxacillin or erythromycin) but + metronidazole
150
BENIGN BREAST DISEASE What is the most common cause of mastitis? What is there a caution with?
- S. Aureus then anaerobes (esp. non-lactational) | - Repeated incision in non-lactational abscess as can develop mammary fistula which is difficult to treat
151
BENIGN BREAST DISEASE What is mastalgia? What are the two types?
- Breast pain - Cyclical = worse prior to and better after period - Non-cyclical (responds well to NSAIDs)
152
BENIGN BREAST DISEASE | What is the management of cyclical mastalgia?
- Supportive bra, reassurance, PO/topical analgesia - Danazol (weak androgen) but SEs = breast shrinkage, acne, weight gain - Tamoxifen (risk of endometrial cancer) - Goserelin
153
BENIGN BREAST DISEASE What is gynaecomastia? What is a differential?
- >2cm lump of breast tissue behind male nipple | - Pseudo-gynaecomastia (deposition of fat in overweight men)
154
BENIGN BREAST DISEASE | What are the two broad causes of gynaecomastia?
- Physiological = oestrogen + testosterone imbalance (puberty) - Pathological
155
BENIGN BREAST DISEASE | What are some pathological causes of gynaecomastia?
- Drugs (spironolactone, oestrogen, anabolic steroids) - Marijuana - Liver failure - Testicular failure or tumour (Can produce beta-hCG)
156
BENIGN BREAST DISEASE | What is the management of gynaecomastia?
- Older men >50 exclude breast cancer by biopsy - Remove or reverse cause/drug - Reassure teenagers
157
BENIGN BREAST DISEASE | When investigating breast disease, what are features of a benign disease?
- Breast exam = soft + mobile mass | - Mammography = rounded mass, smooth edged, well-defined margins, low score
158
CERVICAL CANCER What is cervical cancer? What is the histological type of cervical cancer?
- Most common cancer in women <35 | - Squamous cell carcinoma 80%, then adenocarcinoma (small cell rare)
159
CERVICAL CANCER | What has a strong association with development of cervical cancer?
- Human papillomavirus (HPV) types 16 + 18 primarily a STI | - Also associated with anal, vulval, vaginal, penis, mouth + throat cancers
160
CERVICAL CANCER | What genes may be implicated in cervical cancer?
- P53 + pRb are tumour suppressor genes - HPV produces two oncoproteins (E6 + E7) - E6 inhibits P53, E7 inhibits pRB
161
CERVICAL CANCER | What are some risk factors for cervical cancer?
- Increased risk of catching HPV = early (unsafe) sex, lots of sexual partners - Smoking (limits availability to clear HPV) - HIV - COCP - High parity - Previous CIN/abnormal smear or FHx
162
CERVICAL CANCER | How does cervical cancer present?
- Asymptomatic + smear detected - Abnormal PV bleeding (POSTCOITAL, intermenstrual or postmenopausal) - PV discharge, pelvic pain, dyspareunia
163
CERVICAL CANCER | How would advanced cervical cancer present?
- Menorrhagia - Ureteric obstruction - Weight loss - Bowel disturbance - Vesico-vaginal fistula
164
CERVICAL CANCER | What are some initial investigations for cervical cancer?
- Speculum + swabs to exclude infection - Abnormal cervix (ulcerated, inflamed, bleeding, visible tumour) = urgent referral for colposcopy - Bimanual = rough + hard cervix
165
CERVICAL CANCER | How would you confirm a diagnosis of cervical cancer?
Colposcopy – - Acetic acid causes abnormal cells to appear white "acetowhite" - Schiller's iodine test = healthy cells stain brown, abnormal do not stain - Punch biopsy or large loop excision of transformation zone (LLETZ) for histology
166
CERVICAL CANCER | How is cervical cancer staged?
FIGO staging – - 1 = confined to cervix - 2 = invades uterus or upper 2/3 vagina - 3 = invades pelvic wall (e.g. ureter) or lower 1/3 vagina - 4 = invades beyond pelvis
167
CERVICAL CANCER | What is the cervical cancer screening?
- Sexually active women 25–64 (triennially 25–50, 5y 50–64) smear test - Exceptions = HIV pts screened annually, women with previous CIN may require additional tests
168
CERVICAL CANCER | What is the process of cervical smears?
- Smear test where cells collected from cervix + placed in preservation fluid for microscopy - Aims to identify precancerous changes (dyskaryosis) in epithelial cells of cervix for early treatment - Samples initially tested for high-risk HPV before examined
169
CERVICAL CANCER What is dyskaryosis? What results would warrant investigating?
- Abnormal nucleus in cell - Borderline/mild = test sample for HPV (-ve = routine recall, +ve = normal 6w colposcopy referral) - Moderate = consistent with CIN II (urgent 2w colposcopy) - Severe = consistent with CIN III (urgent 2w colposcopy)
170
CERVICAL CANCER | How do you manage smear results?
- Repeat inadequate smears within 3m or after 2 consecutive refer for colposcopy - HPV +ve but normal cytology = 12m, if +ve, 12m, if +ve at 24m > colposcopy (if HPV -ve then normal recall)
171
CERVICAL CANCER | What is used to grade the level of dysplasia, or premalignant change, in the cells of the cervix after colposcopy?
- Cervical intra-epithelial neoplasia (CIN) - CIN I = mild, affects 1/3 thickness of epithelial layer, likely to return to normal without Tx - CIN II = mod, affects 2/3 thickness of epithelial layer, likely to progress to cancer without Tx - CIN III or cervical carcinoma in situ = severe, v likely to progress to cancer without Tx
172
CERVICAL CANCER | After treatment for CIN, when do patients have screening?
- Screening at 6m for test of cure
173
CERVICAL CANCER | What is the prophylaxis for cervical cancer?
- Children 12–13 HPV vaccine (6+11 genital warts, 16+18 cervical cancer) - Cervical screening
174
CERVICAL CANCER What is the management of... i) CIN or early stage 1A cervical cancer? ii) Stage 1B-2A iii) Stage 2B-4A iv) Stage 4B
i) LLETZ or cone biopsy with -ve margins (maintain fertility) ii) Radical hysterectomy + removal of pelvic LN with chemo (cisplatin) + radiotherapy iii) Chemo + radiotherapy iv) Combination of surgery, chemo/radio + palliative care
175
CERVICAL CANCER | What is the difference between LLETZ and cone biopsy?
- LLETZ = LA during colposcopy, loop of wire with electrical current to cauterise tissue - Cone = GA where cone-shaped piece of cervix removed with scalpel
176
CERVICAL CANCER | What are the side effects of LLETZ and cone biopsy?
- Bleeding + abnormal discharge weeks after, intercourse + tampon avoided as infection risk, may increase preterm labour - Pain, bleeding, infection, increased risk of premature labour + miscarriage
177
CERVICAL ECTROPION What is cervical ectropion? What is it associated with?
- Columnar epithelium of endocervix extends out to ectocervix - Endocervix cells more fragile so prone to trauma + to bleed (post-coital) - High oestrogen > young women, COCP, pregnancy
178
CERVICAL ECTROPION | How does cervical ectropion present?
- Increased vaginal discharge | - Abnormal PV bleeding (IMB + PCB)
179
CERVICAL ECTROPION | How does cervical ectropion present on speculum?
- Well-demarcated border between redder, velvety columnar epithelium extended from os + pale pink squamous epithelium of ectocervix - 'Red ring' around cervical os (transformation zone)
180
CERVICAL ECTROPION | What is the management of cervical ectropion?
- Problematic bleeding = cauterisation (silver nitrate or cold coagulation during colposcopy)
181
OVARIAN CANCER What is ovarian cancer? When do patients present?
- Cancer of ovaries, usually presents late as non-specific Sx > worse prognosis - ≥70% present after spread beyond pelvis (most commonly para-aortic LN + liver)
182
OVARIAN CANCER | What are the 4 causes of ovarian cancer?
- Epithelial cell tumours (85–90%) - Germ cell tumours (common in women <35) - Sex cord-stromal tumours (rare) - Metastatic tumours
183
OVARIAN CANCER | What are some types of epithelial cell tumours?
- Serous carcinoma (#1) | - Endometrioid, clear cell, mucinous + undifferentiated tumours too
184
OVARIAN CANCER | What are germ cell tumours?
- Often benign teratomas containing various tissue types like skin, teeth, hair - Rokitansky's protuberance
185
OVARIAN CANCER | What are sex-cord stromal tumours?
- Arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles) - Sertoli-Leydig + granulosa cell tumours
186
OVARIAN CANCER | What are metastatic tumours?
- Secondary tumours | - Krukenberg = metastasis in ovary, usually from GI (stomach) > CLASSIC "SIGNET-RING" CELLS ON HISTOLOGY
187
OVARIAN CANCER | What are some risk factors of ovarian cancer?
``` Unopposed oestrogen + increased # of ovulations – - Early menarche - Late menopause - Increased age - Endometriosis - Obesity + smoking Genetics (BRCA1/2, HNPCC/lynch syndrome) ```
188
OVARIAN CANCER | Hence, what are some protective factors of ovarian cancer?
- COCP - Early menopause - Breast feeding - Childbearing
189
OVARIAN CANCER | How does ovarian cancer present?
- Abdo pain, discomfort + bloating (IBS like) - Early satiety or loss of appetite - Urinary Sx as pressure on bladder (freq, urgency) - Change in bowel habit (obstruction later) - Abdo or pelvic mass, ascites - Germ cell = rapidly enlarging abdo mass (often causes rupture or torsion)
190
OVARIAN CANCER | What warrants a 2ww gynae oncology referral?
- Ascites - Abdo or pelvic mass (unless clearly fibroids) - ≥250 risk of malignancy index score
191
OVARIAN CANCER | How is the risk of malignancy index calculated?
- Menopausal status = 1 (pre) or 3 (post) - Pelvic USS findings = 1 (1 feature) or 3 (>1 feature) - CA-125 levels IU/mL as marker for epithelial cell ovarian cancer
192
OVARIAN CANCER | What are concerning pelvic USS findings?
- Ascites - Metastases - Bilateral lesions - Solid areas - Multi-locular cysts
193
OVARIAN CANCER | What can cause falsely elevated CA-125 levels?
- Endometriosis - Fibroids + adenomyosis - Pelvic infection - Pregnancy - Benign cysts
194
OVARIAN CANCER | What other investigations should be performed in ovarian cancer?
- CT CAP for Dx + staging - Biopsy for histology - Paracentesis if ascites to test ascitic fluid for cancer cells
195
OVARIAN CANCER | What staging is used in ovarian cancer?
FIGO staging – - 1 = confined to ovary - 2 = past ovary but contained to pelvis - 3 = past pelvis but inside abdomen (can be microscopically in lining of abdomen) - 4 = spread to other organs
196
OVARIAN CANCER | What is the management of ovarian cancer?
- Abdominal hysterectomy + bilateral salpingo-oopherectomy | - May need bowel resections + chemo
197
OVARIAN CYST | What is a cyst?
- Fluid-filled sac
198
OVARIAN CYST | What are the 4 types of ovarian cysts?
- Functional (physiological) - Benign epithelial neoplasms - Benign germ cell neoplasms - Benign sex-cord stromal neoplasms
199
OVARIAN CYST What are functional cysts? Who are they seen in? How do they present
- Cysts relating to fluctuating hormones in the menstrual cycle - Pre-menopause, COCP is protective (inhibits ovulation) - Simple cysts = 2-3cm (can be up to 10cm), clear serous liquid, smooth internal lining, thin walls
200
OVARIAN CYST | What are the three types of functional cysts?
- Follicular (most common) - Corpus luteum - Theca lutein
201
OVARIAN CYST What are follicular cysts? How is it managed?
- Non-rupture of dominant follicle or failure of atresia > growth - Commonly regress after several cycles
202
OVARIAN CYST What are corpus luteum cysts? When are they seen?
- Corpus luteum fails to breakdown, may fill with fluid or blood - May burst causing intraperitoneal bleeding - Early pregnancy
203
OVARIAN CYST What are theca lutein cysts? Association?
- Stimulates growth of follicular theca cells so usually bilateral as resting follicles on both sides - Overstimulation of hCG (multiple + molar pregnancy as hCG v high)
204
OVARIAN CYST | What are some features of neoplastic cysts?
- Often complex - >10cm - Irregular borders - Internal septations appearing multi-locular - Heterogenous fluid
205
OVARIAN CYST | What are the 2 benign epithelial neoplasms?
- Serous cystadenoma (most common epithelial tumour) | - Mucinous cystadenoma
206
OVARIAN CYST | How does serous cystadenoma present?
- May be bilateral, filled with watery fluid, 30–50y
207
OVARIAN CYST | How does mucinous cystadenoma present?
- Often very large + contain mucus-like fluid - Pseudomyxoma peritonei where abdo cavity fills with gelatinous mucin secretions if rupture - 30–40y
208
OVARIAN CYST | What are benign germ cell neoplasms?
- Dermoid cysts or teratomas - Common in women <35 - May contain various tissue types (skin, teeth, hair + bone) - Can be bilateral, associated with ovarian torsion as heavy
209
OVARIAN CYST | What is an example of sex cord-stromal neoplasms?
- Fibromas (small, solid benign fibrous tissue tumour) | - Associated with Meig's syndrome
210
OVARIAN CYST | What are some risk factors of ovarian cysts?
- Obesity, tamoxifen, early menarche, infertility - Dermoid cysts = most common in young women, can run in families - Epithelial cysts = most common in post-menopausal (?malignant)
211
OVARIAN CYST | What is the clinical presentation of ovarian cyst?
- Unilateral dull pelvic ache + may have dyspareunia - Pressure effects (frequent urination or bowel movements) - Abdo swelling or mass (ascites suggests malignancy, ruptured mucinous cystadenoma or Meig's syndrome)
212
OVARIAN CYST What is Meig's syndrome? Who is it commonly seen in? What is the management?
- Triad of fibroma, pleural effusion + ascites - Older women - Removal of fibroma = complete solution
213
OVARIAN CYST | What clinical presentation would suggest ovarian cyst rupture?
- Acute, sharp abdo/pelvic pain - PV bleed, N+V (esp. torsion) - Shoulder tip pain if referred diaphragmatic pain - If peritonitis + shock occurs (fever, syncope, low BP, high HR)
214
OVARIAN CYST | What investigations should be done for ovarian cysts?
- Beta-hCG to exclude uterine or ectopic - FBC for infection or haemorrhage - CA-125 if >40 - Germ cell tumour markers if <40 with complex ovarian mass - Imaging (TVS or MRI abdo if larger mass) - Diagnostic laparoscopy (gold standard in ruptured cyst) - May need USS guided aspiration + cytology to confirm benign
215
OVARIAN CYST | What are the germ cell tumour markers?
- Lactate dehydrogenase - Alpha-fetoprotein - Human chorionic gonadotropin
216
OVARIAN CYST | What are some complications of ovarian cysts?
- Torsion leading to ovarian ischaemia = pain may be intermittent if untwists or stop if necrotic - Haemorrhage into cyst = sudden increase in size + pain (follicular + corpus luteal cysts) - Rupture of contents into peritoneum = peritonitis (associated with sex)
217
OVARIAN CYST | What is the management of a ruptured ovarian cyst?
- ABCDE approach + admission - Stable = analgesia, fluids - Unstable or bleeding = surgery (?laparotomy)
218
OVARIAN CYST | What is the management of simple cysts in pre-menopausal women?
- Small <5cm = likely to resolve within 3 cycles, no follow up - Mod 5–7cm = routine gynae referral + yearly USS - Large >7cm = ?MRI + surgical evaluation
219
OVARIAN CYST | What is the management of post-menopausal women presenting with an ovarian cyst?
- Risk of malignancy index calculation - Simple cysts <5cm + normal CA-125 = monitor with 4–6m USS - Complex cyst or raised CA-125 = 2ww gynae oncology referral
220
OVARIAN CYST What is the surgical management of ovarian cysts? What are the indications? What are the cautions?
- Laparoscopic ovarian cystectomy ± oophorectomy - Persistent or enlarging cysts, Sx, ovarian torsion or Sx of rupture - Caution of chemical peritonitis with dermoid cysts if contents spill
221
OVARIAN TORSION | What is ovarian torsion?
- Ovary twists in relation to surrounding connective tissue, fallopian tube + blood supply (adnexa) leading to ischaemia ± necrosis if persists
222
OVARIAN TORSION | What are some risk factors of ovarian torsion?
- Pregnancy - Ovarian tumours/cysts - Previous surgery - Reproductive age
223
OVARIAN TORSION | What is the clinical presentation of ovarian torsion?
- Sudden onset, severe unilateral iliac fossa pain - Colicky if twists/untwists - May occur during exercise - N+V - Fever + pain stopping may indicate necrotic ovary
224
OVARIAN TORSION | What are the investigations for ovarian torsion?
- Localised tenderness ± palpable mass in pelvis - Beta-hCG to exclude ectopic - USS with colour doppler
225
OVARIAN TORSION | What might USS show in ovarian torsion?
- Free fluid in pelvis + oedema of ovary - "Whirlpool sign" = wrapping of vessels around central axis - Doppler studies may show lack of blood flow
226
OVARIAN TORSION | What are some complications of ovarian torsion?
- Delay in treatment may lead to loss of function > infertility or menopause if other ovary non-functional - Necrotic ovary may become infected > abscess > sepsis (or rupture causing peritonitis + adhesions)
227
OVARIAN TORSION | What is the management of ovarian torsion?
- Laparoscopy for definitive diagnosis + treatment - Untwist ovary + fix into place (detorsion) - Oophorectomy based on visual appearance (necrotic) - Analgesia + fluid resus
228
ENDOMETRIAL CANCER What is endometrial cancer? What is the prognosis?
- Cancer of endometrium (lining of uterus) = oestrogen dependent - 90% women are >50, good prognosis, 5-year survival in stage 1 = 80%
229
ENDOMETRIAL CANCER What is the most common histological type of endometrial cancer? What are some others?
- Adenocarcinoma (80%) | - Adenosquamous, squamous, papillary serous, clear cell + uterine sarcoma
230
ENDOMETRIAL CANCER | What are some risk factors for endometrial cancer?
Unopposed oestrogen – - Obesity (adipose tissue contains aromatase) - Nulliparous - Early menarche - Late menopause - Oestrogen-only HRT - Tamoxifen - PCOS - Increased age - T2DM - HNPCC (Lynch syndrome)
231
ENDOMETRIAL CANCER | What are some protective factors for endometrial cancer?
- COCP - Mirena coil - Multiparity - Cigarette smoking (Seem to have anti-oestrogenic effect)
232
ENDOMETRIAL CANCER | What is the clinical presentation of endometrial cancer?
- PMB is endometrial cancer until proven otherwise - May have abnormal bleeding (PCB, IMB, menorrhagia) - Abnormal PV discharge + pain less commonly
233
ENDOMETRIAL CANCER | What is the first line investigation for endometrial cancer?
- TVS = endometrial thickness should be <4mm | - Recommended for >55 w/ unexplained PV discharge + visible haematuria
234
ENDOMETRIAL CANCER | What other investigations is recommended in endometrial cancer?
- Pipelle biopsy via speculum (highly sensitive so useful for exclusion in low risk) - Hysteroscopy with endometrial biopsy - 2WW urgent gynae oncology referral if PMB in ≥55y
235
ENDOMETRIAL CANCER | What is the staging for endometrial cancer?
FIGO staging – - 1 = confined to endometrium + uterus - 2 = tumour invaded cervix - 3 = cancer spread to ovary, vagina, fallopian tubes or LN - 4 = cancer invades bladder, rectum or beyond pelvis
236
ENDOMETRIAL CANCER | What is the management of stage 1 + 2 endometrial cancer?
- Total abdominal hysterectomy with bilateral salpingo-oopherectomy + pelvic LN
237
ENDOMETRIAL CANCER | What other treatments are there for endometrial cancer?
- Surgery = radical hysterectomy ± pelvic LN - Radiotherapy = adjuvant (brachytherapy/external beam) - Chemo, progesterone therapy to slow progression of cancer
238
ENDOMETRIAL POLYP What is an endometrial polyp? What is the main differential?
- Benign growths of endometrium, some may be (pre)cancerous | - Fibroids
239
ENDOMETRIAL POLYP | What are some risk factors of endometrial polyps?
- Being peri or post-menopausal - HTN - Obesity - Tamoxifen
240
ENDOMETRIAL POLYP | What is the clinical presentation of endometrial polyps?
- Irregular menstrual bleeding (IMB, PMB), menorrhagia | - Infertility in younger as competing with foetus for space
241
ENDOMETRIAL POLYP | What are the investigations for endometrial polyps?
- TVS/TAS | - Hysteroscopy ± endometrial biopsy
242
ENDOMETRIAL POLYP | What is the management of endometrial polyps?
- Conservative but monitor or biopsy if concerns - GnRH analogues as oestrogen sensitive - If post-menopause or pre but symptomatic = hysteroscopic resection or morcellation of polyps - Hysterectomy if severe
243
VULVAL CANCER What is vulval cancer? What is the most common histological type?
- Rare compared to other cancers | - Squamous cell carcinomas (90%), malignant melanoma less common
244
VULVAL CANCER | What are some risk factors for vulval cancer?
- Vulval intraepithelial neoplasia (VIN) due to HPV in younger women - Lichen sclerosus in older women
245
VULVAL CANCER | What is the clinical presentation of vulval cancer?
- Vulval itching, soreness + persistent lump on labia majora - Ulceration, bleeding, pain (sometimes on urination) - May be lymphadenopathy in groin
246
VULVAL CANCER | What are the investigations for vulval cancer?
- Suspected = 2ww urgent gynae oncology referral | - Biopsy lesion with sentinel node biopsy to see if LN spread
247
VULVAL CANCER | How is vulval cancer staged?
FIGO staging – - 1 = <2cm - 2 = >2cm - 3 = adjuvant organs or unilateral nodes - 4 = distant mets or bilateral nodes
248
VULVAL CANCER | What is vulval intraepithelial neoplasia (VIN)?
- Premalignant condition affecting squamous epithelium that can precede vulval cancer
249
VULVAL CANCER | What are 2 types of VIN?
- High grade squamous intraepithelial lesion = type of VIN associated with HPV typically in younger women 35–50 - Differentiated VIN associated with lichen sclerosus
250
VULVAL CANCER | What is the management of VIN?
- Biopsy to Dx - Watch + wait with close follow up - Wide local excision to surgically remove lesion - Imiquimod cream or laser ablation
251
VULVAL CANCER | What is the management of vulval cancer?
- Radical or conservative surgery (WLE ± groin LN dissection) - Radio ± chemotherapy
252
``` VAGINAL CANCER What is the most common histological type of vaginal cancer? What causes it? What is the prognosis like? How does it present? What is the management? ```
- 90% squamous - HPV or metastatic spread from cervix or vulva - Poor prognosis, average survival at 5 years 50% - Bleeding or discharge, evident mass or ulcer - Intravaginal radiotherapy or sometimes radical surgery
253
MENOPAUSE What is menopause? What is the average age of onset? When is it premature?
- Permanent cessation of menstruation where ovarian activity ceases to function, can occur after TAH-BSO - Average 51, premature <40
254
MENOPAUSE | What is perimenopause?
- Time around menopause where woman may have vasomotor Sx + irregular periods - Includes time leading up to LMP + 12m after
255
MENOPAUSE | What is the physiology of menopause?
- Starts with decline in development of ovarian follicles - Less oestrogen + progesterone production - Absence of -ve feedback loop so FSH + LH rises - Falling follicular development = anovulation so irregular menstrual cycles - Low oestrogen = endometrium does not develop so amenorrhoea + perimenopausal Sx
256
MENOPAUSE | What are the peri-menopausal symptoms?
- Vasomotor = hot flushes, night sweats, impact on QOL - General = mood swings, decreased libido, vaginal dryness, headache, dry skin, loss of energy, joint aches, muscles pains, irregular periods
257
MENOPAUSE | What are some medium-term presentations of menopause?
- Urogenital atrophy leading to dyspareunia, recurrent UTIs + PMB
258
MENOPAUSE Why does urogenital atrophy occur? What can it lead to?
- Urogenital tract has oestrogen receptors + continual stimulation keep it strong + supple - Urinary incontinence + pelvic organ prolapse
259
MENOPAUSE | What are the investigations for menopause?
- Retrospective diagnosis after 12m of amenorrhoea in women >45y - NICE recommends FSH (high) blood test in women <40 with suspected premature menopause or women 40–45 with menopausal Sx or change in menstrual cycle
260
MENOPAUSE | What are the long-term complications of menopause?
- Osteoporosis as oestrogen inhibits osteoclasts + can become hyperactive - CVD, stroke (esp. in early menopause) + dementia
261
MENOPAUSE When is contraception recommended in relation menopause? Why?
- 2y after LMP in <50, 1y after LMP in >50 | - Pregnancy >40 has increased risks + complications
262
MENOPAUSE What contraception is suitable in older women? How do hormonal contraceptives affect the menopause?
- UKMEC1 = barrier, IUS/IUD, POP, long-acting progesterone (<45), sterilisation - UKMEC2 = COCP after 40 used until 50, try ones with levonorgestrel or norethisterone as lower VTE risk - They don't but may mask Sx
263
MENOPAUSE | What is the initial management of menopause?
Lifestyle – - Vasomotor symptoms last 2-5y without intervention so ?no treatment - Regular exercise can improve hot flushes, mood + cognitive Sx - Good sleep hygiene can improve sleep disturbance
264
MENOPAUSE | What is the management of menopause in more severe cases?
- HRT first-line for vaso-motor Sx as most effective - Clonidine (alpha adrenergic receptor agonist) second line with low-dose antidepressants like venlafaxine (not C/I in breast cancer Tx) or fluoxetine - CBT - Vaginal oestrogen cream/tablets + moisturisers for dryness
265
MENOPAUSE | What is the mechanism of action of clonidine?
- Alpha-adrenergic receptor agonist
266
HRT What is Hormone Replacement Therapy (HRT)? How does this compare to the COCP?
- Treatment to alleviate Sx associated with menopause by giving physiological dose of oestrogen as replacement for what body is used to - COCP gives a supraphysiological dose of oestrogen
267
HRT | What are some indications for HRT?
- Replacing hormones in POI even without Sx - Reducing vasomotor + other Sx in menopause - Reduce osteoporosis risk in women <60
268
HRT | What are some benefits of HRT?
- Improved Sx control - Improved QOL - Reduced risk of osteoporosis
269
HRT | What are some risks with HRT?
- Increased risk of breast cancer by adding progesterone - Increased risk of endometrial cancer by oestrogen alone - Increased risk of VTE - Increased risk of stroke + IHD
270
HRT How can the HRT risks be managed for... i) breast cancer? ii) endometrial cancer? iii) VTE? iv) IHD?
i) Local (Mirena) instead of systemic progesterones, risk declines after 5y stopping ii) Add progesterone (esp Mirena) to prevent endometrial hyperplasia iii) Transdermal patch iv) Do not take for >10y after menopause
271
HRT | What are some contraindications to HRT?
- Undiagnosed PV bleeding - Current or past breast cancer - Any oestrogen sensitive cancer (endometrial)
272
HRT What HRT would you give to... i) woman without uterus? ii) woman with uterus? iii) woman with period within past 12m? iv) woman with period >12m ago?
i) Continuous oestrogen-only HRT ii) Add progesterone (combined HRT) iii) Cyclical combined HRT iv) Continuous combined HRT
273
HRT | What preparations of HRT are there?
- Pessary + cream (local Sx like bleeding, pain, UTI), transdermal patch, tablets - Tibolone is a synthetic steroid hormone that acts as continuous combined (only used >12m from LMP)
274
HRT When would patches be used for HRT? What is the most common side effect?
- Pt choice - GI upset (Crohn's) - VTE risk - Co-morbidities like HTN - Skin irritation #1
275
HRT | How can oestrogen be given?
- Tablets or transdermal (patches or gels)
276
HRT | When would you use cyclical progesterone compared to continuous?
- Perimenopausal women to allow monthly breakthrough bleed during oestrogen-only part of cycle (10–14d/month) - Continuous after amenorrhoeic for 2y <50 or 1y >50 as before this can cause irregular breakthrough bleeding - After 12m of treatment can switch to continuous
277
HRT | How can progesterone be given?
- Tablets, transdermal (patches) or IUS (Mirena)
278
HRT What would you give for... i) cyclical combined HRT? ii) continuous HRT?
i) Sequential tablets or patches | ii) Mirena licensed for 4 years for endometrial protection – also treats menorrhagia
279
HRT What are the side effects associated with... i) oestrogen? ii) progesterone?
i) Nausea, bloating, headaches, breast swelling or tenderness, leg cramps ii) Mood swings, fluid retention, weight gain, acne + greasy skin
280
ATROPHIC VAGINITIS | What is atrophic vaginitis?
- Dryness + atrophy of vaginal mucosa related to lack of oestrogen
281
ATROPHIC VAGINITIS | What is the pathophysiology of atrophic vaginitis?
- Epithelial lining of vagina + urinary tract responds to oestrogen by becoming thicker, more elastic + producing secretions so reduced oestrogen has opposite effect - Tissue more prone to inflammation + changes in vaginal pH + microbial flora that contribute to localised infections
282
ATROPHIC VAGINITIS | What are some risk factors for atrophic vaginitis?
- Menopause - Oophorectomy - Anti-oestrogen (tamoxifen, anastrozole)
283
ATROPHIC VAGINITIS | What is the clinical presentation of atrophic vaginitis?
- Postmenopausal with PV dryness, dyspareunia + occasional spotting - Consider with recurrent UTIs, stress incontinence or pelvic organ prolapse
284
ATROPHIC VAGINITIS | What might the PV examination show in atrophic vaginitis?
- Sparse pubic hair - Pale mucosa - Dryness - Thin skin - Reduced vaginal folds - May be painful
285
ATROPHIC VAGINITIS | What is the management of atrophic vaginitis?
- Vaginal lubricants + moisturisers like Sylk + Replens | - Topical oestrogen like estriol cream, HRT if severe
286
POI | What is premature ovarian insufficiency (POI)?
- Premature menopause before the age of 40
287
POI | What are some causes of POI?
- Majority idiopathic - Iatrogenic (chemo/radio, oophorectomy) - Autoimmune (coeliac, T1DM) - Genetic (FHx, Turner's) - Infections (mumps, TB, CMV)
288
POI | What is the clinical presentation of POI?
- Secondary amenorrhoea (or irregular) + typical peri-menopause Sx before age 40
289
POI | What are some investigations for POI?
- Clinically = menopausal Sx in woman <40y with 4m of amenorrhoea - FSH level = >25IU/L on 2 samples >4w apart - Hypergonadotrophism + hypoestrogenism
290
POI | What are the complications of POI?
- Higher risk of conditions due to lack of oestrogen > CVD, stroke, osteoporosis, dementia + cognitive impairment + Parkinsonism
291
POI | What is the management of POI?
- HRT imperative until at least average age of menopause to reduce risks - HRT or COCP can be used
292
POI | What is the difference between traditional HRT and COCP in POI?
- Traditional HRT associated with lower BP than COCP | - COCP may be more socially acceptable if younger + acts as contraceptive
293
POI | Are there the same risks of HRT in POI as in menopause?
- No increase in breast cancer risk as women normally produce these hormones at that age - Slight increased risk of VTE but reduced by transdermal patch
294
URINARY INCONTINENCE | What is urinary incontinence?
- Involuntary leakage of urine at socially unacceptable times - Affects 20% of adult women
295
URINARY INCONTINENCE | What is the physiology of micturition?
- Detrusor = smooth muscle, transitional epithelium normally only contracts during micturition = sacral parasympathetic innervation from S2-4 - M2+3 muscarinic receptors with ACh - Sympathetic nerve fibres from T11-L2 maintain relaxation of bladder for storage
296
URINARY INCONTINENCE | What are the 6 main types of incontinence?
- Overactive bladder/urge incontinence - Stress incontinence - Mixed incontinence (of the 2 above) - Overflow incontinence - Fistula - Neurological
297
URINARY INCONTINENCE | What causes urge incontinence/OAB?
- Overactivity + involuntary contractions of the detrusor muscle
298
URINARY INCONTINENCE What causes stress incontinence? What happens? What can cause it?
- Weakness of pelvic floor + sphincter muscles - Detrusor pressure > closing pressure of urethra - Low oestrogen in menopause > weakened pelvic support, parity, pelvic surgery
299
URINARY INCONTINENCE | What is overflow incontinence?
- Chronic urinary retention due to outflow obstruction leads to overflow of urine + incontinence without the urge to pass, M>F
300
URINARY INCONTINENCE | What are some causes of overflow incontinence?
- Anticholinergics - Fibroids - Pelvic tumours - BPH (men) - Neuro (damage, MS, diabetic neuropathy, spinal cord injuries)
301
URINARY INCONTINENCE How does i) fistula ii) neurology cause incontinence?
i) Between urinary tract + vagina or bowel | ii) Nerve damage, MS or functional
302
URINARY INCONTINENCE | What are some risk factors for urinary incontinence?
- Increasing age - Multiparity - High BMI - FHx - Previous pelvic surgery (hysterectomy)
303
URINARY INCONTINENCE | What is the clinical presentation of urge incontinence/OAB?
- Urgency, frequency, nocturia - 'Key in door' + 'handwash' trigger bladder contractions - Intercourse - May affect activities + QOL as worried about toilet access
304
URINARY INCONTINENCE | What is the clinical presentation of stress incontinence?
- Involuntary leakage when increased pressure (cough, laugh, lifting, exercise)
305
URINARY INCONTINENCE | What are some investigations in urinary incontinence?
- Hx most important - Bladder diary (frequency volume chart) first line - Urine dipstick + MSU - Residual urine measurement - Electronic Personal Assessment Questionnaire - Urodynamics - Cystogram with contrast
306
URINARY INCONTINENCE | What does a bladder diary look at?
- Frequency + quantity of both urination and leakage | - Fluid intake + diurnal variation
307
URINARY INCONTINENCE | What are you looking for in urine dipstick + MSU?
- Nitrites + leukocytes = infection - Microscopic haematuria = glomerulonephritis - Proteinuria = renal disease - Glycosuria = DM, nephropathy
308
URINARY INCONTINENCE | How do you measure residual urine?
- In/out catheter or USS
309
URINARY INCONTINENCE | What is the Electronic Personal Assessment Questionnaire (ePAQ)?
Determines impact on QOL + assesses – - Urinary (pain, voiding, stress, OAB, QOL) - Vaginal (pain, capacity, prolapse, QOL) - Bowel (IBS, constipation, continence, QOL) - Sexual (dyspareunia, overall sex life)
310
URINARY INCONTINENCE What is the purpose of i) urodynamics? ii) cystogram with contrast?
i) Measures pressure in abdomen + bladder to deduce detrusor pressure ii) Visualise the bladder
311
URINARY INCONTINENCE | What is some lifestyle advice for urinary incontinence?
- Weight loss - Stop smoking - Reduce caffeine + alcohol - Avoid straining + constipation
312
URINARY INCONTINENCE | What are some conservative treatments for urinary incontinence?
- Leakage barriers (pads), skin care + odour control - Bladder bypass with urethral, suprapubic or intermittent self-catheters - PV oestrogen to reduce urinary Sx
313
URINARY INCONTINENCE | What is the stepwise management of urge incontinence/OAB?
- 1st line = bladder retraining (6w gradually increasing time between voiding) - 1st line drugs = anti-muscarinics (oxybutynin, tolterodine, darifenacin) - Mirabegron (beta-3-adrenergic agonist) if anti-muscarinics not tolerated
314
URINARY INCONTINENCE What is the mechanism of action of anti-muscarinics? What are some side effects?
- Parasympathetic so Pissing = decreases need to urinate + spasms - "Can't see, spit, pee or shit" > caution in elderly as falls esp oxybutynin immediate release in frail
315
URINARY INCONTINENCE What is the mechanism of action of beta-3-adrenergic agonists? What is a caution of these?
- Sympathetic so Storage = relaxes detrusor + increases bladder capacity - C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
316
URINARY INCONTINENCE | What are last resort options for urge incontinence?
- Augmentation cystoplasty with bowel tissue - Bypass (urostomy) - Botox can paralyse detrusor + block ACh release
317
URINARY INCONTINENCE | What is the first line management of stress incontinence?
- Pelvic floor exercises with physio for 3m | - Pelvic floor muscle contraction > clamping of urethra > increased urethral pressure so reduced leakage
318
URINARY INCONTINENCE | What medical management can be used in urinary incontinence?
- Duloxetine (SNRI)
319
URINARY INCONTINENCE | What are the surgical interventions for stress incontinence?
- Colposuspension - Tension free vaginal tape (TVT) - Autologous sling procedures (TVT but strip of fascia from abdo wall)
320
URINARY INCONTINENCE | What are the aims of surgical interventions of stress incontinence?
- Restore pressure transmission to urethra - Support or elevate urethra (anterior wall + pubic symphysis stitches in colposuspension, mesh sling looping urethra in TVT) - Increase urethral resistance
321
PELVIC ORGAN PROLAPSE | What is pelvic organ prolapse?
- Descent of ≥1 pelvic organs resulting in protrusion on the vaginal walls - Due to weakness + stretching of ligaments + muscles surround uterus, rectum + bladder (levator ani + endopelvic fascia support pelvic organs)
322
PELVIC ORGAN PROLAPSE | What are the 5 types of prolapse?
- Cystocele - Rectocele - Enterocele - Uterine prolapse - Vault prolapse
323
PELVIC ORGAN PROLAPSE | What is a cystocele?
- Defect in ant. vaginal wall = bladder prolapses backwards into vagina (can get urethrocele or cystourethrocele)
324
PELVIC ORGAN PROLAPSE What is a rectocele? How may this present?
- Defect in post. vaginal wall = rectum prolapses forwards into vagina - Faecal loading in that part of rectum may lead to lump in vagina + have to use finger to press lump to aid defecation
325
PELVIC ORGAN PROLAPSE What is... i) enterocele? ii) uterine prolapse? iii) vault prolapse?
i) Defect in upper posterior wall of vagina > intestine protrusion ii) Uterus descends into vagina iii) If had total hysterectomy, top of vagina (vault) descends into the vagina
326
PELVIC ORGAN PROLAPSE | What are some risk factors of pelvic organ prolapse?
- Age - BMI - Multiparity (vaginal) - Spina bifida - Pelvic surgery - Menopause
327
PELVIC ORGAN PROLAPSE | What is the clinical presentation of pelvic organ prolapse?
- "Something coming down" = dragging/heavy sensation in pelvis - Pain, lump, discomfort - Urinary Sx (cystocele) = incontinence, urgency, frequency, poor stream + retention - Bowel Sx (rectocele) = constipation, incontinence + urgency - Sexual dysfunction = pain, altered sensation + reduced enjoyment
328
PELVIC ORGAN PROLAPSE | What are the investigations for pelvic organ prolapse?
- Sim's speculum (U-shaped) to show if something is there | - May have urodynamics, USS or MRI
329
PELVIC ORGAN PROLAPSE | What is the management for pelvic organ prolapse?
- Conservative = pelvic floor exercises, weight loss + diet changes - Vaginal pessary = ring (preferred as can have sex), shelf or Gellhorn - Surgery (symptomatic or severe like outside vagina, ulcerated, failed Mx)
330
PELVIC ORGAN PROLAPSE What surgical intervention is provided for... i) cystocele/cystourethrocele? ii) uterine prolapse? iii) rectocele?
i) Anterior colporrhaphy or colposuspension ii) Hysterectomy or sacrohysteropexy iii) Posterior colporrhaphy
331
PREMENSTRUAL SYNDROME | What is premenstrual syndrome (PMS)?
- Psychological, emotional + physical Sx that occur prior to menstruation
332
PREMENSTRUAL SYNDROME | What is thought to cause PMS?
- Fluctuation in oestrogen + progesterone during the cycle
333
PREMENSTRUAL SYNDROME | How may PMS present?
- Mood = anxiety, swings, stress, fatigue, low confidence - Physical = bloating, headaches, breast pain - Resolves on menstruation - Absent before menarche, during pregnancy or after menopause
334
PREMENSTRUAL SYNDROME | How is PMS diagnosed?
- Sx diary spanning 2 menstrual cycles | - Definitive Dx with GnRH to temporarily induce menopause = Sx resolve
335
PREMENSTRUAL SYNDROME | What is the conservative management of PMS?
- Healthy diet, exercise, alcohol + smoking cessation, stress reduction, good sleep patterns
336
PREMENSTRUAL SYNDROME | What management can be trialled in primary care for PMS?
- SSRIs - COCP - CBT
337
PREMENSTRUAL SYNDROME | What specialist management can be given for PMS?
- Continuous transdermal oestrogen with progestogens - GnRH analogues if severe (add HRT to mitigate osteoporosis risk) - Hysterectomy + bilateral oophorectomy to induce menopause if severe - Danazol + tamoxifen for cyclical breast pain - Spironolactone for breast swelling + bloating
338
DYSMENORRHOEA What is dysmenorrhoea? What are the two types?
- Painful menstruation ± N+V | - Primary + secondary
339
DYSMENORRHOEA What is... i) primary dysmenorrhoea? ii) secondary dysmenorrhoea?
i) No underlying pathology, may be due to excessive endometrial prostaglandins – presents as suprapubic cramps just before or within few hours of period starting ii) Secondary to endometriosis, adenomyosis, fibroids, PID, IUDs, cancer
340
DYSMENORRHOEA | What is the management of primary dysmenorrhoea?
- NSAIDs like mefenamic acid during menstruation | - COCP second line
341
FGM | What is female genital mutilation (FGM)?
- All procedures involving partial or total removal of female external genitalia or injury to female organs for non-medical reasons, often pre-pubertal
342
FGM | Is FGM illegal?
- Yes as stated in FGM Act 2003 – legal requirement for HCPs to report cases of FGM to the police - Illegal to assist in carrying out FGM (booking flights)
343
FGM | What is the epidemiology in FGM?
- Very common in Africa (Somalia, Egypt, Ethiopia, Sudan) | - UK hotspots = Sheff, London, Manc, Oxford
344
FGM | What is the WHO classification for the types of FGM?
- 1 = partial or total clitoridectomy - 2 = excision - 3 = infibulation - 4 = all other non-medical harmful procedures incl. pricking, piercing, incising
345
FGM What is... i) excision? ii) infibulation?
i) Partial or total removal of clitoris + labia minora ± excision of labia majora ii) Narrowing/closing of vaginal orifice with creation of a covering seal (stitch labia together)
346
FGM | Is female labia reduction illegal?
- <18 = FGM | - >18 = legal but only performed privately
347
FGM | What are some potential reasons for FGM?
Based on customs – - It will bring status + respect to family (social norm) - Rite of passage + being part of woman - Preserves girls' virginity so acceptable for marriage - Cleanses + purifies girl with perceived religious requirement
348
FGM | What are some acute complications of FGM?
- Pain - Bleeding - Infection (BBV) - Sepsis - Swelling - Urinary retention
349
FGM | What are some chronic complications of FGM?
- Dyspareunia - Dysmenorrhoea - Infertility + pregnancy issues - Keloid scar - Haematocolpos (period backs up in uterus as cannot be released) - PTSD
350
FGM | What is the initial management of suspected or confirmed FGM?
- Report ANY FGM in <18 to police + Record in notes (consider in >18 after risk assessment e.g. others at risk like unborn children) - Educate pts + relatives that FGM is illegal + health consequences - Services = social, safeguarding, paeds, counselling, FGM specialists
351
FGM | What is the overall management of FGM?
- De-infibulation by specialist in FGM in some type 3 to try restore function - Re-infibulation may be requested after childbirth but this is illegal
352
AIS | What is androgen insensitivity syndrome (AIS)?
- X-linked recessive condition (androgen receptor gene mutation) with end-organ resistance to testosterone causing male genotype 46XY but female phenotype
353
AIS | What is the pathophysiology of AIS?
- Absent response to testosterone + conversion of additional androgens to oestrogen result in female secondary sexual characteristics - Typical male sexual characteristics (Wollfian structures) do not develop
354
AIS | What is the clinical presentation of AIS?
- Infancy = inguinal hernias with undescended testes - Puberty = primary amenorrhoea + infertile - Tend to be taller than average, lack of pubic + facial hair as well as male muscle development - Female external genitalia (but not internal) + breasts
355
AIS | Why is their female external genitalia but not internal in AIS?
- Undescended testes in abdo or inguinal canal produce AMH which prevents uterus, upper vagina, tubes + ovaries developing (Mullerian duct structures)
356
AIS | What is the clinical presentation of partial AIS?
- More ambiguous - Micropenis - Clitoromegaly - Bifid scrotum - Hypospadias - Reduced male features
357
AIS | What are the investigations for AIS?
``` Hormone tests show raised – - LH - FSH (or normal) - Testosterone (or normal for male) - Oestrogen (for male) Pelvic USS = absent female internal organs Karyotyping = 46XY ```
358
AIS | What is the management of AIS?
- Specialist MDT (paeds, gynae, urology, endo, psychology) - Bilateral orchidectomy to avoid testicular cancer - Oestrogen therapy - Vaginal dilators or surgery to create adequate length - In general, raised as female but counselling for support
359
ASHERMAN'S SYNDROME | What is Asherman's syndrome?
- Adhesion formation within uterus following damage
360
ASHERMAN'S SYNDROME | What is the pathophysiology of Asherman's?
- Damage to basal layer of endometrium, damaged tissue may heal abnormally, creating scar tissue (adhesions) - Adhesions can bind uterine walls together or endocervix, sealing it shut causing obstruction > infertility, 2* amenorrhoea
361
ASHERMAN'S SYNDROME | What causes Asherman's syndrome?
- Pregnancy-related dilatation + curettage procedures - After uterine surgery - Pelvic infection like endometritis
362
ASHERMAN'S SYNDROME | What is the clinical presentation of Asherman's syndrome?
- Secondary amenorrhoea - Infertility - Significantly lighter periods - Dysmenorrhoea
363
ASHERMAN'S SYNDROME | What is the management of Asherman's syndrome?
- Hysterosalpingography = contrast injected into uterus + XR - Sonohysterography = uterus filled with fluid + pelvic USS - Hysteroscopy gold standard + can dissect adhesions (recurrence after common)
364
BARTHOLIN CYST What are the bartholin glands? What causes a bartholin cyst? What causes a bartholin abscess? Presentation?
- 2 glands behind labia minora which secrete lubricating mucus for coitus - Blockage of duct - Infection (Staph or E.coli) = acutely painful (can't sit), swollen + tender red swelling of labia
365
BARTHOLIN CYST | How is a bartholin abscess managed?
- Abx - Incision + drainage (word catheter) - Marsupialisation (incision sutured open to reduce risk of reformation)
366
NABOTHIAN CYST | What is a nabothian cyst?
- Columnar epithelium of endocervix produces cervical mucus | - When squamous epithelium of ectocervix slightly cover these it traps mucus + forms cyst
367
NABOTHIAN CYST What can cause a nabothian cyst? How does it present?
- After childbirth, minor cervical trauma or cervicitis | - Asymptomatic + incidental, white or opaque swellings on ectocervix near os
368
NABOTHIAN CYST | What is the management of a nabothian cyst?
- Majority resolve spontaneously | - Cryocautery if symptomatic (rare)
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