1
Q
What are the risks associated with vaginal rejuvenation lasers?
A
pain, burning, chronic pain
2
Q
What should you advise for patients wanting to undergo vaginal reconstructive surgery?
A
see a sexual counsellor
large variation in vulval appearances and it changes over life
3
Q
What is vaginal rejuvenation devices?
A
devices which deliver thermal energy to the vaginal mucosa
include erbium lasers, CO2, lasers and radiofrequency ablation
4
Q
What are vaginal rejuvenation devices marketed for?
A
for treatment of menopause symptoms, sexual dysfunction and UI.
5
Q
What is the definition of morcellation?
A
division of a large specimen into smaller fragments to allow removal from the peritoneal cavity
6
Q
What are the risks of morcellation?
A
injury to organs, vessles
dissemination of disease
complicates pathology for diagnosis
7
Q
What are the rules for power morcellation use?
A
- keep tip in view
- do not morcellate any pre malignancy or malignancy
- control specimen
- minimise spillage
- remove all fragments
feed spec to device in controlled manner
8
Q
What is the risk of diagnosing a leiomyosarc when you presume it is a fibroid on histology?
A
0.01-0.08%
9
Q
What are risk factors for leiomyosarcoma?
A
mean age 60
menopausal status
african american
previous tamoxifen use
pelvic RT
genetic conditions
10
Q
What genetic conditions
A
11
Q
What gebetic conditions are associated with LMS?
A
retinoblastoma syndrome, li fraumeni syndrome, hereditary leiomyomatosis renal cell carcinoma syndrome
12
Q
What on clinical exam/history would make you be alerted to a possible LMS?
A
- Rapidly expanding mass
- PMB or AUB
- Ascites
Lymphadenopathy
evidence of secondary spread
13
Q
What should be done in pre op if planning morcellation?
A
engage patient in discussion of the method of tissue extraction, including risks, benefits and other options
13
Q
What are findings on USS or MRI suspicious for LMS?
A
- Large size or large interval growth
- Tissue signal heterogeneity
- Central necrosis
- Ill-defined margins
- Ascites
- Metastases
No established tumour markers for LMS, but elevated LDH can be related to increased cell turnover
14
Q
Can you use morcellation if the patient has atypical hyperplasia?
A
no
15
Q
What is power morcellation?
A
electromechanical morcellation, using specific devices
16
Q
What benign disease can disseminate?
A
endo
fibroids
17
Q
Who is allowed to do power morcellation?
A
AGES RANZCOG levels 5 and above
18
Q
What is hereditary leiomatosis renal cell carcinoma syndrome a mutation in? what is the genetic pattern?
A
fumarate hydratase gene
AD
get skin leimyomas also
19
Q
What are the most common symptoms associated with endo? how often are they present?
A
painful periods, heavy periods, pain with sex, infertility, pelvic pain. 50-75%
20
Q
When looking at diagnosis of endometriosis what is the first step after hx and exam?
A
TV USS
if unable then MRI
if unable then consider TA USS
surgery not required as first line option for diagnosis
21
Q
What is first line treatment in suspected or confirmed endo? not TTC
A
COCP or progestogen
+/- physio, psych and analgesia
trial for 3/12
22
Q
When can you consider GnRH agonist or antagonist in endo?
A
if not improvement on hormones after 3/12
23
Q
Why should you offer hormones treatment to women after endometriosis resection if not TTC?
A
reduces pain and recurrence
24
What is the cancer risk in endometiosis?
small increase in ovarian and endometrial
possible reduced cervical cancer
25
What should be considered if laparosocopy in young woman for endo?
experienced surgeon in young women with endo
26
What is the definition of endometriosis?
A chronic inflammatory condition marked by endometrial like tissue out side the uterus.
27
What % of women in Australia are diagnoses with endo by age 44-49?
14
28
What is the apporximate cost of endo over the lifetime to the patient in time lost, costs?
300,000
29
What are less common symptoms in endo and how often are they present?
* Bowel symptoms
* Severe fatigue
* Back pain
* Sleep difficulty
* Headache
* Urinary symptoms
Allergies
10-25% of the time
30
What can VE in ? endo show to indicate endo?
* Reduced organ mobility and enlargement
* Tenderness of the pelvis and vaginal wall
* nodularity in the posterior vaginal fornix
Visible vaginal endometriotic lesions
31
What are approaches to reduced endo diagnostic delay?
* Diagnose based on non surgical methods
* Early treatment base on symptoms, signs and clinic findings
* Earlier detection through patient and clinician awareness of the condition
32
When should a patient with suspected of confirmed endo be referred to gynae?
* Initial management is not effective, tolerated of CI
* Signs OE of endo and do not respond to 1st line treatment
* USS or imaging suggests endometrioma or DIE
* Severe, persistent or recurrent symptoms
Ongoing concerns about fertility delay
33
Who should be offered imaging for ?endo?
anyone with symptoms of endo
34
What can TVUSS identify in ? endo?
To identify endometriomas , endo in the pelvis, assess for other conditions which could be causing the symptoms, guide further treatment
35
What is 3D USS best as looking at in ? endo?
deep bladder deposits
36
What is the use of MRI in endo?
Consider pelvic MRI to assess the extent of deep endometriosis involving the bowel, bladder or ureter pre op or if USS was negative or inconclusive.
37
When should you consider laparoscopy for ? endo?
to diagnose and treat people with suspected endometriosis, preferably after a treatment trial, even if the USS or MRI is normal
38
When should you biopsy ? endo?
for histological diagnosis
to exclude malignancy is endometrioma not excised
39
What is stage I endo?
minimal, few superficial endometriosis implants
40
What is stage II endo?
mild, more moderate implants
41
What is stage III endo?
moderate, many deep implants, small endometriomas, filmy adhesions
42
What is stage IV endo?
severe, many deep implants, large endometriomas, many dense adhesions
43
Why is the use of endo staging systems not advised to guide management?
do not improve patient outcomes, treat based on symptoms
44
What is the score in endo which is useful clinically?
endometriosis fertility index EFI
45
What does the EFI predict?
done after immediately after surgery to predict natural pregnancy rates after surgery
46
What does the EFI look at?
age, duration of infertility, pregnancy history, location of endo and functional assessment of tubes
47
What imaging is first and second line in adenomyosis diganosis?
TVUSS first
MRI second
48
Why is diagnosis of adenomysois diffcult?
lack of agreed diagnostic criteria
49
What is adenomyosis?
An estrogen responsive condition which can occur with or without endometriosis.
Glands and stroma of the endometrium are found in the muscle layers of the uterus. No histological diagnosis consensus.
50
What are the kinds of adenomyosis you can get?
focal (adenomyoma), diffuse, cystic
51
What % of women with adenomyosis are asymptomatic?
30%
52
What are the three kinds of pain people with endo can experience?
neuropathic
noiciceptive
Noiciplastic
53
What is neuropathic pain?
from disease effecting somatosensory system (burning, stabbing)
54
What is noicipceptive pain?
tissue damage, inflammation pain (throbbing, aching)
55
What is nociplastic pain?
altered nervous system(hypersensitivity, no tissue damage)
56
What is the evidence for neuromodulator mediations in endo?
there is none at this stage
57
When should a patient with suspected endo be referred to secondary care?
* Initial management is not effective, tolerated of CI
* Signs OE of endo and do not respond to 1st line treatment
* USS or imaging suggests endometrioma or DIE
* Severe, persistent or recurrent symptoms
Ongoing concerns about fertility delay
58
In general how long should a patient trial meds in. ? endo prior to review of effect?
3 months
59
Why is hormonal treatment recommended for endo?
help slow growth and reduce the long term impact.
Hormonal treatments aim to suppress endometrial cells growth and stop menstruation
60
Why is hormones recommended after surgery for endo?
reduces pain and recurrence of disease (at 2 years)
61
What hormones are first line in endo?
COCP, oral progestogen, Jadelle, IUD and dienogest
none superior
62
What is second line hormonal treatment in endo?
GnRH agonist/antagonist with add back
63
What points should be discussed when surgery a possibility for a patient with suspected of confirmed endo?
* What surgery involves
* That surgery may include treatment of lesions
* How surgery could affect endometriosis symptoms
* The possible benefits and risks of surgery including no improvement in pain
* The possible need for further surgery, for example for recurrent endometriosis or if complications arise
The possible need for further planned surgery for deep endometriosis involving the bowel, bladder or ureter
64
What is the aim for surgery for endo?
remove or destroy any endometriosis deposits, and to correct any alteration to the normal anatomy that has results from inflammation and healing including adhesions, fibrosis and scar tissue.
65
If removing an endometrioma in surgery how should this be done? why?
cyst excision, reduced risk of recurrence and no difference in post op ovarian reserve compared to diathermy
66
What are the benefits and harms of endometrioma excision vs ablation? excision
excision
improves painful periods
improved dyspareunia
reduced recurrence
reduced risk of surgery
risks
little to no difference on reserve
67
What are the benefits and harms of endometrioma excision vs ablation? ablation
benefits
may have some improvement in pain
risks
recurrence
may need further surgery
68
What are the benefits and harms of diagnostic laparoscopy vs excision of endo?
there may be no difference in pain or QOL
diagnosis is important to people
surgical risks is with excision
69
What are the benefits of excision vs ablation of endo? ablation
little to no difference for pain post op
pain improved from baseline (dyschezia, periods, pain)
unclear about dyspareunia
risk of thermal injury
70
What are the benefits of excision vs ablation of endo? excision
little to no difference for pain post op
pain improved from baseline (dyschezia, periods, pain)
unclear about dyspareunia
risk may result in adhesions
71
why is hormonal treatment after surgery if not TTC recommended?
reduces pain and recurrence of disease
72
for DIE what are the risks and benefits of colorectal segemental resection vs shaving or disc?
colorectal segmental resection has little to no difference on pain or QOL or recurrence.
increases the risk of major complications and rectal vaginal fistula
73
what surgical management of adenomysosis is recommended?
there is no evidence to guide it, individualise
74
when is hysterectomy offered in endo?
medical treatment and uterus sparing surgical options have been tried, failed or deemed inappropriate
75
What is the effectiveness of oophorectomy in endo?
unclear
possible decreased need for surgery
increased mortality from POI
76
Is there evidence for or against hysterectomy for endo?
no, especially for pain
77
If considering hysterectomy for endo or adenomysosis what should be discussed?
* Discuss benefits and risks of keeping ovaries
* Will not necessarily improve the symptoms or cure the disease
* Should excise all the endometriotic lesions
* Endometriosis may recur with the need for further surgery
Benefits of MHT if performing oophorectomy and recommendation of use until natural menopause
78
What are the non pharmacological options which are recommended for endo and are evidence based?
physio
minfulness
counselling
psych interventions
79
What are the non pharmacological options which are recommended for endo and are not evidence based?
acuptuncture - may have short improvement
FODMAP diet, fish oil vitamin D
80
What is physio shown to improve in enod?
dyspareunia and pelvic pain
81
What is the evidence for yoga in enod?
unclear if benefit or harm
82
what is the regime for physio for endo?
pelvic floor physio 11 weeks - 5 x30 mins per weeks 1,3,5,8,11
manual therapy over 8 weeks 30 minute session every 15 days
83
What should be considered being offeredin women with endo and infertility?
excision or ablation to people with infertility who are diagnosed with superficial peritoneal endometriosis at the time of having a laparoscopy, as it may improve the chance of viable intrauterine pregnancy. Consider also testing for tubal patency and performing adhesiolysis.
84
What is the utility of drainage of endometriomas for infertility?
little to no difference in pregnancy rate at 12 months and AMH at 3 and 6 months
85
What is the utility of surgery in DIE with infertility?
discuss the benefits and risks of laparoscopic surgery as a treatment option, as there is no evidence for the improvement of fertility outcomes
86
In women who are asymptomatic of endo what should be be discussed?
low likelihood of progression and consider individualised care for follow up
including DIE and endometrioma
consider follow up for DIE and endometrioma patients
87
What is the recurrence rate of endometrioma at 12 and 24 months? does hormones reduce this risk?
12 months 17%
24 months 27%
yes
88
What are the two types of epithelial ovarian cancers? what is type I
clear cell, endometrioid, mucinous, squamous transitional (20% of all ovarian cancers)
more indolent
89
What are the two types of epithelial ovarian cancers? what is type II
serous, mixed epithelial-stromal carcinoma, undifferentiated (70% of all ovarian cancers)
90
What % of adolescents have painful periods?
71%
91
what is the likelihood of finding endo in a laparoscopy in 10-19y for pain?
50% lower if on hormones
92
What imaging options are available for painful periods in 10-19?
TA USS if TV not appropriate, MRI, transperineal, transrectal
93
What % of adolescents with pelvic pain will have a mullerian anomaly?
3-6%
associated with endo
94
What is the vulva?
the external genitalia
95
What is the difference in anatomical make up of the labia majora and minora?
minora - no hair, no adipose
96
What do the labia do anteriorly?
seperate into lateral and medial parts
lateral forms the prepuce
medial forms the frenulum below the clitoris
97
what is the vestibule?
antero-posteriorly from the frenulum of the clitoris to the fourchette
laterally from hymen to harts line
98
What is in the vestibule?
vagina, urethra and bartholins ducts
99
What is the harts line?
2/3 medially on the inner aspect of the labia minora, the junction at which tissue of ectodermal origin changes to endodermal derived tissue (interior)
100
What are the parts of the clitoris organ?
erectile organ under the prepuce
not glandular tissue
root and a body made up of two crura deep to the ischiocavernosus muscle, two corpora cavernosa (proximal to crura), bulb of vestibule and a glans
101
What does the hymen seperate?
The vestibule and vagina
102
Where do the bartholins glands lie in relation to the bulcocavernosus muscles?
inferior and lateral to the bulbocavernosus muscle
103
Where do the skenes glands open?
lateral and posterior to uterthra just at the meatus
104
What are the two columns in the endometriosis flow chart from RANZCOG
two coloumns:
1. start symptom management
2. consider diagnostic intervention
105
Describe the start symptoms management arm of the endo flow chart?
offer first line hormonal treatment and consider analgesia, PT, psychological intervention
- if not improved in 3-6 months offer alternative 1st line
- if not improved in 3-6 months refer to gynae for consideration of and line for 3-6 months
- if not improved gynae may offer alternative 2nd line treatment.
-if improving continue treatment with annual reviews
106
Describe the consider diagnostic imaging flow chart of the endo guideline?
offer TV USS with or without exam
if normal offer first line treatment
- if endo diagnostised, offer first line treatment or laparoscopy
- if DIE consider specialist referral for MRI or surg opinion to consider surgery
107
When does the external differentiation of the vulva begin?
10 weeks gestation
108
What becomes the clitoris embryologically?
The genital tubercle
109
what embryological structure becomes the labia minora?
urogenital folds (mesenchyme)
110
what embryological structure becomes the labia majora?
the labioscrotal folds
111
what embryological layer becomes the cutaneous epithelium of the mons pubis, labia and clitoris?
ectoderm, keratinised
112
what embryological layer and structure becomes the cutaneous epithelium of the vestibule & urethra and lower 1/3 vagina?
urogenital sinus (endoderm)
non keratinised (harts line)
113
what embryological layer becomes the upper 2/3 vagina, estrogen responsive?
mullerian ducts, mesoderm
114
what is the vulval blood supply? two arteries
internal pudendal artery from the IIA
external pudendal artery from the FA
115
What is the venous drainage of the vulva?
labial veins --> internal pudendal veins
116
What are the nerves which supply the vulva (4)?
1. ilioinguinal
2. Genital branch of the
genitofemoral nerve
3. perineal branch of the femoral cutaneous nerve of the thigh
4. pudendal nerve
117
What level is the ilioinguinal nerve at what does it supply in the vulva?
L1
upper medial thigh and mons and labia majora
118
What level is the genital branch of the genitofemoral nerve nerve at what does it supply in the vulva?
L1-2, runs with the round ligament
mons, labia majora
119
What level is the perineal branch of the lateral cutaneous nerve of the thigh nerve at what does it supply in the vulva?
L2-4
mons, medial thigh
120
What level is the pudendal nerve nerve at what are its three branches?
S2-4
1. dorsal clitoris nerve
2. perineal nerve
3. inferior rectal nerve
121
What is the vulval lymphatic drainage?
inguinofemoral LNs --> pelvic LNs --> para aortic LNs
midline (~1cm) can drain either side
122
What investigations can be tried in vulval disease?
patch testing
swabs
punch biopsy
123
What are the general vulval hygeine advice?
1. avoid soaps and perfumed products
2. water only for vulva
3. wash vulva with water after urination
4. wash once daily avoid scrubbing
5. avoid antiseptics
6. loose cotton underwear
7. wash underwear in water only
8. wash hair in sink
9. lubricant with sex
10. tampons if possible
11. avoid condoms with spermicides
124
What are potential side effects of vulval steroids?
skin fragility
systemic effects
infection
bruising
atrophy
rosacea
contact allergy
125
What would you see with vulval eczema?
eczema elsewhere
erythema, skin scaling, fissuring
126
How do you diagnose vulval eczema?
biopsy
127
Where else can lichen planus lesions be present?
oral, skin, nails, hair/scalp, external auditory meatus, oesophagus, lacrimal duct
128
What is a clearing lesion?
when a fungal infection has a pale centre with a defined edge
129
What is the lifetime incidence of lichen sclerosus?
1.5-3%
130
Where can you get extra genital lesions of lichen sclerosus?
eye lids, back in 10%
131
What are complications of lichen sclerosus?
SCC a
dysuria
sexual dysfunction
vulvodynia
clitoral pseudo cyst which can get infected
reactivation of HSV of HPV with steroids
132
what additional organ can have auto immune disease in lichen sclorosus and what should you test?
thyroid
TOP Ab and TSH R ab
133
What regime of clobetasol is common in the start of Lichen slerosus treatment?
OD for one month, alternate for one month, twice weekly for one month. review
134
What is different about ointment than cream ultra potent steroids?
oinment has less preservatives and thus less contact allergy
135
When first diagnosed with lichen slerosus when should they have follow up?
3, 6, 12 months
136
which vulval conditions often occur concurrently?
lichen sclerosus and planus
137
What are symptoms of lichen planus?
itch, pain, discharge, urinary symptoms, dyspareunia
138
Does lichen sclerosus involve the vagina?
no
139
What is lichen planus?
a chronic inflammatory condition affecting skin and mucosal surfaces
T cell mediated, attack protein in skin and basal keratinocytes
140
What is the % of population effected with lichen planus?
1
141
What is the most common age for lichen planus?
30-60
142
what are the different groups of lichen planus (categories)?
classical
hypertrophic
erosive
143
What is classical lichen planus?
papules with keratinised skin
hyperpigmentation follows resolution
144
What is hypertrophic lichen sclerosis?
thickened warty plaques which can ulcerate
rare
145
What is erosive lichen planus ?
most common subtype to cause vulval symptoms, mucosal surfaces eroded, at the edges of the erosions are pale lilac/mauve lace-like network (Wickham's striae)
146
What can occur with erosive lichen planus?
stenosis
147
What causes the vaginal discharge in lichen planus?
desquamative vaginitis
148
What can differentiate lichen sclerosus from planus?
planus can have vaginal involvement
149
How do you diagnose lichen planus?
can be clinically but biopsy can be used to r/o malignancy
150
What else should you consider testing for in lichen planus?
other autoimmune conditions
151
What are treatment options for lichen planus?
topical steroids
topical calcineuron inhibitors (tacrolimus)
systemic treatment
surgery
152
What is tacrolimus and how does it work?
calcineurin inhibitor
calcineurin in an enzyme needed for T cell activation and cytokine release
immunomodulating and anti inflammatory properties
153
What follow up does lichen planus need?
annual specialist review
154
What is lichen simplex chronicus?
Chronic itchy skin disorder charactarised by poorly demarcated erythematous patches and plaques of thickened leathery skin. lichenification
155
What can contribute to lichen simplex chronicus?
primary - normal skin
secondary - underlying dermatoses
systemic illness
environmental factors
psychiatric disorders
156
What are the clinical features of lichen simplex chronicus?
* Erythematous inflammation with poorly demarcated margins, may be fissuring present
* Skin dry, slightly scaly and if chronic changes -> thickened and lichenified from scratching
Diagnosis
157
What are conditions to consider in lichen simplex chronicus as differntials?
psoriasis, scabies, tinea, candida
158
What do you advise for management in lichen simplex chronicus?
meticulus skin care
use of emollients or soap substitutes
avoid allergens
barrier creams if incontinent
topical steroids moderate OD
ointment>creams allergens
oral steroids is severe
sedating antihistamine
CBT
treat underlying disorder:
psych
oral antibiotics or antifungal if needed
159
what is vulval psoriasis?
chronic inflammatory condition of the epidermis
160
what % of the population does vulval psoriasis effect?
2%
161
What are typical features of genital psoriasis?
symmetrical well demarcated erythematous plaques on mons, labia majora, groin folds, natal cleft and legs
fissuring can be seen
no usually scaling due to moisture
162
What secondary infections can occur in psoriasis?
streptococcal and candida
163
How is vulval psoriasis diagnosed?
clinically
164
What are treatment options in vulval psoriasis?
avoid irritants
emolliants
topical steroids - weak to moderate. can use strong for short bursts if needed (limited to a few weeks)
weak coal tar preparations
vitamin D analogues
topical immunomodulators (tacrolimus)
systemic treatment may be needed in severe disease eg MTX, ciclosporin
165
What is the criteria for vulvodynia diagnosis?
vulval pain for 3 months in the absence of disease
diagnosis of exclusion
166
What are the categories of vulvodynia?
localised, generalised or mixed
provoked, unprovoked or mixed (when touched)
primary, secondary
167
What should you do on exam for vulvodynia?
q tip test + mapping 0-10 pain score
digital exam of hymenal ring
evaluate pelvic floor hypertonicity
speculum - vaginal mucosa
168
What can you use to manage unprovoked vulvodynia?
as a chronic pain syndrome
main:
amitriptyline 10mg up to 100mg
MDT care
others:
transcutaneous nerve stimulation
CBT
acuptuncture
PT
botox injections
169
What are symptoms of provoked vulvodynia?
vulval pain at the introitus with penetration, described as tearing in nature and can persist after the event,
170
What are treatment for provoked vulvodynia?
main three:
local gel pre sex
PT
CBT
others:
pelvic floor biofeedback
transcutaneous nerve stimulation
botox
pain modifiers
vestuibulectomy
171
What is the GTG definition of chronic pelvic pain?
intermittent or constant pain in the lower abdo or pelvis of a woman lasting 6 months
not exclusively with menstruation or intercourse, not in pregnancy
172
how common in chronic pelvic pain?
1/6 women
173
What are symptoms of IBS?
continuous or recurrent pain on at least 3 days per month from 3 months with at last 2 of:
improvement with defacation
associated with change in stool frequency
onset with change in stool form
174
What findings on pelvic exam for CPP would indicated MSK cause for pain?
tender SI or SP joint
175
What proportion of laparoscopies are negative for CPP?
1/3-1/2
176
What investigations can be considered for CPP?
TV USS
STI swabs for ?PID
diagnostic laparoscopy
177
What treatment is advised for CPP?
hormonal treatment 3-6 months prior to considering surgery
if IBS - amend diet, anti spasmodics
analgesia
neuropathic pain - amitriptyline
TENS and acupuncture may be helpful
178
What should assessment of CPP aim to do?
identify contributory factors rather than assign one pathology as cause
179
What is the definition of pain?
a sensory and emotional experience associated with actual of potential tissue damage
180
What causes chronic pain?
change in the aff and eff nerve pathways.
local factors TNF a and chemokines change peripheral nerve function.
persistent pain leads to CNS changes --> intensified pain signals
nerve damage from inflammation or surgery contributes to CNS alteration of pain perception and visceral function
181
what can adolescents get adenomyosis?
yes
182
What can be used in women with suspected pelvic venous congestion?
ovulation suppression
progestagins
GnRH agonists (best)
183
What does the GTG advised for pelvic adhesions and CPP?
resect dense adhesions
no evidence to support fine adhesion division
184
What is trapped ovary syndrome?
when the ovary gets buried in adhesions after hysterectomy
185
What is residual ovary syndrome?
when a small of ovarian tissue is left behind after oophorectomy and buried in adhesions
186
How do you manage pain from trapped ovary syndrome or residual ovary syndrome?
GnRH agonist or surgery
187
how can MSK pain contribute of CPP?
postural changes
POP
joint pain
injury to muscles in pelvic floor
188
What is nerve entrapment?
scar tissue, fascia or a narrow foramen may result in pain and dysfunction in the distribution of that nerve
189
What is the risk of nerve entrapment after one pfannenstiel?
3.7%
190
What are the broad categories which can cause CPP?
endo/adeno
adhesions
pelvic congestion syndrome (controversial)
MSK
IBS
interstitial cystitis
nerve entrapment
psychological and social issues
191
What imaging modalities are used for diagnosing adenomyosis?
MRI and USS TV
192
If soft signs on USS of endo present such as immobile or tender ovaries what is the likelihood of finding endo intra op?
73% (from 58%)
193
If no soft signs on USS of endo present such as immobile or tender ovaries what is the likelihood of finding endo intra op?
20%
194
What is the sensitivity or specificity of TV USS for adenomyosis? is MRI better
about 82% for both
comparable to MRI
195
What is the risk of bowel, bladder and vessel injury at diagnostic laparoscopy?
2.4 in 1 000
196
What is the risk of death in diagnostic laparoscopy?
1 in 10 000
197
What antispasmodic can be tried for IBS?
mebeverine hydrochloride
198
What % of women undergoing laparoscopy for non CPP have endo found?
45%
199
What approach to pain management in CPP does ANZCA recomend?
sociopsychobiomedical
200
That is the most common cause of NSGU?
EBV
201
What is NSGU?
non sexually acquired genital ulceration
202
What what are the major criteria which must be filled for NSGU?
* Acute onset of one or painful vulval ulcers
Exclusion of infectious and non infectious causes
203
What are the 4 minor criteria for NGSU which must have two fulfilled?
* Ulcers on the vestibule or labia minora
* No history of SI in the last 3 months
* Flu like symptoms
Systemic illness in the preceding 2-4 weeks
204
What time do NSGU heal over?
15 days
205
What is the most common condition to effect the anogenital skin area
lichen sclerosus
206
What are the areas effected by lichen sclerosus?
labia minora and majora, clitoral hood, perianal skin. Clitoris and vaginal are not effected
207
What are the signs of LS?
pallor (early change), purpura/ecchymosis, erosions, loss of architecture can lead to resorption of the labia minora and/or midline fusion with introital stenosis, lichenification and hyperkeratosis can occur but these are atypical features a
208
What is the risk of SCC development in LS if not treated?
<5%
209
What can be seen on biopsy in LS?
○ Epidermal atrophy
○ Sub epidermal hyalinisation of collagen
○ Lymphocytic dermal infiltrate
In early disease can be indeterminate
210
When should you biopsy ? LS?
uncertain diagnosis, atypical, any suspicion of VIN or SCC (not whole lesion), failure to respond to treatment, pigmented lesions
211
Is lifelong steroids needed for LS?
up for debate
212
what is lichen sclerosus?
an inflammatory dermatosis of the vulva which is suspected to be AI. autoimmune factors likely to be involved, autoantibodies to ECM protein 1 have been demonstrated.
213
What antibodies have been found in 60% of erosive LP patients?
Basement membrane zone antibodies have been shown in 61% of patients with erosive LP.
214
What is vulvovaginal gingival syndrome?
syndrome of erosive LP - oral, vaginal and vulval involvement
215
Is there a link between LP and SCC?
possible with hypertrophic type only 3%
216
What can look similar to linchen planus erosive?
bollous pemphygoid
217
What kin of lichen planus can have a non specific biopsy? what can be done?
erosive
take from the edge of the lesion
218
How effective is topical steroids for LP and what alternative is there for flares?
75% get improvement 54% symptoms free. rarely gets ride of inflammation completely
oral pred for flares
219
what can been seen on erosive lichen planus biopsy?
saw toothed acanthosis, increased granulocyte layer, basal cell liquefaction.
220
When should you review LP?
2-3 months then annually when controlled.
221
is lichen planus common in younger women?
no
222
When are the two peaks of LS diagnosis? which peak is larger
prepubertal (6-7) and post menopausal (65-80)
largest peak by far is Post M
223
What is lichen simplex chronicus most commonly associated with?
eczema, psoriasis
224
What is the new name for VIN?
squamous intraepithelial lesion (SIL)
225
What are the 3 groups in SIL?
LSIL
HSIL
dVIN
226
What are the SIL groups which have malignant potential?
HSIL and dVIN
227
What is the most common kind of SIL?
HSIL 95%
228
what % of SIL if dVIN?
5%
229
what conditions is dVIN associated with?
LS and rarely hypertrophic LP
230
What does HSIL look like?
white, erythematous, pigmented, plaques.
231
What does dVIN look like?
ulcerated, hyperkeratotic, erosive. Most commonly near the vestibule, clitoris, labia minora, introitus
232
What symptoms can you get with SIL?
pain, burning, itch, asymptomatic, nodules or plaques
233
What is the risk of progession in SCC in dVIN and HSIL?
dVIN 50%
HSIL 10%
234
What other complications occur in SIL?
psychosexual
multifocal
recurrence
235
How should you diagnose SIL?
multiple biopsies
236
What IHC result d you get with HSIL VIN?
p16 staining +ve
237
What histology results do you get in HSIL SIL?
disruption of the architecture, high nuclear-to-cytoplasmic ratios, hyperchromasia, pleomorphism, cytological atypia and mitoses.
238
What IHC do you get in dVIN?
P16 negative and abberant of null p53 staining
239
What should you also consider when diganosis SIL?
full exam
UTD cervical screening
240
What options are there for management of dVIN?
excision only, may need partial vulvectomy
241
What options are there for HSIL SIL?
surgical excision
medical - imiquimod 5% or cidofovir 1%
242
how does imiquimod work?
Activates toll like receptor 7 to trigger immune response and cytokine release.
243
How do you use imiquimod in SIL?
Apply nocte was off after 6-10 hours. 3 x weekly for 16 weeks
244
What did the lancet study looking at imiquimod vs surgery show in HSIL SIL?
as effective in achieving complete response 80%
245
Should you give HPV vaccine in HISL SIL?
no evidence for this.
246
What kind of SIL has higher recurrence?
dVIN
247
What kind of SIL had more multifocal diseaase?
HSIL
248
What is provoked vulvodynia?
usually
characterised as pain at the vestibule on penetration
249
How do you use lidocaine gel for dyspareunia? what can occur with use?
15-10 mins prior then wash off
can cause irritation and penile numbness, use condom to reduce
250
What are the associated medical conditions with LS? (4)
* AI disease
* Obesity and metabolic syndrome
* Anxiety and depression
Urinary incontinence
251
What other AI conditions occur with LS and what % will have one?
in 19-28% of women - Thyroid disease, SLE, T1DM, IBD
252
What are the factors involved in LS development? (4)
* Genetic
* Immunological
* Hormonal
Environmental
253
What race gets more LS?
white women
254
Lichen sclerosus is a inflammatory dermatosis with two parallel processes what are they?
Lichenoid tissue reaction
Dermal sclerosis
255
what causes lichenoid tissue reaction in LS?
T cell medicated attack on basilar keratinocytes.
256
what causes dermal sclerosis in LS?
dehydration and cross linking of fibrin leads to sclerosis
257
What is the risk of SCC in LS if untreated?
about 4%
258
What biopsy technique should be done for LS?
* Take biopsy from the most abnormal area of each lesion, take one from each site
259
What size punch biopsy is preferred for LS?
3-4mm
260
What depth punch biopsy is preferred for LS?
depth 3mm on hairless skin, 5mm on hair bearing
261
What adverse effects can occur with high potency steroids in vulva?
Talengectasia, atrophy, straie, steroid dermatitis
262
what can be done to reduce adverse effects of topical steroids?
○ Reduce potency
Use barrier for surrounding tissue
263
what is a canal of Nuck cyst?
is a rare, benign, fluid-filled mass in the inguinal region caused by the failure of the processus vaginalis to close in women. presents as groin swelling
264
What is the lifetime incidence of barts abscess or cyst?
2%
265
Who should you consider a bart biospy in?
age >40
266
Why is a bart less common >30
gland involution
267
where are barts gland and how big are they?
4 and 8 oclock <1cm
268
How long is the barts gland?\
2cm
269
What kinds of barts ca are common?
SCC and adeno ca
can be HPV
270
What are common pathogens in bats abscess?
ecoli, staph aureus. Increasing are strep pneumonia, haemophilus influenza from oral sex.
271
What is the recurrence rate after a words for bart?
3% at 6 months
12% at 12
272
What is the recurrence rate after a marsupilisations for bart?
10% at 12 months
273
how long should a words stay in?
4-6 weeks
274
What options are there for barts?
jacobi ring
words
marsupiliasation
sclerotherpy - ETOH or silver nitrate
gland excision
I+D
275
What are the two kinds of dermatitis of the vulva?
exogenous - contact due to irriants
endogenous - atopic eg eczema
276
What is a diagnostic clue for vulval psoriasis?
erythema involving the inguinal folds and extending into the gluteal crease
277
does psoriasis involve the mucosa?
no
278
What is acute pain?
provoked by a specific disease or injury, serves a useful biologic purpose, and is self-limited. It is the normal, predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus ... associated with surgery, trauma, or acute illness.
279
What symptoms are hallmark fro pelvic congestion syndrome?
pain after SI, exacerbated by standing and activity
280
What imaging modality is used for diagnosing pelvic congestion syndrome?
venography
281
What findings on venography would indicated pelvic congestion syndrome?
* Ovarian vein diameter >10mm
* Uterine venous engorgement
* Congestion of the ovarian plexus
Filling of the pelvic veins across the midline and/or filling of the vulvovaginal thigh varicosities
282
What are fibroids?
smooth muscle tumours arising from the myometrium
283
What % of fibroids have an impact on QOL?
30%
284
What is the lifetime prevalence on fibroids?
75%
285
What usually happens to fibroids in menopause?
shrink but do not go away
286
Who are high risk groups of fibroids?
ethnicity - black and SE asian
age
early menarche
nulliparity
genetic risk
obesity
red meat
TOH
vitamin D deficiency
287
What are protective against fibroids?
green veges
exercise
smoking maybe
later age at first child
higher parity
COCP/progestogens
288
What is the lifetime risk of LMS?
6 in 1 000 000
289
What is the likelihood in findings a LMS on histology when you expect fibroid?
1 in 8300
290
what is a STUMP?
smooth muscle tumour of uncertain malignant potential
between LMS and fibroid
typically benign but recur in 12%
291
What % of fibroids are related to HLRCC?
1.6
292
What does a usual fibroid look like on a cellular level?
monoclonal smooth muscle tumour comprising of disordered myocytes in an extracellular matrix (ECM) with mutation free fibroblasts (40% of fibroid mass)
Increased collagen in ECM
293
What makes fibroids hard, dense and pale as they grow?
increased collagen compared to surround myometrium. as they grow they become more collagen by proportion
294
What are some other kinds of fibroids other that 'usual' type?
ceelular
mitotically active
lipomatous
hydropic
atypical (can become LMS)
IV
diffuse hereditary
295
What are fibroids thought to arise from?
one cell mutation in a myocyte. can be a translocation or deletion
296
What is the most common genetic mutation found in a fibroid? what %
MED12, in 70%
297
What is the pseudocapsule in a fibroid made of?
It is the interface between the myocytes and the fibroid. dense tissue around the fibroid, made up of compressed myocytes and connective tissue.
298
What is the ring of fire on a fibroid on USS?
small vessels anchoring the fibroid to the pseudocapsule
299
What is the relationship between fibroid growth and estrogen ?
Estrogen stimulated progesterone receptors and makes the fibroid more responsive to progestone
300
What does progesterone do in fibroid growth?
stimulates proliferation and increases growth factors
301
What phase of the menstrual cycle do fibroids grow in?
the secretory phase (prog)
302
What happens as fibroids grow to the cellular strcuture?
As the fibroids grow the cells get more spaced out and so does the capillary supply and the collagen increases. This means you get ischaemia and myocyte atrophy.
This creates the hypovascular, hypocellular, hyalinised areas in fibroids >2cm
303
What fibroids tend to grow faster small of large?
small
304
What is the growth trajectory of fibroids in pregnancy and PP?
Typically growth in T1 and T2 then stabilise in T3 and shrink PP (50% by 6/12). BF further reduces size.
305
What does a fibroid vs a LMS look like microscopically?
LMS - high mitotic index, hypercellular, severe nuclear atypia
fibroid - low mitotic index, hypocellular, hypovascular
306
How do fibroids cause infertility?
* Anatomical distortion
* Affect proximal fallopian tubes/ostia
* Affect fimbria and ovaries relationship
* Endometrial physiology/receptivity
Myometrial contractility and thus sperm transport to tube
307
What cytokine in fibroids impacts endometrial receptivity and haemostasis?
TGF beta 3
308
what is fibroid type 0?
pedunculated intracavity
309
what is fibroid type 2?
>50% intramural
310
What is fibroid type 3?
contacts endometrium but intramural
311
What is fibroid type 4?
fully IM doesn't contact mucosa or serosa
312
What is fibroid type 6?
subserosal <50% intramural
313
what is type 7 fibroid?
subserous, pedunculated
314
What is type 8 fibroid?
other eg cervical
315
What is AUB L-SM?
submucosal fibroids type 0-2
316
What is AUB L-O?
other fibroids type 4-8
317
What defines a fibroid stalk?
10% diameter
318
what is thought to be the pathogenesis of fibroids causing HMB?
* Fibroid related microscopic and macroscopic vascular abnormalities
* Impaired endometrial homeostasis
* Angiogenic factors
* Altered myometrial contractility.
319
What pregnancy complications can occur with fibroids?
PTB, malpresentation, PPH, labour dystocia, abruption, placenta praevia, CS, miscarriage
320
What can be seen on USS in firboids?
Typically regular or lobulated contour, well defined margins and asymmetric uterine walls. Edge shadowing and homogenous echotexture. Circumferential blood flow and a non thickened junctional zone
321
What is the first line imaging for fibroids? how can sensitivity be improved
TV USS
SHG
322
How can MRI be useful in fibroids?
most accurate imaging
mapping fibroids
vascular perfusion for UAE
tissue degenration
distinguish from adenomyoma
LMS
323
What is MRI Sens for LMS?
90%
324
what MRI findings do you see in adenomyosis?
* Irregular junctional zone
* Myometrial cysts
* Adenomyomas - ill-defined myometrial lesions with tiny cystic or haemorrhagic components
325
What are features of adenomyosis on USS? from muscle hyperplasia
Myosis (muscular hyperplasia):
* Focal of diffuse myometrial bulkiness (posterior or fundal)
* Indistinct borders of adenomyomas
* Asymmetrical myometrial thickening
* Thickened TZ - hypoechoic halo surrounding endometrial layer
Vascularity
Increased
326
What are features of adenomyosis on USS? from ectopic endometrial glands hyperplasia
Adeno (ectopic endometrial glands):
* Subendometrial cysts
* Venetian blind shadowing
* Thinner myometrium anteriorly
* Hyper echoic islands
* Irregular endometrial myometrial junction
327
How does TXA work?
lysine analogue which Binds to lysine receptor sites on plasminogen and stops it turning to plasmin (active). This means plasmin cannot bind to fibrin to break it down.
328
How much can TXA reduce bleeding in HMB by?
40-50%
329
What size fibroid increases risk of mirena expulsion?
>3cm
330
What is the reduction in median blood loss with mirena after one year in fibroids?
95%
331
How do progestogens to reduce AUB in fibroids?
inhibit endometrial growth, and fragility and inhibits angiogenesis
332
Why do you get an atrophic endometrium with progesterone?
* Inhibit ovulation and steroidogenesis, interrupting estrogen stimulation of endometrium -> atrophic endometrium
333
What is advised in HRT and fibroids?
may increase the size so should have exams regularly and stop if growth
334
How long does a flare with an GnRH agonist last?
1-2 weeks
335
How much does zoladex shrink fibroids by?
50%
336
What evidence is there for using zoladex pre hysterectomy for fibroids?
improved Hb(pre and post), ferritin and size, intra op bleeding, vertical incision reduced difficulty of surgery
337
How quickly do you get menopause symptoms with a GnRH antagonist?
48-72 hours
338
What is Ryeqo?
relugolix 40mg + estradiol 1mg + NEA 0.5mg
relugolix is an GnRH antagonist
339
What is ryeqo used for?
endo and fibroids
340
What is the time duration you can used ryeqo for?
no time limit
no effect on bones at 2 years
341
What are serious risks of ryeqo?
VTE, fibroid expulsion, anaphylaxis, stroke, MI, HTN
342
What are the categories of hormonal treatments for fibroids?
* Progestins - oral or IUD
* COCP
* GnRH - agonist or antagonist
PR modulators (mife)
343
What are the three main image guided therapies for fibroids?
1. Uterine artery embolisation (UAE)
2. Radiofrequency ablation (RFA)
3. High intensity focused USS (HIFU)
344
what % of patients get reduction in bleeding from fibroids after UAE at one year?
90%
345
What % of patients need repeat procedure after UAE at 3 years?
14%
346
How much does UAE reduce mean fibroid volume at 12 months
50-60%
347
Why is zoladex not good pre UAE? how long do you with hold it?
make the vessels smaller and the procedure more difficult due to vessel spasm, 4-6 weeks
348
What are contraindications to UAE?
infarcted fibroid, size <1cm or >24 weeks, contrast allergy, pedunctulated, intracervical
349
comparing myomectomy and UAE what outcomes are similar?
Regular cycles, bleeding scores, amenorrhoea, HMB
350
what are the pregnancy rates after UAE?
39%
351
surgery vs UAE what are satisfaction rates, hospital stay, reintervention and minor complication rate for UAE?
similar satisfaction rates
shorter hospital stay
more minor complications
higher reintervention rate 2-5 years
352
What are ADRs to UAE?
Pain 25%, 10-20 minutes after embolisation, can last for hours
Post embolisation syndrome
vaginal discharge
Arterial perforation
Infection, abscess 1%
Tissue expulsion
353
What is the course of post embolisation syndrome?
19-35% - flu like illness. Occur within 24-48 hours and resolve in 2 days, max 7 days
354
How common is tissue expulsion after UAE?
5-10% but increased with pedunculated fibroids
355
How does radio frequency ablation work on treatment of fibroids?
Used targeted thermal energy to induce coagulative necrosis in the fibroid tissue, heating soft tissue to greater than 100deg c
TV, TC, laparoscopic
USS guidance
356
How does high intensity focussed USS treat fibroids?
USS or MRI guidance
Heat targeted tissue inducing coagulative necrosis while preserving surrounding tissues
357
what are the general rules of who would be contra indicated for image guided therapy for fibriods?
heart disease, liver failure, acute inflammation of genital tract, cancer or suspected of pelvis
358
What pregnancy complications are associated with previous UAE?
PTB malpresentation, PPH, abn placentation.
359
Should you offer treatment for SM fibroids to change pregnancy outcomes?
individualise but no evidence it changes outcomes
360
How long does it take to heal endometrium after myomectomy, and thus guide advice on wait to conceive?
3-6 months
361
why do fibroids grow in the first trimester?
HCG thought to be involved
362
When does pain normally occur from fibroids in pregnancy?
late T1 and early T2
363
What is red degeneration?
Acute peripheral venous thrombosis leading to infarction and necrosis of fibroid in pregnancy
364
What symptoms do you get with red degeneration in preganncy of fibroid?
pain, nausea, vomiting, fevers, leucocytosis
365
What are risks associated with NSAIDs in pregnancy and what is the safest time for use?
NEC
oligo
PHTN
closure of DA
20-30 weeks
366
What laparoscopic pressures are safe in preganncy?
10-25mmHg
367
How far from a fibroid do you want to incise at C section?
2cm
368
What % of fibroids reduce PP?
90
369
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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Week 6253
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Week 7259
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Week 8232
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Week 9206
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Week 10364
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Week 258
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week 371
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Week one136
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Week 11237
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Week 12314
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Week 13381
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GONC 1395
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GONC 2259
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Week 16134
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Week 17410
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Week 18266
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Week 19347
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Week 20307
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Week 21430
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Week 22370
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Week 23298
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Week 24325
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Week 261
