Obs and Gynae Flashcards
What are the phases of the menstrual cycle
Follicular phase
- Increasing FSH and LH - stimulate primary follicle growth, secretion + conversion of androgens to oestrogens and inhibin section.
- this increases oestrogen - starts to inhibit FSH - dominant follicle grows
- once reaches maturity oestrogen ↑↑ –> LH surge –> follicle rupture
Luteal phase
- remaining follicle become corpus luteum
- Progesterone ↑ - maintain conditions for fertilisation and implantation
- if not fertilised - corpus luteum spontaneously regresses (PG cut of blood supply) - ↓ Oest & prog –> menses
- if fertilised - syncytiotrophoblast of embryo will produce hCG –> maintain endometrium (prod progesterone)
Phases of the uterine cycle
Proliferative Phase (same time as follicular - prepare for fertilisation) - Oestrogen fallopian tube formation, thickening of endometrium, ↑ growth and motility of myometrium and produce thin alkaline cervical mucus (to facilitate sperm transport)
Secretory Phase (along luteal phase) - Progesterone further thickening of the endometrium (glandular secretory form + development of spiral A.) and the myometrium; ↓ of motility of the myometrium (don’t want contractions); thick acidic cervical mucus production (prevent polyspermy); ↓ fallopian tube motility, secretion and cilia activity; changes in mammary tissue and other metabolic changes; elevates basal body temperature.
What is the menopause
The end of the reproductive life - the ovarian follicles are depleted and there has been amenorrhoea for 12 months.
Usually between the ages of 45 and 55y/o.
2 FSH levels >30IU/L - suggestive
Symptoms of menopause
• Menstrual irregularity - cycles become anovulatory, before stopping
• Vasomotor disturbance—sweats, palpitations, and hot flushes (peripheral vasodilation and a transient rise in body temp)
• Atrophy of oestrogen-dependent tissues (genitalia, breasts, bladder and urethra) and skin. Vaginal dryness can lead to vaginal and urinary infection, dyspareunia, traumatic bleeding, stress incontinence, and prolapse.
• Osteoporosis: ↓ oestrogen –> ↑ osteoclast activity –> acceleration of age related loss of bone density and ↑ frequency in # - femur, neck, radius and vertebrae
• Oest. is protective effect against IHD (↓ LDL + ↑ HDL)
Other: Joint stiffness/soreness; dizzy; interrupted sleep; anxiety; reduced concentration; irritable/ mood swings
Management of menopause
Lifestyle
o Stop smoking, healthy diet, exercise + weight loss,↓ stress, ↓ caffeine/spicy food/ alcohol
o Stay cool at night; Vaginal lubrication
o Annual BP, breast checks
HRT
- oestrogen only (if had hysterectomy)
- cyclical - if still periods –>oestrogen every day then progesterone either last 14d of -cycle(reg)/ 3m (irreg)
- continous combined - if post-menopausal
o SSRI - for hot flushes
o Clonidine - ↓ hot flushes + night sweats (doesn’t affect hormone levels – no ↑ risk Ca)
SE –> dry mouth, drowsiness, depression and constipation
o Tibolone – agonist at oestrogen receptor – relieve symptoms (same risks HRT)
o Raloxifene (SERM) - protects bones, ↓ breast & endometrial ca risk (ineffective for flushes)
o Natural hormones not recommended as not regulated and effect not known
o Complementary therapies (be careful about ADR) Black cohost and st johns wart
o Alternative -acupuncture, reflexology, aromatherapy or homeopathy
o Psych - CBT - elevate low mood
Methods of administration, risks and benefits of HRT
Tablets; cream/pessary/ring (for vaginal dryness) ; transdermal e.g. patch/gel (dependent on skin conditions); implants (oestrogen/IUS)
Benefits
- Improves vaginal dryness and sexual function, reduces vaginal atrophy
- ↓ CV risk
- Improved QOL - Improves symptoms, sleep, mood, BMD, etc
- ↓ flushing frequency + severity
- ↓ CRC risk – combined
Risks
- ↑ Risk VTE (Stop 4 weeks pre-elective surgery)
- ↑ Risk ischaemic stroke (>60 y/o) – oral HRT
- ↑ Breast ca risk
(combined) ; after stopping HRT risk returns to normal. Encourage breast awareness. - Unopposed - ↑ Endometrial and ovarian Ca risk
CI and SE of HRT
CI
- Oestrogen-dependent Ca
- Past PE
- Undiagnosed PV bleeding
- LFT ↑
- Pregnancy
- Breastfeeding
- Phlebitis
SE
- Weight ↑
- ‘premenstrual’ syndrome
- cholestasis;
- vomiting
- muscle cramps
- irregular bleeding
What is an early menopause and what are the risk factors
Menopause - 40-45 y/o
Risk factors –> High BMI, FH, Early menarche, Low parity, hx oral contraceptive treatment
Ix and Mx of early menopause
Ix - FSH - > 40 Iµ/L x 2 (4-6 weeks apart)
Mx - HRT (may require higher oestrogen dose)
What is premature ovarian insufficiency and the cause.
Menopausal sx in women <40y/o - May be reversible
Cause - ↓ no. follicles at birth/ accelerated follicle atresia/ follicle or FSH R dysfunction
Sx, Ix, Mx and complications of POI
Sx - Amenorrhoea, ↑ gonadotrophins, ↓ Oestrogen (Hot flushes + vasomotor)
Ix - FSH x 2 raised (4-weeks apart) are diagnostic; Estradiol - low (<50 pmol/L)
o ? DEXA - Assess BMD and Tests for cause: Genetic karyotyping + Adrenal antibodies
Mx - MDT important to consider physical + psychological issues o Adcal D3 to prevent Osteoporosis and monitor CVD o HRT (cont/ cyclic) --> until age of natural menopause (~51 years old) with higher oest levels
Complications –> 80% greater chance of CV mortality, osteoporosis, Dementia
What are fibroids and describe the different types
benign growths of SM in the uterine myometrium
o Intramural (commonest) – confined to the myometrium of the uterus.
o Submucosal -immediately underneath the endometrium, protrudes into the uterine cavity.
o Subserosal - protrudes into and distort the serosal (outer) surface of the uterus. They may be pedunculated (on a stalk).
RF for fibroids
- Obesity
- Early menarche
- ↑ age
- FH
- African-American
Presentation of Fibroids
- Prolonged / HMB
- Pressure sx (e.g. urinary) ± abdo distension
- Chronic pelvic pain
- Subfertility (? Obstructive fibroid)
- Solid/ enlarged uterus – smooth, non-tender
Differentials of abnormal uterine bleeding
PALM - COEIN PALM: Structural Causes - Polyp (endometrial/cervical) - Adenomyosis - Leiomyoma (Fibroid) - Malignancy & hyperplasia
COEIN: Nonstructural Causes
Coagulopathy (esp vW)
Ovulatory dysfunction (↓ T3/4; PCOS; ↑ prolactin)
Endometriosis - <5%
Iatrogenic (IUD; TCA; warfarin; hormones)
Not yet classified (AV malformation)
Differential for enlarged uterus
Uterine Fibroids Pregnancy/ Molar pregnancy Haematoma Leiomyosarcoma/ endometrial carcinoma Adenomyosis
Extra-uterine Ovarian cyst Ovarian malignancy Ectopic pregnancy Pyosalpinx Hydrosalpinx Primary fallopian tube neoplasm Pelvic abscess CRC Bladder carcinoma
Investigations for enlarged uterus
- Pregnancy test/ ßHCG levels
- Bloods – FBC; iron studies, TFT; FSH+LH; oestrogen
- Pelvic USS – Confirm fibroids diagnosis and size
- ?MRI
Management of Fibroids
Medical - If Sx
- NSAIDs / Tranexamic acid/ mefenamic acid – may reduce bleeding
- Hormonal contraception –> COCP; POP; Mirena – control menorrhagia
- GnRH agonists – ↓ fibroid size within a few months – use pre-op– use 6m only (risk osteoporosis). Often recur after stopping the medication.
- Ulipristal acetate –>↓ size of fibroid and menorrhagia – use pre-op
Surgical
- Myomectomy (excise fibrois S.E blood loss; adhesions; C-section)
- Hysterectomy
- Hysteroscopy and transcervical resection of fibroid (submucosal fibroids)
Radiological
UAE (Uterine artery embolisation) - occlude vascular supply to fibroid
Complications of fibroids
- Recurrent miscarriage
- Iron deficiency anaemia
- Bladder / bowel symptoms
- Torsion (penduculated fibroid)
- Acute pelvic pain in pregnancy (red degeneration) - rapidly growing fibroid undergoes necrosis and haemorrhage
In pregnancy - Premature labour; PPH; Hydronephrosis; fetal malpresentation; IUGR
Pathophysiology of PCOS
Endocrine disorder –>excess androgen production and the presence of multiple immature follicles (“cysts”) within the ovaries.
↑ pulse frequency GnRH –> Excess LH –> ↑androgens –> testosterone)
o Suppress LH surge - no ovulation
o Follicles develop but arrested in early stage - ovarian cysts
o Unopposed oestrogen - ↑ risk endometrial hyperplasia
o Insulin resistance - ↑ levels insulin secretion –> suppress hepatic production SHBG –> higher levels of free circulating androgens.
RF and presentation of PCOS
Risk factors –> DM; Irregular menstruation; FH
Presentation
- Amenorrhoea / Oligomenorrhoea
- Weight gain/ obesity (+Insulin resistance
- -> Acanthosis nigricans)
- Masculinisation (Hirsutism, acne, male-pattern hair-loss)
- Chronic pelvic pain
- Depression (and other psychological symptoms)
- Infertility
Differentials for PCOS
- Hypothyroidisism
- Hyperprolactinaemia
- Cushing’s disease
- CAH
Ix for PCOS
Rotterdam Criteria - 2 out of 3
1) Oligo- ± anovulation
2) Clinical ± biochemical signs of hyperandrogenism
- ↑ test + LH and ↓ SHBG +prog
- ↑ 3:1 LH:FSH
3) USS –> Polycystic ovaries - ≥ 12 peripheral ovarian follicles ± ovarian volume >10 cm3 (string of pearls)
Consider oral glucose tolerance test (esp if BMI >30).
Mx of PCOS
Treat underlying DM; HTN; dyslipidaemia and OSA
Oligomenorrhoea/Amenorrhoea
• Low dose COCP – control bleeding and ↓ risk unopposed oestrogen
• Dydrogesterone – a progesterone analogue –> withdrawal bleed (~3monthly)
Obesity -Aim BMI <30 - will help trigger regular menstrual cycle.
- Healthy diet, exercise to ↑ insulin sensitivity, smoking cessation
- In severe cases –> orlistat (pancreatic lipase inhibitor) can be prescribed.
Hirsutism
- Cosmetically ± with anti-androgen medication (cyproterone, spironolactone or finasteride) - avoided during pregnancy as teratogenic.
- Eflornithine (topical cream) - ↓ growth rate of facial hair.
Fertility
• 50mg Clomifene (Selective oestrogen R modulator) –>induce ovulation- 50-60% conceive in 6m
- ↑ risk multiple pregnancies, ovarian hyperstimulation syndrome, ovarian Ca (limit to 6 cycles)
• ± Metformin improves insulin sensitivity, helps menstrual disturbance and ovulatory function (recommended up BMI >25 and want to conceive)
• Women with a normal BMI could also benefit from laparoscopic ovarian drilling ( reduce test, and increase FSH - ovulate)
Complications of PCOS
- Infertility
- Miscarriage
- Gestational DM/ T2DM
- Endometrial hyperplasia –> malignancy
- HTN/CVD
Classification and causes of amenorrhoea
Primary - failure to commence menses
Secondary - cessation of periods for >6m excluding pregnancy
Hypothalamic –> (↓ GnRH - ↓Fsh:LH )
- eating disorder; ↓/↑ T3/4 (affects LH/FSH); Kallman syn
Pituitary –> prolactinoma (I.GnRH sec); pitutary tumour; Sheehans syn (post-partum necrosis); AI/ radiation affecting pit; prolonged use contraception (downreg)
Ovarian - PCOS; Turners; POI; haemochromatomis (hypogonadism)
Adrenal gland - CAH
Genital tract abnormality - Ashermanns; Imperforate hymen; vaginal atresia; Androgen insensitivity; cryptomenorrhoea (hidden period as obstruction)
Causes and management of oligoemenorrhoea
Intervals between cycles >35d
o PCOS; Contraceptive/Hormonal treatments; Perimenopause
o Thyroid disease/Diabetes
o Eating disorders/excessive exercise
o Medications e.g. anti-psychotics, anti-epileptics
Mx
- treat cause
- COCP;POP
Pathophysiology and sx of dysmenorrhoea
As corpus luteum regress - ↓ progesterone endometrial cells release prostaglandin
- Spiral artery vasospasm - leading to ischaemic necrosis and shedding of the superficial layer of the endometrium.
- ↑ myometrial contractions
Secondary - underlying pelvic pathology
Sx
Crampy lower abdominal pain, - starts at the onset of menstruation ± radiation to back/thigh. Lasts 48-72 hrs, worse at onset of menses.
Other Sx: malaise, N+V diarrhoea, dizziness. ± uterine tenderness
RF and differentials for dysmenorrhoea
RF:
Early menarche; Long menstrual phase;Smoking; Nuliparity; Heavy periods (clot dysmenorrhoea – pain when endometrium expels clot)
Differentials (diagnosis of exclusion)
- Endometriosis (pain before period)
- Adenomyosis
- PID
- Adhesions
- IBS/IBD
Mx of dysmenorrhoea
- Stop smoking; local application of heat
- treat any underlying cause
1) NSAIDs (inhibit PGs) ± paracetamol
- Start few days before usual onset of pain
2) 3-6m trial of COCP/ POP/ Coil
Causes and Ix of heavy menstrual bleeding
- 40-60% no underlying cause (Abnormal uterine bleeding)
- Other: leukaemia, IUCD, PIC, hypothyroidism, Liver disease, SLE, Ca, Progesterone contraception, most commonly fibroids
Ix
• Bloods –> FBC (anaemia); TFT (?↓); hormones (?PCOS); Clotting screen (vW)
• USS – Detect Fibroids/ adenomyosis
• Urine pregnancy test (?ectopic)
• ?Hysteroscopy – biopsy pelvic masses
• ?Laparoscopy –abdo masses
• ?Endometrial biopsy – pathology/ inconclusive ± failure of pharm treatment
RF for heavy menstrual bleeding
- Age (more likely at menarche and approaching the menopause) (>45 ↑ risk)
- Obesity;
- Previous caesarean section
Ix and Mx of Abnormal uterine bleeding
Ix - Smear up to date
- STI screen
- USS for structural pathology
- ?laparoscopy (endometriosis)
1) Mirena Coil
2) tranexamic acid/NSAID or COCP/POP
3) Endometrial ablation/ hysterectomy
Ix for amenorrhoea/ oligomenorrhoea
- Pregnancy test
- TFT
- Hormone levels (prolactin, GnRH, LH, FSH, Oest, test)
- ?Karyotyping
- USS
- ? progest challenge (if get withdrawal bleed adequate oest but not ovulating)
Sx and mx of premenstrual syndrome
- sx 5-11 d before period with >1 symptom free week after
- sx –> bloating, breast tenderness, headaches, tension & irritability, fatigue, forgetfulness, mood swings, sleep problems, depression, carbohydrate craving, clumsiness, libido↓
Mx
- support, lifestyle change, vit B6, COCP
- Bromocriptine (Da Ag)
MOA and SE of Tranexamic acid
MOA - Antifibrinolytic - reversibly binds to lysine R on plasminogen/ preventing plasmin binding to and degrading fibrin.
SE - Headaches; Back ache; Abdominal pain
Example, MOA and SE of GnRH analogue
Zolidex (Nasal spray/ impant)
MOA - Analogue which activates GnRH R -↑ LH + FSH
Induces hypoestrogenic state –> amenorrhoea (due to pituitary desensitisation)
SE - Menopausal like symptoms e.g. night sweats, headaches, ↓ libido, mood swings
MOA; CI and SE of Ulipristal acetate
Used in fibroids and emergency contraception
- Selective Progesterone R modulator – acts by I. ovulation
CI – breast/gynae Ca/ hepatic disorder
SE • Dysmenorrhoea • Hepatic failure • Pelvic pain • Breast tenderness
MOA and SE of Danazol
Gonadotrophin inhibitior – suppressing the pituitary-ovarian axis by inhibiting the release of LH + FSH
SE - Androgenic effects
(hirsutism, acne); Breast atrophy; Hot flushes
Example, MOA, CI and SE of COCP
Microgynon –> Inhibits ovulation (stops LH surge), and reduces bleeding and period pain (Vaginal ring and patch work in same way)
CI - BMI>35/ breastfeeding; HTN; FH breast/cervical; hx migraines
SE • VTE • Breast / Cervical Ca • Headaches • Mood changes
Example, MOA, CI and SE of POP
- Norethisterone
- inhibit ovulation, thickening the cervical mucus
SE
Nausea; Headache; Bloating/ weight gain; Skin rash
MOA, CI and SE of Mirena Coil
Releases Levonorgestrel into the Uterus, preventing uterine shedding and reducing bleeding – thins endometrium and contraceptive
CI – recent STI/ hx PID/ endometritis
SE - Spotting; Ectopic pregnancy; Falling out
MOA and SE of MPA
Medroxyprogesterone acetate- Agonist of progesterone androgen and glucocorticoid R - i. follicular development and prevent ovulation
Thin endometrium + change cervical mucus
SE - menstrual disturbance/ acne; headaches; bone loss; blood clots
Types of Hysterectomy and SE
Subtotal (partial) - Uterus, not cervix
Total (Cervix + uterus)
+/- bilateral salpoingo-oophorectomy (fallopian tubes and ovaries)
Radical - Total + parametrium, vaginal cuff + part/ whole of fallopian tubes.
SE - Haemorrhage requiring blood transfusion
- Early menopause (change in blood supply to ovaries)
- Infection/ Pain/ Adhesions
- Anaesthetic risks
- total vault prolapse
Uncommon Damage bladder/bowel wound dehiscence Pelvic abscess/ infection Vaginal prolapse VTE/ PE (early mobilisation)
UAE SE
- Infection
- Infertility
- Failure
- Pain and fever post - op
Types of endometrial ablation; SE and CI
Transcervical resection (GA) - uses diathermy
Balloon ablation (LA/GA) - using heated fluids
- need cervical dilation
Microwave energy (LA) - <72s
Bipolar mesh (LA/GA)
- need cervical dilation
SE
• Infection
• internal organ damage uterine perforation/ bowel/bladder
• Haemorrhage
• new adhesions
• intrauterine scarring - obstructed outflow of menstrual blood - haematometra + pelvic pain
• Fluid overload/ electrolyte imbalance ( transcervical)
CI
Only if don’t want any more children - risk placenta praecia +/- accerta
- Endometrial hyperplasia/ Ca
What is a vasectomy and the complications
LA; vas deferens cut/blocked
Complications - haematoma (scrotum); infection; epidymitis; sperm granuloma; testicular pain
Types of uterine prolapse
Anterior
- Urethrocele (Lower) –> Prolapse of Urethra into the vagina; Stress incontinence
- Cystocele (Upper) –> Prolapse of Bladder into vagina; Few / no symptoms; If large may cause increased frequency, recurrent UTI
Middle
- Uterine prolapse –> Descent of the Uterus into the vagina
1st ° –> cervix stays in the vagina.
2nd ° –> cervix protrudes from introitus when standing/ straining.
3rd ° –> the uterine fundus lies outside the vagina. The vagina becomes keratinized and the cervix may ulcerate (bleeding ± discharge from ulcer)
o Pressure, urinary incontinence, dyspareunia
- Vaginal vault prolapse–> Descent of the vaginal vault after Hysterectomy; Often associated with cystocele, rectocele and enterocele’ Urinary retention, distal ureteric obstruction
Posterior
- Rectocele (Middle) - Prolapse of the rectum into the vagina (through levator ani); Sx - Constipation, urgency or symptomless - may have to reduce herniation prior to defecation
- Enterocele (Upper) –> Herniation of the Pouch of Douglas into the vagina
o Usually asymptomatic
RF for uterovaginal prolapse
Weakened pelvic floor:
- Post-menopause (reduced oestrogen)
- Pelvic surgery
- Obesity / Frequent heavy lifting
- Congenital/ genetics
- Loss of muscle tone / Repeated straining (chronic constipation/COPD
- Childbirth >1 –? Trauma / macrosomic fetus
Types of incontinence
Stress Urge Mixed (stress and urge) Overflow - Functional Fistulae
Pathophysiology and RF for stress incontinence
Weakness of pelvic floor and urethral sphincter leads to passage of urine when ↑ intra-abdo P
e.g coughing / laughing)
RF - weak pelvic floor (childbirth; obesity; chronic cough; post-pelvic surgery; post-menopausal
- prostacetectomy ; TURP;
- Infection; neurological disease; age; female
Pathophysiology and causes for urge incontinence
Detrusor overactivity causing high bladder pressure leading to sudden urge/ uncontrolable bladder emptying –> Large volumes, (day and night)
Causes
- idiopathic (overactive bladder) - precipitated by arriving home; running water; coffee
- Neurogenic (hyperreflexia): MS, PD, spinal cord injury (incl prolapsed disc/DM), stroke
- Bladder outlet obstruction: prostate/ bladder/ cervical/ colon ca; BPH/stone/stricture; STI/trauma/ blood clot/ faecal impaction
- UTI
Pathophysiology and causes for overflow incontinence
Bladder doesn’t empty properly/ incomplete voiding; overfill –> overflow
- hesitancy; terminal dribbling; poor stream
Causes
- bladder outflow obstruction (e.g. BPH/stricture/stone/ faecal impaction)
- impaired detrusor contractility (M.S/PD)
Reversible causes of incontinence
DIAPPERS Delirium Infection (UTI) Atrophy Pharm Psych (demenita) Excess UO (↑ intake/DI) Restricted mobility Stool impaction
RF for urinary incontinence
Predisposing
- Race; FH; Anatomy/neurology abnormality
Promoting
- Co-morbidites; ↑ intra-abdo P; cognitive impairment; UTI; pelvic prolapse; diet (caffeine, citrus fruit juice, alcohol), meds (diurectics; anti-cholinergics; anti-dep; sedatoves; alpha blockers
Red flags when present with urinary incontinence
- haematuria
- prolapse beyond introitus
- pelvic mass
- weight loss
- pain assoc micturition
- > 3 infections in 6m
Examination for urinary incontinence
- general –> BMI (heigh/weight); MMSE
- CVS - signs CR disease
- CNS - gait; check L1-S3 sensation and neuro exam
- Abdo - surgical scars, hernias, masses, distended bladder after voiding
- DRE - impaction; tone; mass (prostate in males)
- Vaginal - atophy; prolapse; urethral tenderness; strength pelvic floor (oxford scale) +/- cough/strain
- speculum
Ix for urinary incontinence
- freq/volume chart
- 3 day bladder diary
- urine dip +/- MC&S
- Bloods - FBC (↑ WCC); U&E (↑ ca - constipated/confused); glucose (DM)
Imaging
- USS kidneys- post-residual vol
- cystoscopy (if haematuria)
- USS abdo (CRF/obstruction)
- CT abdo (mass)
Specialist - urodynamic studies
- uroflowmetry
- cystometry (get detrusor P)
- video/ ambulatory urodynamics
Mx of uterovaginal prolapse
Conservative
- watch and wait
- lifestyle modification (stop smoking, constipation mx, weight loss)
- pelvic floor exercises
- vaginal pessary (frail) - S.E –> Vaginal discharge (smelly), discomfort, UTI, discomfort, ulceration , interfere with sex, incontinence
- topical oestrogens (if post-meno
Surgery
- hysterectomy
- Sacrocolpopexy/ Sacrospinous fixation - to fix vaginal vault
- colposuspension - strengthen pelvic floor (SE- Anaesthetic risk, infection, bleeding, DVT, voiding difficulty, urinary retention, urinary incontinence)
Mx of urinary incontinence
Stress
- pelvic floor exercises (trial 3m)
- vaginal tampon
- duloxetine
- vaginal tape (only if others fail - sling around urethra; SE - bladder perf; Damage to vessels/viscera; Voiding difficulties + urinary retention (short-term); Urgency and frequency; Groin/ suprapubic pain (short duration); Vaginal tape erosions.
- Other –> rectus fascial sling; repair; injection of bulking agents into bladder neck
Urge
- bladder training (6wk) - pelvic floor+ scheduled voiding
- Reduced caffeine intake, weight loss, modify fluid intake (none after 8pm)
- Oxybutynin
Other –>botox injection; sacral N stim; self-catheter (if neuro)
Overflow - review meds/bowel/ intermittent catheter; education; rx cause
Functional - mobility aids; continence aids etc
MOA of duloxetine and SE
Inhibit pre-synaptic 5HT + NAdr in Onuf’s nucleus of sacral spinal cord
↑ [5HT+NAdr] in synaptic cleft Stronger urethral contractions and persistent sphincter tone during storage phase
SE • N&V; GI Sx • Insomnia • Dizzy; drowsy • Anxiety; ↓ appetite • dry mouth; palpitation • flushing; headache • vision disorders (CI in glaucoma) • sweat changes
MOA of Oxybutynin and SE
Direct anti-spasmodic effect, acting on M1/2/3 SM R –> ↓ Detrusor activity - increase bladder capacity
Modified release tablets -↓ SE
SE • Dry mouth; headache • Urinary retention • Constipation/ diarrhoea • Blurred vision • Nausea; abdo pain
RF for PID
- Sexually active/ Aged 15-24 y/o
- Multiple sexual partners
- Intercourse without barrier contraception
- Hx of STIs/ PID
- Instrumentation of cervix - gynae surgery, TOP, and insertion IUS
- Retrograde menstruation
- Hormonal changes – ↓ barrier from cervix (COCP ↓ risk)
What is PID
• Infective inflammation of endometrium, uterus, fallopian tubes, ovaries + peritoneum
- Acute - <6 months; Chronic >6 months
- ~ 25% - Chlamydia and gonorrhoea
Presentation of PID
- asymptomatic
- Lower abdo pain (unilateral / bilateral)
- Deep dyspareunia/ Post-coital bleeding
- Menstrual abnormalities (e.g menorrhagia, dysmenorrhoea or IMB)
- Dysuria
- Abnormal vaginal discharge (purulent ± unpleasant odour)
Advanced - severe lower abdo pain, fever (>38° C), and n&v
Ix for PID
Vaginal examination
- tenderness of uterus/adnexae or cervical excitation
- palpable mass in the lower abdomen
- Speculum –> abnormal vaginal discharge noted ± cervicitis
- Endocervical (gonorrhoea and chlamydia) + High vaginal swab (TV,BV) NAAT
- Full STI screen
- Urine dipstick +/- MSU – to exclude UTI
- Pregnancy test
- ? FBC (CRP &WBC)
- TV USS – severe/ diagnostic uncertainty.
- ? Laparoscopy – severe
Complications of PID and when to admit
- Infertility - (tubal adhesion)
- Ectopic pregnancy - narrowing and scarring of the fallopian tubes
- Fitz-Hugh-Curtis syndrome (peri-hepatitis) – infection of the Glissons capsule around the Liver, leading to acute RUQ pain and tenderness
- Tubo-ovarian abscess (pocket of pus)
- Chronic pelvic pain
- Reiter syndrome
Admit –> pregnant; n&v/fever; signs abscess; need IV; HIV
Mx of PID
14-day Abx
• Low risk of Gonococcal –> Ofloxacin + Metronidazole BD
• High risk –> Ceftriaxone IM stat; then Doxycycline + Metronidazole BD
Advice
• Pain relief and rest
• Avoid sexual intercourse until Abx course complete and partner treated
• Contact tracing
RF for UTI
- Sexual activity
- New sexual partner
- Pregnancy
- Urinary/ faecal incontinence
- Renal tract malformation • Use of spermicides (condoms)
- ↓ oestrogen/menopause
- Immunocompromised/ DM
- Dehydration
- Obstruction (stones/catheter)
Causes of chronic pelvic pain
Gynae o Endometriosis/ Adenomyosis o Chronic PID o Ovarian cysts o Post C-section o Prolpase o Fibroids o Tumours
GI o Adhesions o Appendicitis o Constipation o Diverticular disease o IBS
Urinary
o UTI
o Calculus
Other o MSK o Degenerative joint disease o Low back pain o Psychological o CRPS
Pathophysiology and RF for endometriosis and adenomyosis
Endo - Chronic oestrogen-dependent condition –> growth of endometrial tissue in sites other than the uterine cavity (?retrograde menstruation), most commonly the pelvic cavity (incl. ovaries). Also includes uterosacral ligaments, the pouch of Douglas, peritoneum and lungs.
Adeno - extension of endometrial tissue and stroma into the uterine myometrium, affecting ~15% of women; causing a bulky, tender uterus and dysmenorrhoea
RF
• Early menarche / late menopause
• Delayed childbearing/ Long duration of menstrual bleeding
• Short menstrual cycles • FH – 1st ° relative
• HMB
• Defects of uterus or fallopian tubes
Presentation of endometriosis
- Dysmenorrhoea (2°) /chronic pelvic pain
- Menorrhagia
- Dyspareunia (↑ in menses)
- cyclical GI/urinary symptoms (?pain)
- infertility - with 1+ of above
Present at distant sites - Haemothorax; epistaxis; rectal bleeding
Symptoms ↓ in pregnancy and menopause
Ix for endometriosis
Examination – can be normal
•fixed, retroverted uterus
•Enlargement (tender + boggy = adenomyosis)
•Tender nodularity in the posterior vaginal fornix and uterosacral ligament
•Visible vaginal endometriotic lesions or Adnexal mass
•Tenderness/ focal pain on examination
- Pregnancy test – exclude ectopic pregnancy
- Urinalysis + cervical swabs -exclude STI/PID cause of pain,
- Laparoscopy(1st!) – visualise endometrial lesions
>Chocolate cysts (active endometriosis); Adhesions (+scars - inactive); Peritoneal deposits - Pelvic USS –severity and demonstrate pelvic mobility ± bowel involvement
MRI –visualise endometrial ectopic endometrial tissues
Mx of endometriosis
Medical
1) NSAIDs OR
2) COCP/vaginal ring - ↓ oestrogen
3) MPA OR Mirena Coil
4) Specialist
- GnRH agonist (e.g. soladex)
Surgical
1) Laparoscopic removal of ectopic endometrial tissue – Excision/ ablate
2) Hysterectomy with bilateral salpingo-oophorectomy (10% pain recurrence)
- replace hormones until menopause age
- Complications –> persistent pain; bladder/bowel injury; infection
3) Artificial insemination - ?IVF; potentially laparoscopic ablation
Presentation and RF for dyspareunia
RF - Peri / post-menopausal; Sexually inexperienced; hx sexual abuse
Presentation • Penetration / deep pain • Tightening of the vagina on penetration • Vulvodynia (vulva pain) ?Pelvic masses/ Suprapubic tenderness
Ix for dyspareunia
- Examination – Assess for Vaginismus, and for tenderness on palpation
- Cervical swabs – To assess for PID and STIs
- Urinalysis – Assess for the possibility of an UTI cause
- Laparoscopy – To assess for endometriosis
Mx of dyspareunia
oSex therapy - Modification of sexual technique + lubrication
oCBT
o Lidocaine – topically ( if pain alone the major complaint)
Treat underlying cause
e.g. vaginismus –> vaginal trainers and PT
What is an ectopic pregnancy and where can it happen
pregnancy which is implanted at a site outside of the uterine cavity
Tubal (>99%)
- Ampullary (55%)
- Isthmic (25%)
present late and often bleed catastrophically
Rare
Ovary; abdo; cervical
Rf for ectopic pregnancy
PMH
- Previous ectopic
- PID (adhesion formation)
- Endometriosis (adhesions)
- tubal pathology
Contraception
- IUD/IUS
- POP/ implant (fallopian tube ciliary dysmotility)
Iatrogenic
- Pelvic surgery – especially tubal surgery
- Assisted reproduction i.e. embryo transfer in IVF
Clinical features of ectopic pregnancy
- Lower abdominal/pelvic pain ± irregular PV bleeding or hx of amernorrhoea
- Vaginal discharge – brown (prune juice) –>result of decidual breakdown (as suboptimal β-HCG)
- Shoulder tip pain (haemoperitoneum)
Other –> Breast tenderness, GI symptoms, dizziness, fainting or syncope, urinary symptoms, passage of tissue, rectal pressure or pain on defecation
Ix of ectopic pregnancy
On examination
- Abdo/ pelvic tenderness; enlarged uterus
Vaginal –>
- Cervical excitation +/- adnexal tenderness.
- Fullness in pouch of douglas (if ruptured)
If ruptured –> haemodynamically unstable
o pallor, ↑ CRT, tachycardia, hypotension, shock/collapse
o signs of peritonitis (abdo rebound tenderness and guarding)
o Abdominal distention
- Pregnancy test
- if +ve pelvic USS (+/- TV USS) -
If can’t see location
(i) very early intrauterine pregnancy (ii) miscarriage (iii) ectopic pregnancy - serum β-HCG
>1500 iU + no intrauterine –> ? ectopic –> diagnostic laparoscopy
<1500 iU + pt stable –> blood test 48 hours later:
• Viable pregnancy –> HCG level double every 48 hours
• Miscarriage –> HCG level halve every 48 hours
Criteria for medical v surgical mx of ectopic pregnancy
Medical
- No significant pain
- Adnexal mass <35mm
- No intra-uterine pregnancy on USS
- Serum hCG <1500 IU/L
- Not ruptured
- Can attend for follow up (2 serum hCG day 4 &7; then every week until -ve)
- 24h access to gynae services (+ sx rupture)
Surgical
- Significant pain
- Adnexal mass >35mm
- Fetal heart beat visible on USS
- Serum hCG >5000IU/L
- Ruptured
- Can’t attend for follow up
Medical v surgical mx of ectopic
Medical
+ve - Avoids surgical complications and the patient can be at home after the injection.
-ve - SE of methotrexate (abdo pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (use contraception for 3-6 m after use), treatment failure
Surgical
+ve: Reassurance about when the definitive treatment can be provided, high success rate.
-ve: GA risk, risk of damage to bladder/ bowel/ureters, DVT/PE, haemorrhage, infection, risk treatment failure (salpingotomy - some of the pregnancy may remain within the tube), ↑ risk of recurrent ectopic in salpingotomy, need Anti-D prophylaxis
Options for mx of ectopic
Conservative –> no sx/ rupture/ <3cm and hcg<1500
- sx of rupture and 24h access
Medical –> Methotrexate IM
Surgical –> Laproscopic salpingectomy
All - Miscarriage Association; Written information / leaflets; Counselling and Support
RF for miscarriage
• >35 (↑ ch. abnormalities) • Previous miscarriage (esp if ≥ 2 before) • Obesity • Ch. abnormalities (maternal or paternal) • Smoking/ caffeine • Uterine anomalies e.g. fibroids • Previous uterine surgery • Anti-phospholipid syndrome/ SLE • Coagulopathies • PCOS • Poorly controlled DM/ thyroid • Serious maternal infection – causing fever --> Rubella, CMV can cross placenta o Malaria, chlamydia, listeria,syphilis • Alcohol (esp >5 units/wk) and drug use • Folate deficiency • Methotrexate
What is a miscarriage and sx
spontaneous loss of the fetus <24/40; occurs in 1/4 pregnancies
Sx
- PV bleed +/- clots/POC
- haemodynamically unstable
- suprapubic pain
- haemoperiteum
- ? distended abdo
- cervic open/closed
- uterine tenderness/ adenxal mass/collection
Classifications and sx of miscarriage
Threatened - mild bleeding/pain; cervix closed (viable)
Inevitable - heavy bleeding/pain; cervix open (?viable)
Missed (silent) - on-going discharge; small for dates; asymptomatic but no fetal heart pulsation; anembryonic (empty gestation sac)
Incomplete - POC partially expelled (retained POC >15mm + proof pregnancy previously); cervix open
Complete - hx bleeding/clots/ POC; pain; cervix closed (previous proof and POC <15mm now)
Septic - Infected POC - fever; tender uterus; bleeding; pain
Mx of miscarriage
Threatened - observe
Inevitable - admit (if haemodynamiccal unstable)/ option for conservative/ med/ surgical mx
Missed - rescanned by 2nd person 7-14d to confirm-conservative/ med/ surgical mx
Incomplete - medical/surgical mx
Complete - discharge to GP
Septic - admit + sepsis 6 + remove infected tissue (med/surgically)
Differentials of miscarriage
- Ectopic pregnancy
- Hydatidiform mole
- Cervical/uterine malignancy
Ix for miscarriage
+ve pregnancy test - send to EPAU
USS (?TV) –> fetal development + heartbeat (if >6/40)
- yolk sac; ovarian cysts; free fluid/ mass; position of uterus
- If no heartbeat 2nd scan 1-2 weeks later
Serum hCG
o> 1500 and no signs of pregnancy in uterus – significant
o<1500 – hCG 48 hours later ( if ↑ x 63% - intrauterine pregnancy; <63% - ?ectopic)
?FBC; blood group and Rh status; triple swaps and CRP (if pyrexic)
Mx of miscarriage
If >12 weeks ? Anti-D prophylaxis
-Conservative (<12/40) - wait
+ve: remain at home, no S.E. of meds/surgery, 24/7 access to gynae services
-ve: Unpredictable timing (takes longer), heavy bleeding + pain during passage of POC, may require further intervention + need for transfusion. Worries about being at home.
Follow-up: Repeat scan in 2/52 OR pregnancy test in 3/52.
- medical (>14/40) –> Mifepristone + Misoprostol (48h later) - stimulate cervical ripening and myometrial contractions.
+ Analgesia + anti-emetics
+ve: Can be at home, 24/7 access to gynae services, no anaesthetic/ surgical risk.
-ve: S.E of meds: vom/d, heavy bleeding (up to 3/52) and pain during passage of POC, chance of requiring emergency surgical intervention.
Follow-up: Pregnancy test 3 weeks later
Surgical - Surgical Evacuation of Retained products of Conception (SERPC) - using suction or manual vacuum aspiration with LA if <12 weeks
+ve: Planned procedure (help pt cope), unaware during the process (under GA), discharged same day
-ve: Anaesthetic risk, infection (endometritis), uterine perforation, haemorrhage, Ashermen’s syndrome, bowel/ bladder damage, retained POC, damage/weakness cervix
- histology on tissue
What is a recurrent miscarriage
Loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner
Causes and mx of recurrent miscarriage
- Balanced (Robertsonian) translocations
- Uterine anomalies
- Antiphospholipid syndrome
o I. of trophoblastic function – poor oxygenation and nutrient supply to the foetus
o Complement activation and inflammatory response at the maternal/foetal interface – Leading to poor oxygenation of the fetus - IUGR, Still birth, Pre-eclampsia - Thrombophilia –>hypercoagulability
- Unexplained
Ix and mx for couples with recurrent miscarriage
- anti-phospholipid Ab (2+ tests >12wk apart)
o Mx - LMWH + lose-dose Aspirin + mx risk of DVT/PE; Stroke - Karyotype
- Pelvic USS/ Hystereoscopy for uterine malformation +/- cervical weakness
- thrombophilia screen
- DM and hypothyroidism
What is GTD
Gestational trophoblastic disease –> Spectrum of disorders of trophoblastic development arising from abnormal ch no. in fertilisation (pregnancy related)
1) Pre-malignant conditions (more common) – such as partial(1 ovum and 2 sperm) /complete (empty egg and 1 sperm) molar pregnancy
2) Malignant conditions (rarer) - invasive mole/
choriocarcinoma (trophoblastic cells of placenta)
Staging of GTD
- Stage 1 – Confined to Uterus
- Stage 2 – Outside uterus, but limited to genital structures
- Stage 3 – Extends to the lungs
- Stage 4 – Affecting any other metastatic site
RF for GTD
- <20 / >35
- hx GTD/ miscarriage
- Asian
- oral contraceptive pill
Presentation of GTD
- Vaginal bleeding + abdo pain in early pregnancy
- Large uterus for dates (+soft/boggy)
- Absence of fetal movement detected
- Met signs (dyspnoea, etc)
Later
• Anaemia
• Hyperemesis (↑ β hCG)
• Hyperthyroidism (↑ β hCG stimulates thyroid)
Ix for GTD
- Urine + blood hCG – remain ↑ after pregnancy
- Histology POC – post treatment/ non-viable pregnancies
- Pelvic USS – T2 onwards - complete mole =granular/ snowstorm appearance + central heterogeneous mass and surrounding multiple cystic areas/vesicles.
- Staging CT CAP – if suspect mets
Mx of GTD
Register with GTD centre for follow-up and future monitoring
Surgical - Suction curettage –complete/partial molar pregnancy
Medical - evacuation (partial mole of a greater gestation with fetal development & isn’t conducive to surgical evacuation) – urinary β -hCG after 3/52
Chemotherapy – rising hCG after surgical evacuation, evidence of mets, or histological evidence of choriocarcinoma
Anti-D prophylaxis
After - 2/52 serum+urine hCG until normal (+ 4/52 if complete for 6m)
Advice - not to conceive until hCG levels have been normal for >6 months, and women who undergo chemotherapy are advised not to conceive for one year after completion of treatment
Presentation of Hyperemesis gravidarum
Prolonged and severe N&v of pregnancy (lasts >20/40) due to rapidly ↑ β – hCG levels
o >5% pre-pregnancy weight loss
o Severe dehydration
o Deranged bloods (e.g.↓ K/Na)
o Marked ketosis
o Nutritional deficiency/ muscle wasting (risk wernickes)
? mallory weiss tear; AKI; liver failure
- baby may have low birth weight/ be premature
Measure using PUQE score (Pregnancy-Unique Quantification of Emesis)
RF for Hyperemesis gravidarum
- First pregnancy
- Hx of hyperemesis gravidarum
- Raised BMI
- Multiple pregnancy
- Hydatidiform mole
- GTD
Differentials for Hyperemesis gravidarum
- Gastroenteritis
- Cholecystitis
- Appendicitis
- Hepatitis
- Pancreatitis
- Chronic H. Pylori infection
- Peptic ulcers
- UTI or pyelonephritis
- Metabolic condition –> thyrotoxicosis, Addisons, DKA
- Neurological conditions
- Drug-induced (Abx / iron)
Ix for Hyperemesis gravidarum
Beside – Weight; Urine dip (ketones)
Lab
o MSU; FBC (anaemia, infection, haematocrit (can ↑)); Blood glucose (exclude DKA)
o U&E (↓ K/Na, dehydration, renal disease)
Severe causes
o LFT: exclude liver disease e.g. hepatitis or gallstones, monitor malnutrition
o Amylase: exclude pancreatitis
o TFT: ↑/↓-thyroid
o ABG: exclude metabolic disturbances, monitor severity
USS –>confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease/ ectopic
Mx for Hyperemesis gravidarum
Mild - Reassurance and rest +/- antiemetics (cyclizine) hydration, dietary advice
Moderate (or community mx failed) – ambulatory daycare.
- IV fluids, parenteral antiemetics and thiamine. Managed until ketonuria resolves.
- PPI for reflux, oesophagitis or gastritis
Severe – inpt mx
- IV rehydration + KCL (guided by electrolytes)
- IV antiemetics
- Thromboprophylaxis
If can’t control may need termination
Choice of anti-emetics in Hyperemesis Gravidarum
1) Cyclizine; Promethazine; Chlorpromazine
2) Metoclopramide (max 5d due to risk EPSE); Domperidone; Ondansetron
3) Hydrocortisone IV (Once sx improve –> pred PO and wean)
Drugs that can can cause fetal abnormalities
In t1 - teratogenesis and T2/3 - affect growth
Li –> Ebstein anomaly, neonatal hypothyroidism, foetal hypotonia, poor reflexes, arrhythmia – strict monitoring
SSRI –> pulmonary HTN, (cardiac defects – paroxetine), miscarriage, low birth weight.
o Fluoxetine safer
oWithdrawal symptoms –> poor adaptation, jitteriness, irritability and poor gaze control
Valproate - ↑ risk NTD (use contraception)
Carbamazepine - cleft lip
Lamotrigine - ↑ risk of SJS
Anti-manic drugs - infants –>sedation, poor feeding, behavioural effects and developmental milestones.
Olanzapine - fetal macrosomia, GDM
Define Infertility
- Primary –Couples who have inability to conceive >12m of regular unprotected intercourse
- Secondary – Couples who have previously been able to become pregnant, but now cannot
Causes of infertility
- Idiopathic
- Female: ovulation disorder (PCOS, ovarian failure, hyperprolactinaemia); Anatomical anomalies (PID, STIs, sterilisation, fibroids, endometriosis); Turners
- Male - disorders of sperm morphology/ vol/ concentration/ motility
Things to ask in the history regarding infertility
Female
Age; Methods of contraception
Duration + Type of infertility 1° /2°
-2° - previous birth e.g C-section/ PPH/ ectopic
Menstrual cycle – ovulating? Regular/irreg; Menorrhagia/ dysmenorrhoea/ amenorrhoea
Tubal surgery/ PID/ Pelvic surgery
pelvic pain – endometriosis/ fibroids
Taking folic acid; Smoking (↑ infertility)
Chemo/RT
Male
- Alcohol/ smoking (↓ sperm quality)
Previous surgery (urogenital) /infections (STI)
Sexual dysfunction – erectile/ ejaculatory
Varicocele; Cryptorchidism
Ask if had semen analysis (abnormal)
Chemo-RT
Ix for infertility in females
BMI
Pelvic exam -structural abnormalities; Fixed/ tender uterus
Mid-luteal progesterone - ? ovulating
Hormone levels (FSH + LH) (Day 2) o ↑↑ may suggest poor ovulatory function o High LH:FSH -?PCOS
Tubal patency assessment
o Hysterosalpingogram
o Diagnostic laparoscopy and dye
Genetic testing (Turners) and presence of 2 ° sexual characteristics
Additional: Pelvic USS (ovaries, uterine abnormalities); Hysteroscopy; Prolactin levels/TFTs; Testosterone/SHBG; Screen for chlamydia; Rubella status (?MMR vaccine. ? Booster)
Ix for infertility in males
Semen analysis x 2 from masturbation after >3d abstinence 3m apart
Hormone analysis (FSH + Testosterone) o ↑ FSH may suggest impaired spermatogenesis
USS Testes
hx urinary sx / abnormal findings when exam testicles,
Genetic testing (Kleinfelters)
Normal semen analysis values
o Volume (ml) - >1.5ml o Total sperm – 39 x 106 per ejaculation o pH - >7.2 o Sperm concentration – 15 x 106 per ml o Total motility ( % progressive & non‑progressive motility): > 40% motile or > 32% progressive motility o Vitality: 58% or more live spermatozoa o Morphology (normal forms) - >4%
Mx for female infertility
Dependent on cause
- unexplained –> IVF (>2 years not concieved)
- tubal blockage –> Tubal anastomosis + reimplantation
- Cervical factors - low pH (sodium bicarb douche); poor mucus quality (intra-uterine insemination)
- Hypothalmic-pit failure –> lifestyles, BMI >19, pulsatile GnRH agonist (stim release FSH+LH - SE- hot flush; headache; osteoporosis)
HPG axis dysfunction (PCOS) - PCOS mx + clomifene citrate (block -ve feedback of oest - SE –>hot flushes, headche, n+v, ovarian enlargement) +/- laproscopic drilling + metformin
Ovarian failure –> IVF with donor egg
Mx for male infertility
Stop drinking/smoking; lose weight; loose fitting underwear and avoid sauna (reduce scrotal temp)
- low semen vol –> IVF/ intra-uterine insemination
- Oligospermia - clomifene citrate / IVF etc
Azoospermia - correct bloackage OR sperm extraction then injection
Hypogonadism - GnRH ag
Ejaculatory failure - sex therapy
Name some Assisted reproduction techniques
IVF - fertilise in a lab. Fertilised egg (zygote) is cultured for 2–6 d in growth medium and then transferred back to uterus to develop
Intra-uterine insemination - Placing sperm in uterus, to ↑ the no. of sperm that reach the fallopian tubes and subsequently ↑ the chance of fertilization
Intracytoplasmic sperm injection (ICSI) - single sperm is injected directly into an egg after being extracted from testicles
WHO principles of screening
- Important health problem.
- Should be a treatment for the condition.
- Facilities for diagnosis and treatment should be available.
- A latent stage of the disease.
- Test/examination for the condition.
- Test should be acceptable to population.
- The natural history of the disease should be adequately understood.
- Agreed policy on whom to treat.
- Total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
Describe the cervical smear test process
- 3-yearly from 25-49, and then 5-yearly to 50-64 year olds
- smear at transformation zone –> detect CIN and HPV status
EITHER:
- normal - routine recall
- inadequate - repeat
- abnormal borderline/ mild dyskaryosis but HPV -ve –> repeat smear 6-12m
- Abnormal borderline/ mild dyskaryosis but HPV +ve –> Colposcopy
- Mod/severe dyskaryosis –> urgent colposcopy +histology
Looking for abnormal vascular pattern (mosaicism, punctation); abnormal staining of the tissue (aceto-white, brown iodine) on colposcopy
What is CIN and the grades
Cervical intra-epithelial neoplasia (CIN) - abnormal growth of the cervical mucosa at transformation zone; it is potentially pre-malignant
CIN 1 (Mild) - Basal 1/3 of epi CIN 2 (Mod) - Basal 2/3 of epi CIN 3 (Severe) - >2/3 of epi /full thickness --> carcinoma in situ
RF for CIN
- Most common aged 25-35 (though can occur at any age)
- Young commencing sexual activity (<18)
- Giving birth <16
- Multiple sexual partners
- Immunosuppression
- Smoking
Mx if CIN
CIN1 –>ablation
CIN 2+3 –>
Excisional: LLETZ (large loop excision of the transformation zone) + histological analysis (under LA)
o Complications – Bleeding, infection, ↑ risk of premature rupture of membranes
Colposcopy after 6 m, then yearly for 10 yrs
Screen for STIs
Don’t treat while pregnancy
Describe the breast cancer screening process
47-73 every 3 years - mammogram (or <47 +RF; if <35 - USS)
RESULTS:
- normal
- abnormal –> breast exam; repeat mammograph +/- breast USS
of the abnormal results 1/4 have cancer
What is endometrial hyperplasia and what causes it
Precancerous prolif of
endometrium –> ↑ volume of endometrial tissue –> abnormal thickening of the lining of the uterus - ↑ risk endometrial ca (hyperplasia +/- atypia)
Cause–> Excess/ unopposed oestrogen
o early menarche, late menopause, PCOS –> ↑ anovulatory cycle
o Exogenous oestrogen therapy (e.g. HRT); Obesity; Low parity
Diagnosis and mx of endometrial hyperplasia
SX –> AUB
Ix –> TV USS - thickened endometrial stripe ↑ suspicion
-Confirm diagnosis - endometrial biopsy
Mx
- Hyperplasia-atypia
o Hormonal - Mirena and surveillance biopsy to identify progression or high dose progesterone
- Atypical hyperplasia
o Total hysterectomy ± bilateral salpingo-oophorectomy
If CI - regular surveillance biopsies
Types +RF and presentation of endometrial cancer
1) Endometrial adenocarcinoma- related to unopposed oestrogen; Obesity; Lynch; endometrial hyperplasia and increasing age
2) Other: papillary serous; clear cell etc - oest indep
Presentation
AUB – intermenstrual, irregular menstruation, postmenopausal (10% risk)
- Less commonly blood stained, watery, purulent vaginal discharge
Abnormal cervical smear
Advanced/ mets (cervix, bladder, rectum, regional LN)
- Abdo pain/distention; weight loss; feeling of fullness in the abdo, abnormal bowel/ bladder function –> CT CAP
Ix for postmenopausal bleeding
- Abdo exam– masses
- Speculum - vulval/vaginal atrophy, or cervical lesions.
- Bimanual– assess size & axis of uterus before endometrial sampling
- TV USS – ix PMB- >4mm endometrial thickness need to pipelle biopsy for histology (of <4 and recurrent AUB)
Hysteroscopy with biopsy - AUB, multiple RF for Ca or v. thick endometrium on USS
Mx of Endometrial Ca
- Weight loss
Stage 1) Total hysterectomy + bilateral salpingo-oophorectomy + Peritoneal washings
Stage 2) Radical hysterectomy + assess & remove pelvic LN ± adjuvant radiotherapy.
Stage 3) Chemo +/- RT +/- max de-bulking surgery
Stage 4) RT / high dose oral prog
Stages of endometrical Ca
Stage 0 – carcinoma in situ
Stage 1 - confined to organ of origin
Stage 2 – Invasion of surrounding organs/tissues
Stage 3 – Spread to distant nodes/ tissue in pelvis
Stage 4 – Distant mets
Differentials for Post-menopausal Bleeding
- trauma/ bleeding from elsewhere
- oestrogen-secreting ovarian tumours e.g. granulosa-thecal cell or oest from HRT
- endometrial –> atrophy; polyps; hyperplasia; cancer; endometritis/PID
- Cervical –> polyps; cancer; cervitis
- vaginal – atrophic vaginitis, vaginal cancer
- vulval pathology – dermatitis; dystrophy; cancer
- systemic problem – bleeding disorders, mets cancer e.g. ovarian, CRC
Pathophysiology and RF for cervical cancer
Mainly SCC (99% caused by HPV) - developed from CIN
Other - adenocarcinoma/ mixed
RF - • HPV infection (16 + 18) • Multiple sexual partners • Young age 1st intercourse • Exposure (no barrier contraception)/ other STIs • Immunosuppression/ HIV • Smoking • use COCP >8 years) • Non-compliance cervical screening
Presentation of cervical cancer
- Screening
- AUB (+ can see ulcer on speculum)
- Vaginal discharge (blood-stained, foul-smelling)
- Dyspareunia
- Pelvic pain
- Weight loss
Late symptoms
- Painless haematuria, painless PR bleeding, leg oedema, altered bowel habit, loin pain, radiculopathy
- ?pelvic masses.
- GI–hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.
Ix for cervical cancer
- test for chlamydia if <50 y/o (if +ve treat)
- colposcopy + biopsy
Confirmed - baseline bloods and CT CAP +/- MRI pelvis
Mx of cervical cancer
1a) Radical trachelectomy (preserve fertility) - removal of the cervix and upper vagina OR
laparoscopic hysterectomy
1b) Radical hysterectomy +/- RT+ neoadjuvant/ adjuvant chemo
2) Radical hysterectomy +chemoradiation
3) Chemoradiation
4) Surgery/ pallative chemo
Review every 4m after treatment complete for 2 years then 6m 3 years
Stages of cervical ca
Stage IA: Invasive cancer identified only microscopically.
Stage IB: Gross lesions confined to the cervix or preclinical lesions greater than
Stage II: extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage III extended into the pelvic sidewall/ lower third of the vagina/ hydronephrosis
Stage IV extended to involve the mucosa of the bladder and/or rectum/ mets
Complications of surgery and RT for endometrical ca
--> Surgery Infection VTE Haemorrhage Vesicovaginal fistula Bladder dysfunction Lymphocyst formation Short vagina
--> RT Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function
