Gynaecology

• Abnormal vaginal discharge
• Abnormal vaginal bleeding
• Lower abdominal pain
• Dyspaerunia
• Adnexal tenderness
• Cervical motion tenderness

• Laparoscopy = gold standard
• Adnexal tenderness (not v specific)
• Cervical motion tenderness + lower abdominal pain (not v sensitive)

• Unprotected sex
• Young age
• Smoking
• Bacterial vaginosis
• Peri-menstrual sex
• IUD insertion

• ABs:
• - Azithromycin 1g stat
• - Ceftriaxone 250mg IM stat or ciprofloxacin 500mg PO stat
• - Doxycycline 100mg bds 14d
• - Metronidazole 400mg bds 14d
• Contact tracing
• Prevent future cases - barrier contraception & screening

• Bloods:
• - FBE
• - BhCG
• - ESR/CRP
• - cultures
• - Serology hep, HIV, syphillis if high risk
• MSU: First catch PCR for chlamydia
• Endocervical PCR for chlamydia or gonorrhea
• HVS - BV & trichomonas
• TVUSS: adnexal mass or tubal oedema
• Laparoscopy = gold standard (adhesions, erythema, oedema, pus, abscess)

• Rotterdam - 2/3 of:-
• - Oligo/an-ovulation
• - Hyperandrogenism (clinical or biochemical - inc free T, inc FAI, dec SHBG)
• - TV USS evidence of polycystic ovaries

• Irregular periods - COC
• Infertility - Wt loss, test ovulation, IVF
• Hirsutism - COC with cyproterone, cyproterone, spironolactone

• CVD (dyslipidaemia)
• Diabetes Mellitus
• Endometrial hyperplasia

• Simple wuth no atypia - <1%
• Complex with no atypia - 3%
• Simple with atypia - 8-9%
• Complex with atypia - 28-30% (20% already have concomitant uterine Ca)

• Type I (80%)
• - Endometrioid (majority adenoCa)
• - Oestrogen-related (unopp E, tamoxifen)
• - Pre/perimenopausal onset
• - Protective factors: COC, smoking, P
• - Presentation - abnormal bleeding, thickened endometrium
• - Good prognosis
• Type II
• - Non-endometrioid (papillary serous, clear cell)
• - Not associated with E exposure
• - Post-menopausal
• - Endometrium not thickened
• - Poorer prognosis

• Hysteroscopy D&C = gold standard
• Pipelle endometrial sample (low sensitivity)
• --> grading of sample

• Pregnancy-related:
• - Ectopic
• - Miscarriage
• Non-pregnancy-related:
• - GIT - appendicitis, mesenteric adenitisi
• - GUT - UTI, renal calclui
• - Gynae - ovarian cyst accident, bleeding, torsion, PID
• - MSK
• - Endocrine - DM
• - Factitious/psychosomatic

• Non-HRT: Bleeding after 1 year of amenorrhea
• Cts E & P HRT: bleeding that persists after the 1st 6/12 of Tx
• Cyclical P HRT: irregular bleeding (regular cyclical withdrawal bleed is normal)

• Vaginal/uterine atrophy (60-80%)
• HRT (15-20%)
• Uterine/cervical polyps )2-12%)
• Endometrial hyperplasia (5-10%)
• Cancer - vaginal, cervical or uterine

• D & C
• Endometrial biopsy (with anti-prostaglandin administration 1h before)
• Hysteroscopy (if cervical stenosis/discomfort/persistent bleeding/inadequate specimen)

• Simple, no atypia --> mirena
• Simple with atypia --> hysterectomy
• Complex without atypia --> mirena/high dose P/hysterectomy
• Complex with atypia --> TAH BSO

• Depends on stage (1-4)
• TAH BSO, peritoneal washings
• Para-aortic lymphadenectomy
• Pelvic irradiation
• Chemotherapy
• R/v 3/12ly for 2 years (80%) - vault/lower 1/3 of vagina

• White-green caseous discharge, fullness in adnexae, vulval pruritis
• HVS shows hyphi
• Antifungals: topical ketoconazole/nystatin, PO fluconazole (single dose)
• NB. mild candidiasis is normal

• Pregnancy
• Premenstrual point in cycle
• Glucose intolerance
• OCP
• Antibiotics
• Steroids

• Grey, frothy, fishy PV DC & pruritis
• Dx whiff test, pH change, HVS (clue cells)
• Metronidazole (2g stat dose)

40%

• Green, frothy, fishy PV DC; strawberry cervix; pruritis
• Dx - whiff test, HVS (flagellae)
• Metronidazole (2g stat, treat partner)

• 70% asymptomatic, present later with complications (infertility, PID)
• Thin, white, anodorous PV DC
• Endocervical (obligate intracellular)/1st catch PCR
• Azithromycin 1g stat & doxycycline 100mg bds 14d

• Thick green DC
• Endocervical/1st catch PCR
• Ceftriaxone 250mg IM stat or ciprofloxacin 500mg PO stat

• Every 2 years
• First smear within 2 years of 1st sexual intercourse or 18-20
• Cease at 70 if two normal smears in past 5 years

Mid-cycle

Ca reduced by 92.5% with two-yearly screens.

• LSIL (HPV & CIN1): repeat in 12m then 24m if normal result; if persistently LSIL, annual smears until 2+ are negative
• Possible/actual HSIL (CIN2 & 3): refer for colpopscopy & biopsy

• CIN1: >2/3 of upper epithelium showing good differentiation
• CIN2: maturation/differentiation in upper half of epithelium with mitotic figures in basal half
• CIN3: <1/3 of upper epithelium showing differentiation

16-25% in 2-4 years

18-35% in 1-23y

• Visualise transformation zone
• Acetic acid --> abnormal epithelium whitens
• Iodine (Schiller's test) --> columnar/abnormal squamous epithelium does not stain
• Other changes: punctation, mosaic, atypical vessels irregular in size, shape and course

• Cryosurgery (CIN2 only)
• Ablative Tx
• Excision - large-loop excision of the transformation zone (LLETZ)
• Cone biopsy (suspected adenoCa in situ, poorly visualised, -ve colposcopy, early invasive disease expected)
• Hysterectomy
• Follow up: colposcopy & pap smear at 6m, repeat Pap & HPV typing at 12m, than annually until 2 consecutive negatives

• Perform colposcopy to exclude invasive cancer
• If CIN, defer Tx to postpartum
• If invasive --> cone biopsy (5% foetal loss)

• HPV 16, 18, 33, & 35
• No pap smear
• Abnormal pap smears
• Early age of sexual activity
• Multiple sexual partners
• Partner with previous partner with cervical cancer
• Smoking
• Immunosuppression
• High parity
• Age bimodal - 35-39 & 60-64

Adenocarcinoma in situ - coexists with CIN in 70% of patients, usually at the squamocolumnar junction

• Cone biopsy (30% risk skip lesion)
• Hysterectomy recommneded if fertility not an issue

Atypical glandular cells of undetermined significance (morphological changes in glandular cells beyond benign reactive process but insufficient for AIS)

Squamous cell Ca (85%), the remainder are adenoCa

Squamous epithelium or endocervix (most squamous Ca arise in transformation zone)

• Abnormal vaginal bleeding - menorrhagia, postcoital, irregular, postmenopausal
• Vaginal discharge

• FBE, eLFT
• CXR, abdominopelvic CT, MRI of pelvis (PET good)
• Staging clinically under anaesthesia (FIGO) - vaginal/pelvic and rectal examination, cervical biopsy, cystoscopy +/- D & C and sigmoidoscopy

• Polyps
• Fibroids
• Endometrial hyperplasia
• Cancer (adenoCa, adenosquamous, papillary serous, clear cell, sarcoma)

• Often asymptomatic
• Menorrhagia
• Intermenstrual bleeding
• Infertility
• Abdo swelling
• Pressure effecgts --> bladder/veins (oedema, DVT)
• Labour obstruction

• Medical: P & GnRH analogues (regrowth 3/12 after cessation)
• Surgical: hysteroscopic resection, myomectomy, hysterectomy (+/- pretreatment with GnRH)

• Red degeneration during pregnancy with torsion (pain & temp)
• Enlarged uterus
• Risk of abortion
• Labour obstruction
• PPH
• Difficult C/S
• Post-myomectomy rupture is rare

• Childhood/post menopausal
• Rapid growth
• Bilateral
• Solid, nodular or irregular consistgency
• Fixation
• Ascietes
• Leg/vulval oedema
• Evidence of metastases

• Nulliparity
• Early menarche or late menopause
• Endometriosis
• Infertility
• PCOS
• Obesity
• FHx (BRCA1 & 2 mutations)
• Previous breast/endometrial cancer
• Lynch syndrome
• Peutz-Jeghers syndrome

• Asymptomatic in early disease
• Mass effects later on:
• - abdo pain
• - pelvic pressure
• - back pain
• - swelling
• - dyspepsia
• - urinary frequency
• - constipation
• - DVT

• FBE, eLFT
• Tumour markers (CA125 - epithelial, CA19.9 - mucinous, CEA - bowel mets)
• hCG, AFT, inhibin, LDH if non-epithelial suspected
• Abdominopelvic USS & CT
• CXR
• Colonoscopy

• Smoking
• Immunosuppression
• HPV
• CIN & vaginal intraepithelial neoplasia

• Surgery: preferred - wide local excision, skinning vulvectomy, laser ablation
• Medical: imiquimod or 5-FU cream (only 75% response)
• Long term follow up: 30% recur!

Squamous cell carcinomas >> melanoma > bartholin's gland

• Transverse cervical (cardinal) ligaments
• Uterosacral ligaments
• (round ligaments --> labia majora, but minimal support)
• (pubocervical ligament attaches Cx to pubic symphysis)

Infundibular ligaments (to posterolateral wall)

• Childbirth:
• prolonged 2nd stage
• large baby
• perineal trauma
• Menopause
• Genetic/congenital
• Gynaecology surgery
• Increased IAP:
• obesity
• chronic cough
• constipation

• 1st deg - Cx does not reach introitus
• 2nd deg - Cx reaches introitus
• 3rd deg - Cx & uterus protrude
• Procidentia - Cx, uterus & vagina completely prolapsed through introitus

• Fascia & associated ligaments:
• uterosacral
• pubocervical
• transverse cervical (cardinal)
• Muscles:
• levator ani -> iliococcygeus; pubococcygeus; puborectalis
• coccygeus

Prolapse of lower anterior vaginal wall involving urethra

Prolapse of upper anterior vaginal wall, involving bladder

Prolapse of bladder & urethra into anterior vaginal wall.

Prolapse of uterus (or vault), cervix & upper vagina

Prolapse of upper posterior wall of vagina (small bowel loops)

Prolapse of lower posterior wall of vagina, involving the anterior wall of rectum

• Dysfunctional uterine bleeding:
• - anovulatory (PCOS, obesity)
• - ovulatory - defective regulation of blood loss
• Systemic #s:
• - hypothyroidism
• - coagualopathy (VWD, platelet dysfunction)
• Gynaecological #s:
• - endometriosis/adenomyosis
• - chronic PID
• - uterine tumours (fibroids, polyps, Ca)
• - ovarian tumours

• Mefenamic acid: PGEi - commence 5-7/7 before menses - 20-50% decr bleed, decr dysmenorrhea; SE. gastric irritation
• Tranexamic acid: antifibrinolytic - take on heavy days; SE abdo bloating
• COCP
• Mirena: 95% decrease, lasts 5 years, daily spotting in first 6/12

• Hysteroscopic removal of polyps/fibroids
• Endometrial ablation (DUB)
• Hysterectomy

• 15-20% of Dx pregnancies
• 50-75% of all pregnancies

• Blighted ovum (1/3 of <k8)
• Foetal chromosomal abnormalities (50-60% of T1)
• Infection (TORCH, chlamydia, gonorrhea, listeria)
• Drugs - chemotherapy, heavy metals
• Anomalous tract
• Uterine fibroids
• Antiphospholipid syndrome
• Parental chromosomal abnormality
• Luteal phase defect

• TVUSS:
• - k5 gestational sac & yolk sac
• - k6 foetus & FH
• Abdo USS:
• - k6 gestational sac
• - k7 foetus & FH

• Detectable 10/7 post-fertilisation
• Doubles every 48h
• Peaks at 100,000 @k9
• Remains at 10,000-20,000 for remainder of pregnancy

• Bleeding is very common (20-30%) (but 50% progress to spontaneous abortion)
• Avoid strenuous activity or sex
• Return if incr bleeding/cramp/pain

Ampullary portion of the fallopian tube (93%)

• PID (esp chlamydia)
• Tubal reconstructive surgery
• Tubal sterilisation
• Reversal of tubal sterilisation
• IUD
• Hx of infertility
• ART
• Previous ectopic pregnancy
• Ruptured appendix
• In utero exp to DES
• Smoking
• >40y

• Surgical:
• linear salpingostomy (with serial bHCG until -ve)
• partial salpiingectomy
• total salpingectomy
• Medical (select pts):
• single dose methotrexate
• multidose methotrexate + folic acid (more effective, but more SEs)

• Vitals - shock - tachycardic & hypotensive
• Lower abdominal distention
• Shoulder tip tenderness
• Ridigity/guarding/rebound
• +ve HCG

• Haemodynamically stable pt w/o active bleed
• No rupture
• No FH on US
• BhCG <15,000
• Ectopic mass <3.5cm

• D & C
• Follow up - 2 -ve BhCG, then monthly for 6/12, 2-monthly for 6/12
• Contraception for >12/12
• Molar registry

• Metabolc syndrome
• DM
• Endometrial hyperplasia
• Endometrial cancer
• Possible incr breast Ca
• CVD

• VTE
• CVD
• Malignancy (slight increase in breast Ca & cervical Ca)
• HTN & stroke in high dose formulations

• E-dependent tumour
• Pregnancy
• Lactation
• VTE/stroke
• Thrombophilia
• Smokers >35yo
• BMI >40
• Liver disease
• Migraine (relative)

• Levonorgestrel - single dose 1.5mg - 3-4d
• Yuzpe (2 doses of 4 tablets of E & levonorgestrel) - less effective, more N&V - 3d
• Copper IUD - 5d

• Menopause
• USS
• CA125