List 5 signs/symptoms of PID.
- Abnormal vaginal discharge
- Abnormal vaginal bleeding
- Lower abdominal pain
- Adnexal tenderness
- Cervical motion tenderness
How would you diagnose PID?
- Laparoscopy = gold standard
- Adnexal tenderness (not v specific)
- Cervical motion tenderness + lower abdominal pain (not v sensitive)
List 5 RFs for PID.
- Unprotected sex
- Young age
- Bacterial vaginosis
- Peri-menstrual sex
- IUD insertion
Management of PID in sexually active female with no other RFs .
- - 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
Investigations in PID?
- - 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)
Diagnostic criteria for PCOS
- Rotterdam - 2/3 of:-
- - Oligo/an-ovulation
- - Hyperandrogenism (clinical or biochemical - inc free T, inc FAI, dec SHBG)
- - TV USS evidence of polycystic ovaries
What are the immediate repercussions of PCOS and how would you manage it?
- Irregular periods - COC
- Infertility - Wt loss, test ovulation, IVF
- Hirsutism - COC with cyproterone, cyproterone, spironolactone
What are the long term repercussions of PCOS?
- CVD (dyslipidaemia)
- Diabetes Mellitus
- Endometrial hyperplasia
How do you classify endometrial hyperplasia, and what is the risk of each subtype progressing to uterine Ca?
- 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)
Compare & contrast the two pathogenetic groups of endometrial carcinomas.
- 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
Investigations for suspected endometrial cancer?
- Hysteroscopy D&C = gold standard
- Pipelle endometrial sample (low sensitivity)
- --> grading of sample
List 6 DDx for a young woman presenting with sudden onset, severe lower abdominal pain.
- - Ectopic
- - Miscarriage
- - GIT - appendicitis, mesenteric adenitisi
- - GUT - UTI, renal calclui
- - Gynae - ovarian cyst accident, bleeding, torsion, PID
- - MSK
- - Endocrine - DM
- - Factitious/psychosomatic
What is the definition of postmenopausal bleeding?
- 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)
List 5 causes of postmenopausal bleeding.
- Vaginal/uterine atrophy (60-80%)
- HRT (15-20%)
- Uterine/cervical polyps )2-12%)
- Endometrial hyperplasia (5-10%)
- Cancer - vaginal, cervical or uterine
Definitive investigations for cause of postmenopausal bleeding?
- D & C
- Endometrial biopsy (with anti-prostaglandin administration 1h before)
- Hysteroscopy (if cervical stenosis/discomfort/persistent bleeding/inadequate specimen)
Management of endometrial hyperplasia.
- Simple, no atypia --> mirena
- Simple with atypia --> hysterectomy
- Complex without atypia --> mirena/high dose P/hysterectomy
- Complex with atypia --> TAH BSO
How would you treat endometrial Ca?
- Depends on stage (1-4)
- TAH BSO, peritoneal washings
- Para-aortic lymphadenectomy
- Pelvic irradiation
- R/v 3/12ly for 2 years (80%) - vault/lower 1/3 of vagina
Clinical appearance & Mx of candidiasis?
- 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
List 5 predisposing factors for candidasis
- Premenstrual point in cycle
- Glucose intolerance
Clinical appearance & Mx of gardnerella vaginalis (BV)?
- Grey, frothy, fishy PV DC & pruritis
- Dx whiff test, pH change, HVS (clue cells)
- Metronidazole (2g stat dose)
How common is bacterial vaginosis?
Clinical appearance & Mx of Trichomonas vaginalis?
- Green, frothy, fishy PV DC; strawberry cervix; pruritis
- Dx - whiff test, HVS (flagellae)
- Metronidazole (2g stat, treat partner)
Clinical appearance & Mx of Chlamydia trachomatis?
- 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
Clinical appearance & Mx of Neisseria gonorrhea?
- Thick green DC
- Endocervical/1st catch PCR
- Ceftriaxone 250mg IM stat or ciprofloxacin 500mg PO stat
What is the recommended schedule of Pap smears for women with no Hx of abnormal bleeding or abnormal cervical cytology?
- 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
When is the best time to perform cervical cytology?
What is the benefit of cervical cytology screening?
Ca reduced by 92.5% with two-yearly screens.
How do you manage an abnormal Pap smear?
- 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
What are the different grades of cervical intraepithelial neoplasia?
- 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
How likely is CIN1 to progress to higher CIN lesions?
16-25% in 2-4 years
How likely is CIN3 to progress to invasive cancer?
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
Options for definitive Mx of high grade CIN
- 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)
- Follow up: colposcopy & pap smear at 6m, repeat Pap & HPV typing at 12m, than annually until 2 consecutive negatives
Mx of CIN in pregnancy
- Perform colposcopy to exclude invasive cancer
- If CIN, defer Tx to postpartum
- If invasive --> cone biopsy (5% foetal loss)
List 3 RFs associated with cervical cancer
- 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
- High parity
- Age bimodal - 35-39 & 60-64
What is AIS?
Adenocarcinoma in situ - coexists with CIN in 70% of patients, usually at the squamocolumnar junction
Mx of AIS?
- Cone biopsy (30% risk skip lesion)
- Hysterectomy recommneded if fertility not an issue
What is AGUS?
Atypical glandular cells of undetermined significance (morphological changes in glandular cells beyond benign reactive process but insufficient for AIS)
The majority of cervical cancers are...
Squamous cell Ca (85%), the remainder are adenoCa
The development of cervical cancer is...
Squamous epithelium or endocervix (most squamous Ca arise in transformation zone)
How does cervical cancer present clinically?
- Abnormal vaginal bleeding - menorrhagia, postcoital, irregular, postmenopausal
- Vaginal discharge
Ix for cervical Ca?
- 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
List 4 types of uterine neoplasia
- Endometrial hyperplasia
- Cancer (adenoCa, adenosquamous, papillary serous, clear cell, sarcoma)
How can leiomyomas present?
- Often asymptomatic
- Intermenstrual bleeding
- Abdo swelling
- Pressure effecgts --> bladder/veins (oedema, DVT)
- Labour obstruction
Mx of fibroids?
- Medical: P & GnRH analogues (regrowth 3/12 after cessation)
- Surgical: hysteroscopic resection, myomectomy, hysterectomy (+/- pretreatment with GnRH)
Effect of fibroids on pregnancy?
- Red degeneration during pregnancy with torsion (pain & temp)
- Enlarged uterus
- Risk of abortion
- Labour obstruction
- Difficult C/S
- Post-myomectomy rupture is rare
What features make an ovarian neoplasm more likely to be malignant?
- Childhood/post menopausal
- Rapid growth
- Solid, nodular or irregular consistgency
- Leg/vulval oedema
- Evidence of metastases
List 5 RFs associated with ovarian cancer
- Early menarche or late menopause
- FHx (BRCA1 & 2 mutations)
- Previous breast/endometrial cancer
- Lynch syndrome
- Peutz-Jeghers syndrome
Presentation of ovarian cancer?
- Asymptomatic in early disease
- Mass effects later on:
- - abdo pain
- - pelvic pressure
- - back pain
- - swelling
- - dyspepsia
- - urinary frequency
- - constipation
- - DVT
Ix for ovarian mass?
- FBE, eLFT
- Tumour markers (CA125 - epithelial, CA19.9 - mucinous, CEA - bowel mets)
- hCG, AFT, inhibin, LDH if non-epithelial suspected
- Abdominopelvic USS & CT
RFs associated with vulval intraepithelial neoplasia
- CIN & vaginal intraepithelial neoplasia
Mx of VIN?
- Surgery: preferred - wide local excision, skinning vulvectomy, laser ablation
- Medical: imiquimod or 5-FU cream (only 75% response)
- Long term follow up: 30% recur!
Vulval cancers are usually (histopathologically)...
Squamous cell carcinomas >> melanoma > bartholin's gland
What are the principle supports of the uterus?
- Transverse cervical (cardinal) ligaments
- Uterosacral ligaments
- (round ligaments --> labia majora, but minimal support)
- (pubocervical ligament attaches Cx to pubic symphysis)
How are the ovaries attached to the uterus?
Infundibular ligaments (to posterolateral wall)
List 5 RFs for genital prolapse.
- prolonged 2nd stage
- large baby
- perineal trauma
- Gynaecology surgery
- Increased IAP:
- chronic cough
What are the different grades of uterine prolapse?
- 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
What are the anatomical supports of the pelvic floor?
- Fascia & associated ligaments:
- transverse cervical (cardinal)
- levator ani -> iliococcygeus; pubococcygeus; puborectalis
Prolapse of lower anterior vaginal wall involving urethra
Prolapse of upper anterior vaginal wall, involving bladder
Prolapse of bladder & urethra into anterior vaginal wall.
Define apical prolapse
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
List 7 DDx for menorrhagia.
- 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
Medical Mx of menorrhagia?
- 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
- Mirena: 95% decrease, lasts 5 years, daily spotting in first 6/12
Surgical Mx of menorrhagia?
- Hysteroscopic removal of polyps/fibroids
- Endometrial ablation (DUB)
How common are spontaneous abortions?
- 15-20% of Dx pregnancies
- 50-75% of all pregnancies
List 8 causes of spontaneous abortion.
- 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
What are important pregnancy dates in USS?
- - k5 gestational sac & yolk sac
- - k6 foetus & FH
- Abdo USS:
- - k6 gestational sac
- - k7 foetus & FH
How does bHCG levels vary throughout pregnancy?
- Detectable 10/7 post-fertilisation
- Doubles every 48h
- Peaks at 100,000 @k9
- Remains at 10,000-20,000 for remainder of pregnancy
What should you advise a woman experiencing bleeding <k20 with a closed os?
- Bleeding is very common (20-30%) (but 50% progress to spontaneous abortion)
- Avoid strenuous activity or sex
- Return if incr bleeding/cramp/pain
What is the most common site of ectopic pregnancies?
Ampullary portion of the fallopian tube (93%)
List 7 RFs for ectopic pregnancy.
- PID (esp chlamydia)
- Tubal reconstructive surgery
- Tubal sterilisation
- Reversal of tubal sterilisation
- Hx of infertility
- Previous ectopic pregnancy
- Ruptured appendix
- In utero exp to DES
Mx of ectopic pregnancy?
- 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)
Clinical presentation of ruptured ectopic?
- Vitals - shock - tachycardic & hypotensive
- Lower abdominal distention
- Shoulder tip tenderness
- +ve HCG
What criteria must be satisfied before medical Mx (methotrexate) of ectopic can be conducted?
- Haemodynamically stable pt w/o active bleed
- No rupture
- No FH on US
- BhCG <15,000
- Ectopic mass <3.5cm
Mx of molar pregnancy
- D & C
- Follow up - 2 -ve BhCG, then monthly for 6/12, 2-monthly for 6/12
- Contraception for >12/12
- Molar registry
What are the long term (systemic) problems associated with PCOS?
- Metabolc syndrome
- Endometrial hyperplasia
- Endometrial cancer
- Possible incr breast Ca
What are the SEs/risks associated with COCP?
- Malignancy (slight increase in breast Ca & cervical Ca)
- HTN & stroke in high dose formulations
List 5 contraindications of COCP use.
- E-dependent tumour
- Smokers >35yo
- BMI >40
- Liver disease
- Migraine (relative)
List 3 forms of emergency contraception & the window in which they are effective.
- 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
What 3 factors make up the risk malignancy index for ovarian cancer?