Gynae - Collated from sources such as Passmed, Zero to Finals, AMBOSS, BMJ best practice PDF

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Collated from sources such as Passmed, Zero to Finals, AMBOSS, BMJ best practice...

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History 

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Menstrual hx: o How regular are the cycles? – 24-38-day cycle is ‘normal’ o How many days of bleeding? 3-8 is normal o Assess how heavy it is – any clots? How many pads/tampons per day? o Normal blood loss is between 35-40ml o What’s normal for you/ has anything changed? Menarche/ Menopause IMB/PCB/PMB Smears o Have they attended? o Any abnormal findings? Contraception Are they sexually active? o Any dyspareunia or PCB? Do they have children? o Any complications during delivery? o Is there family complete? Systems review – bladder/bowels ok? Previous gynae history o STI hx o PCOS FHx of any gynae conditions?

Cervix 

Cervical Os opens when nearing/during ovulation (day 14 Vs day 6)

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Luteal mucous is thick and white and continues until the end of the cycle A Multiparous cervix has more of a mouth shaped os

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Leucoplakia is a white patch on the cervix due to deposition of keratin in the epithelial cells o It can be induced by HPV and be a sign of CIN or cancer, but it can also be idiopathic o It needs to be biopsied

Nabothian cysts     

Mucous retention cysts Harmless More common after childbirth Can be left alone Cryocautery can be used if they’re discharging

Cervical Ectropion  

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An area of columnar epithelium extending from the endocervix onto the ectocervix Extend temporarily due to: o Oestrogen changes in puberty o Pregnancy (usually big) o OCP It’s normal, non-malignant Usually asymptomatic but can see: - Heavy discharge - PCB or IMB Normal smear, but with fleshy area on cervix

Mx:  Usually can be left alone  Electrocautery if symptomatic (e.g. excessive discharge or spotting) Lichen Sclerosis  Affected skin is thin, shiny and can be white (leucoplakia) or red due to inflammation  Very itchy, which can lead to bleeding  Diagnosis is via biopsy

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Mx: Emollient creams if mild Topical steroids may be needed Can be pre-malignant, so long-term surveillance needed

Smear tests  Offered to ages 25-64 years  Every 3 years up till the age of 49, then every 5 years  Cells are taken from the transformation zone / squamocolumnar junction between the ecto and endocervix, where 90% of Ca’s arise  Smears use liquid-based cytology and centrifuge so the liquid can be tested for HPV using PCR first, then a pathologist analyses the cells if it’s HPV +’ve  Women who are HIV +’ve are offered annual smears  If you’ve had a hysterectomy where the cervix is removed – no need to go  Cannot have a smear test whilst having a period – ideal time is midcycle  If pregnant: - With previously normal smear tests: post-pone screening till 3 months post-partum

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- Previously abnormal: colposcopy at 3-6 months gestation Results should be within 2 weeks – contact GP/clinic if no news after 6 weeks If the result is unsatisfactory/inadequate a repeat smear is needed after 3 months Findings on smear tests: o Borderline dyskaryosis  HPV triage o Colposcopy if +’ve o If –‘ve back to routine recall o Moderate or severe dyskaryosis/ high risk of HPV (CIN II or III)  Urgent Colposcopy o Suspected cancer  Urgent Colposcopy Colposcopy involves looking at the cervix through a microscope using different stains – abnormal areas appear white. ‘See and treat’ involves managing CIN II or III when it’s seen using a LLETZ procedure (long loop excision of the transformation zone), involving diathermy o Women who have been treated for CIN need a repeat smear after 6 months for ‘test of cure’ cytology

Polyps    

Benign tumours of the endometrium or endocervix Can cause atypical endometrial hyperplasia in rare cases Very vascular – can cause IMB or PCB Can cause mucous discharge

Mx:  Removal by resection under direct vision with hysteroscopy Cervical Carcinoma  

HPV types 16 and 18 are implicated in 90% of cases Cervical intraepithelial neoplasia (CIN) is a premalignant lesion which can progress to cervical Ca o CIN I = mild dysplasia, basal 1/3 of epithelia involved. Can be left alone (goes away) o II = moderate, 2/3 involved o III = severe / carcinoma in-situ, 3/3 involved. 30% of CIN III will progress to Ca  90% of cervical Ca’s are Squamous cell, 10% are adenocarcinoma’s  Colposcopy = Dx  Major complication = spread to nearby organs e.g. vagina, bladder, uterus  Main sx = IMB  Other sx: - Foul smelling discharge if there’s necrosis - Pain if there’s invasion into the nerves - Haematuria if there’s invasion into the bladder - PR bleed if there’s invasion into the rectum - Hyperuraemia, hydronephrosis, infection, kidney failure if there’s invasion into the ureters causing obstruction

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Risk factors: related to sex (doesn’t run in families because it’s a sexually transmitted thing) - 50% 5-year mortality for women with invasive disease  Adenocarcinoma has a worse prognosis than squamous  Need annual smears for at least 10 years to check for recurrence

P/C – Heavy Periods   

Menorrhagia / Heavy Menstrual Bleeding (HMB) which interferes with QOL Anaemia is the most common complication Depression often co-exists with menorrhagia

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Differentials: PALM COEIN Polyp

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Adenomyosis Leiomyoma (fibroid) Malignancy Coagulopathy e.g. VWD Ovulatory dysfunction e.g. PCOS Endometrial disorders e.g. endometriosis Not yet quantified - DYSFUNCTIONAL UTERINE BLEEDING = #1

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o No known cause o Usually at extremes of reproductive age o Maintaining healthy BMI can help IUCD, PID, Hypothyroidism  (Hyper = amenorrhoea)

Investigations:  FBC for everyone  Can just start pharmacological tx for HMB w/o investigating cause if they’re low risk for fibroids, uterine cavity abnormality or Adenomyosis Mx:  1st line for women wanting contraception = Mirena IUS (Levonorgestrel) - Can take 6 months before benefits are seen, and it can change bleeding patterns nd  2 line drugs are: o Anti-prostaglandins e.g. Mefenamic acid – taken during bleeding 500mg every 8hrs PO. - Taken if there’s dysmenorrhoea + pain - CI in Peptic Ulceration - Can cause seizures in OD o Anti-fibrinolytics e.g. Tranexamic Acid – taken during bleeding 1g every 6-8 hrs PO for max 4 days - Taken if there’s just bleeding, no pain - CI in thromboembolic disease o OCP  3rd line recommendation is Progestogens IM (taken from day 5 to day 25, then break to bleed) Fibroids      

Fibroids are benign smooth muscle tumours from the myometrium (leiomyomas) 30% of women have fibroids Start off intramural then can grow out = subserosal, or in = submucosal Under the peritoneum = subserosal (20%) o Can cause subfertility or recurrent miscarriage Under the endometrium = submucosal o Prolonged periods Risk factors: o Afro Caribbean o Obesity o Oestrogen sensitive - grow in size:  HRT  OCP  Pregnancy  (shrink after menopause)

Px  Usually asymptomatic, but otherwise: o HMB o Pelvic pain (dysmenorrhoea or dyspareunia) o Bloating due to mass o Pressure sx if subserosal and pressing on bladder  ^ urinary frequency

Investigations  Bloods: FBC (anaemic?)  Pelvic USS = Dx - confirming size & position  Red degeneration is when thrombosis of local vessels occurs, followed by engorgement and inflammation causing abdominal pain, vomiting and pyrexia. Then fibroids spontaneously die. It’s especially seen in the 3rd trimester of pregnancy, and only analgesia is needed Mx: 

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Conservative: o No tx if asymptomatic o Encourage weight loss if obese Medical: o Mirena coil o GnRH analogues e.g. Leuprorelin to shrink fibroids before surgery Surgical: Indications  >3cm fibroid Pressure sx Subfertility Failed medical therapy o Maintaining fertility = Myomectomy or uterine artery embolization  Get MRI before uterine artery embolization o Completed family = hysterectomy o If symptomatic but 20 days Amenorrhoea can be primary = failure to start menses by 15 years old in girls with normal secondary sex characteristics e.g. breasts, or by 13 if there’s no secondary sex characteristics Or secondary = cessation of established menses for 6 months in women with previous regular menses, or 12 months in women with a hx of oligomenorrhoea Precocious bleeding is menarche 1000 IU/L) - TSH levels - Urinary or serum hCG to exclude pregnancy - Testosterone levels - >5 nmol/L suggests a tumour or late onset congenital adrenal hyperplasia - Oestradiol

Premature ovarian failure 

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Menopause 12 months o Sx are menopausal e.g. hot flushes, irritability, vaginal dryness, sleep problems Risk factors: o FHx o Fragile X PCOS Autoimmune disorders Toxin exposure e.g. chemotherapy, radiotherapy, mumps Hysterectomy  Even without oophorectomy, still undergo menopause ~4 yrs sooner than norm o Smoking In Turner’s syndrome (xo) oocyte apoptosis starts at 12 weeks and numbers deplete in the first 10 years of life, causing primary amenorrhoea as 2 X chromosomes are needed for oocyte production o o o o

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Investigations  Need to do all investigations for amenorrhoea to rule out other causes  Persistently ^^FSH and LH  Low oestradiol Mx:  Conservative: o Pt counselling and psychosocial support (for pt + partner) - depression and low libido are common o Lifestyle modifications to improve bone health post-menopause e.g. quit smoking, reduce alcohol, healthy BMI, ensure adequate calcium intake (consider a bisphosphonate  Medical: as you would manage menopause o HRT (if there’s no contraindications) o Vaginal topical oestrogens if there’s vaginal dryness/irritability o Tx any underlying autoimmune disease

Polycystic Ovary Syndrome   

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Most common endocrine disorder affecting women of reproductive age Due to ^^^LH stimulating Testosterone production from the ovaries Risk factors: o FHx o Obesity Features revolve around hyperandrogenism e.g. o Oligo or amenorrhoea o Acne o Hirsutism o Associated with obesity, HTN, insulin resistance  Acanthosis nigricans Complications = T2DM, Cardiovascular disease, infertility, endometrial cancer (from endometrial hyperplasia and prolonged amenorrhoea), psychological disturbance e.g. anxiety or depression, OSA o Need to ask about mental health, daytime fatigue and snoring to check for some of these complications Investigations Rotterdam criteria: (2 of) PCOS  Polycystic ovaries on TVUS  12 follicles or ovarian volume >10ml o In adolescents don’t need this for dx  Oligo/amenorrhoea (cycle >42 days)  Skin changes e.g. acne, hirsutism, alopecia, male pattern balding or biochemical signs of hyperandrogenism: o ^Testosterone

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o ^^LH (&FSH) o Low/normal sex hormone binding globulin Bloods: OGTT, lipid panel

Mx:  Conservative: o Weightloss - only intervention which improves all sx o Pt education and counselling about ^ risk of cancer if left untreated o Lifestyle advice to reduce cardiovascular risk factors e.g. smoking, alcohol, diet/exercise o Psychosocial consideration - ask about emotional wellbeing  Medical: o Metformin: improves insulin sensitivity, menstrual disturbance and ovulatory function. Recommended for women with BMI >25, trying to conceive o OCP for hirsutism and acne  Co-cyprindiol can be used as an alternative but it’s high risk for VTE so has to be stopped 3-4 months after hirsutism has resolved. It’s also CI in uncontrolled HTN or breast cancer pt’s  Clomiphene for infertility. Best when used with Metformin - Risk of multiple pregnancy, OSH and Ovarian Ca

P/C – Non-menstrual bleeding

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Can be PCB or IMB If it’s mid-cycle its usually physiological Starting or changing the contraceptive pill, esp the POP can cause IMB Copper coil or IUS insertion can cause irregular bleeding Differentials: o Physiological e.g. Midcycle bleed or Cervical Ectropion (most common cause of PCB) o Pelvic pathology e.g. polyps, PID, Endometrial hyperplasia o Atrophic vaginitis o Cancer o Pregnancy related e.g. implantation bleed, early miscarriage or ectopic o Trauma e.g. tear or rape o Iatrogenic e.g. contraception changes, following gynaecological surgery

Endometrial hyperplasia    

When the endometrium becomes abnormally thick, usually due to excess oestrogen Can lead to atypical endometrial hyperplasia – a pre-malignant condition of endometrial cancer where there’s overgrowth of abnormal cells IMB is the most common sx Endometrial biopsy and dilation and curettage are used to diagnose

Mx:  High-dose Progesterone therapy if wanting to remain fertile (IUS may be used), with repeat sampling in 3-4 months  Hysterectomy if family complete

P/C – Post-menopausal bleeding     

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PV bleeding 6 months or more after menstruation cessation Very common, usually fine It’s the commonest first sign of endometrial Ca so needs investigating TVUS is always the first investigation With PMB the cut off for a thickened endometrium is >5mm, if there’s no hx of PMB then >10mm would be considered abnormal Differentials: Endometrial Cancer Atrophy e.g. atrophic vaginitis, urethral caruncle Infection Iatrogenic e.g. HRT related, Tamoxifen related, ring pessary or IUS

Endometrial Carcinoma    

Makes up 25% of all gynae emergencies Most common Gynae Ca Endometrial Ca’s are usually Adenocarcinoma’s o 10-20% are Squamous 10% are hereditary - DNA mismatch repair mutations, 5% - HNPCC

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PMB or menorrhagia >40 yrs is endometrial ca until proven otherwise Risk factors: - Hormonal related e.g. Prolonged oestrogen exposure (esp when unopposed by progesterone) - HRT, tamoxifen, late menopause - Obesity (making it the no.1 gynae cancer seen now) - HTN - DM - PCOS, which can be seen in obesity, HTN and DM and is probably the reason these increase risk because it involves endogenous androgens being converted to oestrogens - FHx of breast, ovarian or colon cancer - Nulliparity

Investigations  TVUS would show endometrial thickening (>5mm) o This isn’t diagnostic - if 4.5) on Litmus testing indicates atrophic vaginitis

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HRT tx to manage oestrogen levels Regular sexual activity using a water-soluble vaginal lubricant

P/C - Pain  

SOCRATES Pregnant?

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Causes of pain by origin: Ovary: Cyst, Torsion, Endometrioma Tube: Ectopic pregnancy, Hydro/Pyosalpinx – blocked duct with either fluid/pus Uterus: Miscarriage, Hematometra/pyometra – trapped blood/pus in the uterus by obstruction, Endometriosis Cervix: Tumour, obstruction Mittelschmerz – mid cycle pain Urinary tract: UTI

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Appendicitis STI or PID

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Pelvic inflammatory disease   

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Usually secondary to an ascending infection Chlamydia is the most common cause (up to 35% of cases), followed by Gonorrhoea There are no specific tests, but absence of Endocervical pus cells has a negative predictive value (presence of them is non-specific) Risk factors for infection include: - Surgical procedures e.g. termination of pregnancy, IUD insertion, IVF - Unprotected sex - Hx of STI’s - Multiple sexual partners - Young age when first sexually active - IUD – acts as a protective site and the strings act as a wick for bacteria to travel up - Ovulation/menstruation as the cervical mucous plug is thinned/gone Px with acute loin-groin pelvic pain

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Worse with movement and intercourse (deep dyspareunia) Uterine and adnexal tenderness, cervical motion tenderness Mucopurulent discharge IMB or PCB Pyrexia >38 – but temp can be normal Cervical excitation is seen

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Complications:  Fitz-Hugh-Curtis syndrome (aka Peri Hepatitis) is a rare complication of PID involving adhesions between the Liver capsule and Diaphragm. Sudden onset of RUQ pain (--> R shoulder) exacerbated by breathing or coughing should raise suspicion. Often there’s a lack of pelvic pain or normal PID sx  Abscess’ can form in severe disease – if it’s in the fallopian tubes = Pyosalpinx or if involving the ovaries as well = tubo-ovarian abscess, which can lead to subfertility  PID increases risk of future ectopic pregnancies by 3x

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Up to 20% of women experience chronic pelvic pain after one episode of PID

Mx:  Delaying tx for PID can lead to complications resulting in a low threshold for tx  Pain relief with NSAID’s & empirical antibiotics depending on causative agent: - IM Ceftriaxone 1g + Doxycycline 100mg OD for 2 weeks + Metronidazole 400mg BD for 2 weeks  If they have an IUD in place consider removal if they request it or if sx haven’t resolved within 72 hrs  Trace sexual partners and treat Ovarian Torsion     

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Twisting of an ovary around its ligamentous support, compromising blood supply to ovary and fallopian tube Surgical emergency Risk factors incl ovarian cancer, cysts and infertility tx Can be brought on by strenuous exercise Sx: - Acute lower abdominal pain - Vomiting - Palpable adnexal mass TVUS shows an enlarged ovary, possibly with a ‘whirlpool’ sign from vessels flowing in opposite directions For children abdominal USS is used – a full bladder is needed

Mx:  Surgical detorsion

P/C – Pelvic mass   

Most pelvic masses are due to benign causes e.g. cystic teratomas, fibroids, cysts Non-gynaecological causes incl a diverticular abscess, constipation volvulus, bowel or bladder cancer Generally, diagnosis is only by laparotomy

Ovarian Cysts

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Follicular Most common Usually unilateral, unilocular simple cysts lined by granulosa cells Considered normal if 6cm as they’re at risk of rupturing – ovarian cystectomy if 40 and family complete Corpus luteum cysts Occur when the corpus luteum doesn’t break down during the menstrual cycle if fertilisation doesn’t occur. Instead it fills with blood or fluid Can px with intraperitoneal bleeding

Mx:  Young, nulliparous woman with an asymptomatic cyst 250  high risk Staging: CT/MRI used I. Disease limited to ovaries II. Growth beyond the ovaries but confined to the pelvis III. Peritoneal implants outside the pelvis e.g. liver, or +ve retroperitoneal or inguinal lymph nodes IV. Distant metastases

Mx:  Surgical debulking followed by 6 months of platinum-based chemotherapy e.g. Carboplatin  Due to the vague sx, 80% of women have advanced disease when they px so prognosis is poor – 5-year survival 4.5 ‘Clue cells’ (squamous cells surrounded by bacteria) may be seen on wet microscopy

Mx:  Only Tx if symptomatic: Metronidazole 2g PO single dose - If pregnant use Metronidazole 400mg/12hrs PO for 5 days – there’s increased risk of preterm labour, intrauterine infection and susceptibility to HIV  Or topical Clindamycin 2% for 7 days  Recurrence is common – again only tx if sx recur Candidiasis      

Thrush is due to an overgrowth of Candida, a commensal organism Candida Albicans is the commonest strain (95%) Risk factors are related to high oestrogen e.g. pre-menstrual, OCP, pregnancy Or DM, immunosuppressive therapies and corticosteroid or antibiotic use Px with cottage cheese non-offensive discharge and pruritis Diagnosis is confirmed by high vaginal swab microscopy showing mycelia or spores

Mx:  Clotrimazole 500mg vaginal pessary  Chronic candidiasis can be tx with Fluconazole 150mg PO - Can only use topical tx during pregnancy or breast feeding STI’s

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Sexual health hx: LMP Contraception When did they last have sex? What type of sex was it? Who was it with? Was it consensual? Did they use protection? Do they...