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Key Points:
NSAIDs are offered first-line as they will inhibit prostaglandin synthesis,
one of the main causes of dysmenorrhea pains
Urinary incontinence - first-line treatment:
o Urge incontinence: bladder retraining; Oxybutinin
o Stress incontinence: pelvic floor muscle training
Bloating and abdominal cramps in females over the age of 50 should
raise suspicion of ovarian cancer. The most appropriate investigation is
to test the serum CA125 level. If raised, an abdominal and pelvic
ultrasound should be arranged. NICE CG122
Endometrial cancer is a common cancer in post-menopausal women
and it is important to rule this out in all women that present with postmenopausal bleeding.
Using hormone replacement therapy is a risk factor along with:
Nulliparity
Late menopause
Early menses
Obesity
Diabetes
Polycystic ovarian syndrome
Family history
The first step: TVUS scan to measure the endometrial thickness.
If the endometrial lining is thickened then a hysteroscopy+ endometrial
biopsy
Treatment laparoscopic hysterectomy with BSO+/- RT
FIGO is the classification of cervical cancer stage.
Gleason is the grade of prostate cancer
source: Passmed
source: Passmed
Menorrhagia
Subfertility
As fibroids get larger they cause symptoms due to their size such as: dysuria,
hydronephrosis, constipation and sciatica.
First line treatment is often tranexamic acid, NSAIDS or
progesterones as they are used in menorrhagia, but surgery is
usually required for troublesome fibroids.
Use of a gonadotrophin-releasing hormone analogue could be
considered prior to surgery which helps to reduce the size of the
fibroids
source: Passmed
source: Passmed
source: Passmed
The National Institute for Health and Care Excellence (NICE) states that
if a woman has a small (<35mm) unruptured ectopic pregnancy with
no visible heartbeat, a serum B-hCG level of <1500 IU/L, no
intrauterine pregnancy and no pain, then first line treatment should be
with methotrexate as long as the patient is willing to attend for followup.
The other treatment option is laparoscopic salpingectomy (or
salpingotomy where there is risk of infertility). This should be offered
where the ectopic is larger than 35mm, is causing severe pain or if the
B-hCG level is >1500. There is a risk of infertility if a problem arises
with the remaining Fallopian tube in the future.
The NHS Breast Screening Programme is being expanded to include
women aged 47-73 years from the previous parameter of 50-70 years.
Women are offered a mammogram every 3 years. After the age of 70
years women may still have mammograms but are 'encouraged to
make their own appointments'.
Vaginal discharge
Vaginal discharge is a common presenting symptom and is not always
pathological
Common causes
physiological
source: Passmed
Candida
Trichomonas vaginalis
bacterial vaginosis
Gonorrhoea
ectropion
foreign body
cervical cancer
Trichomonas vaginalis
Bacterial vaginosis
Key features
'Cottage cheese' discharge
Vulvitis
Itch
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Offensive, thin, white/grey, 'fishy' discharge
source: Passmed
Bacterial vaginosis
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic
organisms such as Gardnerella vaginalis. This leads to a consequent fall in
lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
>4.5
Whilst BV is not a sexually transmitted infection it is seen almost exclusively
in sexually active women.
Features
asymptomatic in 50%
Management
source: Passmed
Trichomonas vaginalis
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite
Features
vulvovaginitis
strawberry cervix
pH > 4.5
Investigation
source: Passmed
Management
oral metronidazole for 5-7 days, although the BNF also supports the
use of a one-off dose of 2g metronidazole
Chlamydia
Chlamydia is the most prevalent sexually transmitted infection in the UK and is
caused by Chlamydia trachomatis, an obligate intracellular pathogen.
Approximately 1 in 10 young women in the UK have Chlamydia. The incubation
period is around 7-21 days, although it should be remembered a large percentage of
cases are asymptomatic
Features
Potential complications
source: Passmed
epididymitis
endometritis
infertility
reactive arthritis
Investigation
urine (first void urine sample), vulvovaginal swab or cervical swab may be
tested using the NAAT technique
Screening
the 2009 SIGN guidelines support this approach, suggesting screening all
sexually active patients aged 15-24 years
source: Passmed
Pap smear demonstrating infected endocervical cells. Red inclusion bodies are
typical
Management
For men with symptomatic infection all partners from the four weeks
prior to the onset of symptoms should be contacted
For women and asymptomatic men all partners from the last six
months or the most recent sexual partner should be contacted
Another Pap smear demonstrating infected endocervical cells. Stained with H&E
Gonorrhoea
source: Passmed
Microbiology
2011 British Society for Sexual Health and HIV (BASHH) guidelines
recommend ceftriaxone 500 mg intramuscularly as a single dose with
azithromycin 1 g oral as a single dose. The azithromycin is thought to
act synergistically with ceftriaxone and is also useful for eradicating
any co-existent Chlamydia infections
source: Passmed
tenosynovitis
migratory polyarthritis
Genital warts
Genital warts (also known as condylomata accuminata) are a common cause
of attendance at genitourinary clinics. They are caused by the many varieties
of the human papilloma virus HPV, especially types 6 & 11. It is now well
established that HPV (primarily types 16,18 & 33) predisposes to cervical
cancer.
Features
Management
Menstrual cycle
The menstrual cycle may be divided into the following phases:
Menstruation
Follicular phase (proliferative phase)
Ovulation
Days
1-4
5-13
14
source: Passmed
15-28
Ovarian
histology
Endometria
l histology
Hormones
Follicular phase
(proliferative phase)
A number of follicles develop.
One follicle will become
dominant around the midfollicular phase
Proliferation of endometrium
Endometrium changes to
secretory lining under
influence of progesterone
A rise in FSH results in the
Progesterone secreted by
development of follicles which in corpus luteum rises
turn secrete oestradiol
through the luteal phase.
When the egg has matured, it
secretes enough oestradiol to
trigger the acute release of LH.
This in turn leads to ovulation
Cervical
mucus
Basal body
temperatur
e
Luteal phase
(secretory phase)
Corpus luteum
source: Passmed
Amenorrhoea
primary (failure to start menses by the age of 16 years) or
secondary (cessation of established, regular menstruation for 6 months or
longer).
Causes of primary amenorrhoea
Turner's syndrome
hyperprolactinaemia PL >
thyrotoxicosis*
Sheehan's syndrome
Initial investigations
source: Passmed
prolactin
oestradiol
Dysmenorrhoea
Dysmenorrhoea is characterised by excessive pain during the menstrual
period. It is traditionally divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects
up to 50% of menstruating women and usually appears within 1-2 years of
the menarche. Excessive endometrial prostaglandin production is thought to
be partially responsible.
Features
pain typically starts just before or within a few hours of the period
starting
suprapubic cramping pains which may radiate to the back or down the
thigh
Management
source: Passmed
Secondary dysmenorrhoea
Secondary dysmenorrhoea typically develops many years after the menarche
and is the result of an underlying pathology. In contrast to primary
dysmenorrhoea the pain usually starts 3-4 days before the onset of the
period. Causes include:
endometriosis
adenomyosis
intrauterine devices*
fibroids
Menorrhagia
Menorrhagia: causes
Menorrhagia was previously defined as total blood loss > 80 ml per menses,
but it is obviously difficult to quantify. The assessment and management of
heavy periods has therefore shifted towards what the woman considers to be
excessive and aims to improve quality of life measures.
Causes
dysfunctional uterine bleeding: this describes menorrhagia in the
absence of underlying pathology. This accounts for approximately half
of patients
anovulatory cycles: these are more common at the extremes of a
women's reproductive life
uterine fibroids
source: Passmed
hypothyroidism
intrauterine devices*
pelvic inflammatory disease
bleeding disorders, e.g. von Willebrand disease
*this refers to normal copper coils. Note that the intrauterine system (Mirena)
is used to treat menorrhagia
Menorrhagia: management
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is
obviously difficult to quantify. The management has therefore shifted towards what
the woman considers to be excessive. Prior to the 1990's many women underwent a
hysterectomy to treat heavy periods but since that time the approach has altered
radically. The management of menorrhagia now depends on whether a women
needs contraception.
Investigations
a full blood count should be performed in all women
further investigations are based upon the history and examination findings
Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as
well) or tranexamic acid 1 g tds. Both are started on the first day of the
period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy
menstrual bleeding.
Menopause
The average women in the UK goes through the menopause when she is 51
years old. The climacteric is the period prior to the menopause where women
may experience symptoms, as ovarian function starts to fail
Diagnosis
source: Passmed
nausea
breast tenderness
source: Passmed
Potential complications
Breast cancer
in the Women's Health Initiative (WHI) study there was a relative risk of
1.26 at 5 years of developing breast cancer
the risk of breast cancer begins to decline when HRT is stopped and by
5 years it reaches the same level as in women who have never taken
HRT
source: Passmed
Causative organisms
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Features
fever
deep dyspareunia
cervical excitation
Investigation
Management
source: Passmed
Complications
ectopic pregnancy
Endometriosis
Endometriosis is a common condition characterised by the growth of ectopic
endometrial tissue outside of the uterine cavity. Up to 10-15% of women
have a degree of endometriosis
Clinical features
deep dyspareunia
subfertility
Investigation
source: Passmed
Surgery
Infertility
gonadotrophins
Miscarriage: types
Threatened miscarriage
source: Passmed
cervical os is closed
mother may have light vaginal bleeding / discharge and the symptoms
of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
Inevitable miscarriage
cervical os is open
Incomplete miscarriage
cervical os is open
An incomplete miscarriage occurs when some, but not all, of the products of
conception are expelled from the uterus. Retained products of conception
pose an infection risk to the mother and so should be treated promptly.
Bleeding in miscarriage can be serious and physiological signs of shock
should not be missed.
The National Institute of Health and Care Excellence (NICE) recommends that
source: Passmed
Recurrent miscarriage
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It
occurs in around 1% of women
Causes
Antiphospholipid syndrome
Endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders.
Polycystic ovarian syndrome
Uterine abnormality: e.g. Uterine septum
Parental chromosomal abnormalities
Smokin
source: Passmed
Ectopic pregnancy
Implantation of a fertilized ovum outside the uterus results in an ectopic
pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who
presents with lower abdominal pain and later develops vaginal bleeding
vaginal bleeding: usually less than a normal period, may be dark brown
in colour
peritoneal bleeding can cause shoulder tip pain and pain on defecation
/ urination
Examination findings
abdominal tenderness
adnexal mass: NICE advise NOT to examine for an adnexal mass due to
an increased risk of rupturing the pregnancy. A pelvic examination to
check for cervical excitation is however recommended
source: Passmed
no significant pain
choriocarcinoma
source: Passmed
Management
Infertility
Infertility affects around 1 in 7 couples. Around 84% of couples who have
regular sex will conceive within 1 year, and 92% within 2 years
Causes
source: Passmed
unexplained 20%
Interpretation
Repeat, if consistently low refer to specialist
Repeat
Indicates ovulation
Basic investigations
semen analysis
folic acid
smoking/drinking advice
Key Points:
Women age is greater than 35 she should be investigated for infertility
earlier after having regular intercourse for 6 months. Regular sexual
intercourse is defined a intercourse every 2-3 days.
In a women below 35 investigation should wait until after 12 months of
regular intercourse.
source: Passmed
Male
Previous surgery on
genitalia
Amenorrhoea
Varicocele
Significant systemic illness
Abnormal genital
examination
Previous
STI
Semen analysis
Semen analysis should be performed after a minimum of 3 days and a
maximum of 5 days abstinence. The sample needs to be delivered to the lab
within 1 hour
Normal semen results*
pH > 7.2
*many different reference ranges exist. These are based on the NICE 2013
values
source: Passmed
Uterine fibroids
Fibroids are benign smooth muscle tumours of the uterus. They are through
to occur in around 20% of white and around 50% of black women in the later
reproductive years
Associations
Features
may be asymptomatic
menorrhagia
bloating
subfertility
source: Passmed
Diagnosis
transvaginal ultrasound
Management
Complications
obesity
Investigations
Subfertility
Diabetes mellitus
Endometrial cancer
source: Passmed
chemotherapy
autoimmune
radiation
Features are similar to those of the normal climacteric but the actual
presenting problem may differ
infertility
secondary amenorrhoea
Ovarian enlargement
source: Passmed
Management depends on the age of the patient and whether the patient is
symptomatic. It should be remembered that the diagnosis of ovarian cancer
is often delayed due to a vague presentation.
Premenopausal women
Postmenopausal women
source: Passmed
Abdominal
pain
Abdominal
bloating
Moderate
As for mild
Nausea and
vomiting
Ultrasound
evidence of
ascites
Severe
As for moderate
Clinical evidence
of ascites
Oliguria
Haematocrit >
45%
Hypoproteinaemia
Critical
As for severe
Thromboembolism
Acute respiratory
distress syndrome
Anuria
Tense ascites
Cervical ectropion
On the ectocervix there is a transformation zone where the stratified
squamous epithelium meets the columnar epithelium of the cervical canal.
Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral
contraceptive pill use) result in larger area of columnar epithelium being
present on the ectocervix
The term cervical erosion is used less commonly now
This may result in the following features
vaginal discharge
post-coital bleeding
source: Passmed
There are dozens of strains of HPV. The most important to remember are:
It should of course be remembered that there are other risk factors important
in developing cervical cancer such as smoking, combined oral contraceptive
pill use and high parity.
Testing for HPV has now been integrated into the cervical cancer screening
programme. If a smear is reported as borderline or mild dyskaryosis the
original sample is tested for HPV
Immunisation
A vaccination for HPV was introduced in the UK back in 2008. As you may
remember the Department of Health initially chose Cervarix. This vaccine
protected against HPV 16 & 18 but not 6 & 11. There was widespread
criticism of this decision given the significant disease burden caused by
genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine
used. Gardasil protects against HPV 6, 11, 16 & 18.
Girls aged 12-13 years are offered the vaccine in the UK
source: Passmed
given as 2 doses - girls have the second dose between 6-24 months
after the first, depending on local policy
Cervical cancer
The incidence of cervical cancer peaks around the 6th decade. It may be
divided into
adenocarcinoma (20%)
Features
vaginal discharge
Risk factors
smoking
high parity
source: Passmed
How is performed?
There is currently a move away from traditional Papanicolaou (Pap) smears
to liquid-based cytology (LBC). Rather than smearing the sample onto a slide
the sample is either rinsed into the preservative fluid or the brush head is
simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC includes
source: Passmed
It is said that the best time to take a cervical smear is around mid-cycle.
Whilst there is limited evidence to support this it is still the current advice
given out by the NHS.
In Scotland women from the ages of 20-60 years are screened every 3 years.
*Cervical cancer screening detects squamous cell cancer and may miss
adenocarcinomas
Moderate
dyskaryosis
Severe dyskaryosis
Suspected invasive
cancer
Inadequate
source: Passmed
Endometrial cancer
Endometrial cancer is classically seen in post-menopausal women but around
25% of cases occur before the menopause. It usually carries a good
prognosis due to early detection
The risk factors for endometrial cancer are as follows*:
obesity
nulliparity
early menarche
late menopause
diabetes mellitus
tamoxifen
Features
Investigation
source: Passmed
Management
Postcoital bleeding
Postcoital bleeding describes vaginal bleeding after sexual intercourse.
Causes
cervical cancer
polyps
trauma
Ovarian tumours
There are 4 main types of ovarian tumours
source: Passmed
metastasis
Benign/malig
nant
Benign
Serous
cystadenoma
Serous
cystadenocarcino
ma
Mucinous
cystadenoma
Mucinous
cystadenocarcino
ma
Malignant
Brenner tumour
Benign
Benign
Malignant
Notes
Most common benign ovarian
tumor, often bilateral
Cyst lined by ciliated cells (similar
to Fallopian tube)
Often bilateral
Psammoma bodies seen
(collection of calcium)
Cyst lined by mucous-secreting
epithelium (similar to endocervix)
May be associated with
pseudomyxoma peritonei
(although mucinous tumor of
appendix is the more common
cause)
Contain Walthard cell rests (benign
cluster of epithelial cells), similar
to transitional cell epithelium.
Typically have 'coffee bean' nuclei.
Benign/malignant
Mature teratoma
(dermoid cyst) - most
common: benign
Notes
Account for 90% of germ cell
tumours
Contain a combination of
source: Passmed
Immature teratoma:
malignant
Dysgerminom
a
Malignant
Yolk sac
tumour
Malignant
Choriocarcino
ma
Malignant
Benign/malig
nant
Malignant
Sertoli-Leydig Benign
cell tumour
Fibroma
Benign
Notes
Estrogen leading to precocious puberty
if in children or endometrial hyperplasia
in adults.
Call-Exner bodies (small eosinophilic
fluid-filled spaces between granulosa
cells)
Produces androgens masculinizing
effects
Associated with Peutz-Jegher syndrome
Associated with Meigs' syndrome
(ascites, pleural effusion)
Solid tumour consisting of bundles of
spindle-shaped fibroblasts
Typically occur around the menopause,
classically causing a pulling sensation
in the pelvis
source: Passmed
Metastatic tumours
Account for around 5% of tumours.
Tumour
Krukenberg
tumour
Benign/malig
nant
Malignant
Notes
Metastases from a gastrointestinal tumour
resulting in a mucin-secreting signet-ring
cell adenocarcinoma
Ovarian cancer
Ovarian cancer is the fifth most common malignancy in females. The peak
age of incidence is 60 years and it generally carries a poor prognosis due to
late diagnosis. Around 90% of ovarian cancers are epithelial in origin.
Risk factors
early satiety
diarrhea
source: Passmed