Gynaecology

Bartholin’s abscess This is an abscess which forms on the Bartholin’s glands which line the vagina. – It arises when one of the ducts carrying fluid from the gland gets blocked, giving a fluid filled lump (cyst) – The cysts can then become infected by bacteria leading to the formation of a Bartholin’s abscess. Symptoms: – Vaginal pain and redness – Unilateral swelling near the vaginal introitus   Diagnosis: Clinical Diagnosis   Management: – 1st line is antibiotics. – If abscess does not respond/is painful, cyst drainage is performed (using word catheter or marsupialization)   Vulval Carcinoma This describes a

Urinary Incontinence This is a very important gynaecological condition which has a huge impact of patients’ lives. – There are two main types of incontinence in females, each of which have different pathologies and treatments. – It affects about 4-5% of the population, being more common in elderly females   i) Urge Incontinence This is the involuntary leakage preceded/accompanied by a sudden desire to pass urine – It occurs due to an overactive bladder due to increase detrusor muscle overactivity   Causes: Mostly idiopathic but can be associated with neurological conditions (e.g. MS, PD) – Can be made worse by

Urinary Incontinence This is a very important gynaecological condition which has a huge impact of patients’ lives. – There are two main types of incontinence in females, each of which have different pathologies and treatments. – It affects about 4-5% of the population, being more common in elderly females   i) Urge Incontinence This is the involuntary leakage preceded/accompanied by a sudden desire to pass urine – It occurs due to an overactive bladder due to increase detrusor muscle overactivity   Causes: Mostly idiopathic but can be associated with neurological conditions (e.g. MS, PD) – Can be made worse by

Ovarian Torsion This is when the ovary twists on its supporting ligaments. It is a gynaecological emergency as it can cut of the blood supply to the ovary, resulting in ischaemia   Risk factors: – Ovarian cysts (especially dermoid cyst/PCOS) – Ovulation induction Symptoms: Sudden onset of sharp, colicky, unilateral lower quadrant abdominal pain – Nausea and Vomiting – May also be a low-grade pyrexia and sinus tachycardia   Tests: Pelvic ultrasound is used –> unilateral ovarian enlargement, oedema, ‘whirlpool’ sign – Laparoscopy is diagnostic   Treatment: Emergency laparoscopy to uncoil twisted ovary + fixation   Polycystic Ovary Syndrome (PCOS)

It is not uncommon to develop cystic masses on the ovaries. – In premenopausal women, most ovarian masses are benign. – The incidence of ovarian cancer increases with age, so postmenopausal women are at a higher risk of malignancy – There are both non-neoplastic and neoplastic types of cysts which can occur naturally or be pathological: a) Non-Neoplastic Cysts: Physiological: These cysts develop as part of the menstrual cycle. They are considered physiological and usually self-resolve over 2-3 menstrual cycles. They include: –> Follicular cysts: These occur when the dominant follicle does not rupture releasing the egg cell   –> Corpus

Menopause refers to the natural halting of the menstrual cycle due to depletion of ovarian follicles. – It is defined as amenorrhoea for 2 years below the age of 50 or 12 months over the age of 50. – The average age of menopause in the UK is 51. – Perimenopause refers to the period before the menopause in which the woman begins to experience symptoms of the approaching menopause  Pathophysiology of Menopause Symptoms: – Menstrual changes -> change in length, frequency and amount of blood loss – Hot flushes and night sweats – Joint and muscle aches – Atrophic

Mastitis This is a condition that refers to inflammation of the breast – It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus Symptoms: Erythematous, tender, swollen area of breast – Systemic upset with fevers, chills and fatigue   Management: – 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied – If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days   Breast Abscess This can occur if mastitis is left untreated Symptoms: Gives a tender, red fluctuant

Endometrial Cancer A uterine cancer usually seen in post-menopausal women, in 2 types: i) Uterine sarcoma: A malignant proliferation of muscles of the uterus ii) Adenocarcinoma: A malignant proliferation of the endometrial glands It is the most common invasive carcinoma of the female genital tract which is further divided into two subtypes: Type 1: – This is called an endometroid carcinoma where the tumours look like normal endometrial glands – Associated with high oestrogen levels and often preceded by endometrial hyperplasia   Type 2: – This has multiple subtypes, is a rarer and not linked to oestrogen exposure   Full adenocarcinoma

Endometrial Cancer A uterine cancer usually seen in post-menopausal women, in 2 types: i) Uterine sarcoma: A malignant proliferation of muscles of the uterus ii) Adenocarcinoma: A malignant proliferation of the endometrial glands It is the most common invasive carcinoma of the female genital tract which is further divided into two subtypes: Type 1: – This is called an endometroid carcinoma where the tumours look like normal endometrial glands – Associated with high oestrogen levels and often preceded by endometrial hyperplasia   Type 2: – This has multiple subtypes, is a rarer and not linked to oestrogen exposure   Full adenocarcinoma

Endometrial Cancer A uterine cancer usually seen in post-menopausal women, in 2 types: i) Uterine sarcoma: A malignant proliferation of muscles of the uterus ii) Adenocarcinoma: A malignant proliferation of the endometrial glands It is the most common invasive carcinoma of the female genital tract which is further divided into two subtypes: Type 1: – This is called an endometroid carcinoma where the tumours look like normal endometrial glands – Associated with high oestrogen levels and often preceded by endometrial hyperplasia   Type 2: – This has multiple subtypes, is a rarer and not linked to oestrogen exposure   Full adenocarcinoma

Premenstrual syndrome (PMS) This describes the distressing physical, psychological and behavioural symptoms in the absence of organic disease that regularly occur during the luteal phase of the menstrual cycle – This occurs in most women and encompasses a whole spectrum of severity from minor to debilitating. – Cause unknown but associated with change in levels of oestrogen + 5-HT levels at the beginning of cycle   Symptoms: – Psychological –> depression, anxiety, irritability – Physical –> fatigue, bloating, mastalgia, acne   Management: – If mild, then reduce salt, caffeine and stress – 1st line is Combined oral contraceptive pill –

Cervical Ectropion A condition in which simple columnar epithelium (lining the endocervix) is present on the ectocervix. – This type of epithelium is more fragile than the stratified squamous epithelium that usually lines the ectocervix and may bleed after sexual intercourse – Ectropion can also lead to increased vaginal discharge as simple columnar cells are mucus-producing – It is diagnosed clinically after ruling out other more sinister pathologies like cervical cancer. Causes: – Raised oestrogen levels (e.g. pregnancy, COCP) Symptoms: Mostly asymptomatic but may cause: – Post-coital bleeding – An increase in vaginal discharge – Pain/bleeding during cervical screening –

Cervical Ectropion A condition in which simple columnar epithelium (lining the endocervix) is present on the ectocervix. – This type of epithelium is more fragile than the stratified squamous epithelium that usually lines the ectocervix and may bleed after sexual intercourse – Ectropion can also lead to increased vaginal discharge as simple columnar cells are mucus-producing – It is diagnosed clinically after ruling out other more sinister pathologies like cervical cancer. Causes: – Raised oestrogen levels (e.g. pregnancy, COCP) Symptoms: Mostly asymptomatic but may cause: – Post-coital bleeding – An increase in vaginal discharge – Pain/bleeding during cervical screening –

Many breast conditions can present with a lump, which can be malignant or benign. When this happens, the standard procedure is to conduct a triple assessment, which involves three types of tests: i) Clinical examination – should involve a chaperone (not a family member) ii) Radiology – Ultrasound for <35years; mammography and ultrasound for >35 years old iii) Histology – Fine needle aspiration (FNA) or core biopsy for new lumps NICE Referral Guidelines   Risk Factors The risk factors are related to oestrogen exposure as well as to specific genes: – Age (most breast cancers occur in women >50yrs) –

Premenstrual syndrome (PMS) This describes the distressing physical, psychological and behavioural symptoms in the absence of organic disease that regularly occur during the luteal phase of the menstrual cycle – This occurs in most women and encompasses a whole spectrum of severity from minor to debilitating. – Cause unknown but associated with change in levels of oestrogen + 5-HT levels at the beginning of cycle   Symptoms: – Psychological –> depression, anxiety, irritability – Physical –> fatigue, bloating, mastalgia, acne   Management: – If mild, then reduce salt, caffeine and stress – 1st line is Combined oral contraceptive pill –

Urinary Incontinence This is a very important gynaecological condition which has a huge impact of patients’ lives. – There are two main types of incontinence in females, each of which have different pathologies and treatments. – It affects about 4-5% of the population, being more common in elderly females   i) Urge Incontinence This is the involuntary leakage preceded/accompanied by a sudden desire to pass urine – It occurs due to an overactive bladder due to increase detrusor muscle overactivity   Causes: Mostly idiopathic but can be associated with neurological conditions (e.g. MS, PD) – Can be made worse by

Menopause refers to the natural halting of the menstrual cycle due to depletion of ovarian follicles. – It is defined as amenorrhoea for 2 years below the age of 50 or 12 months over the age of 50. – The average age of menopause in the UK is 51. – Perimenopause refers to the period before the menopause in which the woman begins to experience symptoms of the approaching menopause  Pathophysiology of Menopause Symptoms: – Menstrual changes -> change in length, frequency and amount of blood loss – Hot flushes and night sweats – Joint and muscle aches – Atrophic

Premenstrual syndrome (PMS) This describes the distressing physical, psychological and behavioural symptoms in the absence of organic disease that regularly occur during the luteal phase of the menstrual cycle – This occurs in most women and encompasses a whole spectrum of severity from minor to debilitating. – Cause unknown but associated with change in levels of oestrogen + 5-HT levels at the beginning of cycle   Symptoms: – Psychological –> depression, anxiety, irritability – Physical –> fatigue, bloating, mastalgia, acne   Management: – If mild, then reduce salt, caffeine and stress – 1st line is Combined oral contraceptive pill –

Bartholin’s abscess This is an abscess which forms on the Bartholin’s glands which line the vagina. – It arises when one of the ducts carrying fluid from the gland gets blocked, giving a fluid filled lump (cyst) – The cysts can then become infected by bacteria leading to the formation of a Bartholin’s abscess. Symptoms: – Vaginal pain and redness – Unilateral swelling near the vaginal introitus   Diagnosis: Clinical Diagnosis   Management: – 1st line is antibiotics. – If abscess does not respond/is painful, cyst drainage is performed (using word catheter or marsupialization)   Vulval Carcinoma This describes a

Cervical Ectropion A condition in which simple columnar epithelium (lining the endocervix) is present on the ectocervix. – This type of epithelium is more fragile than the stratified squamous epithelium that usually lines the ectocervix and may bleed after sexual intercourse – Ectropion can also lead to increased vaginal discharge as simple columnar cells are mucus-producing – It is diagnosed clinically after ruling out other more sinister pathologies like cervical cancer. Causes: – Raised oestrogen levels (e.g. pregnancy, COCP) Symptoms: Mostly asymptomatic but may cause: – Post-coital bleeding – An increase in vaginal discharge – Pain/bleeding during cervical screening –

Endometrial Cancer A uterine cancer usually seen in post-menopausal women, in 2 types: i) Uterine sarcoma: A malignant proliferation of muscles of the uterus ii) Adenocarcinoma: A malignant proliferation of the endometrial glands It is the most common invasive carcinoma of the female genital tract which is further divided into two subtypes: Type 1: – This is called an endometroid carcinoma where the tumours look like normal endometrial glands – Associated with high oestrogen levels and often preceded by endometrial hyperplasia   Type 2: – This has multiple subtypes, is a rarer and not linked to oestrogen exposure   Full adenocarcinoma

It is not uncommon to develop cystic masses on the ovaries. – In premenopausal women, most ovarian masses are benign. – The incidence of ovarian cancer increases with age, so postmenopausal women are at a higher risk of malignancy – There are both non-neoplastic and neoplastic types of cysts which can occur naturally or be pathological: a) Non-Neoplastic Cysts: Physiological: These cysts develop as part of the menstrual cycle. They are considered physiological and usually self-resolve over 2-3 menstrual cycles. They include: –> Follicular cysts: These occur when the dominant follicle does not rupture releasing the egg cell   –> Corpus

Ovarian Torsion This is when the ovary twists on its supporting ligaments. It is a gynaecological emergency as it can cut of the blood supply to the ovary, resulting in ischaemia   Risk factors: – Ovarian cysts (especially dermoid cyst/PCOS) – Ovulation induction Symptoms: Sudden onset of sharp, colicky, unilateral lower quadrant abdominal pain – Nausea and Vomiting – May also be a low-grade pyrexia and sinus tachycardia   Tests: Pelvic ultrasound is used –> unilateral ovarian enlargement, oedema, ‘whirlpool’ sign – Laparoscopy is diagnostic   Treatment: Emergency laparoscopy to uncoil twisted ovary + fixation   Polycystic Ovary Syndrome (PCOS)

Many breast conditions can present with a lump, which can be malignant or benign. When this happens, the standard procedure is to conduct a triple assessment, which involves three types of tests: i) Clinical examination – should involve a chaperone (not a family member) ii) Radiology – Ultrasound for <35years; mammography and ultrasound for >35 years old iii) Histology – Fine needle aspiration (FNA) or core biopsy for new lumps NICE Referral Guidelines   Risk Factors The risk factors are related to oestrogen exposure as well as to specific genes: – Age (most breast cancers occur in women >50yrs) –

Mastitis This is a condition that refers to inflammation of the breast – It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus Symptoms: Erythematous, tender, swollen area of breast – Systemic upset with fevers, chills and fatigue   Management: – 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied – If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days   Breast Abscess This can occur if mastitis is left untreated Symptoms: Gives a tender, red fluctuant

This describes the 28-day cycle which occurs in women around the ages of 14 to 51, which controls the synthesis and release of egg cells and the associated hormonal changes that go along with this. – The cycle starts on the first day of the period (menstruation) and ovulation usually occurs on day 14.   The changes that occur in the female reproductive system are coordinated by the hypothalamic-pituitary-ovarian axis: – The hypothalamus produces gonadotrophin releasing hormone (GnRH) – This stimulates the anterior pituitary to secrete follicular stimulating hormone (FSH) + luteinising hormone (LH) – These hormones act on follicles

The female reproductive system lies posterior to the bladder and anterior to the rectum. – It includes the uterus, ovaries, cervix, fallopian tubes and the vagina. Ovaries The ovaries are the main female reproductive organs, as they produce egg cells and sex hormones oestrogen and progesterone. – They lie lateral to the uterus close to the pelvic wall – The right lies close to caecum/appendix and left near sigmoid   Blood supply: – Ovarian artery (direct from abdominal aorta)   Venous drainage: – Ovarian vein –> IVC on right/renal vein on left   Nerve supply: – Sympathetics from T10 –>

Introduction Uterine fibroids (leiomyomas) are benign tumours that arise from the muscle layer of the uterus termed the myometrium. Fibroids are the most common type of pelvic tumour in women, usually arising in those of child-bearing age. They may be asymptomatic or present with a variety of symptoms including bleeding (e.g. menorrhagia), pelvic pain and/or infertility. Epidemiology They are the most common type of pelvic tumour and a leading cause of hysterectomy. The exact epidemiology of uterine fibroids is difficult to assess as many women are asymptomatic. In general, the incidence of uterine fibroids increases with age until the menopause with peak incidence in women in

Introduction Urinary incontinence refers to the involuntary leakage of urine. Urinary incontinence is common in women and incidence increases with advancing age. There are a number of subtypes: Stress incontinence: related to increased intra-abdominal pressure Urgency incontinence: related to an overactive bladder Mixed incontinence: a combination of the above two causes Overflow incontinence: secondary to ‘overflow’ in patients with urinary retention This note focuses specifically on urinary incontinence in women and those with female pelvic organs. Epidemiology It is estimated that 5-69% of females have urinary incontinence. There is a wide range of incidence and prevalence estimates for urinary incontinence in women.

Introduction Polycystic ovary syndrome (PCOS) is an endocrine condition characterised by menstrual dysfunction and features of hyperandrogenism. PCOS is one of the most common endocrine disorders in women of reproductive age, with features often developing at puberty. It is a heterogeneous condition presenting with a wide clinical spectrum. Some women experience relatively mild symptoms whilst others suffer from debilitating effects. Clinical features are those of menstrual irregularity (oligo/amenorrhoea), hyperandrogenism (e.g acne, hirsutism) and anovulatory infertility. Management depends on the manifestation of the condition in each individual but often involves the restoration of ovulation, preventing endometrial hyperplasia, reducing hyperandrogenism and screening for

Overview Ovarian cancer refers to a malignancy arising from ovarian tissue. Ovarian cancer is the second most common gynaecological cancer following endometrial cancer, with a lifetime risk in women estimated at 1 in 52. It is relatively rare before the age of thirty with incidence increasing with age (highest in those aged 75-79). The majority of ovarian cancers (around 90-95%) arise from epithelial cells, so-called epithelial ovarian carcinomas, with the remaining being classified as non-epithelial ovarian carcinomas. It can be asymptomatic, particularly in early disease, and when features do develop they may be non-specific. As such it is often diagnosed at an advanced

Introduction A miscarriage refers to the spontaneous loss of pregnancy before 24 weeks of gestation. Miscarriage is common, affecting up to 30% of all pregnancies. It tends to present with per vaginal (PV) bleeding that may be associated with abdominal pain/cramps. The symptoms can be dismissed as a period in early miscarriage in those who do not know they are pregnant. Miscarriages may be classified as early (less than 13 weeks gestation) or late (between 13 and 24 weeks gestation). Foetal genetic/chromosomal abnormalities are the single most common cause of miscarriage though often there is no identifiable cause. Management may be

Definition Menorrhagia refers to excessive, abnormal uterine bleeding, which occurs over several consecutive cycles and interferes with a woman’s physical, emotional, social, and material quality of life. Menorrhagia is hard to define clinically. We must first consider parameters of normal menstrual bleeding. The key parameters in normal menstrual bleeding include frequency, regularity, volume and duration of menses. Frequency: every 21-35 days Regularity: consistent cycle frequency Volume: approximately 5-80 mL of blood Duration: bleeding for 5 days Markers of menorrhagia include increased frequency of blood soaked pads/tampons or blood loss that interferes with daily activities. In the literature, menorrhagia is traditionally quoted as blood loss exceeding 80 mL. Menorrhagia is often

Overview Menopause is the natural cessation of menstruation due to loss of ovarian follicular activity. It most commonly occurs between the ages of 45 – 55 with a mean age of 51. As hormonal levels change, many will experience irregular periods and vasomotor features (e.g. hot flushes). This is followed by the cessation of menstruation. There are a number of key terms that students should be aware of: Premature menopause: in some women, menopause occurs early for a myriad of reasons. If it occurs prior to 40 it is termed premature menopause. Perimenopause: occurs prior to menopause and is characterised by an irregular

Overview Lichen sclerosus is a chronic, progressive skin disorder that most commonly affects the genitalia and perianal area. Lichen sclerosus is a chronic dermatological condition that is characterised by pruritus and irritation in the anogenital area. The condition is ten times more common in women and classically affects the labia minora and/or majora with development of white atrophic plaques that may lead to architecture destruction overtime. Other terms: Lichen sclerosus et atrophicus (old term used in women) Balanitis xerotica obliterans (used to describe lichen sclerosus of the gland penis in men) Epidemiology Lichen sclerosus is much more common in woman. Lichen sclerosus is up to ten times

Overview Endometriosis refers to the extrauterine implantation and growth of endometrial tissue. It is often a chronic and debilitating condition that is likely under-recognised and often diagnosed after repeated presentation. Like endometrial tissue in the uterus, endometriosis responds to cyclical hormones leading to inflammation, bleeding and scaring. The deposits are most frequently on pelvic structures – with the ovaries most affected – though they may also occur on extra-pelvic structures (on rare occasions even in the pleural cavity or brain). It commonly causes pain but may also lead to reduced fertility and the formation of adhesions. Two specific terms to be aware of are: Adenomyosis: Specifically

Overview Endometrial cancer refers to malignancy of the lining of the uterus (i.e the endometrium). Endometrial cancer (EC) is the most common gynaecological malignancy in developed countries. It is due to abnormal proliferation of endometrial cells, which commonly presents with abnormal uterine bleeding. Due to the early presentation with bleeding, the five-year survival is more favourable than some cancers, estimated around 75%. EC is strongly linked to obesity. The rising rates of obesity has led to a significant increase in the incidence of EC. It is the sixth most common female malignancy worldwide. The mean age of diagnosis is around 60 years for non-inherited EC. However, in

Introduction Ectopic pregnancies refer to any pregnancy that develops outside the endometrial cavity. They affect approximately 1 in 90 pregnancies in the UK, translating to around 11,000 cases a year. The key to safe management and minimising maternal mortality is prompt recognition. When missed or late presenting, ectopic pregnancies can lead to serious and potentially fatal complications. Two national guidelines are available covering the diagnosis and management of ectopic pregnancy: RCOG/AEPU Joint Guideline: Diagnosis and Management of Ectopic Pregnancy, Nov 16. NICE Guideline 126: Ectopic pregnancy and miscarriage: diagnosis and initial management, Apr 19. Site 97% of ectopic pregnancies develop in the fallopian tube. The fallopian

Introduction NHS Cervical Screening Programme (NHSCSP) that screens women and transgender men (with retained cervix) aged 24.5-64. Cervical cancer is a common malignancy whose aetiology is intimately related to human papillomavirus. There are around 3,200 cases of cervical cancer in the UK each year and in 2017 it was the 14th most common cancer in women. The NHSCSP aims to prevent the development of cervical cancer through the early identification and treatment of premalignant lesions. The cervix The cervix, derived from the Latin cervix meaning neck, is a fibromuscular structure that sits at the lower portion of the uterus. It has an external

Overview Cervical cancer is a common malignancy whose aetiology is intimately related to human papillomavirus. In the UK it is the most common cancer in women younger than 35. In the developing world cervical cancer is the second most common cancer in women. It can occur in women, transgender men (with retained cervix) and non-binary individuals (assigned female at birth). Cervical screening can help to prevent cervical cancer by diagnosing and treating pre-malignant lesions. Unfortunately, attendance to screening fluctuates and has been falling recently prompting a number of national campaigns to combat this. Epidemiology There are around 3,200 cases of cervical cancer in

Overview A Bartholin gland cyst refers to cystic dilatation of one of the greater vestibular glands due to obstruction. The Bartholin glands, also known as the greater vestibular glands, form part of the vulva (external female genitalia). A common abnormality of these glands is the formation of a cyst due to obstruction. A Bartholin gland cyst may become infected forming an abscess. Cysts can be small and asymptomatic or large and cause discomfort. Infection of the Bartholin glands often causes severe pain and swelling due to abscess formation. Management depends on the cyst size and presence or absence of abscess but usually