Obstetrics and Gynaecology 2
Summary
• Approximately 15-20% are ADENOCARCINOMAS • Majority caused by HPV virus – especially HPV16, 18 • Over 99% of all cervical cancers can be prevented by regular screening-note: ACOG recommends that Pap tests to begin by Age 21, with annual testing from ages 21 to 29 and less frequent screening (every 3 years) among women age 30 and older • Addition of HPV testing for all women over 30 may improve screening • Sexually active women should receive HPV vaccination to reduce their risk of HPV related conditions
Learning objectives
• But about 10% are ADENOCARCINOMAS • Both are associated with high risk HPV:
• HPV16 and 18 • HPV31 and 45• HPV33 and 52 • HPV39 and 59• HPV58 • Oncogenic HPV virus can integrate into the host genome • Cervical screening is organised by NHS cervical screening programmes, check individual country programme
• Screening test can detect cell changes in precancerous lesions • HPV is common, but persistent persistent infection is associated with increased CIN Learning Objectives:
- Identify symptoms of gynaecological cancers, urogynaecology, benign gynaecology, reproductive medicine, subfertility and menopause care.
- Explain the appropriate next steps in management when presented with a patient with a gynaecological cancer.
- Explain the features of an endometrial cancer.
- Describe the investigations for an endometrial cancer.
- List the conditions warranting a 2 week wait referral for a cancer presentation.
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GYNAECOLOGYPart1 Dr Nina Cooper SpR Obstetrics & Gynaecology North West Thames DeaneryWhoamI? • Graduated from Imperial in July 2017 • BSc Reproductive & Developmental Sciences • Academic Foundation Programme in Women’s Health – North Central Thames Foundation School • Specialty Training North West Thames • Research interests: paediatric and adolescent gynaecology, ultrasound, gynaecological cancersStructureforToday: There is MORE INFORMATION on the slides than I can explain in 45 minutes, so I will share the slides with the committee. Session 1 • Gynaecological cancers • Urogynaecology 10 minute break Session 2 • Benign gynaecology • Reproductive medicine, subfertility and menopause care To be covered at a later date: early pregnancy, acute gynaecology and gynaecological emergenciesDISCLAIMER All questions have been written by myself and should not be copied, distributed or shared without prior permission. Every effort has been made for answers to be in line with national guidance, however you should follow guidance from your local medical school if any answer conflicts with your teaching.Session 1: GYNAECOLOGICALCANCERSQuestion1 A 65 year old woman presents to her GP with episodes of heavy vaginal bleeding with clots over 2 weeks. She completed her menopause at the age of 52. What would be the most appropriate next step in her management? 1. Commence norethisterone 2. Referral to rapid access clinic under 2 week wait 3. Urgent CT abdomen and pelvis 4. Urgent Ca-125 level 5. Urgent transvaginal ultrasoundQuestion2 Which HPV subtypes are screened for at cervical cancer screening? 1. 21 & 24 2. 6, 11, 21, 24 3. 16 & 18 4. 6 & 11 5. 6, 11, 16 & 18Question3 Which type of ovarian cancer is derived from primary embryonic germ layers? 1. Borderline 2. Epithelial 3. Granulosa cell 4. Fibroma 5. Immature TeratomaQuestion4 A 22 year old girl presents to rapid access clinic with persistent bloating, 5kg weight loss and lower abdominal pain. Abdominal examination demonstrates tense ascites. VE reveals a mobile AV uterus with a firm right-sided adnexal mass. What would be the most appropriate next step in her management? 1. Staging CT chest-abdomen-pelvis 2. Admit for inpatient investigations 3. Urgent ultrasound abdomen/pelvis 4. Refer to medical oncology 5. Admit for same-day TAH+BSOQuestion5 A 84 year old woman presents with persistent vulval itching and has noticed some spots of blood on wiping. Which of the following features of her history would make you most concerned regarding vulval cancer? 1. Personal history of atrophic vaginitis 2. Personal history of lichen sclerosus 3. Personal history of lichen planus 4. Personal history of vulvovaginitis 5. Personal history of lichen simplexSession 1: ANSWERSQuestion1 A 65 year old woman presents to her GP with episodes of heavy vaginal bleeding with clots over 2 weeks. She completed her menopause at the age of 52. What would be the most appropriate next step in her management? 1. Commence norethisterone 2. Referral to rapid access clinic under 2 week wait 3. Urgent CT abdomen and pelvis 4. Urgent Ca-125 level 5. Urgent transvaginal ultrasound POST-MENOPAUSALBLEEDINGIS ENDOMETRIALCANCERUNTILPROVEN OTHERWISECAUSESOFPOST-MENOPAUSALBLEEDINGEndometrialCancer • Endometrial thickness: <4mm post-menopausal, <10mm pre- menopausal • Pre-malignant = CAH • 90% adenocarcinoma of the endometrial glands • Type 1 = oestrogen dependent • Associated with unopposed oestrogen exposure, obesity, subfertility, PCO • Well-differentiated • Endometrioid carcinomas • Type 2 = non-oestrogen dependent • Serous, clear-cell • Associated with advanced age • Poorer prognosis • Uterine sarcoma: very rare, leiomyosarcoma/endometrial stromal/mixed mullerian • V poor prognosisInvestigations • Women presenting with PMB, unscheduled bleeding on HRT or persistent prolonged or intermenstrual bleeding should receive an abdominal, speculum and pelvic examination at their clinical assessment • Women with menorrhagia over 45 years, or those with irregular bleeding or failure of treatment over 45, need endometrial sampling. • TVUS with measurement of endometrial thickness should be employed as initial investigation • In patients with a TVS endometrial thickness measurement of ≥4 mm, an outpatient endometrial biopsy should be carried out • Hysteroscopy should only be carried out if outpatient endometrial biopsy is not feasible or for women with ultrasound irregularities and at high risk of endometrial cancer.Investigations • Women presenting with PMB, unscheduled bleeding on HRT or persistent prolonged or intermenstrual bleeding should receive an abdominal, speculum and pelvic examination at their clinical assessment • Women with menorrhagia over 45 years, or those with irregular bleeding or failure of treatment over 45, need endometrial sampling. • TVUS with measurement of endometrial thickness should be employed as initial investigation • In patients with a TVS endometrial thickness measurement of ≥4 mm, an outpatient endometrial biopsy should be carried out • Hysteroscopy should only be carried out if outpatient endometrial biopsy is not feasible or for women with ultrasound irregularities and at high risk of endometrial cancer. ManagementofEndometrialCancer Early disease (FIGO Stage I and II) Late Disease (FIGO Stage III and IV) • Surgery may be limited to hysterectomy and bilateral Complete surgical resection of all visible salpingo-oophorectomy in those patients with grade 1 or 2 disease in advanced endometrial cancer may endometrioid adenocarcinoma which appears confined to be considered in selected patients who are fit the uterus • Lymphadenectomy in this instance does not improve to undergo surgery as limited evidence shows this may prolong survival. survival or reduce the risk of disease recurrence • There is no evidence to support routine lymphadenectomy in low risk endometrial cancers. Whentorefer? Cancer Referral Vulval 2WW referral for an unexplained vulval lump, ulceration or bleeding Vaginal 2WW referral for an unexplained palpable mass in or at the entrance to the vagina Endometrial 2WW referral if they are aged 55 and over with post-menopausal bleeding (new NICE recommendation for 2015). Unexplained vaginal bleeding is defined as more than 12 months after menstruation has stopped because of the menopause. Cervical 2WW if, on examination, the appearance of their cervix is consistent with cervical cancerQuestion2 Which HPV subtypes are screened for at cervical cancer screening? 1. 21 & 24 2. 6, 11, 21, 24 3. 16 & 18 4. 6 & 11 5. 6, 11, 16 & 18 CervicalCancerataglance: • Majority are SQUAMOUS CELL CARCINOMAS (>90%) – high association with HPV • Cx smear test protocol now varies between regions • Some only test for HPV and then perform cytological analysis for high risk strains (HPV16&18) • Other continue wit cytology • If mild dyskaryosis with high risk HPV then referred, otherwise return to normal • Moderate-severe requires referral • Colposcopy – apply acetic acid +- biopsies • If malignant will require imaging for FIGO staging • Microinvasive disease (stage 1a) – cone biopsy • Stage 1-2a – usually surgical (radical hysterectomy or radical trachelectomy if willing to preserve fertility) • If nodes negative opt for surgery • If nodes positive opt to chemo-radiotherapy • Stage 2b or wose – usually chemo-radiotherapyQuestion3 Which type of ovarian cancer is derived from primary embryonic germ layers? 1. Borderline 2. Epithelial 3. Granulosa cell 4. Fibroma 5. Immature TeratomaQuestion4 A 22 year old girl presents to rapid access clinic with persistent bloating, 5kg weight loss and lower abdominal pain. Abdominal examination demonstrates tense ascites. VE reveals a mobile AV uterus with a firm right-sided adnexal mass. What would be the most appropriate next step in her management? 1. Staging CT chest-abdomen-pelvis 2. Admit for inpatient investigations 3. Urgent ultrasound abdomen/pelvis 4. Refer to medical oncology 5. Admit for same-day TAH+BSOOvarianCancer PRIMARYCAREPERSPECTIVE: • 2WW if examination identifies ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids) • Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis — particularly more than 12 times per month: • Persistent abdominal distension (women often refer to this as 'bloating'). • Feeling full (early satiety) and/or loss of appetite. • Pelvic or abdominal pain. • Increased urinary urgency and/or frequency. • Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habitTESTSINPRIMARYCARE • Measure serum CA125 • If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis • If the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation INVESTIGATIONSINSECONDARYCARE Ca125 +/- CT (chest) + AFP/hCG (<40 US abdomen abdomen + years old) and pelvis pelvis Measure aFP/hcg in women Can offer MRI if nature of unon-epithelial ovarian cancerh mass remains indeterminate MANAGEMENTOFOVARIANCANCER Conservative Medical: • Chemotherapy first-line usually paclitaxel + platinum-based e.g. cisplatin/carboplatin • Bevacizumab (Avastin) only for advanced Surgical: • Usually ultra-radical surgery • Primary or interval debulkingQuestion5 A 84 year old woman presents with persistent vulval itching and has noticed some spots of blood on wiping. Which of the following features of her history would make you most concerned regarding vulval cancer? 1. Personal history of atrophic vaginitis 2. Personal history of lichen sclerosus 3. Personal history of lichen planus 4. Personal history of vulvovaginitis 5. Personal history of lichen simplexVulvalCancerataGlance VIN: atypical changes to vulval epithelium • Usual-type = associated with HPV (16) » Also smoking and immunosuppression » Leads to warty or basaloid SCC • Differentiated-type = associated with lichen sclerosus » Leads to keratinising SCC of the vulva 95% of vulval carcinomas = squamous cell • (Rest = melanoma, BCC, adenocarcinoma) • Metastasise to inguinal lymph nodes • Can perform wide local excision (1a), groin lymphadenectomy or radical vulvectomy 2WW referral for an unexplained vulval lump, ulceration or bleedingVulvalCancerataGlance 95% of vulval carcinomas = squamous cell • (Rest = melanoma, BCC, adenocarcinoma) • Metastasise to inguinal lymph nodes • Can perform wide local excision (1a), groin lymphadenectomy or radical vulvectomy 2WW referral for an unexplained vulval lump, ulceration or bleedingVaginalCancer • Vaginal carcinoma – rare • Clear cell adenocarcinoma = in teenagers, rare, associated with DES (diethyltilbestrol) • Primary vaginal carcinoma = usual squamous cell carcinoma, older womenSession 2: UROGYNAECOLOGYQuestion1 Which of the following statements is true? 1. Detrusor overactivity leads to stress incontinence 2. Overactive bladder is treated with a ring pessary 3. Stress incontinence may be provoked by chronic cough 4. Interstitial cystitis should be treated with a daily dose of prophylactic antibiotics 5. Physiotherapy is the first line management for vesicovaginal fistulaQuestion2 You are a doctor in Gynaecology Outpatients. A 80 year old woman presents with a 15 year history of leaking urine on coughing and sneezing. She was referred for physiotherapy by her GP but has not had a significant improvement in her symptoms. On examination there is a small cystocele. Which would be the most appropriate next step in her management? 1. Insertion of ring pessary 2. Start duloxetine 3. Anterior repair 4. Vaginal mesh repair 5. Tension-free vaginal tapeQuestion3 Which of the following lifestyle measures is not recommended by NICE for the management of pelvic organ prolapse? 1. Weight loss 2. Increase physical activity 3. Prevent constipation 4. Stop caffeine 5. Minimise heavy liftingQuestion4 A 45 year old complains of increased urinary frequency and episodes of incontinence. She reports that she ‘cannot make it to the toilet on time’. She is keen to try a medication for her symptoms. Which of the following is offered first line for overactive bladder? 1. Imipramine 2. Flavoxate 3. Oxybutynin 4. Desmopressin 5. MirabegronQuestion5 A woman presents with a feeling of rectal fullness and having to press inside her vagina to aid defaecation. A diagnosis of rectocoele is suspected. Which of the following surgical procedures would be most appropriate? 1. Posterior repair 2. Anterior repair 3. Sacrocolpopexy 4. Manchester repair 5. Vaginal hysterectomyQuestion1 Which of the following statements is true? 1. Detrusor overactivity leads to stress incontinence 2. Overactive bladder is treated with a ring pessary 3. Stress incontinence may be provoked by chronic cough 4. Interstitial cystitis should be treated with a daily dose of prophylactic antibiotics 5. Physiotherapy is the first line management for vesicovaginal fistulaQuestion2 You are a doctor in Gynaecology Outpatients. A 80 year old woman presents with a 15 year history of leaking urine on coughing and sneezing. She was referred for physiotherapy by her GP but has not had a significant improvement in her symptoms. On examination there is a small cystocele. Which would be the most appropriate next step in her management? 1. Insertion of ring pessary 2. Start duloxetine 3. Anterior repair 4. Vaginal mesh repair 5. Tension-free vaginal tapeQuestion3 Which of the following lifestyle measures is not recommended by NICE for the management of pelvic organ prolapse? 1. Weight loss 2. Increase physical activity 3. Prevent constipation 4. Stop caffeine 5. Minimise heavy liftingQuestion4 A 45 year old complains of increased urinary frequency and episodes of incontinence. She reports that she ‘cannot make it to the toilet on time’. She is keen to try a medication for her symptoms. Which of the following is offered first line for overactive bladder? 1. Imipramine 2. Flavoxate 3. Oxybutynin 4. Desmopressin 5. MirabegronUROGYNAE Main issues 1. Urinary incontinence • Stress (associated with weakened pelvic floor, surgery can help) • Urge (usually associated with overactive detrusor muscle, surgery less helpful) • Mixed • Stress incontinence may be associated with a weak pelvic floor and pelvic organ prolapse 2. Pelvic organ prolapse • Cystocoele • Rectocoele • Uterine prolapse • Vaginal vault prolapseURINARYINCONTINENCE ESTABLISH IF STRESS VS. URGE VS. MIXED • If mixed, treat predominant symptom Stress incontinence: involuntary leakage of small amounts of urine where there is increased intra-abdominal pressure i.e. coughing or laughing Urge incontinence: involuntary leakage of urine which is accompanied or preceded by an “urge” to pass urine Overactive bladder syndrome = increased frequency and nocturia, not necessarily with incontinence (if incontinent, classed as urge incontinence) Mixed incontinence: both urge and stressINVESTIGATIONURINARYINCONTINENCE • Examine patient – PV/PR, signs of POP • Urine dipstick • Bladder diary (3 days) • Post-void residual volume (usually via bladder scan) • Can refer for urodynamics if considering surgical management or complex historyMANAGEMENTOFURINARYINCONTINENCE Non-surgical management • Lifestyle Interventions • Reduce caffeine • Modify fluid intake • If BMI >30, advise to lose weight • Physiotherapy: at least 3 months supervised • Bladder training for urge/mixed incontinence for 6 weeks Medical: only for urge/OAB, 2 ndline if conservative measures fail • First line anticholinergics e.g. tolterodine, oxybutynin (not for >80s) • Second line anticholinergics: mirabegronINVASIVEMANAGEMENTOFURINARYINCONTINENCE Invasive options if incontinence if caused by detrustor overactivity • Botox injection • Percutaneous sacral nerve stimulation • Augmentation cystoplasty • Urinary diversionSURGICALMANAGEMENTOFSTRESSINCONTINENCE 2ND line management after conservative measures fail Offer either • Colposuspension or • Autologus rectal fascia slingSURGICALMANAGEMENTOFSTRESSINCONTINENCE 2ND line management after conservative measures fail Offer either • Colposuspension or • Autologus rectal fascia sling • Can also offer mid-urethral mesh sling but should not be offered first line as per NICE guidanceSURGICALMANAGEMENTOFSTRESSINCONTINENCE https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress- urinary-incontinence-patient-decision-aid-pdf-6725286110SURGICALMANAGEMENTOFSTRESSINCONTINENCE https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress- urinary-incontinence-patient-decision-aid-pdf-6725286110SURGICALMANAGEMENTOFSTRESSINCONTINENCE https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress- urinary-incontinence-patient-decision-aid-pdf-6725286110SURGICALMANAGEMENTOFSTRESSINCONTINENCE https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress- urinary-incontinence-patient-decision-aid-pdf-6725286110USEFULINFORMATION https://www.nice.org.uk/guidance/ng123/resources/surgery-for- stress- urinary-incontinence-patient-decision-aid-pdf-6725286110 https://www.nice.org.uk/guidance/ng123/resources/surgery-for- vaginal- vault-prolapse-patient-decision-aid-pdf-6725286114 https://www.nice.org.uk/guidance/ng123/resources/surgery-for- uterine- prolapse-patient-decision-aid-pdf-6725286112Question5 A woman presents with a feeling of rectal fullness and having to press inside her vagina to aid defaecation. A diagnosis of rectocoele is suspected. Which of the following surgical procedures would be most appropriate? 1. Posterior repair 2. Anterior repair 3. Sacrocolpopexy 4. Manchester repair 5. Vaginal hysterectomyMANAGEMENTOFPROLAPSE Examination for • Presence and degree of prolapse using POP-Q score • Assess activity of pelvic floor muscles • Assess for vaginal atrophy • Rule out pelvic mass or other pathology Non-surgical management: • Lifestyle management: weight loss if BMI >30, minimise heavy lifting, treat/prevent constipation • Consider vaginal oestrogen if vaginal atrophy • 16 week supervised pelvic physiotherapy if symptomatic and POPQ score ½ • Consider vaginal pessary and review in clinic every 6 monthsMANAGEMENTOFPROLAPSE Examination for • Presence and degree of prolapse using POP-Q score • Assess activity of pelvic floor muscles • Assess for vaginal atrophy • Rule out pelvic mass or other pathology Non-surgical management: • Lifestyle management: weight loss if BMI >30, minimise heavy lifting, treat/prevent constipation • Consider vaginal oestrogen if vaginal atrophy • 16 week supervised pelvic physiotherapy if symptomatic and POPQ score ½ • Consider vaginal pessary and review in clinic every 6 months SURGICALMANAGEMENTOFPELVICORGANPROLAPSE For uterine prolapse: • Vaginal hysterectomy +/- sacrospinous fixation • Sacrospinous hysteropexy • Manchester repair (a.k.a Fothergill operation) • Sacro-hysteropexy with mesh For cystocoele: anterior repair For rectocoele: posterior repair https://www.nice.org.uk/guidance/ng123/resources/surgery-for-uterine-prolapse- patient-decision-aid-pdf-6725286112SURGICALMANAGEMENTOFPELVICORGANPROLAPSESURGICALMANAGEMENTOFPELVICORGANPROLAPSESURGICALMANAGEMENTOFPELVICORGANPROLAPSESURGICALMANAGEMENTOFPELVICORGANPROLAPSESURGICALMANAGEMENTOFPELVICORGANPROLAPSECYSTOCOELEVSRECTOCOELECYSTOCOELEVSRECTOCOELEEND OF SESSION 1 ANYQUESTIONS?