gyne

Quick comparison: Risk factors: female cancers
Mutations of the BRCA2 geneovarian cancerbreast cancer
Hormone replacement therapy (combined oestrogen + progesterone) breast cancer, cervical cancer

family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity

Diagnosis often is delayed because of lack of specific symptoms.
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea

CA125
>NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
>if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
> a CA125 should not be used for screening for ovarian cancer in asymptomatic women
ultrasound
Diagnosis is difficult and usually involves diagnostic laparotomy

Management
usually a combination of surgery and platinum-based chemotherapy
Prognosis
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%

*It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

pco
Quick comparison: Risk factors: female cancers
Polycystic ovarian syndrome >> endometrial cancer
Combined oral contraceptive pill use >> breast cancer, cervical cancer

>obesity
>nulliparity
>early menarche
>late menopause
>unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
>diabetes mellitus
>tamoxifen
>polycystic ovarian syndrome
>hereditary non-polyposis colorectal carcinoma

>postmenopausal bleeding is the classic symptom
>premenopausal women may have a change intermenstrual bleeding
>pain and discharge are unusual features

*women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
*first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
*hysteroscopy with endometrial

*localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
*progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

the combined oral contraceptive pill and smoking are protective

*may be detected during routine cervical cancer screening
*abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
*vaginal discharge

*Squamous carcinoma
*Adenocarcinoma

Human papillomavirus (HPV) particularly serotypes 16,18 & 33

-Human papilloma virus (HPV) infection
-Smoking
-smoking
-human immunodeficiency virus
-early first intercourse, many sexual partners
-high parity
-lower socioeconomic status
-combined oral contraceptive pill*

-HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
-E6 inhibits the p53 tumour suppressor gene
- E7 inhibits RB suppressor gene

Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.

-chronic pelvic pain
-secondary dysmenorrhoeapain often starts days before bleeding
-deep dyspareunia
-subfertility
-non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
-on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

laparoscopy is the gold-standard investigation

Management depends on clinical features
-NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
-if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
-If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
*GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels
*drug therapy unfortunately does not seem to have a significant impact on fertility rates
*surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

*ovarian cancer
*endometrial cancer
*breast cancer

Estrogen antagonist --> binds to estrogen receptor but fails to induce conformational change required to cause transcriptional activation
used as a ttt in breast cancer but it is a risk factor for endometrial cancer

-advancing age
-previous pregnancy and childbirth
-high body mass index
-hysterectomy
-family history

-bladder diaries should be completed for a minimum of 3 days
-vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
-urine dipstick and culture
-urodynamic studies

- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line: *NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
*Immediate release oxybutynin should, however, be avoided in 'frail older women'
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

a combined noradrenaline and serotonin reuptake inhibitormechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

- pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
- duloxetine may be offered to women if they decline surgical procedures

-subfertility and infertility
-menstrual disturbances: oligomenorrhea and amenorrhoea
-hirsutism, acne (due to hyperandrogenism)
obesity
-acanthosis nigricans (due to insulin resistance)

- pelvic ultrasound: multiple cysts on the ovaries
- FSH, LH, prolactin, TSH, and testosterone are useful investigations:
raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
*check for impaired glucose tolerance

Inhibits ovulation

Inhibits ovulation

Primary: Toxic to sperm and ovumAlso: Inhibits implantation

Inhibits ovulation

Thickens cervical mucus

Primary: Inhibits ovulation, Also: thickens cervical mucus

Primary: Inhibits ovulation, Also: thickens cervical mucus

Primary: Inhibits ovulation, Also: thickens cervical mucus

Decreases sperm motility and survival

Primary: Prevents endometrial proliferation, Also: Thickens cervical mucus