Gynaecology

Not starting menstruation by:

13 years with no evidence of pubertal development
OR
15 years with other signs of puberty [breast bud development]

Hypogonadism [lack of sex hormones],
Congenital adrenal hyperplasia, Androgen insensitivity syndrome,
Structural pathology

This is where there is a lack of LH and FSH due to damage or abnormalties to the hypothalamus or pituitary gland

Causes include: hypopituitarism, damage to the hypothalamus or pit. gland such as radiotherapy / surgery, excessive exercise or dieting [delays puberty onset], constitutional delay in growth / development, endocrine disorders [GH deficiency, Cushings, hypothyroidism], Kallmans syndrome [anosmia]

This is when the gonads fail to respond to FSH and LH, leading to no negative feedabck response from the sex hormones. Results in hypergonadotrophic and reduction in androgens

Causes: damage to the gonads [torsion, cancer, infection], congential absence of ovaries, Turners syndrome

Deficiency in 21-hydroxylase enzyme [autosomal recessive]. This leads to low aldosterone / cortisol and an overproduction of androgens. This can lead to unwell neonates and absent periods later on.

Tissues dont respond to androgen hormones so typical male sexual characteristics do not develop. Results in an external female phenotype [sexually male but externally female], Patients will have normal female external genitalia and breast tissue BUT testes will be present in the abdomen / inguinal canal WITH absent uterus, upper vagina, fallopian tubes and ovaries.

Imperforate hymen can present with teenagers who experience regular painful cycles. Transverse vaginal septae, vaginal agenesis, absent uterus, FGM

Take a detailed Hx and examination. Take FBC / ferritin [for anaemia], U&E for CKD, anti-TTG / anti-EMA for coeliac disease.

Check hormone blood levels [FSH, LH, thyroid, IGF-1, prolactin, testosterone], genetic testing, imaging [pelvic US, brain MRI, wrist Xray for constitutional delay]

Find underlying pathology. Conservative management for stress or low BMI causes via diet or CBT.
Give pulsatile GnRH in some cases like hypogonadotrophic hypogonadism, HRT in other cases if pregnancy is unwanted.

no menstruation for more than 3 months after previous regular menstrual periods.

If irregularly infrequent previously, consider 6-12 months, to warrant investigations

pregnancy is the most common cause. Menopause and premature ovarian failure, hormonal contraception, Pituitary tumour / prolactinoma / damage / Sheehans

Psychological or physiological stress such as excessive exercise, low body weight, eating disorders, chronic diseases.

PCOS, Ashermans syndrome, thyroid pathology

Detailed Hx and examination. beta-HCG to rule out pregnancy. Take LH and FSH as low levels can indicate a hypothalamic cause whilst high levels indicate ovarian problems. High FSH may indicaate primary ovarian failure, high LH may suggest PCOS.

Pelvic US for PCOS

Find underlying pathology and treat that. Give replacement hormones to induce menstruation and improve sx. PCOS patients need to induce a withdrawal bleed every 3-4 months to reduce the risk of endometrial hyperpalsia / cancer. Medroxyprogesterone is used for 14 days or COCp use regularly.

Amenorrhoea associated with low oestrogen levels have increased risk of osteoporosis. Ensure adequate vitamin D and calcium intake and give HRT or COCp.

the psychological, emotional, physical symptoms that occur during the luteal phase of menstrual cycle. Usually the days prior to the onset of menstruation. These Sx can affect QOL and usually resolves once menstruation begins

When premenstrual syndrome sx are severe / distressing and have significant impact on QOL

thought to be caused by fluctuation in oestrogen / progesterone hormones during menstrual cycle

Can develop in the absence of menstruation after a hysterectomy, endometrial ablation or the mirena coil. This is due to the ovaries still functioning and the hormonal cycle continuing

sx of premenstrual cycle due to response to COCp / cyclical hormone replacement therapy

low mood / anxiety, mood swings / irritability, bloating, fatigue / headaches, breast pain, reduced confidence, coginitive impariment, clumsiness, reduced libido

Sx diary spanning two monthly cycles to see that cyclical symptoms occur before and resolve after menstruation.

Definitive diagnosis is to induce menopause with GnRH analogues to stop sx.

Conservative: exercise, stop smoking / alcohol, dietary changes, CBT

Medical: COCp [Drospirenone]. SSRIs can be used for severe sx. Danazole or Tamoxifen for cyclical breast pain. Spironolactone for bloating / water retention

Surgical: hysterectomy / bilateral oophorectomy only in cases where everything else has failed. If women under 45 years, need HRT.

heavy menstrual periods, more than 80mls is excessive but this is not calculatable.

dysfunctional uterine bleeding, extremes of reproductive age, fibroids, endometriosis / adenoymosis, pelvic inflammatory disease, contraceptives, anticoagulant meds, bleeding disorders, endocrine disorders, CT disorders, endometrial hyperplasia / cancer, PCOS

thorough history taking [more than usual, more pads needed]

Pelvic examination with speculum should be done to look for fibroids / cancer UNLESS the Px has menorrhagia confirmed from Hx with no other RFs and Sx OR the patient young and not sexually active.

FBC for anaemia. Outpatient hysteroscopy can be done, if declined then transvaginal US can be done.

Swabs for infection, Coag screen if FHx relevant. TFTs

Treat underlying pathology if able. If unable, ask if they need contraceptives. If yes, Mirena coil [levonorgestrel releasing IUS] is first line. 2nd line is COCp and 3rd line is long-acting progesterone

if no, Tranexamic acid if there is NO PAIN. Mefanemic acid if there IS PAIN

Surgical management involves endometrial ablation / balloon thermal ablation. Hysterectomy if all else fails

benign tumours of the smooth muscle of the uterus. They are oestrogen sensitive so they grow in response to raised levels

Intramural: within the myometrium of the uterus, distorting the shape of the uterus

Subserosal: below the outer layer of the uterus, fibroids grow outwards into the abdominal cavity

Submucosal: below the endometrium

Pedunculated: on a stalk, hanging inside the uterine cavity

Menorrhagia

prolonged menstruation, bulk related problems [bloating, feeling full, abdo pain on menstruation], deep dyspareunia, decreased fertility

Polycythaemia 2ndary to autonomous production of erythropoietin is RARE

1st line: hysteroscopy / transvaginal US

Pelvic US for larger fibroids.

MRI scanning may be considered if more information about the fibroid is needed

if ASx = no Tx

Treat the menorrhagia secondary to fibroids.

GnRH agonists can be used to reduce the fibroid size but usually are only used in short term due to menopausal Sx

Surgical: Myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation

Anaemia, infertility, pregnancy complications like miscarriages. Constipation, UTI and urinary outflow obstruction, red degeneration, fibroid torsion

malignant change to a leiomyosarcoma [rare]

when fibroid growth outstrips blood supply, they degenerate and undergo necrosis. Usually large fibroids > 5cm during pregnancy.

Presents with severe abdominal pain, fever, tachycardia, vomiting

Manage via rest, fluids, analgesia

usually regresses are menopause due to no oestrogen

A life-threatning obstetric emergency in which the fertilised ovum implants outside the uterine cavity, usually in the Fallopian tube

previous ectopic pregnancy / recurrence, tubal abnormalities / adhesions / congenital / surgery, assisted reproduction methods, intrauterine device use, endometriosis, smoking [impairs tubal and cilia function]

Either due to impaired tubal transport or environment [infection / endometriosis] OR abnormal embryo-tubal interactions

typical history is a female with 6-8 weeks amenorrhoea + lower abdominal pain and later vaginal bleeding

other sx may be shoulder tip pain [phrenic nerve], pain on defecation / tenesmus, dizziness, fainting, syncope

Serial human chorionic gonadotrophic levels: if the rise is slower than expected or there is a decline = suspicion

Intravaginal US is first line, might see “tubal ring sign”. If CI, abdominal US

if size is less than 35mm, unruptured, ASx and hCG is less than 1000 = closely monitor the patient over 48hrs and if hCG levels rise again or sx manifest, intervene

Medical management involves giving methotrexate only if the patient is willing to attend follow-up

if the size > 35mm, ruptured, pain sx, hCG levels is more than 5000 = surgical management via salpingectomy [1st line for women with no other RFs for infertility] or salpingotomy

tubal rupture can lead to intraperitoneal haemorrhage [haemoperitoneum], persistent trophoblastic tissue producing hCG, dmg to reproductive organs, psychological impacts

ectopic endometrial tissue build up outside the uterus, sensitive to oestrogen levels

the ectopic tissue leads to irritation / inflammation of tissues around sites of endometriosis, leading to cyclic dull burning pain during menstruation. These can form adhesions which can lead to ovaries being fixed to the peritoneum.

cyclic extreme pain around menstruation with sometimes bleeding occuring elsewhere. Patients will also complain of deep dyspareunia, infertility and cyclical urinary / bowel sx

Speculum examination can show endometrial tissue on the vagina, bimanual may show a fixed cervix. There will be tenderness in the vagina, cervix, adnexa

Pelvic US may show very large endometriomas but are often unremarkable.

Laparoscopic surgery is the gold standard with a biopsy

Stage 1: small superficial lesions
Stage 2: mild, deeper lesions
Stage 3: deeper lesions with mild adhesions on the ovaries
Stage 4: deep large lesions affecting the ovaries with extensive adhesions

Conservative: analgesia for pain

Medical: Hormonal management via COCp, POP, Mirena coil. GnRH agonists can be used if the pill doesnt work but has menopause sx

Surgical: laparoscopic surgery, hysterectomy / bilateral salpingo-ophoerectomy

endometrial tissue inside the myometrium. it is more common in women’s later reproductive years and those that have had multiple pregnancies.

no period for more than 12 months

time around menopause where women may experience vasomotor sx and irregular periods. Includes the time leading up to the last menstrual period and 12 months after

Women younger than 40 years old experiencing menopause due to premature ovarian insufficiency

menopause starts with the decline in the development of the ovarian follicles which leads to less oestrogen. No oestrogen leads to no -ve feedback which leads to a rise in FSH / LH and the endometrium does not develop = amenorrhoea

Periods become irregular, hot flushes, urogenital changes [vaginal dryness / atrophy], psychological [low mood, low libido, short term memory impairment], joint pain / osteoporosis

Diagnosis can be made in women over 45 years with sx, without investigations.

FSH blood test can be used if women is under 40yrs for suspected premature menopause OR 40-45years with menopausal sx

Risks of pregnancy increases with age so women should use effective contraception for 2yr after LMP in women under 50yrs OR 1yr after LMP in women over 50yrs

Most contraceptives are UKMEC1 such as the mirenal coil, POP.

COCp is UKMEC2 in women over 40yrs

weight gain and osteoporosis, so therefore unsuitable in women over 45yrs old

Vasomotor sx usually resolve after 2-3yrs without Tx.

Lifestyle changes: exercise, weight loss, sleep, CBT to help with hot flushes and mood

HRT is increasingly used but has its own risks like endometrial cancer / hyperplasia, VTE, stroke

Fluoxetine / citalopram can be used for vasomotor sx. Moisturisers for vaginal dryness. Vaginal oestrogen prescribed for urogenital atrophy

vaginal bleeding after 12 months of amenorrhoea. Exclude malignancy is important. If the patient is older than 55 and has post menopausal bleeding = 2 week referral for endometrial cancer.

other causes include vaginal atrophy, HRT, endometrial hyperplasia and other cancers

Initial insulin resistance leads to increased insulin production in the pancreas. This promotes the release of androgens from ovaries / adrenal glands. Insulin also suppresses sex hormone binding globulin [SHBG] production in the liver which usually binds to androgens to suppress it. High insulin levels also halt the development of follicles in the ovaries leading to anovulation and multiple partially developed follicles = cysts

subfertility, menstrual disturbance [oligomenorrhoea / amenorrhoea], hirsutism / acne, obesity, acanthosis nigricans, hair loss in male patterns

bloods for baseline FSH / LH, prolactin, TSH, testosterone, SHBG, glucose tolerance levels.

Pelvic US for string of pearls appearance

Rotterdam criteria: need 2 of the 3

infrequent / anovulation

clinical signs of hyperandrogenism

cysts on US scan [more than 12 follicles in ovaries]

weight reduction, orlistat for BMI > 30. COCp to regulate cycle and induce a monthly bleed. This needs to be done to reduce the risk of endometrial cancer due to a build up of oestrogen

this is done by medroxyprogesterone acetate 10mg for 14 days OR the COCp

Menopause before 40yrs of age, due to a decline in normal activity of ovaries at an early age. Causes vary from idiopathic, iatrogenic [chemotherapy, radiotherapy, surgery], autoimmune, genetic, infections [mumps, TB, cytomegalovirus]

irregular menstrual periods / amenorrhoea, infertility, vasomotor sx [hot flushes, night sweats, vaginal dryness]

Diagnosed in women under 40yrs with typical menopause sx and persistently raised FSH [>25] OR 2 consecutive samples separated by 4-6 weeks apart

HRT until usual age of menopause [-51yrs of age]. Advise use of contraception as still able to get pregnant. Remind that traditional HRT does not increase risk of breast cancer in women < 50yrs BUT does increase risk of VTE which can be handled via transdermal delivery. Alternatively, use COCp

Due to the presence of a cyst of another type of adnexal mass [>5cm], the ovary twists in relation to the surrounding tissue, fallopian tube and blood supply. This leads to ischaemia, to necrosis and eventually, ovary function loss

90% Ovarian Mass cause, being in reproductive age, pregnancy, ovarian hyperstimulation syndrome

sudden onset severe unilateral colicky abdominal pelvic pain. Constant, progressively worsens usually, n / v

Can resolve spontaneously, think hernias.

There will be localised tenderness and perhaps a palpable mass

Pelvic US is first line to see whirlpool sign, free fluid or oedema of the ovary. Doppler scans may show ischaemia. Laparoscopic surgery is definitive

Emergency admission to gynaecological surgery unit. Laparoscopic surgery to either untwist [detorsion] or remove the affected artery [oophorectomy]

refers to the descent of pelvic organs into the vagina. This results in weakness / lengthening of ligaments and muscles surrounding the uterus, rectum and bladder.

Uterine prolapse: uterus into the vagina
Vault prolapse: top of vagina descends, usually in hysterectomy px
Rectocele and Cystocele

defect in the posterior vagina wall which allows the rectum to prolapse into the vagina. It is associated with constipation due to faecal loading in prolapse and urinary retention, due to compression on urethra and palpable lump in the vagina

anterior wall defect, allowing bladder to prolapse into the vagina.

urethra prolapse vs urethra AND bladder prolapse

multiple vaginal deliveries, instrumental / prolonged / traumatic deliveries, age / post menopausal status, obesity, chronic respiratory disease [coughing], chronic constipation causing straining

Px complain of “something coming down”, dragging / heavy sensation in pelvis, palpable lump

Urinary sx [retention, urgency, incontinence, frequency, weak stream], Bowel sx [constipation, incontinence, urgency], Sexual dysfunction [pain, altered sensation, less enjoyment]

Signs include a palpable lump, usage of a Sim’s speculum to support the vaginal walls and ask px to cough to see the descent

Grade 0: normal
Grade 1: lowest part is >1cm above introitus
Grade 2: within 1cm of introitus
Grade 3: >1cm below introitus but not fully descended
Grade 4: full descent and eversion of vagina

Prolapse beyond introitus = uterine procidentia

Conservative is for women with mild sx or not suitable for surgery / pessaries: physiotherapy, weight loss, lifestyle changes for stress incontinence, vaginal oestrogen cream

Medical: vaginal pessary to provide support. There are many types and they should be replaced every 4 months as they can cause vaginal irritation and erosion over time

Surgical is definitive management [Sacrocolpoplexy]. Mesh repairs are NOT recommended by NICE

Overactivity of detrusor muscle of the bladder leads to the px needing to go to the toilet frequently / nocturia. Px can become self-conscious and impact QOL

Pelvic floor muscles become weakened which allows the canals to become lax and allow urine to leak at times of increased pressure like laughing / coughing

chronic urinary retention due to obstruction to flow.

Causes include anticholinergic meds, fibroids, pelvic tumours, neurologic conditions like MS

If the bladder is still palpable after urination = overflow

Increasing age, postmenopausal status, high BMI, previous pregnancies / vaginal deliveries, pelvic organ prolapse, pelvic floor surgery, neurological conditions, cognitive impairment / dementia

Urine dipstick for infection, haematuria

Post-void residual bladder volume used to assess incomplete emptying.
Bladder diary for fluid intake / urination episodes

Urodynamic testing is used for px not responding to first line meds or unclear diagnosis. This involves a catheter into the bladder to measure pressures

Conservative: avoid caffeine / diuretics / overfilling, avoid excessive / restrictive fluid intake, weight loss, supervise pelvic floor exercises for at least 3 months

Medical: Duloexetine used if surgery not preferred. It is a SNRI

Surgical management involves: Tension free vaginal tape around the urethra for support, colosuspension, intramural urethral bulking.

In cases of neurological disorder, can do specialist referral for artificial urinary sphincter surgery with manual control of continence

Bladder retraining for 6 weeks is first line.

Anticholinergic medication like oxybutynin can be given [SEs: dry mouth / eyes, constipation, cognitive decline, memory problems]

Mirabegron is used for elderly px but need to monitor BP

Surgical involves botulinium toxin injections, urostomy, percutaneous sacral nerve stimulation

Dryness and atrophy of the vaginal mucosa due to lack of oestrogen. Epithelial lining responds to oestrogen to become thicker and produce secretions. No oestrogen leads to dry tissue, inflammation, changes in pH

itchiness, dryness, dyspareunia, bleeding due to localised inflammation.

Pale mucosa, thin skin, erythema / inflammation, dryness, sparse pubic hair

Vaginal lubricants like Sylk

Topical oestrogen like estriol cream / pessaries / tablets. CI for FHx of breast cancer, angina, VTE. Monitor women annually.

Primary if less than 24hrs with more than 1000mls. Secondary if more than 24hrs and 12 weeks post-natal

Minor is 500-1000mls, major is up to 2000, severe is more than 2000, lifethreatning is more than 2800mls

bleeding, hypovolaemic shock, oligouria, delayed CRT

Tone: placenta praevia, multiple pregnancies, prolonged labour, big baby, age above 40, obesity, previous PPH
Trauma: cervical tears, episiotomy, instrumental delivery
Tissue: retained placenta
Thrombin: abruption, pre-eclampsia

call for help 2222 or red button, massive obstetric haemorrhage. ABC + request G+S, cross match, give fluids take bloods. Monitor and arrest the bleeding if possible

Conservative / management: bimanual uterine compression + rubbing [buys time for other interventions]

Medical: syntocinon infusion [prostaglandin infusion], Ergometrine, Carboprost, Misoprostal, IV tranexamic acid

Surgical: balloon tamponade, brake suture [b-lynch / haymans], bilateral uterine artery ligation or internal iliac artery, hysterectomy, admit to HDU / ITU

All procedures that involve partially or totally removing the external female genitalia or any other injury to the female genital organs for non-medical reasons.

Female circumcision / cutting

The right to be free from gender discriminaton, the right to life / physical integrity, right to health, rights of the child.

Somalia [98%], Guinea [96%]. Dijbouti [93%]

Type 1: clitoris removal
Type 2: clitoris and labia minora removal
Type 3: all of above + narrowing / closing of vaginal orifice
Type 4: anything else, tatoos, piercings

infection, haemorrhage, urinary retention, death

vulval / pelvic pain, recurrent UTI, urinary incontinence, recurrent vaginal infections, painful menstruation, dyspareunia, recurrent abscesses, infertility, pregnancy complications, depression / anxiety / PTSD

profressional duty to record and report.
inform px that FGM is illegal, take thorough history of relatives and any plans of going abroad or doing any similar procedures for future daughters

if over 18yrs old, offer referral to FGM clinic to support and consider surgical procedures like deinfibulation

if under 18yrs old, this is a criminal offence, call police or social services

medical conditions: endometrial hyperplasia / cancer, breast cancer or FHx, liver disease

Uncontrolled HPTN, active angina / MI, VTE

Pregnancy, undiagnosed abnormal bleeding

3 month follow up for SEs and sx. Mention to px that sx usually settle after 3 months. Any problematic / irregular bleeding should be referred to specialist. Any major surgery planned, stop HRT 4 weeks before hand

A fluid filled sac, usually benign, in the ovaries. Ovarian cysts are related to the fluctuating hormones of the menstrual cycle and are common in premenopausal women

When the follicle failes to rupture and release the egg, a cysts can persist. These are the most common ovarian cyst and tend to disappear after a few menstrual cycles. Reassuring on US due to thin walls and no internal structures.

When the corpus luteum fails to break down and fills with fluid. Causes pelvic discomfort, pain, delayed menstruation. Often seen in early pregnancy

Teratomes [benign germ cell tumour] so they can contain various tissue types. Associated with ovarian torsion

Serous cystadenoma AND
Mucinous cystadenoma [these can become huge and take up lots of space in pelvis]

lumps of endometrial tissue within the ovary causing pain and ovulation problems

these arise from stroma or sex cords. Includes Sertoli-Leydig cell tumours and granulosa cell tumours

usually ASx, found incidentally on US scan

can cause vague sx of:
Pelvic pain [may be acute if there is torsion, haemorrhage or rupture], bloating, fullness in abdomen, palpable pelvic mass

Detailed history / examination for malignancy.

CA125 can be taken if cyst is cancer related. if the woman is under 40yrs old, can test for possible germ cell tumour via alpha-fetoprotein or hCG

US will show “string of pearls” appearance. Biopsy can be taken to exclude malignancy

Suspected ovarian cancer needs 2 week urgent referral for GYN oncology specialist.

Tx depends on size of cyst:
less than 5cm = almost always resolves within 3 cycles, needs follow up
between 5-7cm: routine referral with yearly US monitoring
over 7cm: consider MRI or surgical evaluation

Persistent or enlarging cysts needs surgical intervention with laparoscopy [ovarian cystectomy or even oophorectomy]

ovarian fibroma, pleural effusion, ascites

remove ovarian fibroma = resolution of ascites and effusion

When adhesions form within the uterus, forming a physical obstruction and distorting pelvic organs and damage to the uterus.

usually occurs after pregnancy-related dilation, curettage procedure, post uterine surgery or several infections

px background of c-section, cutterage, surgery w/ :

secondary amenorrhoea, significantly lighter periods, dysmenorrhoea, infertility

hysteroscopy is gold standard. Others include hysterosalpingography or sonohysterography. MRI is also an option

Dissecting adhesions but reoccurence is common after treatment

when the columnar epithelium of the endocervix has extended out to the ectocervix [outside the cervical canal]. Will see a visible difference and these cells are prone to trauma / more fragile

higher oestrogen levels such as pregnancy or women using COCp

increased vaginal discharge, vaginal bleeding, dyspareunia

cervix examination will show well-demarcated border between the red columnar epithelium vs the pinker stratified squamous

rule out cervical infection first before diagnosing

if ASx = no treatment as usually resolves as px gets older, stops using pill or is no longer pregnant

Cauterisation of the ectropion with silver nitrate or “cold coagulation” during colposcopy ONLY if there is problematic bleeding

fluid filled cysts seen on the cervix surface. usually 1cm in size, harmless and unrelated to cervical cancer.

Columnar endocervix produces cervical mucus. The squamous ectocervix covers the endocervix, leading to mucuous being trapped and a cyst formed. Usually after childbirth OR trauma to the cervix OR cervicitis

incidentally found on speculum, usually no sx unless very large where the px will feel full / bloated in pelvis.

reassure women if diagnosis is clear, no tx required as resolves spontaneously.

if unclear, refer for colposcopy and take biopsy to exclude other pathologies

Bartholins glands are a pair of glands located on either side of the posterior vaginal introitus. These produce mucus for lubrication. If these ducts become blocked = bartholin cyst formation usually unilateral.

These cysts can become infected and lead to an abscess formation

Conservative: resolves with good hygiene, analgesia and warm compress. usually avoid incision due to reoccurence risk. Biopsy taken if vulval malignancy needs to be avoided

Medical: ABx given depending on sensitivities, most commonly E.coli

Surgical: Word catheter is inserted under LA to drain pus from abscess and then filled with saline to keep space and prevent reoccurence. These are held in place until the tissue heals around the catheter when they can be removed afterwards

chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin, commonly on the labia, perineum and perianal skin.

45-60yr old px with vulval itching and skin changes, Affected skin may appear shiny, tight, thin, slightly raised, papules or plaques may be present

made on clinical grounds but can take biopsy if atypical features occur. Histological examination is advisable as well if there are atypical features or any suspicion of neoplastic changes.

Biopsy taken if there is suspicion of neoplastic change OR failure of Tx, extragenital lichen sclerosus with overlap of morphoen OR pigmented areas OR second line therapy is needed

cannot be cured, control sx and follow up every 3-6 months via GYN or dermatologist

Emollients can be used, topical steroids like clobetasol propionate can be used

cells unable to respond to androgen hormones due to lack of receptors [x linked recessive condition]. Patients will be genetically male but will appear female externally. Testes may be in the abdomen, will lack a uterus, cervix, ovaries, vagina.

Px will be infertile with increased testicular cancer risk and inguinal hernias

Bloods will show raised LH and FSH. There will be very high oestrogen for a male. Chromosomal analysis will show 46XY genotype

Specialist MDT approach.

Bilateral orchidectomy to avoid tumours, oestrogen therapy, vaginal surgery / dilation

in women 50 or over of age, if they have IBS sx in the last 12 months, suspects ovarian cancer