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Menopause, Urogynaecology, Gynae Oncology

MDIII Revision Lecture

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Today’s Topics

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SECTION 1: MENOPAUSE

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Menopause

  • DEF: final menstrual period. Confirmed clinically after 1y of amenorrhoea
  • PERI MENOPAUSE = period from onset first menopause symptoms to 1y after menopause
  • POST MENOPAUSE = period 1y onwards after menopause
  • PREMATURE MENOPAUSE= menopause < 40y (<1% of women)
  • EPI: average 51y

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Menopause SX

  • Irregular menstruation
  • Hot flushes (MOST COMMON)
  • Mood swings
  • Impaired sleep
  • Atrophy of vagina/urinary system
  • Long term
    • Osteoporosis
    • heart disease

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Menopause DX

  • CLINICAL DIAGNOSIS, unless suspected POI (<40y)
  • INDICATIONS FOR TX are CLINICAL

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Premature menopause

  • DEF: LMP <40y
  • AET: primary or secondary
  • IX
    • Initial: BHCG
    • Diagnostic: 2 x FSH
  • Diagnosis: >4m amenorrhoea + 2 sets of FSH ↑

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Menopause

MX

  • Conservative
    • SNAPS
    • Ca + VitD supplementation
    • Avoid caff, ETOH
  • Medical
    • 1st: HRT
    • Situational/2nd line
      • Psychotropics (e.g. venlafaxine) – hot flushes
      • tibolone: for mastalgia if >2y postM

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HRT

    • Oestrogen only
      • IND: hysterectomy
    • Combined E + P
      1. Cyclic – if still having spontaneous menses
      2. Continuous

Types

    • Oral
    • Transdermal
      • Less risk of DVT and migraines
    • Transvaginal
      • Good for genitourinary symptoms

Mode of delivery

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HRT

    • High risk of DVT, stroke, CVD
    • High risk of breast/gynae cancers

CI

    • If POI, continue HRT until at least 51

Duration

    • <50y: contraception until 2 year post LMP
    • >50: contraception for 1 year post LMP

Extra Contraception

    • If on HRT, tolerate for 6m before investigating

BLEEDING

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Vulvovaginal atrophy

  • EPI: 50% post menopause
  • RF: lack of oestrogen (menopause, oophorectomy, chemo/radio)
  • CX: UTI, vaginitis

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Vulvovaginal atrophy

    • Dryness
    • Itch
    • Light bleeding
    • sexual/urinary dysfunction

PC

    • smooth shiny
    • scarce pubic hair
    • reduced labial fat pad

EXAM

    • Conservative – reduce irritation
    • Medical
      • 1st – lube, moisturiser
      • 2nd – vaginal HRT

MX

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Osteoporosis

  • DEF
    • loss of bone mineral density due to imbalance of osteoclasts and osteoblasts.
  • Oestrogen induce apoptosis of osteoclasts
  • RF
    • Inactive
    • lack of oestrogen
    • smoking/ETOH
    • medications
  • PC: usually ASYM until fractures
  • DX
    • 1. MTF (minimal trauma fracture) in hip or spine
    • 2. MTF in other site + DXA < -1.5 (T score)
    • 3. no MTF + DXA < -2.5 (T score)

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Osteoporosis

  • MX
    • Conservative
      • Ca + VitD
      • Falls prevention + physio
      • SNAPS
    • Medical
      • 1st: Bisphosphonates
      • Denosumab
      • Oestrogen replacement/SERMs – raloxifene

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SECTION 2: INCONTINENCE + PROLAPSE

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Pelvic organ prolapse

RF

    • childbearing
    • Regular straining: constipation, chronic cough, heavy lifting
    • Pelvic surgery
    • Menopause

Types

    • Anterior wall
    • Posterior wall
    • Apical/Uterine

DEF: Protrusion of pelvic organs into vaginal vault due to decreased pelvic floor support

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Pelvic organ prolapse SX

  • PC
    • Fullness or pressure
    • Dragging sensation
    • Bulge/lump
    • Specific urinary/bowel symptoms depending on location
  • Exam
    • SIM’s speculum

​

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Prolapse Management

Mild prolapse

    • SNAPS (esp weight loss)
    • Pelvic floor exercise
    • Ring pessary
    • Local oestrogen

Complicated prolapse - SURGICAL

    • External (Grade 3-4)
    • Pelvic pain
    • Recurrent UTI
    • retention
    • AUB

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Prolapse Surgery

  • Obliterative
    • colpocleisis

​

  • Reconstructive
        • Anterior/Posterior Wall Repair (most common)
        • Others

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Prolapse Surgery

  • Obliterative
    • colpocleisis

​

  • Reconstructive
        • Anterior/Posterior Wall Repair (most common)
        • Others
          • Sacrocolpopexy
          • Sacrospinous fixation

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Stress incontinence

  • DEF
    • Involuntary urine leakage following raise intra-abdo pressure
  • RF
    • chronic straining
    • previous surgery
    • childbearing
  • PC
    • frequent, predictable, small volume urine loss
    • NO URGE prior to leakage
  • IX
    • Urinalysis
    • Pad test
    • Others
      • Cystoscopy if pain, haematuria, recurrent infections
      • Urodynamics if initial treatment failure, or before surgery

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Stress incontinence

​

    • Initial: Conservative
      • Pelvic floor exercise (60% success rate)
      • Continence pessaries
      • SNAPS
    • If persistent: Urodynamics + Surgery
      • Mid urethral sling (MUS)
      • Others
        • Burch Colposuspension
        • Urethral bulking

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Mid urethral sling

Burch Colposuspension

Urethral Bulking

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Overactive bladder

PC

    • Urgency
    • Frequency
    • Nocturia

IX

    • Bladder diary
    • Pad test

MX

    • 1st – bladder training
    • 2nd – anticholinergic
    • 3rd - Surgical (botox)

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Interstitial Cystitis

Young

PC: abdo pain relived by voiding

HX of pain syndromes

Hunner spots

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SECTION 3: TUMOURS + CANCERS

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Types of hysterectomy

(aka radical hysterectomy)

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Uterine

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Endometrial Polyps

    • Obesity
    • late menopause
    • Tamoxifen (SERM)

RF: increased oestrogen

    • IMB
    • Infertility

PC

    • 1st TVUS
    • 2nd Hysteroscopy
      • Biopsy if suspecting malignancy

IX

    • ASYMP - observation
    • SYMP - Hysteroscopy + polypectomy

MX

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Endometrial Carcinoma

    • Endometrial hyperplasia – unopposed oestrogen!
    • Genetic – Lynch syndrome (HNPCC)

AET

    • Obesity
    • Nulliparity
    • Late menopause
    • Tamoxifen (SERM)

RF

    • COCP
    • Progestin-based contraceptives
    • Pregnancy
    • Smoking

Protective

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Endometrial Carcinoma

PC

    • Painless PMB
    • IMB

DDX

    • HRT bleeding
    • Atrophic vaginitis

IX

    • 1st TVUS: endometrium >=5mm
    • 2nd Endometrial biopsy
      • Pipette (aka Pipelle) – can be done bedside
      • Hysteroscopy – gold standard, preferred if there is focal polyp or ulcer

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Endometrial Carcinoma

PC

    • Painless PMB
    • IMB

DDX

    • HRT bleeding
    • Atrophic vaginitis

IX

    • 1st TVUS: endometrium >=5mm
    • 2nd Endometrial biopsy
      • Pipette (aka Pipelle) – can be done bedside
      • Hysteroscopy – gold standard, preferred if there is focal polyp or ulcer

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Endometrial Carcinoma

    • Early stage + preserve fertility
      • Mirena
    • Early stage + postmenopause
      • TAH + BSO +/- node dissection
    • Advanced stage or Mets
      • Chemo

MX

    • Lynch: hysterectomy after childbearing (~40y)

Prevention

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Endometrial Sarcoma

  • Leiomyosarcoma
    • malignant fibroid
  • PC:
    • Postmenopausal
    • Rapidly enlarging fibroid
    • PMB
    • Systemic cancer symptoms e.g. LOW

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Cervix

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Cervical Anatomy

  • Ectocervix is PINK: stratified squamous epithelium
  • Endocervical is RED: simple columnar epithelium
  • Squamocolumnar junction (SCJ): junction between ectocervix and endocervix
    • Fluctuates under hormonal influence
  • Transitional zone: gap between current and previous SCJ

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Cervical Cancer

  • Majority is squamous cell carcinoma
  • AET
    • high risk HPV
    • Transmitted through skin to skin contact
    • 90% of adults are infected at some point in time
    • 98% clear in 5 years
  • RF
    • Smoking
    • Immunocompromised
    • Sexually active and many sexual partners
  • PPX
    • Integration of HPV DNA into epithelial cells in transformational zone leads rapid cell turnover

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Cervical Screening

Cervical Screening Test

Liquid based cytology

HPV PCR

+/-

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Cervical Cancer - CST

​

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Screening from 25 to 74

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Colposcopy

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CIN

    • Precancerous lesion
    • 20-30% of CIN3 progress to cancer in 10 years
    • ASYMP

Summary

    • Low grade: expectant
    • High grade: excision or ablation
      • 1st line: Loop diathermy
      • 2nd line: Cone biopsy. Done if lesion is DEEP INSIDE CANAL.
      • Avoid procedures in pregnancy, even if CIN 2/3. Revaluate after birth.

MX

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Cervical Cancer

  • PC
    • PCB
    • blood stained/purulent discharge
  • Exam
    • cervical ulceration which bleeds on contact
  • MX
    • Non invasive (1A): clear margin excision
    • Clinically invasive (1B-4)
      • Most effective: Radical hysterectomy
      • Fertility sparing: Radical trachelectomy

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Cervical ectropion

    • Seen in young patientsNORMAL

Summary

    • squamous epithelium (pink) replaced by columnar epithelium (red) under the physiological influence of oestrogen

PPX

    • AUB - IMB, PCB
    • Clear discharge

PC

    • ASYMP – no treatment
    • SYMP
      1. Switch away from oestrogen based contraceptives
      2. Cervical ablation to destroy glandular columnar cells

MX

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Cervical polyps

    • Mostly benign
    • Different location vs endometrial polyp

Summary

    • Commonly ASYMP
    • AUB (e.g. PCB)

PC

    • ASYMP: observation
    • SYMP or LARGE: surgical resection

MX

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Nabothian Follicles

  • SUMMARY
    • Not pathological, usually ASYMP
  • PPX
    • When columnar glands within transformation zone become sealed over
    • Forms small mucus filled cysts visible on ectocervix
  • MX
    • Observation – often self resolve
    • Large – drain with needle

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Ovaries

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Functional ovarian cysts

    • Cause by non rupture of cyst in menstrual cycle
      • Follicular or luteal
    • Common when young
    • Unilateral

Summary

    • Increased number of ovulatory cycles

RF

    • usually, asymp and incidental

PC

    • Rupture
      • sudden unilateral abdo pain. NO N/V
      • MX: expectant with analgesia

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    • Torsion
      • Sudden severe abdo pain + N/V
      • MX: urgent detorsion

CX

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Benign ovarian tumours

  • 3 TYPES
    • Epithelial (90%)
      • Occurs middle age
      • Serous cystadenomas most common
      • Form cysts which contain fluid
    • Germ cell
      • occurs in young women (<30yo)
      • Dermoid cyst most common
      • Struma ovarii, a subtype, can cause hyperthyroidism
    • Sex cord stromal
      • Occurs post menopause
      • fibroma (most common) – may be associated with Meigs syndrome
      • thecoma – produce oestrogen leading to PMB

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Benign ovarian tumours

    • Abdo discomfort
    • Adnexal mass
    • Specific symptoms depend on tumor type

General PC

    • 1st line: PVUS
    • Consider tumour markers e.g. CA-125

IX

    • Rule out malig
    • Small: Conservative
    • Large or symptomatic: Surgical resection

General MX

Serous cystadenoma

Dermoid cyst/Teratoma

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Ovarian carcinoma

Summary

    • Different subtypes similar to ovarian tumours
    • RF
      • Elevated number of lifetime ovulations (e.g. Nulliparity)
      • BRCA

PC (general) – most cases are late stage

    • Abdominal distension +/- ascites
    • Bloating, early satiety
    • Urinary and faecal retention

PC (specific)

    • Granulosa cell tumour – produce oestrogen leading to PMB
    • Sertoli-Leydig tumour – produce testosterone leading to virilisation
    • Struma ovarii (mature teratoma) – produce thyroxine leading to hyperthyroidism
    • Meigs syndrome – triad of fibroma + ascites + pleural effusion

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Ovarian carcinoma

    • 1st: TVUS
    • Tumour markers
      • CA 125 – epithelial tumours
    • Diagnostic - Biopsy

IX

    • Most effective: BSO + TAH + omentectomy
    • Fertility sparing: Unilateral SO
    • Follow up with tumour markers e.g. CA125

MX

    • Prophylactic BSO for women with BRCA

Prevention

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Vulva + Vaginal

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Vulval carcinoma

    • SCC 90%
    • Caused by high risk HPV (16, 18, 31, 33)
    • Vulvar intraepithelial neoplasia (VIN) is precancerous lesion

Summary

    • NEW VULVAL LUMP IN ELDERLY
    • Bleeding
    • Discharge
    • Itch

PC

    • Biopsy

IX

    • Lipoma, Bartholin’s cyst, lichen sclerosis

DDX

    • Radical vulvar excision

MX

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Vaginal carcinoma

    • Similar to vulvar cancer, but in vaginal wall
    • Caused by high-risk HPV (16, 18, 31, 33)
    • Most commonly SCC

Summary

    • Vaginal ulceration with contact bleeding
    • Malodorous discharge
    • Urinary symptoms

PC

    • Immobile, erythematous mass on posterior wall

Exam

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Vulval/Vaginal cysts

  • Bartholin’s cyst
    • Blockage of Bartholin duct, forming cyst
  • PC
    • Young woman 20-30
    • Vulvar Lump + discomfort
  • EXAM
    • Unilateral mass in posterior vaginal introitus
  • MX
    • Sitz bath
    • If abscess (tender, red) – incision and drainage

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Lichen Sclerosus

Summary

    • Chronic inflammatory skin lesion characterized by white, atrophic plaques with intense pruritis

PC

    • Postmenopausal
    • Vulvar itching
    • Exam shows white plaques and atrophic labial folds

IX

    • biopsy (to rule out SCC)

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Lichen planus

Summary

  • Chronic inflammatory skin condition, characterized by purple papules with well demarcated borders

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PC

  • Itchy rash
  • White lace-like lines on buccal mucosa (Wickam’s Striae)

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Today’s Topics

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Contact

  • Ray Ren
  • tren0003@student.monash.edu

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