O&G Matrix

Leiomyomata Fibroids (R1) Ix

Benign uterine tumour primarily composed of smooth muscle and fibrous connective tissue

• Round, firm, and well-circumscribed nodules

• Located either submucosal (beneath endometrium), intramural (within uterine wall), or subserosal (beneath peritoneum)

Sx: mostly asympt., excess uterine bleeding → anaemia/menorrhagia, back/abdo/pelvic pain, bowel/urine sx miscarriage/infertility (distorted uterine cavity)

RF: obesity, age 25-40yrs, nulliparity, early menarche, African Americans

First Line: Exam (enlarged irregular uterus, irregular firm pelvic mass on bimanual exam)

Gold Standard: Pelvic US (well circumscribed uterine tumours), Endometrial Biopsy, Hysteroscopy

Other: MRI pelvis ± IV contrast (characterise leiomyomas), Sonohysterography, Bloods (CBC, BMP, Urine preg.; Abn. Bleeding = PT, PTT, fibrinogen, TSH, LFTs, von Will disease studies)

Leiomyomata/Fibroids (R1) Mx

First Line: nil if asymp., annual follow-up

Long Term:

• Surgical: hysterectomy, myomectomy (remove leiomyomas to preserve fertility)

• Uterine Artery Embolisation

• Pharmacotherapy: GnRH Agonists/Antagonists, IUDs, Oral Contraception

Cx: miscarriage/infertility (distorted uterine cavity)

DDx: Adenomyosis, Endometriosis, Uterine Polyps, Uterine Leiomyosarcoma

Endometrial Carcinoma (R2)

Type I = endometrioid origin/hyperplasia; Type II = serous/clear cell origin

Early stage = favourable prognosis

RF: postmenopausal women (age 55-64yrs)

Sx: Painless Abnormal Uterine Bleeding!, Pelvic Pain, Palpable Mass

Ix: Transvaginal US → Endometrial Biopsy

Mx: Surgical (Total hysterectomy w bilat. salpingo-oophrectomy), Radiotherapy/Chemo, Hormone therapy

Endometritis (R2)

Inflammation of the uterine lining (endometrium) caused by infection typically postpartum (within first week or 1-6wks)

Usually a polymicrobial infection

• Rare = Critically Ill w Sepsis/Septic Shock from Strep. pyogenes (GAS) or Clostridiums

RF: C section

Sx: fever (>38°C), lower abdo pain, uterine tenderness, purulent vaginal discharge

Ix: vitals + clinical exam

Mx: Abx (nonsevere = amoxicillin + clavulanate, severe = IV gent/tobramycin + amoxi/ampicillin + met)

Endometrial Polyps (R2)

Benign endometrial tumor: localised overgrowths of endometrial tissue within uterine wall

0.5-4% of polyps are premalignant/malignant

RF: postmenopausal women, HTN, Obesity, Tamoxifen, Lynch syndrome

Sx: asymp., irregular vaginal bleeding = menorrhagia/spotting, infertility in premenopausal

Ix: Transvaginal US, hysteroscopy, Endometrial biopsy (rule out)

Mx: surgical removal if symp. (hysteroscopy)

Adenomyosis (R2)

Benign endometrial tissue within the uterine wall

RF: early menarche, increased parity, past uterine surgery

Sx: dysmenorrhea, abnormal bleeding, menorrhagia, chronic pelvic pain; Exam = bulky, tender, diffusely enlarged uterus

Ix: Transvaginal US, Endometrial Biopsy

Mx: IUD!, Hysterectomy, Hormone Therapy, NSAIDs/TXA

Congenital Uterine Malformations (R3)

Structural malformations of the uterus occurring during fetal development when the Müllerian ducts fail to properly fuse, affecting approx. 5% of women

Often asymptomatic, but can cause infertility, recurrent miscarriage, preterm birth

Types of Malformations:

• Septate Uterus (Most Common): A partition (septum) divides the uterus into two parts, though the external shape is normal

• Bicornuate Uterus ("Heart-shaped"): The uterus has an abnormal, indented top, creating two distinct cavities

• Uterus Didelphys ("Double Uterus"): The Müllerian ducts fail to fuse at all, resulting in two separate uteri and often two cervices

• Unicornuate Uterus: Only one side of the uterus develops fully

• Arcuate Uterus: A minor variant with a slight indentation at the top, usually considered a minor anatomical variation.

• Absent Uterus (Müllerian Agenesis): Uterus fails to develop

Uterine Sarcoma (R3)

Uterine cancer developing in the supporting muscles or connective tissues (myometrium/mesenchymal cells), often unrelated to estrogen

Much rarer than Endometrial Carcinomas (5% of cases)

Often more aggressive

Cervical Carcinoma + Pre-Cancer (R1) Ix

Third most common type of gynecological cancer (after endometrial and ovarian) but declining with Pap Smears and HPV Vaccinations

Types:

• Squamous Cell Carcinoma: Most Common (80%), Usually HPV 16, invasive, irregular cell morphology (hyperchromatic, loss of basal membrane)

• Adenocarcinoma: (20%) Usually HPV 18, Atypical columnar epithelium

• Small Cell Carcinoma: (2%) Neuroendocrine tumour, infiltration of monotonous round atypical cells in a nesting pattern (nuclei w salt + pepper chromatin)

• Cervical Intraepithelial Neoplasia/CIN: premalignant epithelial dysplasia preceding cervical carcinoma

RF: HPV infection (types 16 + 18) → early onset sexual activity, multiple sexual partners, STD Hx, immunosuppression; DES exposure in-utero, smoking

Sx: early = asymp.; advanced = vaginal bleed/postcoital spot, purulent discharge, pelvic pain ± lower back pain

First Line/Screening: Pap Smear, HPV DNA test, Speculum/Bimanual Vaginal Exam

Gold Standard: Colposcopy + Cervical Biopsy (Grades CIN I-III)

Cervical Carcinoma +.Pre-Cancer (R1) Mx

High-Grade CIN: Excision

Invasive: surgery, radiation therapy ± chemotherapy

Prevention: HPV Vaccination (age 9-26yrs), Screening (PAP Smear = age 25-65yrs every 5yrs)

Mx of Abnormal Screening Results: HPV 16/18 = Colposcopy; Other HPV = Repeat Screen in 12m

Cervical Ectropion (R3)

Benign, common and harmless condition where glandular cells typically lining the cervical canal spread to the outer surface of the cervix. Driven by estrogen levels influencing fragile cervical epithelium

• Does not increase risk of cervical cancer

• Usually no Hx of purulent discharge

RF: Commonly seen in adolescent or pregnant women, women on contraceptive pills and fertile women

Acute & Chronic Cervicitis (R3)

Inflammation of the cervix characterised by a purulent endocervical exudate and/or easily induced endocervical bleeding (caused by manipulation with an atraumatic instrument like a cotton swab)

Pathogens: Neisseria gonorrhoeae, Chlamydia trachomatis, HSV

Sx: Often Asymptomatic, ‘Strawberry Cervix’ (trach.), postcoital bleed, purulent vaginal/cervical discharge

Cx: Pelvic Inflammatory Disease (if left undiagnosed or untreated) → infertility, chronic pelvic pain

Cervical Polyps (R3)

Small, benign, finger-like growths developing on the surface of the cervix or inside the cervical canal

• Rarely cancerous, usually asymptomatic incidental findings

Most common in women >20yrs (esp. premenopausal or multiparous)

Generally associated w chronic inflammation or hormonal fluctuations

Nabothian Follicles/Cysts (R3)

Small, benign, mucus-filled lumps forming on the surface of the cervix

Naturally occurring due to normal cervical skin cells blocking the small mucus-producing glands, trapping mucus

Are harmless and require no Mx unless if grown exceptionally large

Endometriosis (R1) Ix

Benign chronic disorder where endometrial tissue occurs outside the uterus

• Common Locations: ovaries, rectouterine pouch, fallopian tubes, bladder, cervix, peritoneum

• Endometrial tissue reacts to the hormone cycle

Sx: dysmenorrhea, dyspareunia, chronic pelvic pain, infertility rectovaginal tenderness (sx may improve after preg./menopause)

First Line: Transvaginal US (chocolate ovarian cysts, nodules in bladder or rectovaginal septum)

Gold Standard: Laparoscopy (endometriotic implants and adhesions), MRI (asym. myometrial thickening, cysts)

Endometriosis (R1) Mx

First Line:

• Analgesia: NSAIDs

• Hormone Therapy: OCP, Progesterone-Only Contraception (IUD, Mini-Pill), GnRH Agonists (goserelin, nafarelin)

• Long Term: Surgical removal of endometriotic tissue (hysterectomy, single excision)

PCOS (R1) Ix

Endocrine Disorder characterised by Hyperandrogenism, Oligoovulation/Anovulation ± presence of Polycistic Ovaries

Sx: Hyperandrogenism (hirsutism, acne, virilisation, alopecia), Oligoovulation/Anovulation (irregular periods, amenorrhea), Metabolic Syndrome (obesity, NAFLD)

First Line:

• Clinical Exam: ↑ BMI, ↑ BP, Signs of insulin resistance (acanth nigr., skin tags), Hirsutism

• US: Transvaginal/Transabdominal, not required for dx, shows cystic follicles

• Laboratory Tests: ↑ Testosterone, ↓ SHBG, Androgens, Lipids, TSH/Prolactin (to rule out), Serume LH/FSH (if amenorrhea - ↑LH w LH/FSH ration >2:1), 24hr urine cortisol (rule our Cushing’s)

  • Confirm hyperandrogenism and exclude similar DDx (congenital adrenal hyperplasia)

PCOS (R1) Mx

Must tailor Mx to reproductive goals

First Line:

• Lifestyle: loss of 5% of body weight, manage RFs (CVD, Psych, Lipids, DM etc)

• OCP/IIUD (if preg. not desired): mx menstrual disturbances

• Ovulation Inducers (if preg. desired): Letrozole

• Antiandrogens: Spironolactone, Finesteride

• Metformin: improves glucose metabolism + suppresses ovarian androgen production (not commonly used)

Long Term: Surgically remove underlying cause (androgen-secreting tumours)

Cx: Metabolic Syndrome (obesity, insulin resistance, hypercholesterolemia), Endometrial Cancer (screen! lack of progesterone-induced endometrial shedding → endometrium proliferation → ↑ risk endo ca.)

Ovarian Carcinoma (R1) Ix

RF: BRCA1/2 gene, Hormonal RFs (↑ nbr lifetime ovulations), Age >60, HNPCC syndrome

Sx: asymp./abdo discomfort/urinary freq/bloating in early stages, ascites, pelvic pain

• Red Flag: persistent bloating in older women

Types of Ovarian Tumours:

1. Epithelial Ovarian Tumour: from ovarian surface epithelium, mostly benign

   • Benign: cystadenomas, brennar tumours

   • Malignant: cystadenocarcinoma, endometrioid carcinoma, clear cell tumout

2. Germ Cell Ovarian Tumour: from primordial germ cells (oocytes), benign or malignant (agressive)

   • Benign: dermoid cysts/mature cystic teratoma, struma ovarii

   • Malignant: immature teratoma, yolk sac tumour, dysgerminoma, nongestational choriocarcinoma

3. Sex Cord and Stromal Ovarian Tumours: from sex cord cells (Sertoli, Granulosa cells) or stromal cells (Fibroblasts, Primitive Gonadal Stroma), benign or malignant

   • Benign: ovarian fibroma, theca cell tumour, Sertoli-Leydig cell tumour

   • Malignant: granulosa cell tumour, occ. Sert-Ley

First Line: Transvaginal US, CA-125 Tumour Marker (can also be raised in menstruation/endometriosis)

Benign:

1. Unilocular

2. Small solid components

3. Presence of acoustic shadows (indicates dermoid cyst/mass)

4. Smooth multilocular tumour

5. No blood flow on doppler

Malignant:

1. Irregular solid component

2. Ascites

3. >4 papillary structures

4. Irregular large multilocular solid tumour

5. Very strong blood flow on doppler

Ovarian Carcinoma (R1) Mx

Poor Prognosis

First Line: surgical staging/debulking, chemo, radiation

Premenstrual Syndrome/PMS (R1) Ix

Somatic and psychological sx during the luteal phase of the menstrual cycle

Sx: irritability, mood swings, anxiety, depression etc, bloating, headache, breast discomfort

First Line: Hx/Sx Charting over 2 menstrual cycles

Exclude Other Causes: thyroid disorders, menopause etc

Premenstrual Syndrome (R1) Mx

First Line/Long Term:

• CBT

• OCP: suppress ovulation → reduce sx (progestogens alone are ineffective)

• SSRIs/SNRIs: Fluoxetine, Sertraline, mx physical/psych sx used only during luteal phase (2wks before menstruation)

• Spironolactone: relieve bloating, swelling, breast discomfort, limited evidence

Ovarian Torsion (R1) Ix

Twisting of an ovary around the adnexal ligaments: partial or complete twisting of the ovary and fallopian tube around their supporting ligaments

Torsion → venous congestion/edema → ovarian blood supply cut off

RF: women of child-bearing age, ovarian enlargement (cysts/dermoid cysts, tumours etc → weight on ovaries), pelvic ligament laxity, Hx PID, previous pelvic surgery

Sx: sudden onset unilateral lower abdominal/pelvic pain, palpable adnexal mass/adnexal tenderness

• Intermittent/spontaneously resolving pain = partial torsion

First Line:

• Pelvic US w Doppler (Transvaginal): enlarged. edematous ovary with decreased blood flow

• Bloods: G+H/Coagulation Panel/CBC (emergency preoperative tests)

Other: MRI/CT Abdo/Pelvis w Contrast (if US inconclusive)

Ovarian Torsion (R1) Mx

Surgical Emergency!

First Line: Exploratory Laparoscopy (indicated in all pts w suspected ovarian torsion) - adnexal detorsion + ovary preservation, oophrectomy ± salpingoectomy (if necrotic ovaries), ovarian cystectomy

Long Term:

Cx: ovarian necrosis + infertility if tx is delayed

Premature Menopause (R2)

Primary Ovarian Insufficiency (POI)

Permanent cessation of menses/ovarian function for >1yr before 40yrs of age

RF: FHx, Chemo/Radiation Exposure, Autoimmune Disease

Sx: clinical features of menopause (hot flushes, mood swings, cessation of menses), infertility, non-returning menstrual cycles post-hormonal contraception

Ix: Clinical Hx, Identify Underlying Cause, ?POI karyotyping (if <30yrs old)

Mx: hormonal therapy (↓ menopause sx) = OCP, HRT

Benign Ovarian Tumours (R2)

First Line Ix: Transvaginal US, CA-125 Tumour Marker (can also be raised in menstruation/endometriosis)

Benign:

1. Unilocular

2. Small solid components

3. Presence of acoustic shadows (indicates dermoid cyst/mass)

4. Smooth multilocular tumour

5. No blood flow on doppler

Types of Benign Ovarian Tumours:

1. Epithelial Ovarian Tumour: cystadenomas, brennar tumours

2. Germ Cell Ovarian Tumour: dermoid cysts/mature cystic teratoma, struma ovarii

3. Sex Cord and Stromal Ovarian Tumours: ovarian fibroma, theca cell tumour, Sertoli-Leydig cell tumour

Ovarian Cysts (Just to Know)

Fluid-filled sacs within the ovary, often resulting from a disruption in the follicles or corpus luteum development

Sx: Usually asymp., menorrhagia, PCOS sx, palpable adnexal mass, abdo pain

Ix: Pelvic US, B-hCG (rule out preg.)

Types of Ovarian Cysts:

1. Follicular Cyst: most common ovarian mass in young women, from growing Graafian follicles that fail to rupture/release egg (ovulation), large (~7cm)

2. Corpus Luteum Cyst: enlagement/buildup of fluid in the corpus luteum following failure to regress after ovum release, produces progesterone → delayed menses, common in preg.

3. Theca Lutein Cysts: multiple cysts typically developing bilaterally, from ↑ B-hCG/gonadotropins causing ↑ stimulation

4. Nonfunctional Ovarian Cysts: ovarian cysts that do not produce hormones (chocolate cysts, dermoid cysts, cystadenoma = serous or mucinous, malignant cysts/ovarian ca.)

Vaginismus (R3)

Involuntary tightening or spasm of the pelvic floor muscles surrounding the vagina

Automatic reaction making vaginal penetration (e.g. sexual intercourse, tampons, pelvic exam) difficult, painful, or completely impossible

Psychological or Physiological Triggers (anxiety, endometriosis)

Sx: Vaginal burning, stinging, or severe pain during any penetration attempts

Mx: pelvic floor physio, vaginal dilators, psychotherapy

Vulvodynia (R3)

Painful vulva of idiopathic origin

Chronic, unexplained pain, burning, or discomfort in the vulva (the external female genitalia) lasting for >3m

Sx: Pain with insertion at intercourse/w tampon + to touch

Mx: supportive/pain mx (Tricyclics, nerve creams etc)

Vulval Carcinoma (R3)

Malignancy of the outer female genitalia (vulva)

Predominantly occurs in postmenopausal women

Poor prognosis

RF: HPV infection, smoking, vulvar dystrophy/neoplasia

Sx: vulval lumps/lesions, itching, burning sensation, ↓ freq., vulvar bleeding

Ix: biopsy

Mx: surgical resection (radical vulvectomy), radiotherapy, chemotherapy

Vaginal Carcinoma (R3)

Malignancy of the inner female genitalia (posterior third of the vaginal wall)

Predominantly occurs in postmenopausal women

Poor prognosis

RF: HPV infection, smoking, vaginal dystrophy/neoplasia

Sx: vaginal lumps/lesions, itching, burning sensation, ↓ freq., vaginal bleeding

Ix: biopsy

Mx: surgical resection, radiotherapy, chemotherapy

Vulval/Vaginal Cysts (R3)

Fluid or pus-filled lumps forming on/near the external genitalia or vaginal walls

Types:

1. Bartholin Cyst: mucus-producing Bartholin glands on inner sides of labia become inflamed/blocked, causing swelling, cyst and abscess (Mx = incision/drain)

2. Vaginal Inclusion Cysts: most common type of vaginal cyst, typically caused by trapped skin tissue (epithelium) following childbirth injuries or surgery

3. Epidermal & Sebaceous Cysts: Often found on the vulva, formed when oil-producing sebaceous glands or hair follicles become blocked

4. Gartner’s Duct Cysts: Form on the vaginal walls from remnants of embryonic development (the Müllerian or mesonepheric ducts)

Lichen Sclerosus (R3)

Chronic inflammatory skin condition predominantly affecting the vulva and anus and is associated with pruritus, pain, and dyspareunia

Can lead to scarring/malformation and ↑ risk of malignancy

Common Signs/Sx: itching, white paper-like skin, figure-8 around vulva

Lichen Planus (R3)

Idiopathic pruritic inflammatory disease affecting the skin, hair, nails, and mucous membranes, usually self-limiting in nature

Affects vulva, vagina and can be found orally

Characterised by pain, vaginal bleeding and discharge