The Unofficial Guide to Obstetrics and Gynaecology: Core O&G Curriculum Covered: 300 Multiple Choice Questions with Detailed Explanations and Key Subject Summaries

ISBN 978-0957149977

Text, design and illustration © Zeshan Qureshi 2018.

Edited by Matthew Wood, Katherine Lattey and Zeshan Qureshi.

Published by Zeshan Qureshi. First published 2018.

All rights reserved; no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers.

Graphic design by Anne Bonson-Johnson, A Poke in the Eye.

A catalogue record for this book is available from the British Library.

Commissioned medical illustrations by Caitlin Monney, Harry Heyes and Sam Goddard.

Medical illustrations:

Caitlin Monney 1.01: Fig 1, 5-7, 1.02: Fig 11, Table 3, Fig 14-16, 18, 1.03: Fig 24, 1.04: Fig 28-29, 1.05: Fig 30-34, 36, 38, 1.06: Fig 40-41, 1.07: Fig 43, 45, 2.01: Fig 3-5, 7, 2.03: Fig 11-13, 2.04: Fig 16-23, 28-29, 31-32, 34, 2.05: Table 26, 2.06: Fig 42, 2.07: Fig 45-46, 48-50.

Sam Goddard and Harry Heyes 1.01: Fig 3, 4, 1.02: Fig 10, 1.03: Fig 21, 23, 1.04: Fig 25-26, 1.07: Fig 43, 2.01: Fig 1, 6-8, 2.04: Fig 14, 24-25, 27-28, 30, 33, 2.05: 35-36, 2.06: 37-39, 2.07: Fig 44, 47-38, 2.08: Fig 51, 53-54, 2.09: Fig 55.

Clinical photographs:

Matthew Wood 1.01: Fig 2, 8, 1.03: Fig 22, 1.05: Fig 35, 1.05: Fig 37.

Molar pregnancy 1.03: Fig 22 image from www.emcurious.com/blog-1/2015/1/17/ultrasound-leadership-academy-ultrasound-in-early-pregnancy. Licensed under a Creative Commons Attribution 4.0.

Lichen sclerosus 1.04: Fig 27, used with permission from DermNetNZ.org.

Although we have tried to trace and contact copyright holders before publication, in some cases this may not have been possible. If contacted we will be pleased to rectify any errors or omissions at the earliest opportunity. Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property that may occur as a result of any person acting or not acting based on information contained in this book.

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Acknowledgements

We would like to thank all of the authors for their dedication and hard work, our panel of student reviewers for their unique input and our senior reviewers for their expertise. We would like to thank you the reader, as a medical student or junior doctor you have inspired this project, believed in it and continued to promote, contribute and distribute this book across the UK and further afield. In addition, we are thankful to the support of medical schools, without whom this project would not be possible.

Additional thanks to our friends and family (mostly our long suffering parents Rachel, Nick, Maurice and Ivy). Finally a massive thank you to our partners (Emma and Greg) who have put up with us, and supported us during this project.

Matt and Kat

The Unofficial Guide

to Medicine Project

We want you to get involved. This textbook has mainly been written by junior doctors and students just like you because we believe:

…that fresh graduates have a unique perspective on what works for students. We have tried to capture the insight of students and recent graduates to make the language we use to discuss this complex material more digestible for students.

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Foreword

Helen Bickerstaff

Senior Lecturer in Medical Education, Honorary Consultant Gynaecologist, Kings College London, UK

The Unofficial Guide to Obstetrics and Gynaecology is a wonderful addition to the range of texts available from the Unofficial Guide to Medicine. The book is the ideal, straightforward antidote to the perceived complexity of O&G. It is poised between traditional textbooks that cover anatomy, physiology, pathology and clinical O&G, and exam crammers for those short of time. This book will help students navigate their new clinical environment, by making sense of the physiological and pathological conditions they will encounter. The logical stepwise progression through the specialities is excellent and reflects the student learning process. I liked the way the scene is set before the complexity discovered. Confusing subjects become clear, and lists and tables complement difficult subjects.

In the book the use of simple language and ‘normal’ words to explain very unusual conditions and complex situations is refreshing. There is no drama about communication here, just clear acknowledgement of the need for sensitivity and the potential vulnerability of women in O&G consultations. Simple steps describe the simple examinations we perform, that none-the-less can create panic in the clinical setting and during an OSCE. Simple tips for examinations are abundant. Following on from this the questions at the end of each topic are well structured, and the references at the end of each subject are relevant and up to date. The answer compendium provides excellent consolidation material.

Practicing O&G as a speciality has, for me, been a passion, privilege and pleasure for my entire working life, but this career does not appeal to everyone! However, every opportunity to educate girls and women about their fertility, pregnancies, hormones and gynaecological concerns, can and should, be seized by doctors, who should remain confident to offer clinical O&G advice to women, throughout their careers. For this to be possible the undergraduate O&G experience must be memorable, beyond finals. The Unofficial Guide will help achieve this through thorough, simple explanation. This book can help students find their O&G rotation one of the most fascinating, life affirming experiences of their medical school career.

Chloe Knox

President of Brighton and Sussex Medical School Obstetrics and Gynaecology Society

This edition is the latest in the The Unofficial Guide to Medicine series, providing comprehensive coverage of the core components of any medical school obstetrics and gynaecology curriculum. O&G can seem a daunting specialty as a student, but the book’s content is helpfully divided into manageable topic areas, each followed by related multiple choice questions. This allows you to test your knowledge and structure your learning effectively.

As with all books in the series, the chapters are clearly written, user friendly, comprehensive, and informed by current national guidelines. Main points are emphasised, and example cases allow an understanding of some of the common presentations of key conditions.

A strength of this book is the integration of anatomy, physiology, practical skills, imaging, clinical management and therapeutics in one place, allowing you to gain a full understanding of each condition. It is suited to those who want a summary resource to thoroughly revise O&G for medical school finals, but equally has further detail for those who have a specific interest in the topic.

The skills sections of the book guide you through obstetric palpation, demystify CTG interpretation and provide guidance on how to professionally and sensitively perform pelvic examination. The content of the practical skills components provides a clear structure and step-by-step guide to ensure precise and efficient examinations, suitable for the time constraints and pressure of OSCEs. All that’s left to do is practice!

Wishing you all the best of luck with upcoming O&G exams!

Introduction

‘The Unofficial Guide to Obstetrics and Gynaecology’ is the ninth book in the Unofficial Guide to Medicine series. Obstetrics and gynaecology is a speciality that covers a broad range of medical and surgical presentations in women and girls of all ages that often appear both on the wards and in medical school exams. However, clinical exposure to this speciality at an undergraduate level is often limited. Therefore, it is crucial that educational resources explain and cover this area of medicine in a concise and accessible manner.

Obstetrics and gynaecology is a challenging specialty because of the grey areas in clinical practice where management strategies are often led more by clinical experience and preference rather than by clear cut guidelines. This can be difficult at an undergraduate level where multiple choice or short answer questions, do not leave much space for explaining these subtle complexities. The core ethos of this project was therefore to produce a book based on guidelines and evidence, minimising the use of potentially differing clinical opinions or variations in practice.

This book presents a succinct, approachable summary for each section which covers information that is both relevant for examinations but also working on the wards. These summaries lead into over 350 questions, both multiple choice and true/false, or extended matching questions. Answers are then explained in full to help gain an understanding of not only why the correct answer is right but also why incorrect answers are inferior options.

'...the core ethos of this project was therefore to produce a book based on guidelines and evidence, minimising the use'.

With this textbook we hope that you gain a greater understanding of obstetrics and gynaecology and whether you are interested in this specialty as a potential future career choice, or you are just learning it to pass exams, we hope you find it a useful resource.

Matthew Wood and Katherine Lattey

Editors

Unofficial Guide to Obstetrics and Gynecology

Abbreviations

Contributors

Editors

Matthew Wood BM MRCOG

Obstetrics and Gynaecology Registrar, West Midlands Deanery, UK

Senior Clinical Fellow in Robotic Gynaecological Surgery, University Hospitals Leicester, UK

Katherine Lattey BMBS (Dist) MRes (Dist)

Foundation Doctor, North West Thames Deanery, UK

Series Editor

Zeshan Qureshi BM BSc (Hons) MSc MRCPCH FAcadMEd MRCPS(Glasg)

Paediatric Registrar, London Deanery, UK

Authors

Stephanie Arrigo MD BSc (Hons)

Surgery Basic Specialist Trainee, Mater Dei Hospital, Msida, Malta

Victoria Awobajo BSc (Hons)

Medical Student, Hull-York Medical School, York, UK

Alexandra Black MBChB BA (Hons) Oxon

Foundation Doctor, Heart of England Foundation Trust, Solihull, UK

Darren Chan MBBS

Radiology Specialist Trainee, Plymouth Hospitals NHS Trust, Devon, UK

Rachel Crane MBBS BSc (Hons) AICSM

Foundation Doctor, East Surrey Hospital, South Thames, UK

Lyndsay Creswell MB BCh BAO

Obstetrics and Gynaecology Specialist Trainee, Belfast Health and Social Care Trust, Belfast, UK

Kirsty Dawson MBChB

GP Registrar, Stockport NHS Trust, Manchester, UK

Megan Durant MBChB

Foundation Doctor, Wirral University Teaching Hospital, Wirral, UK

Charlie Dyson MBBChir MA (Cantab) MRCOG

Obstetrics and Gynaecology Specialist Trainee, Peterborough City Hospital, Peterborough, UK

Patrick Green MBChB MRes MRCS

Academic Foundation Doctor, Royal Liverpool Hospital, Liverpool, UK

Marcus Hards MBChB MSc (Dist)

Anaesthetic Trainee, Maidstone and Tunbridge Wells NHS Trust, Kent, UK

Sofia Hart

Medical Student, St George’s University of London, London, UK

Sarah Hobern BSc BMBS

Obstetrics and Gynaecology Specialist Trainee, Birmingham Women’s Hospital, Birmingham, UK

Emily Hotton MBChB (Dist) BSc (Hons)

Obstetrics and Gynaecology Specialist Trainee, Severn Deanery, Bristol, UK

Marie Jasim DPMSA

Medical Student, St. George’s University of London, London, UK

Katherine Lattey BMBS (Dist) MRes (Dist)

Foundation Doctor, St Mary’s Hospital, London, UK

Shujing Jane Lim MBChB BMedSci (Hons)

Academic Foundation Doctor, Leeds Teaching Hospitals NHS Trust, Leeds, UK

Georgina Martin MBBS BSc (Hons)

Academic Foundation Doctor, Royal Preston Hospital, Lancashire, UK

Emily Mayo BMBS BMedSci (Hons)

Trust Doctor, Peterborough and Stamford NHS Foundation Trust, Peterborough, UK

Rayna Patel MA (Cantab) MBBS MRCP (UK) AIFL MPhil HFEA

Academic Clinical Fellow, Cambridge University Hospitals NHS Trust, Cambridge, UK

Prateush Singh MB BChir MA BA MRCS

Plastic Surgery Core Trainee, London Deanery, London, UK

Yashashwi Sinha MRes MBChB FHEA

Academic Foundation Doctor, Imperial College London, London, UK

Emily Slade BMBS

GP Specialist Trainee, Wessex Deanery, Southampton, UK

Thivya Sritharan MBBS

Obstetrics and Gynaecology Specialist Trainee, Northampton General Hospital, UK

Steve H. Tsang BSc MBBS

GP Registrar, Great Western Hospitals NHS Foundation Trust, Swindon, UK

Laura Wharton MB BChir MA Hons (Cantab)

Obstetrics and Gynaecology Specialist Trainee, Yorkshire and Humber Deanery, Sheffield, UK

Matthew Wood MB MRCOG

Obstetrics and Gynaecology Registrar, West Midlands Deanery, UK

Senior Clinical Fellow in Robotic Gynaecological Surgery, University Hospitals Leicester, UK

Reviewers

Rebecca Best BSc (Hons) - obstetrics and gynaecology chapters

Medical Student, Cardiff University, Wales, UK

Dean Connolly BA (Hons) (Cantab) – obstetrics and gynaecology chapters

University College London & University of Cambridge

Chiamaka Maduanusi MBBS BSc – obstetrics and gynaecology chapters

Foundation Doctor, South Thames, London, UK

Jennifer Mall – obstetrics chapter

Medical Student, Trinity College Dublin, the University of Dublin, Ireland

Phillip Molloy – gynaecology chapter

Medical Student, Keele University Medical School, Stoke-on-Trent, UK

Jordan Palmer – gynaecology chapter

Medical Student, Keele University Medical School, Stoke-on-Trent, UK

Azmi Rahman – obstetrics and gynaecology chapters

Medical Student, Imperial College London, London, UK

Salman Sadiq – gynaecology chapter

Medical Student, Keele University Medical School, Stoke-on-Trent, UK

Senior Reviewers

Catherine Aiken MB/BChir MA PhD MRCP MRCOG

Clinical Lecturer in Obstetrics and Gynaecology, University of Cambridge, UK.

Charlie Dyson MBBChir MA (Cantab) MRCOG

Obstetrics and Gynaecology Specialist Trainee, Peterborough City Hospital, Peterborough, UK.

Paul Mills MRCOG MRCSEd

Consultant Obstetrician and Gynaecologist , St Johns Hospital, Livingston, Scotland.

Contents

SECTION 1: GYNAECOLOGY

CHAPTER 1.01

INTRODUCTION

GYNAECOLOGICAL ANATOMY AND EXAMINATION

CHAPTER 1.02

HPO AXIS

THE MENSTRUAL CYCLE AND PHYSIOLOGY OF THE HPO AXIS

PUBERTY

DISORDERS OF SEXUAL DEVELOPMENT

SECONDARY AMENORRHOEA

POLYCYSTIC OVARIAN SYNDROME

INFERTILITY

CHAPTER 1.03

EARLY PREGNANCY COMPLICATIONS

HYPEREMESIS GRAVIDARUM

MOLAR PREGNANCY

ECTOPIC PREGNANCY

MISCARRIAGE

RECURRENT MISCARRIAGE

TERMINATION OF PREGNANCY

CHAPTER 1.04

BENIGN GYNAECOLOGY

CONTRACEPTION

EMERGENCY CONTRACEPTION

MENORRHAGIA AND OTHER MENSTRUAL BLEEDING DISORDERS

FIBROIDS

PREMENSTRUAL DISORDER

MENOPAUSE

VULVAL DISORDERS

CHAPTER 1.05

UROGYNAECOLOGY

PELVIC ORGAN PROLAPSE

URINARY INCONTINENCE

CHAPTER 1.06

PELVIC PAIN

ENDOMETRIOSIS

SEXUALLY TRANSMITTED INFECTIONS

BENIGN OVARIAN CYSTS

CHAPTER 1.07

ONCO-GYNAECOLOGY

GENERAL PRINCIPLES OF GYNAECOLOGICAL CANCER MANAGEMENT

OVARIAN CANCER

ENDOMETRIAL CANCER

CERVICAL SCREENING

CERVICAL CANCER

VULVAL AND VAGINAL CANCERS

CHAPTER 1.08

GYNAECOLOGY ANSWERS

SECTION 2: OBSTETRICS

CHAPTER 2.01

ANTENATAL CARE

ORGANISATION AND PRINCIPLES OF ANTENATAL CARE

OBSTETRIC ABDOMINAL PALPATION

ANTENATAL SCREENING AND DIAGNOSTIC TESTS

CHAPTER 2.02

MEDICAL DISORDERS IN PREGNANCY

DIABETES IN PREGNANCY

EPILEPSY IN PREGNANCY

CARDIAC DISORDERS IN PREGNANCY

THE IMPACT OF MATERNAL WEIGHT ON PREGNANCY

THYROID DISEASE IN PREGNANCY

HEPATITIS B IN PREGNANCY

HIV IN PREGNANCY

SICKLE CELL DISEASE IN PREGNANCY

OBSTETRIC CHOLESTASIS

CHAPTER 2.03

MULTIPLE PREGNANCY

TWIN PREGNANCY

CHAPTER 2.04

MANAGEMENT OF LABOUR

NORMAL VAGINAL DELIVERY

MONITORING THE FETUS

INDUCTION AND AUGMENTATION

PAIN RELIEF IN LABOUR

MALPRESENTATION AND MALPOSITION OF THE FETUS

BREECH

CHAPTER 2.05

METHODS OF DELIVERY

CAESAREAN SECTION

VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC)

ASSISTED DELIVERY AND INSTRUMENTAL BIRTHS

CHAPTER 2.06

OBSTETRIC COMPLICATIONS

ANTEPARTUM HAEMORRHAGE

PRE-ECLAMPSIA AND PREGNANCY-INDUCED HYPERTENSION

PRETERM LABOUR

CHORIOAMNIONITIS

SMALL FOR GESTATIONAL AGE BABIES AND INTRAUTERINE GROWTH RESTRICTION

FETAL HAEMOLYTIC DISEASE

CONGENITAL INTRAUTERINE INFECTIONS

STILLBIRTH

CHAPTER 2.07

OBSTETRIC EMERGENCIES

CORD PROLAPSE

SHOULDER DYSTOCIA

RETAINED PLACENTA

POSTPARTUM HAEMORRHAGE

AMNIOTIC EMBOLISM

MATERNAL COLLAPSE

CHAPTER 2.08

POSTNATAL COMPLICATIONS

VENOUS THROMBOEMBOLISM

BACTERIAL SEPSIS FOLLOWING PREGNANCY

PERINEAL TRAUMA

MASTITIS

POSTNATAL MENTAL HEALTH

CHAPTER 2.09

OBSTETRICS ANSWERS

SECTION 3: CAREERS

CHAPTER 3.01

CAREERS IN OBSTETRICS AND GYNAECOLOGY

INDEX

1.01

INTRODUCTION

CONTENTS

Gynaecological anatomy and examination

Matthew Wood

GYNAECOLOGICAL ANATOMY AND EXAMINATION

Matthew Wood

Gynaecology is an exciting, wide ranging specialty. It is predominantly a surgical speciality, but endocrinology plays a crucial role in many of the diseases and treatments offered. Like obstetrics, aspects of the speciality are highly emotive, requiring good communication and interpersonal skills to guide patients through challenging times in their lives. Gynaecologists have the enviable role of making a difference to a panoply of different aspects of patients’ lives:

›Creating life – subfertility.

›Prolonging life – oncology, colposcopy.

›Saving life – emergency surgery to treat ectopic pregnancies and heavy bleeding following miscarriage.

›Improving quality of life – treating chronic pain from endometriosis, acute pain from ovarian torsion, incontinence, menstrual disorders.

This introduction will explain the key aspects of the gynaecological examination. As this is a surgical speciality, we will also highlight the important anatomy and provide an overview about obtaining consent for surgery.

Examination

The pelvic examination is completed in three stages:

›Abdominal exam – similar to a surgical examination.

›Speculum examination – to inspect the vulva, vagina and cervix.

›Bimanual examination – to palpate the internal organs.

Pelvic examination is intimate and invasive. It is essential to communicate well with the patient prior to any examination to adequately prepare her. This can be achieved by completing the following steps:

1Formally introduce yourself and check the identity of the patient.

2Ask if the patient has had a pelvic examination before.

3Explain what the examination involves and the reasons why it is being offered.

4Gain verbal consent.

5Ask the woman if she would like to empty her bladder prior to the examination.

6Introduce the chaperone to the patient. It is imperative for a clinician to be chaperoned for any intimate examination.

7Ask the patient if she would like a friend or relative with her at the time of the examination, for support.

8Allow the patient to move over to the examination couch. The patient should have privacy so she can remove her clothes from the lower half of her body and be given a sheet so that she can cover herself while on the examination couch. This limits unnecessary exposure and discomfort.

Abdominal examination

Conducting an abdominal examination before vaginal examination is important, as it enables the patient to get used to being examined prior to the more intimate part of the examination.

1Wash your hands.

2Expose the lower abdomen and inspect.

3Ask the patient if she has any areas of tenderness.

4Palpate in the four quadrants like in any standard abdominal examination, identifying masses and areas of tenderness. Take particular notice of tenderness or masses palpated over the ‘triangle’ area (Figure 1) between the anterior superior iliac crests and symphysis pubis, as this is where the ovaries, uterus and bladder will be palpated.

5Assess other aspects of the standard abdominal examination, as dictated by the history and examination findings, such as balloting the kidneys, palpating the liver and spleen, testing for pain on a straight leg raise and listening for bowel sounds.

6Allow the patient to pull her top back down.

7If a rectal examination is indicated, this can be performed after the bimanual examination.

Speculum examination

1Obtain consent for a speculum examination during the introduction.

2Put on a pair of non-latex gloves.

3Prepare the trolley – appropriate sized Cusco speculum (Figure 2), lubricating jelly and any swabs or other investigation tools required, dependent on the case. If the speculum is metal, warm the speculum to avoid patient discomfort. A Sims speculum may be used in some circumstances, such as when examining for vaginal prolapse. The examination technique for a Sims speculum is discussed under pelvic organ prolapse.

[See ‘Pelvic organ prolapse’ page 105.]

4Put a small amount of lubricant on either side of the speculum.

5Explain clearly for the patient to bring your heels up to your bottom and then move your knees apart. It may help to suggest that she concentrate on placing her knees as far apart as possible, as this maximises space to examine the vagina and it helps keep the patient relaxed.

6Position the light and switch it on.

7Inspect the vulva (Figure 3 and 4) for any ulceration, masses, erythema, rashes, papules, discharge, bleeding and distortion of normal anatomy.

8Carefully part the labia, ensuring all hair and skin is out of the way, and insert the speculum into the vagina with the dominant hand, with the handle of the speculum at around the 2 o’clock position. Once the speculum is a few centimetres into the vagina, turn the speculum so the handles are at 12 o’clock. Swap hands and hold the speculum handles in the non-dominant hand. Apply pressure with the thumb of the dominant hand at the base of the speculum and insert the speculum as far as possible, gently and slowly. This technique reduces patient discomfort.

9Once the speculum is inserted, place the non-dominant hand against the patient’s pubic bone and hold the speculum handles between finger and thumb of the non-dominant hand.

10Reapply pressure to the speculum base with the dominant thumb and gently open the speculum by squeezing the two handles together with the non-dominant hand.

11Identify and inspect the cervix and the external os.

12If required, take vaginal swabs and perform any other investigations or procedures needed; for example, a cervical smear, insertion of an intrauterine device, or taking an endometrial biopsy. To help with this, most Cusco speculums have a screw that locks the speculum in the open position.

13To remove the speculum, hold the handles tightly in position, undo the screw and then gently release pressure on the handles, letting the speculum close. Apply a little pressure to stop the speculum from fully closing as it can pinch the vaginal tissue and cause pain.

14Gently pull back the speculum, holding the handles with the non-dominant hand and the base of the speculum with the thumb of the dominant hand. While removing the speculum, view the rest of the vaginal walls for any abnormality.

15Once the speculum is out, dispose of the speculum, turn off the light and label any swabs taken.

16Cover the patient with a sheet while preparing for the bimanual examination.

FIGURE 1

Triangle of palpation between the pubic bone and the anterior superior iliac spines.

FIGURE 2

Cusco speculum.

FIGURE 3

The vulva.

Speculum tips

The cervix can sometimes be difficult to visualise on speculum examination. Here are some additional techniques to bring the cervix into view:

■If part of the cervix can be seen but not the full view, getting the patient to cough can push the cervix into the open speculum.

■Ask the patient to make a fist with her hands and then putting her hands under her bottom. This alters the angle of the pelvis, bringing the cervix to a more anterior position.

■Use the speculum upside down, particularly if the anterior wall of the vagina is obstructing the view.

■Gently examine with two fingers to feel where the cervix is, and then insert the speculum, aiming for the area felt. It is important to remember that when the patient is lying on the couch, the vagina is not parallel to the couch; instead, it angles upwards.

■Sometimes a longer speculum is required to reach the cervix. Similarly, in adolescents and the elderly, a small speculum will be needed to avoid discomfort.

■In obstetrics and gynaecology (O&G) departments, some examination couches are equipped with leg stirrups so the patient can be placed in the lithotomy position.

Bimanual examination

1Clearly explain that an internal examination is going to be done.

2Wash hands and put on gloves.

3Lubricate the index and middle finger of the dominant hand. Insert these two fingers gently into the vagina. Place the non-dominant hand on the abdomen in the suprapubic region.

4Move the fingers inside the vagina behind the cervix and attempt to push the uterus up, while pushing downwards with the non-dominant hand and attempting to palpate the uterus between the examining hands. Comment on the size and mobility of the uterus. The uterus is normally mobile, but if it cannot move, the uterus is fixed; this is usually a result of adhesions. A normal sized uterus (when not pregnant) is roughly the size of a plum.

5Move the fingers in the vagina, anterior to the cervix, and again try to ballot the uterus between the examining hands (Figure 5). If the bulk of the uterus can be felt, the uterus is anteverted (the most common finding). If not, then it is likely retroverted.

6Gently wobble the cervix from side to side by pushing it with a finger. This stretches the visceral peritoneum of the broad ligaments. If this causes pain, it is referred to as ‘cervical excitation’. Ectopic pregnancy and large ovarian cysts can cause this sign.

7Move the two fingers to the lateral aspect of the cervix. Move the non-dominant hand to the same side on the abdomen and again push the two hands together, attempting to palpate the ovary and any abnormal masses (Figure 6). Normal sized ovaries are the size of a large grape, so it is rarely possible to palpate them. Repeat this step on the other side to examine the other adnexa.

8Remove the examining fingers and, if indicated, perform a rectal exam if consent has been gained.

9Cover the patient. Explain that the examination is now over, and leave the patient in private to get changed after giving her some tissue for self-cleaning.

10Ensure the patient is comfortable after the examination, explain the findings and discuss the ongoing management plan.

Presenting normal findings of an examination

■Inspection of the abdomen was unremarkable. On palpation, the abdomen was soft, with no distension, no areas of tenderness and no palpable masses.

■Speculum examination revealed no abnormality on inspection of the vulva, vagina and cervix. Normal vaginal discharge was observed.

■Digital vaginal examination revealed no tenderness of the introitus or vagina. A normal sized, mobile, anteverted uterus was palpated. No adnexal masses or tenderness were identified. The cervix felt normal and there was no cervical excitation.

FIGURE 4

The perineum and pelvic diaphragm.

FIGURE 5

Sagittal section of the pelvis.

FIGURE 6

Uterus and ovaries in situ.

FIGURE 7

Anterior aspect of the internal female organs.

Anatomy

Important anatomy for pelvic surgery

Uterus

Blood supply (Figure 7)

›Uterine arteries – the major blood vessels supplying the uterus are the uterine arteries, which are branches of the internal iliac arteries.

›Ovarian arteries – supplies a collateral blood supply to the uterus with vessels running from the ovary within the broad ligament.

›Vaginal arteries – branches of these vessels commonly anastomose with branches of the uterine arteries. The vaginal arteries originate from the internal iliac arteries.

Ligaments (Figure 8)

The uterus is supported by a number of paired ligaments:

›Uterosacral ligaments – the strongest ligaments of the uterus. They attach the posterior aspect of the lower uterus/cervix to the sacrum.

›Cardinal ligaments – provide support by attaching the cervix to the lateral pelvic wall.

›Round ligaments – provide support running from the top of the uterus to the deep inguinal ring.

›Broad ligaments – these are a double layer of peritoneum which have attachments to the uterus, ovaries, fallopian tubes, round ligaments, ovarian ligaments and pelvic side walls. They do not provide much structural support to the uterus, but they are important surgically as they often need dividing to identify the course of the ureters in the pelvis.

FIGURE 8

Normal female pelvis at laparoscopy.

Ovaries

Blood supply

›Ovarian artery – this is a direct branch off the aorta. Branches from the ovarian artery also supply the fallopian tube and provide a supply to the uterus.

›The right ovarian vein drains into the inferior vena cava, whereas the left ovarian vein drains into the left renal vein. The vascular anatomy is similar for the testicles in males.

Ligaments

›Infundibular pelvic ligament – attaches the ovary to the pelvic side wall. The ovarian vessels run within this ligament.

›Ovarian ligament – attaches the ovary to the uterus.

Urinary system

The most common organ injuries during gynaecology surgery are to the bladder and the ureters, due to their proximity to the other reproductive organs. The bladder lies anteriorly to the uterus and is attached to the uterus by a folded piece of visceral peritoneum, the uterovesical fold. At the time of hysterectomy, and at caesarean section, this peritoneum is incised and the bladder is reflected away from the uterus to prevent injury.

The ureters are retroperitoneal. They enter the pelvis and can be seen lying anterior to the bifurcation of the common iliac arteries. As they descend into the pelvis they then run close to the posterior aspect of the ovaries. Then they pass just below the uterine arteries and then laterally to the cervix, before running medially and anteriorly to enter the posterior aspect of the base of the bladder. Therefore, at multiple sites, the ureter lies very close to structures operated on in gynaecology, particularly for hysterectomy. One of the early steps in a hysterectomy is to open the broad ligament to allow a clear view of the course of the ureter.

Consent for surgery

For any surgical procedure, consent can be obtained either by the person doing the procedure or by someone delegated by that person who has sufficient knowledge and experience to provide an adequate explanation of all the relevant aspects of the procedure to the patient. Key items to discuss are:

›The name of the procedure.

›A brief overview of what the procedure involves.

›The recovery period, including the likely length of hospital admission.

›Reasons to undertake the procedure and the perceived benefits.

›The potential risks.

›Alternative options – this should always include no treatment, as well as any other conservative, medical or surgical alternative therapies.

The patient should be given this information in easy-to-understand language, by a combination of methods:

›Verbal discussion with the doctor.

›A copy of the consent form.

›Information leaflets relating to the proposed procedure.

The patient should be given time to weigh up the information, discuss with friends or relatives, and seek any further information she wishes, either researching herself, or by asking further questions of the clinician. Once the patient is satisfied, she can give informed consent.

Common gynaecology procedures and the risks

All common and serious risks of surgical procedures should be explained to the patient, including how likely they are to occur. Generic risks applicable to all gynaecology surgery are:

›Infection – the most common risk for most operations. It may be appropriate to discuss where the infection is likely to occur; for example, the urinary tract, chest, wound or uterus.

›Bleeding.

›Venous thromboembolism (blood clot in the leg or lung).

›Pain after the procedure.

›Failure of procedure.

›Injury to adjacent organs – in O&G these occur most commonly to the bladder, bowel, ureters and major blood vessels.

›Blood transfusion.

›Anaesthetic risks – usually discussed in more detail by the anaesthetist.

›Death.

The likelihood of a risk occurring will vary depending on the operation (Table 1) and the individual patient.

Nirja, a 28-year-old woman, presents to the clinic with acute pelvic pain. After taking a thorough history, it is determined that a bimanual examination is required to determine the cause.

Q1Answer true or false, regarding the use of chaperones.

AThe chaperone is present only for the benefit of the patient.

BThe chaperone must be a nurse or other qualified doctor.

CChaperones should be assumed necessary unless the patient states otherwise.

DIn certain situations, a chaperone may be a family member.

EChaperones are not necessary when the doctor performing the examination is female.

Q2If this patient had a body mass index (BMI) of 35 kg/m², which of the following is most correct regarding a discussion of her weight?

AAs a patient’s BMI is a clinical matter, this can be discussed at any point in the patient’s history or examination.

BAs long as the patient is fully dressed, then comments regarding the patient’s weight may be made.

CDue to the potentially sensitive nature of discussing a patient’s weight, the doctor should wait until after the examination, when the patient has dressed and is back in the consultation room.

DThe doctor should discuss the patient’s BMI before the examination, as this could be deemed inappropriate if done afterwards.

EThe doctor should not comment on the patient’s weight, as it is unrelated to the patient’s presentation.

Q3If pain is experienced on moderate pressure to the cervix, what does this suggest?

AAppendicitis.

BCervical cancer.

CFibroids.

DPelvic inflammatory disease.

EThis is a normal examination finding.

[Answers on page 160.]

1.02

HPO AXIS

CONTENTS

The menstrual cycle and physiology of the HPO axis

Yashashwi Sinha

Puberty

Yashashwi Sinha, Matthew Wood

Disorders of sexual development

Alexandra Black

Secondary amenorrhoea

Emily Hotton

Polycystic ovarian syndrome

Emily Hotton

Infertility

Thivya Sritharan, Matthew Wood

THE MENSTRUAL CYCLE AND PHYSIOLOGY OF THE HPO AXIS

Yashashwi Sinha

The hypothalamic pituitary ovarian (HPO) axis refers to the interplay of hormones between these areas. The axis is referred to in this way because these glands normally behave in a coordinated manner as one system. The HPO axis controls the menstrual cycle, which is, in turn, responsible for development of the ovarian follicles (folliculogenesis), maturation of the oocyte (egg) within each follicle, ovulation of the oocyte from the dominant follicle and maturation of the uterine environment to facilitate pregnancy (Figure 9).

The hormones involved in the HPO axis

Gonadotropin releasing hormone (GnRH)

›Peptide hormone.

›Produced by the arcuate nucleus in the hypothalamus, released in a pulsatile manner.

›Stimulates the production of gonadotropins; luteinising hormone (LH) and follicle stimulating hormone (FSH) from the anterior pituitary (adenohypophysis).

Follicle stimulating hormone (FSH)

›Peptide hormone.

›Produced by the anterior pituitary in response to GnRH.

›Stimulates growth of the granulosa cells of primordial follicles (primitive follicles which each contain an oocyte) within the ovary, which leads to the development of the ovarian follicles.

›The granulosa cells of the follicles produce oestrogen and inhibin, which act by negative feedback to inhibit GnRH and FSH production. The follicle with the most FSH receptors is able to grow, while other follicles regress as the FSH levels fall in response to the negative feedback. The one remaining dominant follicle (also called the Graafian follicle or tertiary follicle) is then ready for ovulation.

Luteinising hormone (LH)

›Peptide hormone.

›Produced by the anterior pituitary in response to GnRH.

›Stimulates production of androgens by theca cells of the follicles within the ovaries. Androgens are then converted to oestrogens in the granulosa cells in the follicular phase.

›The release of oestrogen and inhibin provides negative feedback to reduce LH and FSH production in the follicular phase. However, at high concentrations, oestrogen then positively feeds back on the anterior pituitary, causing a sudden release of high concentrations of LH (the LH surge). The LH surge causes prostaglandin synthesis in the dominant follicle, causing the follicle to burst and release the oocyte inside. This event is ovulation.

›After ovulation, LH promotes the luteinisation of the granulosa cells, which then begin to produce progesterone, converting the remnants of the dominant follicle into the corpus luteum.

Oestrogen

›A steroid hormone.

›Produced by the ovarian follicles from the granulosa cells in response to FSH.

›Stimulates proliferative changes in the endometrium, building up the lining of the uterus in preparation for a potential pregnancy.

›Increasing levels of oestrogen in the follicular phase has a negative feedback effect on the hypothalamus and pituitary glands, leading to a decreased release of GnRH, FSH and LH. However, when high levels of oestrogen are sustained for approximately 40–50 hours, the negative feedback on LH becomes a positive feedback and the LH surge occurs.

Progesterone

›A steroid hormone.

›Produced by the granulosa cells of the corpus luteum.

›Stimulates secretory changes of the endometrium, preparing it for blastocyst implantation.

Androgens, for example, testosterone and androstenedione

›Steroid hormones.

›Produced by the theca cells of the ovarian follicles in response to LH. Some androgens are also produced by the adrenal cortex.

›Androgens are the precursors of oestrogen. They are converted into oestrogen through aromatase enzyme activity within granulosa cells.

FIGURE 9

The HPO axis in the follicular phase.

Menstrual cycle

The menstrual cycle (Figure 10) is the preparation of the body for pregnancy, whereby the oocyte (egg) is developed and released and the endometrium is developed to maintain a pregnancy. If pregnancy does not occur, the endometrium is shed (commonly known as ‘the period’) and the cycle repeats. The classic menstrual cycle is 28 days long.

The phases of a normal 28 day menstrual cycle are summarised in Table 2 and Figure 10.

Follicular phase

The first day of menstruation denotes day one of the menstrual cycle and the start of the follicular phase. Rising levels of GnRH released from the hypothalamus increase FSH production by the anterior pituitary. The FSH stimulates the receptors on the ovarian follicles, stimulating up to 20 follicles to mature each cycle.

FSH increases the production of oestrogen from the granulosa cells of the ovarian follicles. Oestrogen has a negative feedback effect on the hypothalamus and pituitary, which decreases FSH and LH levels. As FSH levels fall, follicles with the fewest FSH receptors stop growing and over time degenerate in a process called follicular atresia. The more developed follicles continue to progress, but as the oestrogen levels rise and FSH production is further inhibited, more and more follicles undergo atresia until only a single dominant follicle continues to mature. The dominant follicle will continue to full maturity, when it is then referred to as a Graafian follicle, and it will then progress to ovulation.

At the start of the follicular phase, the thickened endometrium from the previous menstrual cycle is expelled (menstruation). Late in the follicular phase, the new endometrium is stimulated to proliferate by the high oestrogen levels.

Ovulation occurs classically at day 14, when oestrogen levels rise to a sustained high level. This causes a shift from negative feedback to a strongly positive feedback on LH production from the pituitary, resulting in a very high mid-cycle LH concentration, known as the LH surge. LH causes ovulation by activating inflammatory prostaglandin release, which causes the Graafian follicle to burst, releasing the oocyte. The inflammation allows ovulation to be identified clinically as a mild body temperature rise of approximately 0.5oC at the time of ovulation.

Luteal phase

Following ovulation, the ruptured Graafian follicle luteinises under the influence of LH to become the corpus luteum. Prior to formation of the corpus luteum, very limited synthesis of progesterone occurred. The corpus luteum produces relatively high levels of progesterone and a smaller amount of oestrogen. These hormones act on the endometrium to ready it for implantation by increasing glandular numbers and secretions. The progesterone and oestrogen produced from the corpus luteum also have a negative feedback on the pituitary, leading to low levels of FSH and LH for the rest of the cycle.

If the egg is fertilised and implantation occurs, β hCG produced from the blastocyst maintains the corpus luteum, now called the corpus luteum graviditatis. This ensures synthesis of oestrogen and progesterone to support the endometrium and maintain the pregnancy. Progesterone is secreted by the corpus luteum for up to approximately 10 weeks. After this time, the corpus luteum declines in function, but the placenta fully takes over this role and oestrogen and progesterone levels rise rapidly.

If fertilisation does not take place, there is an absence of β hCG so the corpus luteum degenerates to its regressed form, called the corpus albicans, and it stops producing progesterone. With a lack of progesterone support from a corpus luteum, the endometrium breaks down and sheds. This is menstruation, and it represents day one of the next menstrual cycle. The cycle is able to restart because the declines in oestrogen and progesterone levels end the negative feedback, allowing the hypothalamus and pituitary to produce GnRH, FSH and LH.

FIGURE 10

Diagram of the menstrual cycle.

Follicles from conception to menopause

Follicular development (Figure 11) begins in utero. The first stage of oocyte development is the production of primordial germ cells (oogonia) in large numbers by mitosis. These oogonia become surrounded by granulosa cells, forming primordial follicles containing primary oocytes. The maximal number of follicles occurs at around seven months’ gestation, when approximately seven million oocytes are contained within the primordial follicles. However, through the process of atresia and apoptosis, only one million follicles remain at birth. These follicles contain primary oocytes, which are arrested in the prophase stage of meiosis 1.

By menarche, approximately 400,000 primordial follicles remain. High FSH and LH levels at the onset of puberty begins the development into primary and secondary follicles. The primary oocytes remain in the prophase of meiosis 1. Then, during the follicular phase of each menstrual cycle, FSH stimulates approximately 20 primordial follicles to mature further. Of these 20, only one oocyte completes meiosis 1, and that follicle goes on to become the dominant (Graafian) follicle, which contains the secondary oocyte. Half the genetic material is discarded into the first polar body during the process of meiosis.

At ovulation, the secondary oocyte begins meiosis 2, but this is arrested in metaphase. The process only completes when a sperm enters the oocyte, fertilising it. At this time, a further polar body is produced containing discarded DNA.

This process of folliculogenesis continues each cycle until the menopause, at which time there are only approximately 1000 primordial follicles remaining, and these do not respond even to very high FSH levels.

Menstruation

›Menarche is the first episode of menstruation. This occurs, on average, when a girl is 13 years old. Menarche is considered abnormally early if it occurs before 10 years of age and late if it has not occurred by age 16.

›Menopause is the natural cessation of menstrual cycles once all oocytes have been used. The average age of menopause in the UK is 51 years old. Premature menopause occurs at less than 40 years of age and late menopause is at more than 55 years.

There are four specific components to consider regarding menstruation:

›Length of menstrual cycles – the average is 28 days.

›Frequent if less than 24 days.

›Infrequent if more than 38 days.

›The luteal phase of a menstrual cycle is always 14 days. Therefore, any variation in cycle length is due to a change in the length of the follicular phase of the cycle.

›Regularity of menstrual cycles is the variation in the cycle lengths over a 12 month period.

›Regular: ± 1–10 days.

›Irregular: varying by more than 10 days or absent.

FIGURE 11

Follicular development.

›Duration of menses – normally 4–8 days.

›Shortened if less than four days.

›Prolonged if more than eight days.

›Volume of monthly menstrual blood loss – average of 40 ml.

›Light if less than 5 ml.

›Heavy if more 80 ml.

›In clinical practice, blood loss is assessed more practically; for example, the ‘number of pads used’, experience of any ‘flooding’ or ‘passing of clots’.

Pain during the menstrual cycle:

›Mittleschmerz is pain that occurs in some women when they ovulate. This is a German term meaning ‘middle pain’ and it occurs in some women due to fluid leaking from the dominant follicle at the same time as the egg is being released. This results in free pelvic fluid which irritates the peritoneum.

›At the time of menstruation, pain (‘period cramps’) is caused by contraction of the uterine myometrium and by the inflammatory necrosis of the endometrium being shed.

Isabella, a 20-year-old girl, comes to clinic concerned that she is having heavy and painful periods. She has read an article online suggesting that her symptoms may be caused by a hormone imbalance. She would like an explanation as to how these hormones affect her periods, and for her hormone levels to be checked.

Questions

Q1Which of the following statements concerning the HPO axis are true or false?

AThe HPO axis acts to bring about secondary sexual changes.

BGnRH is released from the adenohypophysis.

CGnRH is released in a pulsatile manner.

DGnRH causes the release of FSH alone.

ENegative feedback from oestrogen occurs in the arcuate nucleus and adenohypophysis.

Q2Which of the following statements concerning the menstrual cycle are true or false?

AThe average length of a menstrual cycle is 32 days.

BOvarian follicles mature during the proliferative phase.

CDeclining FSH levels in the follicular phase can lead to follicular atresia.

DThe mid cycle LH surge occurs in response to high oestrogen levels.

EThe follicle which released the egg may later become the corpus albicans.

Q3Which of the following statements regarding the luteal phase are correct?

AThe end of the menstrual cycle occurs secondary to regression of the corpus luteum.

BSecretory changes of the endometrium are largely due to LH.

CIncreasing levels of progesterone cause a breakdown of the endometrium at the end of the menstrual cycle.

DThe basal body temperature is lower in the luteal phase.

EIf the egg is fertilised, the endometrium is maintained despite falling progesterone and oestrogen levels.

AAsherman syndrome.

BDysfunctional uterine bleeding.

CEndometrial hyperplasia.

DEndometriosis.

EEndometritis.

FImperforate hymen.

GMenopause.

HPolycystic ovarian syndrome.

I Pregnancy.

J Premature menopause.

KSheehan syndrome.

LTurner syndrome.

Select the most appropriate diagnosis from the above list that corresponds to the following statements.

Q4A 15-year-old girl, presenting with cyclical lower abdominal pain for 10 months, denies any history of menstruation. She has normal secondary sexual development.

Q5A 28-year-old lady presented to the emergency department following haemorrhagic shock during a normal delivery at home. Following recovery, the mother is unable to lactate for her child.

Q6A 17-year-old girl presents with her mother complaining of irregular menstrual cycles. Both the mother and girl are overweight and the girl complains of ‘having to shave like a man’.

Q7A nulliparous 35-year-old lady complains of a two year history of mild cyclical pelvic pain with a recent onset of pain and bleeding on defecation commencing before menstruation.

Q8A 51-year-old lady presents to her primary care physician with a 13 month history of absent periods and palpitations, and she would also like to explore treatment for vaginal dryness.

[Answers on page 162.]

References

1Royal College of Obstetricians and Gynaecologists. (2007) Long term consequences of polycystic ovarian syndrome. RCOG green top guideline (GTG 33).

2Tsutsumi R, Webster N. GnRH pulsatility, the pituitary response and reproductive dysfunction. Endocrine journal. 2008;56(6):729-37.

3Farage MA, Neill S, et al. Physiological changes associated with the menstrual cycle: a review. Obstetrical & gynecological survey. 2009;64(1):58-72.

4Christian CA, Moenter SM. The neurobiology of preovulatory and estradiol-induced gonadotropin-releasing hormone surges. Endocrine reviews. 2010;31(4):544-77.

PUBERTY

Yashashwi Sinha, Matthew Wood

Puberty is a process that begins in late childhood and leads