10 - Men and Women's Health Flashcards
What are the definitions of the following words? (revise ovarian and uterine cycles when doing this card)
- Menorrhagia
- Metorrhagia
- Oligomenorrhea
- Prolonged or heavy bleeding
- Bleeding at irregular intervals
- Infrequent menstrual periods. Over 35 days cycles insteaded of normal 21-35 days
What are the two main things you need to consider when a patient presents with ‘period problems’?
- Pregnancy
- Menopause
What are some red flags that point towards ovarian cancer? What are some symptoms?
Red Flags: (2 week referral)
- Ascites and/or pelvic mass identified by abdominal exam that is not obviously uterine fibroids
- US suggest ovarian cancer
Symptoms: (carry out tests including CA125)
- Appetite loss/early sateity especially if over 50
- IBS or change in bowel habits
- Fatigue
- Urinary urgency and/or frequency
- Weight loss
- Raised CA125
- Haematuria
What are some red flags/concerning features in a history that point towards the following cancers:
- Cervical
- Endometrial
- Vaginal/Vulval
Cervical: appearance of cervix, IMB (inter menstrual), PMB (post menstrual), PCB (Post coital)
Endometrial: PMB very important, blood glucose levels high with haematuria, vaginal discharge, abnormal menstrual bleeding, blood in stools, dysparaunia
Vaginal/Vulval: mass, bleeding, ulceration
What are some questions you should ask a woman presenting with abnormal menstrual bleeding?
- Menstrual: LMP, duration, associated symptoms, factors that aggravate bleeding such as intercourse
- Obstetric: previous pregnancies including ectopics/terminations, breastfeeding, risk of current pregnancy
- Gynaecological: current contraception, smears, sexual history, current medication
What are some causes of
- Intermenstrual bleeding
- Post coital bleeding
- Breakthrough bleeding (Spotting or bleeding between periods)
- spotting during ovulation, ectopic pregnancy, oestrogen secreting ovarian cancers, tamoxifen, SSRIs, steroids, anticoagulants, following smear, SEE IMAGE FOR MORE
- Infection, ectropion, polyps, vaginal/cervical cancer, trauma, vaginal atrophic change, no specific cause
- COCP, POP, IUS, emergency hormonal contraception
What examination and investigations should you do for a woman with abnormal PV (per vaginal) bleeding?
- Check BMI as obesity is risk for endometrial cancer
- Abdominal exam looking for masses
- Speculum and bimanual PV exam
- Pregnancy test
- STI screening
- FBC, clotting, FSH/LH levels
- Transvaginal ultrasound
- Colposcopy if persisitent PCB as high sensitivity
How can menorraghia be assessed and investigated?
- Take a clinical history and if no associated symptoms go straight to treatment
- If other symptoms do physical exam e.g abdominal, bimanual, speculum, look for goitre for hypothyroidism, looks for bruising for clotting disorders, look for hirtuism and acne for PCOS
- Ix: FBC to look for iron deficiciency anaemia, refer to hysteroscopy if suspect fibroids, vaginal/cervical swab, thyroid function tests, tests for coagulation disorders
How can you treat a woman with menorraghia?
- Refer urgently if suspect cancer, or fibroids >3cm/compressive symptoms
- 1st line offer levonorgestrel intrauterine system LNG-IUS (Mirena)
- 2nd line offer tranexamic acid or NSAIDS (mefenamic acid) or POP
- Can offer uterine atery ablation and myomectomy to preserve fertility
- Last line can offer hysterectomy or endometrial ablation
What are the differences between primary and secondary dysmennorhoea and how is it assessed?
- Primary no underlying pathology, due to hormones. associated with other symptoms like dizzy
- Secondary: PID, endometriosis, adenomyosis, fibroids, cervical cancer, ovarian cancer, IUD insertion
- Take a history including age of menarche and FH
- Perform abdominal and pelvic exam
- Take pregnancy test, high vaginal/endocervical swabs
- Possible US for fibroids
What is it called if there is no underlying cause for menorraghia?
Dysfunctional Uterine Bleeding
What are some causes of amenorrhea?
- Primary: constitutional delay, genitourinary malformation, ovarian failure e.g Turners, Kallman’s, hypothalmic failure
- Secondary: premature ovarian failure, depot, loss of weight, hyperprolactinoma, Asherman’s syndrome, thyroid issues, post pill amenorrhoea, pregnancy
How is dysmenorrhoea treated?
Primary
- Offer NSAID or paracetamol e.g ibuprofen, naproxen, mefenamic acid (be careful seizures)
- Offer COCP or POP/Depo
- Local application of heat
- TENS
Secondary
- Refer
How is amenorrhoea investigated?
- Pregnancy test
- FSH and LH to see if raised and ovarian failure
- Prolactin to see if raised
- TFTs if low TSH
- Pelvic US to check for PCOS
- Karyotyping
How is amenorrhoea managed after investigation?
Primary Amenorrhoea
Refer:
Girls who have no secondary sexual characteristics who have not started menstruating by 13 years of age.
Girls with normal secondary sexual characteristics who have not started menstruating by 15 years of age.
Secondary Amenorrhea
Manage- Hypothyroidism, Menopause and pregnancy
Refer all other people with secondary amenorrhoea for specialist investigation and, where appropriate, management of the cause:
Early menopause (<40), History of surgery, Infertility, Suspected PCOS, Hyperprolactinaemia, Increased testosterone, Cushings
What is the T score?
- T-score is the number of standard deviations below the mean BMD of young adults at their peak bone mass
- Uses a DEXA scan
- Often worked out after breaking a bone, early menopause with no HRT, if taking steroids, have arthritis, menopausal with risk factors
- If less than -1.5 offer bone protection, if between 0 and -1.5 repeat scan in 1-3 years
What symptoms suggest the menopause?
- Perimenopausal women may have shorter cycles of 2-3 weeks or may lengthen and have heavier perioids
- Hot flushes/night sweats
- Changes in mood e.g depression
- Joint aches
- Sleep disturbance and short term memory/concentration issues
- Vaginal dryness and loss of libido (can occur up to 10 years after menopause)
How is the menopause diagnosed?
No tests needed if over 45 and symptoms
Consider FSH test if:
- Over 45 with atypical symptoms
- Women between 40-45 with menopausal symptoms
- Women below 40 where menopause is suspected
Can only do FSH test if not taking combined oestrogen/progestogen or high dose progestogen
What is the difference between storage, voiding and post-micturition urinary symptoms?
- For storage ask about bed wetting as can indicate chronic urinary retention
How should you assess a man that is presenting with LUTS?
- Establish type e.g storage, voiding, post-micturition
- Examine abdomen for distended bladder e.g suprapubic dullness
- Perform DRE, look at genitalia, look at perineum
- Drug history and co-morbidities that can contribute
- Complete urinary frequency chart for at least 3 days
- Complete IPSS
What are some LUTS that could suggest a serious underlying pathology?
Urological Cancer: hard/irregular prostate, haematuria, lower back pain, bone pain, weight loss
Urological Infection: pain urinating, pelvic pain, loin pain, fever, abnormal urine dipstick
Sciatica: tingling in legs
How do you investigate a man with LUTS after you have assessed them?
- Urine dipstick
- eGFR and creatinine
- Consider PSA if concern of obstruction or prostate cancer
What is PSA and what patients may have a low PSA level?
Glycoprotein released into prostatic fluid to liquify semen and allow spermatozoa to move freely
- Obesity
- Drugs such as aspirin, statins, 5-alpha reductase inhibitors, thiazides
How can you assess what type of incontinence a woman has in clinic after she has told you her symptoms?
Examine abdomen for palpable bladder or mass
Vaginal exam:
- Ask to cough and check leakage around external urethral meauts
- Check pelvic floor tone by asking to squeeze finger
- Check for prolapse, masses and urethral diverticulum
What is the definition of
-Frequency
-Polyuria
-Nocturia
-Nocturnal polyuria