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?
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, PMB, PCB
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 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 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 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 some causes of 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 abdomincal 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, pregnancy, 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,
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?
- Offer reassurance for constitutional delay
- Refer to fertility clinic
- HRT with premature menopause (<40) until average age of menopause around 50
- In testicular feminisation removal testicular tissue to prevent malignancy
- Assess for osteoporosis risk as low oestrogen
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 polyuria and nocturnal polyuria?
What are some causes of LUTS in women?
- UTI
- Menopause/Vaginal Atrophy
- Urge/Stress incontinence from child birth
- Diabetes
- Bladder stones
- Bladder cancer
- Neurological conditions e.g MS
- Medication e.g antidepressants like amitriptyline make it difficult to wee, lithium and diuretics can cause urgency
- Urogenital fistula
How is stress incontinence managed in women?
- Refer urgently via 2 week if over 45 and haematuria
- Refer to appropriate specialist e.g urologist, gynacaeologist
Conservative
- Reduce caffiene and fluid intake
- Weight loss if BMI >30
- Stop smoking
- Offer referral to 3 month PFMT, 8 contractions TDS
- Absorbent products and hand-held urinals only to manage leakage whilst waiting for treatment
Pharmacological
- 1st line surgical management like urethral bulking and slings
- 2nd line offer Duloxetine
How is urgency incontinence managed in women?
Consider 2 week referral or referral to specialist if neccessary
Conservative
- Reduce caffiene, reduce fluids weight loss, stop smoking
- Offer referral for bladder training for at least 6 weeks before pharmacological
Pharmacological
- Alongisde bladder training can give anticholinergic or B3 agonist (Mirabegron) and explain may take up to 4 weeks for improvement (see image)
- Review after 4 weeks then every 12 months if working (6 months if over 75)
- If post-menopausal can offer PV oestrogen therapy regularly checking for endometrial hyperplasia
- If nocturia can give desmopressin
- If all of these not working refer to urology
What are some things a urologist can do for urgency incontinence?
- botulinum toxin type A injection into the bladder wall
- percutaneous sacral nerve stimulation
- augmentation cystoplasty
- urinary diversion
How is mixed urinary incontinence managed in a woman?
- Referral if need 2 week or specialist
- Treat based on the most predominant of stress or urgency
- Only give absorbency pads to cope with leakage whilst awaiting response to ongoing treatment or long term if all treatment options explored. Check skin efficacy regularly
What are some of the causes of the following in men:
- Voiding symptoms
- Overactive bladder syndrome
- Nocturnal polyuria
- Stress urinary incontinence
- Acute urinary retention
Voiding: BPH, drugs with antimuscarinic action (TCAs, antihistamines), phimosis, cancer of prostate/bladder/rectum, diabetic neuropathy
Overactive: BPH, lower UTI, STI, bladder stones, neurological conditions (MS, dementia, Parkinson’s), prostatitis, cancer of bladder/prostate
Nocturnal: DM, drugs (CCBs, diuretics, SSRIs), DM, chronic heart failure, DI
Stress: prostatectomy, injury to urethral area, drugs that increase urine production (alcohol), drugs that cause retention and overflow (pseudoepinephrine), drugs that reduce awareness to urinate (benzos and zopiclone)
Retention: stones, sympathomimetics, pelvic tumor, sever constipation, prostate cancer, BPH, anaesthetics, opioids
How is a man with predominantly voiding symptoms managed?
First exclude other causes
1st line
- Active surveillance*
- Conservative management* e.g limit alcohol/caffiene/fizzy drinks, pelvic floor and bladder training, containment products
2nd line
- Drugs (see image)
3rd line
- Referral to urologist for catheterisation or prostate surgery
Refer anyone to Bladder and Bowel Foundation or NHS website
How is a man with an overactive bladder managed?
- Lifestyle advice e.g limit caffiene/sweetners, keep fluid intake high to eliminate UTIs
- Temporary urine containment products e.g leg bags and sheaths, which you can get from district nurses/bowel bladder foundation
- Offer referral to supervised bladder training
- Anticholinergics like oxybutynin (not if frail due to risk of delirium) or mirabegron
- Refer to urologist for botulin/surgery if nothing working
- Just Can’t Wait card from Bowel Bladder Foundation
What are the psychological and drug related causes of erectile dysfunction?
Psychological
- Generalised e.g lack of arousability
- Situational e.g partner/performance issues, psychiatric illness like anxiety and depression
Drug related:
- Antihypertensives (beta blockers, verapamil, methyldopa)
- Diuretics (spironolactone, thiazides)
- Antiarrhythmics (digoxin, amiodarone)
- Antipsychotics (chlorpromazine, haloperidole)
- Hormones (5-alpha reductase inhibitos, antiandrogens)
- H2 Antagonists (ranitidine)
- Recreation drugs (heroin, alcohol, steroids, cannabis)
What are some biological causes of erectile dysfunction?
- Vasculogenic: CVD, hypertension, radiotherapy, prostatectomy, hyperlipidaemia
- Central Neurogenic: MS, Parkinson’s, multiple atrophy, stroke
- Peripheral Neurogenic: DM, chronic renal failure, surgery of the pelvic
- Anatomical: Peyronie’s disease, penile cancer, prostate cancer, micropenis, hypospadias, phimosis
- Hormonal: hypogonadism, hyperprolactinaemia, hyper/hypothyroidism, Cushing’s, hypopituitarism after head injury
How do you assess a man presenting with erectile dysfunction to determine the cause?
- Psychosexual history: current emotional status, current relationship status/health, sexual orientation, sexual aversion or pain
- Medical: include surgical and psychiatric history, check drug history
- Lifestyle: use of alcohol, tobacco, illicit drugs, level of exercise tolerance
- Physical exam: BMI, B.P, waist circumference, look at genitalia, check for gynaecomastia/reduced body hair, DRE
What are some investigations you can do after assessing a man with ED?
- Measure HbA1c to look for diabetes
- Take lipid profile to calculate Qrisk
- Morning sample of total testosterone, if low measure FSH, Prolactin and LH
- Look at PSA
- Carry out cardiac risk stratification (see image)
What are the non-pharmacological treatment options for ED?
- Admit to hospital if priapism
- Consider referral to urology, endocrinology, cardiology, mental health
- Manage risk factors e.g control hypertension and diabetes, substitute any drugs inducing ED
-Lifestyle advice e.g stop smoking, lose weight, increase exercise, no herbal remedies, if cycling >3/7 suggest trial period without or change seat
- Signpost to SDA or BAUS
- Follow up in 6-8 weeks
What pharmacological treatment can be used for ED?
- PDE-5 inhibitor regardless of cause
- Sildenafil (Viagra), Tadalafil, Vardenafil, Avanafil
- Sildenafil available OTC
- Take 1 hour before sexual activity
- Explain doesn’t induce erection, need sexual stimulation
What is the pathological process behind endometriosis?
- Growth of endometrial like tissue outside of the uterus, e.g pouch of douglas, ovaries, peritoneum, uterosacral ligaments
- Associated with menstruation that causes bleeding, inflammation, scar tissue
- Cause unknown but could include retrograde menstruation, personal genetics, metaplasia, and environmental factors
What symptoms may a woman with endometriosis present with?
- Look at risk factors like early menarche, FH, nulliparity
- Exclude differential diagnoses like IBS
Definitive diagnosis can only be made with laparoscopy but things like US, pelvic/ab exam can assist diagnosis
How is endometriosis treated in primary care and when would you consider referral to secondary care?
Tx:
- Consider 3 month trial of paracetamol/NSAIDs to manage pain
- Offer hormonal treatment for pain e.g COCP, Mirena
- Possibly amitriptylline as a neuropathic pain modulator
- Assess for fertility, anxiety, depression and offer treatment
- Provide info on disease and signpost
- Explain chinese medicine not proven to work
- Review after 3-6 months and refer if hormonal tx not working
Referral
- If symptoms are persistent, severe or recurrent
- Women with pelvic signs of endometriosis
- If initial management is not effective
How does adenomyosis present?
- Presence of endometrial tissue in the myometrium and often present with fibroids
- Causes menorraghia, dysmennorhoea that starts cyclical then daily, deep dyspareunia
- Risk factors: uterine surgery, pregnancy, miscarriage
- Usually symmetrically enlarged uterus on bimanual exam
How is adenomyosis diagnosed and managed?
Dx:
- Histological after hysterectomy
- Transvaginal US and MRI can help
Mx:
- Hysterectomy is only cure
- NSAIDs for pain
- Hormones e.g COCP, Mirena, GnRH agonists
- Uterine artery embolisation
How do fibroids present?
- Benign tumour of smooth muscle cells and fibroblasts in the myometrium that develop in reproductive age
- Often asymptomatic but can cause pressure symptoms (frequency/retention), menorraghia, subfertility, enlarged uterus/mass on bimanual exam
- Risk factors: early puberty, increasing age, black, obese, FH
How are fibroids diagnosed and treated?
Dx:
- Pelvic US
- If unknown mass or ascites refer urgently
Tx:
- Most can be left and followed up if asymptomatic and small
- Medical see image
- Surgical can do hysteroscopy and TCRF
- Surgical can also do uterine artery embolisation, myomectomy, hysterectomy
- Be careful giving HRT to women with fibroids
When should you refer a woman with fibroids to secondary care?
- Compressive symptoms e.g dysparaunia, constipation
- Fertility issues
- Suspicion of malignancy
- Fibroids that are palpable abdominally or measured over 12cm at US
What is the pathophysiology behind PCOS?
Excess of androgen production and presence of multiple immature follicles (cysts) in the ovary
Even though high LH, androgens stop the LH surge so follicles in the ovary arrest at an early stage and stay as cysts in the ovary
Need at least 12 cysts on ovary for diagnosis
What are some complications with PCOS and how do they develop?
Secondary ammenorrhoea/Oligomenorrhoea: due to lack of LH surge less ovulations
Androgenism/Weight gain: insulin resistance so increased insulin secretion and increased male androgens causing male weight gain (abdomen) and male characteristics (acne and hirtuism)
Reduced fertility: follicles do not matures so anovulation
- Increased risk of Type 2 DM: due to more likely to be obese and due to high insulin levels
- See image for presenting symptoms such as sleep apnea, anxiety, pre-eclampsia, gestational diabetes, endometrial cancer
How is PCOS diagnosed?
- Blood tests (see image): including prolactin, OGTT, TFTs to rule out other causes
- US to look for peripheral cysts
- Need 2 of following 3 for definitive diagnosis:
- clinical and/or biochemical signs of androgenism
- oligoovulation or anovulation
- polycystic ovary/ies >12 follicles or enlarged ovary >10cm3
How is PCOS managed?
Always promote healthy lifestyle and weight loss as will help all symptoms. Always screen for diabetes
Oligomenorrhoea: low progesterone levels so increased risk of malignancy. Give cyclical hormones like COCP and POP to induce at least 3 bleeds a year
Obesity: keep BMI below 30 by encouraging healthy lifestyle and exercise to increase insulin sensitivity. Give orlistat to stop pancreatic lipases breaking down fats into absorbable fats in the gut
Infertility: clomifene +/- metformin when trying to concieve. Can cause multiple pregnancies and ovarian cancer so limited to 6 cycle use. If BMI<30 can use laparascopic ovarian drilling
Hirtuism/Acne: antiandrogen like finasteride/spironolactone. These are teratogenic so be careful. Can use Eflornithine as topical cream to stop facial hair growth
What are some conservative management options for the menopause?
- Explain symptoms and available treatment
- Explain importance of screening, bone protection and contraception as fertile for up to 2 years after LMP
- Refer to Menopause Matters or Daisy Network
- Lifestyle advice:
- Hot flushes: exercise, weight loss, lighter clothing, avoid triggers like spicy food, sleep in cold room
- Sleep disturbances: avoid exercise late in the day and keep bedtime routine
- Mood disturbances: sleep, regular exercise, relaxation activities
- Cognitive symptoms: exercise and good sleep hygiene
Apart from HRT, what pharmacological treatments can be offered for a women going through the menopause?
- Vasomotor symptoms: trial 2 weeks fluoxetine, citalopram or venlafaxine or clonidine
- Vaginal dryness: low dose oestrogen cream, pessary, ring etc
- Mood disturbances: self help, CBT or antidepressants for around 1-2years symptom free then withdraw
- Isoflavanes and Black Cohosh can help vasoactive symptoms but not sure how safe
- Review in 3 months
Why might you use transdermal HRT over oral?
With patches progestogen may be given orally/mirena or combined in the patch
- Better if high risk of venothrombous embolism
- Lactose intolerance
- History of migraines
- Less GI side effects like nausea
- Woman has bowel disorder that may affect absorbance
- Taking hepatic enzyme inducing drug e.g carbamazepine
- Women may just prefer this route
When do you use oestrogen only HRT and when do you use combined?
- Oestrogen only when have had hysterectomy or mirena (levonorgesterol) in situ
- Combined otherwise to stop endometrial proliferation
What are the pros and cons of HRT?
Pros:
- Bone protection
- Controls vasomotor symptoms
- Control mood
Cons:
- Higher risk of breast cancer and ovarian cancer particularly taking over 2 years
- Unscheduled vaginal bleeding for first 3 months and reinduction of a ‘period’
- Increased clotting so risk of heart disease
- Breast tenderness
- Fluid retention
- Headaches
When should you use cyclical combined HRT and when should you use continuous HRT?
Cyclical: normally used when menopausal symptoms but still having periods (perimenopausal).
Oestrogen every day then progestogen for last 14 dys
Continuous: used when post menopausal (no bleed for a year) and preferred as less likely to have a withdrawal bleed
Tibolone is a no bleed option for menopausal women who haven’t bled for a year
What hormones are used in HRT?
- Natural oestrogen: e.g estradiol, estriol NOT ethinylestradiol which is synthetic
- Progestogen: Medroxyprogesterone Acetate better tolerated thanNorethisterone or Levonorgestrel as less anti-androgenic
What is the role of low-dose vaginal oestrogen?
- Helps with vaginal dryness so sex less painful
- Does not have risk of breast cancer as not systemically absorbed and oestrogen too low to cause endometrial proliferation
What drugs are used for storage symptoms and what drugs are used for voiding symptoms?
Storage: Anticholinergic like oxybutynin
Voiding: Alpha Blocker like doxazosin. 5-Alpha reductase inhibitor if enlarged prostate
How is BPH managed in primary care?
- Start with 5-Alpha Reductase inhibitor as can shrink the prostate due to less testosterone. Then add alpha blocker
- Stop taking antidepressants or decongestants that can make urinary retention worse
- Lifestyle changes like double voiding, drinking less caffiene
- Bladder training
- TURP and prostatectomy
What advice can you offer to a man if he is having post-micturition dribble but no underlying prostate pathology?
- Milk the urethra
- Incontinence pads
If someone has microscopic haematuria and is aged over 55 what is the working diagnosis?
Until proven othewise bladder cancer
