204 - gynaecology Flashcards
define intermenstrual bleeding
vaginal bleeding at any time during the menstrual cycle apart from during normal menstuation
define menorrhagia
excessive loss of blood during menstuation (>80mL)
how would you classify bleeding that occurs immediately after sexual intercourse
post coital bleeding
what is mid cycle spotting
spotting occurring just before ovulation usually due to the decline in oestrogen levels
what is the term for painful menstrual periods and what is it caused by?
Dysmenorrhoea
causes - primary no cause. secondary to endometriosis or Pelvic Inflammatory Disease (PID)
what us the term for pain associated with sexual intercourse?
dyspareunia
what is a bladder prolapse called?
cystocoele
what is a rectum prolapse called?
rectocoele
what should be asked in a menorrhagia history?
dysmenorrhoea, dyspareunia, abnormal vaginal discharge, quality of life, clots, flooding, gp treatment, previous obstetrics hx
what are the most common causes of menorrhagia (most common first)?
Dysfunctional Uterine Bleeding (DUB) - no organic disease - 60%
Fibroids (uterine leiomyomas) - benign growths
Endometriosis (uterine tissue outside uterus) or Adenomyosis (ectopic endometrial tissue within the myometrium)
what should be carried out on examination for menorrhagia?
signs of anaemia,
abdominal exam for masses and tenderness
speculum exam of cervix
pelvic exam for SSPMT (size, shape, position, mobility and tenderness)
what investigations can be carried out for menorrhagia?
- swabs - high vaginal and endocervical - check for pelvic inflammatory disease caused by chlamydia or gonorrhoea)
- FBC to check for anaemia
- USS/CT/MRI to check for fibroids, endometriosis and free fluid
- endometrial biopsy (pepel) in women over 40 for endometrial cancer
what treatment can be given for menorrhagia?
- tranexamic acid (antifibrinolytic) during menstruation only reduces 50%
- mefenamic acid (NSAID) - pain relief & reduced bleeding
- progestogens
- gnrh analogues
- surgical
What progestogen treatments are available for menorrhagia and what are the benefits/side effects?
- mirena coil (1st line) slow release of progestogen- reduces loss by 90%, 30% amenorrhoeic by 1 yr, excellent contraceptive, lasts 5yrs, irregular bleeding for 3-4months, breast tenderness 7 bloating.
- Combined oral contraceptive pill - 20-30% reduction & reduces pain.
- High dose progestogens - used in continuous bleeding/severe anaemia to stop quickly
- oral progestogens (not used in regular menorrhagia)- norethisterone, medroxyprogesterone acetate
what GnRH analogues are used to treat menorrhagia and what are their benefits/side effects?
*Prostap (leuprorelin acetate)
*Decapeptyl (Triptorelin)
mimic GnRH action on hypothalamus (-ve feedback) causing less GnRH release and less LH/FSH & oestrogen secretion. Used to achieve menorrhoea quickly. side effects hot flushes, osteoporosis (so can only use for 6-12 months)
what surgical treatments are available for menorrhagia and what are the benefits/side effects?
- endometrial ablation - destruction of endometrium down to basal membrane, 80-90% effective. Novasure (electrical impedance) and thermachoice (thermal balloon)
- hysterectomy - abdominally and vaginally
What is Dysfunctional uterine bleeding?
menorrhagia not associated with organic disease of the genital tract. Diagnosis of exclusion when there are no fibroids , endometriosis/adenomyosis, anovulatory cycles, malignancy, clotting disorders
what are fibroids (leiomyomas)?
common benign tumours of the smooth muscle of the uterus (cancerous fibroids (leiomyosarcomas) rare & dont develop from benign fibroids)
- majority assymptomatic, common in afro carribean,obese, mid-late reproductive years, HTN & those with family hx
- grows in response to oestrogen & progesterone
what are the different sites of fibroids?
- submucosal - most likely to cause menorrhagia due to incr. surface area of mucosa. also affects fertility
- intramural - most common. may cause menorrhagia
- subserous - on outside of uterus. usually asymptomatic
- intracavitary - grow in papillary manner. may cause infertilty
- pedunculated - grow in papillary manner from outer wall into peritoneal cavity
what are the symptoms & signs of fibroids?
menorrhagia, dysmenorrhoea, dypareunia, infertility, abdominal fullness, painful defecation, urinary freq/obstruction
abdominal mass that is slow growing
what are the investigations for fibroids?
haemoglobin, tumour markers CA125/CEA, USS, endometrial biopsy, hysteroscopy, diagnostic laparoscopy
what treatment can be given for fibroids?
medical
- esmya - blocks progesterone receptors inhibiting cell proliferation & stimulate apoptosis. reduces LH and FSH and inhibits ovulation
- GnRH agonists - shrink fibroid & reduce vascularity
-mirena IUS
surgical - myomectomy, hysterectomy, uterine artery embolisation
What is endometriosis?
presence of endometrial tissue outside the uterus. commonly spreads to ovaries but can also go to kidneys, bladder, bowel
what is adenomyosis?
presence of endometrial tissue in muscle layer of uterus
what are the signs/symptoms of endometriosis/adenomyosis?
often asymptomatic
pain - dysmenorrhoea, chronic pelvic pain, deep dyspareunia
infertlity
what treatment is available for endometriosis/adenmyosis?
analgesia, progestogen (mirena IUS,COCP), pituitary-gonadal supression (GnRH analogues), surgery (ablation, excision, total abdominal hysterectomy & bilateral salpingo-oophrectomy
What is an ectopic pregnancy and what can cause it?
one that is not growing in the uterus, usually tubal. Chlamydia or gonorrhoea- the cilia that push the egg out of the uterine tube damaged.
what is a molar pregnancy?
an overgrowth of placenta tissue that can become a choriocarcinoma. treatment is methotrexate (antimetabolite)
what us the medical management for a miscarriage?
mifepristone and prostaglandin (misoprostol)
what is seminal plasma and what does it contain?
slightly alkaline fluid (to protect from vaginal acidity) secreted by the prostate & vesicles. It contains 15million/ml sperm (40% motile, 5% normal), white clls, sugars, prostaglandins and proteins
what are the components of sperm?
- acrosome - cap containing enzymes to digest through zona pellucid
- head - containing nuclear material
- midpiece - contains mitochondria to power flagellum
- Flagellum - tail to propel spermatocyte
what is capacitation?
sperm spend 24 hours in uterine tube before they can penetrate zona pellucid
what happens to the fallopian tubes and cervical mucous at ovulation?
fallopian tubes mobile and chemotactically attracted to ovum at ovulation
cervical mucous normally acidic with white cells but at ovulation becomes alkaline, low in cells and spinbarkheit (elastic and stretchy)
where is the ovum usually fertilised?
ampulla of fallopian tube
what are the causes of subfertility?
sperm dysfunction 30%
ovulation disorder 25%
tubal disease 20%
endometriosis 10%
what is the term for absence of sperm?what is primary and secondary?
azoospermia
primary - failure of sperm production
secondary - inability of sperm to reach urethra (obstructive)
what is the term for low sperm concentration?
oligozoopermia
what is the term for poor sperm motility?
asthenozoospermia
what is the term for abnormal shaped sperm?
teratozoospermia
what treatments are available for sperm dysfunction?
IVF & intracytoplasmic sperm injection or donor insemination
what can cause ovulation disorders?
- hypothalamo-pituitary-ovarian axis dysfunction
- other endocrine disorders eg hyperthyroidism, CAH
- Polycystic Ovarian syndrome (PCOS) - 2 out of three: oligo/anovulation, infertility, excess androgen
what treatments are available for ovulation disorders?
- ovulation induction (can cause multiple pregnancy) 1) oestrogen antagonists - inhibit -ve feedback and incr. LH & FSH 2) synthetic LSH
- assisted conception procedures
- ovarian drilling for PCOS
what treatments are available for tubal disease caused by infection or inflammation?
- cuff salpingostomy -hole cut in tube allowing ovum to enter lower down. can cause ectopic pregnancy
- ablation of endometriosis
- IVF
what are the assisted conception techniques?
- IUI - Intrauterine insemination - washed prepared sperm injected high into uterine cavity
- IVF - In-vitro-fertilisation - prepared sperm injected into ova, zygote cultured, inserted into uterus via catheter. risks - multiple pregnancy, ovarian hyperstimulation syndrome, ovarian sepsis, ovarian torsion
what are other options to sterilisation?
- mirena IUS - progestogen, lasts 5yrs
- implanon - rod in arm, lasts 3 yrs
- vasectomy for partner - more effective
how does laparoscopic slip sterilisation work?
2 scars -subumbilical & supra pubic
filshie clips occlude fallopian tubes from ouside, lumen then fibroses over time. Can cause bowel, bladder or blood vessel damage
what hormone is produced by a developing embryo, what does it do and how is it useful in determining pregnancy?
- Human chorionic gonadotrophin
- prevents corpus luteum dterioation and maintains progestorone production
- level doubles every 48hrs during 1st trimester
what classifications of miscarriage are there?
- threatened - vaginal bleeding in early pregnancy without cervical dilation or change in cervical consistency
- inevitable - vaginal bleeding in early pregnancy with cervical dilation, products of conception in lower uterine segment
- incomplete - heavy vaginal bleeding, cervical dilation with products still in uterus
- complete - all products past, empty uterus on USS, closed cervical os
- missed - products retained in uterus, only symptom is amennorhoea
what investigations should be carried out in suspected miscarriage?
transvaginal USS and beta hCG assays
how would you complete miscarriage medially?
- mifepristone - causes decidual degeneration of endometrium & cervical softening/dilatation
- misoprostol - induces labour, synthetic PGE1 analogue (prostaglandin E1), softens cervix, causes contrations
what are the risk factors for ectopic pregnancy?
- Pelvic inflammatory disease
- previous ectopic pregnancy
- tubal surgery
- smoking
- advanced maternal age
what are the clinical features of ectopic pregnancy?what investigations should be carried out?
abdominal pain and cramping, shoulder tip pain, amenorrheoea, vaginal bleeding, nausea & GI symptoms
beta-hCG assay to confirm pregnancy, USS to locate pregnancy, laparoscopy to locate and remove, FBC to monitor blood loss and progesterone test to evaluate viability of pregnancy
what medical options are available to terminate a tubal pregnancy?
*methotrexate (folate antagonist) - prevents DNA, RNA & protein synthesis, kills embryo. can cause abdo pain
