8. Common Gynaecological Disorders Flashcards
Menstrual blood loss
35-45mls per cycle
Prostaglandins controlling uterine vasoconstriction
- PG F2a – causes vasoconstriction
- PG E2 and Prostacyclin (PGI2) – causes vasodilatation
- Prostacyclin (PGI2) – inhibits platelet aggregation
List 7 menstrual disorders
- Amenorrhoea
- Menorrhagia
- Metrorrhagia
- Intermenstrual bleeding
- Polymenorrhoea
- Oligo/Amenorrhoea
- Dysmenorrhoea
Primary amenorrhoea
Temporary or permanent absence of menses due to dysfunction of hypothalamus /pituitary /ovaries /uterus/ vagina.
Puberty stages
- Growth spurt
- Axillary and pubic hair development
- Apocrine sweat glands, breast development
1* Amenorrhoea and short statue
–> Turner syndrome or growth hormone deficiency
1* Amenorrhoea and Galactorrhoea
Hypothalamic or pituitary disease, or drug induced (metoclopramide)
1* Amenorrhoea and PCOS + hyper-androgenism (acne, hirsutism)
Adrenal tumour
Kallmann’s syndrome and amenorrhoea
Kallmann;s causes 1* amenorrhoea - absence of GnRH neurons. (associated with ansomnia and colour-blindness)
Kallmann’s Syndrome inheritance
Autosomal dominant or X-linked recessive
Anatomical abnormalities in primary amenorrhoea
- Intact hymen
- Transverse vaginal septum
- Mullerian/vaginal agenesis
Tanner staging
Rates development of 2ndary sexual characteristics; Sexual Maturity Rating
Treatment for 1* Amenorrhoea in Primary Ovarian Insufficiency
Give HRT to prevent bone loss or premature coronary heart disease
Treatment for 1* amenorrhoea for pts to get pregnant
Exogenous GnRH or pulsatile GnRH
Secondary amenorrhoea
Absence of Menses for >6 moths in someone with previous regular periods
2* amenorrhoea and hypothalamic-pituitary involvement
Polyuria, polydipsia, fatigue, visual defects, headaches
2* amenorrhoea and oestrogen deficiency
hot flushes, vaginal dryness, poor sleep, decreased libido
Laboratory test for 2* amenorrhoea
hCG, FSH, TSH, Prolactin
How to manage low bone density in 2* amenorrhoea?
Oestrogen replacement
Menorrhagia
Ovulatory heavy menstrual bleeding
Investigations in menorrhagia
Pelvic USS, FBC, TFT, Clotting screen, endometrial biopsy (all women >45yo)
Medical therapies for Menorrhagia
NSAIDs, Haemostatics, Hormones, IUS
Menorrhagia and NSAIDs drugs
Mefenamic acid, Indomethacin, Ibuprofen, Naproxen
Menorrhagia and NSAIDs
- Taken only during menstruation
- 50% reduction in menstruation volume loss
- Improves dysmenorrhoea and dyspareunia
Menorrhagia and haemostatics drugs
- Antifibronolytics (tranexamic acid - cyclokapron)
- Capillary wall stabiliser (ethamsylate - dicynene)
Antifibrinolytics for menorrhagia
- Taken only during menstruation
- > 50% reduction in mestruation volume loss
- Superior to NSAIDs controlling the loss, but not the pain
Capillary wall stabiliser for menorrhagia
- Taken only during menstruation
- No contraindications
- 20-30% blood loss reduction
Menorrhagia and hormones
- Oral contraceptives (cycle regulation, reduction of loss and dysmenorrhoea)
- HRT (cycle regulation only)
- Synthetic progestagens (cycle regulation, loss reduction)
Menorrhagia and hormones HPO axis regulation
- Danazol (reduces flow, lots of side effects and expensive)
- Gestrinone (similar to danazol)
- GnRH analogues (induce menopause, lots of side effects and expensive)
IUS for Menorrhagia
Levonorgesterol
Surgical therapy for menorrhagia
Hysteroscopy, Hysterectomy, Endometrial destruction
Menorrhagia and hysteroscopy
- Endometrial resection (TCRE)
- Endometrial ablation (ELA, RFA)
Endometrial resection
TCRE - transcervical resection of the endometrium
Endometrial ablation
ELA - endometrial laser ablation
RFA - radiofrequency ablation
Hysterectomy
TAH - total abdominal hysterectomy
VH - vaginal hysterectomy
LAVH - laparoscopy assisted vaginal hysterectomy
Endometrial destruction
- No risk of menopause induction
- Intra and post operative complications
Indication for therapy in menorrhagia
Women <40 yo, Regular cycles and no IMB, no risk factors for malignancy, clinically normal pelvis
Metrorrhagia definition
An-ovulatory Heavy Menstrual Bleeding
Intermenstrual bleeding differential diagnosis
ovulatory dysfunction, neoplasia, uterine structural pathology, disorders of haemostasis
Disorders that cause Abnormal Uterine Bleeding
- Bleeding disorders, Endocrine disorders, Coeliac disease, Anticoagulant use, hyperprolactinemia
AUB: PALM - COEIN
Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified
Fibroids treatment:
- conservative management
- uterine artery embolisation
- MRI-guided ultrasound coagulation
- Myomectomy (surgical removal of fibroids)
- Hysterectomy
Fibroid treatment
- Uterine artery embolization
- Ultrasound coagulation
- Myomectomy (surgical removal of fibroids)
- Hysterectomy
Vaginal epithelium
Non-keratinized, stratified squamous; rich in glycogen.
Doderlein Lactobacilli
Convert glucose (from glycogen from sloughed cells) into lactate to provide acidic environment (pH 4.0-4.5)
The role of acidic pH in the vagina
- Maintain vaginal flora
- Inhibit growth of pathogens
Non-specific vulvovaginal symptoms:
- Change in volume, colour, or odour of vaginal discharge
- Pruritis
- Burning and irritation
- Erythema
- Dyspareunia
- Spotting
- Dysuria
Symptoms of bacterial vaginosis (BV)
Malodorous, thin grey discharge, symptoms during and just after period
Symptoms of vaginal candidiasis
Scant thick white, odourless discharge
Symptoms of trichomoniasis
Purulent, malodorous discharge + burning, pruritis, dysuria, dyspareunia, symptoms during and just after period
Pruritis characteristics
Diffuse infection and allergy; chronic -> malignancy or neoplasia
Burning and irritation – diseases:
- Candida vulvo-vaginitis
- Vulvodynia
Candida vulvo-vaginitis:
Inflammation, pruritis and soreness (premenstruation symptoms)
Vulvodynia:
Non-infectious disorder
Erosive vulvo-vaginitis
Multifocal rounded macular erythematous lesions (burises/spotter rash-like), purulent discharge and tenderness
BV discharge
Fishy-smelling, grey thin, homogenous discharge
Trichomoniasis discharge
Greenish-yellow purulent discharge
Candidiasis discharge:
Thick white, adherent, ‘cottage cheese like’ discharge
What do chocolate cysts suggest?
Endometrioma
Endometriosis treatment
- Continuous COCP or POP
- Mirena IUS
- GnRH agonists
- Surgery (ablation and pelvic clearance)
Differential diagnosis in Pelvic Inflammatory Disease
- Ectopic pregnancy
- Acute appendicitis
- Endometriosis
- Ovarian torsion
- Ovarian cyst rupture
- UTI
Symptoms of PID
- Lower abdominal pain
- Dyspareunia
- Abnormal vaginal bleeding
- Dysmenorrhoea
- Abnormal discharge
- Fever, positive test for gonorrhoea, chlamydia, or M genitalium
Outpatient treatment for PID
IM ceftriaxone 1000mg (Single dose), Doxycycline PO BD 100mg (14 days), Metronidazole PO BD 400mg (14 days)
Inpatient treatment for PID
- IV continued for 24h post improvement and switched to oral
- IV ceftriaxone 2g daily
- IV doxycycline 100mg BD
NEXT: - Doxycycline PO BD 100mg (14 days)
- Metronidazole PO BD 400mg (14 days)
Chronic PID treatment
- Abx
- Anaelgesia
- Adhesiolysis
- Hysterectomy and bilateral salpingectomy
Ovarian cysts blood tests:
- FBC
- CA125
- Lactate dehydrogenase
- A-FP and hCG
RMI (Risk of Malignancy Index)
U x M x CA-125
U – ultrasound (1 for: multilocular cysts, solid areas, metastases, ascites, bilateral lesions)
M – menopausal status (1 – premenopause, 3 – postmenopause)
Serum CA125 – IU (0-1000s)
Ovarian cyst management
<5cm no treatment
5-7cm yearly USS
>7cm MRI/surgical intervention (laparoscopic cystectomy but no aspiration!)
Bartholin glands (greater vestibular glands)
Secretes mucus and lubricates vulva and vagina (Bartholin ducts drain here – if blocked - vulvar mass)
Bartholin cyst
If Bartholin duct is obstructed, mucus accumulates -> dilatation of duct -> obstruction causes a cyst
Bartholin abscess
Obstructed duct becomes infected and forms an abscess
Fluid from Bartholins mass:
Cyst: clear or white fluid
Abscess: yellow or green
Bartholin abscess/cyst management
Abx, word’s catheter, marsupialisation
