acute gynaecology + menopause Flashcards
ovarian torsion
where ovary twists in relation to surrounding connective tissue, fllopian tube + blood supply (adnexa) –> medical emergency
- torsion more likely with a cyst >5cm - dermoid
- more likely to occur during pregnancy
ovarian torsion in premenopausal women vs post
pre - long infundibulopelvic ligaments that twist more easily, likely bening
post - likely malignant
25% of adenexal torsions occur in children
- twisting of adnexa + blood supply leads to ischaemia, necrosis -> ovary loss of function
risk factors for ovarian torsion
ovarian mass - present in around 90%
of reproductive age
pregnancy
ovarian hyperstimulation syndrome
ovarian torsion presentation
sudden onset severe unilateral pelvic pain - deap-seated colicky abdominal pain
pain is constant, gets progressively worse
assoc N+V
localised adenexal tenderness
palpable mass in pelvis - absence does not exclude diagnosis
occasionally can twist + untwist intermittently - pain that comes + goes
ovarian torsion investigations
pelvis US - transvaginal ideal but transabdominal also fine
- “whirlpool sign”
- free fluid in pelvis
- oedema of ovary
doppler studies may show lack of blood flow
definitive diagnosis = laparoscopic surgery (also therapeutic)
ovarian torsion management
laparascopic surgery
- untwist ovary + fix in place
- remove affected ovary - oophrectomy
laparotomy may be equired where there is large ovarian mass or malignancy is suspected
complications of ovarian torsion
necrosis of ovary - loss of function
- other ovary usually compensates so fertility is not typically affected (loos of this one too = infertility + menopause)
- where necrotic ovary not removed - infection->abscess-> sepsis, may rupture resulting in peritonitis + adhesions
pelvic inflammatory disease + causes
ascending infection from endocervix
- chlamydia, gonorrhoea
- mycoplasma
- endometritis
- enarobes
pelvic inflammatory disease presentation
bilateral lower abdo pain
fever
deep dyspareunia
dysuria
abnormal vaginal bleeding
vaginal or cervical excitation
discharge
N+V in 50%
pelvic inflammatory disease investigation
pregnancy test to exclude ectopic
high vaginal swab
screen for chlamydia + gonorrhoea
management of pelvic inflammatory disease
Outpatient
o Ofloxacin + metronidazole 400mg twice daily
–> Patients <18 / at high risk of gonorrhoea, sexual contact, diplocci on microscopy = IM ceftriaxone + doxycycline
Inpatient
o IV ceftriaxone + IV metronidazole 3x a day + PO doxycycline
consider removing IUD, barrier contraceptive, contract tracing
bartholins abscess
blocked ducked -> infection + swelling
bilateral glands 5+7 oclock
lubricates
investigation = swab
Mx = antibiotics (broad spectrum), incision + drainage
menopause
point at which menstruation stops
- caused by lack of ovarian follicular function, resulting in changes in sex hormones assoc with menstrual cycle
- oestrogen + progesterone levels are low
- LH + FSH are high in response to an absence of neg feedback
average symptoms duration of menopause
7.4yrs
average no of symptoms = 7
menopause age
average = 51
premature ovarian insufficiency <40yrs
early menopause = 40-44yrs
perimenopause = irregular periods
postmenopause = no periods > 12months
diagnosis of menopause
no routine FSH test in women >=45yrs
- except women >=50 on hormonal contraception who don’t want to continue till 55yrs
FSH levels x 2 (6weeks apart) possibly indicated
- women >45 with atypical symptoms
- women between 40-45 with menopausal symtpoms +/- iatrogenic ammenorhoea (hysterectomy, ablation)
FSH, E2, TFT, glucose, prolactin, FAI in -
- women <40
- check chromosomes + exclude autoimmune in <35
consider therapeutic trial of HRT
contraindications of HRT
Hx of breast or endometrial cancer
coronary heart disease, TIA or stroke
active liver disease
unexplained vaginal bleeding
risks
- increased breast cancer risk - over 50s
- VTE risk when taken orally - NOT transdermally
- CVD risk >60s
main benefits of HRT
vasomotor symptoms - hot flushes, night sweats
improve low ood
reduces osteoporosis risk
improve sexual + cognitive function
prevention/treatment of urogenital + vulvovaginal atrophy
HRT management in women with premature ovarian sufficiency
give HRT till average age of menopause - 51
HRT does not add risk of breast ca compared to women without - just giving back what shes missing
continue with contraceptions
genitourinary syndromes of menopause
atrophy of minora + majora
narrowing of vaginal opening - loss of vaginal fornix, thinning of vaginal wall, decrease length
reduced blood flow to vagina
petechial haemorrhage
management of genitourinary syndromes of menopause
vaginal oestrogens
- does NOT causes hyperplasia or endometrial cancer long term
symptomatic
- lubricants
- vibrators
- cycle makes her tighten up + avoid/fear sex
perimenopausal contraception
age <40
- premture insufficiency of ovaries might be transitional
- continue with contraception
age 40-49
- contraception can be stopped
— 2yrs after last natural menstrual period (not while on hormonal contraception) OR
— 2yrs after 2 results of FSH of >= 30, taken at least 4-6weeks apart
age >=50
- contraception can be stopped
—- 1 yr after last natural menstrual period OR
—-1yrs after 1 result of FSH >=30
age >=55
- contraception can be stopped even if still having periods due to poor oocyte quality
—- might consider continuing contraception for another year or 2 if periods troublesome
UKMEC1 options for perimenopause
barrier
mirena or copper coil
progesterone only pill or implant
progesterone injection (under 45yrs)
- SE = weight gain + reduced bone mineral density
COCP = UKMEC2 after age 40
